NUTRITION AND CRANIOFACIAL

GROWTH

P MUHAMMED RAHEESH
1st year PG
Contents:

 Introduction

 Nutrition and nutrients

 Carbohydrates

 Fats

 Proteins

 Vitamins

 Minerals

 Conclusion

 References

INTRODUCTION
Nutrition is an important aspect in human growth and development,Development and
maturation of cranio facial structure also thus depends on nutrition So its important to know
the nutritional dependence of craniofacial structure during its growth period and extend to
which it is influenced.

NUTRITION
Nutrition can be Defined as utilisation of food by living organism, A sound knowledge of
chemistry and metabolism of all nutrients is essential for better understanding of nutrition.

NUTRIENTS
• Carbohydrates

• Fats

• Proteins

• Vitamins and

• Minerals
Nutrients are again classified as

 Essential – which body cannot manufacture

eg :-proteins,fats,minerals,water soluble and

lipid soluble vitamins

 Non essential – can be manufactured in the body be raw materials supplied by food

eg :-glucose,fructose,lecithin,cholesterol

carbohydrates:

60-70% of total caloric requirement.Main source of energy.it Provide 4kcal/gm,its Required for
synthesis of aminoacid,fats,for protien sparing,and it can be seen in three forms as
Monosacharides,disacharides and polysaccharides.

Lipids :

15-50% of total dietary requirement.its the Energy store house of human body, Provide 9
kcal/gm, Lipids are divided into fats and oils. also classified as triglycerides, phospholipids and
sterols and into saturated and unsaturated fats unsaturated are further divided into mono and
polyunsaturates

Proteins :

10-15% of total body energy is derived from proteins,Fundamental basis of cell structure and
function,All enzymes,several hormones, immunoglobulins are proteins, Provide 4 kcal/gm

Essential – leucine, lysine, isoleucin, histidine, methionine, threonine, tryptophan, valine,phenyl

alanine

Non essential – glycine, alalnine, serine, aspartate, glutamate, cystine, proline, tyrosine

VITAMINS
They are a group of essential nutrients required in very minute amounts to participate and
regulate chemical reactions within the body.

They are of two types

 FAT SOLUBLE - A ,D(calciferol), E(tocopherol), K(menadione)

  WATER SOLUBLE – C , B (thiamine ,riboflavin , niacin , folate , pyridoxine ,vit B 12 , biotin
, choline, inositol , pantothenic acid )

VITAMIN A :

The fat soluble vitamin A is present only in foods of animal origin, however its provitamins
carotenes are found in plants.

Dietary sources: animal sources contain preformed vitamin A, like liver, kidney, egg yolk, milk,
cheese, butter, fish (cod or shark) liver oils. Vegetable sources contain provitamin A-carotenes.
Yellow and dark green vegetables and fruits are good sources e.g. carrots, spinach,
amaranthus, pumpkins, papaya, mango etc

Biochemical functions: Vitamin A is necessary for a variety of functions like vision, proper
growth and differentiation, reproduction and maintenance of epithelial cells.

Carotenoids function as antioxidants and reduce the risk of cancers initiated by the free radicals
and strong oxidants,It is responsibe for maintaining differentiation of special kind of epithelium.

Best known deficiency symptoms are xerophthalmia,bitots spot,keratomalacia, night blindness.

Change in odontogenic epithelial differentiation also occur which causes enamel hypoplasia.

Oral changes include retarded eruption, hyperplastic gingiva, retarded alveolar bone formation,
periodontal diseases and microabscess, enamel hypoplasia , uneven dentin formation.

Requirement – 420 mcg to 800-1000 mcg

Measurement of serum retinol, tests of dark adaptation, impressioon cytology of conjuctiva

and measurement of body pools either by liver biopsy or isotopic dilution are various methods.

Increased dose of retinoic acid during parturation period caused defective development of
craniofacial stuctures,mandibular gonial angle and mandibular length was found to be
decreased,midfacial deformial deformities was also evident with increased palatal depth.

Teratological and Radiocephalometric Analysis of Craniofacial MaIformati ons Induced With Retinoic Acid in Rhesus
Monkeys (Macaca mulatta)

A.G. HENDRICKX, S. SILVERMAN. M. PELLEGRINI. AND A.J. STEFFEK

TERATOLOGY 22:13-22 (1980)

VITAMIN D :
Commonly reffered as anti rachitic vitamin,It generally occurs in two forms, vit D2
(ergocalciferol) and vit D3 (cholecalciferol).It’s the only vitamin which also acts as a hormone,
Plays key role in regulation of calcium and phosphorus haemostasis.

