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Transcript of CHAPTER 8 VITAMINS REQUIRED FOR CALCIFIED STRUCTURES Copyright © 2015, 2010, 2005, 1998 by...
CHAPTER 8CHAPTER 8
VITAMINS REQUIREDVITAMINS REQUIREDFOR CALCIFIED STRUCTURESFOR CALCIFIED STRUCTURES
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 2
Overview of VitaminsOverview of Vitamins
From Fehrenbach MJ, Herring SW: Illustrated Anatomy From Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck, ed 4. St. Louis: Saunders, 2012.of the Head and Neck, ed 4. St. Louis: Saunders, 2012.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 3
Overview of VitaminsOverview of Vitamins
Deficiencies result when adequate amounts of a Deficiencies result when adequate amounts of a nutrient are not available to sustain biochemical nutrient are not available to sustain biochemical functionsfunctions
Groups at risk for deficienciesGroups at risk for deficienciesPatients with periods of rapid growthPatients with periods of rapid growthMedically compromised patientsMedically compromised patientsPatients with substance abuse issues Patients with substance abuse issues
(alcohol, tobacco, methamphetamine)(alcohol, tobacco, methamphetamine)Those with psychological & physical stressThose with psychological & physical stressVegansVegans
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 4
Overview of VitaminsOverview of VitaminsCharacteristics of fat-soluble vitaminsCharacteristics of fat-soluble vitamins
1.1. Called fat-soluble because they Called fat-soluble because they dissolve in lipid and fat solventsdissolve in lipid and fat solvents
rather than waterrather than water
2.2. Fairly stable to heat, as in cookingFairly stable to heat, as in cooking
3.3. Organic substances (contain carbon)Organic substances (contain carbon)
4.4. Absorbed in intestine along with fats Absorbed in intestine along with fats and lipids in foodsand lipids in foods
5.5. Require bile for absorptionRequire bile for absorption
6.6. Transported via the lymphatic systemTransported via the lymphatic system
7.7. Stored in liver and adipose tissuesStored in liver and adipose tissues
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 5
Overview of VitaminsOverview of Vitamins
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 6
Vitamin AVitamin AClassesClasses
Retinoids (preformed): in animal productsRetinoids (preformed): in animal products 70% to 90% absorption70% to 90% absorption
Carotenoids (precursors): fruits and vegetablesCarotenoids (precursors): fruits and vegetables 9% to 22% absorption9% to 22% absorption
FunctionsFunctionsVision in dim lightVision in dim lightGrowth: cell differentiation (DNA/RNAGrowth: cell differentiation (DNA/RNA
synthesis), bone, tooth developmentsynthesis), bone, tooth developmentIntegrity of skin, mucous membranesIntegrity of skin, mucous membranesMaintenance of immune functionMaintenance of immune function
From Daniel SJ, Harfst SA, Wilder RS: From Daniel SJ, Harfst SA, Wilder RS: Mosby’s Dental Hygiene: Concepts, Mosby’s Dental Hygiene: Concepts,
Cases, and Competencies, ed 2. St. Louis: Cases, and Competencies, ed 2. St. Louis: Mosby, 2008.Mosby, 2008.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 7
Sources: Vitamin ASources: Vitamin ARetinoids (preformed) Retinoids (preformed)
Found in animal productsFound in animal products LiverLiver Fortified dairyFortified dairy FishFish Fortified foodsFortified foods
Carotenoids (precursor)Carotenoids (precursor)Deep-colored fruits and vegetablesDeep-colored fruits and vegetablesDark green, yellow & orangeDark green, yellow & orange
CarrotsCarrots CantaloupeCantaloupe SquashSquash
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 8
Requirements: Vitamin ARequirements: Vitamin ARDARDA
Women Women >>19 years19 years 700 mcg700 mcg Pregnancy: 770 mcgPregnancy: 770 mcg Lactation: 1300 mcgLactation: 1300 mcg
Men Men >>19 years19 years 900 mcg900 mcg
Median dietary intake: 1168 mcg (NHANES)Median dietary intake: 1168 mcg (NHANES)Median intake from supplements: 1430 mcgMedian intake from supplements: 1430 mcg
