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Preventive Pedodontics
(Part 2)
Diet & Nutrition
Dr. Sucheta Prabhu
Second Year MDS
15/03/18

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 CONTENTS
• Definition
• Balanced diet
• Components of nutrition
• Macro-nutrients
• Vitamins
• Minerals and other micro-nutrients
• Assessment of nutritional status
• Diet counselling
• AAPD recommendations
• Nutrition affecting growth and development of infant to
Adolescent
• Nutrition considerations in children with special health Care
needs
• References

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 Questions asked previously
• Long essays
1. How is vitamin D formed & activated in the
body. How it regulates body calcium
pool.Add a note on hypo and
hypervitaminosis in growing child.
2. Discuss the role of nutrition in dental and
oral health of children.
3. Discuss the role of nutrition in a changing
society and their dental implications.

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 Short essays
1. Vitamin D & Calcium homeostasis
2. Relationship between diet, nutrition & dental caries.
3. Vitamin C
4. Trace elements in dental caries
5.Fat soluble vitamins
6.Dietary recommendations in children with caries risk
7. Balanced diet
8. Stepwise nutritional evaluation of a child
9.Diet diary
10. Diet counselling in rampant caries

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definitions

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 Nizel 1989
It is referred to food Total oral intake of
and drink regularly substance that provide
consumed nourishment and
energy.

DIET

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 Who 1971 The sum of processes
Science of food and concerned in the
its relationship to growth, maintenance
health.It is concerned and repair of the living
primarily with the part body as a whole or of
played by the nutrients its constituent parts.
in body
growth,development
and maintainence

NUTRITION

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 Nizel 1989
Any substance which
when taken into the Anything that is
body of an organism eaten,drunk or
may be used either to absorbed for
supply energy or to maintenance of
build tissue. life,growth and
repair of the tissues

FOOD

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 BMR
• Minimum energy required to carry out
essential life processes.
 BALANCED DIET
• One which supplies all the nutrients in the
right quantity and proportion.

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 RDA
“levels of intake of
Assuming 2400 kcal as 1 unit of energy, RDA is
essential nutrients that
expressed as a proportion of this.(ICMR, Hyderabad)
on a basis of
scientific knowledge are
Holliday and Segar formula adequate to meet the
age of the child known
nutrient needs of all
healthy persons.”
Weech formula American food &
For bedside approximation of expected weight and nutrition board
height
Infant weight = (age in months)+9/2

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Food group guide

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Food guide pyramid

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Food guide pyramid

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FOOD PYRAMID

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COMPONENTS OF DIET

MAJOR NUTRIENTS
Carbohydrates: 65 to 80 per
cent
Proteins :7 to 15 per cent
Fats/lipids:10 to 30 per cent

MICRO NUTRIENTS
RDA < 1mg/day
TRACE NUTRIENTS
Vitamins
Minerals

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 Proteins
24 amino acids of which 9 are essential amino acids
and the remaining are non essential amino acids.

Functions
Body building
Tissue repair & maintenance
Synthesis of antibodies,plasma proteins,Hb,
Hormones,Enzymes

Deficiency:PEM

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 PEM
• First indicator: Underweight child
• Clinical forms: MARASMUS KWASHIORKOR

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 Kwashiorkor

Prof Cicely Williams

‘red boy’ “deposed
child”.

Classic signs:
Grading Stunted growth
Grade I- pedal Hepatomegaly
oedema Anaemia
Grade II- I +facial Oedema
oedema
Grade III – II +
paraspinal and chest
oedema
Grade IV- III +
ascites
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 MARASMUS
Greek word
.
Marasmos
=Wasting • Affected children exhibit extreme wasting.
• Old man appearance to jaws and skin and bones.
• Wasting of brown fat occurs first.
Grading
Grade I: wasting starting in
• Marasmic Kwashiorkar: when marasmic children
axilla and groin. develop oedema.
Grade II: I + wasting in thigh
and buttock region
Grade III: II+ chest and
abdomen
Grade IV: buccal pad of fat

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Tongue: Bright
Proteins & Oral health
red,loss of
papilla,edema

Dry mouth

Fissured lip
Loss of
circumoral
pigmentation Malocclusion In A Pem Child Hypoplasia Of Pem Child

Reduced caries Atrophy of the gingiva

activity(Lack of
Degeneration of cementum and supporting periodontal
substrate)
tissues
Delayed
eruption

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 VITAMINS
• Vitamins and Minerals form the protective
foods and are also called functional foods.
• Vitamins do not yield energy but enable the
body to use other nutrients

Water
Fat soluble
soluble

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 Vitamin A
Importance
Plays an
important
role in Walds
visual cycle Oral Manifestations
1. Keratinising Metaplasia of
epithelium(increased keratin
RDA:
formation)
1500 IU (500 μg)
2. Occlusion of salivary gland
ducts with keratin.
3. Enamel hypoplasia
Deficiency 4. Atypical dentin formation
-Night blindness 5. Epithelial invasion of
Xeropthalmia connective tissues
-Bitots spots 6. Delayed eruption of teeth.
Keratomalacia

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Vitamin D (Anti Rachitic Vitamin)

1,25 –DHCC is active form.

