2. CONTENTS :
BRIEF OVERVIEW OF PROTEINS
DEFINITION OF PROTEINS
TYPES OF PROTEINS
BIOLOGICAL FUNCTIONS
ROLE IN DENTISTRY
PROTEIN METABOLISM OVERVIEW
METABOLIC DISTURBANCES OF
PROTEINS
7. DAILY REQUIREMENTS
One gram of protein is required for each kg of body
weight.
However requirement can increase in various normal
physiological situations like:
Last half of pregnancy
During lactation
Infancy
Childhood
Adolescence
8. TYPES OF PROTEINS
On the basis of composition :
1. Simple proteins :- contain only a.a
2. Conjugate proteins :- contain a non a.a component in addition to
the a.a
3. Complete proteins :- contain sufficient amount of essential a.a
4. Incomplete proteins :- contain insufficient quantities of one or
more essential a.a
5. Complementary proteins :- incomplete when ingested singly,but
when combined provide sufficient essential a.a
9. TYPES OF PROTEINS (CONTD.)
On the basis of function :
1. Hormonal
2. Enzymatic
3. Structural
4. Defensive
5. Storage
6. Transport
7. Receptor
8. Contractile
10. BIOLOGICAL FUNCTIONS
Static functions :- provides stucture and strength to the body e.g
collagen.
Dynamic functions :- hormonal, enymatic, defensive etc.
Source of energy
Role in dentistry :-
Pre-eruptive and post-eruptive effects on teeth as they form an
integral component of cells necessary for the normal development
of teeth and specifically for the formation of matrix of hard tissues
of teeth e.g Amelogenin,BMP.
Chemical nature of protein foods can neutralize the acids produced
by oral bacteria.
Dental pellicle- an acellular layer of salivary proteins protects the
enamel against abrasion and serves as a diffusion barrier thus
preventing the solubility of enamel surface.
11. PROTEIN METABOLISM OVERVIEW
Dietary protein body proteins
Protein synthesis amino acids synthesis of N-compounds
α-ketoglutarate
transamination
glutamate
deamination
ketoacids ammonia
urea
Energy Glucose Fat Non-essential amino acids
12. PROTEIN METABOLISM (CONTD.)
Amino acid contains two components:
Carbon skeleton- its converted to keto acids
a.a transamination Keto acids
.
Amino group- its converted to urea as an excretory product.
a.a deamination Urea
13. METABOLIC DISTURBANCES OF PROTEINS
I. Protein Energy Malnutrition (PEM) :-
PEM is a spectrum of diseases whose
essential feature is a deficiency of protein at
one end as in Kwashiorkor and ; total
inanition(starvation of infant due to severe and
prolonged restriction of all food at other end as
in Marasmus. In the middle of spectrum,there
is Marasmic Kwashiorkor in which there are
clinical features of both disorders.
14. Causes of PEM :-
Dietary deficiency
Serious illness
Infections in babies
Low socio-economic status
Problems in mother leading to inadequate
production of milk
Dietary factors like inadequate breast feeding,
ignorance of weaning
15. PROTEIN ENERGY MALNUTRITION
a) KWASHIORKOR
b) MARASMUS
CAUSES
CLINICAL MANIFESTATIONS
INVESTIGATIONS
TREATMENT
17. KWASHIORKOR
Introduction –
Its a maladaptive response to starvation due to lack of
physiological adaptation to unbalanced deficiency
where body utilizes proteins and conserves fat
Occurrence –
Seen predominantly between 1-5 years of age
Causes –
Due to insufficient intake of proteins, as the diet of
weaning child mainly consists of carbohydrates
18. Biological manifestations –
Decreased plasma albumin levels
Visceral compartment is severely affected
Hypoproteinemia and hypoglycemia
Decreased level of electrolytes
Low enzyme levels
Percentage of body water is increased
Iron deficiency anemia
Fatty liver (due to decreased synthesis of carrier proteins of
lipoproteins)
Hypoplastic bone marrow
Decreased immunity
Multi-vitamin deficiency
19. Clinical symptoms -
Weight is about 60-80 % of normal as loss of true weight is masked by
increased fluid retention
Generalized edema (due to decreased colloidal osmotic pressure) of
pitting variety
Sparing of subcutaneous fat and muscle mass as body utilizes its
proteins to compensate the deficient state
Swollen abdomen
Moon face
Characteristic skin lesions with alternating layers of hyperpigmentation,
desquamation hypopigmentation; giving a flaky paint appearance
Hair changes like loss of colour or alternate bands of pale and darker
colour, straightening and loss of firm attachment to scalp
Diarrhoea (due to impaired synthesis of digestive enzymes and loss of
electrolytes in stools)
Eyelashes give a ‘Broomstick’ appearance
Dehydration (due to diarrhoea and vomitting)
Prone to infections
Psychomotor changes (due to cerebral atrophy)
20.
