وزارة التعليم العالي والبحث العلمي
جامعة بابل
كلية طب الاسنان

بسم الله الرحمن الرحيم

اعداد الطلبة:
امير عباس محمد
زيد نجاح عباس
عبدالله حيدر محمد
نور صالح هادي

تحت اشراف الدكتورة:
زهراء محمد حسين ويس
ماجستير طب اسنان الوقائي







nutrition :

nutrition is considered as one of the most important factors influencing the quality of human life worldwide, also nutritional deficiency is directly related to the retardation of growth and development, decrease resistance to infection and environmental hazards1

. the role of nutrition in the maintenance of health and growth, food choices and nutritional intake may affect the dental health2, it might also be affected by poor dental health. adequate nutrition and exercise are important for the fulfilment of growth and maturation3 , so insufficient food for a significant period at any time during childhood may prevent an individual from reaching his full potential in height and weight4. foundations for good health in adulthood lies on adequate nutrition and healthy eating and physical exercise habits at this age5.

nutrients are the constituents of food necessary to sustain the normal functions of the body. these compounds provide that needs both energy and essential molecules for growth and maintenance. nutritional science investigates the metabolic and physiological responses of the body to diet. the study of how food affects the body implying the study of nutrition. it is the enough providing of elements like minerals, vitamins, water, fibers and other food ingredients to organisms and cells, for supporting life. there are many health problems that are common and can be prohibited or avoided with good diet6 .

nutritional status :

food and nutrient intake, absorption and utilization relates to the condition of health can be defined as nutritional status which is an important factor in enhancing immune system and resistance to general and oral infectious diseases7. nutritional status is the condition of health of a person that is influenced by the intake and utilization of nutrients8.

nutritional status is essentially supported by diet. a healthy diet contains all the important nutrients in amounts required to meet individual s needs7 .world health organization defined the nutritional status as an outcome of a wide range of socio-economic condition, it is a sensitive indicator of overall level of development and for estimation the need for increased food supplies1.


the growth and prosperity of a nation depend heavily on the nutritional status and development of adolescent girls as they not only constitute one tenth of its population but also influence the growth of the remaining population9.

nutrition and oral health :

the relationship between nutrition and oral health is interdependent that good oral health promoting good nutritional health and vice versa . the well-being of the oral tissues, the quality and quantity of saliva and the dimension of taste depend on the intake of nutrients. oral health determines the type and quality of food consumed and ultimately the nutritional level6. oral tissues, such as teeth, gingival and muscles of mastication, are living tissues, and as any other living tissue in the body have the same nutritional requirements10.

nutrition could have a strong impact on oral health11. there is an ongoing interaction among the integrity of the oral cavity in health and disease and nutrition12. diet and nutrition affects the integrity and developing of the oral cavity in addition to the evolution of oral diseases13. nutrition, for example, influences craniofacial development, oral cancer and oral infectious diseases, dental diseases related to diet include dental caries, developmental defects of enamel, dental erosion and periodontal disease. in developing countries, these diseases exert a social, physical, mental and financial burden on global scale, despite widespread preventive measure, oral health problems continue to be one of the most common infectious disease14,15. nutritional imbalance can affect tooth development and calcification.


carbohydrates & caries

the relationship between carbohydrates and dental caries depends on the type of carbohydrate (sugars or starches) consumed because the cariogenic potential (i.e., promoting the development of tooth decay) of a given carbohydrate is dependent on how efficiently it can be metabolized by the bacteria that ferment it. sugars, specifically, are considered to be the most important drivers of caries development. the term free sugar includes all sugars added to food/beverages, as well as the naturally occurring sugars found in fruit juices and concentrates, honey, and natural syrups. collectively, natural and free sugars (e.g., sucrose, glucose, fructose) are considered the primary necessary factors in the development of caries. sucrose, a disaccharide of glucose and fructose, is the most cariogenic sugar. sucrose acts as a substrate for the synthesis of intra- and extracellular polysaccharides in dental plaque. additionally, dental plaque formed in the presence of sucrose has been shown to have lower concentrations of calcium, inorganic phosphate, and fluoride, which are the ions required to remineralize enamel and dentin. sucrose and its constituent monosaccharides, glucose and fructose, are also more cariogenic than starches because they enter the glycolytic pathway more rapidly and result in a more pronounced droping in ph .although lactose is also a sugar, it is less cariogenic than sucrose, fructose, and glucose


