NUTRITION IN

ORTHODONTICS

Dr Varun Shankar
 CONTENTS
• INTRODUCTION
• DEFINITION
• BALANCED DIET
• ORAL HEALTH AND NUTRITION
• CLASSIFICATION
• THE NUTRIENTS- CARBOHYDRATES, VITAMINS,
MINERALS, LIPIDS , PROTEINS
• ORTHODONTIC IMPLICATION
• IMPORTANCE OF NUTRITION DURING
ORTHODONTIC TREATMENT
• CONCLUSION
 INTRODUCTION

◦ Maintenance of good general dental health and optimal orthodontic outcomes are
greatly dependent on adequate nutrition.

◦ Good nutrition can maximize while poor nutrition can undermine the appropriate
biological response of the periodontal ligament and alveolar bone to orthodontic
forces.
 DEFINITIONS
Nutrition

The process of nourishing or being nourished, especially the process by which a

living organism assimilates food and uses it for growth and for replacement of tissues.
The science or study that deals with food and nourishment, especially in humans.

The science of nutrition plays a key role in dealing with several health problems.

Diet
It is the pattern of food intake, the ways in which people eat. This includes their
individual food choices, the frequency of eating, and the underlying values that
determine what foods are eaten or avoided.
 BALANCED DIET

A Balanced diet refers to

intake of appropriate types and
adequate amounts of foods and
drinks to supply nutrition and
energy for the maintenance of
body cells, tissues, organs and
to support normal growth and
function.
 Dietary reference intakes ( DRI)
◦ DRI’s are estimates of nutrient intakes required for evaluating and planning diets
for healthy people
◦ They are the amount of nutrients to prevent deficiencies and maintain optimal
health

Recommended Dietary Allowance (RDA)

Average daily level of intake, sufficient to meet the nutrient requirements of nearly
all (97%-98%) healthy people.

Adequate Intake (AI)

Established when evidence is insufficient to develop an RDA and is set at a level
assumed to ensure nutritional adequacy.
 FOOD GUIDE PYRAMID

A Food pyramid is a
recognizable nutrition tool that
was introduced by the USDA in
1992. It is shaped like a pyramid
to suggest that the person should
eat more food from the bottom of
pyramid and fewer foods from the
top of the pyramid. It was updated
in 2005 to "MyPyramid", and then
it was replaced by “MyPlate" in
2011.
The most recent and most comprehensive food grouping

system for the United States is called MyPlate.

• Make half your plate fruits and

vegetables.
• Enjoy your food, but avoid
oversized portions.
• Cut back on foods high in solid
fats and added sugar and salt.
• Drink Water instead of sugary
drinks.
• Switch to fat free or low fat milk.
• Make atleast half your grains
whole grains.
• Go lean with Protein.
 Oral Health And Nutrition

◦ In his 2000 report on Oral Health in America, the Surgeon General of the United
States emphasized the need for ‘all healthcare providers’ to incorporate nutrition
counselling into their practices.’

◦ This is particularly important for dental professionals, as oral health plays an

important role in nutrition and vice versa.
 CLASSIFICATION

◦ MACRO NUTRIENTS-

Carbohydrates

Proteins

Fats

◦ MICRONUTRIENTS-

Vitamins

Minerals
 Carbohydrates

◦ Energy yielding nutrients.

◦ Largest single component of most diets.

◦ Composed of – carbon, hydrogen, oxygen.

Classified as
◦ Monosaccharides - eg : glucose ,fructose, galactose.

◦ Disaccharides -35% of the dietary carbohydrates. eg. sucrose , lactose , maltose

◦ Polysaccharides. eg –starch, glycogen ,cellulose

 RDA for Carbohydrate

◦ 130gm per day - 1 year or older

◦ 175gm per day - pregnancy
◦ 210gm per day - lactation
◦ Adult – 60% of carbohydrates in 2000 calorie diet
Digestion of
Carbohydrate
◦ Almost nothing is known of the effect of carbohydrate deficient diet in the oral
cavity.

◦ There is a group of disease which represents a primary genetically determined

disturbance of the mucopolysaccharide metabolism.
Hurler syndrome
Hurler syndrome is the most severe form of
mucopolysaccharidosis type 1 , a rare lysosomal storage
disease, characterized by skeletal abnormalities, cognitive
impairment, heart disease, respiratory problems, enlarged
liver and spleen, characteristic facies and reduced life
expectancy.