ULUL3000 mcg/day3000 mcg/day
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 9
Hyperstates: Vitamin AHyperstates: Vitamin AHigh doses referred to as hypervitaminosis AHigh doses referred to as hypervitaminosis A
Birth defects reported in children of women taking 13-Birth defects reported in children of women taking 13-ciscis-retinoic -retinoic acid (isotretinoin) for skin conditions during pregnancy acid (isotretinoin) for skin conditions during pregnancy
Catabolism of collagen and bone resorption by osteoclastsCatabolism of collagen and bone resorption by osteoclasts DiplopiaDiplopia AlopeciaAlopecia Dry, rough skin and mucosaDry, rough skin and mucosa Reddened gingivaReddened gingiva Cracked lips Cracked lips Thinning of epitheliumThinning of epithelium
Carotene excessCarotene excess Hypercarotenemia: skin turnsHypercarotenemia: skin turns
deep yellow, especially ondeep yellow, especially onpalms and solespalms and soles
From Patton KT, Thibodeau GA: Anatomy & Physiology, ed From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Louis: Mosby, 2013.8. St. Louis: Mosby, 2013.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 10
Hypostates: Vitamin AHypostates: Vitamin AGrowth restriction in Growth restriction in
children children Impaired dark adaptation Impaired dark adaptation
and night blindnessand night blindnessKeratinization of lung, GI Keratinization of lung, GI
tract, and urinary tract tract, and urinary tract epithelia epithelia
Susceptibility to infectionsSusceptibility to infectionsFollicular hyperkeratosis of Follicular hyperkeratosis of
the skinthe skinSometimes deathSometimes death
Enamel hypoplasiaEnamel hypoplasiaXerophthalmia, Xerophthalmia,
keratomalacia, and Bitotkeratomalacia, and Bitot’’s s spots in advanced spots in advanced deficiencydeficiency
From Daniel SJ, Harfst SA, Wilder RS: Mosby’s Dental From Daniel SJ, Harfst SA, Wilder RS: Mosby’s Dental Hygiene: Concepts, Cases, and Competencies, ed 2. Hygiene: Concepts, Cases, and Competencies, ed 2.
St. Louis: Mosby, 2008.St. Louis: Mosby, 2008.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 11
Vitamin D (Calciferol)Vitamin D (Calciferol)Called a vitamin, but more appropriately Called a vitamin, but more appropriately
classified as a classified as a hormone hormone Skin cells able to make vitamin D precursor Skin cells able to make vitamin D precursor
7-dehydrocholesterol with further processing 7-dehydrocholesterol with further processing by liver and kidneysby liver and kidneys
Physiological rolesPhysiological rolesEnhances intestinal calcium and phosphorus Enhances intestinal calcium and phosphorus
absorptionabsorptionMay be involved in cells in May be involved in cells in hematopoiesis hematopoiesis (the (the
formation of RBC), the skin, cardiovascular formation of RBC), the skin, cardiovascular functionfunction,, and immune response and immune response
From Patton KT, Thibodeau GA: Anatomy & From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Louis: Mosby, 2013.Physiology, ed 8. St. Louis: Mosby, 2013.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 12
Requirements: Vitamin DRequirements: Vitamin D
AI (conversion 1 mcg = 40 IU)AI (conversion 1 mcg = 40 IU)19 to 50 years19 to 50 years
5 mcg (200 IU)/day5 mcg (200 IU)/day51 to 70 years51 to 70 years
10 mcg (400 IU)/day10 mcg (400 IU)/day> 70 years> 70 years
15 mcg (600 IU)/day15 mcg (600 IU)/day
Median intake (NHANES)Median intake (NHANES)90 to 114 mcg/day90 to 114 mcg/day
ULUL50 mcg (2000 IU)/day50 mcg (2000 IU)/day
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 13
Factors Affecting Vitamin D Factors Affecting Vitamin D RequirementsRequirements
AgingAgingFourfold Fourfold in production in in production in
those >65 yrthose >65 yrMalabsorption conditionsMalabsorption conditions
Sprue, CrohnSprue, Crohn’’s disease, cystic s disease, cystic fibrosisfibrosis
Kidney failureKidney failure
Exposure to sunlightExposure to sunlightUse of sunscreenUse of sunscreen skin melanin skin melanin
pigmentationpigmentationLatitude, time of day, Latitude, time of day,
