Nutrition and its relevance in orthodontics.pptx

Nutrition is a key factor in orthodontics. It can affect the growth of the patient, be etiological in malocclusion, affect treatment outcome, period of the orthodontic treatment and influence the post treatment stability.

1. Nutrition and its relevance in orthodontics Dr sunil skariya 1 st year PG

2. INTRODUCTION It is often said that maintaining a normal growth pattern is nature's lab test for good health. Growth is influenced by many factors such as heredity, genetic or congenital illness and medications, nutrition, hormones, and psychosocial environment Growth is regulated by a complex interaction of hormonal influences, tissue responsiveness, nutrition, psychosocial and environmental factors which exert a powerful influence on the growing child

3. Nutrition: It is the science of food, the nutrients and other substances there in, their action and interaction, and balance relation to health and disease and the process by which the organism ingests, absorbs, transports, utilities and excretes food substance.

4. Nutrition may be defined as the science of food and its relation to the health. It is concerned primarily with the part played by nutrients in body growth, development, and maintenance. Dietics -the practical application of the principles of nutrition PARK AND PARK, community medicine

5. Malnutrition : malnutrition is a disorder which may be caused by improper or inadequate food intake or by faulty absorption of nutrients, is influences by stress and disease and may be acute or chronic and either reversible or irreversible Recommended dietary allowances (RDA ) :Quantities of the nutrients to be provided in the diet daily for maintaining good health and physical activity of the body. Balanced diet : The diet which contains which different types of food possessing the nutrients in proportions to meet the requirements of the body

6. Relation of nutrition and orthodontics Adequate nutrition is important for proper body growth, it’s development and maintenance. If diet is deficient in any as essentials nutrients then it affects the normal development of the organs. If the deficiency occur in early period of development the damage will be more. Severe and Irreversible.

7. The orthodontic treatment involves dealing with growth and development to the movement of teeth through the medium of surrounding periodontal tissues. So, orthodontic treatment and diet have a strong relationship on each other. This is because diet influences the periodontal status, oral flora, healing potential, immune response and growth of the individual and also the orthodontic treatment affects the intake, quality and consistency of food.

8. Growth and development are affected by the nutritional environment. Diet can affect the process of cell replication and enlargement, thereby influencing tissue and organ growth. Many nutrients affect the enzymatic processes of the body and, therefore, enzymatic regulation is also influenced by the diet. Factors to be considered are The points at which a nutrient deficit occurs during the growth timeline The type of nutrient deficit involved

9. permanent damage from decreased cell numbers for a particular tissue or organ may be the result of inadequate nutrition during a hyperplastic phase of growth. If the same deficit occurred during a hypertrophic phase, however, then it may be compensated for later, in the way of "catch-up" growth, when nutrition is adequate. The critical-period concept, which has been demonstrated in both animal and human models, reveals the importance of nutrition in allowing the body to attain its full growth and development potential.

10. COMPONENTS OF NORMAL OR ADEQUATE DIET The basic composition of diet is highly variable, as it differs from country to country, depending upon the availability of food. Social and cultural habits, economic status, age, sex and physical activity of individual largely influence the intake of diet A balanced diet is defined as the diet that which contains different food stuffs possessing nutrients-carbohydrates, fats, proteins, vitamins and minerals-in proportion to meet the requirements of the body.

11. THE NUTRIENTS Essential nutrients Non essential nutrients Proteins, fats, carbohydrates, vitamins, minerals water Cellulose, hemicelulose, pectins

12. 12 CARBOHYDRATES Main source of energy They should comprise one-fourth of the total diet. Provides 4kcals per gram REFERENCE Satyanarayana u, Chakrapani u. Essentials of biochemistry. 2 nd edition.