◦ Head - appears large with prominent forehead , puffy

eyelids.

◦ Progressive corneal clouding

◦ Saddle nose

◦ Nasal congestion with noisy breathing

◦ Claw hands

◦ Shortening and broadening of the mandible.

◦ Wide intergonial distance

◦ Increased arch length from ramus to ramus

◦ Dentition-small and mishaped teeth , spacing.

◦ Soft tissue –gingival hyperplasia.

◦ Enlarged tongue.

◦ Delayed eruption
 LIPIDS
These are the most concentrated energy yielding group of nutrients.
Basic structure –molecules of glycerol to which one to three fatty
acid molecules.

Sources
Fruits , egg yolk, vegetables, butter milk, ghee, meat , cereals, fish.

Classification
a)Simple –triglycerides
b)Compound –phospholipids
c)Derived –cholesterol(helps in making many hormones)
 Pancreatic lipase and intestinal lipase

triglycerides

diglycerides

monoglycerides

Absorption and storage

Digested and divided molecules are
taken up from the GIT .
30%-free fatty acids combine with bile
salts .
70%-resynthesized immediately to form
triglycerides.
Functions
•Excellent source of energy
•Inflammatory mediators.
•Provide essential fatty acids
•Fat soluble vitamins.
•Maintain body temperature
•Cushioning mechanism against injury
•Pleasant flavor and consistency to food
•Sense of fullness and satisfaction
◦ Watkins et al - Intake of certain fatty acids influences bone modelling by
maintaining bone mineral density in the elderly and increasing it in children.

◦ Watkins etal.2001-Demonstrated dietary lipid modulating ex-vivo bone PGE2

production and concentration of IGF1 in bone tissues , leading to altered bone
formation rates.
 PROTEINS

• The term proteins mean – to take first place -Mulder -1883

• It forms 20% of the total weight of an adult.

Basic structure

• Complex substances made up of many amino acids.

• There are 20 different naturally occurring amino acid that

have been identified as the building blocks for body protein

 Source

◦ Animal - milk ,meat, eggs, cheese, fish etc.

◦ Vegetable – pulses, cereals, beans, nuts, oil, cakes etc.

Classification Of Amino Acids
Digestion and absorption
Attached to another substance or surrounded by fat or

carbohydrate.

• Stomach – gastric proteases (pepsin)

• Small Intestine – pancreatic enzymes

• 30 %- absorbed directly
• 70%- chain of two or three amino acids
• Amino acids – enters blood stream
Functions
•Essential for growth-hair, skin, nail

•Formation of essential body compounds

•Regulation of the water balance

•Act as buffers

•Protective role

•Transport of nutrients.

•Biosynthesis of organic matrix of bone tissue.

 Protein deprivation affects:
1. Epiphyseal growth height.

2. The number of chondrocytes per column in the proliferative and hypertrophic

zones of the growth cartilage.

3. The size of hypertrophic chondrocytes.

◦ Martin et al – protein restriction inhibits bone formation and longitudinal

growth in the mandibular condylar process.
 The inadequate consumption of protein and energy as a result of primary dietary
deficiency may cause loss of body mass and adipose tissue, resulting in protein
energy malnutrition (PEM).

◦ Kwashiorkor

◦ Marasmus
Kwashiorkor
Definition- protein deficiency with sufficient calorie
intake.

Decreased plasma albumin concentration (<2 g/dl)

Features
◦ Growth failure

◦ Wasting of muscles

◦ Edema

◦ Enlarged fatty liver

◦ Low Serum protein

◦ Flag sign-
Bands of discoloration of hair resulting from fluctuatio
ns in nutrition
MARASMUS
Definition – Starvation in infants with an overall lack of calorie.

Age - infants under 1 year of age.

Features
◦ Wasting of all tissues

◦ No edema

◦ No hepatic enlargement

◦ Monkey like face

◦ Anaemia

◦ Weakness
 VITAMINS
• Defined as ‘Accessory food factors

which are organic in nature & must

be supplied from outside to maintain

health , growth, state of well being

of a person.’

