Protein malnutrition and its effect on oral health

PROTEIN ENERGY
MALNUTRITION AND ITS
EFFECT ON ORAL HEALTH
By
N.Nitya krishna
First Year Postgraduate
Department of Public Health Dentistry
1

CONTENTS
• Introduction
• Definition of nutrition
• Malnutrion and types
• Definition , classification and requirements of protein
• Protein energy malnutrition
• Epidemiology
• Pathophysiology
• Factors related to malnutrition
• Web of causation for protein energy malnutrition
• Classification of protein energy malnutrition
• Protein malnutrition-marasmus
• Kwashiorker
• Marasmic-kwashiorker
• Effects of protein malnutrition on oral health
• Diagnosis of malnutrition
• Management
• Prevention
• Conclusion
• References
2

INTRODUCTION
• The nutritional requirements of individuals at different stages of life vary
depend on age, sex, health and physical status,environmental conditions and
physical activity
• Food is the best source of all the nutrients.
• Inadequate nutrition to the body can lead to various forms of malnutrition
• Malnutrition is the condition that develops when the body does not get the
right amount of the vitamins, minerals, and other nutrients which it needs to
maintain healthy tissues and organ functions.
• Such a malnutrition status of the body during its development, can affect the
oral structures.
3

DEFINITION OF NUTRITION
4
W.H.O: Nutrition is the science of food and its relationship to health. It is
concerned primarily with the part played by the nutrient in body growth,
development & maintenance
 NIZEL(1989): The science which deals with the study of nutrient and foods and
their effects on the nature & function of organism under different condition of
age, health & disease.
NUTRIENTS

Macronutrients Micronutrients

MALNUTRITION
• OBESITY
5
UNDERNUTRITION OVERNUTRITION
ACUTE
MALNUTRITION
CHRONIC
MALNUTRITION
• Marasmus
• kwashiorkor
• Marasmic- kwashiorkor
• Wasting
Stunting
PROTEIN-ENERGY
MALNUTRITION
MICRONUTRIENT
MALNUTRITION
W.H.O- an imbalance between the supply of protein and energy and the body's
demand for them to ensure optimal growth and function

DEFINITION OF PROTEIN
Any of a group of complex organic macromolecules that contain carbon,
hydrogen, oxygen, nitrogen and usually sulfur and are composed of one or more
chains of amino acids.
(Satyanarayana U, Biochemistry.3rd edition)
6

CLASSIFICATION OF PROTEINS
I Based on chemical nature and solubility:
PROTEINS
SIMPLE CONJUGATED DERIVED
Globular
proteins
Sclero
proteins Primary Secondary
7

CLASSIFICATION OF PROTEINS
II. Based on the function:
1. Structural proteins
2. Enzymes
3. Transport proteins
4. Hormonal proteins
5. Contractile proteins
6. Storage proteins
7. Genetic proteins
III. Nutritional classification of proteins
1. complete proteins- eg:- Egg Albumin, Milk Casein
2. Partially incomplete proteins- eg:- Wheat, Rice proteins
3. Incomplete proteins- eg:- Gelatin
8

COMPOSITION OF PROTEINS
o Carbon: 50-55%
o Oxygen: 19-24%
o Nitrogen: 13-19%
o Hydrogen: 6-7.3%
o Sulfur: 0-4%
o Phosphorus
o Iron
o Copper
o Magnesium
o zinc
Major elements
Minor elements
9

REQUIREMENTS OF PROTEIN
For a person who is accustomed to sitting or taking little exercise, the recommended
daily protein intake is
0.75g per kg of body weight.
Person whose physical activity level is good enough and who performs exercises for
about an hour or so, for them the ideal protein intake is about
1.0-1.2g of protein per kg of body weight.
For athletes 1.6-1.7gm of protein per kg of body weight.
 The estimated requirement for protein during pregnancy is 60 gm per kg of body
weight.
 Lactating mothers: 65 gm of protein per kg of body weight.
10