13. Carbohydrate excess Sugar consumption at typical levels does not directly contribute to any chronic health or behavioral problems Excessive sugar consumption results in energy imbalance and weight gain 13

14. Carbohydrate deficiency When carbohydrates are eliminated in an effort to lose weight. This can result in an insufficient intake of B vitamins, iron and fiber. 14

15. Carbohydrate effect on oral health Dental caries formation. Increases the volume and rate of plaque formation . Sucrose can lower the ph of dental plaque, hastening the dissolution of the enamel . Tooth erosion 15

16. Leptin Levels in Gingival Crevicular Fluid During Orthodontic Tooth Movement Alparslan Dilsiza ; Nihat Kilic ¸ b; Tugba Aydinc ; F. Nesibe Atesd ; Meltem Zihnic ; Caglar Bulute Angle Orthod . 2010;80:504–508.) Obesity result in high levels of leptin in body Orthodontic tooth movement is decreased in over weight individuals when compared with underweight individuals

17. PROTEINS Fundamental basis of structure and function of life. They are made up of amino acids . There are 22 amino acids- Essential(9) and Non-essential(11). REFERENCE Satyanarayana u, Chakrapani u. Essentials of biochemistry. 2 nd edition. 17

18. 18 Protein excess causes Obesity Effects calcium balance Fluid imbalance Increased water requirement

19. Protein deficiency causes Certain physiological conditions and impaired digestion or absorption cause excessive protein losses and may also precipitate protein energy malnutrition (PEM). PEM is usually accompanied by other nutritional deficiencies. In areas, where quantities of high quality protein and kilocalories are insufficient, PEM is commonly seen.

20. Kwashiorkor protein deficiency with sufficient calorie intake. Age-6 months and 3yrs Normal caloric intake Features -growth failure -wasting of muscles - peripheral edema present -enlarged fatty liver -serum protein low - flag sign

21. Marasmus starvation in infants with a overall lack of calorie. Age-infants under 1 yr of age Inadequate caloric intake Feature- wasting of all tissues - no peripheral edema -no hepatic enlargement - no hair changes -skin is dry and wrinkeled -absent subcutanious fat - monkey like face

22. Effect of proteins on oral health PEM affects the whole body, including every component of the orofacial complex . During tooth development , mild to moderate protein deficiency results in smaller molars , significant delayed eruption and retardation during development of mandible.

23. Smaller salivary glands results in diminished salivary flow ; this saliva is different in its protein composition , amylase and amino-peptidase activity , thereby compromising the immune function of saliva. In malnourished children, secretory IgA levels are depressed which is the predominant immunoglobulin in oral, nasal, intestinal and other mucosal secretions and provide the first line of defense in the oral cavity. Poor nutrition results in delayed eruption and delayed exfoliation of deciduous teeth. Also epithelium , connective tissue and bone may be poorly developed.

24. LAW OF MINIMUM JUSTUS VON LEIBIG (1843) Among the substances nutritionally essential for growth, that one which is furnished to the organism in minimum ,(to the need for growth at the normal rate )will thereby determine the rate of growth ,the organism growing only to the extent that it can increase in size and at the same time conform to the normal composition of its kind. Applicable to proteins but not minerals.

25. Decreased overall growth of jaws Delayed eruption. PEM related to poor peridontal status -Russell SL et al…..

26. LIPIDS/ FATS Lipids may be regarded as organic substances relatively insoluble in water, soluble in organic solvents They are classified as simple, complex, derived and miscellaneous. Fatty acids further classified as saturated, mono-unsaturated and poly-unsaturated.

27. Functions Provide energy. Facilitate absorption of fat soluble vitamins. Provide essential fatty acids. Body fat helps to maintain body temperature. Body fat also protects vital organs such as kidneys and reproductive organs. 27

28. Deficiency states of Fats Essential fatty acid deficiency results in poor growth , dermatitis, lowered resistance to infection and poor reproductive capacity . A patient with inadequate fat intake will be thin , will have dry skin and dull hair and will be sensitive to cold temperatures. 28

29. Excess consumption of Fats The following conditions suggest excess of fat in diet Obesity Diabetes mellitus Hyper- lipidemia Fatty infiltration of liver 29

30. Studies have shown that people with increased lipid content in their diet show lesser incidence of dental caries . Some PUFA have shown to have a positive effect on the health of the periodontal tissue . 30

31. Fats have cariostatic effect Fats reduce dissolution of hydroxyapatite by acid Fats act as a lubricant on the tooth surface and prevent it from penetration of acid Fats delays gastric emptying and enhances absorption of other nutrients