• The term vitamin is derived from

the word vitamine, coined in 1912

by Polish biochemist Casimir Funk.

FAT SOLUBLE WATER SOLUBLE

1.Absorption along with fats. Require Simple

bile salts
2.Carrier proteins present Not required

3.Storage - Liver No appreciable storage

4.Excretion - No Excreted

Rapidly
5.Deficiency - Manifests only when
stores are depleted

6.Toxicity - Hyper vitaminosis Unlikely

 VITAMIN A
• Elmer McCollum and Marguerite Davis in 1914

Source
• Animal origin- Sea fish liver oils, milk ,cheese, butter, meat,
egg
• Plant origin- spinach, carrot, broccoli, mangoes, potato.

Recommended dietary requirement

• Adults-750ug
• Infants and young children- 300ug
• Women during pregnancy and lactation- 1200ug
• Also called as anti-night blindness factor.

• Vitamin A is an alcohol also referred to as retinol.

• It may be converted into an aldehyde (retinal) or an

acid (retinoic acid).

• All three forms are found in different tissues in humans.

 Functions
• Vitamin A is necessary for a variety of functions like vision

• Proper growth and differentiation of cells

• Reproduction

• Maintenance of epithelial cells

• Carotenoids function as antioxidants and reduce the risk of

cancers initiated by the free radicals and strong oxidants
DEFICIENCY
1. Impaired vision (night blindness)
2. Xeropthalmia
3. Bitots spots
4. Keratomalacia
5. Complete blindness
6. Dry skin
7. Immune deficiency
8. Renal stones
ORAL MANIFESTATIONS

◦ Disturbances in differentiation and growth of developing teeth.

◦ Calcification of teeth.

◦ Retardation of eruption.

◦ Disturbances in periodontal tissues.

◦ Failure to form tooth enamel.

◦ Xerostomia
HYPERVITAMINOSIS A

Excessive consumption of vitamin A leads to toxicity.

• Acute - Headache, Vomiting, Papilledema, Symptoms

suggestive of brain tumor.

• Chronic - Weight loss, nausea, vomiting, dryness of mucosa

of lips, bone and joint pain, hyperostosis, and hepatomegaly

with parenchymal damage and fibrosis.

 ORTHODONTIC IMPLICATIONS OF VITAMIN A

◦ Togari et al.,1991. supplementation of Vitamin A increases breaking strength of

healing wounds, collagen production.

◦ Kaczmarczyk –Sedlak etal 2005- Hypervitaminosis of vitamin A causes increased

bone resorption led to osteopenia, bone deformation and pathologic fractures.

◦ Retinol deficiency – inhibits bone remodelling by decreasing activity of osteoclasts

and bone deformation
 VITAMIN D
• Vitamin D is a fat soluble vitamin
resembling sterols in structure and
functions like a hormone.
• Group of compounds called as
Calciferol.
• Elmer McCollum in 1922.

Source
• Exogenous - deep sea fish, fish liver oil,
butter, milk, egg yolk.
• Endogenous synthesis in the skin and
diet.
Recommended daily requirement

• Infants: 400 to 800 IU daily

• Children and adolescents: 400 IU daily
• During pregnancy and lactation: 400 to 800 IU daily
• Ergocalciferol and cholecalciferol are
the sources of vitamin D activity and are
referred to as provitamins.

• The biologically active form is

calcitriol.

• Calcitriol regulates the plasma calcium

and phosphate levels. It acts on intestine,
bone and kidney to maintain calcium
levels.
FUNCTIONS

• Maintains normal plasma level

of calcium and phosphorus.

• It is necessary for all animals

with a bony skeleton , since it

facilitates absorption and

utilization of calcium and

phosphorus for bone formation.

 DEFICIENCY

Predisposing factors for deficiency:

1. Inadequate synthesis or dietary deficiency of vitamin D.

2. Decreased absorption of fat soluble vitamin D.

3. Derangements in vitamin D metabolism.

4. End - organ resistance to 1,25(OH)2 D.

5. Phosphate depletion.
 Deficiency manifestations

◦ Results in demineralization of bone.

◦ They result is rickets in children and osteomalacia in adults.

◦ Rickets in children is characterized by bone deformities due to incomplete

mineralization resulting in soft and pliable bones and delay in teeth formation.