PROTEIN ENERGY MALNUTRITION
• Chronic pathological condition which arises due to absolute or relative lack
of protein and energy in the diet over an extended period of time and is
commonly associated with infection in young children.
• Major health and nutritional problem in India.
• Occurs particularly in weaklings in children in the first five years of life.
• It is not only an important cause of childhood morbidity and mortality, but
leads also to permanent impairment of physical and possibly, of mental
growth of those who survive.
11

EPIDEMIOLOGY
• Nearly half of all deaths in children under 5 are attributable to undernutrition.
• Undernutrition puts children at greater risk of dying from common infections,
increases the frequency and severity of such infections, and contributes to
delayed recovery.
• In addition, the interaction between undernutrition and infection can create a
potentially lethal cycle of worsening illness and deteriorating nutritional status.
• Poor nutrition in the first 1,000 days of a child’s life can also lead to stunted
growth, which is irreversible and associated with impaired cognitive ability and
reduced school and work performance.
12

• Now, in the Post-2015 development era, estimates of child malnutrition will
help determine whether the world is on track to achieve the Sustainable
Development Goals – particularly, Goal 2 to “End Hunger, Achieve Food
Security And Improved Nutrition, And Promote Sustainable Agriculture”.
• UNICEF/WHO/WORLD BANK GROUP JOINT CHILD
MALNUTRITION ESTIMATES
• In September 2016, UNICEF, WHO and World Bank Group released the 2016
edition of the joint child malnutrition estimates for the 1990–2015 period,
representing the most recent global and regional figures.
• A suite of seven on-line interactive dashboards were developed to enable users
to explore the entire time-series (1990 – 2015) of global and regional estimates
of prevalence and number affected for stunting, overweight, wasting and
severe wasting.
13

• Between 1990 and 2015, stunting prevalence globally declined from 39.6%
to 23.2% and the number of children fell from 255 million to 156 million.
• In 2015, just 2 out of 4 stunted children lived in South Asia
• In 2015 globally, 50 million children under age 5 were wasted and 17 million
children were severely wasted. Half of which lived in South Asia.
• South Asia's prevalence is close to becoming a public health problem.
Indian scenario-
• Childhood malnutrition is the underlying cause of death in 35% of all deaths
under age 5.
• During 1st 6 months, when most babies are breast feed, 20-30% are already
malnourished.
• By 18-23 months, during weaning, 30% are severely stunted, 1/5th are
severely underweight.
14

Factors related to Malnutrition
Social & Economic
15
Biological factors
 Poverty
 Ignorance
 Female gender
Rural area
Low birth weight
Illiterate mother
Scheduled caste/
scheduled tribe
Cultural & social practices
Maternal malnutrition, prematurity
Birth spacing < 47 months
Age of mother: 18 – 23 yrs
Birth order > 3
Underweight status of mothers
Infectious disease
Diarrhea, TB, measles,
Malaria, AIDS
Environmental
Unsanitary living,
Droughts, floods, wars, forced
migrations

WEB OF CAUSATION FOR PROTEIN
ENERGY MALNUTRITION
18

ntake
Malnutrition in
children
Traditional Bio-Medical Concept
Decrease
immunity
Recurre
nt
ARI/GI
tract
infectio
ns
Low
birth
weig
h
Inadequate energy
intake
19

IAP CLASSIFICATION
Grade of malnutrition Weight for age of the
standard
Malnutrion
Normal >80%
Grade 1 71-80% Mild malnutrition
Grade 2 61-70% Moderate malnutrition
Grade 3 51-60% Severe malnutrition
Grade 4 <50% Very severe malnutrition
22
CLASSIFICATION OF PROTEIN ENERGY
MALNUTRITION

GOMEZ CLASSIFICATION
Nutritional status Weight for age
Normal >90
First degree malnutrition 75-90
Second degree malnutrition 60-75
Third degree malnutrition <60
23
ALL CASES WITH OEDEMA TO BE INCLUDED IN GRADE THREE PEM
IRRESPECTIVE FOR AGE
Reference standard WHO growth chart
Weight For Age %= Weight Of The Child/Weight Of A Normal Child Of Same Age X
100

