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Bhatia G et al. Nutrition in Oral Health and Disease

Review article

Nutrition in Oral Health and Disease

Gouri Bhatia 1, Shruti Gupta 2, Ankita Arora 3, Sameer Saxena 4, Neha Sikka 5

1Department of Periodontology, Eklavya Dental College, Kotputli, Jaipur, Rajasthan,303108; 2Department of Oral Pathology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab; 3Department of Pedodontics and Preventive Dentistry, KM Shah Dental College and Hospital, Pipariya, Vadodara, Gujarat; 4Department of Periodontology, Institute of Dental Studies & Technologies, Modinagar, U.P. 201201; 5Department of Prosthodontics and Crown and Bridge, Eklavya Dental College, Kotputli, Jaipur, Rajasthan, India

Abstract Corresponding Author: Diet and nutrition are important factors in the Dr.Gouri Bhatia, MDS, promotion and maintenance of good health for the entire life. Nutrition plays an important role Assistant Professor, to establish and sustain the structure and function Department of Periodontology, of the body to keep it running in a perfect order. Oral health and nutrition have a synergistic Eklavya Dental College and Hospital, relationship. Oral infectious diseases, as well as Kotputli, Jaipur (District), systemic diseases with oral manifestations, impact functional ability to eat as well as diet and Rajasthan, India. 303 108. nutrition status. Likewise, nutrition and diet may E-mail: [email protected] affect the development and integrity of the oral cavity as well as the progression of diseases of Received: 06-05-2014 the oral cavity. This article reviews the effects of Revised: 15-05-2014 nutritional elements on the oral cavity. Keywords: diet; health; minerals; nutrition; Accepted: 17-04-2014

This article may be cited as: Bhatia G, Gupta S, Arora A, Saxena S, Sikka S. Nutrition in Oral Health and Disease. J Adv Med Dent Scie 2014;2(2):74-85.

Introduction Nutrition is the act of using food by series nutrition status.” 2 Nutrition and diet affect of co-ordinated processes thus affecting the the development and integrity of the oral nourishment of the body. The primary cavity along with the progression of purpose of nutrition is to establish and diseases for example, nutritional influences sustain the structure and function of the on craniofacial development, oral cancer, body maintaining the state of health. 1 oral infectious diseases and exacerbation of American Dietetic Association states that periodontal diseases. 3 Nutritional intake can “nutrition is an integral component of oral largely be divided into two main groups of health. Oral infectious diseases, as well as nutrients, the macronutrients acute, chronic and terminal systemic (carbohydrates, protein and fats) and the diseases with oral manifestations, impact micronutrients (vitamins and minerals). 4 functional ability to eat as well as diet and

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Role of nutrition in health a) Carbohydrates: They are the most provitamin. Vitamins are classified as fat abundant organic molecules in nature soluble and water soluble.6 (Table 1) primarily comprising of elements carbon, e) Minerals: Minerals are inorganic hydrogen and oxygen being classified into elements that constitute only a small monosaccharides, oligosaccharides and proportion of the body weight but are polysaccharides. 5 Carbohydrates are also essential for life and are required for known as protein sparing in that if normal growth and maintenance of the inadequate amounts of dietary body. Minerals are considered as carbohydrate are ingested, the body will macrominerals (principal elements) if breakdown protein to provide glucose for present in relatively high amounts in the essential functions. 6 body and microminerals (trace elements) b) Proteins: Protein is the most common if requirement is less than 100mg/day. 11 A substance in the body after water, making delicately balanced homeostasis of metals up about 50% of body’s dry weight. 7 is achieved by coordinated interaction Proteins are polymers of amino acids among highly evolved and regulated which form the fundamental basis of uptake, storage and secretion processes. structure and function of life and are Shortage or excess of metal ion components of defensive molecules that availability due to nutritional imbalance help to control the disease process. 6 From can tilt this balance with deleterious the nutritional point of view, proteins are effects including the very survival of the classified into complete proteins cell. 12 (Table2) (consisting of all essential amino acids), partially incomplete proteins (partially Role of nutrition in disease lack one or more essential amino acids) a) Carbohydrates: Displacement of and incomplete proteins (completely lack foods containing complex carbohydrates one or more essential amino acids). 8 and naturally occurring sugars is involved c) Lipids: Lipids are a heterogeneous in the causation of specific diseases viz. group of organic compounds relatively coronary heart disease, diabetes mellitus, insoluble in water and soluble in organic obesity and dental disorders. The number solvents. They are the concentrated fuel of diseases, severity and time to develop is reserves of the body and are important as directly related to the percentage of cellular metabolic regulators. They carbohydrates in the diet. Carbohydrates constitute the cell membrane, give shape drive insulin production that cause and smooth appearance to the body, cardiovascular disease which along with protect the internal organs and act as an high-cortisol levels resulting in insulating material. 9 demineralization of bones with reduction d) Vitamins: In 1912, Casimir Funk in their tensile strength by weakened originally coined the term "vitamine". 10 connective tissue at the joints. Dietary Vitamins are organic substances that are carbohydrates lead to the colonization of required in the diet in small quantities to microorganisms on the tooth surface perform specific biological functions for which coupled with their continuous normal maintenance of optimum growth metabolic activities permit plaque and health of an individual. Vitamins are formation resulting in dental caries and not made by the body hence must be periodontal diseases. 13, 14 supplied by food or made from a