because its fermentation produces a smaller droping in ph. amount/frequency of sugar intake in addition to the type of sugar consumed, the amount consumed may affect caries development. a 2014 systematic review examining the effect of free sugar consumption on dental caries observed a consistent association between free sugar intake and caries development higher incidence of caries was found in populations where free sugar intake was greater than 10% of total energy intake compared to those with free sugar intake of less than 10%.14 this systematic review informs the world health organization (who) guidelines for sugar intake, which recommends that free sugars be less than 10% of total energy intake, with a further reduction to less than 5% suggested. frequency, or how often free sugars are consumed, may also play a role in caries development. increased frequency of sugar consumption and additional snacking between meals have been hypothesized to be more important in predicting caries risk than total sugar consumption. a possible rationale for this concept is that it takes approximately 30 minutes for the ph to droping after an intake of sugar, so additional sugar intake within that 30-minute period is less harmful than additional intake after 30 minutes. it is, however, difficult to determine the relative contribution of amount of sugar and frequency of sugar

consumption to dental caries risk, given that the two are highly interrelated.31,32

chemical classification of carbohydrates

on the basis of the number of forming units, three major classes of carbohydrates can be defined: mono saccharides, oligosaccharides and polysaccharides.

1-mono saccharides

or simply sugars are formed by only one polyhydroxy aldehydeidic or ketonic unit. the most abundant monosaccharide is d-glucose, also called dextrose.

2-oligosaccharides

are formed by short chains of monosaccharidic units (from 2 to 20) linked one to the next by chemical bounds, called glycosidic bounds.the most


abundant oligosaccharides are disaccharides, formed by two monosaccharides, and especially in the human diet the most important are sucrose (common table sugar), lactose and maltose. within cells many oligosaccharides formed by three or more units do not find themselves as free molecules but linked to other ones, lipids or proteins, to form glycoconjugates.

3-polysaccharides

are polymers consisting of 20 to 107 monosaccharidic units they differ each other for the monosaccharides recurring in the structure, for the length and the degree of branching of chains or for the type of links between units.whereas in the plant kingdom several types of polysaccharides are present, in vertebrates there are only a small number.

polysaccharides are defined omopolysaccharides if they contain only one type of monosaccharide as starch, glycogen and chitin

eteropolysaccharides, instead, contain two or more different kinds (e.g.

hyaluronic acid).

note: the term “saccharide” derives from the greek word “sakcharon”, which means sugar.

stephan s curve

acidogenic bacteria in dental plaque rapidly metabolize fermentable carbohydrates producing acidic end products. in the mouth, these changes over time in response to a challenge are known as stephan responses or stephan curves.

the curve on a graph, first described by robert stephan in 1943, showing the fall in ph below the critical level of ph 5.5, at which demineralization of enamel occurs following the intake of fermentable carbohydrates, acidic liquids, or sugar in the presence of acidogenic bacteria. after


consumption, there is an elimination of the acid and a return to normal saliva or plaque ph, at which point repair of any destruction of the enamel structure takes place (remineralization). repeated intakes of fermentable carbohydrates cause the low ph to be maintained for longer periods, thereby not allowing remineralization to take place34.


































malnutrition:

the world health organization defines malnutrition as a number of condition with specific etiology derived from the imbalance of the cells between supply of one or more energy, nutrients and the body s demand for them to ensure maintenance, growth, reproduction and specific functions1,16.

the term malnutrition refers not only to deficiency state, but also to excess or imbalance in the intake of calories, proteins and or other nutrients17. malnutrition may occur due to lack of breast feeding,


improper weaning, poverty, long economic blockade, deprivation, social inequality, war as well as lack of education18,19. malnutrition can either be
over-nutrition or under-nutrition.

modern western malnutrition consists of children being fed wrong food either high carbohydrates leading to too many calories and obesity, or protein, calories, vitamins and minerals deficiencies resulting malnutrition20. malnutrition can be diagnosed by anthropometric measurement by using specific criteria of physical growth and development specially in the absence of clinical and subclinical signs18. malnutrition has many types these are 21 :

1. protein energy malnutrition (pem).

2. iron deficiency disorders (idd).

3. vitamin a deficiency.