32. Omega 3,6 fatty acids (fish oil, flax seed) in large amounts may mildly to moderately decrease OTM by blocking inflammation pathways. Orthodontics and especially combined orthodontic/ orthognathic treatment may adversely affect eating habits by patients selecting poor food choices. Often a nutritionist may be of help in order to ensure that proper carbohydrates, proteins, lipids, essential vitamins and minerals are taken, and to keep our patients in a healthy state during and after orthodontic treatment. Biological Mechanisms of Tooth Movement by Vinod Krishnan

33. VITAMINS Vitamins are regarded as organic compounds required in the diet in small amounts to perform specific biological functions They act as co-factor in metabolic reactions. Participate in formation of blood cells, hormones , genetic material and nervous system chemicals. They are classified as fat-soluble and water-soluble. 33

34. VITAMIN A Fat-soluble Recommended daily allowance: 420 mcg to 800-1000 mcg. Major roles played in vision and differentiation of epithelial cells. Animal sources (liver, kidney, egg yolk, milk, cheese, butter, fish liver oils) Vegetable sources (yellow and dark green vegetables and fruits, eg.-carrots, spinach, pumpkin, mango, papaya, etc.) 34

35. Deficiency causes Hypoplastic incisors Abnormal calcification of teeth Endochondral bone growth is retarded Crowding of teeth Disturbances in periodontal tissues 35

36. Vitamin A has important roles to play in bone remodeling and collagen metabolism, through its action on cell metabolism. Animal studies have demonstrated that supplementation of vitamin A increases the breaking strength of healing wounds along with enhanced collagen production ( Togari et al., 1991). Retinol deficiency leads to inhibited processes of bone remodeling by decreasing the activity of osteoclasts and bone deformation. However Vitamin A appears not to affect OTM clinically. 36 Biological Mechanisms of Tooth Movement by Vinod Krishnan

37. VITAMIN D Sun-shine vitamin It resembles sterols in structure and functions like a hormone. In countries with good sunlight like India, RDA goes down to 200 IU (5 gms). Main sources include- fatty fish, fish liver oils, egg yolk, etc . 37

38. Deficiency of vitamin D leads to demineralization of bone. The result is rickets in children and osteomalacia in adults Primary defects in rickets are Interference with the mineralisation of bone Deranged endochondral and intra membranous bone growth Rickets occur in growing children from 6 months to 2 years of age

39. Dental Disturbed calcification of teeth, poor enamel formation and especially in the form of dentin Retarded eruption of the deciduous and the permanent teeth Early loss of the deciduous teeth due to caries Jaw bones are thickened and the teeth irregularly arranged Narrow maxilla and high arched palate. The mandible is shortened The mandiblar incisors appear flattened from canine to canine. Vitamin D is of specific importance to children undergoing orthodontic treatment. Vitamin D deficiency can lead to skeletal decalcification, rickets and osteomalacia .

40. Vitamin D3 actions on bone Another important target for D3 is the bone. D3 acts on osteoblasts which activates osteoclasts to resorb Ca ++ from the bone matrix. D3 also stimulates osteocytic osteolysis . In its absence, excess osteoid accumulates from lack of D3 mediated repression of osteoblastic collagen synthesis. Inadequate supply of vitamin D3 results in rickets, a disease of bone deformation . 40

41. Retarded jaw , teeth and condyle development Rickets Maxillary dysplasia Difficulty in closure of facial sutures Osteoporosis of alveolar bone and cemental resorption

42. Iosub Ciur et al . (2016) showed local administration of vitamin D3 seemed to increase the rate of OTM of cuspids in a split‐mouth controlled study. Orthodontic research has demonstrated that a local injection of vitamin D can increase OTM. However, it is more likely that the orthodontist might notice no effect or a mild increase in OTM during patient supplementation of vitamin D systemically. Biological Mechanisms of Tooth Movement by Vinod Krishnan

43. Vitamin E It is also called as Tocopherol . RDA- 3 mg for infants to 10 mg for adults. Vitamin E is found in plant-based oils, nuts, seeds, fruits, and vegetables. Toxicity of vitamin E Among the fat soluble vitamins (A, D, E, K), vitamin E is the least toxic. No toxic effect has been reported even after ingestion of 300 mg/day for 23 years 43