◦ In osteomalacia demineralization of bone occurs making them susceptible to

fracture
RICKETS
Oral Manifestations of Vitamin D deficiency

• Disproportionate growth occurs between face and skull. It may

cause interference with bone growth.

• Maxilla become narrow and palate becomes high.

• Mandible becomes short.

• It causes retarded eruption of teeth, early loss of deciduous teeth

due to caries.

• Teeth are irregularly arranged

• Increased susceptibility of
osseous tissue to muscular
traction as undesirable oral
habits.

• Open bite, transverse

hypodimensions and
misshapen palate are
frequently observed in
vitamin D deficiency
 Hypervitaminosis D

Main symptoms of vitamin D overdose are those of Hypercalcemia:

◦ Anorexia, nausea, and vomiting can occur, frequently followed by polyuria,

polydypsia, weakness, insomnia, nervousness, pruritus, and, ultimately, renal failure.

◦ Proteinuria, urinary casts, and metastatic calcification may develop.

◦ Other symptoms include mental retardation in young children, abnormal bone growth
and formation, diarrhoea, irritability, weight loss, and severe depression.
◦ Kale et al(2004) compared the effects of local administration of 1,25-DHCC
and PGE2 on orthodontic tooth movements in rats and reported that both
molecules enhance tooth movement significantly when compared with control
group.

◦ In that study 1,25 DHCC found to be more effective than PGE 2 in modulating
bone turnover during tooth movement, because of its well balanced effects on
bone formation and resorption.

◦ Local applications of vitamin d can enhance the re establishment of dental

supporting tissues, especially alveolar bone, after orthodontic treatment in turn
can cause rapid tooth movement during application of orthodontic forces.
 VITAMIN E
◦ Discovered in 1922 by Herbert McLean
Evans and Katharine Scott Bishop.

◦ A group of 8 closely related compounds- 4

tocopherols and 4 tocotrienols.

◦ This is a naturally occurring antioxidant

essential for normal reproduction and hence
known as ‘anti sterility vitamin’

Source
◦ Occur abundantly in plants.
◦ All green plants, especially lettuce and Alfa
alfa are rich sources.
◦ Vegetable oils like wheat germ oil and seed
germ oil, milk, eggs and meat are also good
sources.
FUNCTIONS

◦ Act as an antioxidant.Vitamin E prevents the non enzymatic oxidation of various

cell components by molecular oxygen and free radicals such as super oxide (O2 - )
and hydrogen peroxide (H2O2 )

◦ It plays a role in termination of free radical – generated lipid peroxidation chain

reactions, particularly in cellular and subcellular membranes .

◦ Vitamin E also plays a role in neurological functions.

◦ Protects against Atherosclerosis and Cancer.

◦ Accumulates throughout the body, mostly in fat depots but also in liver and muscle.
 DEFICIENCY
Recommended requirement: 20-
25mg .
◦ Neurologic manifestations- Depressed or absent tendon reflexes, ataxia, dysarthria,
loss of position and vibration sense, loss of pain sensation.

◦ Muscle weakness.

◦ Impaired vision and disorders of eye movement.

◦ Vit E deficient erythrocytes are more susceptible to oxidative stress and have a
shorter life in blood.

◦ Sterility.
Excess intake of Vitamin E leads to:

Nausea

Diarrhea

Cramps and bleeding

Interferes with the action of anticoagulant drug.

 Vitamin K
This is the only fat soluble vitamin with a specific coenzyme
function.

It is required for the production of blood clotting factors, hence

essential in coagulation.

Basic structures consist of a group called as quinones.

Three types of vitamin k:

1.Vit k1-phylloquinone

2.Vit k2-menaquinone

3.Vit k3-menadione
 Sources

◦ Cabbage, cauliflower, tomatoes, Alfa

alfa, spinach and other green
vegetables are good sources.

◦ It is also present in egg yolk, meat,

liver, cheese and dairy products.

RDA- approximately 100 mg/day

 Deficiency of Vitamin K
◦ Prolonged bleeding

◦ Increased clotting time

Oral manifestations
◦ Increased gingival bleeding,

◦ Prothrombin level <35%--bleeding after tooth

brushing,

◦ Prothrombin level <20%--spontaneous gingival

hemorrhage
Hypervitaminosis K

• Administration of large doses produces hemolytic anemia

and jaundice particularly in infants.