Requirements – 10mcg during growth

Deficeincy causes rickets in children and osteomalacia in adults.

Rickets :-

 Defect in vitaminD-calcuim-phosphorus axis which results in hypomineralsied bone

matrix

 Caused due area deprived of sunlight, deit rich in phytates.

 Changes are seen in bone at the epiphyseal plates,metaphysis and shaft

 Oral findings include disturbed calcification of teeth, delayed eruption of decidous and
permanent teeth, thick jaw bones,maxilla is narrow and high,mandible is short,
malalignment of teeth

 High caries index and enamel hypoplasia is also seen

Osteomalacia :-

 Only the flat bone sand diaphysis of the long bones are affected.

 The disease is most commonly seen post menopausal females with a history of low
deitary calcium intake and little exposure of ultravoilet light

 Results in softening and distortion of of skeleton and an increased tendency towards

fracture.

vitamin D-free and low calcium diet caused a disturbed osteogenesis in growth sites
determining the growth and form of the viscerocranium and its relation to the neurocranium.

Craniofacial morphology and growth in the rat. Cephalometric analysis of the effects of a low calcium and vitamin
D-deficient diet.

C Engström, A Linde B Thilander

Jornal of anatomy
VITAMIN E :
Also known as Tocopherol,Prevents peroxidation of PUFA, hence known for its antioxidant
property.Cause decreased fertility, increased foetal maternal vascular relationship, nutritional
muscular dystrophy and encephalomalacia,increased vascular disruption, and haemolysis.

Requirement – 3mg for children and 10mg for adults

VITAMIN K :
It exist in three forms K1 - phylloquinone

K2 - menaquinone

K3 – menadione

Its is essential for synthesis and activation of clotting factors, Deficiency are rare in adults,in
children it can be seen as hypoprothrombinemia

Found in green leafy vegetables, butter, margarine ,liver,milk also in vegetable oils.

Most common oral manifestation is gingival bleeding.prothrombin level below 35% cause
bleeding on brushing,below25% causes spontaneous gingival bleeding

Requirement : 1-2mcg/kg

The interference with the production of extrahepatic vitamin K-dependent proteins during the
first trimester results in neonatal maxil- lonasal hypoplasia of varying degrees

Vitamin K - its essential role in craniofacial development A review of the literature regarding vitamin K and
craniofacial development

Andrew M. Howe,William S. Webster

Australian Dental Journal 1994

VITAMIN B1 (thiamine):
Thiamine is a colourless basic organic compound composed of sulphated pyramidine ring.In
tissue thiamine is found as thiamine pyrophosphate.

Main source of vitamin A is yeast,pork,legumes,whole grains and nuts

Thiamine deficiency leads to wet and dry beriberi

There is no convincing evidence that thiamine deficiency effects the oral tissue
Requirement – 0.3mg in infants to 1.5mg for adults

VITAMIN B2(riboflavin) :
Riboflavin consist of two groups :

FMN –flavin mono nucleotide and

FAD – flavin adenine dinucleotide

Deficiency is always due to deitary deficiency.

Requirement – 0.4mg for infants to 1.5mg for adults.

Source : liver, dried yeast, egg ,fish, whole cereals ,legumes

Deficiency symptoms : glossitis, magenta coloured tongue , cheilosis, angular stomatitis

VITAMIN B3(NIACIN) :
Niacin also called as nicotinic acid, Niacin is converted to NAD+ and NADH+,there are various
reactions occuring in the human body which are NADH and NADPH dependent.

Niacin deficiency causes;

pellegra – means rough skin

- causes dermatitis – bright red erythema in ankle,feet

and face

- casals necklace :increased

pigmentation around the neck

- diarrhea

- dementia – irritablity,inability to concentrate, poor

memory

Patients complain of burning sensation of of tongue.In acute stage entire oral mucosa
become red and painful,oral procedures cannot be performed at this time,Ulceration,
pain ,redness and tenderness begin at inter dental gingival papillae superimposed
commonly by anug or vincents infection involving the tongue,gingiva , oral mucosa
Requirement – 20mg/day

Sources - dried yeast, polished rice, liver, peanut, whole cereal ,legumes, meat and fish.

VITAMIN B5 (pantothenic acid) :

Widely distrubuted in plants and animals, Produced in intestine

Source – yeast ,liver and egg.