WATERLOW CLASSIFICATION
Nutritional
status
Stunting
(Height for age %)
Wasting
(Weight/height %)
Normal >95 >90
Mildy
Impaired
87.5-95 80-90
Moderately
Impaired
80-87.5 70-80
Severely
Impaired
<80 <70
24
Height/Age%= Height Of The Child/Height Of A Normal Child At Same Age X
100

Age independent indices
Name of Index Calculation Normal value
Value in
malnutrition
Kanawati and
McLaren’s index
Mid arm
circumference /
head circumference
(cm)
0.32-0.33
Severely
malnourished <0.25
Rao and Singh’s
index
(weight (in kg) /
height2 (in cm)) x
100
0.14 0.12-0.14
Dugdale’s index
weight (in kg) /
height1.6 (in cm)
0.88-0.97 <0.79
Quaker arm
circumference
measuring stick
(quac stick)
Mid-arm
circumference that
would be expected
for a given height
75-85%
malnourished
<75% severely
malnourished
Jeliffe’s ratio
Head circumference
/ chest
circumference
Ratio <1 in a child
>1 year
malnourished
25

CLINICAL ( WELLCOME )
▫ Parameter: weight for age + oedema
▫ Reference tandard (50th percentile)
▫ Grades:
 60-80 % without oedema is under weight
 60-80% with oedema is Kwashiorkor
 < 60 % with oedema is Marasmus-Kwashiorker
 < 60 % without oedema is Marasmus
26

TYPES OF PROTEIN ENERGY
MALNUTRITION
• Kwashiorker
• Marasmus
• Maramic –kwashiorker
27

KWASHIORKOR
• It is an acute form of childhood protein-energy
malnutrition characterized by inadequate protein intake
with reasonable caloric (energy) intake; it tends to occur
after weaning, when children change from breast milk to
a diet consisting mainly of carbohydrates.
• characterized by edema, irritability, anorexia, ulcerating
dermatoses, and an enlarged liver with fatty infiltrates.
• Prof Cicely Williams in 1933 from Gold Coast.
• She observed that this was the disease of the first child
when the second was on the way displacing the first child
from breast feeding.
• She named it Kwashiorkar, word taken from Ga language
of Ghana, which means the ‘red boy’ due to
characteristic pigmentary changes.
• Later on, the term was interpreted as “deposed child”.
28

ETIOLOGY:
• Dietary Inadequacy:
rapid period of transition from the balanced diet supplied by the breast milk to an
unbalanced inadequate diet, which is very low in protein, and consists mainly of
carbohydrates due
Precipitating Factor
1. Acute infections like acute infantile diarrhea and measles due to:
• Anorexia, which usually accompanies infections.
• The bad habit of withholding food during measles and diarrhea up to the degree
of starvation.
2. Malaria and severe parasitic infestations may play a role in the development of
kwashiorkor in some region of the world.
3. Studies suggest that aflatoxin poisoning is an important factor in the
development of kwashiorkor.
• Aflatoxins damage liver DNA.
29

SIGNS AND SYMPTOMS
The clinical signs of kwashiorkor is divided into 2 groups:
• Constant manifestation.
• Occasional manifestations
 Clinical manifistation is affected by:
• The degree of deficiency
• The duration of deficiency
• The speed of onset
• The age at onset
• Presence of conditioning factors
• Genetic factors
30

Constant Manifestations
1. Growth retardation
2. Edema:
• starts in the feet and lower parts of the legs - becomes-generalized.
• soft and pitting, affecting -back and dorsum of hands and feet
• The cheeks become bulky, pale and waxy in appearance (doll-like cheecks).
Ascites is unusual.
3. Disturbed muscle/ fat ratio -(Muscle wasting)
• generalized muscle wasting -preservation of subcutaneous fat.
• demonstrated clinically by measuring the mid-arm circumference which is
diminished in these cases.
• children are often weak, hypotonic and unable to stand and walk.
4. Psychomotor changes:
• marked apathy; misery and they lack interest in the surrounding.
• They don't move, look sad and never smile.
• Their cry is weak.
31