44. Muscle weakness Weakening of periodontal ligament Cracked and red lips Oral ulcers Regularly occurring oral ulcers and lesions due to Vitamin E deficiency makes it hard for the patient to tolerate metal brackets and wires. 44

45. Vitamin K It is the only fat soluble vitamin with specific co-enzyme function. “coagulation vitamin” It is actively involved in both extrinsic and intrinsic systems of coagulation, particularly with prothrombin synthesis. RDA: 1-2 mcg/kg 45

46. Deficiency of Vitamin K leads to increase in blood clotting time Bleeds in oral mucous membrane Bruising Delayed wound healing Low bone density Oral Implications 46

47. VITAMIN C (Ascorbic acid) Versatile vitamin RDA: 35 mg/day in infants 60 mg/day in adults Dietary sources include- Citrus fruits Green vegetables (Spinach, cabbage, etc.) Tomatoes, potatoes (particularly skin) Its deficiency causes scurvy . 47

48. Functions Collagen and bone formation . Iron and hemoglobin metabolism. Tryptophan and tyrosine metabolism. Folic acid metabolism. Peptide hormones and corticosteroid synthesis. Sparing actions on other vitamins. Immunological functions and prevention of chronic diseases. 48

49. Vitamin C on periodontium It has been suggested that ascorbic acid may play a role in periodontal disease by one of the following mechanisms: Low levels of ascorbic acid influence the metabolism of collagen within the periodontium , thereby affecting the ability of the tissue to regenerate and repair itself. Vit C deficiency interferes with bone formation and remodeling of the periodontal bone Its deficiency may aggravate the gingival response to plaque and worsen the edema, enlargement and bleeding 49

50. 50 Normal dietary ingestion of vitamin C is needed for a healthy peridontium during orthodontics. Based on one animal study, vitamin C supplementation possibly increases OTM slightly. However, human trials are needed to evaluate the effect of vitamin C administration clinically. Biological Mechanisms of Tooth Movement by Vinod Krishnan

51. VITAMIN B COMPLEX VITAMIN B1 (THIAMIN) Burning tongue Loss of taste Sensitive oral mucosa VITAMIN B2 (RIBOFLAVIN) Glossitis Angular stomatitis Fissured and red lips It also affects nasolabial fold causing Dermatitis 51 The Vitamin B Complex in Health and Dentition Angle Orthod  (1933) 3 (3): 204–210.

52. Vitamin B3 (Niacin) Dermatitis Diarrhoea Dementia Oral manifestations include: Oral mucosa becomes red and painful Increased salivation Desquamative patches seen on tongue Burning sensation Glossitis Macrocytic anemia Angular chelitis Neural defects in fetus Vitamin B9 ( Folate ) 52

53. Vitamin B12 (Cyanocobalamin) Deficiency may lead to : Oral ulcers Burning sensation Pernicious anaemia Glossitis 53

54. Vitamin B on periodontium Deficiency leads to gingivitis, glossitis and glossodynia, angular chelitis and inflammation of the oral mucosa. Folic acid deficient animals present necrosis of the gingival, periodontal ligament and alveolar bone without inflammation. The absence of inflammation is the result of deficiency induced granulocytopenia. 54

55. MINERALS They are constituents of bones and teeth , giving rigidity to their structure. They play a part in maintaining the natural muscle and nerve reaction to stimulus. They help to maintain the acid- base balance and fluid- electrolyte balance in the body. Minerals combine with organic compounds to make up certain hormones found in the body. 55

56. Classification of minerals 1. Macro- minerals: There are 7 essential elements- Calcium, Magnesium, Sodium, Potassium, Phosphorus, Sulphur and chlorine. 2. Trace elements: Iron, Iodine, Copper, Zinc, Fluorine, Manganese, Nickel, Tin, Cilicon , Cobalt.