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Bhatia G et al. Nutrition in Oral Health and Disease

b) Proteins: One of the principal for increased periodontal pocket formation consequences of protein deficiency is has been noticed.19 Deficiency has been depressed phagocytic function and T-cell associated with enamel hypoplasia and mediated responses resulting in increased salivary gland atrophy.19 Retinoids susceptibility to infection, periodontitis prevent tumoral promotion and and alveolar bone loss. 4 Protein depletion progression by sequestration of free results in pathologic changes, including radicals, activation of cellular muscular atrophy, weakness, , differentiation processes and stimulation anemia, leucopenia, edema, impaired of immune system.1 lactation, slow wound healing, reduced A leads to gradual loss ability to form certain hormones and of hair, dryness of skin, lips and oral enzymes.15 Degeneration of the mucosa, hepatomegaly, skeletal connective tissue of the gingiva and decalcification, pigmentation, follicular periodontal ligament, osteoporosis of keratosis and purpura. 8 alveolar bone, retardation in the deposition of cementum and atrophy of D: Vitamin D is not a vitamin in the tongue epithelium, accentuation of the a strict sense as its main source does not come from diet hence is considered as a destructive effects of local factors and 20 occlusal trauma on the periodontal tissues prohormone. Vitamin D has been traditionally considered important for is also noticed. Conversely, excess protein 21 can have a deleterious effect on calcium skeletal health. Deficiency causes homeostasis in bone. 16,17 in children and in adults, conditions where the ratio of to 22 c) Lipids: Growing animals who are osteoid in bone is reduced. Clinical totally deprived of essential fatty acids manifestations include irritability, growth show a range of symptoms, including poor retardation, prominence of costochondral wound healing due to failure of junctions (rachitic rosary), bowing of long connective tissue, loss of membrane bones, developmental anomalies of dentin integrity, in particular the skin and and enamel, delayed eruption, high caries impaired immune function and increased rate, abnormally wide predentin zone, host susceptibility.6 interglobular dentin. Osteomalacia frequently results in diffuse skeletal pain 8,15 d) Vitamins: and fracture with relatively mild injury. Vitamin A: Deficiency of vitamin A Hypercalcemia is responsible for results in ocular, dermatologic and producing most of the symptoms of mucosal manifestations. Ocular vitamin D toxicity. Symptoms include manifestations include nocturnal blindness gastrointestinal disorders, (nyctalopia), xeropthalmia, keratomalacia demineralization of bone, bone pain, and total blindness. Dry and rough skin drowsiness, continuous headaches, with degeneration of mucosa leading to irregular heartbeat, loss of appetite, infections constitutes dermatological muscle and joint pain, frequent urination, excessive thirst, weakness, nervousness, effects. Epithelial cells of gastrointestinal 23 tract, urinary tract and respiratory tract itching and kidney stones. Primary can undergo keratinizing metaplasia.8,18 In hyperparathyroidism, granulomatous diseases and some cancers also cause experimental animals, hyperkeratosis and 24 hyperplasia of the gingiva with a tendency vitamin D hypersensitivity.

