vitamins role in oral surgery

2. Contents
 Introduction
 Classification of vitamins
 Functions
 Dietary sources
 Deficiency
 Hyper vitaminosis
 Supplements
 Drug interactions
 Conclusion
 References

3. Introduction
 Nutrients: the chemical substances in food that are used by the body
to produce energy.
 Vitamins : the chemical compounds necessary for human body. They
regulate chemical reactions by which the body to converts food into
energy.
 Fat soluble vitamin: a vitamin that can be stored and accumulated in
the liver and other fatty tissues.
 Water soluble vitamin: a vitamin that cannot be stored in the tissues.
Must be provided regularly as deficiencies can develop in a short
time.
 Vitamin deficiency: decline in health due to the lack of a vitamin in a
ration.

4. History
In 1912 -- Frederick Gowland Hopkins found unknown
factors present in milk that were not fats, proteins or
carbohydrates, but were required to aid growth in rats.
In 1918, Elmer McCollum “accessory factors” were described
as fat soluble
In 1920, they were referred to as vitamin A.
In 1913 McCollum and Davis-the discovery of vitamin D and
its production in skin caused by ultraviolet light.
In 1922 -- Vitamin E was discovered by Evans and Bishop
In 1929 -- Vitamin K was first discovered by Henrik Dam

6. Vitamin A ( retinol)
Functions
 The 11-cis-retinaldehyde (retinal) form of vitamin A is
required by the eye for the transduction of light into
neural signals necessary for vision
 The Retinoic Acid form is required to maintain normal
differentiation of the cornea and conjunctival
membranes.
 Vitamin A is said to have Anti-Oxidant Property .
 Vitamin A is required for the integrity of epithelial cells
throughout the body.

7. Dietary Sources
 Organ Meats liver (beef, pork, fish)-6500 mcg
 Cod Liver Oil– 30000 mcg
 Cheese, Milk products -28 mcg
 Egg – 140 mcg
 Capsicum red- 2081 mcg
 Carrots – 835 mcg
 Sweet Potato – 961 mcg
 Tomato -42 mcg
 Mango – 38 mcg
 Papaya –55 mcg
 Pumpkin- 426 mg
 Spinach- 469 mcg
 Kale or cabbage leaf-681 mcg
 Broccoli leaf – 800 mcg
 Mixed Green leafy vegetables

9. Recommended Dietary Allowance
Units:
1 International Unit (I.U) = 0.3 mcg Retinol
0.6 mcg β-Carotene
RDA:
Children : 400 mcg/day
Adult Male: 900 mcg/day
Adult Female: 700 mcg/day
Pregnant Female : 1000 mcg/day
Lactating female : 1200 mcg/day
Normal serum retinol ---- 30 - 95 µg/dL

10. Xerophthalmia Classification
Vitamin A Deficiency
 XN--Night blindness
 X1A-- Conjunctival xerosis
 X1B--Bitot’s spot
 X2-- Corneal xerosis
 X3A -- Corneal ulceration/keratomalacia (< 1/3 corneal
surface)
 X3B-- Corneal ulceration/keratomalacia (≥ 1/3 corneal
surface)
 XS -- Corneal scar
 XF--Xerophthalmic fundus

11. Conjunctival Xerosis
Corneal Xerosis
Keratomalacia followed by Blindness
Bitot Spot- Plaques In Conjunctiva

12.  Epithelium lining the upper respiratory passage
and urinary tract is replaced by keratinizing
squamous cells (squamous metaplasia)

13. Hyper vitaminosis
 GI effects- diarrhea
 Blurred vision
 Poor muscle coordination
 Bone and muscle pain
 Loss of appetite
 Skin disorders
 Headache
 Dry skin
 Hair loss
 Increased liver size

14. Vitamin A prophylaxis programme
Individual Oral dose Timings
0-6 m0nths infants 25,000 IU retinyl
palmitate
1 – 3 times over the 1st
6months of life
6-11 months children 1,00000 IU retinyl
palmitate
Once every 4 to 6
months
> 12 months old 2,00000 IU retinyl
palmitate
Once every 4 to 6
months
Women of child
bearing age
2,ooooo IU retinyl
palmitate
With in one month
of giving birth
Pregnant and
lactating women
5,000 to 10,000 IU
retinyl palmitate
Daily