• The toxic effect is due to increased breakdown of RBC.

 Orthodontic implications of vitamin k
• Yamguchi,2006:Vitamin k2 is essential for gabba-
carboxylation of osteocalcin, a bone matrix containing
gabba-carboxyglutamic acid,which is synthesized only in
osteoblasts. Reduction in levels of vitamin K will result in
reduced bone density and possibly bone strength

• Iwamoto et al 2006: vitamin k2 prevented the acceleration of

bone resorption and the reduction in bone formation and
counteracted cancellous bone loss

• Cashman 2005: Patients on anticoagulants will be more

prone to rapid bone resorption and tooth mobility following
mechanical force application.
 Vitamin C (Ascorbic Acid)
First demonstrated by Holst and Frolich
in 1912.
Source : fresh citrus fruits –
orange ,lemon ,grape ,certain
vegetables, potato, cabbage.
RDA-approximately 60 mcg/day.
Functions:
Synthesis of collagen- bone formation,
stability of capillary wall, wound
healing.
• Aids in iron absorption.
• Reduces chance of atherosclerosis
and cancer.
Functions

• Synthesis of collagen- bone formation, stability of

capillary wall, wound healing.

• Aids in iron absorption.

• Reduces chance of atherosclerosis and cancer.

Deficiency

◦ Defect in collagen synthesis – hemorrhages,

purpura, ecchymosis.

◦ Loose attachment of periosteum to bone-

subperiosteal hematomas and bleeding into joint
spaces.

◦ Skeletal change-defective formation of osteoid

matrix.

◦ In severe cases, the gums may become retracted,

formation of periodontal pockets. Loosening of
teeth and loss of teeth.

◦ Impaired wound healing.

◦ Anemia
• Vitamin C deficiency produces
sub-clinical scurvy which is
related with damage in
development and eruption of the
teeth and formation of hypo
dimensional osseous bases.

Hypervitaminosis C
Gastrointestinal upset, diarrhea,
and iron toxicity.
◦ Ishikawa et al 2004- Vitamin C induces differentiation of stem cells into osteoclasts
through :

-Synthesis of type I collagen.

-Interaction with specific integrins.

-Activation of a protein kinase pathway

- Phosphorylation of osteoblast specific transcription factors.

◦ Spanheimer et al., even short term fasting ( 4 days) -40% reduction of collagen
production.

◦ NHANES III(National Health and Nutrition examination Survey)- odds of having

periodontal disease are 1.2 times greater in people with low dietary Vitamin C intake.

Orthodontic implication
We should always be cautious in trying to evoke PDL and bone remodeling in patients
with Vitamin C deficiency.
 VITAMIN B COMPLEX
◦ These consists of a group of
essential compounds which are
biochemically unrelated but occur
together in some foods.

Sources
◦ Green leafy vegetables,

cereals ,yeast , milk etc.

 THAIMINE(B1)

Source – polishings of rice , husks of wheat, yeast, pork, meat,

poultry and egg, peas, beans, pulses.
RDA - approximately 1.1mg

Function - Carbohydrate metabolism.

Plays 3 major functions.
1. Regulates oxidative decarboxylation of alpha-keto acids,
leading to synthesis of ATP.
2. Cofactor for transketolase in pentose phosphate pathway.
3. It maintains neural membranes and normal nerve
conduction.
Deficiency
Dry Beri beri

◦ Poly neuropathy-symmetric and appears as nonspecific peripheral neuropathy with

myelin degeneration and disruption of axons.

◦ Progressive sensory loss is accompained by muscle weakness and hyporeflexia.

Wet beri beri

◦ Peripheral vasodilation, peripheral edema.

◦ Heart –enlarged and globular

 Wernicke-korsakoff syndrome

◦ Wernicke encephalopathy- Degeneration of ganglia cells, Focal demyelination and

haemorrhage in nuclei surrounding region of ventricles and aqueduct.

◦ Opthalamoplegia, Nystagmus, Ataxia.

