GUIDED BY: PRESENTED BY:DR. RUPINDER KAUR DR. VIRSHALI GUPTA

CONTENTS• INTRODUCTION

• DEFINITION • CLASSIFICATION• LOCAL EFFECT OF DIET ON PERIODONTAL HEALTH• INTERACTION OF IMMUNITY, INFECTION &

NUTRITIONAL STATUS• NUTRITION AND PERIODONTAL HEALTH

INTERRELATIONSHIP• EFFECT OF NUTRITION UPON ORAL

MICROORGANISMS.• HOST NUTRITION AND PLAQUE BIOFILM• CONCLUSION

• REFERENCES

INTRODUCTION• The diet plays primarily a modifying role in the

progression of periodontal disease.

• Nutrient deficiencies, excesses, or imbalances do not initiate periodontal disease nor do mega doses of supplements cure or prevent periodontal disease.

• However, nutrition may alter development, resistance, and/or repair of the periodontium.

DEFINITIONS• DIET : pattern of individual food intake, habit, kind and

amount of food eaten.

• NUTRITION: science of how the body uses food to meet its requirement of growth, repair, development and maintenance.

• NUTRITIONAL STATUS : condition of health as it relates to food and nutrient intake, absorption and utilization.

• MALNUTRITION: impaired health related to nutrient or caloric deficiency, absorption, utilization or excretion.

BALANCED DIETA BALANCED DIET is defined as one which contains a variety of foods in such quantities and proportions that the need for energy, amino acids, vitamins, minerals, fats, carbohydrates and other nutrients is adequately met for maintaining health, vitality and general well being and also makes a small provision for extra nutrients to withstand short duration of leanness. – Park.

A balanced diet has become an accepted means to safeguard a population from nutritional deficiencies.

• In constructing balanced diet, following principles has to be followed---

• Daily requirement of protein should be 15-20 % of daily energy intake.

• Fat requirement should be limited to 20-30 % of daily energy intake.

• Carbohydrates rich in natural fibers should constitute remaining energy intake.

• Requirements of micronutrients should be met.

NUTRIENTS

• Organic and inorganic complexes contained in food.• About 50 different nutrients are normally supplied

through the foods we eat. • Each nutrient has specific functions in the body.• Most natural foods contain more than one nutrient. • may be divided into :

MACRONUTRIENTS MICRONUTRIENTS

proteins, fats, and carbohydrates,

vitamins and minerals

PROTEINS

Complex organic nitrogenous compounds composing of carbon, hydrogen, oxygen, nitrogen and sulphur in varying amounts. Some proteins also contain iron and phosphorous.

Made up off smaller units called amino acids.

• SOURCES• Animal sources– milk, meat, eggs, cheese, fish.• Vegetable sources– pulses, cereals, beans, nuts, oil

seeds.

• DAILY REQUIREMENT: 60-65 gms/day for adults.

•FUNCTIONS:

• Necessary for growth and repair of the body.• Build up new tissues during the period of growth or

pregnancy & lactation.• Required for the formation of digestive enzymes,

hormones, plasma proteins, hemoglobin and vitamins.

• Provide 10-15% of the energy during emergencies e.g., starvation, inadequate food intake.

• Act as buffers helping to maintain the PH of plasma at a constant level.

PROTEIN DEFICIENCY & PERIODONTAL DISEASE

• Degeneration of the connective tissue of the gingival and periodontal ligament.

• Osteoporosis of alveolar bone.• Retardation in the deposition of cementum.• Delayed wound healing.• Atrophy of tongue epithelium. (Chawla & Glickman

1951)

CARBOHYDATES

• DAILY REQUIREMENT: 300-500 gm/day

FUNCTIONS

• Primary function is to provide a source of energy to facilitate body metabolism (1200 kcal).

• Brain and nervous tissue utilize only glucose as energy source (5 grams per hour).

• Muscles including the heart muscles derive energy for contraction from stored glycogen.

• Protein sparing effect- adequate carbohydrate spare protein during metabolism which can be utilized for growth and repair of the body.

• Major components of the ground substance are derived from carbohydrates.

FATS AND OILS

• Fats are solid at 20 deg c. • Called oils if they are liquid at that temperature.• Fats and oils are sources of energy. • Fats yield fatty acids and glycerol on hydrolysis. • Poly unsaturated fatty acids are found in

vegetable oils and saturated fatty acids in animal fats.

• Coconut oil and palm oil contain saturated fatty acids.

• SOURCES:• Animal fats: ghee, butter, milk, cheese, egg,

meat, fish.• Vegetable fats: ground nut, mustard, coconut.• Others: cereals, pulses, nuts, vegetables.

FUNCTIONS

• Provide energy -- 9 kcal every gram.• Serve as vehicle for fat soluble vitamins.• Act as thermal insulators for skin.• Essential fatty acids are required for the body

growth and structural integrity.