21. Oral manifestations of Kwashiorkor –
Bright reddening of tongue with loss of papillae
Bilateral angular cheilosis (inflammation)
Fissuring of lips
Loss of circumoral pigmentation
Crowded and rotated teeth giving an appearance of mouth full of
jumbled teeth
Delayed eruption and hypoplasia of deciduous teeth
Mouths of Kwashiorkor patients have been described by Van
Wyk to be dry, dirty, caries free, easily traumatized with
epithelium readily become detached from the underlying
tissue, leaving a raw, beeding surface
Incisor and molar growth is retarded
Radicular osteocementum decreased
Increased acid solubility of enamel of incisors
Decreased salivary volume
22. Oral cytological smear study –
Perinuclear vacuolization or halo around nucleus in a
remarkable number of epithelial cells which is interpreted as
a sign of atrophy
Investigations –
A. Routine tests :-
• Full blood count -
• Stool and urine study – KETONURIA
• Blood glucose profile - HYPOGLYCEMIA
• Hb estimation - ANEMIA
B. Non-routine tests :-
• Hair analysis – ALTERNATE BANDS OF HAIR
• Skin biopsy - PARAKERATOSIS WITH DESQUAMATION
• Oral findings – BLEEDING SURFACE
23. Treatment –
Provide adequate nutrition by dietary supplements
Restore normal body composition
Dietary support in the form of 3-4 gm protein and 200
cal/kg body weight
Cure the conditions that cause the deficiency
Prevention –
Breastfeeding a baby for at least 6 months to prevent
PEM
Improved food distribution systems, public health
programs and agricultural development should be
promoted
24. MARASMUS
Introduction –
Its an adaptive response to starvation
Occurrence –
Seen mostly in the first year of life
Causes –
Due to deficiency of calories
Biological manifestations –
Serum albumin level normal or slightly decreased
Somatic compartment of proteins is lost
Anemia
Multi vitamin deficiency
Immune deficiency
Hypoplastic bone marrow with increased red cell precursors
25. Clinical symptoms –
Growth retardation due to low calorie intake
Loss of muscle mass as muscle proteins are mobilised as use for
fuel to provide body with a.a as a source of energy to
compensate malnutrition. Due to muscle wasting rib cage is
prominent
Subcutaneous fat is lost due to lipolysis
Lean body, so head appears too large
Body weight falls to 60 % of normal
Child looks older than his age
Weakened body is under stress
More chances of infections
Dry and baggy skin
Sparse hair and wrinkled appearance (Old man face)
No edema
Bones are prominent due to absence of fat around them
Hypotension and slow pulse
26.
27. Investigations –
Full blood count -
Electrolyte, serum protein level study –
ALBUMIN LEVEL NORMAL OR LOW.
Blood glucose level -
Treatment –
Dietary support by giving food as proteins and supplements
Bring the child out of starvation
28. POINTS OF DIFFERENTIATION BETWEEN
KWASHIORKOR AND MARASMUS
KWASHIORKOR MARASMUS
1. Malnutrition that occurs due
to insufficient intake of
proteins
2. Large belly, diarrhoea,
pigmented skin, hair changes
3. Children of 1-5 yrs age
4. Weaned from mother’s milk
to a diet low in protein
5. Edema-Present (pitting type)
6. 60-80 % of normal body wt.