◦ Korsakoff psychosis- Confusion, Derangement of mental function, Retrograde

amnesia, Inability to acquire new information.
 RIBOFLAVIN( VITAMIN B2 )
Source- yeast, liver, germinating seeds, egg.
DRI-depends on total calorie intake, energy needs, body size
and growth rate. Around 1.1mg.
Function : As FAD or FMN, riboflavin acts as hydrogen carrier
in the process of oxidation.
Deficiency
• Cheilosis ,angular stomatitis
• Glossitis.
• Dermatitis
• Ocular changes
• A prenatal maternal riboflavin (B2) deficiency produces
anomalies of jaw and teeth, which shows shortness of
mandible and maxilla, cleft palate, severe anomalies of
incisor teeth, dentofacial malformations resembled angle’s
class II malocclusion.

• Vitamin B2 deficiency produces retardation of growth of

dentofacial structures.
 VITAMIN B3 (NIACIN)
Source – grains ,legumes and seed oils.
Synthesized endogenously.
DRI– approximately 14mg
Function – Essential component of coenzymes
NAD , NADP.
NAD- Metabolism of carbohydrates, amino
acids, fat.
NADP- HMP shunt in glucose metabolism.
Deficiency-Pellagra - Dermatitis.
Diarrhoea.
Dementia.
 PYRIDOXINE(B6)

3 Forms - Pyridoxal, Pyridoxol,

Pyridoxamine.

Source - present in all foods. food

processing may destroy
Functions -fat and protein metabolism
-transmission of neural impulse
Deficiency- dermatitis
-glossitis
-angular stomatitis
Excess intake of B6

• Permanent neurologic damage.

• That includes numbness in extremities and uncoordinated

muscle movement.

RDA- around 1.4mg/day.

 VITAMIN B-9 (FOLIC ACID)

Function- Helps in amino acid

synthesis.

Source- Dark green leafy vegetables

Deficiency- Causes fetal neural tube

defect and macrocytic anemia

RDI- approximately 400mcg/day

 VITAMIN B -12 (COBALAMINE)

Function- Converts Folate into the

form in which it can be used to produce
red blood cell and nucleic acids for
DNA synthesis

Deficiency- may cause pernicious

anemia.

RDI—approximately 2.4mcg/day
VITAMINS DEFICIENCY

A XEROPTHALMIA, DRY EYE.

B-1 BERIBERI
B-2 ARIBOFLAVINOSIS
B-3 PELLAGRA
B-6 MICROCYTIC ANEMIA
B-9 NEURAL TUBE DEFECT OF FETUS.
B-12 PERNICIOUS AND MEGALOBLASTIC
ANEMIA.
C SCURVY .

D RICKETS AND OSTEOMALACIA

E HEAMOLYTIC ANEMIA
K HEAMORRAGE –FAILURE TO BLOOD
CLOT.
 Oral deficiency symptoms

Vit A - Xerostomia
Oral leukoplakia
Hyperkeratosis
Softening of skull bone due to less Calcium deposition
Vit Bs- Red swollen lips
Burning, smooth, red tongue
Ulcerated burning gingiva
Vit C - Bleeding, swollen gums.
Loose teeth, slow healing.
Vit D - Failure of bone wounds to heal
Enamel hypo calcification
Loss of alveolar bone
Thinning of trabeculae

Vit E - No known deficiency symptoms

Vit K - Failure of wounds to stop bleeding

 MINERALS
Macro minerals which are present in relatively high amount in
body.
• Calcium
• Phosphorus
• Potassium
• Sodium
Micro minerals those which are <0.005% of the body weight.
• Iron
• Copper
• Manganese
CALCIUM

Inert inorganic element which is associated with bone and

tooth formation.

RDA - 360mg for infants and 800mg children and adults.

• Total calcium in the body is 100-170g.

• 99% of which found in hard tissue.
• The level of the blood calcium controlled by parathyroid
gland.
Functions
1. Bone formation.

2. Tooth formation.

3. Essential for growth

4. Blood clotting.
Abnormalities of Ca Metabolism

Osteoporosis
• Middle aged women
• Decreased density of bone
• Shortening stature
• Bone fractures

Osteomalacia
• Decrease in the mineral content.
• Lack of Vitamin D.
◦ Sidiropoulou et al. on the effect of osteoporosis on periodontal status, alveolar
bone and orthodontic tooth movement.

