23: Nutritional and Metabolic Disorders

Nutritional and Metabolic Disorders

Nutriology as per Dorland’s Medical Dictionary is the science of nutrition. It is the science of how the body utilizes food to meet requirements for development, growth, repair, and maintenance. Nutrients are biochemical substances that can be supplied only in adequate amounts from an outside source, usually from food.

The relationship between nutrition and oral health is multifaceted. Nutrition has both local and systemic impacts on the oral cavity. While diet and eating patterns have a local effect on the teeth, saliva and soft tissues, the systemic impact of nutrition also has considerable implications and it too merits assessment as a component of comprehensive care. The systemic effect is the impact of the nutrients consumed as they assume their biological functions in relation to the development and maintenance of the extra- and intraoral structures and secretions. The oral cavity is often one of the first sites where nutrient deficiencies can be clinically noted.

Clinical manifestations of nutrient deficiencies can have a significant impact on the function of the oral cavity. Functional properties of the oral cavity include taste, salivation, mastication and swallowing food. Any alterations in the structure and function of the oral cavity may compromise intake and contribute to the development of a nutrient-deficiency state. When the associated oral structures are affected, these alterations may be compounded even further, leading to subsequent inadequate dietary intake and compromised nutritional status.

There are six classes of nutrients: water, carbohydrates, proteins, fats, minerals and vitamins. Nutrients work together and interact in complex metabolic reactions. Proteins, carbohydrates and fats provide energy for body needs. However, the body cannot use this energy without adequate amounts of vitamins and minerals.

Nutritional Requirements of Indians

Energy requirement is defined as the amount that will balance the energy expenditure of the individual (as determined by body size and composition and level of physical activity) consistent with long-term good health. This intake will allow for the maintenance of economically necessary and socially desirable physical activity. In children and pregnant/lactating women, the energy requirement will include energy needed for deposition of tissue and secretion of milk at the rate consistent with good health. All estimates of requirement are based on habitual intakes though these are expressed as daily intake.

Recommended dietary allowance (RDA) is the amount of selected nutrients considered adequate to meet the known nutrient needs of healthy people. The Canadian equivalent is the recommended nutrient intakes (RNIs). The energy needs of men and women for different activity levels computed on the basis of recommendations made by a Joint Expert Consultation of the World Health Organization (WHO)/Food and Agricultural Organization (FAO)/United Nations University (UNU) in 1985 and by an Expert Committee constituted in 1988 by the Indian Council of Medical Research (ICMR) are as shown in Tables 1 and 2. The ICMR’s RDA is higher than those recommended by the WHO/FAO/UNU.

Table 1

ICMR’s recommended dietary allowance for energy


Source: Dr BS Narasinga Rao–Gopalan Oration (2001).

Table 2

Recommended dietary allowance of infants and children


Source: *WHOIFAO/UNO (1985); ICMR (1988).

For computing RDA, the ICMR has taken body weight of ‘reference man’ as 60 kg and that of ‘woman’ as 50 kg. Average weight of Indian men is 52 kg and women 44 kg. For children and adolescents, weight for age from National Center for Health Statistics (NCHS), USA/well-to-do Indian children have been utilized by ICMR for deriving the RDA so that energy intake enables optimum growth. However, as in adults, majority of children and adolescents weigh substantially less and hence their energy requirement is lower.


Carbohydrates have been the major sources of energy since the dawn of history and furnish up to 90% of energy needs. Carbohydrates provide about 4 kcal/g. The average adult stores about 300 g of carbohydrate in the liver and muscle tissue as glycogen.


Second to water, proteins are the most abundant substances in the body. The structural units of proteins are amino acids. Of the 20 amino acids present in nature, nine are considered essential, i.e. these are to be supplied by the diet.


Protein energy malnutrition

This term covers the spectrum of clinical conditions seen in undernutrition. The two clinical forms of protein energy malnutrition (PEM) include kwashiorkor and marasmus.

Kwashiorkor occurs when a child is fed on a diet with very low protein content relative to energy. This results in a high level of plasma insulin and low levels of plasma cortisol. This hormonal pattern leads to an uptake of amino acids in muscle, diverting these from liver, leading to decreased albumin synthesis and therefore edema.

Thus a child with kwashiorkor shows apathy, lethargy and severe anorexia. There is generalized edema, muscle wasting in shoulders and upper arms. The child may have a ‘moon face’. Potbelly due to weakness of abdominal muscles occurs. Skin changes in the form of thickening, cracking and areas of denudation occur. Hair changes color and becomes sparse.

Marasmus occurs when there is inadequate food intake resulting in energy deficiency. This leads to low insulin and high plasma cortisol levels. This results in amino acids being released from muscles making them available for protein synthesis.

