Perspective Chapter: Effects of Malnutrition on Pediatric Oral Health – A Review

Abstract

Malnutrition occurs when there are deficiencies, excesses, or imbalances in a person’s intake of energy and or nutrients. Diet and nutrition affect oral health in several ways. Early childhood malnutrition is in association with dental caries, enamel hypoplasia, salivary gland hypofunction, and delayed eruption. Poor oral health is in association with tooth decay, periodontal disease, and lesions in other oral tissues among children and older adults. This correlation between malnutrition adversely affects the oral structures and poor oral health, which in turn, leads to poor nutrition (Malnutrition). Various nutritional deficiencies, along with deficiencies of protein, energy foods, or both affect the development of the oral cavity. Dietary practices, nutritional status, general health status, and oral health conditions are all interrelated factors. Due to malnutrition, there are multiple effects on the oral tissues and subsequent development of oral disease. This paper gives an insight into the interrelationship of malnutrition affecting the development of the oral cavity and the progression of the oral disease.

1. Introduction

Nutrition is the intake of food, considered in relation to the body’s dietary requirement. Good nutrition is an appropriate, well-balanced diet combined with regular physical activity which is a keystone of good health. Poor nutrition (Malnutrition) can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

Malnutrition is the condition that develops when the body does not get the right amount of vitamins, minerals, and other nutrients that it needs to maintain healthy tissues and organ functions. Deficiencies of protein, energy foods or both which are relative to body’s needs leads to Protein-Energy Malnutrition (PEM) [1, 2]. Malnutrition affects oral health and poor oral health, therefore, leads to malnutrition. Good nutritional health aids good oral health and vice versa, this interrelationship between good oral health and good nutritional health leads to homeostasis. Malnutrition alters this homeostasis leading to decrease resistance to the microbial biofilm, decrease in immune response and capacity of tissue healing is lowered. Malnutrition leads to disease development in the oral cavity [3].

Studies have indicated that enamel hypoplasia, saliva compositional changes, and salivary gland hypofunction may be the mechanisms by which malnutrition is associated with caries, where altered eruption timing may create a challenge in the analysis of the age-specific caries rates [3]. Malnutrition is wide-ranging in rural, tribal, and urban slum areas. Malnourishment in children is due to adverse cultural practices, destruction of the environment, gender inequality, inaccessible medical care, lack of education, large family size, overpopulation and poverty [4]. Poor oral health, including tooth decay, periodontal disease and lesions in other oral tissues among older adults can profoundly diminish quality of life and have an adverse impact on general health [5, 6].

2. Oral cavity and its structural manifestations in nutritional status of the body

Nutrition is the study of how food affects the body. It is the adequate provision of materials like vitamins, minerals, fiber, and water and other food components to cells and organisms, to support life. Many common health problems can be prevented or alleviated with good nutrition [7].

“Malnutrition is the cellular imbalance between the supply of the nutrients and the energy and the body’s demand for them to ensure growth, maintenance, and specific functions” [8].

The oral cavity is influenced by the diet for development, depending on whether there is an early or late nutritional imbalance, the consequences are certainly different. A shortage of minerals and vitamins in the conception period influences the development of the dental organogenesis in the future embryo, the growth of the maxilla, and skull/facial development. Early nutritional disproportion influence malformations at most. Diet influence the health of the oral cavity, conditioning the onset of caries, development of the enamel, the onset of dental erosion, state of periodontal health, salivary characteristics, and oral mucous in general [9].

There exist a strong interconnection between poor oral health and malnutrition. Poor oral health such as missing teeth or gum disease leads to inability in chewing or swallowing food can negatively impact nutritional intake (e.g., children tend to consume soft, fewer and lower nutritional value meals) leading to poor nutritional status and increased risk of malnutrition [10, 11]. Malnourished children lack proper nutrients leading to increased risk of oral health related disease which can negatively impact oral health related quality of life [3]. PEM (Protein Energy Malnutrition) is of mild, moderate and severe type. Such malnutrition status during development of the body can affect the oral structure also (Table 1) [1].