season of yearseason of yearHomebound or Homebound or
institutionalized elderlyinstitutionalized elderlyReligious/cultural Religious/cultural
habits requiring habits requiring covering the bodycovering the body
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 14
Sources: Vitamin DSources: Vitamin D
SunlightSunlightFood sourcesFood sources
Fish liver oilsFish liver oilsFatty fishFatty fishFortified foodsFortified foods
MilkMilk 10 mcg (400 IU) per quart
CerealsCereals Orange juiceOrange juice
SupplementsSupplements
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 15
Hyperstates: Vitamin DHyperstates: Vitamin D
Toxic effects occur in adults receiving 2500 Toxic effects occur in adults receiving 2500 µg (100,000 IU)/day for several months µg (100,000 IU)/day for several months Anorexia, nausea, and vomiting initiallyAnorexia, nausea, and vomiting initiallyFollowed by polyuria, polydipsia, weakness, Followed by polyuria, polydipsia, weakness,
nervousness, and pruritus nervousness, and pruritus HypercalcemiaHypercalcemia
Calcification of renal and cardiac tissuesCalcification of renal and cardiac tissues
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 16
HypostatesHypostates: Vitamin D: Vitamin D
Vitamin D deficiency a pandemic problem in Vitamin D deficiency a pandemic problem in 40% to 60% of adults and teens40% to 60% of adults and teens
RicketsRicketsMost visible lower ends of radius and ulna Most visible lower ends of radius and ulna Characteristic deformities result from bones Characteristic deformities result from bones
bending at the cartilage-shaft junctionbending at the cartilage-shaft junctionEnamel hypoplasiaEnamel hypoplasia
Osteomalacia Osteomalacia Decreased bone mineralization or softening; leads Decreased bone mineralization or softening; leads
to deformities of limbs, spine, thorax, and pelvis to deformities of limbs, spine, thorax, and pelvis Symptoms are skeletal pain and muscle weakness Symptoms are skeletal pain and muscle weakness Loss of the lamina duraLoss of the lamina dura
From Kumar V, Abbas AK, From Kumar V, Abbas AK, Fausto N: Robbins and Fausto N: Robbins and
CotranCotran.. Pathologic Basis of Pathologic Basis of Disease, ed 8. Philadelphia: Disease, ed 8. Philadelphia:
Saunders, 2010.Saunders, 2010.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 17
Hypostates: Vitamin DHypostates: Vitamin D
OsteoporosisOsteoporosisVitamin D deficiency interferes withVitamin D deficiency interferes with
mineralization mineralization bone density bone density
and and risk for fracture risk for fracture
Cancer and cardiovascular riskCancer and cardiovascular riskVitamin D may be protective against some cancersVitamin D may be protective against some cancers
Higher levels in blood associated with reduced colon and Higher levels in blood associated with reduced colon and colorectal cancerscolorectal cancers
In animal studies, tumor growth has been decreased with vitamin In animal studies, tumor growth has been decreased with vitamin D supplementationD supplementation
Low levels may increase risk for heart attackLow levels may increase risk for heart attack
From Patton KT, Thibodeau GA: From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Anatomy & Physiology, ed 8. St.
Louis: Mosby, 2013.Louis: Mosby, 2013.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 18
Physiological Roles: Vitamin EPhysiological Roles: Vitamin EAntioxidantAntioxidant
Protects polyunsaturated fats in phospholipid cell Protects polyunsaturated fats in phospholipid cell membranesmembranes
Prevents oxidation of fatty acids and vitamins A and CPrevents oxidation of fatty acids and vitamins A and CEnhances release of a prostaglandin that inhibits the Enhances release of a prostaglandin that inhibits the
aggregation of platelets, enhances vasodilation and aggregation of platelets, enhances vasodilation and immune responseimmune response
AnticoagulantAnticoagulant
From Patton KT, Thibodeau GA: Anatomy & Physiology, ed From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Louis: Mosby, 2013.8. St. Louis: Mosby, 2013.