Occasional Manifestations
1.Skin Changes:
Dermatosis:
• The rash appears mainly in areas of increased pigmentation. These pigmented
areas subsequently desquamate leaving atrophic, hypopigmented and easily
damage skin or even ulcerations.
• rash - back of thighs and axillae;
• petechiae-over the abdomen.
2. Hepatomegly:
• It is caused by fatty infiltration of the liver, which is a constant pathological
finding in kwashiorkor that may or may not be accompanied by hepatomegaly.
3. Anemia:
• Deficiency of protein, iron, zinc, copper etc.
• Infections may be responsible by disturbing the iron metabolism.
4. Poor resistance and liability to infections.
32

Laboratory Findings:
1 total plasma protein (less than 4 gm/dl).
2. serum albumin (less than 2 gm/dl).
3. Urea in blood and urine is markedly reduced because of deficient intake of
exogenous protein.
4. Total body sodium is higher than normal. Serum sodium may be low due
to the excessive amount of water extracellular fluid compartment.
5. Low total body potassium due to potassium losses by diarrhea
33

ORAL MANIFESTATIONS
• Bright reddening of tongue
• Loss of papillae: erythematous and smooth dorsum of tongue
• Kwashiorkar:
▫ Edema of tongue with scalloping around the lateral margins due to
indentation of the teeth.
• Bilateral angular cheilosis
• Fissuring of lip
• Loss of circumoral pigmentation
• Dry mouth
▫ Reduced caries activity due to lack of substrate carbohydrate.
• Decreased overall growth of jaws
• Delayed eruption
• Deciduous teeth may show linear hypoplasia.
34

Marasmus
Marasmus is a form of severe PEM occur as result from a negative energy balance
that may occur at any age, particularly in early infancy and is characterized by:
• Severe wasting (body weight is less than 60% of the expected), the body utilizes
all fat stores before using muscles.
• Loss of subcutaneous fat.
• Gross muscle wasting.
• Absence of edema.
• “Marasmus” comes from greek origin of word “to waste”
• Children adapt to an energy deficiency with:
1- a decrease in physical activity.
2- lethargy.
3- a decrease in basal energy metabolism.
4- slowing of growth.
5- finally, weight loss.
35

Etiology:
The specific cause may be:
1. Poor feeding habits due to improper training. lack of breast feeding and the
use of dilute animal milk.
2. A physical defect e.g. cleft lip or cleft palate or cardiac abnormalities, which
prevent the infant from taking an adequate diet.
3. Diseases, which interfere with the assimilation of food e.g. cystic fibrosis.
4. Infections, which produce anorexia.
5. Loss of food through vomiting and diarrhea.
6. Emotional problems e.g. disturbed mother- child relationship.
36

SIGNS AND SYMPTOMS
• Severe growth retardation
• Loss of subcutaneous fat
• Severe muscle wasting
• The child looks appallingly thin and limbs appear as
skin and bone
• Shriveled body
• Wrinkled skin
• Bony prominence
• Associated vitamin deficiencies
• Failure to thrive
• Irritability, fretfulness and apathy
• Frequent watery diarrhoea and acid stools
• Dehydration
• Temperature is subnormal
• Muscles are weak
• Oedema and fatty infiltration are absent
37

Laboratory Findings:
1. Plasma protein may be normal or slightly lowered. This is because
marasmic infants live on their own muscle protein.
2. Blood urea is low since the protein utilized by the infant is totally
endogenous protein.
3. Blood glucose level is low due to deficient glycogen stores in the
liver
38

