Nutrition is very important for a growing child as it not only effects the general health but also the oral health, which are ultimately interrelated. This presentation will help you to understand Nutrition as a Pediatric Dentist.

1. Nutrition In Oral
Health Of Children
Dr. Divya Banu
PG Pediatric and Preventive Dentistry
1

2. CONTENTS
• DEFINITION
• RDA
• COMPONENTS :
1. Macro-nutrients
2. Vitamins
3. Minerals and other micronutrients
• BALANCED DIET
• NUTRITION IN ORAL HEALTH OF CHILDREN
1. Prenatal nutritional counseling
2. Effect on growth and development
3. Malnutrition
• NUTRITION IN CHIDREN WITH SPECIAL HEALTH CARE
NEEDS
• CONCLUSION
• REFERENCES
2

3. DEFINITION
According to Taber’s Medical Dictionary,
1. Diet: What you eat and drink.
2. Nutrition: Internal processing of foods and beverages, such as
ingestion, digestion, absorption, assimilation, distribution, and
elimination (metabolism).
According to Dr. Nizel: Science that deals with the study of nutrients
and foods, their effects on nature and function of organism under
varied conditions of age, health and disease.
According to WHO, Nutrition is the science of food and its relationship
to health.
‘Clinical’ Nutrition refers to macro-nutrient (protein, carbohydrate, and
fats/oils) and micro-nutrient (vitamins, minerals and water)
deficiencies at a cellular and tissue (clinical) level that leads to
organ or gland dysfunctions and eventually to disease.
3

4. RDA: Recommended Dietary
Allowance
• Levels of intake of essential nutrients that on a basis of scientific
knowledge are adequate to meet the known nutrient needs of all
healthy persons – American Food and Nutrition Board
• Published in 1943 during world war II
• 1944 by the Nutrition Advisory Committee of Indian Research
Fund Association (IRFA), now ICMR (in 1960).
REQUIREMENT + SAFETY MARGIN = RECOMMENDED
DIETARY INTAKE
4

5. Methods of Calculation:
1. ICMR Recommendations
2. Coefficient of calorie requirement:
 By National Institue of Nutrition, Hyderabad.
 Assuming 2400 kcal as 1 unit of energy, RDA is
expressed as proportion of this.
 Lower than ICMR recommendations.
3. Holliday and Segar formula:
 Based on age of the child and not present weight.
4. Weech formula:
 For bedside approximation of expected weight and height.
5

6. • ICMR Recommendations:
– Dietary fat should be 20-30% of total daily intake.
– Saturated fats not more than 105 of total energy intake.
– Excessive consumption of refined carbohydrate to be
avoided.
– Energy-rich sources such as fats and alcohols-
consumption to be restricted.
– Salt intake reduced to not more than 5 gm/day.
– Protein 15-20% of daily intake.
– Reduced consumption of colas, ketchups, and other
foods that supply empty calories.
6

7. Recommended dietary allowance for
Indians
7

8. COMPONENTS OF DIET
• MAJOR NUTRIENTS
– Carbohydrates 65-80%
– Proteins 7-15%
– Fats/lipids 10-30%
• MICRO-NUTRIENTS
– VITAMINS
– MINERALS
– TRACE NUTRIENTS
8

9. BALANCED DIET
• Diet which contains different types of foods possessing
the nutrients- carbohydrates, fats, proteins, vitamins,
and minerals, in a proportion to meet the requirements
of the body.
• Highly variable.
• ICMR recommendations:
– Indian balanced diet is composed of cereals, pulses,
vegetables, roots and tubers, fruits, milk and milk products,
fats and oils, sugar and groundnuts.
– Meat, fish and eggs are present in non-vegetarian diets.
– Vegetarians may need additional intake of milk and pulses.
9
According to the UNICEF 2006- Progress for Children World Report, 5.6 million
children who are under the age of 5 years in the developing countries, contribute to
the country’s death rate, because of a high prevalence of malnutrition. This
accounts to 10 children per minute.
Malnutrition and dental caries: a review of the literature.Psoter WJ, Reid BC, Katz
RV, Caries Res. 2005 Nov-Dec; 39(6):441-7

10. FOOD PYRAMID
10

11. 11

12. PROTEINS
• Mediates most of the actions of life.
• Essential for all body tissues: Skin, tendons,
bone matrix, cartilage and connective tissues.
• Formation of hormones, enzymes, antibodies,
acts as chemical messenger within the body.
• Requirement: 40-65 g/day.
• Excess is stored as fat.
• Protein nutrition status assessed by serum
albumin concentration.It should be more than
3.5 g/dl.
• Less than 3.5 g/dl: Mild malnutirion
• Less than 3 g/dl: Severe malnutrition.
Deficiency: Protein Energy
Malnutrition
(Kwashiorkar, Marasmus)
12
Psoter reported a delayed tooth exfoliation and emergence of
the permanent teeth between 11 and 13 years of age when
malnutrition was experienced between birth and 5 years of age.

