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Protein-Energy Malnutrition and Oral Health

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Protein-energy malnutrition is detrimental to the millions of children in developing countries. Learn its features, management, and oral impact on these patients.

Medically reviewed by

Dr. Infanteena Marily F.

Published At January 21, 2022
Reviewed AtApril 26, 2023

What Is Protein-Energy Malnutrition?

One of the fundamental balancing acts in the human body is the protein-energy metabolism that energizes our system and is pivotal for functioning a healthy systemic apparatus. This protein-energy metabolism, in other words, is the cellular balance for nutrient enrichment in our system that in turn ensures or promotes growth maintenance and development. PEM or protein-energy malnutrition occurs when a dietary insufficiency of proteins would be either acute or chronic in origin. Affected children are at increased risk of multisystemic diseases apart from gross oral impact exhibited due to nutritional deficiencies.

Protein-energy malnutrition nearly affects 5-6 million children globally, as per the 2006 UNICEF report given the lack of a proteinaceous diet to compensate for children of low socioeconomic status in developing countries. This breach of immune defenses seen mainly due to imbalanced protein-energy metabolism in this global condition may result in numerous immunodeficiencies, mainly in children below five years of age and young adults. The most common systemic comorbidities resulting from poverty are especially diarrhea and malaria. Though initial symptoms of these conditions can be addressed effectively by the physician, these children are still prone to health risks like the transmission of infectious diseases via community spread or prenatal and genetic components of malnutrition hampering their immunity.

The risk of hospitalization is observed more with the occurrence of the following diseases that may increase the fatality or mortality rate:

These conditions lead to eventual loss of gastrointestinal immunity, and increased metabolic demand of the body causes fat and visceral volume loss (due to electrolyte imbalance and abnormalities). Severe cases of PEM do result in multi-organ failure if not treated in time.

How Does Protein-Energy Malnutrition Impact Oral Health?

Vitamin B Deficiency -

  • In children suffering from PEM, iron and folic acid deficiency often accompanies vitamin B complex deficiency (iron absorption orally may also be severely impaired in most children). Vitamin B supplementation, mainly in the form of vitamin B12 along with folic acid and iron, are fundamental constituents to the functioning of erythrocytes (red blood cells) of the bone marrow.

  • Burning sensation in the mouth, angular cheilitis (cracking at the mouth corners), sore throat, oral aphthous ulcerations, oral mucosal inflammation or inflammation of the tongue, and its borders usually signify vitamin B deficiency. It is usually due to vitamin B2 (Riboflavin) deficiency or vitamin B complex (B12) deficiency, or, in other words, pernicious anemia.

  • Vitamin B2 or riboflavin deficiency can also lead to a condition that is a combination or triad of cracked lips, burning mouth, tongue inflammation, or oral mucosal inflammation, also known as ariboflavinosis or a deficiency of riboflavin.

Vitamin C and Calcium Deficiency -

  • Vitamin C deficiency or ascorbic acid deficiency, also known as scurvy, is a detrimental impediment to healthy connective tissue and gingiva. That is why gingival bleeding, defective collagen synthesis, and impaired wound healing in the oral cavity due to lowered antioxidant bound immunity are all a part of vitamin C deficient features clinically in PEM children. Vitamin C is also linked to periodontal health.

  • Calcium deficiency is also linked to periodontal health as calcium plays a crucial role in maintaining and protecting alveolar bone. Bone density is mainly affected due to disturbance in the calcium metabolism and lowered calcium levels.

Bacterial Colonization and Hypomineralization of Enamel -

  • Similarly, a strong relationship or a linear linkage of enamel hypoplasia has been evidently documented in undernourished or malnutrition children.

  • Hypomineralization of enamel causes the bacterium to invade the tooth's enamel at a quickened pace, with the primary maxillary incisors being affected the most, as per research. Cariogenic bacteria causing dental caries is a sequela often following hypomineralized enamel (host factors and a diet of fermentable carbohydrates are other factors linked to dental caries in children). It leads to rapid progression of dental carious lesions causing dental decay and pain in children.

  • According to research conducted in the Indian continent, children and young infants suffering from PEM (early childhood PEM/EC-PEM) had a reduction in salivary secretion, low serum concentrations of vitamin A, lowered protein secretion, and also a reduction in the defense factors (agglutinating factors) in saliva.

  • These reduced oral cavity immune defense mechanisms also result in poor nutritional status, stunted growth, and delayed eruption patterns throughout childhood.

  • Dental caries can thus be defined mainly as carious lesions in the teeth due to the demineralization of the enamel and the dentine by organic acids (which are formed by the bacteria in the dental plaque) through the anaerobic metabolism of dietary derived sugars.

What Is the Treatment for Protein-Energy Malnutrition?

  1. The dental surgeon should primarily address dietary issues and advise suitable vitamin supplementation and prophylactic and restorative treatment for the affected (or impacted) teeth. Timely diagnosis and intervention by the dentist in these children for observing the impact of PEM on permanent erupting dentition would be incredibly beneficial for addressing prosthetic and restorative concerns if needed.

  2. PEM usually requires multidisciplinary management via all aspects of medicine, mainly addressing the patients' environmental needs, dietary changes, and feeding assistance.

  3. Daily nutrient supply in these patients may be increased upto 2 gram of protein per kilogram bodyweight. In those hospitalized due to PEM, fluid and electrolyte abnormalities need to be attended by the physician along with management of hyperglycemia, cardiac arrhythmias, and diarrhea by the diabetologist, cardiologist, and gastroenterologist.