15. Vitamin A supplements
 Vitamin A(Retinol)-PO, IM --4000-5000IU/day
 Tretinoin
 Isotretinoin –topical --Apply/hrs
Recommended xerophthalmia treatment schedule
6 -12 months > 1 yr
 Immediately 100,000 IU 200,000 IU
 Next day 100,000 IU 200,000 lU
 2–4 weeks later 100,000 IU 200,000 IU

16. Drug interactions
 Medications for skin conditions (Retinoids)
medications for skin conditions have vitamin A effects.
Taking vitamin A and these medications for skin
conditions could cause too much vitamin A effects and side
effects.
 Antibiotics (Tetracycline antibiotics
Vitamin A can interact with some antibiotics. Taking
very large amounts of vitamin A along with some
antibiotics can increase the chance of a serious side effect
called intracranial hypertension. But taking normal doses
of vitamin A along with tetracyclines doesn't seem to cause
this problem.
 Warfarin (Coumadin)

17. Vitamin D
 Two Major Forms of Vitamin D
 Vitamin D2, ergocalciferol
 Vitamin D3, cholecalciferol
 Vitamin D1: molecular compound of ergocalciferol
with lumisterol
 Vitamin D4: 22-dihydroergocalciferol
 Vitamin D5: sitocalciferol (made from 7-
dehydrosisterol)

18. Functions
 Maintain normal blood levels of Calcium and
Phosphorus
 Aids in absorption of calcium
 Promotes bone mineralization
 Prevents rickets in children and Osteomalacia in
adults

19. VITAMIN D IN CANCER PREVENTION AND
RECOVERY:
 The vitamin D hormone, calcitriol, has been found to
induce death of cancer cells. Although the anti-cancer
activity of vitamin D is not fully understood, it is
thought that these effects are mediated through
vitamin D receptors expressed in cancer cells.
 The anti-cancer activity of vitamin D observed in the
laboratory, vitamin D supplementation might be
beneficial in the treatment or prevention of some
types of cancer.

20.  Vitamin D regulates the expression of genes associated
with cancers and autoimmune disease by controlling the
activation of the vitamin D receptor (VDR), a type 1
nuclear receptor and DNA transcription factor. Research
has indicated that vitamin D deficiency is linked to colon
cancer and more recently, to breast cancer.
 Cancer prevention specialists have concluded that
taking 1,000 international units (IU) of vitamin D3
per day may lower an individual’s risk of developing
certain cancers including breast, colon, prostate and
ovarian, by up to 50 percent.

21. Sources of vitamin D
 Cod Liver Oil -- 1 tablespoon (1,360 IU)
 Salmon -- cooked, 3 ounces (447 IU)
 Sardines canned fish oil , 1 table spoon (1400IU)
 Milk,
 vitamin D-fortified orange juice, 1 cup (137 IU)
 vitamin D-fortified milk, 1 cup (115-124 IU)
 vitamin D-fortified yogurt, 6 ounces (80 IU).
 Dry cereal
 Liver, beef
 2 large Eggs (contain 1/8 of recommended dose)
 swordfish, cooked, 3 ounces (566 IU)
 tuna fish, 3 ounces (154 IU)
1 ounce = 28 grams =1 table spoons = 3 tea spoons
1 cup = 100grams

23. Recommended Dietary Allowances (RDA)
 Adult male-- 15mcg (600IU)
 Adult female—15mcg
 Pregnancy and lactation –15mcg
Normal values of vitamin D --10 - 55 ng/mL

24. Vitamin D Deficiency
 Deficiency of vitamin D or an inability to utilize vitamin D may
lead to a condition called rickets and osteomalacia ( a
weakening and softening of bones brought on by extreme
calcium loss)
Rickets in childrens Osteoporosis in adults

25. CLINICAL FEATURES OF RICKET
HEAD
 Craniotabes --- softening of cranial bones
 Frontal Bossing
 Delayed Fontanelle Closure
 Delayed Dentition, early numerous caries, enamel hypoplasia-
mostly deciduous teeth are concerned
 Craniosynostosis
BACK
Scoliosis ,Kyphosis
Anterior bowing of tibia and femur

26. CHEST
 Rachitic rosary -Widening of costochondral junction
 Harrison Groove - pulling of softened ribs by
the diaphragm during inspiration
 Thoracic asymmetry
 Widening of thoracic bone
Osteomalacia
 Bones that fracture very easily.
 Muscle weakness and bone pain
 Skeletal mineralization defect.

