Lactose intolerance is the inability to digest significant amounts of lactose due to a shortage of the enzyme lactase. The role of adequate calcium intake in the formation and maintenance of healthy bone and enamel structure, is well documented. Most calcium intake in childhood is derived from dairy products. Sourcing dietary calcium form alternative sources will help ensure adequate intake for both skeletal and dental tissue formation. Providing dental treatment for children with ADHD can be challenging. Using some simple methods to manage behavior and addressing possible dietary effects on ADHD will improve both oral and systemic health.

​

Introduction

 

Childhood nutrition has a significant influence on health and development throughout life.  Adequate nutrition is of importance in  two key developmental stages in childhood : the pre school years and the adolescent growth spurt , as these are times of rapid growth and development. It is important therefore to establish good eating patterns in childhood in order to set down a good foundation for life long habits.   As far as oral development is concerned the  eruption and completion pattern of the permanent dentition  continues between ages 3 and 18 years with mineralisation factors being of particular importance during this time. Common childhood conditions and their associated medications can present both nutrition and oral health risks. This article looks at three increasingly more common conditions that can affect both nutrition and oral health in teenagers and young children.  

 

Asthma and Oral Health  

 

The most common oral health conditions affecting asthmatic children include oral thrush/ candidaisis, Xerostomia, gingival conditions, dental erosion and caries.   The incidence of oral candida  has been found to be  significantly greater in asthmatic patients taking inhaled steroids compared with those who are not. (1,2)   Evidence of the effect of asthma on the periodontal condition and caries rate in children is mixed. A study from New Zealand has  suggested there is little evidence to support a causal relationship between asthma and caries. (3)  A UK study, however, revealed that asthmatic children had significantly more plaque, gingivitis, and calculus compared with the control group. It was concluded that asthmatic children have more decay affecting their permanent teeth, poorer periodontal status, and more tooth surface loss than the  healthy controls.(4)  

​

There are a number of factors which may predispose an asthmatic child to caries and periodontal conditions. One primary factor is  that the use of short-acting beta-agonists is associated with impaired saliva secretion, thus increasing the risk of caries prevalence.(5)  The use of short-acting beta-agonists is also  associated with oral mucosa injuries that are probably provoked by decreased concentrations of immunoglobulin A (IgA) in saliva.(6) ( IgA is an antibody found in saliva which protects the mucous membrane lining of the mouth). It has also been suggested that a decrease in pH of saliva and plaque in medicated asthmatics could be caused by inhaler drugs such as  beta-agonists and inhaled corticosteroids.(7)   Asthma medication also places patients at risk of dental erosion by reducing salivary protection against extrinsic or intrinsic acids.  Clinical differences are a higher incidence of tooth hypersensitivity, xerostomia and  salivary gland abnormalities(8).  

 

Nutritional Influences in Asthma  

 

The dietary intake of antioxidant micronutrients,essential fatty acids and the removal of food allergies, appear to be the most significant nutritional influences in asthma. Compared with the non-asthmatic child, the asthmatic child has a 14-fold higher risk of developing a severe allergic reaction to the ingestion of food. The most commonly cited foods are fruits with a rind, cow's milk and nuts.(9)  Fifty- five percent of children reporting a severe wheeze also report eczema or hay fever, highlighting the link between respiratory and allergic conditions.(9)   

 

Oxidative stress is implicated in the pathogenesis of asthma, and clinical studies show an imbalance in the level of oxidants to the level of antioxidants in subjects with asthma (10) It has been suggested that reactive oxygen species play an important role in the modulation of airway inflammation.(11) Levels of vitamin C are also  lower in asthmatic patients suggesting  that reactive oxygen species may be a contributing factor in asthma.(12) Magnesium is involved in a wide range of biological activities, including some that may protect against the development of asthma and chronic airflow obstruction. High dietary magnesium intake is associated with better lung function, and a reduced risk of airway hyper-reactivity and wheezing in adults.(13) Low magnesium intake may therefore be involved in the aetiology of asthma and chronic obstructive airways disease. 