Deficiency is rare.

Requirement – 10mg/day

VITAMIN B6 (pyridoxine):
Active form of pyridoxine is pyridoxal phosphate (PLP).Functions include transamination,
decarboxylation ,production of sulphur containing amino acids, heme synthesis, production of
niacin ,glycogenolysis, Deficiency causes nuerological manifestations, pellegra, anemia.

Source : yeast ,polished rice, cereals, legumes, oil seeds ,egg, milk ,meat ,fish and green leafy
vegetables.

Requirements – 1 to 2mg /day

Excess leads to sensory neuropathy

VITAMIN B7(BIOTIN):
Earlier known as vitamin H or coenzyme R.Main enzyme in many metabolic process.Deficiency
causes scaly, greasy dermatitis and eventual alopecia.

No dental changes are noted in deficiency .

Requirement 200-300mg

Source – produced by bacteerial flora,yeast ,liver ,peanut ,soyabean ,milk, eggyolk

VITAMIN B9(folic acid):

Readily absorbed from the upper part of jejunum,transported by beta globulins, taken up by
liver where the co enzymes are produced.

folate deficiency is caused by

pregnancy,
 defective absorption,

drugs like hydantoin, dilantin, phenytoin, phenobarbitone

haemolytic anemia

deitary deficiency

Deficiency causes reduced DNA synthesis, macrocytic anemia, homocystenemia (coronary

artery disease),birth defects like spina bifida, neural tube defects, cancer.

Sources – yeast, green leafy vegetables, cereals , pulses, egg, milk

Requirements – 200 mcg/day

VITAMIN B12 :
Cobalamin, extrinsic factor of castle and anti pernicious anemic factor.

seen in various forms as cyanocobalamine

hydroxy cobalamin

adenosyl cobalamin

methyl cobalamin

Deficiency causes are:

1) nutritional – veg

2) decreased absorption

3) pernicious anemia

4) gastric trophy

5) pregnancy

Deficiency symptoms include folate trap, megaloblastic anemia, demylenation, achlorhydria

Assessment of deficiencyis by measuring serum B12, schilling test, methyl malonic acid, figlu
test

Requirements:

1-2mcg/day
VITAMIN C :
Ascorbic acid

Functions – reversible oxidation and reduction

hydroxylation of proline and lysine

tryptophan metabolism

tyrosine metabolism

hemoglobin metabolism

iron metabolism

folic acid metabolism

steroid synthesis

phagocytosis

antioxidant property

Deficiency causes– scurvy

hemorrhagic tendency

internal hemorrhage

anemia

Orally deficiency of asborbic acid causes painful gums which are swollen and spongy due to
abnormal collagen formation with defective intercellular substance.

The dental pulp is seperated from dentine, and finally the tooth become non vital

Delayed wound healing

In bones the deficiency results in failure of osteoblast to form intercellular substance osteoid.

Thus without normal ground substance the deposition f bone is arrested,and form bone will be
fragile.

Deitary source : amla ,guava ,lime ,lemon ,green leafy vegetables

Requirements – 75mg/day.
MINERALS
They provide structural components for the body.(bones ,teeth ) ,They allow for nerve muscle
function ,blood clotting ,tissue growth ,repair,acid base balance of fluids .

classified as major and trace minerals

 Major minerals –needed in amounts greater than 100mgs/ day Ca ,Mg ,P ,K ,Na ,Cl ,S.

 Trace minerals -needed in lesser amounts –F ,Zn ,Se ,Cu ,I,Mo, Mn

calcium
Total calcium in body is 100-170 g. 99% in bone as carbonates and phosphonates, Serum
calcium level of 9-11mg/dl, Calcium found in plasma as ionised calcium,protein bounded
calcium and complexed calcium.

Deitary requirement – 800mg /day

Calcium plays a major role in skeletal maturity and maintanence, Other functions are heart
rhythm,neuromuscular conduction,muscular contraction and coagulation of blood.

CALCIUM HOMEOSTASIS

Calcium homeostasis is the process by which mineral equilibrium is maintained. Maintenance of

serum calcium levels at about 10 mg/dl is an essential life support function. When substantial
calcium is needed to maintain the critical serum calcium level, bone structure is sacrificed.,The
alveolar processes and basilar bone of the jaws also are subject to metabolic bone loss.