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Table 1: Role of Vitamins in Health 8,15,18 Nutrient Major Function Major sources Fat Soluble vitamins Vitamin A - Helps maintain good vision (necessary for Milk, eggs, meat, fish liver oils. Beta- Retinol, beta- night vision), resistance to infections, and carotene and other carotenoids are carotene and supports growth and repair of body tissues. found in: Green leafy vegetables, various other Also maintains integrity of white and red Yellow vegetables - carrots, sweet carotenoids blood cells, assists in immune reactions, helps potatoes, pumpkin. Yellow and orange maintain the stability of cell membranes, fruits - mango, papaya and apricots. regulation of epithelial differentiation Vitamin D Regulates absorption of calcium and Formed in skin when exposed to Cholecalciferol, phosphorus for bone health, has a role in the sunlight. Also found in dairy products, ergocalciferol immune system- Antigen-presenting cells, egg yolk, fish liver oils, Yeast macrophages and lymphocytes express a nuclear receptor for vitamin D. Fat-soluble . Helps maintain cell Found primarily in plant oils, green Tocopherol, membranes, red blood cell integrity, prevents leafy vegetables, wheat germ, whole Tocotrienols peroxidation of polyunsaturated fatty acids grains, egg yolk, nuts, seeds and liver Vitamin K Helps make factors that promote blood Bacterial synthesis in the digestive clotting, necessary for postransitional tract. Green, leafy vegetables, cabbage- carboxylation of glutamic acid type vegetables and milk Water Soluble Vitami ns Vitamin B1 Helps metabolize carbohydrates, maintain Whole grain cereals, legumes, beans, Thiamine appetite and normal digestion. Part of a nuts, brewer's yeast, wheat germ and coenzyme used in energy metabolism, have a liver. role in peripheral nerve conduction Vitamin B2 Part of coenzymes used in energy metabolism, Milk, yogurt, meat, leafy greens, whole supports normal vision and skin health grains. Vitamin B3 Part of coenzyme used in metabolism, Meat, whole grains, cereals, pulses nuts Niacin, supports skin, nervous and digestive system, nicotinic acid, important in pentose, steroid, fatty acid niacinamide biosynthesis, glycolysis, protein metabolism and oxidation of lactate and pyruvate Vitamin B5 Part of Coenzyme A, which is used in energy Widespread in foods. Pantothenic metabolism Acid Part of a coenzyme that helps the body to Green leafy vegetables, meats, fish, Pyridoxine, synthesize nonessential amino acids. role in poultry, shellfish, wheat, corn, pyridoxal, protein metabolism especially tryptophan cabbage, legumes, whole grains Vitamin B12 Part of coenzymes used in new cell synthesis; Animal products (meat, fish, poultry, Cobalamin helps to maintain nerve cells. shellfish, eggs, cheese, milk, curd). Biotin Part of a coenzyme used in energy Widespread in foods, rich sources are metabolism, fat synthesis, amino acid liver, kidney, egg yolk, milk, tomatoes, metabolism and glycogen synthesis. grains Folic acid Part of coenzymes used in new cell synthesis. Green leafy vegetables, liver, fortified Folate, folacin blood cell formation, protein metabolism and grain products, legumes, milk prevention of neural tube defects, synthesis of DNA is impossible in the absence of folic acid Vitamin C Essential element in collagen formation Abundant in most fresh fruits (esp. (ascorbic acid) (strengthens blood vessels, forms scar tissue, citrus) and vegetables is a matrix for bone growth); an antioxidant; strengthens resistance to infections and improves absorption of iron, involved in formation of folinic acid

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Vitamin E: α-tocopherol was discovered of the oral mucosa, minute vesicles nearly 100 years ago because it was (simulating herpes) on the buccal mucosa, required to prevent fetal resorption in under the tongue or on the palate and pregnant rats.25 Role of vitamin E in erosion of the oral mucosa. 28 cancer prevention is accredited to its B) Vitamin B 2: Riboflavin deficiency action as an antioxidant, by protecting the results in pallor of lips followed by cell membrane from oxidative damage, by cheilosis, dermatitis and glossitis blocking nitrosamine formation, by characterized by a magenta discoloration influencing humoral and cell-mediated and atrophy of the papillae and engorged immunity and increasing cell-repair fungiform papillae, which project as capacity. 1 Severe symptoms of deficiency pebble-like elevations. Ocular changes are not seen in humans except increased comprising of corneal vascularization, fragility of erythrocytes and minor photophobia and interstial keratitis have neurological symptoms. Deficiency in also been described. 27 experimental animals, attributes to C) Vitamin B 3: Niacin deficiency results decreased male fertility, nutritional in a condition called as muscular dystrophy, increased vascular characterized by dermatitis, diarrhoea and disruption, loss of pigment and atrophic dementia. Glossitis and stomatitis may be and degenerative changes in enamel the earliest sign of niacin deficiency.28 In organ. 26 acute stages, entire oral mucosa becomes Vitamin E is the least toxic amongst all fat fiery red and painful with profuse soluble vitamins salivation and desquamation of tongue. Vitamin K: Deficiency leads to Ulceration begins at interdental papillae coagulopathy because of inadequate and spreads rapidly. Epithelial changes synthesis of prothrombin and other particularly in the areas exposed to clotting factors. The most common oral sunlight (neck region) result in a manifestation is gingival bleeding, with characteristic skin rash called Castle’s chances of spontaneous bleeding at levels necklace. 8,28 6,8 below 20%. D) Vitamin B 5: Pantothenic acid Vitamin B Complex: Deficiencies of deficiency in experimental animals results vitamin B-complex can cause disturbances in anaemia, fatty liver and decreased in protein, carbohydrate and fat steroid synthesis. However, no deficiency metabolism. Deficiencies can also manifestations have been reported in decrease resistance to infection secondary humans. 18 to antibody formation. Oral changes E) Vitamin B 6: Pyridoxine deficiency is common to B-complex deficiencies are associated with neurological symptoms gingivitis, glossitis, glossodynia, angular such as depression, irritability, cheilitis and inflammation of the entire nervousness, mental confusion and oral mucosa. 15 convulsions, hypochromic microcytic A) Vitamin B 1: Deficiency of Vitamin B 1 anemia, albuminuria and leucopenia. results in beri beri disease which is Deficiencies of vitamin B 6 are usually insidious in onset and chronic in course. related to an overall deficiency of all the 27 Alcoholic patients with chronic thiamine B-complex vitamins. deficiency manifest neurologic symptoms F) Vitamin B 12 : Cyanocobalamin known as Wernicke’s Encephalopathy. 27 deficiency is associated with neuropathy, Oral disturbances include hypersensitivity subacute combined degeneration of spinal

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cord, paresthesia of fingers and toes, statistically significant dose-response confusion, loss of memory and psychosis. relationship between the levels of dietary Most commonly deficiency leads to a vitamin C intake and periodontal disease relatively common chronic hematological in current and former smokers as disease, pernicious anemia which was first measured by clinical attachment. Ascorbic described by Addison in 1855. It is also acid, and some polyphenolic compounds called as Addisonian anemia, Biermer found in green tea, fruit and vegetables, anemia, Hunter Addison anemia and has shown to be effective in inhibiting Lederer anemia. 18 Oral symptoms include tumoral promotion. 35 glossitis, glossodynia, glossopyrosis, atrophy of papillae of tongue resulting in Minerals smooth and bald tongue (Hunters glossitis Macrominerals or Moellers glossitis) and inflamed tongue Calcium: Calcium in crystalline form is which is described as beefy red in color. the major structural support of the body Gatrointestinal manifestations (diarrhea, with its normal serum level being about 9- , weight loss, dyspepsia), 11mg/dl. Hypocalcemia exists when the hepatomegaly, spleenomegaly, congestive serum calcium level falls below 7 mg/dl heart failure and hemorrhagic and results due to renal failure, manifestations may also be noticed. 29,30 hypoalbuminemia or surgically induced 8 Vitamin C: Vitamin C insufficiency in hypoparathyroidism causing tetany. the food or as a conditioned deficiency Osteoporosis, a systemic skeletal disease affects the immunocompetence and results characterized by low bone mass and in . Clinical manifestations of microarchitectural deterioration with a scurvy include ecchymoses, hemorrhagic consequent increase in bone fragility and lesions into the muscles of the extremities susceptibility to fracture occurs due to and joints, petechial hemorrhages, often various extrinsic or intrinsic factors around hair follicles; increased (Estrogen deficiency associated with susceptibility to infections and impaired menopause, decreased secretion of wound healing. 31 Other manifestations are parathyroid hormone, increased secretion of calcitonin and decreased calcium bone pain, osteoporosis, arthralgias, 36 myalgias, joint effusions, hyperkeratosis, absorption). edema, ascites, cardiomegaly and Hypercalcemia (serum calcium level > electrocardiographic abnormalities 11mg/dl) occurs as a result of primary suggestive of cardiac disease. , hyperparathyroidism, acute adrenal lassitude and emotional changes insufficiency or acute renal failure and is (depression and hypochondriasis) characterized by lethargy, loss of sometime may precede the development appetite, constipation, nausea, increased 32 muscle contractility and susceptibility to of frank scurvy. Cardinal oral signs of 11 scurvy include fetid odor and loosened fractures. teeth with bright red, hemorrhagic, Phosphorus: Body phosphorous is swollen, smooth and shiny interdental and intimately associated with calcium in the marginal gingiva. 33 In a retrospective metabolism of bones and teeth. analysis of 12,419 adults studied in the Hypophostasia occurs due to vitamin D Third National Health and Nutrition deficient rickets, renal rickets, liver Examination Survey (NHANES III), disease decreased intake or Nishida et al 34 found that there was a malabsorption of phosphorous leading to