4. vitamin c (ascorbic acid) deficiency .

obesity

nutrition is vital to human development and maintaining health. today, more than ever before, people are concerned with optimising their health by acquiring nutritional information and applying it to their daily lives, because obesity and other nutritionally related chronic disorders are on the rise35 . obesity has become a global health problem existing throughout post-industrial and developing regions. the prevalence of overweight status is higher than 30% in latin america36. global changes over the past decade have led to serious dietary changes in populations, like the trend towards consuming soft drinks and fast foods, which together with other life styles changes have contributed to the ever-increasing number of overweight people worldwide .

according to the american academy of pediatrics, committee on nutrition (2003), being overweight is now the most common medical condition of childhood, with the prevalence having doubled over the past 20 year diets high in sugar (for example, added sugar) have been associated with various health problems, such as dental caries, dyislipedemias, obesity, bone loss and fractures and poor diet quality. added sugar is defined as sugar that is eaten separately at the table or used as an ingredient in processed or prepared foods, such as cakes and cookies, soft drinks and ice cream. this term helps consumers to identify food and beverages that mostly provide energy but are poor sources of micronutrients37. in addition, sweetened drinks (fruitades, fruit drinks, soft drinks, etc) constitute the primary source of added sugar on children’s daily diet38. furthermore, soft drinks pose a risk of dental caries because of their high sugar content and enamel erosion due to their acidity39 . when sugar intake exceeds 15 to 20 kilograms per person per year, such intake is directly associated with increasing caries prevalence40

. in addition, people with early tooth loss clearly showed a deviation from preferred foods, as well as a deficiency of certain vitamins and microelements. this may be because people who cannot chew or bite comfortably are less likely to consume high-fibre foods such as bread, fruit and vegetables, thereby risking reducing their intake of essential nutrients41.

dentition status

dental caries

dental caries is a demineralization of the inorganic part of the tooth with the dissolution of the organic substance depending on interaction of several factors: oral micro flora (acidogenic bacteria) diet (fermentable carbohydrate), time and host42,43 . it is the most prevalent chronic disease and most common infectious disease affecting persons of both gender in all races and every age group44 . the disease may start early in life, if not

treated it may progress to involve bulk tissues and end up with tooth loss45 .


dental caries is a dynamic process of demineralization of tooth structure which occur between pathological factors (cariogenic bacteria, reduced saliva and frequency of fermentable carbohydrate) and protective factors (salivary flow, fluoride exposure and dietary component)46.

etiology :

the etiology and pathogenesis of caries of tooth are well-known to be multifactorial involving many element including dietary exposure (fermentable carbohydrate), oral microflora (acidogenic bacteria), and

susceptible host (physiochemical composition of saliva, quality of tooth) with enough time47,48. tooth factor had a role concerning resistance or

susceptibility to caries this is achieved through its morphological and compositional characteristic49 .

genetic factors may represent a correlation factors with dental caries as they may affect susceptibility in addition oral immune system and parameters of saliva50 .

factors affecting caries prevalence:

1. age:

dental caries starts early in life, shortly after tooth eruption and increase with age advancing so the world health organization recommended special age groups (index age) these are 5 years for primary teeth and 12, 13, 35-44 and 65-74 years for permanent teeth1 . concerning with age, 15 year- old is one of the target age groups at this age, all permanent teeth will have erupted excepting third molars so that it is used for monitoring of disease trends and international comparisons . the carious attack is spread out more throughout life and caries has to be viewed as a life time disease, where caries experience is severing, the disease seems to start early and it is common in the young . caries experience for permanent dentition increased with age, the cause may be related to accumulative and irreversible nature of dental caries also as the longer a tooth is exposed to the oral cavity, the more time for the caries process to work .

2. gender :

a controversy was seen by different studies concerning the relation between gender and dental caries. some studies showed that males were higher than females in caries experience . other studies showed that females were higher than males in caries experience , this may be related to earlier tooth eruption among females as the risk for dental caries is a function of a time a tooth is exposed to the oral. on the other hand, many studies showed no differences between two genders.

3. oral hygiene :

it can be defined as regular different activities and methods to keep mouth and teeth clean in order to prevent dental and periodontal problems

. many studies reported the relationship between the oral hygiene and dental caries and most of them revealed that people with good oral hygiene had a fewer caries occurance than those with poor oral hygiene .

