As health professionals, we do not expect to come across malnutrition and nutritional deficiency often in daily practice. The typical understanding of these terms often conjures up images of underweight and starving individuals. From an oral health standpoint, examples of scurvy and pernicious anaemia are often used as the oral manifestation of deficiency symptoms. In the western world, however, we are unlikely to see such examples of acute nutritional deficiency states in our clinics on a regular basis. What we may be observing, however, is marginal nutritional deficiency states.
Malnutrition is defined as: ‘The absence of essential elements needed for health, arising from a deficiency in the diet’ (The Concise Oxford Dictionary, 8th Edition). Malnourishment, therefore, can arise in both deficient and excess dietary states. These states also have both physical and oral manifestations.
Risk factors
General physical observation can identify possible nutrient deficiencies, such as overall appearance, weight/height ratio, and the condition of the skin, hair and nails. Many conditions often cause inadequate dietary and nutrient intake, malabsorption and utilisation of nutrients and, even, increased nutrient intake. A checklist can help identify any conditions or eating habits that may put the patient at risk both nutritionally and orally. A review of the patient’s medical history will help identify those potentially at risk.
In addition to medical disorders, eating disorders and extreme fad diets can have detrimental effects on both the oral cavity and the nutritional status of the individual. These include:
• Strict fruitarianism
• Very low carbohydrate/high protein diet
• Very low protein diet
• Repeated strict weight loss diets
• Unsupervised, self-diagnosed lactose and/or gluten intolerance
• Poorly constructed vegan diet
• Poorly constructed vegetarian diet.
Protein deficiency symptoms
Although protein deficiency is not one of the most commonly seen nutrient deficiencies, it can occur in a poorly balanced vegetarian diet. Since the oral cavity has a high turnover rate for many of its constituents, particularly collagen, a deficiency of dietary protein can produce clinical changes in the soft tissues. One of the principal consequences of protein deficiency is an increased susceptibility to infection.
Mild protein malnutrition has been shown to reduce the effectiveness of the inflammatory response to invading pathogens (Sherman AR, 1992). In addition to this, depressed immunoglobulin A (IgA) in saliva, complement protein, phagocytic function, interleukin-1 secretion from monocytes and T-cell mediated responses exist that may all facilitate oral infection, periodontitis and alveolar bone loss. The World Health Organization (WHO) recommends that 0.5g of protein per kilo of body weight is needed each day for repair and maintenance.
Fatty acid deficiency
Most people desiring to achieve a healthy regime will often aspire to a fat-free diet. Essential fatty acids (EFAs), however, are just that – essential. EFA deficiency often produces a range of symptoms. Among the main ones are poor wound healing due to failure of connective tissue, loss of membrane integrity, in particular the skin, impaired immune function and increased host susceptibility.
Gamma-linolenic acid (GLA) from plant oils and eicosapentaenoic acid (EPA) from fish oils are essential dietary components for humans. EFA deficiency is manifested by the inability to synthesise prostaglandins (El-Attar TMA, 1978). Some of the most potent mediators of the immunoinflammatory pathways are prostaglandins. The prostaglandin groups 1 and 3 (PGE1 and PGE3) are known be anti-inflammatory and oppose the excess production the pro-inflammatory prostaglandin group 2 (PGE2). GLA works as an anti-inflammatory agent, by blocking the mobilisation of PGE2. EPA from fish oils also appears to prevent the synthesis of the pro-inflammatory PGE2 (Horrobin DF, 1980). Studies have shown that levels of PGE2 are significantly elevated in periodontally diseased tissue when compared to healthy periodontal tissue (El-Attar, 1981). While it is by no means certain that EFA deficiency is involved in the aetiology of periodontal disease, it is easy to see how deficiency may modify the host’s response to bacterial plaque and compromise the integrity of the oral mucosa.
Other EFA deficiency symptoms include dry, cracked lips, dry skin, apthous ulceration, peeling, brittle or split nails, hair loss or thinning hair, and poor wound healing.
Vitamin A
Vitamin A is important in the synthesis of connective tissue and the collagen matrix of cartilage and bone. It is also produced intracellularly by metabolism of beta-carotene. Vitamin A acts on cells that have both a rapid turnover and the potential to differentiate in more than one direction (Zile MH et al, 1983). It is, therefore, particularly indicated in the maintenance and integrity of the mucous membrane. For instance, a decrease in the rate of proliferation of epithelial cells is one of the earliest symptoms of vitamin A deficiency (Tinker D et al, 1985). A deficiency, therefore, can affect epithelial tissue and bone formation and maintenance. Lack of vitamin A can cause decreased salivary flow and hyperplasia of the gingival epithelium. Other deficiency symptoms may include apthous ulceration, acne and dry, flaky skin.
