Nutritional diseases moQG.pdf

Week exam ORAL AND SYSTEMIC MANIFESTATIONS OF NUTRITIONAL DISEASES  LEARNING OBJECTIVES Recognize and discuss the systemic and oral manifestations of nutritional diseases, including severe acute malnutrition, anorexia, bulimia, vitamin deficiencies, and o...

Week exam ORAL AND SYSTEMIC MANIFESTATIONS OF NUTRITIONAL DISEASES  LEARNING OBJECTIVES Recognize and discuss the systemic and oral manifestations of nutritional diseases, including severe acute malnutrition, anorexia, bulimia, vitamin deficiencies, and obesity. Compare and contrast marasmus and kwashiorkor.  Nutrition Adequate diet should provide CHO’s, protein & fats for daily metabolic needs Essential amino acids, fatty acids, vitamins & minerals  Malnutrition Primary – diet deficient in 1 or more components Secondary – supply OK, problem with absorption, storage, utilization, excessive loss, increased requirements utilization after poor Know dirt between Acute t chronic SEVERE ACUTE MALNUTRITION (PROTEIN-ENERGY MALNUTRITION) weight for height ratio below 3 SD of WHO standards developing countries: ~25% children affected, high death rates developed countries: older/debilitated, children in poverty 2 MAJOR TYPES OF SEVERE ACUTE MALNUTRITION ? 2 MAJOR TYPES OF SEVERE ACUTE MALNUTRITION ? MARASMUS KWASHIORKOR  COMPARE AND CONTRAST MARASMUS AND KWASHIORKOR  lack of nutrient lack of protein MARASMUS KWASHIORKOR Diet lacking in calories Protein deprivation > calorie reduction Somatic compartment (skeletal Visceral compartment (organs, esp. muscle) liver) E organs.ae More marked loss of fat/muscle Edema (low albumin) mass; emaciated extremities Enlarged fatty liver Serum albumin NL or slightly Skin /hair changes, fatty liver, small decreased bowel atrophy a bones More marked thymic and lymphoid emaciated skin atrophy Growth retardation, bone marrow hypoplasia, immune deficiency, vitamin deficiencies in both  MARASMUS diet severely lacking in calories growth retardation loss of muscle mass, fat stores emaciated anemia, immunodeficiency y RBC IG 8.17A. Kumar, Vinay, et al. Robbins Basic Pathology -Book. Available from: VitalSource Bookshelf, (10th 989 4 Edition). Elsevier Limited (UK), 2017. can't bind 02  I swollen due to KWASHIORKOR y lack of albumin protein deprivation > caloric deficit Africa: children weaned too early fed exclusively carbohydrates no protein loss of visceral proteins rn over hypoalbuminemia: edema, as albumin useddue ascites lack OF skin/hair changes, fatty liver, rotein defects of immunity Weight 60 - 80% of normal (but misleading due to edema) FIG 8.17B. Kumar, Vinay, et al. Robbins Basic Pathology E-Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Lim (UK), 2017.  CACHEXIA w utilization problem Secondary malnutrition as a complication of AIDS, cancer, other illnesses  Cachexia necrosis Morfactor TNF and other cytokines secreted by tumor cells è protein degradation / fat mobilization catabolic processes cause emaciases due to lack of energy Internet Archive Book Images, No to rage depression restrictions, via Wikimedia Commons, https://commons.wikimedia.org/wiki/File:Typ es_of_malarial_cachexia_from_A_practical_st udy_of_malaria_(1909)_(14782001371).jpg  CLINICAL CASE CC: 18 yo WF c/o sensitive teeth Background and current findings: – Cold sensitivity for 3 years – Denies h/o GERD – Does not use tobacco or drink alcohol – Intraoral exam: extensive dental erosion Differential diagnosis for diffuse dental erosion?  Differential diagnosis for diffuse dental erosion? INTRINSIC: GERD, excessive vomiting (bulimia, chronic alcoholism, hyperemesis gravidarum) EXTRINSIC: acidic drinks/foods/other exogenous substances (e.g., soft drinks, sports drinks, citrus, fruit juices, vinegar, pickles, vit C chewables, airborne industrial acids, swimming in poorly monitored pools) Management?  