27. Hyper vitaminosis
 nausea
 vomiting
 poor appetite
 constipation
 weakness
 weight loss

28. Vitamin D Supplements
 Calciferol
 Calcirol sachets –60,000IU/oral or injection
 Arachitol – 3 lakhs and 6 lakhs IU/ml
 Adexolin A&D—vit A5000IU ,vit D400IU
 Calcitriol
 Ergocalciferol

29.  For preventing osteoporosis and fractures: 400-1000 IU per
day has been used for older adults.
 For preventing all cancer types: calcium 1400-1500 mg/day
plus vitamin D3 1100 IU/day in postmenopausal women has
been used.
 The Canadian Cancer Society recommends 1000 IU/day
during the fall and winter for adults in Canada, reduced risk
for colorectal, breast and prostate cancers
 The National Osteoporosis Foundation recommends
vitamin D 400 IU to 800 IU daily for adults under age 50, and
800 IU to 1000 IU daily for older adults.
 The North American Menopause Society recommends
700 IU to 800 IU daily for women at risk of deficiency due to
low sun exposure.

30. Drug interactions
 Aluminum interacts with VITAMIN D
 Calcipotriene (Dovonex)
 Digoxin (Lanoxin)
 Vitamin D helps your body absorb calcium. Calcium can affect the
heart.
 Diltiazem (Cardizem, Dilacor, Tiazac)
 Verapamil (Calan, Covera, Isoptin, Verelan)
 Water pills (Thiazide diuretics)
 Heparin

31.  Antioxidant(most powerful natural)
 Free radical scavenger
 Protects cell membranes
 Protects RBCs from hemolysis.
 Structural & functional integrity of all cells.
 Slowing down of ageing process.
Functions
Vitamin E

33.  Stabilize reactions or situations that typically
produce free radicals
 Required for Proper Hair Growth (Beauty
Vitamin along with BIOTIN)
 Preserves & maintains germinal epithelium of
gonads.
 Optimal absorption amino acids.
 Proper storage of creatine in skeletal muscle.

34. Dietary Sources
 Richest source –
 Wheat Germ Oil,
 Sunflower Oil – 1 cup (46mg)
 Cotton Seed Oil.
 Almonds butter -- Cup (38mg)
 Coconut oils – relatively low.
 Tomato – 0.66mg
 Mango- 2.2mg
 Kiwi –1.1mg
 Cooked spinash – ½ cup( 3.36mg)
 Fish liver oils – devoid.

36. Recommended Dietary Allowance
 Males – 10mg/day.
 Females – 8mg/day.
 Pregnancy - 10mg/day.
 Lactation- 12mg/day.
 Normal plasma level -5 - 20 µg/mL

37. Vitamin E Deficiency
 Rare in humans.
 Hemolytic anemia – increased red blood cell
fragility.
 Muscular weakness & creatinuria.
Hypervitaminosis
 Severe symptoms not seen in humans.
 Tendency of hemorrhage.
 Neurological symptoms.

38. Vitamin E Supplements
 Evion, Tocofer,Ecod – 100mg, 200mg, 400mg, 600mg
pearls
 Evion drops 50mg/ml
 For vitamin E deficiency: dose in adults is alpha
tocopherol 60-75 IU per day.
 For healing the eyes after a surgery called keratectomy:
230 mg vitamin E and vitamin A 25,000 units have been
used 3 times daily for 30 days, followed by twice daily for
2 months.
 Bladder cancer. Taking 200 IU of vitamin E
by mouth for more than 10 years seems to
help prevent death from bladder cancer.

39. Drug interaction
 Cyclosporine (Neoral, Sandimmune)
 Medications for cancer (Chemotherapy)
 Medications that slow blood clotting (Anticoagulant /
Antiplatelet drugs)
 Warfarin (Coumadin)
 Medications used for lowering cholesterol (Statins)

40. Vitamin K
 Three compounds have the biological activity of
vitamin K
 Phylloquinone (Vitamin K1), the normal dietary
source, found in green vegetables
 Menaquinones (vitamin K2), synthesized by
intestinal bacteria, with differing lengths of side chain;
 Menadione and menadiol diacetate, synthetic
compounds that can be metabolized to phylloquinone.