A child with marasmus presents with no subcutaneous fat and wasted muscles. The body weight is severely reduced. There is no edema, and skin and hair changes are mild or absent.

Studies have shown that the incidence of PEM among Indian children could be as high as 51.6–70%.

Dental considerations

During tooth development, mild-to-moderate protein deficiency results in smaller molars, chemical alterations of the exposed enamel surface, significantly delayed eruption and retardation of mandibular development. Smaller salivary glands develop resulting in decreased salivary flow. This saliva has a different protein, amylase and aminopeptidase activity, thereby compromising its immune function. Delayed eruption and decreased salivary flow lead to increased incidence of dental caries. Epithelium, connective tissue and bone may be poorly developed. Insufficient intake of protein results in negative nitrogen balance, decreased levels of secretory IgA. This leads to a lowered resistance to infections, reduced ability to withstand the stresses of injury or surgery, and prolonged recovery time. PEM may be a major reason for the occurrence of necrotizing ulcerative gingivitis (NUG) and noma.


Lipids provide more energy per gram than either carbohydrates or proteins and are an essential component of tooth enamel and dentin.

Chemistry and sources

The structural units of lipids are fatty acids. Saturated fatty acids contain only single bonds. Examples include palmitic and stearic acids found in animal fat, butter, coconut oil, chocolate, etc.

Monounsaturated fatty acids contain only one double bond. The most abundant of these is oleic acid found in olive, peanut oil and animal products.

Polyunsaturated fatty acids (PUFAs) contain two or more double bonds. Three PUFAs that are considered to be essential fatty acids include linoleic, linolenic and arachidonic acids. These are found in safflower, soybean, fish and corn oils, nuts and seeds.

Deficient consumption of fats leads to loss of weight. Deficiency of linoleic acid leads to growth retardation, skin lesions, and reproductive failure.

Over consumption of fats leads to excessive fat stores and obesity. Other conditions related to fat consumption include diabetes mellitus, hyperlipidemia, fatty infiltration of liver, and certain types of cancer.

Dental considerations

Epidemiological and laboratory studies indicate that fats have a cariostatic effect. Dietary fats probably have local rather than systemic influence. Hypotheses for anticariogenicity include:


Vitamins are catalysts for all metabolic reactions using proteins, fat and carbohydrates for energy, growth and cell maintenance. Vitamins are vital to life, but are required in minute amounts.

Vitamins are classified as fat soluble—vitamins A, D, E, K and water soluble—vitamins B, C.

Vitamin A

Vitamin A (retinol) is an essential nutrient needed in small amounts by humans for the normal functioning of the visual system; growth and development; and maintenance of epithelial cellular integrity, immune function, and reproduction. These dietary needs for vitamin A are normally provided as preformed retinol (mainly as retinyl ester) and provitamin A carotenoids or β-carotene.


Vitamin A functions at two levels in the body: the first is in the visual cycle in the retina of the eye; and the second is in all body tissues where it systemically maintains the growth and soundness of cells.

In the visual system, carrier bound retinol is transported to the retina. Rhodopsin, the visual pigment critical to dim-light vision, is formed in rod cells after conversion of all-trans-retinol to retinaldehyde, isomerization to the 11-cis-form, and binding to opsin. Alteration of rhodopsin through a cascade of photochemical reactions results in the ability to see objects in dim light. The speed at which rhodopsin is regenerated is related to the availability of retinol. A deficient intake of vitamin A thus leads to night blindness.

The growth and differentiation of epithelial cells throughout the body is especially affected by vitamin A deficiency. In addition, goblet cell numbers are reduced in epithelial tissues and as a consequence, mucous secretions (with their antimicrobial components) diminish. Cells lining protective tissue surfaces fail to regenerate and differentiate, hence they flatten and accumulate keratin. Both factors—the decline in mucous secretions and loss of cellular integrity—reduce the body’s ability to resist invasion from potentially pathogenic organisms. Pathogens can also compromise the immune system by directly interfering with the production of some types of protective secretions and cells. Classical symptoms of xerosis (drying or non-wettability) and desquamation of dead surface cells as seen in ocular tissue (i.e. xerophthalmia) are the external evidence of the changes also occurring to various degrees in internal epithelial tissues.

Current understanding of the mechanism of vitamin A action within cells outside the visual cycle is that cellular functions are mediated through specific nuclear receptors. Binding with specific isomers of retinoic acid (i.e. all-trans-and 9-cis-retinoic acid) activates these receptors. Activated receptors bind to DNA response elements located upstream of specific genes to regulate the level of expression of those genes. These retinoid-activated genes regulate the synthesis of a large number of proteins vital to maintaining normal physiologic functions. There may, however, be other mechanisms of action that is as yet undiscovered.