Management? Screening/counseling for possible eating disorder; consider referral for medical / psychological evaluation Low abrasive toothpaste / soft toothbrush / limit brushing (esp. after acid exposure) Buffering substances: sugar-free dairy and antacids Rinse with water or baking soda rinse after acid exposure Fluoride varnish / rinses Xylitol gum (increase salivation) Desensitizing toothpastes ANOREXIA & BULIMIA esp. young females self-induced starvation vs. binge eating and purging  lack of consumption Anorexia severe acute malnutrition ~ SAM Endocrine findings: amenorrhea, decreased thyroid hormone low it hinders hearts ability to Electrolyte abnormalities: reset action potentials during lack of consumption contractions g– Hypokalemia è cardiac arrhythmia Anemia, lymphopenia, hypoalbuminemia Constant catabolic patways weaken tissues bones immune system  Bulimia x complications due to vomiting/ laxatives/ diuretics hypokalemia è cardiac arrhythmia pulmonary aspiration of gastric contents esophageal & gastric rupture https://upload.wikimedia.org/wikipedia/commons/5/50/BulemiaEnamalLoss.JPG, James Heilman, MD, CC BY-SA 4.0 , via Wikimedia Commons  Bulimia signs I Abdullakutty A, et al. Sialosis in builimics and surgical management. J Med Radiol Pathol Surg. DOI: 10.15713/ins.mjrps.133, https://creativecommons.org/licenses/by/4.0/ SIALADENOSIS (bilateral parotid enlargement; https://commons.wikimedia.org/wiki/File:Russell%27s_Sign. png, User:Kyukyusha, Public domain, via Wikimedia Commons nutritional/endocrine/neurogenic origin) RUSSELL SIGN V  VITAMIN DEFICIENCIES Primary: diet Secondary: malabsorption, metabolic disorders, tissue storage, liver dz  know which are fat solub Vitamins t which are water soluble 13 vitamins necessary for health: – fat soluble (ADEK) readily stored (in fatty tissues) BUT poorly absorbed in fat malabsorption disorders xs toxic – water soluble (Bs/C/Folate) excreted in urine (toxicity rare) Often multiple vitamin deficiencies present stoppedhere  VITAMIN A retinol & related substances FXNS: – vision (visual pigment) – cell growth/differentiation (mucus- secreting epithelia) – lipid metabolism – immunity to infection ITO CELLS (liver storage) FIG 8.18. Kumar, Vinay, et al. Robbins Basic Pathology E-Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Limited (UK), 2017.  VITAMIN A DEFICIENCY Eyes blindness (night/total) xerophthalmia corneal keratin plaques (Bitot's spots) keratomalacia (corneal destruction/softening) FIG 8.19. Kumar, Vinay, et al. Robbins Basic Pathology E-Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Limited (UK), 2017.  VITAMIN A DEFICIENCY Resp tract - squamous metaplasia, pulmonary infection Urinary tract – keratin debrisè stones Skin – hyperkeratosis Immune deficiency FIG 8.19. Kumar, Vinay, et al. Robbins Basic Pathology E-Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Limited (UK), 2017. VITAMIN D  Vitamin D FXNS: – maintenance of plasma Ca and P bone development & mineralization neuromuscular transmission metabolic functions 2 sources: – endogenous synthesis in skin (UV light) –(major source)(~90% in light-skinned) – exogenous – diet  CAUSES OF VIT D DEFICIENCY: – inadequate sunlight – diet / malabsorption – liver dz – renal disorders (dec. synth 1,25 (OH)2 vit D, phosphate depletion) FIG 8.20. Kumar, Vinay, et al. Robbins Basic Pathology E-Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Limited (UK), 2017.  VITAMIN D DEFICIENCY RICKETS (growing children) – craniotabes – rachitic rosary – bowing of legs FIG 8.21. Kumar, Vinay, et Semionov A, Kosiuk J, Ajlan A, Discepola F. Imaging of Thoracic Wall al. Robbins Basic Pathology E- Abnormalities. Korean J Radiol. 2019 Oct;20(10):1441-1453. doi: Book. Available from: VitalSource 10.3348/kjr.2019.0181. https://creativecommons.org/licenses/by-nc/4.0/ Bookshelf, (10th Edition). Elsevier Limited (UK), 2017. VITAMIN D DEFICIENCY Fig. 17.14 Oral and Maxillofacial Pathology (4th hypocalcified teeth in rickets Edition) by Neville BW, Damm D, Allen CM, Chi AC. Available from VitalSource Bookshelf, Elsevier Health Sciences (US).  VITAMIN D DEFICIENCY Costa SA, Souza SFC, Nunes AMM. Oral manifestations of renal tubular acidosis associated with secondary rickets: case report. J Bras Nefrol. 2019 Jul-Sep;41(3):433-435. doi: 10.1590/2175- 8239-jbn-2018-0105. , https://creativecommons.org/licenses/by/4.0/ hypomineralized teeth in 14yo F with renal disease and secondary rickets  SCURVY vitamin C deficiency (ascorbic acid) sailors, elderly, alcoholics, dialysis, food faddists  Vitamin C fruits & veg functions: – collagen metabolism – antioxidant FIG 8.22 Kumar, Vinay, et al. Robbins Basic Pathology E-Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Limited (UK), 2017.  Scurvy bleeding (gingiva, skin), skin rash, corkscrew hairs impaired wound healing Japatti SR, Bhatsange A, Reddy M, Chidambar YS, Patil S, Vhanmane P. Scurvy-scorbutic siderosis of gingiva: A diagnostic challenge - A rare case report. Dent Res J (Isfahan). 2013;10(3):394-400.. Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, “SCORBUTIC GINGIVITIS” / https://creativecommons.org/licenses/by-nc-nd/3.0/nz/, https://dermnetnz.org/topics/scurvy  THIAMINE (VITAMIN B1) coenzyme (decarboxylation) sources- grains, nonpolished rice, nuts, fish, meat,  Thiamine Deficiency esp. chronic alcoholics dry beri-beri (polyneuropathy) – myelin degeneration wet beri-beri (CV) - vasodilation, heart failure, edema Wernicke-Korsakoff syndrome - ataxia, confusion, ophthalmoplegia, amnesia, confabulation VITAMIN B12 (COBALAMIN) Sources: eggs, meat, dairy DNA synthesis & folate metabolism  VITAMIN B12 (COBALAMIN) requires intrinsic factor (IF) for reabsorption in terminal ileum EBM Consult; https://www.ebmconsult.com/articles/vitamin-b12-absorption-mechanism- intestine-intrinsic-factor  Vitamin B12 Deficiency Causes: – pernicious anemia (autoantibodies to IF and parietal cells) – strict vegan diet  Vitamin B12 Deficiency Ed Uthman from Houston, TX, USA, CC BY 2.0 , via Wikimedia Commons megaloblastic anemia degen of posterolateral spinal cord tracts (paresthesia, numbness) atrophic glossitis, burning/erythema https://www.dermis.net/dermisroot/en/23885/image.htm, Dermatology Image Atlas  ATROPHIC GLOSSITIS Associated with deficiency in – Fe – B12 – Riboflavin – Niacin – Folate https://www.dermis.net/dermisroot/en/ 23885/image.htm, Dermatology Image Atlas  IRON DEFICIENCY ANEMIA Hypochromic microcytic anemia Findings: – Atrophic glossitis – Mucosal pallor – Angular cheilitis – Fatigue, palpitations, lightheadedness Address underlying causes (iron supplementation, treatment of GI malabsorption, blood loss from intestinal disease) https://upload.wikimedia.org/wikipedia/commons/4/49/Severe_iron_deficiency_a nemia.jpg, SpicyMilkBoy, CC BY-SA 4.0 , via Wikimedia Commons  References / Resources “Nutritional Diseases” section in Chapter 8, Kumar, Vinay, et al. Robbins Basic Pathology E-Book. pages 323 – 338 Neville B, Damm D, Allen C, Chi A. Oral and Maxillofacial Pathology, 4th edition. – “Erosion” section, pages 56-57. – Sections on “Vitamin Deficiency,” “Iron-deficiency Anemia,” “Plummer-Vinson Syndrome, “ and “Pernicious Anemia” pages 769-774. “Eating Disorders” in Little and Falace’s Dental Management of the Medically Compromised Patient. Available from: VitalSource Bookshelf. Pages 550-558