Acts like a hormone.
Calcitriol increases the serum
calcium & phosphorus level by
increasing intestinal absorbtion
& reducing renal excretion

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 Vitamin D (Anti Rachitic Vitamin)

Oral manifestations

1. Delayed eruption of
primary & permanent
teeth.
2. Developmental
anomalies of enamel
Deficiency
Plasma and dentin
Rickets in children
calcitriol 3. Wide predentin zone
Osteomalacia in adults
4. Increased
Pigeon chest is a feature
Alkaline interglobular dentin
Renal rickets (CRF)
phosphatase 5. Elongated pulp horns

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 Vitamin E(Shady lady of nutrition)
• Antioxidant
• Protects liver from toxic Deficiency • Loss of pigmentation
compounds
• Maintains germinal health of • Atrophic degenerative
gonads • Decreased male fertility changes in enamel.
• Protects RBC from hemolysis • Enacephalomalcia • Derangement of
• Nutritional muscular ameloblasts.
• Prevents heart disease by
preventing oxidation of LDL dystrophy

Oral
manifestations

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Vitamin K(Coagulation vitamin)
• Brings about post translational
modification of 2,7,9,10 protein c
protein s factors.
• Deficiency is uncommon may result in
prolonged CT
• Prothrombin levels below 35% results
in bleeding on brushing.
• Below 20% results in spontaneous
bleeding.

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 Vitamin B1(THIAMINE)

Plays important role in metabolism of

carbohydrates, alcohol and branched
chain amino acids.
Deficiency is seen in populations consuming polished rice.
Dry beri beri (peripheral neuritis)
Wet beri beri( Cardiac manifestations)
Cerebral or Wernickes encephalopathy with Kosakoff’s psychosis.

Oral manifestations
Burning tongue
Senstive OMM
Loss of taste 30
 Vitamin B2 (Riboflavin)
• Has a vital role in cellular oxidation.
• It is a cofactor in number of enzymes involved with energy
metabolism.
• Deficiency manifests as angular stomatitis,
cheilosis, atrophic papillae on tongue
• In severe cases, tongue becomes glazed and
smooth due to complete atrophy of papillae.
• Lips: red and shiny because of epithelial
desquamation.

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 Niacin
• Nicotinic acid is essential for metabolism of
carbohydrate, proteins, and fat.
• It is also essential for normal functioning of skin,
intestinal and nervous system.
• Part of NADP co-enzymes.
• Deficiency state is termed PELLAGRA which
leads to dermatitis, diarrhoea and dementia.
• Casal’s necklace and glove and stocking type
dermatitis occurs in the exposed parts..
• Glossitis & Stomatitis

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Pyridoxine
•Plays an important role in the metabolism of
amino acids, fats, and carbohydrates
It keeps up the level of GABA, an
inhibitory neurotransmitter.
• Deficiency:
Peripheral Neuritis
Rashes
Convulsions
•Oral manifestations:
Cheilosis
Glossitis
Angular stomatitis

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Folic acid
Folic acid plays an important role in the synthesis of
nucleic acids and development of Red blood cells in the
bone marrow.

Deficiency leads to megaloblastic anemia,

diarrhoea, and knuckle and periungual pigmentation.

Oral manifestations: Chelitis,glossitis

Preconceptional administration can prevent neural tube

defects in the baby.(RDA : 400mcg in pregnancy)

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Vitamin B12(Cyanocobalamine)
Takes part in synthesis of fatty acids in myelin.
Essential in nucleic acid synthesis.
Deficiency leads to pernicious anemia,peripheral
neuritis,degeneration of spinal cord .

Oral Manifestations:
Sore painful tongue, glossitis and glossodynia
Beefy red tongue
Small shallow ulcers with atrophy of papillae with a
loss of normal muscle tone, called as Hunter’s
glossitis.