CLINICAL FEATURES OF PEM
FEATURES MARASMUS KWASHIORKOR
Clinical Always Present
Muscle wasting Obvious Sometimes hidden by edema
and fat
Fat wasting Severe loss of subcutaneous fat Fat often retained but not firm
Edema None Present in lower leg and
usually in face and lower arms
Weight for height Very low Low but may be masked by
edema
Clinical Sometimes present
Appetite Usually good Poor
Diarrhea Often Often
Features Marasmus Kwashiorkor
Skin changes Usually none Diffuse pigmentation,
sometimes flaky paint
dermatosis
Hair changes Seldom Sparse, easily pulled out
Hepatic enlargement None Sometimes due to
accumulation of fat
39

A severely malnourished child with
features of both marasmus and
Kwashiorkor.
• The features of Kwashiorkor are
severe oedema of feet and legs and
also hands, lower arms, abdomen
and face. Also there is pale skin and
hair, and the child is unhappy.
• There are also signs of marasmus,
wasting of the muscles of the upper
arms, shoulders and chest so that you
can see the ribs.
40
MARASMIC-KWASHIORKOR

COMPLICATIONS OF PEM
PEM
Electrolyte
imbalance
Multiple nutritional
deficiencies
Vitamin deficiency
Congestive cardiac
failure
Infections
Dehydration
and diarrhea
Hypothermia
Hypoglycemia
41

EFFECTS OF PROTEIN MALNUTRION ON ORAL HEALTH
1. Effect on salivary gland
The normal functioning of the salivary gland is necessary for the maintenance of a
healthy oral cavity.
• Psoter WJ et al has showed that hypofunctioning of the salivary glands has
been reported with PEM, which results in a decreased salivary flow rate, a
decreased buffering capacity, and decreased salivary constituents, particularly
proteins.
• PEM and vitamin A deficiency are associated with salivary gland atrophy,
which subsequently reduces the defence capacity of the oral cavity against
infection and its ability to buffer the plaque acids
42

2. Effect on dental caries
• PEM can be correlated with the host factors which are associated with the
development of caries, especially tooth defects and the salivary system.
• The tooth defects of interest are the external structural defects (hypoplasia)
that can provide a more cariogenic environmental niche and less protective
enamel and defects that include hypomineralization, which might increase the
susceptibility to demineralization
• Navia et al 1970 showed that a protein-deficient diet fed to experimental
animals during the pre-eruptive tooth development period increases their
caries susceptibility.
43

3.Delayed eruption
Gebrian B et al conducted aretrospective cohort study which was to determine the
effects of Early Childhood Protein-Energy Malnutrition (EC-PEM) and the eruption
patterns of teeth among adolescents, concluded that a delayed exfoliation of the
primary teeth and a delayed eruption of the permanent teeth were associated with
EC-PEM.
4.Effect on periodontal status
• Russell SL et al conducted a retrospective cohort study to examine whether an
exposure to Early Childhood Protein-Energy Malnutrition (ECPEM) was related to
a worsened periodontal status in the permanent dentition during adolescence.
• This study revealed that ECPEM was related to a poorer periodontal status.
• Because ECPEM is likely to affect the developing immune system, a person’s
ability to respond to the colonization with the periodontal pathogens may be
adversely affected permanently
44

5.Effect on jaws and teeth
• An adequate protein diet during pregnancy has been shown to benefit
significantly the bone and dental development of children.
• Infante PF et al has showed that 71% of infants whose mothers had a poor
protein diet during pregnancy had retarded development of bone and teeth
45

DIAGNOSIS OF MALNUTRITION
• History- including detailed dietary history.
-Anthropometric measurements.
▫ Weight
▫ Length/height
▫ Mid upper arm circumference MUAC)
▫ Chest circumference
▫ Head circumference
47

Height
• 1 yr 72-75 cm
• 2 yrs 88-90 cm
• 4 yrs 100 cm
• Used when child over age 2.
• If unable to stand, use recumbent length or knee height.
• Use calibrated stadiometer.
• Measure to 0.1 cm.
• Consider parental height.
• Consider chronic illness or special health care needs.
48
Weight –
Weight at birth-3kgs
At 5-6 month double of birth weight -6kgs
At 3 years weight 5 time double of birth weight -15kgs
At 6 years weight 6 times double of birth weight.