13. • AMINO ACIDS:
• Building blocks of proteins.
• Total 24, out of which 8 are essential as they cannot
be synthesized by the human body.
• Glutamine- anti-stress nutrient.
• Tryptophan- Nature’s sleeping pill: Precursor of
serotonin
• Proviatmin B3- Precursor of niacin (60 mg
tryptophan = 1 mg niacin)
13

14. KWASHIORKAR
• Discovered by Prof Cicely Williams in 1933 from Gold Coast.
• Name derived from Ga language of Ghana meaning ‘RED BOY’
due to characteristic pigmentary changes.
• Later on, termed as deposed child.
• Protein deficiency during 1-5 years.
• Classic signs:
1. Stunted growth
2. Hepatomegaly
3. Anemia
4. Oedema
• Grading:
I- Pedal edema
II- I + Facial edema
III- II + Paraspinal and chest edema
IV- III+ Ascites
14

15. MARASMUS
• Derived from Greek word Marasmus, which
means ‘wasting’.
• Old man appearance to jaws, skin, and body.
• Protein deficiency in infancy 0-1 year
• Grading:
I – Wasting starting in axilla and groin.
II- I + Wasting in thigh and buttock
region
III- II + Chest and abdomen
IV- Buccal pad of fat
• Wasting of brown fat occurs first in the body.
• When Marasmic children develop edema-
Marasmic Kwashiorkar
15

16. 16

17. ORAL MANIFESTATIONS
• Bright reddening of tongue.
• Loss of papillae: erythematus and smooth dorsum of tongue.
• Kwashiorkar: Edema of tongue with scalloping around the lateral
margins due to indentation of 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.
17

18. CARBOHYDRATES
• Found in cereals, fruits and vegetables.
• Essential in diet for glucose and cellulose (major sources of energy).
• Energy supplied: 4 kcal/g
• Essential for oxidation of fats.
• Required for synthesis of certain non-essential amino acids.
• Excess: obesity, CVS disease, hyperglycemia.
• Deficiency: Weight loss, can affect the intake of B vitamins, iron, fiber.
• Associated with dental caries.
18

19. LIPIDS
• Fats: Insulate against the cold, cushion organs, slows
digestion, carry fat soluble vitamins A, D, E, K, And improves
the taste of food.
• Types:
SATURATED FATS
1.From animal foods like meat,
poultry, butter and whole milk.
2. Increase risk of CVS disease ,
cancer, and obesity.
UNSATURATED FATS
1. Mono and polyunsaturated fats
are heart healthyfats.
2. Essential fatty acids-
polyunsaturated fatty acids-
called as queen of vitamins-
later designated as vitamin F.
19

20. 20

21. METABOLISM
21

22. VITAMINS
• Vitamins and minerals- Protective foods; Functional foods.
• RDA < 100 mg/day were traditionally called micronutrients.
VITAMINS
FAT
SOLUBLE
A,D,E,K
WATER
SOLUBLE
B complex
and C 22

23. VITAMIN A
• Is widely distributed in animal and plant foods.
• Animals –pre-formed – Retinol.
• Plants – pro-formed – carotene.
• Dietary sources of vitamin A:
• Pre-form Vitamin A : Meat, liver & dairy products Pro-
form Vitamin A : Yellow, red and green vegetables and
fruits.
• Recommended dietary allowance :
– Men and women – 600 mcg per day
– Pregnancy and lactation – 950 mcg per day
– Infants – 350 mcg per day
– Children – 600 mcg per day
23

24. • Physiological Functions of Vitamin A:
– Vision
– Epithelial cell integrity
– Reproduction
– Resistance to infectious disease
– Bone remodeling
– Growth
• The signs of vitamin A deficiency:
– Ocular:
• Night blindness
• Conjunctival xerosis
• Bitot’s spot
• Corneal xerosis
• Keratomalacia
– Extra ocular:
• Retarded growth
• Skin disorders
• Effect on reproductive organs
• Effect on bone
24