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 Vitamin C (Ascorbic Acid)

Functions
Converts proline to
Deficiency
hydroxyproline, which is a Oral manifestations
constituent of collagen. Scurvy
Involved in collagen synthesis Spongy ,sore gums,loose
Pathognomic signs swollen and
and teeth formation. teeth,anemia,swollen
spongy papillae , particularly
joints,haemorrhage.
Increases iron absorption. interdental papillae producing
Acts as antioxidant due to its scurvy buds.
reducing property. “Cork screw hair pattern” In severe cases haemorrhages
“Woody legs” to periodontal membranes
followed by loose teeth.

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 Minerals

Major
Ca,P,Mg

Trace elements Trace elements

with no known
Fe,I,F,Mo,Se,Sn, function
Ni,Si,Mo,Cr,Cu Al,Hg,Pb

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 Calcium
A major element of the body.
• Provides rigidity and strength to
bones and teeth.
• Calcium plays an important role
in blood coagulation, muscle
contraction, myocardial action,
and neuro muscular irritability
Vitamin D
and is responsible for integrity
of various membranes.
Deficiency
Osteomalacia, rickets, fracture
susceptible bones.
Impaired enamel apatite crystals
Calcitonin Parathhormone
formation.
Low blood calcium causes TETANY. 38
 Phosphorus
Second most abundant mineral.

Formation of bone and tooth.

Absorption and transport of nutrients.

Regulates acid – base balance.

energy released due to metabolism of carbohydrates, fats

and proteins is accomplished by phosphates (ADP).

Phosphates play an important role in cell protein

synthesis. It is a part of DNA and RNA.

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 Magnesium
Magnesium is essential for cellular respiration,
functioning chiefly as an activator for numerous
important coenzymes such as carboxylase and Co
enzyme A.

Plays an important role in synthesis of carbohydrates,

Magnesium fats and proteins.
deficiency causes
chronic
malabsorption Helps in regulation of acid base balance of the
syndrome, acute Magnesium is present in enamel and dentin but
diarrhea, renal more in dentin.
failure, weakness,
tremors,convulsions,
hyper excitability.

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 Iron
Iron is necessary for formation of hemoglobin, brain development and
function.

Regulates body temperature and muscle activity.

Increases the production of T CELLS.

It helps in the production of antibodies.

Iron binds oxygen to blood cells, and helps in oxygen transport and cell
respiration.

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 Iron Deficiency
Stages
less than 12 1. Decreased storage of iron
g/dl for a child. without any detectable
abnormalities.
2. Intermediate deficiency of iron
stores getting exhausted
but no evidence of anemia.
3. Overt iron deficiency with
Iron-deficiency anaemia – decreased hemoglobin
hypochromic concentration.
microcytic anemia
characterized by low
serum iron, increased serum
iron-binding
capacity, decreased serum
ferritin, and
decreased marrow iron
stores. 42
 Clinical features of Anemia
• Weakness, fatigue, pallor, tingling of extremities, brittle nails.
• Spoon shaped nails (koilonychias), altered hair growth.

ORAL MANIFESTATIONS

•Inflammation of the tongue, atrophy of tongue.

•Smooth shiny red appearance of tongue.
•Dysphagia, grayish mucous membrane.
•Angular stomatitis.
•Combination of above all features is termed as
• PLUMMER VINSON SYNDROME.

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 Iodine
• Iodine is an integral part of the thyroid
hormones THYROXIN and tri IODO THYRONINE
whose function is to maintain the control of
energy metabolism of the body.

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 Deficiency of Iodine
• Hypothyroidism
• CRETINISM and MYXEDEMA
are pathological conditions
• Skin is dry and coarse
• Metabolism is slow.
• Macroglossia
• Stunted growth, delayed tooth
eruption
• Retarded mental activity

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 Hyperthyroidism
• The excessive activity of the
thyroid gland that is
brought on by a deficiency
of iodine characterized by
increased pulse
rate,temperature and blood
pressure with nervousness ,
irritability,sweating, weight
loss, dyspnea, and
tiredness. Patients may also
develop EXOPTHALMOUS.

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 TRACE ELEMENTS AND DENTAL CARIES

• Aside from fluorine certain trace elements in diet possess

increased resistance or susceptibility to caries.

• Molybdenum(Hungary) • Selenium(Oregon)
• Vanadium(Tank & • Magnesium
Storvick) • Cadmium
• Strontium(works with F)

CARIOSTATIC CARIOGENIC
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Assessment of Nutritional status
1. Clinical examination.