Deficient Nutrient	Effect on oral structures
Protein/calorie; Malnutrition	Delayed tooth eruption, Reduced tooth size; Decreased enamel solubility, Salivary gland dysfunction.
Vitamin A	Decreased epithelial tissue development, Impaired tooth formation, Enamel hypoplasia.
Vitamin D/Calcium; Phosphorus	Lowered plasma calcium, Hypomineralization; Compromised tooth integrity, Delayed eruption pattern Absence of lamina dura, Abnormal alveolar bone patterns.
Vitamin C	Irregular dentin formation, Dental pulpal alterations, Bleeding gums, Delayed wound healing, Defective collagen formation.
Vitamin B1(Thiamine)	Cracked lips, Angular cheilosis
Vitamin B2 (Riboflavin); Vitamin B3 (Niacin)	Inflammation of the tongue, Angular cheilosis, Ulcerative gingivitis
Vitamin B6	Periodontal disease, Anemia, Sore tongue, Burning sensation in the oral cavity.
Vitamin B12	Angular cheilosis, Halitosis, Bone loss, Hemorrhagic gingivitis, Detachment of periodontal fibers,; Painful ulcers in the mouth
Iron	Salivary gland dysfunction, Very red, painful tongue with a burning sensation, Dysphagia, Angular cheilosis

Table 1.

Effects of malnutrition on the oral cavity and its structures.

Nutritional status of the body influence the pre-eruptive phase of the teeth. The deficiencies of vitamin D, vitamin C, vitamin B, and vitamin A and Protein Energy Malnutrition (PEM) have been associated with disturbances in the oral structures. Enamel hypoplasia are the hypoplastic grooves and/or pits, which is often horizontal or linear in appearance which is a characteristic of the lesion [1]. Enamel hypoplasia and pits correlate to a lack of vitamin A. More diffused hypoplastic forms of the enamel have been reported with a vitamin D deficiency as well [12, 13]. The structural damage can testify to the period in which the lack of nutrition has occurred.

Nutritional deficiencies such as vitamin B and iron deficiencies causes the conditions like recurrent aphthous stomatitis, atrophic glossitis, or a painful, burning tongue which is characterized by inflammation and defoliation of the tongue [7, 10, 14]. In maintaining the healthy oral cavity, salivary gland function should be normal. In PEM it has been reported that there will be salivary gland hypofunction, which results in a decreased salivary flow rate, a decreased buffering capacity, and decreased salivary constituents, particularly proteins [1, 15]. PEM and vitamin A deficiency are associated with salivary gland atrophy which leads to reduce defense capacity against infection and buffering ability to plaque acids [15].

Host factors are also associated with the development of caries, delay in the exfoliation and the eruption [16], especially tooth defects and the salivary system in PEM. Malnutrition was not associated with crowding, but crowding was seen in permanent dentition only in mouth-breathing adolescents [17]. The tooth defects on external structural defects (hypoplasia) provide a more cariogenic environmental niche and less protective enamel, which might increase the susceptibility to demineralization. The salivary flow rates are related to caries directly through oral clearance and in terms of the buffering capacity and the antimicrobial components [1]. Periodontal disease evolves more quickly in undernourished populations. The most important risk factor in the development of periodontal disease is represented by inadequate oral hygiene. Malnutrition and bad oral hygiene represent the two important factors that predispose to necrotizing gingivitis [12].

3. Discussion

The onset of the malnutrition is early during the intrauterine life or childhood, or it can occur during an individual’s lifetime as a result of poor nutrition [16]. Malnutrition is a multifactorial. Deficiencies of protein, vitamin D and vitamin A have been associated with enamel hypoplasia. Vitamin A deficiencies and protein energy malnutrition are commonly associated with salivary gland atrophy. Protective Role of saliva, its amount and composition, buffering capacity, defense against infection in oral cavity is reduced and manipulated during salivary gland atrophy [13].