  4. Parenteral supplementation of vitamins and magnesium supplementation (0.4 mEq/kg/day) is necessary for at least a week. Due to low oral absorption of iron, these children need oral or intramuscular iron supplementation.


PEM is not just a multisystemic condition in affected children, but it also impairs oral health and well-being to the maximal extent. Hence treatment should include diverse approaches from physicians and dental surgeons and a nutrient-rich diet, supplementation, and vitamin therapy.

Frequently Asked Questions


What Are the Effects Caused Due to Protein Deficiency on Dental Caries?

Protein deficiency causes increased susceptibility to dental caries. This occurs due to decreased immunity in the body due to protein deficiency. Decreased immunity also affects salivary glands and their function. This has a direct effect on dental caries. Salivary proteins help in maintaining tooth integrity and caries prevention.


What Is the Role of PEM in Dentistry?

Teeth are affected by PEM (protein energy malnutrition) during the pre-eruptive phase due to nutritional deficiencies resulting in disturbances in the oral structures. It causes a delayed eruption of the tooth, a smaller size of the tooth, decreases enamel solubility, and affects salivary gland function.  Decreased salivary gland functioning effects are decreased flow of saliva, buffering capacity, and constituents of saliva, especially proteins. One study showed that delayed exfoliation of the deciduous and late eruption of permanent teeth was observed in early childhood (EC) -PEM. Deficiencies of vitamin A, D, and PEM are found to cause enamel hypoplasia.


What Is the Role of Nutrition on Oral Health?

Nutrition and oral health have a bidirectional relationship. Nutrition can affect the oral tissues if not consumed properly, and affected oral tissues do not allow an individual to have proper food. Hence both these are interconnected with each other.


Which Are the Factors That Are Responsible for Affecting Oral Health?

Poor oral hygiene, tobacco chewing, consuming alcohol, frequent sugar consumption, and other social and commercial determinants may harm oral health. Systemic diseases like diabetes, cardiovascular diseases, and respiratory diseases may be responsible for poor oral health.


What Is the Action of Protein in Dryness of Mouth?

At low pH, salivary proteins combine with whey protein, thereby reducing the amount of salivary proteins in the mouth for lubrication. This causes dryness of the mouth.


What Effects Can Be Caused Due to Poor Oral Health?

Poor oral health may have effects like mouth and jaw pain, bleeding from gums and mouth sores, loosening of teeth, changes observed in tooth surfaces, bad breath (halitosis), white patches or lumps in the mouth, etc. Poor oral health may also cause other systemic diseases like cardiovascular disease.


How Protein Is Related to Dental Caries?

The mechanisms that help in the integrity of teeth and the prevention of caries are by forming an acquired pellicle on the surface of the tooth, thereby protecting the tooth surface from an acidic environment and microbes and inhibiting the loss of calcium and phosphate ions from the teeth. An individual's immune system will be affected in case of a deficiency of a protein that may add to the formation of dental caries, thereby affecting salivary gland functioning.


What Is the Role of Malnutrition on Tooth Decay?

Malnutrition can affect an individual in intrauterine life and childhood or even in later life due to poor nutrition. It has many effects on oral health and its development. It affects the oral disease progression through oral homeostasis and decreases resistance to actions of oral biofilms, reducing tissue repair capacity.


Is It Possible to Cure Protein Energy Malnutrition?

Yes, it can be corrected. It can be treated by giving a balanced diet, preferably orally. Liquid diets may be used when solids cannot be taken. If diarrhea persists, yogurt-based formulas may be used. Along with this, multivitamins should be given. In severe cases, they are treated in hospitals with a controlled diet. Fluid and electrolyte abnormalities should be treated. Then macronutrients are given orally. If not possible, then a feeding tube, nasogastric tube, or gastrotomy tube may be used.


Is There Any Medication Available to Treat Malnutrition?

There is no single medication for malnutrition. Changing diet to a balanced diet is the best way to fight malnutrition. If undernourished, nutrition should be taken through food or supplements.


What Preventive Actions Can Be Taken to Fight PEM?

Infections are more common in PEM. Hence immunization, deworming of children, and oral rehydration therapy for diarrhea are three preventive measures of PEM. PEM can be prevented by practicing to have a balanced diet regularly. Micronutrients are to be taken twice a day as per the daily recommended allowance.


Is There Any Quickest Method Available to Restore From Malnutrition?

Treatment of malnutrition depends on the cause and to what extent an individual is malnourished.
- Advice by a healthcare professional or dietician at home.
- In severe cases, they are treated in a hospital.
- Dietary changes and supplements are to be given. A balanced diet and extra nutrients are to be taken.
- Having three small meals and two to three- snacks in between the meals.
- Add protein to each meal, like egg, meat, beans, and lentils.
- Avoid low-fat, sugar-free diets and drinks.


Which Are the Vitamins that Are Useful in Treating Malnutrition?

Vitamins B, D, A, iron, and zinc are the most common micronutrients that help malnutrition.


What Are the Ways That Can Help in Preventing Protein Malnutrition?

Protein malnutrition can be prevented by reducing poverty, educating about nutritional values, and adopting public health measures. Practicing to have balanced diet regularly may help to prevent protein malnutrition.


Which Is the Test That Helps Determine the PEM?

Body mass index (BMI) is measured, and other laboratory values like serum albumin level, total lymphocyte count, transferrin, and response to skin antigens are used to test for PEM.
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Dr. Achanta Krishna Swaroop
Dr. Achanta Krishna Swaroop



oral health
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