​

Fish consumption in the first year of life may reduce the risk of developing asthma and allergic rhinitis in childhood.(14) There are indications that inclusion of omega three fatty acids in the diet may be useful in the treatment of asthma (15). Fish oil in the diet has been shown to ameliorate the symptoms in some animal models of chronic inflammatory disease and to protect against the effects of endotoxin and similar inflammatory challenges. Clinical studies have reported that oral fish oil supplementation has beneficial effects in rheumatoid arthritis and among some patients with asthma, supporting the idea that the omega three fatty acids in fish oil are anti-inflammatory.(16)    

 

 

Lactose Intolerance   

 

Lactose intolerance is the inability to digest significant amounts of lactose due to a shortage of the enzyme lactase, a brush border enzyme which breaks down the disaccharide lactose into galactose and glucose. Common symptoms include nausea, cramps, bloating, diarrhoea ,flatulence, and burping, which begin about 30 minutes to two hours after eating or drinking foods containing lactose. The severity of symptoms varies depending on the amount of lactose each individual can tolerate. Children between birth and five years may experience a failure to thrive and slow growth.  

 

Although some children are born with a lactase deficiency , others can develop lactose intolerance as they get older. At birth and early childhood large amounts of lactase are usually produced. From the age of two however, the body produces less lactase. By the teenage years the body is producing only 5-10 percent of the lactase produced in infancy.  

 

 

Oral Health Implications  

 

The role of adequate calcium intake in the formation and maintenance of healthy bone and enamel structure, is well documented.   From a dental health point of view, milk is often recommended as the preferred alternative to fizzy drinks, squash and acidic fruit juice.  Excessive soya milk consumption has also been indicated as a risk factor in renal calculus formation, due to its high oxalate content (17).  In addition, a calcium deficient diet can result in poor bone density and impaired enamel structure, increasing the risk of dental  caries.  Calcium deficiency has been shown to slow the rate of growth and reduce dentine apposition and enamel mineralisation.(18)   Other oral symptoms may include a dry mouth as a result of the dehydration that may occur with chronic diarrhoea. Micronutrient absorption may also be affected and this can manifest itself as multiple vitamin and mineral deficiency symptoms.  Other symptoms include pale skin, dark circles under the eyes and  slow growth.  

​

The recommended daily calcium intake for children is(19):  

 

Babies                          1-3yr                            4-6yrs                           7-10yrs                        11-18yrs

525mgs                        350mgs                        450mgs                        550mgs                        800mgs  

​

 

Nutrition Guidelines  

 

The most convenient and rich source of calcium for many people is milk and milk products with one pint of milk providing 700mgs of calcium. However from a biochemical standpoint the availability of calcium ions(Ca+) from the diet is only part of the picture.  Whilst lactose increases the uptake of calcium from the digestive tract, absorption and storage of Ca+ in bone tissue requires magnesium and vitamin D.  

 

For children who do not consume milk or milk products, alternative food sources of calcium need to be provided. There are increasingly more lactose free milk products available and  some lactose intolerant children and adults can digest goats or sheep’s milk,  yoghurt and cheeses. The casein and lactose structure is different to cows milk and better tolerated.  

 

Lactase enzymes are also available . The tablets are taken with food and the liquid form can be added to milk to help make it more digestible. The National Digestive Diseases Information Clearinghouse (20) recommends that young children with a lactose intolerance should not eat any foods containing lactose. Older children and adults, however, may find supplemental lactase helpful.

​

Attention Deficit Hyperactivity Disorder (ADHD) 

 

Attention Deficit Hyperactivity Disorder (ADHD) was first described in 1902 by Dr George Still.  It is a neurological condition which is estimated to affect approximately 1.7% of children in the UK, 3-5% in the US and 2% of children in Australia.   The first behavioural symptoms are often found in early childhood between the ages of 5-9 years, with boys more frequently affected than girls. It is thought that up to 60% of these children may carry some symptoms through to adulthood.   It has also been suggested that ADHD may also run in families, indicating inheritance as being a risk factor. Between 10 and 35% of children with ADHD have a close relative with past or present ADHD. (21)      

 

Behavioural Symptoms   ADHD is characterised by two distinct set of symptoms: Inattention and Hyperactivity- Impulsivity. Many of the symptoms listed occur from time to time in normal children, however, with ADHD they occur very frequently in a variety of settings and interfere with the child’s functioning.    