CHEST CIRCUMFERENCE
• Measured at the nipple midway between inspiration and expiration.
• At birth, the head circumference is more than chest circumference, but it
equalises by 1 year.
• Thereafter, chest circumference is more than head circumference.
49

HEAD CIRCUMFERENCE
• At birth, the head circumference is 35 cm.
• Increases to 40 cm by 3 months.
• 43 cm by 6 months.
• 45 cm by 9 months.
• 47 cm by 1 year.
• 49 cm by 2 years.
• 50 cm by 3 years.
• Approximate increase is 2 cm/month in the first 3 months, 1cm/month in
the next 3 months and 0.5 cm/month in the next 6 months.
• Head circumfernce <2 – small head
• < 3- microcephaly- late stages of malnutrition
50

Mid-upper arm circumference
MEASUREMET COLOR INDICATION
MUAC less than
(11.0cm)
Red color Severe
malnutrition
Between
(11.0- 12.5cm)
Orange Moderate
Between
(12.5- 13.5cm)
Yellow At risk or
mild
Over (13.5cm) Green Well
nourished
51

CHECKING FOR BILATERAL OEDEMA
52

MANAGEMENT
1. Initial treatment (emergency treatment)
2. Rehabilitation
3. Follow up
53

INITIAL TREATMENT
(EMERGENCY PHASE) USUALLY 2-7 DAYS
Fluids and electrolyte balance:-
• Iv infusion - indicated in a severely malnourished child with circulatory
collapse (otherwise N/G feeding)
• ½ strength Darrow’s solution with 5% dextrose
• Half normal saline (0.45%) with 5% dextrose
• Give IV fluid 15 ml/kg over 1 hour
MILD INFECTIONS: Cotrimoxazole BD x 5 days
SEVERE INFECTIONS WITH COMPLICATIONS:
• Ampicillin:50mg/kg I/M, I/V 6hr x 2days
• Amoxicillin:15mg/kg oral 8hr x 5 days
• Gentamicin:7.5mg/kg I/M,I/V O.D x 7days
54

DIETARY MANAGEMENT
For 2-3 weeks
• Calorie : 120 -140 cal/kg/day
• Protein :3- 5 gm/kg/day
• Elemental iron: 3-6 mg/kg/day
(ferrous sulphate)
• Vitamin A: 300,000I.U then 1500I.U/day
• Vitamin D: 4000 I.U/day
• Vitamin k: 5mg I/M, I/V once only
• Folic acid: 5 mg on day 1, then 1 mg/day
55

Initial refeeding
• Frequent small feeds of low osmolarity & low lactose
• Oral/NG feeds (never parenteral preparation)
• 100 cal/kg/day
• Continue breast feeding if the child is breast fed.
Nutritional rehabilitation
• Eating well
• Improvement of mental state
• Sits, stands or walks
• Normal temperature
• No vomiting/ diarhea/ edema
• Gaining wt > 5 gm/kg body wt/day x 3 consecutive days
• Infants <24 months fed exclusively on liquid/ semi solid food
• Older children given solid food.
56

FOLLOW UP
▫ Follow up at regular intervals after discharge
▫ Child should be seen after
▫ Every 2 days for 1 wk
▫ Once weekly for 2nd wk
▫ At 15 days interval for 1 - 3 months
▫ Monthly for 3- 6 months
▫ More frequent visits if there is problem
57

WHO PROTOCOL OF PEM
PHASE STABILISATION REHABILITATION
Day1-2 Day2-7+ Week 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients
7. Cautiousfeeding
8. Rebuild tissues
9. Sensorystimulation
10. Preparefor follow-up
noiron with iron
58

Prevention of Malnutrition
• Primary Prevention
▫ Health Education to mothers about good nutrition and food hygiene
through Lady Health Workers
▫ Immunization of children.
▫ Growth monitoring on Growth Charts specially of all children under
3 years of age
• Secondary Prevention
▫ Mass Screening of high risk populations, using simple tools like
(Weight for age) or MUAC.
• Tertiary Prevention
▫ Good Nutritional Care, supplementary feedings and rehabilitation,
▫ counseling of mothers.
59