Calcium homeostasis is regulated by thre hormone namely

1)Calcitriol

2)Parathyroid hormone

3)Calcitonin

1) Calcitriol :-

 physiologically active form of vitamin D

 Induces synthesis of specific calcium binding protein in intestinal cells

 Blood ca level is thus increased

  Promotes ca uptake by osteoblast of bone and promotes mineralisation

2) Parathyroid hormone:-

 Secreted by parathyroid gland.

 Single chain polypeptide – preproPTH –proPTH – PTH

 Secreted under the negative feedback regulation of serum calcium.

 PTH acts by binding to membrane receptor protein on the target cell to release cAMP,
thus increasing the serum calcium.

 PTH acts on bone, kidneys and intestine

 In bones, it causes demineralisation ,by osteoclasts ,by increasing the activity of

phosphatase enzyme, thus increasing the blood calcium level.

 In kidneys, PTH increases calcium reabsorption by kidney tubules,its also stimulates the
production of calcitriol in kidney

 Action on intestine is in an indirect way, by increasing absorption of calcium by

promoting the synthesis of calcitriol

3) Calcitonin

 Secreted by parafollicular cells of thyroid gland

 Action is antagonist to that of PTH

 Decrease the serum calcium level by increaasing osteoblastic activity,decreasing bone

resorption,increasing the excretion of calcium

phosphorus
Total phosphorus in body is 500-800 g., 85-90% in bone

Serum level of 2-4mg/dl

Deitary requirement – 800mg /day

Most of the portion is associated with calcium in metabolism of bone and teeth.

Deficiency causes anorexia, weakness, malaise and bone pain.

Rickets and osteomalacia can also be seen due to deficiencies along with calcium and vitamin D,
Hyperphosphataemia is due to factitious anemia, increased intake of vitD, increased release
from from bone due to excretion, decreased excretion etc

magnesium
Magnesium is the fourth most abundant ion in body.25mg of phophorus in an human weighing
75kg, Half in bones

Requirement – 400mg

Serum level – 1-3mg/dl

Hypermagnesaemia is rare, if occurs can cause sedative or hypnoic effects(>5mg/dl), can also
cause coma or even death(18-21 mg/dl)

Activator of wide enzymatic reaction, High level depress nerve conduction and low level causes
tetany, 70% of total element is found in bone,enamel and dentin

sodium
Mainly found in body associated with chloride, present as NaCl, NaHCO3

Sodium content 83- 97 gm, one –third of this is found in skeleton

Requirement – 0.5 gm

Plays a major role in maintenance of acid base balance.

Hypernatremia occurs in dehydration, diabetes insipidus, excess sodium intake and steroid
therapy.Hyponatremia occurs as a result of diuretic medication, excessive sweating, kidney
diseases, congestive heart failure.

Deficiency causes weakness, fatigue, lassitude, apathy, anorexia, nausea, muscle cramps.

Pottasium
Major intracellular cation.Constant exchange of pottasium occurs between intracellular and
extra cellular phase through a regulated mechanism, Average human body contains 3.6 moles
of potassium, An average amount of 4gm of pottasium is present in the diet.

Normal blood plasma level is 4mEq/l

It influences the muscular activity,acid base balance, cardiac function, and is involved in
neuromuscular irritablity.
 deficiency is secondary due to causes like diarrhoea and vomiting,death occurs in defiency due
to cardiac or repiratory failure.

Hyperkalemia occurs due to excessive tissue breakdown, adrenal insufficiency, dehydration,

excessive intake of potassium and it causes mental confusion,numbness,tingling sensation of
extremities,pallor, cold, weakness, Oral symtoms have not been reported

chlorine
Chlorine together with sodium and potassium acts on the acid base balance.

Requirement – 6 – 8 gm /day

Serum conc 550 – 650 gm/dl

No oral manifestations were reported on chlorine deficiency

iodine
Widely distributed in small amount in the body, The sources are seafood,vegetables and
milk.Plama level – 8 – 12mcg/dl, The level is increased during pregnancy and in
hyperthyroidism, Decreased in hypothyroidism.

Iodine is essential for thyroid formation.

copper
Adult human contains 100-150 mg of copper

Requirement – 2.5 – 5.0 mg

Deficiency of copper leads to microcytic hpochromic anemia, because it is essential for normal
erythropoesis.

Iron
Most essential of trace elements.Most prevarlrnt nutritional deficiency in india.Normal human
contain 2.3 -3.8gm of iron, Requirement – male 10mg/day

female 20 mg/day

Iron deficiency causes anemia along with plummer vinson syndrome, sore tongue.