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weakness, malaise, anorexia and bone headaches, Alzheimer’s disease, pain. Usually phosphate depletion in cerebrovascular accident, hypertension, man does not exist under most dietary cardiovascular disease, type 2 diabetes regimens. 8,11 mellitus, sickle cell disease, pre- Hyperphosphatemia occurs due to eclampsia, atherosclerosis, factitious hemolysis, increased vitamin postmenopausal osteoporosis and D intake or decreased excretion of chronic alcoholism.38,39 Recent research vitamin D. found that increased serum Mg/Ca was Sodium: Sodium deficiency in man significantly associated with reduced probably never occurs in an probing depth and a higher number of uncomplicated form but may present as remaining teeth. 41 Researchers theorize sodium and chloride deficiency. When that low magnesium content of white diets low in salt are used for long period blood cells has an important effect on of time, gradual weakness, excessive the pathogenesis of asthma. 42 fatigue, lassitude, apathy, anorexia, sense of exhaustion, nausea, muscle Microminerals cramps and peripheral vascular collapse Flouride: Fluoride is called as a double may occur. 11 edged sword as inadequate ingestion is Sodium is generally reported to be associated with dental caries and elevated in most cases of heart failure excessive intake leads to fluoride and in ischemia/reperfusion. 37 toxicity (acute or chronic). Signs and Potassium: Primary dietary deficiency symptoms of acute toxicity include of potassium has not been observed but nausea, vomiting, diarrhea, abdominal depletion secondary to some cramps, paresthesia, central nervous pathological condition has been noticed. system depression, coma, hypotension, Signs of this deficiency are decreased pallor, shock, acidosis, hypocalcemia muscular irritability, reduced or absent and hypomagnesemia. The effect of reflexes, mental confusion, paralysis, chronic fluoride toxicity is on the contractility of heart muscles, alterations enamel (dental fluorosis) and bone in gastrointestinal tract and death. 11 fluorosis. Fluorosis is an endemic Hyperkalemia may be associated with disease characterized by lusterless, mental confusion, numbness, tingling of opaque white patches in the enamel extremities, pallor, cold skin, weakness, leading to pitting and mottling of disturbances in cardiac rhythm and enamel. 43,44 peripheral collapse. The effects of : Inability of the thyroid gland to potassium deficiency or excess on the produce thyroxine hormone during oral structures have not been reported. 37 infancy leads to cretinism characterized Chloride: A reduction in serum chloride by mental defects, retarded somatic level may occur due to vomiting, growth, generalized edema, dentofacial diarrhea, excessive sweating, respiratory changes like underdevelopment of the alkalosis, Addison’s disease. No oral mandible and overdevelopment of the manifestations of this maxilla. If this insufficiency occurs in have been reported. 8 childhood then juvenile myxedema Magnesium: Low levels of magnesium results wherein the tongue is enlarged have been associated with a number of due to edema leading to continuous chronic diseases including migraine protrusion and malocclusion, delayed