◦ Osteoporosis could affect the rate of tooth movement through the involvement
of alveolar bone. In healthy individuals, bone is constantly being remodelled
in the coupled sequence of bone resorption and formation.

◦ Experimental studies suggest that systemic-osteoporotic hormone imbalance

increases bone turnover and accelerates tooth movement while under
orthodontic treatment and subsequent relapse can be seen. Based on these
observations it can be concluded that deviations in bone turnover and
consequent periodontal problems influence the response to orthodontic forces,
and this should be taken into consideration when planning orthodontic
treatment in postmenopausal females or those on chronic medication affecting
bone metabolism.
 PHOSPHORUS
Forms 1% of the total body weight.

Functions
• Major constituents of bone and
teeth , is a part of hydroxyapatite
crystals

• Maintaining acid base balance

and regulation of pH of body
fluids

• Essential for cell multiplication

• Regulates the release of energy in

the form of ATP.
Deficiency

• It may lead to many neuromuscular , skeletal and

renal manifestations.

• Similar to hypocalcemia , hypophosphatemia may

lead to rickets in children and osteomalacia in adults.
 Fluoride
• It is form of element flourine.

• Studies in 1940’s till today confirms that Fluoride can

prevent dental caries.

Functions

• Important for all mineralized tissues in the body.

• “The Center for Disease Control and Prevention named

fluoridation of drinking water one of ten great public
health achievements of the 20th century noting that it is a
major factor responsible for the decline in dental decay.
How does fluoride act in dental caries prevention?

Three theories prevail:

1.Fluoride becomes incorporated into the hydroxyapatite
crystals of teeth, rendering them more resistant to acid attack.

2.Presence of saliva promotes remineralization of early carious

lesions. By means of having the molecule F replace the
molecule OH in the hydroxyapatite and transform it to
fluoroapatite, this process will make the enamel more resistant
to caries, only of the fluoride is given for a long period of time
on regular bases.

3. Fluoride interferes with metabolic pathways of bacteria, thus

reducing acid.
 Probable Toxic Dose
Minimum dose that would cause toxic signs and symptoms including death and
should trigger treatment management and hospitalization.
◦ 5 mg fluoride/kg (Whitford,1987)

Acute fluoride toxicity

The acute lethal dose of fluoride for man is probably 5g
Acute fluoride intoxication is rare.
Acute fluoride poisoning have been recorded :
◦ As a result of accidents
◦ Deliberate attempts to suicide
 Chronic fluoride toxicity

Effects on enamel:
◦ The influence of chronic fluorine intoxication is on the structure of enamel in the
development of mottled enamel
◦ Mottled enamel is characterized by minute white flecks, yellow or brown spot
areas , scattered irregularly all over the tooth stucture
◦ Premolars are most commonly affected
◦ Permanent teeth are particularly affected
 Dental Fluorosis
◦ If fluoride intake > 2 ppm
◦ Mottling of tooth enamel
◦ Developmental disturbance of enamel
◦ Caused by excessive exposure to high concentrations of fluoride
◦ Teeth become rough with brown / yellow patches on their surface
◦ Occurs at the age of 0-6 year only
◦ It is believed that fluorosed enamel may be more resistant to acid etching,
resulting in decreased bond strengths of orthodontic attachments to the enamel.

◦ Because of the increased porosity of fluorosed enamel, its physical strength may
Suffer and this may result in enamel damage during debonding, particularly if
high bond strengths to enamel are achieved on certain areas of the tooth.
◦ It is believed that fluorosed enamel may be more resistant to acid etching,
resulting in decreased bond strengths of orthodontic attachments to the
enamel.

◦ Because of the increased porosity of fluorosed enamel, its physical strength

may Suffer and this may result in enamel damage during debonding,
particularly if high bond strengths to enamel are achieved on certain areas of
the tooth.

◦ Fluorosed teeth manifest as an extensive hypomineralized subsurface layer

underneath an outer well-mineralized acid-resistant surface Layer. It is this
outer acid-resistant hypermineralized layer that prevents conventional 37%
phosphoric acid from effectively etching.