57. CALCIUM The “National Osteoporosis Foundation” says “Calcium plays an important role in building stronger,denser bones early in life and keeping bones strong and healthy later in life.” Approximately 99% of the body’s calcium is stored in the bones and teeth . 57

58. Normal value Normal blood calcium level is 9-11 mg/dl. Calcium in plasma is of 2 types - Ionized or diffusible Non-ionized or non-diffusible Calcium in bone - Small quantity of readily exchangeable calcium. Large quantity of stable calcium. 58

59. Sources Rich source- Milk and cheese. Good source- Egg yolk, nuts, fish, beans, etc. RDA: 360 mg/day for infants 800 mg/day for children and adults. 59

60. Functions Formation of bone and teeth . Maintenance of skeletal structures and teeth structure . Maintain normal membrane permeability. Maintain normal heart rhythm. Coagulation of blood. Essential for muscular contractions . Regulate the neuronal activity. 60

61. Absorption of Calcium Calcium is taken in diet as- calcium phosphate, carbonate, tartrate and oxalate. It is actively absorbed in upper intestine and regulated by vitamin D which is produced in liver and kidney in response to decrease plasma concentration.

62. Calcium and Phosphorus metabolism Bone remodelling is the crux of orthodontics. Bone has hydroxyapatite crystals as their inorganic structure. The biomechanical response to altered function and applied loads depends on the metabolic status of the patient. Therefore, favourable calcium and phosphorus metabolism is an important consideration in orthodontics . The role of calcium and phosphorus is most effectively started in post-natal period .

63. Regulation of blood calcium levels This is finely regulated by- 1. Parathormone 2. Vitamin-D 3. Calcitonin These exert their actions on the bone , kidneys and intestine.

64. Parathormone activity increases tooth movement and consequently influences orthodontic tooth movement . Calcitonin inhibits tooth movement and consequently delays orthodontic treatment .

65. Phosphorus Helps in development of bones and teeth Formation of ATP, GTP, Nucleic acid Maintains blood Ph at around 7.4 Deficiency of Phosphorous may lead to : Bone pain Poor bone development Teeth become brittle

66. ACTION OF FLOURIDE Flouride iIs incorporated into hydroxyapatite crystals of bone and teeth- making them more resistant to acid attack. Optimum levels in drinking water – 1ppm Excessive fluoride – fluorosis- mottling of enamel Chronic fluoride toxicity – osteoporosis, osteosclerosis , britttle bones.

67. Gonzales et al . (2011) showed a decreased OTM in rats after administering 10 ppm of fluoride in water for 12 weeks. Karadeniz et al . (2011) found an increase in OTM using high forces during 4 weeks in adult extraction patients who were ingesting high fluoride levels in drinking water (2 ppm). However, no increased tooth movement was seen with low forces and high fluoride when compared with drinking water with low fluoride levels (0.05 ppm). Biological Mechanisms of Tooth Movement by Vinod Krishnan

68. The small amount of fluoride ingested to decrease dental decay may have mild changes in OTM but needs further human study. Biological Mechanisms of Tooth Movement by Vinod Krishnan

69. Copper and manganese These are inorganic nutrients that are required by humans in very small amount (0.001mg-<100mg/day) Copper is important in crosslinking of collagen and elastin, deficiency of which can lead to decreased tensile strength of collagen, and osteoporotic‐like bone lesions. Manganese is involved in several enzyme systems such as metalloenzymes pyruvate carboxylase , in protein and energy metabolism and glucose utilization. This element is implicated in playing a major role in bone remodeling. Biological Mechanisms of Tooth Movement by Vinod Krishnan

70. It was found to be associated with decreased bone resorption, production of labile bone, and decreased synthesis of organic matrix in rats deficient in manganese - Strause et al., 1987).

71. BRACES-FRIENDLY EATING TIPS Stop (Never Eat) Chewing gum, caramel, toffee and all sticky candy, ice cubes, popcorns kernels, hard pretzels, pizza crust, chocolate chips, nuts, carbonated drinks. Halt (Think Before Eat) Chips, chicken wings, raw vegetables, hard fruits when cut into small pieces, loose corns, crusty bread, high sugar foods. Go (Can Eat) steamed vegetables, French fries, yoghurt, pudding, jelly, soup, cereal in milk, cheese, eggs, milk shakes, ice cream without nuts.

72. Conclusion Nutrition is a key factor in orthodontics. It can affect the growth of the patient , be etiological in malocclusion , affect treatment outcome , period of the orthodontic treatment and influence the post treatment stability . Nutrition or nutritional status of the patient can help identify the general state of the patient . Nutrition and orthodontics have an interdependent relationship, hence it is of great importance to the practitioner.