2. Anthropometry.

3. Biochemical evaluation

4. Functional assessment.

5. Assessment of dietary intake.

6. Vital and health statistics

7. Ecological studies.

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 Clinical
examination

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 ANTHROPOMETRICS
Rayner and Rudolf
low weight
• STATURE:CDC guidelines define a height-for
for-age is a
age value less than 5th percentile as short marker of
stature. Failure to
thrive
• CHEST CIRCUMFERENCE:Measured at the
nipple midway between inspiration and
expiration.

Head circumference
35cm at birth
50 cm by 3 yrs

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Laboratory & Biochemical tests

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 Assesment of dietary intake
Weightment of raw foods
Types of diet surveys
- 24 Hour Recall Diet Surveys
- Food Frequency Questionnaire
Weightment of cooked foods
- Diet History
- Food Diary

Oral questionnaire method

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 24 hour dietary recall
• Does not truly represent intake

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 Food Frequency Questionnaire
• List of around 100
items +servings,
• Daily ,monthly
• Errors in noting
serving size
• Long,tedious

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 Diet history

• Interview method
• Establish overall eating
First pattern
• 24 hour recall
part • Household measures of
servings

• Cross check
Second • Food preferences
established
part
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 Food diary
• Amount , frequency,
type of food
consumed
• Period of collection
1-7 days
• Reliable,but difficult
to maintain

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• Diet counseling (Katz 1981)- it is the correction of
diet imbalance that could affect the patients general
health and sometimes is also reflected in his oral
health.

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 Five ‘W’ and one ‘H’ of diet consultation

• WHO may be benefited?

• WHAT are the objectives of diet and nutrition counseling?
• WHY is counseling beneficial?
• WHEN is counseling conducted?
• WHERE should the counseling occur?
• HOW to counsel?

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 DENTAL HEALTH DIET SCORE

• Screening device
• Food score (adequate intake of foods from each of the food
groups) + Nutrient score(consuming foods from especially
recommended groups of ten nutrients) - Sweet score (frequent
ingestion of foods that are overtly sweet)
• 60-100- acceptable- dietary counselling not given unless
requested
• 56 or less indicated and recommended

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 Instruction for calculating a dental
health diet score

Put it all
Sweet together
8 columns of score
food
Circled Check & add
Uncircled nutrient
Record score(56)
Check
(what,when,
how much)

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 FOOD GROUP EVALUATION CHART

Food group RDA NO.OF POINTS

SERVINGS
MILK 3 X8 HIGHEST
POSSIBLE
SCORE 24
MEAT 2 X 12 24
FRUITS AND 1 X6 6
VEGETABLES
OTHERS 2 X6 12
BREAD AND 4 X6 24
CEREALS

FOOD GROUP SCORE 96 IS THE HIGHEST

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 NUTRIENT EVALUATION CHART
Protein and Niacin Vitamin A 7 Iron 7 Folic acid
7
Cheese Apricot margarine Beef Asparagus
Dried beans Broccoli milk Broccoli Broccoli
Dried peas Butter peaches Eggs Cereals
Eggs Cantaloupe squashes Green Kidney
Fish Carrots spinach leafy Liver
Meat Eggs sweet vegetables Spinach yeasts
Milk potato Liver
Nuts Greens Oyster
poultry Liver Sardines
shrimp

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Riboflavin 7 Ascorbic acid 7 Calcium and Zinc 7
phosphorus 7

Broccoli Broccoli Broccoli Beef

Chicken breasts Grapefruit Cheese Liver
Eggs Raspberries Green leafy Lobster
Liver Green peppers vegetables Oysters
Milk Greens Milk shrimp
Mushrooms Oranges Oranges
Pork Strawberries String beans
Okra tomatoes
spinach

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 Step 4-Scoring the sweet

• Classify each sweet into liquid, solid and sticky or slowly dissolving
• For each time the sweet was eaten either at the end of a meal or
between meals(atleast 20 mins apart) place a check in the frequency
column
1. Add the checks
2. (Highest score-35)

FORM FREQUENCY POINTS

liquid 5
Solid and sticky 10
Slowly dissolving 15

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 Step 5

• Now put it all together

• Food group score
• 72-96-excellent
• 64-72-adequate
• 56-64-barely adequate nutrition counselling
• 56 or less-not adequate

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• Sweet score
• 5 or less- excellent
• 10 -good
• 15 or more-watch out zone
• If your sweet score is in “watch out” zone your dentist will
talk about improvements

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 • Separate room • Eye contact
• Indicates respect for • Verbal,Non verbal
privacy • Teaching,motivation