Interventions Proven to Reduce Malnutrition When Linked with Health Services
(Essential Nutrition Actions)
Vitamin A and
iron
Iodized salt
Breast feeding
Mother’s nutritionComplementary
feeding
Sick/severe
cases
60

NUTRITIONAL PROGRAMMES
1. Balwadi nutrition programme (1970)
Beneficiary group
 Preschool children 3-5years of age.
Services
300kcal and 10gm protein
for 270 days in a year.2.
Special nutrition programme
2. 2. Special nutrition programme
1970 Ministry of Social Welfare.
Operation in urban slums, tribal areas and backward rural areas.
Beneficiary group
• Children below 6 years
 Pregnant and lactating women
Services
 Preschool children : 300kcal and 10-12gm protein
 Pregnant & lactating mothers :500kcal and 25 gm protein
61

3.Integrated child development service(ICDS) scheme
Beneficiaries
 Children < 6 years
 Pregnant & Lactating women
 Women in Reproductive age group
(15-44 yr)
 Adolescent Girls.
4.Mid-day meal programme (1961)
 First started in Tamilnadu.
 Also known as School lunch programme.
Aim
 To provide at least one nourishing meal to school going children per day
(197 5) 62

CONCLUSION
• A proper food including all essential nutrients are very important for normal
growth and development of the body.
• Among these, protein is considered primary or first place as it is building block
of body.
• As for all other body structures, protein nutrition is a basic consideration in the
growth and development of the oral cavity.
• If the diet includes too little or none of the essential amino acids during the
critical period of active growth, permanent structural damage can occur.
• Lack of protein consumption can lead to manifold diseases like Kwashiorkor
and Marasmus,
• Hence protein should be one of the most important constituents of daily diet
and its proper consumption should be given importance.
63

REFERENCES
• Park K.Textbook Of Preventive And Social Medicine. 23rd ed. Bhanot
publishers.2015.
• Peter S. Essentials Of Public Health Dentistry. 5th ed. Arya
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• Palmer CA, Boyd LD. Nutrition diet and oral conditions. In : Norman O
Harris. Primary preventive dentistry. 6th ed. Alexander publisher.p.419-448.
• Darcy J, Hofmann CA. According To Need? Needs Assessment And
Decision Making In Humarian Sector.HPG Report 15, September 2003
• Food Security Analysis Unit- Somalia. Integrated Food Security And
Humanitarian Phase Classification: Technical Manual Version I, Technical
Manual Version Iv.11. May 2006.
64

• Sheetal A, Hiremath VK, Patil AG, Kumar RS. Malnutrition and its oral
outcome - a review. J Clin Diagn Res. 2013 Jan; 7(1): 178–180.
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assessment of a patient at risk. Best Pract Res Clin
Gastroenterol. 2006;20(3):419-39.
• Energy and protein requirement – Report of a joint FAO/WHO/UNO expert
consultation, 2007.
• Psoter WJ, Reid BC, Katz RV. Malnutrition and Dental Caries: A Review of
the Literature. Caries Res. 2005 ; 39(6): 441–47.
• Russell SL, Psoter WJ, Charles GJ, Prophte S, Gebrian B. Protein-energy
malnutrition during early childhood and periodontal disease in the permanent
dentition of Haitian adolescents aged 12–19 years: a retrospective cohort
study. Int J Paediatr Dent. 2010 ;20(3): 222–29.
• Psoter W, Gebrian B, Prophete S, Reid B, Katz R. Effect of early childhood
malnutrition on tooth eruption in Haitian adolescents. Community Dent Oral
Epidemiol. 2008;36(2):179-89.
65

• Abraham E. Nizel, Athena S. Papas, Nutrition in clinical dentistry, 3rd ed.
W.B. Saunders.pg.475-512.
• A.S. Cole, J.E. Eastole Biochemistry and oral biology; 2nd edition;
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66

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