25. • Hypervitaminosis A:
– If the daily dose > 30,000 mcg
– Toxic symptoms:-
• Painful joint
• Thickening of long bones
• Anorexia
• Low grade fever
• Rashes
• Irregular menstruation
• Fatigue
• Loss of hair
25

26. 26

27. Oral Manifestations Of Vitamin A
Deficiency
• Teeth: Defective enamel formation.
• Hypoplasia of teeth- since enamel forming cells are disturbed.
• Dentin- lacks normal tubular structure
• Caries- increased risk.
• Eruption- delayed in prolonged deficiency.
• Alveolar bone- retarded rate of formation.
• Gingiva- hyperplastic gingival epithelium, keratinization in
prolonged deficiency.
• Periodontal disease- Easy invasion of bacteria.
• Salivary gland- typical keratinizing metaplasia.
27

28. TREATMENT
• Prophylaxis:
– 9 months to 3 years: 5 megadoses of vitamin A concentrate
at 6 months interval.
• Preparations:
– Aquasol A : 50,000 IU/capsule, inj 50,000 IU/ml.
– Arovit: 50,000 IU/tab, drops
• Depending upon deficiency symptoms, dose of
7,500 to 15,000 mcg per day for one month.
• Hypervitaminosis: restriction of diet.
28

29. VITAMIN D
• Sunshine vitamin
• Available in 2 forms: D3- Cholecalciferol and
D2 Calciferol
• Sources: Fatty fish, fish liver, egg yolk, liver
oil, sunlight, etc.
• RDA: 400 IU of cholecalciferol (In countries
with good sunlight like India, RDA is 200 IU
per day).
29

30. • Active form (Calcitriol) promotes bone resorption and mineralization and
intestinal calcium and phosphorus absorption.
• Pre-term babies not exposed to sunlight, babies of mothers with severe
deficiency, those with fat malabsorption are prone to develop deficiency.
• Preterm babies: Deficiency manifest as early as 8 weeks of age, leading to
rickets.
• TREATMENT: 6 lakhs IU of Vitamin D oral or IM.
• HYERVITAMINOSIS: GI upset, hypotonia, polyuria, polydypsia,
hypercalcemia, hypercalciuria, metastatic calcification.
30

31. RICKETS
• Derived from old English word “twist” or “wrick”
• Large head
• Wide open anterior fontanelle
• Frontal, parietal and occipital bossing
• Pigeon chest
• Rachitic rosaries
• Harrison’s sulcus
• Knock knee
• Lateral bowing of tibia
• Widening of wrist
• Double malleoli
PREPARATIONS:
•Calcirol sachets 60000 IU/sachet
•Arachitol 3 lakhs and 6 lakhs IU/ml
•Alphadol tablet 0.25 microgram
•Adexoln A&D capsule A 5000 IU, D
400 IU
31

32. • ORAL MANIFESTATIONS:
1. Enamel and dentin developmental
abnormalities.
2. Delayed eruption
3. Malaligned teeth
4. Higher caries index
5. Enamel: Hypoplastic, mottled, yellow gray.
6. Large pulp chambers
7. High pulp horns
8. Delayed closure of root apices.
9. Soft osteoid leading to displacement of teeth
and hence, malocclusion.
32

33. OSTEOMALACIA
• Adult rickets.
• Only flat bones and diaphyses of long bones are
affected.
• Common in post-menopausal women with a history
of low dietary calcium intake and low exposure to
UV light.
• Severe periodontitis in a few cases.
33

34. VITAMIN D RESISTANT
RICKETS
• X-linked trait with some defect in reabsorption.
• Oral manifestations:
1. Abnormal, wide pulp chambers with faulty calcifications and marked
interglobular space in dentin.
2. Elongated pulp horns reaching DEJ often.
3. Periapical involvement of a grossly norml appearing primary or
permanent tooth followed by development of multiple gingival
fistulae.
4. Abnormal cementum formation.
34

35. VITAMIN E
• Protection of tissues from oxidation
damage.
• Formation of RBC and use of
vitamin K.
• Promotes healthy circulatory
system function.
• ‘Shady lady of nutrition’ as still its
applications are to be known.
• Vitamin E supplementataion is
required in fat malabsorption and
cholestasis, in premature infants.
• 15-25 IU/day given in such cases.
• Excess- necrotizing enterocolitis in
the new born.
RDA: 5-15 IU (5-15 mg)/
day
Preparations:
•Evion
•Tocofer
•E cod 100 mg, 200 mg,
400 mg pearls
•Evion drops 50 mg/ml
35

