A.BRIEF RESUME OF THE INTENDED WORK
NEED FOR THE STUDY Malnutrition refers to the syndrome of inadequate intake of protein, energy and micronutrients combined with frequent infections. Protein-energy malnutrition (PEM) occurs when protein and energy foods are deficient relative to food needs. Dietary protein and energy deficiencies usually occur together1. PEM, a health problem in developing countries is not rare in developed countries. According to WHO 1998 (NHFS data), in Jammu and Kashmir, 35% of children are malnourished and the rural figures are as high as 64%.In Srinagar, the percentage of malnourished children is as high as 60% with a higher prevalence in females2. In PEM, host factors in caries development are more pertinent, specifically salivary system. An increase in incidence of dental caries has been depicted in perinatal and post weaning period3,4. Reduced salivary secretion attributed to reduced amount of protective protein synthesized and secreted has been determined. An alteration in buffering systems as bicarbonate, phosphate and protein buffers occurs5. Lowered titres of proteins comprising enzymes, amylase activity, traces of albumin, polypeptides-statherin, sialin, glycoproteins (bacteria aggregating glycoproteins) due to low dietary intake results in lowered capacity of microbial clearance and enhanced microbial colonization. Calcium and chloride concentrations are altered to favour dissolution of hydroxyapatite6,7,8,9. Thus, it appears opportune to determine the effect of malnutrition on certain anti bacterial components of saliva and the development of dental caries.
REVIEW OF LITERATURE A progressive fall of salivary protein and arginase activity in saliva with the increasing severity of malnutrition in children has been studied7. Effects on caries development and on some antibacterial substances in saliva in malnourished rats were measured and reduced secretion of specific proteins in saliva was evaluated8. Development of caries during protein deficiency and analyses of saliva composition have been related to altered conditions for synthesis and release of protein from salivary secretory cells4. The salivary flow due to impaired secretion of saliva and buffer capacity in Indian children suffering from chronic malnutrition showed increased caries incidence 5. Salivary composition in Indian children with chronic protein-energy malnutrition showed reduced protein secretion in stimulated saliva, lowered calcium and impaired defense factors in saliva6. An association of early childhood malnutrition with dental caries as well as the evidenced enamel hypoplasia and salivary gland hypofunction may be the underlying explanatory mechanisms for the effect of PEM on dental caries1.
1 OBJECTIVES OF THE STUDY : To evaluate the status of dental caries in children diagnosed with protein–energy malnutrition. To assess the salivary pH, bicarbonate, total salivary protein and salivary calcium levels in children with PEM. To establish a relationship between the salivary changes, dental caries and lowered protein and energy intake in children with protein–energy malnutrition. To assess the same parameters in healthy children and co-relate the above findings.
B. MATERIALS AND METHODS : 100 children diagnosed with protein-energy malnutrition between the age group of 4-10 years from Jammu and Kashmir will be a part of the study and 100 normal children of the same age from the same areas will be the control group. STUDY DESIGN- The children will be divided into two groups containing 100 individuals in group 1(study group) and 100 individuals in group 2(control group). Group 1: children diagnosed as suffering from protein –energy malnutrition. Group 2: (control group) healthy children.
INCLUSION CRITERIA: All children with protein-energy malnutrition will be included in this study.
EXCLUSION CRITERIA:
Children who are severely ill or with underlying systemic disease, under medication and highly un co-operative children will not be included in the study.
METHOD OF COLLECTION OF DATA: Children diagonosed as protein energy malnourished will be graded as per Waterlow classification10.
The dental caries will be evaluated using modified WHO format11.
Whole saliva will be collected in ice chilled tubes for 5 minutes. Children will not be allowed to eat 1 hour prior to saliva collection5.
The stimulated salivary pH and bicarbonate will be determined by blood gas analyzer (Copenhagen)12.
Total salivary protein level will be estimated by Pyrogallol Red Method13.
Salivary calcium level will be estimated by O-Cresolphthalein Complexone Method14.
Fully automatic Biochemistry analyzer BT-100 will be used.
The results thus obtained will be subjected to statistical analysis. Students‘t’ test will be applied.
Does the study require any investigations or interventions to be conducted on patients or other humans or animals? Yes, the study requires the informed consent of the parents/ guardians and children.
Has the ethical clearance been obtained from your institution in case of 7.3? Yes, ethical clearance letter will be enclosed.
C. List of references 1. Psoter W.J., Reid B.C., Katz R.V. Malnutrition and Dental Caries: A Review of literature. Caries Res. 2005; 39(6):441-447.
2. Ghosh S., Shah Dheeraj, Nutritional problems in urban-slum children: Indian Pediatrics- Environmental Health Project 2004; 41:682-696.
3. Menaker, Navia. Effect of undernutrition during the Perinatal period on caries development in the Rat: II Caries Susceptibility in underfed rats supplemented with protein or caloric additions during the suckling period. J Dent Res 1973; 52: 680-687.
4. Johansson I, Ericson T. Saliva Composition and Caries development during protein deficiency and B receptor stimulation or inhibition. J Oral Pathol 1987; 16: 145-149. 5. Johansson, Rajan, Parmeswaram. Salivary flow and Dental caries in Indian children suffering from Chronic Malnutrition. Caries Res 1992; 26:38-43.
6. Johansson, Leanander- Lumikari. Saliva composition in Indian children with chronic protein –energy malnutrition. J Dent Res 1994; 73(1): 11-19.
7. Agarwal et al. Biochemical changes in saliva of malnourished children. Am J Clin Nutr 1984; 39: 181-184.
8. Johansson, Ericson, Bowen, Cole. The effect of malnutrition on caries development and saliva composition in the Rat. J Dent Res 1985; 64(1): 37-43.
9. Ronald R. Watson, John G. Tye. Pancreatic and salivary amylase activity in undernourished Columbian children. Am J clin Nutr.1977; 30: 599-604.
10. Waterlow JC: Classification and definition of protein-energy malnutrition;in nutrition in Preventive Medicine. WHO Monogr Ser No.62.Geneva, World Health Organization, 1976.
11. World Health Organization. Oral health survey: Basic method 4th ed. Geneva. WHO; 1997.
12.Jensdottir .T. , Nauntofte B., Buchwald C., Bardow A., Effects of Sucking Acidic Candy on Whole-Mouth Saliva Composition. Caries Research 2005; 39: 468-474.
13. Seugnet L., Boero J., Gottschalk L., Paul J. Identification of a biomarker for sleep drive in flies and humans.Proc Natl Acad Sci U S A. December 2006; 103(52): 19913–19918.
14. Little, Holt C., An equilibrium thermodynamic model of the sequestration of calcium phosphate by casein phosphopeptides. European Biophysics Journal,Aug 2004;33(5):435-447.