4. geographic location:

the caries experience was varied from one geographical location to another, these variations in prevalence and severity of dental caries between urban and rural area was attributed to the interaction of several factors among such as water and fluoride, soil elements, dietary habits, culture, tradition, occupation, educational and socioeconomic levels, genetic and others . several studies have shown that the prevalence of dental caries was more in people resident in urban areas than those resident in rural area . while other studies found that caries experience was higher in the rural area than in urban .

5. race:

race or ethnic background is considered to be an effective factor on the prevalence and severity of dental caries to a degree that it implies cultural, social, economic and possibly genetic differences and therefore differences in the diet, oral hygiene and education . studies found a lower caries experience among asian and african as compared with european children . on the other hand, other studies found that high caries experience among asian compared to european . study revealed that white and black students had similar caries experience.

6. fluoride:

fluoride plays important role in prevention and declination of dental caries by its effect during development and maturation of the teeth which made them more resistance to caries attack. both pre and post-eruptive fluoride exposure maximize the caries preventive effects . many studies showed that a lower caries experience following fluoride administration .

in iraq, epidemiological studies have been conducted to determine the concentration of fluoride in drinking water. hilm et al (1971) found that the public water supply in baghdad contained 0.9 ppm of fluoride, while alalousi and khadhim (1983) found that fluoride concentration ranged (0.090.24) ppm. al-azawi (2000) revealed that the concentration of fluoride in drinking water in different governorates in iraq is ranging from (0.12-0.22) ppm. this level is considered very low, that may explain a high prevalence of dental caries in iraq. finally, al-shuker (2014) in al-muthna revealed that the concentration of fluoride in drinking water is (0.79-1.76) ppm. the declination of caries experience in many countries was attributed to communal water fluoridation as well as the commonly use of fluoridated topical products as fluoridated dentifrices and mouth rinse along with professionally applied fluoride. with regard to fluoridated toothpaste, studies have shown consistent reduction in caries experience .

7. socioeconomic status (ses(:

the relation between socioeconomic status of individuals and dental caries have been well established for a long time . a study reported that the following social factors (socioeconomic level, education, income and occupation) affect the prevalence, severity and type of treatment of the dental caries . socioeconomic and behavioral factors may act as caries-promoting factors .

socioeconomic status (ses) is typically divided into three divisions, low ses, middle ses and high ses to explain the three area of families .

the families with higher level of education, higher income, better occupation and those residing in higher costal residency have caries


experience which attributed to the reason of consuming more refined sugar and cariogenic foods. while in developed countries this relation is reversed, studies had shown that subject from high social class have lower caries experience than those who belong to lower social class and this could be due to more awareness of the importance of utilizing the dental services and the use preventive measures in high classes in the developed countries.

some studies showed that there is no significant correlation between ses and dental caries . while other studies show increase dental caries prevalence among low socioeconomic groups. other studies show increase caries prevalence among high socioeconomic groups.

8. diet and nutrition :

they are important factors in the promotion and maintenance of good oral health throughout the entire life course . they can affect tooth either locally (post eruption) or systemically (pre eruption), the post eruption effect is seen to be more important than pre eruption, the post eruptive local effect of diet especially sugar consumption without doubt lead to increase in caries prevalence . while nutritional deficiencies impaired immune response and intensify the severity of oral infection including dental caries .

numerous epidemiological studies were conducted in the world as well as in iraq and showed that the nutritional status and malnutrition greatly affected on the dental caries and lead to increase its prevalence and severity . while many studies reported no association between caries and malnutrition . other studies showed that the amount and the frequencies and sugar intake lead to increase in dental caries .


dental caries and malnutrition :

there are three mechanisms explained that malnutrition during tooth development can make teeth more susceptible to dental caries. the first is that malnutrition causes defectively formed tooth, the second one is that the eruption of teeth is delayed among malnourished children, the last mechanism is that malnutrition can lead to increased dental caries by affecting salivary gland development and function (reduced salivary flow



and altered the composition of saliva resulted in reduced the buffering capacity of the saliva and increases the acid genic load of the diet, develops the hypoplasia which increases dental caries susceptibility51,52. it was thought that provision of good nutrition while the teeth were developing was the principle way to prevent dental caries. it is known that the topical effect of diet in the mouth after the teeth have erupted plays a much more important role53.
several studies found that there is a significant association between dental caries and malnutrition among adolescents. other epidemiological studies observed that malnourished were more susceptible to dental caries than well-nourished due to it interfaces with dental composition, morphology and eruption time of tooth for both primary and permanent dentition54,58.
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