36. • ORAL MANIFESTATIONS OF VITAMIN E DEFICIENCY
1. Loss of pigmentation
2. Atrophic degenerative changes in enamel.
36

37. VITAMIN K
• Synthesized by intestinal flora.
• Participates in oxidative phosphorylation.
• Increases concentration of prothrombin (II), proconvertin (VII), plasma
thromboplastin component (IX) and stuwart-prower factor (X).
• K1 (phytomenadione)- Naturally occuring vitamin K
• K2 (menaquinones) is of bacterial origin.
• Deficiency: hemorrhagic disease of new born (HDN). It is commonly seen
in breast-fed babies due to delayed colonization of gut and lower
concentration of vitamin K in breast milk (15 microgram%) compared to
cow’s milk (60 microgram%).
• Treatment: 2-5 mg vit K. In severe cases, blood transfusion is needed.
ORAL MANIFESTATIONS:
Gingival bleeding.
PREPARATIONS:
Menadione
Sodium 10
mg/ampule 37

38. VITAMIN B1 (Aneurin/Thiamine)
• Discovered by Eijkman in 1897.
• Metabolism of carbohydrates, alcohol and branched
chain amino acids.
• RDA: 0.5-1.5 mg/day (1mg/1000 cal)
• Deficiency: Beri-beri and wernickle-korsakoff
syndrome. (WKS)
1. Wet beri-beri manifests as high output cardiac failure.
2. Dry beri-beri presents with neuritis.
3. Infantile beri-beri presents with aphonia and combined
features of dry and wet types.
4. Treatment: Thiamine
38

39. 39
MAGENTA COLORED
TONGUE
ATROPHY OF
FILIFORM PAPILLAE

40. VITAMIN B3 (Niacin/ Nature’s
vallum)
• A part of NADP co-enzymes.
• Tryptophan amino acid is the precursor: Nature’s
sleeping pill.
• RDA: 5-15 mg/day.
• 70 mg protein provides 12 mg of Niacin.
• Deficiency: Pellagra – Photosensitive dermatitis,
diarrhea and dementia.
• Casal’s necklace and glove and stocking type
dermatitis occurs in exposed parts.
40

41. PELLAGRA
41
ATROPHIC GLOSSITIS

42. VITAMIN B6
• Pyridoxal , pyridoxamine and phosphates have B6 activity.
• It keeps up the level of GABA- an inhibitory neurotransmitter.
• RDA: 0.5-1.5 mg/day
• Beneficial in homocystinuria, hyperoxaluria, sideroblastic
anemia and radiation sickness.
• Deficiency: Neuritis, anemia, convulsions.
• Oral manifestations: cheilosis, glossitis, angular stomatitis,
halitosis (due to tooth decay).
42

43. VITAMIN B9
• Also known as vitamin M.
• Sources: Beans, legumes, citrus fruits, whole-grains, dark
green leafy vegetables, poultry, pork, shell fish and liver.
• Important in DNA synthesis.
• RDA: 50-150 microgram/day
• Deficiency: Megaloblastic anemia, diarrhea, knuckle and
periungual pigmentation.
• Preconceptional administration can prevent neural tube defects
in the baby.
43

44. VITAMIN B12
• Cyanocobalamine /Red vitamin: Contains cobalt in the
molecule (only vitamin containing mineral).
• Present only in animal foods, fish and milk. Though the
colonic bacteria can synthesize it, it is not bio-available.
• Absorbed from ileum under the influence of intrinsic factor
secreted from the stomach.
• Takes part in synthesis of fatty acids in myelin.
• RDA: 0.5- 1.5 microgram/day.
• Deficiency: pernicious anemia, and subacute combined
degeneration of spinal cord. A few more signs include weight
loss, pallor, confusion, and hypotension.
44

45. • Oral Manifestations:
1. Sore, painful tongue, glossitis, glossodynia.
2. Beefy red tongue.
3. Small shallow ulcers with trophy of papillae with
a loss of normal muscle tone- HUNTER’s
GLOSSITIS.
45
APHTHOUS ULCERTION

46. VITAMIN B COMPLEX
Vitamin B5: Pantothenic acid
 Described by Dr. Gopalan.
 Deficiency: Dermatitis, hallucination
• Preparations:
 Neurobion
 Polybion
 Becosules
 Berocin C
46

47. VITAMIN C
• Converts proline to hydroxyproline (constituent of collagen).
• Collagen synthesis and teeth formation.
• Increases iron absorption.
• Antioxidant due to its reducing property.
• Deficiency: Scurvy, defective bone growth, bleeding gums, delayed wound
healing, subperiosteal bleeding and calcification.
• Scorbutic rosaries are tender and angulated.
• White line of Frankel: A dense white line at metaphyses due to excessive
calcification.
• Preparations:
– Celin 100 mg, 500 mg.
– Suckcee, Limcee
47
Inflamed Bleeding Gingivae

48. 48

49. • Oral Manifestations:
– Mainly affects gingival and periodontal region.
– Interdental and marginal gingiva are bright red,
swollen, smooth, shiny surface producing SCURVY
BUD appearance.
– Fully developed lesion: gingiva becomes boggy,
ulcerated and bleeds easily.
– Fetid breath.
49

50. 50

51. 51

52. 52

53. 53

54. DIETARY
GUIDELINES
54

55. INFANT AND TODDLER (0 to 2
years)
• 0-6 months: Most rapid growth.
• AAP recommends human milk as the sole source of nutrition for first six
months with continued intake for the first year and as long as desired
thereafter.
• Breastfeeding:
– Advantageous to the child and mother.
• Adequacy of milk intake:
– Assessed by voiding and stool patterns.
– Well hydrated infant voids 6-8 times a day.
– By 5-7 days: loose yellow stools passed atleast 4 times a day.
– Most objective indicator: Rate of weight gain
1. Total weight loss should not exceed 7% after birth.
2. Birth weight should be regained by 10 days.
55

56. Serum bilirubin:
– Increased in breastfed infants than formula-fed.
– Feeding frequency during the first three days of life are
inversely related to the level of bilirubin.
Breast-milk jaundice (1-2 weeks):
– After first week of life, serum bilirubin is elevated due
to some unknown factor in the milk that increases
intestinal absorption of bilirubin.
56

57. • Milk substitutes:
– Regular unmodified cow’s milk not suitable.
– Low fat milk should not be used.
• Cases of severe nutrient deficiencies resulting in kwashiorkor and rickets
have been reported from regular consumption of non-fortified rice, soy
based health food milk alternatives.
• Solid diet:
– No nutritional need for introducing before 6 months of age.
– Earlier use can cause allergies or increased risk of obesity.
– Egg yolk can be safely given in weaning diet with no elevation in plasma
cholesterol level or egg allergies.
• Infant must excrete more water than adults to excrete comparable waste.
Dehydration should be noted.
• Supplements:
– Vitamin D, Iron, Fluoride.
57

58. • 2nd Year Of Life To Toddler:
– Reduction in appetite: NORMAL.
– High demand for proteins and minerals.
• 40-50% energy should come from fat during first two
years of life.
• Older than 2 years:
– Approximately 30% should come from fat, with no more
than 10% from either saturated fats or polyunsaturated fats.
– Carbohydrates: 55-60% of calorie requirements with no
more than 10% from simple sugars.
– RDA of dietary fiber equals 5 plus the age of the child.
58

59. DIET GUIDELINES FOR CHILDREN
OLDER THAN 2 YEARS
• GENERAL REOMMENDATIONS:
– Consume 3 regular meals daily with healthful snacks (2-3/day) according
to appetite, activity and growth needs.
– Include a variety of foods with abundant vegetables and fruits.
• KEY NUTRIENTS:
– Carbohydrates:
• Complex >/= 55-60% of daily calories, half of all grains should b whole grain,
high-fibre foods.
• Simple sugars: <10% daily calories.
– FATS:
• <30% of total calories should come from dietary fat.
• Saturated and polyunsaturated fats: <10% total calories each.
• Monounsaturated fats: atleast <10% total calories.
• Lean cuts of meat, fish, low-fat dairy products, vegetable oils.
• Cholesterol intake: 100mg/1000kcal/day (max 300 mg/day).
• Severe fat restriction (<= 15-20% of total calories) should be avoided: can lead
to growth failure. 59

60. PRESCHOOLER (3-6 YEARS)
• Growth spurts for physical growth.
• Less calories, more protein and minerals are needed.
• Baby fat lost by increasing physical activity and not by severe
restriction of calories.
• Dental considerations:
– Wholesome, nutritious, low sugar snacks can promote
adequate intake of essential nutrients without adding
calories or promoting dental caries.
60

61. SCHOOL-AGED CHILDREN (6-12
YEARS)
• Decline in food requirements per unit body weight (because of
reduction in growth rate).
• High requirement of nutrients.
• Diet counseling: Children encouraged to have breakfast and
healthy snacks.
61