 

Various treatments include behaviour management, dietary regimes, educational management and medication.  The medication of choice appears to be amphetamine like stimulants such as Ritalin or Dexedrine. It is thought that ADHD symptoms respond well to stimulants because they increase the availability of dopamine.This neurotransmitter plays a key role in initiating movement, increasing alertness and reducing appetite. The dopamine hypothesis has thus driven much of the recent research into the causes of ADHD. There are however, growing concerns over the use of these drugs in children. Like amphetamines Ritalin is a class A drug and must be used with caution as they may retard growth. Adverse effects of these drugs include insomnia, anorexia, irritability, nausea and vomiting, mood alterations, headaches, tachycardia and/or hypertension.(23) The long term effect of such therapy is largely unknown. Treatment of children under six is also not recommended.    

​

Behaviour Management Techniques  

 

Providing treatment for children with ADHD is not without its problems. These children often find it difficult to sit still, concentrate and understand instructions. Many have behavioural and performance fluctuations from day to day as well as from hour to hour. Bear in mind too that the ADHD child is on average about 30 percent behind in age appropriate self control. A 7 year old patient would equal a five year old, 10 years would equal 71/2 and a sixteen year old would equal the behaviour of a 12 year old patient.   The following guidelines adapted for surgery use may be useful when treating ADHD affected children. 

 

 

• Provide  structured boundaries and surgery routine for the child. Rudeness is unacceptable.

• Be specific in your instructions e.g. instead of telling the child to “ behave” while Mum is in the chair, suggest “ play quietly with the Lego for the next 10 minutes.”

• Remove distracting elements from the surgery. E.g. other siblings from the room when having their check up or treatment. Background noise such as the radio.

• Communicate on a one to one basis, making direct eye contact. Avoid addressing other children or family members at the same time.

• Use rewards ( such as stickers) consistently and frequently to reinforce good behaviour such as sitting still, listening to adults and concentrating.

• Use short appointments and gradually lengthen the child’s concentration span. E.g. do fissure sealants one at a time instead of trying to do four different quadrants in the first appointment.

​

Dietary Effects 

 

The effect of dietary regimes in ADHD has mixed reviews, with some researchers concluding no significant effects (24). Other research, however , points to a number of negative dietary factors which may exacerbate the symptoms of ADHD. These include reactive hypoglycaemia, refined carbohydrate intake, artificial colourings, vitamin and mineral deficiencies, food allergies  and a lack of omega three fatty acids. (25,26,27)   Many of the behavioural symptoms of ADHD are exacerbated by reactive hypoglycaemia, particularly in children. When blood sugar is low the body releases adrenaline to normalise blood glucose levels. In children this adrenaline release may induce behavioural symptoms such as hyperactivity, aggression and lack of concentration. Other symptoms include rapid heartbeat and sugar cravings. Eating simple sugars particularly on an empty stomach rapidly increases blood glucose levels which results in reactive hypoglycaemia a few hours later when blood sugar levels dramatically drop, triggering an adrenaline release.

 

Making sure the child has a stable blood sugar prior to treatment may therefore, be of value. This can be achieved by asking the parent to give the child a small snack containing protein and complex carbohydrate an hour before treatment. Suggestions may include a baby avocado, a small piece of fruit with a pot of yoghurt, rye crackers with cottage cheese, wholemeal bread fingers with peanut butter. Avoid simple carbohydrates such as white bread, crisps, potato snacks or biscuits and fizzy drinks or squash. In addition to protecting the dentition from caries, a balanced blood glucose level may help improve the child’s behaviour during treatment.

 

  Many children simply “grow out” of ADHD. About half of those affected appear to function normally by young adulthood, however, many will also carry some problems through into their adult life. These may take the form of depression, anti social behaviour and attention problems.  The same brain function, however, that causes ADHD problems for a child may also give that child qualities for success. Intuition, energy, creativity and artistic skills to name a few.  

 

 

References

​

1 Fukushima C, Matsuse H, Tomari S, Obase Y, Miyazaki Y, Shimoda T, Kohno S.:

Oral candidiasis associated with inhaled corticosteroid use: comparison of fluticasone and beclomethasone.

Ann Allergy Asthma Immunol. 2003 Jun;90(6):646-51  

 

2 Guillot B. Adverse skin reactions to inhaled corticosteroids: Expert Opin Drug Saf. 2002 Nov;1(4):325-9.            

 

 

3 Meldrum AM, Thomson WM, Drummond BK, Sears MR.: s asthma a risk factor for dental caries? