Adequate nutrition is of importance in two key developmental stages in childhood: the pre-school years and the adolescent growth spurt, as these are times of rapid growth and development. The school years before adolescence represent a time of more gradual, steady growth, with nutritional risks being lower.
As far as oral development is concerned, the eruption and completion pattern of the permanent dentition continues between ages three and 18, with mineralisation factors (such as calcium and vitamin D) being of particular importance during this time. Other nutrients of importance in oral development include: calcium, magnesium, zinc, vitamins A, D and C, folic acid, the B vitamins, and protein. Changes in the structural integrity of the oral mucosa may signal ongoing deficiencies of the B vitamins, biotin, vitamin C, vitamin K, iron and protein calories.
The key mineralisation factors in the diet are calcium, magnesium and vitamin D. As vitamin D is found exclusively in animal foods, vegan or vegetarian children need to eat fortified foods or take a supplement, particularly in the winter months or if the child is covered extensively and so not exposed to sunlight. For children who do not consume milk, good sources of calcium and magnesium are found in dark green vegetables, nuts and seeds, fortified soya milk and nut milks.
Other key minerals such as iron and zinc are less easily absorbed from non-animal sources. Cereals high in fibre and phytic acids inhibit the absorption of these key minerals if eaten at the same time. Absorption of iron is aided by vitamin C rich foods.
The most common deficiencies in poorly balanced diets are those associated with the B vitamin complex. The B vitamins are found in most meat and animal products, however they are also found in adequate amounts in cereals, grains, rice and pulses. The refining of grains vastly reduces B vitamin levels, while inadequate protein intake can also affect B vitamin status. Ensuring the inclusion of a wide range of lean protein, cereals, nuts and pulses provides adequate complete proteins and B complex intake.
In good health, a child’s tongue is an even, red colour. Geographic tongue occurs from a prolonged deficiency of the B vitamins, as well as zinc; the taste buds clump together and fissures and ridges are present.
Having an enlarged tongue (including lateral taste buds) that is shiny, bright red and grooved indicates B vitamin deficiency.
A sore mouth is one of the first indications of a B6 deficiency. Riboflavin (B2), B6 and iron deficiency is often indicated in angular cheilitis or stomatitis. Other common symptoms include:
• Cracks and sores to the lips or angles of the mouth
• A red, sore tongue and dry scaling around the nose, mouth and forehead
• Friable mucus membranes
• Apthous ulceration.
Followers of a vegan diet are particularly at risk of vitamin B12 deficiency in the long term. This particular member of the B complex is found only in animal produce, and although the body needs relatively small amounts, gastro-intestinal conditions or prolonged antibiotic use can adversely affect B12 synthesis and absorption from the gut.
The most significant manifestation of B12 deficiency is the potentially fatal condition pernicious anaemia, characterised by pale skin and mucus membranes, exhaustion and poor co-ordination.
Vitamins A and C
Vitamin A is important in the synthesis of connective tissue and the collagen matrix of cartilage and bone. It is particularly indicated in the maintenance and integrity of mucus membrane. A deficiency can affect epithelial tissue and bone formation and maintenance. Lack of vitamin A can cause decreased salivary flow and hyperplasia of the gingival epithelium. Vitamin A deficiency is also known to cause morphologic changes in tooth structures (Punyasingh JT et al, 1984). Dentinogenesis and early mineralisation of enamel and dentine are affected (Navia JM et al, 1984). For vegetarian children, intake of vitamin A as beta carotene is essential. Deficiency symptoms may also include apthous ulceration, acne and dry, flaky skin.
As for vitamin C, ascorbic acid is essential to the biosynthesis of collagen, the major organic matrix component of dentine. Studies indicate that ascorbic acid deficiency hampers dentine formation (Ogawara M et al, 1997).
Because collagen is the essential organic matrix necessary for the deposition of calcium phosphate crystals during bone formation, a deficiency in vitamin C will also affect bone formation. Deficiency symptoms may include:
• Easy bruising
• Frequent colds or infections
• Nose bleeds and slow wound healing
• Sores and spots on the skin
• Bleeding gingival tissues in the absence of dental plaque.
Early studies have also suggested that vitamin C deficiency is associated with a decreased rate of eruption (Berkovitz BK, 1974).
The importance of breakfast
Blood sugar levels are low in the morning and studies have shown that children who do not eat breakfast are more likely to suffer from poor concentration and often have poor academic performance. Stable blood sugar levels help to prevent the urge to snack on sweets, biscuits or refined carbohydrates throughout the day. Many children do not have breakfast and often eat sweets and crisps on the way to school.
From a nutrition point of view, snacking throughout the day helps to ensure stable blood sugar levels and, when chosen wisely, can increase nutrient content of the diet.
From a dental health point of view, snacking on foods containing sugars and fermentable carbohydrates increases the risk of caries. Choosing tooth-friendly snacks is therefore vital. Home-made popcorn is fun to make and portable. Made at home, minimal oil in cooking can be used and no salt or sugar added. Other snack foods can be cooked in advance and kept in the fridge such as: good quality grilled sausages and chicken drumsticks or cheese sticks.
Fresh fruit and vegetables
In line with the Government’s recommendation to eat ‘five a day’, fresh fruit is often the most versatile snack. It is nutritious, widely available and portable. Most supermarkets offer ‘fun size’ or ‘baby’ options. Finishing a snack with a small cube of low-fat hard cheese will help to remineralise the enamel surface.
Nuts and seeds
Nuts and seeds provide essential minerals such as calcium, magnesium, zinc and chromium. Essential fatty acids needed for nervous growth and development are also provided.
For those children who are not sensitive to nuts, brazils and almonds can be dry roasted along with seeds such as sesame, pumpkin and sunflower. Nut butters such as peanut, almond or hazelnut can be spread on wholemeal bread fingers or mini rice cakes. Many supermarkets offer sugar- and salt-free nut butter.
When children complain of headaches, tiredness or manifest symptoms such as fatigue or irritability, this can be taken as a sign of dehydration.
Waiting until the mouth feels dry or the child feels thirsty is often too late to avoid mild dehydration. Combine this with the active lifestyle of most children and the intake of sweets, chocolate and crisps, and it is easy to see how dehydration can quickly occur.
Still water is the most obvious choice from both a dental health and hydration point of view. Bottled water is easily accessible and portable, is widely available and makes a good choice instead of fizzy drinks. Lightly flavouring water with fresh fruit juice can make it more interesting. Milk is also a good choice and trying unsweetened soya milk can make an interesting change.
For older teenagers who wish to eat with their peers, nutritious choices can be made at the local shop. Most shops now stock a variety of sandwiches, fruit and yoghurt.
Wholegrain bread sandwiches filled with chicken, ham, tuna, eggs or salad make good choices.
When considering the caries challenge of specific foods, we must not forget the other significant parts of the equation – the local oral environment, age, bacterial composition, oral clearance and plaque control are all significant factors in the cariogenicity of certain foods.
Poorly balanced diets can lead to significant deficiencies in the long term. Many of these deficiency states exhibit oral manifestations first. As a profession we are in an ideal position for the early diagnosis of possible nutritional deficiency states.
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