Vitamin C
Vitamin C contributes to the integrity of fibroblasts, osteoblasts, chondroblasts and odontoblasts. It plays a key role as a reducing substance in the synthesis of collagen, which is the main organic component of extracellular matrices of many tissues, as well as bone.
Without vitamin C for collagen synthesis, connective tissue formation and maintenance, wound healing and scar tissue formation would all be adversely affected.
Because collagen is the essential organic matrix necessary for the deposition of calcium phosphate crystals during bone formation, a deficiency in vitamin C may also affect bone formation.
Recent study has suggested that periodontal disease is more common in patients with poor vitamin C intake (Nishida M et al, 2000).
Vitamin C is also required for the integrity of the blood vessels. A deficiency could therefore increase the intracellular permeability of blood vessels, as well as the sulcular epithelium (Nakamoto T et al, 1984), thus predisposing the patient to periodontal disease and/or bleeding disorders.
Vitamin C is also involved in the immune response; it is involved in phagocytosis and can increase the resistance of tissues to infection. Those at risk of deficiency include smokers and diabetic patients, in addition to patients with eating disorders. Deficiency symptoms may include easy bruising, frequent colds or infections, nose bleeds and slow wound healing, sores and spots on the skin, increased susceptibility to periodontal disease, and swollen, bleeding gingival tissues in the absence of dental plaque.
B vitamins and iron
B vitamin deficiency is particularly manifest in the mouth. The most common symptom is loss of integrity in the oral mucosa (Bamji MS et al, 1979). A sore mouth is one of the first indications of a B6 deficiency. Riboflavin (B2), B6 and iron deficiency is often indicated in angular chelitis or stomatitis. A lack of folic acid causes apthous ulceration and can exacerbate sore mouth, throat and oesophagus. When in good health, the tongue is an even red colour and resembles a fresh, juicy strawberry. Geographic tongue occurs from a prolonged deficiency of the vitamins, as well as zinc; the taste buds clump together and fissures and ridges are present. Inadequate riboflavin (B2) can discolour the tongue, giving it a purple appearance, while insufficient niacin (B3) can colour it bright red. A smooth, shiny tongue, as in glossitis, indicates B12, riboflavin, niacin and folic acid deficiency. An inflamed, sore tongue can reflect B6, B12, riboflavin, niacin and iron deficiency. A large, plump-looking tongue can result from a lack of pantothenic acid (B5).
Zinc
Zinc is an essential trace element of significant biological importance in cell membrane integrity, epithelial cell turnover (Hsu T et al, 1992), connective tissue (Fernandez-Madrid F et al, 1973) and immune system regulation (Allen JL et al, 1983).
Studies show zinc deficiency leads to T-cell depletion, phagocytic activity is lowered and sulcular epithelial permeability is increased (Spiers RL et al, 1992).
Zinc is also needed for adequate wound healing (Lansdown AB, 1996; Faure H et al, 1992). Deficiency symptoms may include white marks on more than two fingernails, acne and/or pale skin, poor sense of taste or smell, frequent infections, poor wound healing, and apthous ulceration.
Calcium, magnesium and vitamin D
The effect of calcium in bone density is well documented (Breslav NA, 1994). Adequate calcium intake is important to attain peak bone mass and oppose age-related bone loss. Recent study reveals periodontal disease with alveolar bone loss is also influenced by calcium intake (Nishida M et al, 2000).
Magnesium is an important co-factor involved in the enzyme-regulated process of Ca+ absorption into hydroxyapitite crystals (Vikkanski I, 1993).
The other important part of the equation is vitamin D, which helps regulate the absorption of calcium from the gastrointestinal tract and influences osteoclast activity (Totora GJ et al, 1993). There is an increasing body of evidence emerging to suggest a link between poor systemic bone density and risk of periodontal disease (Krall EA et al, 1994).
In addition to eating disorders, calcium, magnesium and vitamin D deficiency often occurs in self diagnosed or poorly supervised lactose intolerance, long-term use of antacid preparations and avoidance of fruit and vegetables, especially dark green vegetables.
Calcium and magnesium deficiency symptoms may include muscle cramps or spasms, high blood pressure and irregular heart beat, osteoporosis or poor bone density, increased dental caries, and exacerbated alveolar bone loss.
Conclusion
While there is no substitute for good oral hygiene in the prevention of oral disease, it is clear that a poor diet and nutrient deficiency will exacerbate the progression of dental caries, periodontal disease and loss of oral function. The health of the oral cavity is fundamental in facilitating and achieving good digestion and absorption of key nutrients. Thus when addressing oral health, good nutrition and excellent oral hygiene go hand in hand.
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