◦ Patients who present to the orthodontist with dental fluorosis need to be

advised about the difficulty and risks in bonding attachments to their teeth.
Importance of nutrition during orthodontic
treatment

Demineralization
◦ The unregulated sugar consumption, inadequate oral hygiene causes
decalcification of teeth under the bands and brackets.
◦ Featherstone and Glatz reported measurable demineralization, gingival to
bands and brackets in a period of 4 weeks.
 Root resorption
◦ The problem of root resorption is an important challenge in orthodontic
therapy which can be influenced by the type of diet.

◦ According to Marshall et al deficient diets cause greater resorption as

compared to adequate diets as seen through animal studies.

◦ Beck study on dogs revealed more susceptibility to resorption following

calcium and vitamin deficiencies .Vitamin D maintains calcium phosphorous
balance and its deficiency leads to cemental resorption .
 Dental decay

◦ The sticky foods and improper oral hygiene raise the vulnerability of
the dentition towards dental caries.
◦ Many foods carry constituents called buffers like calcium from milk
and protein from meat, which can neutralize or absorb acids.
◦ Topical Fluoride application inhibits dental caries by conversion of
hydroxyapatite crystals of enamel into less acid soluble fluorapatite.
◦ But excess fluoride should be avoided to prevent dental fluorosis
characterized by brownish and corroded appearance of teeth.
 Effect on tooth movement and stability of
orthodontic correction

◦ The orthodontic forces induce biologic responses, which involves complex

coupling of osteoclastic and osteoblastic activities.
◦ Collagen metabolism depends on adequate supply of Vitamin C for production
of mature collagen.
◦ The lack of Vitamin C affects periodontal ligament and creates enlarged
endosteal and periosteal spaces with osteoclastic activity.
◦ It has also been observed in vitamin C deficient individuals that
orthodontically corrected teeth were unstable and relapse is faster as compared
to individuals with no vitamin C deficiency.
 Effect on bone health

◦ For modest bone health, Calcium phosphorous ratio should be greater than 1 .

◦ In adolescent diet and with orthodontic treatment, this ratio was found to be less
than 1 due to the consumption of phosphorous rich soft drinks and fast foods
with avoidance of calcium rich dairy products .
 Orthodontic Treatment and Balanced Diet

◦ During orthodontic treatment, nutritional history should be accounted and

patients’ diet should be adjusted to include all necessary elements keeping in
mind the habits, convenience, likes and dislikes of the patients.
◦ Dairy products (milk, cheese, ice cream) should be prescribed during
orthodontic treatment as they are soft and assist bone remodelling during tooth
movement
◦ Understanding the importance of nutrition, American dental association has
delineated in 1987 guidelines “the graduate must be competent to provide
dietary counselling and nutritional education relevant to oral health”
◦ Learning of nutrition and diet is also incorporated in dental education in Indian
institutions.
 During orthodontic treatment, patients are advised to follow stop, halt and go
pattern of food consumption.

Stop (Never Eat)

◦ Chewing gum, caramel, toffee and all sticky candy, ice cubes, popcorns
kernels, raw apple or carrot, corn on corb, 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)
◦ Potato chips, steamed vegetables, french fries, yoghurt, pudding, jelly, soup,
cereal in milk, cheese, eggs, milk shakes, icecream without nuts.
CONCLUSION

◦A basic understanding of nutrition as well as good guidance

and communication skills, will help orthodontic
practitioners to improve their orthodontic outcomes in
addition to helping improve the quality of life of their
patients.
◦The key to effective diet education in the orthodontic office
is a logical, ordered approach, which includes patient
education, data collection, data evaluation/ diagnosis,
providing nutrition guidance, follow-up and re-evaluation,
and a few key personalized recommendations.
 REFERENCES

• Integrated Clinical Orthodontics - Vinod Krishnan, Ze’ev Davidovitch.

• Pathologic basis of disease - Robbins.
• Textbook of medical physiology - Guyton and Hall.
• Textbook of social and preventive medicine – K.PARK.
• Orthodontic tooth movement during an ascorbic acid deficiency. AJODO
1974 ; 65: 3, 290–302.
• Adrian E. Martına,Maria del R. Pania,Nora Ruiz Holgado, Laura I. Lo pez
Mirandaa,Hector E. Meheris, Juan A. Garata. Facial development disorders
due to inhibition to endochondral ossification of mandibular condyle process
caused by malnutrition. Angle Orthod. 2014;84:473–478.