7. Decreased plasma albumin
8. Treated by High protein
foods
1. Malnutrition that occurs due
to starvation (i.e deficiency of
proteins, carbs. and fats in
diet
2. Muscle wasting, skin
foldings, prominent rib cage ,
shrunken abdomen
3. Children under 1 yr
4. Failed breastfeeding
(inadequate calorie intake)
5. Absent, rather wasting
6. Less than 60 % of normal
7. Normal / slightly decreased
plasma albumin
8. Treated by a Well banced
diet
31. AMYLOIDOSIS
Introduction :-
Disorder characterized by extracellular deposits
of fibrillar proteins which is a result of
aggregation of misfolded proteins.
Misfolded proteins being unstable start self
associating forming oligomers and fibrils that r
deposited in tissues.
33. FORMS OF AMYLOID PROTEINS :-
1. Amyloid light chain protein (AL)- Here IG light
chains accumulate due to monoclonal B cell
proliferation affecting heart
2. Amyloid associated protein ( AA)- Here SAA
accumulates due to increased activation by chronic
inflammatory mediators affecting liver mainly.
3. AB amyloid – Here APP deposits in the cerebral
vessels.
4. Transthyretin – Here ATTR accumulates due to
mutation of normal transthyretin.
5. B2 Microglobulin – accumulates in patients with
renal disease ,with deposits in joints.
35. Clinical manifestations :-
Weakness,fatigue,weightloss
Renal and hepatic diseases
Proteinuria
Cardiac arrythemia
Changes in skin color
Clay-colored stools
Feeling of fullness
Joint pain
Low red blood cell count (anemia)
Shortness of breath
Swelling of the tongue
Tingling and numbness in legs and feet
Weak hand grip
37. A. Tongue amyloidosis :-
Feature of systemic amyloidosis
Macroglossia with nodular deposits
Lateral ridging of enlarged tongue due to
teeth indentation
Firm tongue with yellow nodules on lateral surface
Interference with taste and hyposalivation may result
from amyloid deposition in salivary glands
Xerostomia n tongue pain
Sub mandibular swelling due to tongue enlargement can
lead to respiaratory obstruction.
38. B. Palatal amyloidosis :-
Rare condition
Feature of localized amyloidosis
Nodular deposits found on palate ,nasal septum
and maxillary sinus.
39. Diagnosis :-
It requires
Demonstration of amyloid in tissues
Demonstration of plasma cell dyscrasia
o For demonstration of tissue amyloid :-
1. BIOPSY - Fine needle aspiration of abdomenal fat.
Tissues for non-invasive biopsy are gingiva, salivary
glands, rectum and skin.
Histological feature is Apple Green Birefringence
with Congo red dye and viewed under polarised
microscope. Other dyes like Thioflavin,Hematoxylin
and Eosin are also used.
41. o For demonstration of plasma cell dyscrasia :-
1. Bone marrow biopsy showing gamma and kappa
light chain producing plasma cells.
2. Presence of monoclonal light chains in serum and
urine.
3. Serum Free Light Chain assay (FLC)
o Imaging techniques for assessment of organ
involvement
42. Treatment :-
(Aim is to reduce the supply of amyloidogenic monoclonal light chains by
suppressing the underlying Plasma cell dyscrasia)
High-dose chemotherapy withstem cell transplant
can help remove the substance that leads to
amyloid formation in those with primary AL
amyloidosis.
Secondary (AA) amyloidosis is treated with
powerful anti-inflammatory medicines called
steroids, which fight inflammation.
Liver transplant may stop the disease in those with
hereditary amyloidosis.
43. A kidney or heart transplant may also be
recommended.