Iron overload causes sideroblastic anemia,thalassemia,and bronze diabetes.

Zinc
Obtained from milk, liver, egg ,unmilled rice, legumes, pulses, oil seeds and leafy
vegetables.Normal human contains 1.4 – 2.3 g of zinc in body, High concentration is seen in
prostate and skin followed by teeth,bone, nails hair etc

Zinc forms the integral part of human enzymes, Zinc deficiency causes acrodermatitis
enteropathica,(AR),primary defect is zinc absorption,cause various mucocutaneous
problems.Zinc deficiency in human results in number of disorders involving taste,
keratogenesis, bone growth, wound healing .

Manganese
10 -18 mg in a normal human, High concentration is found in kidney and liver.,Obtained in deit
from vegetables, cereals, nuts ,fruits and tea.Manganese act as a cofactor for many enzymatic
reactions

Deficiencies produce alteration of bone,ataxia and infertility.

Cobalt
Major constituent and integral part of vitamin B12, Normal deit contain 5-8 gm of cobalt, It is
essential for normal bone marrow function and maturation of RBC.

Deficiency caused mactrocytic anemia and deficiency causes polycythaemia.

Chromium
6 -20 mcg/100 ml in normal adult.Has a role in carbohydrate and lipid metabolism,Chromium
metabolism is one important etiological factor to be taken into consideration in disorders or
carbohydrate metabolism,ranging from infants suffering from protein caloric malnutrition to
elderly people with impaired glucose tolerance.

Selenium
Human body contains 4 -10 mg of selenium.Major source is plant materials.Biological form
occur as selenium analogues of selenium containing amino acids

Found in higher concentration in liver,nails and kidneys.

Deficiency causes liver cell necrosis,muscular dystrophies, pancreatic degenerations,

myopathies,Chronic dermatitis, loss of hair, brittle nails
Flouride
Souce from food,water,tea, salmmon, sardel ,meckeral.,Daily deitary flouride should not exceed
3mg per day, Added to drinking water at an amount of 1ppm.Its is present in human dentition
and bone,provide hardness to ename and resist caries.Excessive flouride intake causes
fluorosis,initially causing osteosclerosis of pelvic vertebra,later on other bones with
ligamentous calcification

Interactions between micronutrient

 vitamin A and zinc

 Vitamin A and iron

 Vitamin A and copper

 Iron and zinc

 Copper and iron

It was told in various studies that interactions are present between this nutrients,future
studies has to be done for confirmation

Micronutrients in fetal growth and development

Harry J McArdle and Cheryl J Ashworth

British Medical Bulletin 1999; 55 (No. 3): 499-511

A nutritional stress may alter the relative growth between the facial functional components to a
greater extent than that between the major functional components; viz. the neurocranium and
the splanchnocranium.

Growth of the Functional Components of the Rat Skull and Its Alteration by Nutritional Effects.
A MULTIVARIATE ANALYSIS

HECTOR M. PUCCIARELLI

AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 56:33-41 (1981)

Conclusion

We could say that nutrition and craniofacial growth studies are important,and adequate
amount of nutrients is necessary for the normal growth and development. An increase or
decrease of nuteints from their normal value can cause various symtoms and condition which
can effect the craniofacial growth.
References

 Textbook of biochemistry for medical students – D M vasudevan

 Essentials of biochemistry - sathyanarayanan

 Textbook of oral pathology – shafers

 Growth of the Functional Components of the Rat Skull and Its Alteration by Nutritional
Effects. A MULTIVARIATE ANALYSIS

HECTOR M. PUCCIARELLI

AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 56:33-41 (1981)

 Micronutrients in fetal growth and development

Harry J McArdle and Cheryl J Ashworth

British Medical Bulletin 1999; 55 (No. 3): 499-511

 Vitamin K - its essential role in craniofacial development A review of the literature

regarding vitamin K and craniofacial development

Andrew M. Howe,William S. Webster

Australian Dental Journal 1994

 Craniofacial morphology and growth in the rat. Cephalometric analysis of the effects of
a low calcium and vitamin D-deficient diet.

C Engström, A Linde B Thilander

Jornal of anatomy

 Teratological and Radiocephalometric Analysis of Craniofacial MaIformati ons Induced

With Retinoic Acid in Rhesus Monkeys (Macaca mulatta)