Dietary sources

Preformed retinal is found in milk, cheese, butter, eggs, meat, cod liver oil and liver. (β-Carotene is also present in yellow, orange and green leafy vegetables (spinach, turnip greens, broccoli).

To express the vitamin A activity of carotenoids in diets on a common basis, a Joint FAO/WHO Expert Group in 1967 introduced the concept of the retinol equivalent (RE) and established the following relationships among food sources of vitamin A:

Older literature describes the International Unit of vitamin A. This may be converted to RE as depicted in Table 3:

Table 3

Estimated mean requirement and safe level of intake for vitamin A

Group Mean requirement (mg RE/day) Recommended safe intake (mg RE/day)
Infants and children    
0–6 months    
7–12 months 180 375
1–3 years 190 400
4–6 years 200 400
7–9 years 200 450
  250 500
10–18 years 330–400 600
19–65 years 270 500
65+years 300 600
19–65 years 300 600
65+years 300 600
Pregnant women 370 800
Lactating women 450 850

Source: Vitamin and mineral requirements in human nutrition, WHO.

Clinical applications

Carotenoids possess antioxidant properties and are very efficient in scavenging singlet oxygen and peroxyl radicals. These free radicals are known to damage the structure and function of cell membranes. Thus a diet rich in antioxidants is associated with a lower risk of cancer and heart disease.

Stich and colleagues gave large quantities of (β-carotene and sometimes vitamin A to chewers of betel quids in Kerala, India, and to Canadian Inuits with pre-malignant lesions of the oral tract and witnessed reductions in leukoplakia and micronuclei from the buccal mucosa.

However, the amount of supplements used in these studies have been large and hence, not advisable other than increasing consumption of fruits and vegetables.

Retinoids have been used in oral precancer, cancer and immunologically mediated diseases such as lichen planus. Retinoids have a potent growth inhibiting effect on cancer in vivo and in vitro. They can induce apoptosis and regulate the function of the immune system. On this basis, retinoids have been used as chemopreventive agents in oral squamous cell carcinoma (SCC). However, clinical trials of retinoids have not yielded significant results. Retinoids have been used in the treatment of oral leukoplakia, and has been shown to cause temporary remission, but also causes toxicity. Retinoids have been used as an adjunctive treatment in the management of oral lichen planus. Retinoids eliminate reticular and plaque-like lesions but these recur following withdrawal of therapy.

Vitamin D


Vitamin D is required to maintain normal blood levels of calcium and phosphate, which are in turn needed for the normal mineralization of bone, muscle contraction, nerve conduction and general cellular function in all cells of the body. Vitamin D achieves this after its conversion to the active form 1,25-dihydroxy vitamin D (1,25-(OH)2D), or calcitriol. This active form regulates the transcription of a number of vitamin D-dependent genes that code for calcium-transporting proteins and bone matrix proteins. Vitamin D also modulates the transcription of cell cycle proteins, which decrease cell proliferation and increase cell differentiation of a number of specialized cells of the body (e.g. osteoclastic precursors, enterocytes, keratinocytes). This property may explain the actions of vitamin D in bone resorption, intestinal calcium transport and skin.


The most physiologically relevant and efficient way of acquiring vitamin D is to synthesize it endogenously in the skin from 7-dehydrocholesterol by sunlight (UV) exposure. In most situations, approximately 30 minutes of skin exposure (without sunscreen) of the arms and face to sunlight can provide all the daily vitamin D needs of the body (Table 4).

Table 4

Recommended nutrient intakes (RNIs) for vitamin D

Group RNI (mg/day)
Infants and children  
0–6 months 5
7–12 months 5
1–3 years 5
4–6 years 5
7–9 years 5
10–18 years 5
19–50 years 5
51–65 years 10
65+ years 15
Pregnant women 5
Lactating women 5

Units: For vitamin D, 1 I U = 25 ng, 40 IU = 1 mg, 200 IU = 5 mg, 400 IU = 10 mg, 600 IU = 15 mg, 800 IU = 20 mg.

Source: Vitamin and mineral requirements in human nutrition, WHO.

Skin synthesis of vitamin D may be influenced by:

It is recommended that individuals not synthesizing vitamin D should correct their vitamin D status by consuming the amounts of vitamin D appropriate for their age group.

Other food sources include cod liver oil, catfish, salmon, turnip greens, tuna, milk, egg yolk and butter.

Jan 12, 2015 | Posted by in Oral and Maxillofacial Radiology | Comments Off on 23: Nutritional and Metabolic Disorders
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