41. Functions of vitamin K
1. Calcium binding proteins
Vitamin K–dependent proteins are clotting factor proteins
2. Role of vitamin K in coagulation
 The ability to bind calcium ions (Ca2+) is acquired by the
activation of the vitamin K-dependent clotting factors, or
proteins, in the coagulation cascade.
 Factors II (prothrombin), VII, IX, and X make up the core of the
coagulation cascade. These factors are synthesized in the liver in
the inactive form.
 They undergo post translational modifications, gamma
carboxylation of glutamic acid residues.
 This process of gamma carboxylation of glutamic acid residues
imparts another negative charge, so as to promote the effective
binding of these factors/proteins to calcium ions.

42. Dietary Sources
 Salad vegetables ( onions) – 207mcg/ 1cup
 Soybeans -66mcg/ 1 cup
 Green leafy vegetables(kale) –1062mcg / 1 cup
 Dried fruits ( blue berries) -103mcg/ 1 cup
 Olive oil – 10mcg/ 1 table spoon
 Pickles (cucumber) – 130mg / 1 cup
 Some amount is contributed by intestinal bacteria

44. Recommended Dietary Allowance
 Infants 0-6 months-- 2 mcg
 Infants 6-12 months-- 2.5 mcg
 Children 1-3 years--30 mcg
 Children 4-8 years--55 mcg
 Children 9-13 years-- 60 mcg
 Adolescents 14-18 years -- 75 mcg
 Men over 19 years--120 mcg
 Women over 19 years ( pregnant and breast-feeding)--
90 mcg.
Normal value of vitamin K—0.2 to3.2ng/ml

45. Vitamin K deficiency
 The main symptom is bleeding (hemorrhage)—into
the skin (causing bruises), from the nose, from a
wound, in the stomach, or in the intestine.
 Blood may be seen in the urine or stool.
 Having a liver disorder increases the risk of bleeding
because proteins that help blood clot (clotting
factors) are made in the liver.
 Vitamin K deficiency may also weaken bones.

46.  Intracranial hemorrhage can occur during the delivery
process and can lead to severe complications.
 Soft tissue hemorrhages may be there.
 A deficiency of vitamin K can lead to extreme bleeding,
which can begin as a gum or nose discharge or bruising

47. hypervitaminosis
 Toxicity from dietary phylloquinone and
menaquinones has not been described.
 High doses of vitamin K can impair the actions of oral
anticoagulants.

48. Vitamin K Supplements
 Menadione sodium( water soluble) 10mg/ ampoule injection
 For bleeding disorders such as hypoprothrombinemia: 2.5-25
mg of vitamin K1 (phytonadione).
 For counteracting bleeding that can occur when too much of
the anticoagulant warfarin is given: 1-5 mg of vitamin K is
typically used; however, the exact dose needed is determined
by a lab test called the INR.

49. Drug interaction
 Warfarin (Coumadin)
Vitamin K is used by the body to help blood clot.
Warfarin (Coumadin) is used to slow blood clotting. By
helping the blood clot, vitamin K might decrease the
effectiveness of warfarin (Coumadin)
 Maternal medications that interfere with vitamin K stores or
function (e.g., carbamazepine, phenytoin, barbiturates, some
Cephalosporins, rifampin, Isoniazid, Warfarin or Warfarin like
drugs) can result in vitamin K deficiency bleeding in the infant.
 Broad-spectrum antibiotics can mess up the good intestinal
bacteria that make vitamin K. In some people this could
lead to unusual bleeding.

50. Conclusion
Number of health conscious people are taking
vitamins or minerals for a variety of reasons.
To help ensure a healthy pregnancy, to strengthen the
immune system, to reduce the risk of cancer.
 Although more studies are needed to confirm whether
these health benefits are significant or not.

51. References
 Nelsons textbook of pediatrics –15th edition
 Nutrition for a healthy mouth ----- Rebecca Sroda
 James C. Fang, Desai N. Chirag, Harry Dym-- Nutritional aspects of
care , Oral Maxillofacial Surg Clin N Am 18 (2006)
 Douglas Mackay, Alan L. Miller--Nutritional support for wound care
, alternative medicine review volume 8 (4) 2003
 pharmacolgy principles and applications – Eugenia M. Fulcher,
Robert M. Fulcher, Cathy Dubeansky soto
 Text book of Oral Surgery volume 2 – Daniel M. Laskin
 Essentials of Biochemistry –U.Satyanarayana, U. Chakrapani
 Nutrition and child development pediatric textbook.
 Vitamin A dificiency and its consequences –Alfred Sommer 3rd
edition
 Graedon’ guide to Drug and nutrient interactions– the peoples
pharmacy.

52. THANK YOU