..
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 19
Requirements: Vitamin ERequirements: Vitamin ERDARDA
15 mg/day α-tocopherol (α-TE) 15 mg/day α-tocopherol (α-TE) ULUL
1000 mg/day1000 mg/dayConversion units vary accordingConversion units vary according
to the type of tocopherolto the type of tocopherolα-TE 1 mg = 1.5 IUα-TE 1 mg = 1.5 IU
Median intakeMedian intake13.6 to 18.4 mg/day13.6 to 18.4 mg/day
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 20
Sources: Vitamin ESources: Vitamin E
Vegetable oils, especially soybean oilVegetable oils, especially soybean oilUnprocessed cereal grains or fortified cerealsUnprocessed cereal grains or fortified cerealsNuts and seedsNuts and seedsWheat germWheat germGreen leafy vegetablesGreen leafy vegetablesSome fruits, such as apples, Some fruits, such as apples,
apricots, and peachesapricots, and peaches
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 21
Hyperstates: Vitamin EHyperstates: Vitamin ESupplementation may significantly Supplementation may significantly
increase risk of mortalityincrease risk of mortalityOccasionally, muscle weakness, Occasionally, muscle weakness,
fatigue, nausea, and diarrhea have fatigue, nausea, and diarrhea have occurred in persons taking 800 to occurred in persons taking 800 to 3200 mg/day 3200 mg/day
Most significant effect at >1000 Most significant effect at >1000 mg/day is antagonism to vitamin K mg/day is antagonism to vitamin K action and enhancement of the action and enhancement of the effect of oral anticoagulants effect of oral anticoagulants (warfarin) (warfarin)
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 22
Hypostates: Vitamin EHypostates: Vitamin EDeficiencyDeficiency
Mild hemolytic anemia associated with increased Mild hemolytic anemia associated with increased erythrocyte hemolysis erythrocyte hemolysis
Peripheral neuropathyPeripheral neuropathySubsequent decline in physical functionSubsequent decline in physical function
At-risk groupsAt-risk groupsSickle cell anemiaSickle cell anemiaSmokersSmokersThose on an extremely low-fat dietsThose on an extremely low-fat diets
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 23
Physiological Roles: Vitamin KPhysiological Roles: Vitamin K
Naturally occurring vitamins are KNaturally occurring vitamins are K11
(phylloquinone), in green plants, and K(phylloquinone), in green plants, and K22
(menaquinone) formed by (menaquinone) formed by Escherichia coliEscherichia coli bacteria in the large intestine bacteria in the large intestine
FunctionsFunctionsCoenzyme for proteins involved in bone crystalline Coenzyme for proteins involved in bone crystalline
formationformationCatalyst for synthesis of blood-clotting factors Catalyst for synthesis of blood-clotting factors
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 24
Requirements: Vitamin KRequirements: Vitamin K
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 25
Sources: Vitamin KSources: Vitamin K
Human gut contains bacteria that produce a Human gut contains bacteria that produce a form of vitamin K, but it is unclear how this form of vitamin K, but it is unclear how this contributes to maintenance of vitamin K statuscontributes to maintenance of vitamin K status
Green leafy vegetablesGreen leafy vegetablesAbsorption enhancedAbsorption enhanced
with presence of dietary fatwith presence of dietary fatFats and oilsFats and oils
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 26
Hypostates: Vitamin KHypostates: Vitamin K
Disease or drugs may cause deficiencyDisease or drugs may cause deficiencyConditions blocking bile flow (celiac disease, sprue)Conditions blocking bile flow (celiac disease, sprue)Diarrheal diseases (ulcerative colitis)Diarrheal diseases (ulcerative colitis)Hemorrhagic disease of the newbornHemorrhagic disease of the newbornAdults with marginal dietary intake who have Adults with marginal dietary intake who have