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eruption of permanent teeth and retained enzymes of epithelial cells and DNA deciduous teeth. In adults it causes damage predispose the patients of myxedema due to extravascular and Plummer-Vinson syndrome to malignant extracelluar accumulation of water and changes especially squamous cell proteins leading to edematous and carcinomas. 48 swollen tongue, lips, nose, eyelids , The most common iron-loading suborbital tissues, puffiness of face and anaemias are intermediate and major slowness in mental and physical forms of β-thalassaemia and rare activities. in diet anaemias like congenital results in simple endemic goiter and is dyserythropoietic anaemia and X-linked normally seen in hilly areas. 45,46 sideroblastic anaemia. 49 Overproduction of thyroid hormone : Selenium deficiency is leads to thyrotoxicosis / hyperthyroidism associated with several disease (Grave’s disease) or enlargement of conditions such as anemia, asthma, adult thyroid gland (exophthalmic goiter). In respiratory distress syndrome (ARDS), children premature exfoliation of teeth AIDS and increased cardiovascular and early eruption of the permanent disease mortality. Low blood selenium dentition occurs with increased concentration and incidence of metabolic rate, nervousness, irritability, carcinogenesis in various organs loss of weight despite increased appetite, including liver, skin, stomach, mammary diarrhea, sweating, sensitivity to heat gland and oral cavity have been and exophthalmoses. 45,46 observed in both animal and human Iron: The commonest nutritional studies. Selenium deficiency results in deficiency disorder present throughout the development of two diseases, the world is anaemia Keshan (cardiomyopathy) & which develops when supply of iron is Kaschinbeck Disease inadequate for the requirement of (Osteoarthropathy). 50 hemoglobin synthesis. Long standing High Se levels in blood can result in a iron deficiency anaemia results in toxic condition called “selenosis”. development of the Plummer-Vinson Symptoms of Se toxicity include syndrome or Paterson-Brown-Kelly or gastrointestinal upsets, hair loss, white sideropenic dysphagia. Characteristic blotchy nails, garlic breath odor, features include dysphagia, iron irritability, fatigue and mild nerve deficiency anemia and upper esophageal damage.51 web, glossitis, glossopyrosis, Zinc: is largely related glossodynia, angular cheilitis, to inadequate intake or absorption of koilonychia, fragility, thinning of nails, zinc from the diet, although excess brittle hair and rarely clubbing of nails losses of zinc during diarrhea may also and tortuous esophagus. 47 contribute. The deficiency is associated One of the earliest suggestions that diet with depressed immunity, frequent may play a role in the etiology of oral infections, impaired taste and smell, cancer is based on studies from Sweden onset of night blindness, impairment of that found a link between Plummer- memory, bullous pustular dermatitis, Vinson syndrome and pharyngeal cancer alopecia, neurodevelopmental in women. High cellular turnover rate of disturbances, , epithelium, depletion of the oxidative hypogonadism and anorexia. 52

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Gestational zinc deficiency may affect dietary practices and optimal nutritional immunological development in the status are important in mitigating the newborn in ways that compromise severity of inflammatory periodontal lesions. Although periodontal disease is

Table 2: Role of Minerals in Health 8,11,18

Nutrient Major Function Major sources Macrominerals Calcium The principal mineral of bones and teeth, also Milk and milk products, small fish involved in normal muscle contraction, coagulation with bones, tofu, broccoli, chard of blood, secondary messenger in hormone action and legumes. Phosphorus A principal mineral of the bones and teeth; part of Abundant in all animal foods. every cell; maintains acid-base balance, helps in muscle contraction Sodium Maintenance of acid- base equilibrium and osmotic Table salt, salt added foods pressure, maintains neuromuscular excitability, viscosity of blood and fluid balance Potassium Works in coordination with sodium, influences Fruits, nuts, vegetables muscular activity, nerve conduction activity, acid- base balance and also has a role in cardiac functio n Chloride An electrolyte that maintains normal fluid balance Salt, soy sauce, moderate quantities and proper acid-base balance, part of hydrochloric in whole, unprocessed foods and acid found in the stomach large amounts in processed foods. Magnesium Involved in bone mineralization, the building of Nuts, legumes, whole grains, protein, normal muscular contraction and beans, green leafy vegetables, transmission of nerve impulses, acts as a co-factor seafood, chocolate. and activator of many enzymes Microminerals Fluoride Involved in the formation of bones and teeth. Drinking water (if fluoridated), tea, seafood Iodine Essential component of that Iodized salt, seafood, plants regulate tissue growth and cell activity. Iron Part of the protein hemoglobin which carries O2 Red meats, liver, poultry, fish, in the body. Part of the protein myoglobin in shellfish, beans, peas, dried fruit, muscle which makes O2 available for muscle eggs. contraction. Necessary for the utilization of energy as part of the cells metabolic machinery Manganese Involved in the formation of bone, acts as a co- Nuts, whole grain cereals, beans, factor and activator of many enzymes involved in rice, dried fruits, green leafy amino acid, cholesterol, and carbohydrate vegetables. metabolism Molybdenum Important in a variety of enzyme systems. Legumes, grains. Selenium Involved in antioxidant function along with Organ meats, sea foods vitamin E; constituent of peroxidase and selenocysteine Zinc Cofactor for enzymes Meat, fish, milk

immune function throughout the lifespan not a nutritional deficiency disease per irrespective of zinc status.5 se, plays a role in predisposing the host to the progression Conclusion of preexisting periodontal lesions and A balanced diet plays an important role influences the outcome of periodontal in maintaining good health. Good treatment. Nutrition and diet affects the

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Journal of Advanced Medical and Dental Sciences Research |Vol. 2 |Issue 2 | April-June 2014 85