• DAILY REQUIREMENTS:• 10-20 gms/day

FAT AND ITS ROLE IN DISEASE

• OBESITY• PHRENODERMA- deficiency of essential fatty

acids in diet is associated with rough and dry skin(toad skin )

• CORONARY HEART DISEASE• CANCER• ATHEROSCLEROSIS• CHRONIC SWELLING OF PAROTID GLANDS due to

disturbances in lipid metabolism.

VITAMINS• Vitamins are essential and biologically active

constituents of a diet.

• The absence or scarcity of certain vitamins has been implicated as being a primary etiological factor in the pathogenesis of periodontal diseases.

• Vitamins are divided into 2 groups:

• FAT SOLUBLE VITAMINS - A, D, E and K• WATER SOLUBLE VITAMINS – B complex and C

VITAMIN A (RETINOL)

VITAMIN A AND PERIODONTAL DISEASE:

Deficiency: marginal gingivitis, gingival bone hypoplasia, pocket formation, alveolar resorption . periodontal disease.

VITAMIN D AND PERIODONTAL DISEASE

• A small number of patients with evidence of rickets develop enamel hypoplasia.

• The enamel does not appear to be weakened, but the rougher surface may facilitate adherence of dental plaque and food residue.

• No studies demonstrate a relationship b/w vit D def and periodontal disease.

VITAMIN C (ASCORBIC ACID)

• DAILY REQUIREMENT: around 30 – 40 mg per day

POSSIBLE ETIOLOGIC FACTORS:• Low levels of ascorbic acid influence the

metabolism of collagen within the periodontium, affecting the ability of tissue to regenerate or repair itself.

• Interferes with the bone formation, leading to loss of periodontal bone.

• def can lead to defect in epithelial barrier.• Megadoses of vit C seem to impair the

bactericidal activity of leukocytes.• An optimal level of ascorbic acid is required to

maintain the integrity of periodontal microvasculature, as well as the vascular response to bac plaque and wound healing.

• Depletion of vit C may interfere with the ecologic equilibrium of bac in plaque and thus inc its pathogenicity.

ASCORBIC ACID AND PERIODONTAL DISEASE

VITAMIN E

ACTION OF THE NUTRIENT: anti oxidant and maintains cell membrane.

• No effect on periodontal tissues.

VITAMIN K

• Daily requirement : about 0.03 mg/kg for the adult. • DEFICIENCY:• Prolonged clotting time and bleeding time.• Gingivitis and periodontal disease.

VITAMIN B1• The earliest symptoms of thiamin deficiency include

constipation, appetite suppression, and nausea as mental depression, peripheral neuropathy, and fatigue.

• Chronic thiamin deficiency leads to more severe neurological symptoms and to cardiovascular and musculature defects (Winston et al. 2000).

• Oral manifestations include: hypersensitivity of oral mucosa, under the tongue or on the palate, and erosion of the oral mucosa.

VITAMIN B2 (RIBOFLAVIN)

• Symptoms associated with riboflavin deficiency include glossitis, seborrhea, angular stomatitis, cheilosis, and photophobia.

ANGULAR STOMATITIS CHEILOSIS

SEBORRHEA

VITAMIN B3 (NIACIN)

• A diet deficient in niacin leads to glossitis, dermatitis, weight loss, diarrhea, depression and dementia.

• The severe symptoms of depression, dermatitis, and diarrhoea are associated with the condition known as pellagra.

• Several physiological conditions (e.g. Hartnup disease and malignant carcinoid syndrome) as well as certain drug therapies (e.g. isoniazid) can lead to niacin deficiency (Carpenter 1983).

FOLIC ACID

• Folate deficiency causes gingival enlargement.• Lack and Thomson, studied the effects of supplementation

with folic acid on pregnancy gingivitis concluded that topical folate application produces significant improvement in gingival health compared to systemic administration and placebo.

TONGUE IN VITAMIN B DEFICIENCY

• Chronic glossitis has been associated with deficiency of most of the B complex vitamins particularly niacin, riboflavin, folic acid.

MAGENTA TONGUE SCARLET TONGUE BEEFY RED TONGUERiboflavin deficiency Niacin deficiency Vitamin B12 deficiency

MINERALS•COPPER:

• A positive correlation has been demonstrated between serum copper and severity of periodontal disease by Freeland et al in 1976.

• Copper is also essential for the development and maturation of connective tissues. (O’Dell et al 1961).

• A copper metalloenzyme contributes to the stabilization of collagen. (Burch et al 1975).

• Freeland et al (1976) suggested that if this enzyme accumulates in blood or if copper is not transferred to the periodontal tissues, then an elevation of serum levels of copper will result.

•ZINC: • Zinc levels are found to decrease with an increase in alveolar

bone resorption. (Frithiof et al 1980).