Diuretic medicine to remove excess water from
your body
Thickeners to add to fluids to prevent choking in
those who have swelling of the tongue
Compression stockings to relieve swelling in the
legs or feet
Diet modifications, especially for those with
gastrointestinal amyloidosis
45. GOUT
Introduction –
Gout is an inflammatory disease caused by deposition
of monosodium urate monohydrate crystals in and
around synovial joints.
Epidemology –
Levels are higher are in men, increase with age and are
associated with body weight
.
Pathophysiology –
It can be due to diminished renal excretion ; or
increased intake of red meat ; or
over production of uric acid .
46.
47. Clinical features –
Severe pain
Extreme tenderness
Marked swelling with overlying red
shiny skin
Crystals may deposit in joints and soft tissues to produce irregular
firm nodules called TOPHI.
Investigations –
Aspiration of urate crystals from a joint, bursa and tophus
Biochemical screen including renal function, uric acid, glucose
and lipid profile should be performed
Levels of ESR and CRP
Radiographs
48. Treatment –
Oral NSAIDs for pain relief
Local icepacks
Oral colchicine
Joint aspiration with intra articular steroid injection
Oral corticosteroids
Urate lowering therapy
Allopurinol drug which reduces conversion of
hypoxanthine and xanthine to uric acid.
49. PRIONS
Are the unique proteineceous infectious agents.
Devoid of nucleic acid.
Transmitted by acquisition of normal mammalian protein
(prion protein PrPc) which is in an abnormal
conformation(PrPsc ) due to replacement of alpha helices
by beta sheets.
The abnormal protein inhibits the enzyme proteasome
26S, leading to vicious circle of further accumulation of
abnormally configured PrPsc instead of normally
configured PrPc.
50.
51. PRIONS DISEASES
Introduction –
Rare disorders which include diff. forms of
CREUTZFELDT JAKOB Disease (CJD) as well as
animal diseases such as SCRAPIE disease in sheep
and Mad cow disease in cattles.
Epidemology –
Common in middle aged to elderly.
Pathology –
Due to mutations in gene coding for prion protein.
53. Oral manifestations of prions diseases are
extremely rare with features as :-
Pseudobulbar palsy may cause dysphagia.
Dysarthria and Orofacial dysesthesia .
Paresthesia, as well as loss of taste and smell.
54. Clinical features –
Progressive dementia
Characteristic EEG pattern due to brain atrophy
Visual disturbances
Diagnosis –
By immunohistochemical staining
Blood test
EEG
Cerebrospinal fluid test
55. PREVENTION –
The theoretical risk of
transmission of prion
disease through dental
treatment points to the
importance
of maintaining optimal
standards of infection control
and
decontamination for infectious
agents, including prions.
56. INBORN ERRORS OF AMINO ACID
METABOLISM
DISORDERS OF PHENYLALANINE N
TYROSINE
PHENYLKETONURIA
TYROSINEMIA
ALKAPTONURIA
ALBINISM
CYSTINURIA
CYSTINOSIS
HARTNUP DISEASE
MAPLE SYRUP DISEASE
58. INBORN ERRORS OF AMINO ACID METABOLISM:-
Phenylketonuria :-
Enzyme defect in Phenylalanine / tyrosine
degradation leading to metabolic disorder. Here,
the deficiency of hepatic enzyme Phenylalanine
Hydroxylase results in accumulation of
Phenylalanine.
Phenylalanine Tyrosine
P.HYDROXYLASE
Phenyketonuria
59. Oral manifestations –
Prominent cheek and jaw bones
Widely spaced teeth
Poor development of tooth enamel.
Patients are susceptible to tooth wear(erosion)
60. Clinical manifestations –
Mental retardation due to its accumulation
Hypopigmentation of hair and skin
Treatment –
Diet low in phenylalanine amino acid
Diet with sufficient amount of tyrosine (to
compensate for its absence)
61. Alkaptonuria :-
Its due to absence of Homogentisate oxidase
activity which is necessary for breakdown of
Homogenetisic acid. As such Homogentisate
accumulates in tissues .