62. ADOLESCENT (12-18 YEARS)
• Nutritional requirements are influenced primarily by onset
of puberty and the final growth spurt of childhood.
• Increased need for energy, protein, minerals and vitamins.
• Adolescent females:
– Consume less food than boys.
– Disordered eating behaviors.
– Social and peer pressure.
– Female athlete triad: ACMS in 1992:
• Seen among female adolescent athletes.
• Disordered eating behaviors.
• Amenorrhea.
62

63. NUTRITION
ASSESSMENT AND
SCREENING
63

64. NUTRITION SCREENING
• Brief assessment of adequacy of usual dietary
intake.
• Food frequency questionnaires, 24-hour
recalls, food records, diaries for adolescents.
64

65. 65

66. 66

67. ANTHROPOMETRICS FOR
NUTRITION ASSESSMENT
• Weight
• Stature
• Others
– Head circumference (<36 months)
– Chest circumference
67

68. • WEIGHT
– Defined as heaviness of the body.
– Measured using a balanced beam scale.
– Indicator of both acute and chronic nutritional
status.
– Typically described with age and height.
– Weight-for-age value compares the child’s weight
to a peer reference group.
– Toddlers and older children should be weighed
with minimal clothing on a standing scale to 0.1
kg.
– Special needs: May need a lift scale or wheel
chair scale.
– Rayner and Rudolf suggested that a low weight-
for-age is a marker of failure to thrive.
68

69. • ANTHROPOMETRY: PRESCRIBED BY
WHO/ICMR
69

70. • STATURE
– Under 2 years, stature is defined as recumbent length and is
assessed using a length board with a stationary head and
adjustable foot.
– After 2 years of age, it is measured in a standing position
with stadiometer or with the heels, buttocks and head flat
against a tape measure embedded in a wall.
– Both compare the child’s height to a peer reference group.
– A value less than 5th or 10th percentile of a peer reference
group has been used to screen for PEM.
– CDC guidelines: height-for-age value less than 5th
percentile- short stature.
70

71. STADIOMETER
71

72. HEAD CIRCUMFERENCE
AGE HEAD CIRCUMFERENCE
At birth 35 cm
3 months 40 cm
6 months 43 cm
9 months 45 cm
1 year 47 cm
2 years 49 cm
3 years 50 cm
Approximate increase in 2 cm/month in the first three months, 1
cm/month in the next three months and 0.5 cm/month in the next
6 months.
72

73. CHEST CIRCUMFERENCE
• Measured at the nipple midway between
inspiration and expiration.
• At birth, head circumference is greater than
chest circumference but equalizes by 1 year of
age.
• Thereafter, chest circumference is more than
head circumference.
73

74. WEIGHT-FOR-HEIGHT
RATIO/BMI
1. Anthropometric measurement measuring weight relative to the height.
2. BMI= mass (kg) / (height (m))2
3. BMI percentile for <20 years of age.
BMI comparison with typical values for other children of same age and
gender.
4. CDC guidelines:
4. Increased prevalence of obesity in developed and developing nations.
BMI Percentile Health (Nutritional ) Status
<5 Underweight
5-85 Normal
85-95 Overweight
>95 Obese
74

75. NUTRITIONAL SCREENING
• Begins with an accurate measurement of height and weight and
calculation of BMI.
• These data should be plotted on age and gender appropriate growth
charts to determine the appropriateness of weight for height and the
presence of potential growth disorders.
75

76. 76

77. WHO SPECIFIC GROWTH
CHARTS
• Road to health chart.
• By David Morley, later modified by WHO.
• Infants, birth to 36 months:
1. Length-for-age and weight-for-age.
2. Head circumference-for-age and weight-for-length
• Children and adolescents, 2 to 20 years
3. Stature-for-age and weight-for-age
4. BMI-for-age
• Preschoolers, 2 to 5 years
5. Weight-for-stature
77
WHO Chart Theory: Optimal nutrition + optimal
environment + optimal care = optimal growth
India adopted new WHO child growth standards
(2006) in Feb 2009

78. 78

79. 79

80. 80

81. 81

82. Interpretation in Growth Chart
82

83. NUTRITION ASSESSMENT
• Key indicators of nutrition risk of adolescents can be based on:
– Food choices
– Food resources
– Physical activity
– Eating behaviors
– Weight and body image
– Growth
– Medical conditions
– Lifestyle
83

84. 84

85. 85

86. 86

87. 87

88. 88

89. 89

90. 90

91. NUTRITION RELATED
PEDIATRIC DISORDERS
• Tooth development
• Dental caries
• Obesity
• Disordered eating
• Xerostomia
• Gingival diseases
• Dental erosion
91