Effective
Interviewing Physical Setting
communication

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 Steps of decision making

Awareness Involvement Habit

Interest Action

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 COUNSELLING APPROACHES

• Role of patient is passive

• Decision made by counselor
DIRECTIVE for patient

• Counselor’s role is merely to

aid the patient
NON-DIRECTIVE • More recommended

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 NIZEL’S RULES
• 4 rules are

Maintain overall Vary slightly from the

nutrition normal diet pattern

Should take into

Should meet body’s consideration
requirements patient’s likes and
dislikes

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For prevention of dental caries general principles
are as follows
Limit no. of eating to three meals per
day

Increase intake of protective food

Decrease carbohydrate

Wean from taste of sweet

Raw fruit and raw vegetable

Fluoridated water

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 The AAPD encourages

Breast-feeding of infants
Educating association
with care to wiping or
between frequent
brushing as the first
consumption of
primary tooth begins to
carbohydrates and caries.
erupt

Educating about health

risks associated with excess Pediatric dentists and other
consumption of simple health care providers who treat
carbohydrates, fat, saturated children to provide dietary and
fat, and sodium. nutrition counseling

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 Furthermore the AAPD encourages

Food and beverage

manufacturers to make School health
education programs and
nutritional content on food services to
food labels more promote nutrition
prominent and programs
“consumer-friendly”.

Pediatric dentists and other

health care providers to
recommend or prescribe
sugar-free medications
whenever possible.

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 Nutritional considerations from
infancy to adolescence
• 0-1 year Milk substitutes:
Regular unmodified cow’s milk is not
suitable:
Insufficient source of vitamin C and iron.
It may cause gastrointestinal bleeding.
Its solute load is too heavy for the infant’s
renal system to handle .
Low-fat milk: should not be used,
Insufficient energy provision.
Lack of essential fatty acids

On guard against dehydration

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 Infant -Toddler
2 years Older than 2 years:
• Reduction in apetite Roughly 30% should come from fat, with no
• Dietary needs for more than 10% from either saturated
proteins and minerals fats or polyunsaturated fats.
remain high. Carbohydrates: 55-60% of calorie
• During first two requirements with no more than 10% from
years of life: 40-50% simple
of energy should sugars.
come from fat.
• Consume 3 regular
meals per day

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 Preschooler
3-6 years

• Physical growth occurs in spurts.

• Fewer calories are required, but relatively
high protein and mineral needs remain.
• Child should be helped to lose ‘baby fat’ by
increasing physical activity rather than by
severely restricting calories.
• Wholesome, nutritious, low sugar snacks
can promote adequate intake of essential
nutrients without adding calories or
promoting dental caries.

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 School going child(6-12 year)
• Decline in food
requirements per unit
body weight( Because
of reduction in growth
rate.)
• Children should be
encouraged to have
breakfast.
• Thus, emphasis on high
nutrient density : High
ratio of nutrients to
calories

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 Adolescence
12-18 years
• Peer pressure & sociocultural influence.
• Weight control
• Development of eating disorders.
• Cigarette smoking to lose weight
• Nutritional requirements are influenced primarily by onset of
puberty and the final growth spurt of childhood.
• Increased needs for energy, protein, minerals and vitamins.
• “Female athlete triad” : American College of Sports Medicine
(ACMS) in 1992.
Seen among adolescent female athletes
• Disordered eating behaviours
• Amenorrhoea
• Osteoporosis

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Special children considerations

Estimated 40%
Factors to be considered
Decreased apetite
Parental overindulgence
,overprotection
Poor oral hygiene & prevention
Long term use of cariogenic
medications
Xerostomia

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 Recommendations(AAPD)

Oral hygiene
Dental home by Antimicrobial
management(2-2-2
age 1 products
rule)

Management of
Remineralising
pain & discomfort,
agents
xerostomia

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 REFERENCES
1. Nutrition in preventive dentistry – Nizel and Papas.277-308
2. Finn SB. Clinical Pedodontics. 4th edn. WB Saunders company,
Philadelphia;2004.
3. Damle SG. Textbook of pediatric dentistry. 4th edn.Arya Medi
Publications, New Delhi.2014.
4. Marwah N. Textbook of pediatric dentistry.3rd edn.
5. Tandon S. Textbook of Pedodontics. 2nd edn. Paras medical
publishers.2009
6. Diet Counselling – A Primordial Level of Prevention of Dental Caries. Dr.
Girish V Chour, Dr. Rashmi G Chour. IOSR .2014;13:64-70.
8. American Association of Pedodontics and American Academy of Pediatric
dentistry . Policy on dietary recommendations for infants children and
adolescents. Reference Manual; 37:no. 6.15-16.

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