Phenylalanine Tyrosine Homogenitisic
acid
H.OXIDASE
Alkaptonuria Intermediates in TCA
62. Clinical features –
Dark urine : also known as Black Urine disease
Homogenetistic acid urination Alkapton (Black colur)
Ochronosis (alkapton deposition in bones, nose,
ear,eyes, etc.)
Arthritis
Treatment –
Not a dangerous disorder,
so no specific treatment.
63. Albinism :-
It is due to lack of synthesis of pigment Melanin
which is due to defect in tyrosinase enzyme, the
most responsible enzyme for Melanin synthesis.
PHENYLALNINE TYROSINE
Tyrosinase
DOPA
ALBINISM
64.
65. Clinical features –
Photophobia
Susceptibility to Parkinson’s disease (as no DOPA
formed)
Hypopigmentation in the form of :
i. Vitiligo – loss of pigmentation around mouth,
nose, eyes, nipples
ii. Leukoderma – loss of pigmentation begins with
hands
66. Tryosinemia :-
It results due to loss of Tyrosine
transaminase which is required for the
degradation of Tyrosine. (Type 1)
Phenylalanine Tyrosine
T.transaminase
TYROSINEMIA Breakdown product
67. Clinical features –
Hepatic dysfunction, cirrhosis
Liver failure
Hyperkeratosis
Treatment –
Diets low in in Tyrosine,
Phenylalanine are
recommended.
68. Cystinuria :-
Characterized by increased excretion of Cystine
due to defective carrier system which is normally
present for re-absorption of amino acids leading to
excretion of amino acids in urine .
Cystine Reabsorption
carrier system in kidney
Cystinuria
69. Clinical features –
Cystine stones in kidneys (due to its insolubility)
Treatment –
Aim of treatment
is to increase its solubility
and thus reduce stone
formation in kidneys.
70. Homocystinuria :-
Due to accumulation of homocystine
Features –
Thrombosis,
Osteoporosis,
MI, Stroke, etc
71. Hartnup’s disease :-
It’s a hereditary disorder of Tryptophan metabolism
characterized by low plasma levels of Tryptophan and
their elevated urinary excretion.
Clinical manifestations –
Rash, light sensitivity
Cerebellar ataxia
Dermatitis
Mental retardation
Treatment –
Dietary Niacin is given
72. Maple Syrup Urine Disease :-
It’s a metabolic disorder of branched chain amno
acids. The urine smells like Maple syrup or Burnt
sugar, hence the name .
Branched chain keto a.a Acetyl CO-
A
acid dehyrogenase
MSUD
73. Symptoms –
Lethargy
Maple syrup odour of urine
Coma
Mental retardation
Treatment –
To feed with a diet having low content of branched
chain amino acids
74. Isovaleric acidemia :-
Inborn error of leucine metabolism with defect in
enzyme Isovaleric Co-A dehyrogenase.
Oral manifestation –
Cheesy odour in breath
Treatment –
Limit intake of leucine in diet
75. Cystinosis :-
Cystine storage disease where cystine crystals are
deposited in many tissues n organs of RES .
Cause –
Lysosomal dysfunction
76. Glycinuria :-
When excessive amount of glycine is excreted in
urine due to defective renal reabsorption .
Symptoms –
Increased tendency for formation of oxalate crystal
stones.
77. BIBLIOGRAPHY
Shafer’s Textbook of oral pathology (7th edition)
U.satyanarayan textbook of biochemistry (3rd edition)
Robbin’s book of basic pathology (9th edition)
Davidson’s book of medicine (22nd edition)
Neville’s textbook of oral and maxillofacial pathology (2nd
edition)
Neurol Neurosurg Psychiatry 2004;75(Suppl I):i36–i42. doi:
10.1136/jnnp.2004.036137
PEM by Keith P. West, Jr., Dr.P.H.international nutrition
Oral Manifestations of Malnutrition III. The Effect of
Proteins
Pages with reference to book,
From 119 To 122 Mohammad Iqbal Khadim ( Dentistry
Department, Khyber Medic College, Peshawar. )