92. 92

93. • FAILURE TO THRIVE:
– Refers to condition when the physical growth of a child is less
than expected, usually below the third or fifth centile, or when a
child has significant loss of weight in a short time.
– Classification:
• Organic: (30%) with a known medical condition.
• Non-organic or psychosocial: (70%) without any known medical
condition; due to psychosocial neglect. Also called as environmental
FTT because of poverty and accidental errors.
• Mixed type.
– FTT and PEM are closely related. FTT is for investigation,
whereas PEM is the diagnosis.
– Causes for organic type:
• GIT
• Renal
• Neurologic
• CVS
• Respiratory
• Endocrine
• Infections
• Miscellaneous
93

94. • Clinical features:
– Developmental delay.
– Growth retardation.
– Mental changes.
– Behavioral problems.
– Soft neurologic signs.
• Management:
– Hospitalization
– Dietary support
– Counseling
94

95. OBESITY
• CDC guidelines prefers terms at risk for overweight and
overweight.
• Weight-for-age values >90th to 95th percentile may be used to
screen for overweight. However, weight-for-height
relationship provides a much more valuable assessment of
body fat.
• Age specific BMI from 85th to less than 95th percentile is
indicative of at risk for overweight.
• BMI greater than 95th percentile is indicative of overweight.
95

96. DISORDERED EATING
• Psychosocial dwarfism:
– Deceleration of linear growth and characteristic behavior disturbances
including bizarre eating patterns and sleeping habits.
– Children do not demonstrate expected growth in response to
appropriate food intake in their home environment secondary to neglect
and/or severely dysfunctional caregiver-child interactions.
– Typical presentation occurs at 18-48 months.
• Rumination:
– Voluntary regurgitation, chewing and reswallowing of stomach
contents.
– Self-stimulatory behavior.
– Typically associated with psychosocial issues and/or mental retardation.
– Age of onset is typically 3-12 months but occurs later in individuals
with mental retardation.
– Children are at risk for enamel erosion.
96

97. • Pica:
– Pathologic craving for a food item or substance not
commonly regarded as food.
– Examples: Starch, ice, dirt, paper.
– Risk of direct toxicity from the desired substance and lead
poisoning from incidental exposure.
97

98. EROSION
• Dental erosion is the main pathological factor leading to tooth wear,
along with abrasion and attrition .
• Changes in lifestyle and the increasing availability of acidic
beverages and juices.
• A wide range of acidic food substances has been implicated by
varying degrees of scientific evidence, including citrus fruit juices
and other acidic fruit juices, acidic carbonated beverages, acidic
uncarbonated beverages, acidic sport drinks, wines, cider, acidic
herbal teas, citrus fruits and other acidic fruits and berries, salad
dressing, vinegar conserves and acidic fruit-flavored candies
98

99. • The erosive potential of dietary sources of acids, namely citric
(citrus juices), phosphoric (soft drinks), malic (apple juice),
tartaric (grape juice and wine), acetic (vinegar) and other acids
found in beverages and foods has been shown in many in vitro,
in situ and in vivo studies.
• Chemical properties (pH, total acid content ,calcium,
phosphate and fluoride content, and adhesiveness).
• Biological factors (salivary flow rate, buffering capacity and
composition, pellicle formation, tooth composition, and dental
and soft-tissue anatomy).
• Behavioral (lifestyle) factors (eating and drinking habits,
especially the frequency, duration and timing of exposure). 99

100. DIET AND DENTAL CARIES
• SUCROSE is the arch criminal
100

101. • CARIOGENIC FOODS:
– Promote formation of caries.
– Fermentable carbohydrates (those that can be broken down
by salivary amylase).
– Result in lower mouth pH.
– Include crackers, chips, pretzels, cereals, breads, fruits,
sugars, sweets, desserts.
101

102. • CARIOSTATIC FOODS:
– Foods that do not contribute to decay.
– Do not cause a drop in salivary pH.
– Includes proteins, fat, fish, egg, meat, poultry, vegetables,
sugarless gums.
102

103. • ANTICARIOGENIC FOODS
– Prevent plaque from recognizing an acidogenic food when
it is eaten first.
– May increase salivation or have antimicrobial activity.
– Includes Xylitol (sweetener), cheese.
103

104. NUTRITIONAL
CONSIDERATIONS FOR
SPECIAL CHILDREN
• Chronic diseases can pose increased risks to the
nutritional status of infants and children.
• It is estimated that as many as 40% of SHCN children
are at risk for nutrition problems.
• Decreased appetite
• Frequency of food intake.
• Parental over-indulgence.
• Poor oral hygiene.
104