• Zinc ions can stabilize the cell membranes of PMNs and inhibit the release of lysosomal enzymes.

• The reduction in serum zinc in periodontal disease may stimulate both leucocyte function and the release of potent enzymes, which will enhance the inflammatory process and lead to loss of periodontal collagen.

(Chapvil et al 1977).

• Kilgore et al. (1969) failed to find a relationship between serum levels and periodontal status.

•CALCIUM AND PHOSPHATE:

• Hypocalcaemia and hypophosphataemia that result from dietary imbalance of these ions will produce a nutritional, secondary hyperparathyroidism, which initiates alveolar bone resorption.

• A hypocalcaemic diet can produce inter – radicular alveolar osteoporosis and thinning of individual trabeculae but it will not initiate inflammation, migration of the epithelial attachment, loss of periodontal fibers or resorption of the alveolar margin – Svanberg et al 1973.

LOCAL EFFECT OF DIET ON PERIODONTAL HEALTH

• Vigorous masticatory function is associated with a widening of the PDL. (Collidge 1937)

• Aukes et al (1987) suggest that chewing pattern depends on the texture of the masticated food, hard and tough food requiring more vertical movements and soft food requiring less vertical movement.

INTERACTION OF IMMUNITY, INFECTION AND NUTRITIONAL STATUS

• Nutrients interact with immune cells in the blood streams, lymph nodes and specialized immune system of the gastrointestinal tract.

• Majority of nutrient deficiencies will impair the immune response and predispose the individual to infection.

• Individuals who are undernourished have impaired immune response including abnormality in adaptive immunity , phagocytosis and antibody function.

• Epidemiological and clinical data also suggests that nutritional deficiencies alter immune responses and increase the risk of infection.

(R.K. Chandra. Am J clin Nutrition 1997)

NUTRITION AND PERIODONTAL HEALTH INTERRELATIONSHIP

• Periodontal destruction is a consequence of infection and a nutritional deficiency alone is no longer believed to initiate periodontal disease, it is more likely, that a state of malnutrition will predispose a subject to onset of a periodontal infection, or will modify the rate of progression of established disease.

(Glickman 1964, Ferguson 1969)

Food and nutrition affect periodontal health at 3 levels:Contributing to microbial growth in gingival creviceAffecting the immunological response to bacterial antigenAssisting in the repair of connective tissue at the local site after injury from plaque calculus and so forth

NUTRITION AND EPITHELIAL BARRIER

• Rapid rate of turn over of epithelial cells of gingival sulcus indicates the need of continuous synthesis of DNA, RNA and tissue protein.

• This indicates that sulcular epithelium has high requirement of such nutrients as folic acid and protein which are involved in cell formation.

• At the base of the sulcular epithelium is a narrow basement membrane made up of collagen.

• Since collagen is the major component of basement membrane and ascorbic acid and zinc are important for collagen synthesis.

• This membrane act as a barrier for entrance of toxic material.

THE EFFECT OF NUTRITION UPON ORAL MICROORGANISMS.• Although dietary intake is generally thought of in

terms of sustaining the individual it also source of bacterial nutrients. Composition of the diet may influence the relative distribution of types of microorganism their metabolic activity, their pathogenic potential which in turn affects the occurrence and severity of oral disease.

(Morhant & Fitzgerald 1976)

HOST NUTRITION AND PLAQUE BIOFILMNutrition has both direct and indirect effects on development and composition of plaque biofilm

The biofilm is made up primarily of microorganisms that include bacteria. Fungi, yeasts. and viruses

In addition, 20 to 3O% of the plaque mass is made up of intracellular matrix consisting of organic and inorganic components

The organic components include polysaccharides, proteins, glycoproteins and lipids.

Inorganic components are primarily calcium and phosphorus with trace amounts of sodium, potassium and fluoride

CONCLUSION

 A well balanced diet is required for the normal growth and development of an individual. Any increase or decrease of the nutrients in the long run may lead to devastating situations.

There are nutritional deficiencies that produce changes in the oral cavity. But, there are no nutritional deficiencies that by themselves will cause these changes.

They can only affect the condition of the

periodontium and thereby aggravate the injurious effects of local factors and excessive occlusal forces.

REFERENCES

• Satyanarayana U. Essentials of Biochemistry. • MR Milward, ILC Chapple. THE ROLE OF DIET IN

PERIODONTAL DISEASE. Volume 52 No 3 of 6 May 2013• Vasudevan DM, Sreekumari S. Text Book of Biochemistry.

3rd Ed. • Carranza’s .Clinical Periodontology. 10th ed. • Robert E. Schifferle. Periodontal Disease And Nutrition

Separating The Evidence From Current Fads. Periodontology 2000: vol.50: 2009, 78-89.

• Boyd LD, Theresa ME. Nutrition, infection and periodontal disease. Dent Clin N Am 2003 ;47: 337 -354.