undergone trauma, extensive surgery, or long-term undergone trauma, extensive surgery, or long-term parenteral nutrition with or without treatment with parenteral nutrition with or without treatment with broad-spectrum antibiotics broad-spectrum antibiotics
Drugs, including anticonvulsants, anticoagulants, Drugs, including anticonvulsants, anticoagulants, certain antibiotics (particularly cephalosporins), certain antibiotics (particularly cephalosporins), salicylates, and megadoses of vitamin A or Esalicylates, and megadoses of vitamin A or E
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 27
Physiological Roles: Vitamin C Physiological Roles: Vitamin C (Ascorbic Acid)(Ascorbic Acid)
FunctionsFunctionsCoenzyme in hydroxylation ofCoenzyme in hydroxylation of
proline for hydroxyproline inproline for hydroxyproline incollagen synthesiscollagen synthesis
Promotes capillary integrityPromotes capillary integrityEnhances iron absorptionEnhances iron absorptionAids in utilization of folic acid and vitamin BAids in utilization of folic acid and vitamin B1212
Coenzyme function in metabolism of amino acids and Coenzyme function in metabolism of amino acids and biosynthesis of bile acids, thyroxine, epinephrine, and biosynthesis of bile acids, thyroxine, epinephrine, and steroid hormonessteroid hormones
AntioxidantAntioxidant
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 28
Requirements and Sources: Vitamin C Requirements and Sources: Vitamin C (Ascorbic Acid)(Ascorbic Acid)
RDARDAMen: 90 mg/dayMen: 90 mg/dayWomen: 75 mg/dayWomen: 75 mg/daySmokers +35 mg/daySmokers +35 mg/day
ULUL2 g/day2 g/day
SourcesSourcesCitrus fruitsCitrus fruitsTomatoesTomatoesRaw, leafy vegetablesRaw, leafy vegetablesStrawberriesStrawberriesPotatoes and sweet Potatoes and sweet
potatoespotatoes
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 29
Hypostates: Hypostates: Vitamin C (Ascorbic Acid)Vitamin C (Ascorbic Acid)
Delayed wound healingDelayed wound healingPoor bone and tooth developmentPoor bone and tooth developmentScurvyScurvy
Red, swollen gingivaRed, swollen gingivaSore, burning mouthSore, burning mouthGingival friability, spontaneous bleedingGingival friability, spontaneous bleedingPeriodontal destruction/tooth mobilityPeriodontal destruction/tooth mobility risk of candidiasis and susceptibility to risk of candidiasis and susceptibility to
infectioninfectionMalformed enamel and inadequate dentinMalformed enamel and inadequate dentin
From Swartz MH: Textbook of Physical From Swartz MH: Textbook of Physical Diagnosis: History and Examination, ed 7. Diagnosis: History and Examination, ed 7.
St. Louis: Saunders, 2014.St. Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 30
Hypostates: Vitamin CHypostates: Vitamin C (Ascorbic Acid) (Ascorbic Acid)
Marginal intakesMarginal intakes intake results in 1.2 times greater risk of PDintake results in 1.2 times greater risk of PD intake in smokers results in a 1.6 times greater riskintake in smokers results in a 1.6 times greater risk
Deficiency does not CAUSE gingivitis or Deficiency does not CAUSE gingivitis or periodontal disease, but may be a periodontal disease, but may be a contributing contributing factorfactor
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 31
Nutritional ConsiderationsNutritional ConsiderationsAssess nutrient intake of groups at Assess nutrient intake of groups at
high risk for developing nutritional high risk for developing nutritional deficiencies (low income, medically deficiencies (low income, medically compromised)compromised)
Encourage consumption of dairy and Encourage consumption of dairy and vitamin D–fortified foodsvitamin D–fortified foods
Supplement in excess of RDA should Supplement in excess of RDA should not be recommendednot be recommended
Encourage daily intake of foods high in Encourage daily intake of foods high in vitamin Cvitamin C