105. • Long-term use of cariogenic medications:
– Children’s Tylenol Suspension contains 2g of high
fructose per teaspoon (5ml).
– Amoxicillin contains more than 5g of sucrose in
the daily dose of 15 ml.
– Digoxin syrup contains 30% sucrose and
Chlorthiazide and Spironolactone contain
approximately 20% sucrose.
105

106. XEROSTOMIA
• Symptom of various medical conditions, a side-effect
of radiation to the head and neck or a wide variety of
medications that may or may not be associated with
decreased salivary gland function.
• Most of the drugs used in ADHD patients can cause
xerostomia.
• Associated with slower clearance of foods from the oral
cavity.
• This allows fermentable carbohydrates to stay in
contact with plaque longer and hence increases acid
production and enhances enamel demineralization.
106

107. • DENTAL DIETARY GUIDANCE OF CHILDREN OF VARIOUS AGE
GROUPS.
I. Prenatal Growth.
• Poor Prenatal nutrition
• Children with hypoplastic enamel
• Mothers with active caries.
II. Birth to 1 year.
• Breast milk and infant formula.
• ≤ 6 months of age.
• At age of 6 months.
Guidance for promoting good nutrition and decreasing caries risk in infants
• Discourage the behavior of placing a child to bed with bottle.
• Prohibit dipping pacifiers in sugar, honey or syrup.
• Discourage a child from carrying and continuously drinking from bottle or sippy
cup.
• Introduce cup to begin weaning from bottle.
• Reduce use of beverages, other than breast milk, infant formula or water.
• Follow infant feeding guidelines to ensure optimal nutrition.
107

108. III. 1-2 Years.
• Between the age of 12-30 months
Guidance for promoting good nutrition and decreasing caries in
toddlers.
• Limit juices or sugar-containing drink in take to 4oz/day and only in
cup.
• Restrict cariogenic foods to meal times.
• Establish routine meal with family members eating together.
• Stimulate a child’s appetite at meal time by reducing between meal
snacking.
IV. 2-5 Years.
• Good dietary habits with regular meal pattern.
• Non-cariogenic snacks should be provided at home and lunch boxes.
• Discourage Sugar containing snacks.
• Promoting nutrition ,non-cariogenic food for meals.
• Strongly discourage the consumption of slowly eaten, sugar-containing
foods.
108

109. ORAL HEALTH
RECOMMENDATIONS
• Oral Health Management:
– AAPD recommends establishing a dental home by one year of age.
• Oral Hygiene Management:
– 2-2-2 rule for brushing of teeth as soon as the tooth erupt. A soft-nylon
bristle manual or electric toothbrush should be used for 2 minutes, 2
times a day with nothing entering the mouth for 2 hours after spitting
without rinsing.
– Caregiver should brush the child’s teeth until age 7-8 years.
– ADA guidelines: Pea-sized amount of fluoridated toothpaste twice a
day beginning at 2-ars old with careful supervision.
– < 2 years: smear of fluoridated toothpaste may be necessary.
– Tooth wipes can be used.
• Antimicrobial products:
– Used in addition to mechanical plaque removal methods.
109

110. • Xylitol: Low calorie, naturally occuring, and diabetic safe
sugar not metabolized by cariogenic bacteria.
• Remineralizing Products:
– Fluoride varnish
– Amorphous calcium phosphate
• Management of Xerostomia:
– Saliva stimulants or sialogogues.
– Frequent sipping of sugarless fluids throughout the day.
– Rinsing 4-6 times daily with salt and baking soda solution to
buffer acidic oral environment.
– Alcohol containing mouthwashes to be avoided as it may cause
drying.
– Flavor enhancers.
110

111. PROBIOTICS
111

112. CONCLUSION
• Malnutrition affects oral health.
• Detailed case history, nutritional assessment is
important.
112

113. REFERENCES
• Textbook of Guide to Nutritional Care, Cynthia A. Stegeman.
• 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.
• Ehizele AO, Ojehanon PI, Akhionbare O. Nutrition and Oral health. Journal of
Postgraduate Medicine. 2009;11(1):76–82.
• Malnutrition and its Oral Outcome – A Review, Anama Sheetal
• Effect of early childhood protein-energy malnutrition on permanent dentition dental
caries, Elisandra et al.
• UNICEF. The state of the world's children 2008, in United Nations Childrens Fund.
New York: 2007
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114

115. THANK YOU
115