Protein-Energy Malnutrition and Oral Health

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:

• HIV infection.

• Otitis media.

• Rickets.

• Anemia.

• Keratomalacia.

• Pneumonia.

• Tuberculosis.

• Cardiac arrhythmias.

• Hypophosphatemia.

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.

Conclusion:

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.