Deficiency of B-complex vitamins also affects oral structures. Burning sensation in the mouth is a common oral effect of B (complex) deficiency, especially on the tongue. Inflammation of the lining of the oral cavity and the tongue, oral ulcers, cracks at the corners of the mouth (angular cheilitis), cracked and red lips, and a sore throat are the other oral symptoms of B-complex deficiencies. The effects of vitamin B deficiency and iron deficiency are similar. To produce healthy red blood cells within the bone marrow the body requires iron, vitamin B12, and folic acid. Deficiency of B-complex vitamins like B12 or folic acid results in pernicious anemia, a condition in which there will be increased number of immature red blood cells in circulation. Riboflavin (vitamin B2) is primarily required for the breakdown of the lipids, ketone bodies, carbohydrate, and proteins. However, ariboflavinosis manifests as cracked lips, dryness, glossitis, glossodynia and glossopyrosis due to vitamin B2 deficiency [7, 14, 18, 19, 20].

In a study, moderate to severe PEM had reduced salivary secretion rate, reduced buffering capacity, lower calcium levels, a lower protein secretion in stimulated saliva, and reduced agglutinating defense factors in unstimulated saliva was found in Indian children [21]. In a retrospective cohort study which was designed by Psoter et al. found a continued effect on the diminished salivary gland function into adolescence, which was a result of Early Childhood Malnutrition (EC-PEM). In EC-PEM, the exocrine glandular systems may be compromised in body’s systemic antimicrobial defenses [15].

Two cross-sectional studies inferred that malnutrition in children not only cause a delay in tooth exfoliation and eruption but also renders the deciduous teeth more susceptible to a caries attack later in life [22, 23]. Another retrospective cohort study showed the evidence of tooth exfoliation/eruption patterns and a nutritional insufficiency (stunting) throughout childhood. There was a delayed exfoliation of the primary tooth and eruption of permanent [16].

Density of the alveolar bone that supports the teeth is determined by the calcium similar periodontal health by vitamin C. Connective tissue repair and its healthy maintenance along with antioxidant properties are the main role of vitamin C. Scurvy a clinical condition due to deficiency of vitamin C is characterized by defective collagen synthesis. Bleeding gums and gingivitis are the main oral manifestations of scurvy [7, 24, 25].

Older adults are at an increased risk of malnutrition and poor oral health. In a study, older patients were screened in three emergency departments (ED) for malnutrition and contributing risk factors, including oral health [26]. A separate study found that over 25% of older patients screened for malnutrition in a dental clinic were malnourished or at risk [27].

These reviews, further support malnutrition and oral health are interrelated. Importance should be given when considering health related problems in children, older adults in healthcare, dental care and social services.

4. Recommendations

1. Breastfeeding should be initiated within 1 hour of the delivery [28].

2. Exclusive breastfeeding importance for the first 6 months and proper weaning thereafter has to be explained to the mothers.

3. Importance of consumption of a cost effective nutritious diet has to be imparted to people through nutritional education.

4. Importance of the family planning and adequate spacing between children should be promoted for limiting the family size and to improve the standard of living.

5. Under nutrition can be halted by promoting proper environmental sanitation.

6. Tackling of malnutrition mainly depends on the rural socioeconomic development.

7. Improvement of the health sectors through integrated health packages should be initiated; in this regard government should allocate more funds.

Incorporate screening for malnutrition and oral health into practice to provide better care and support to children, older adult patients, and clients. It is evident from the present review that malnutrition and poor oral health in children, older adults are prone to the development of oral disease. Malnutrition has multiple effects on oral cavity with subsequent development of oral disease. Altered tissue homeostasis, reduced resistance to microbial biofilms and tissue repair capacity are result of malnutrition. It is associated with salivary gland changes, enamel hypoplasia and dental caries. Change in the salivary characteristics reduces the defense mechanism of saliva and its ability to buffer the plaque acids [29].

5. Conclusion

Various studies have shown that malnutrition and protein-energy malnutrition affects tooth eruption patterns, enamel hypoplasia, dental caries prevalence, and periodontal ligament. They also have other effects on the oral cavity, like inflammation of the lining of the oral cavity, salivary gland hypofunction, the tongue, and oral ulcers. Malnutrition is a risk to oral health and poor oral health, in turn, leads to malnutrition with unfavorable socio-demographic factors, which calls for a need to improve the living conditions and adequate utilization of available health and nutritional supplementary services through an intersectoral approach.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.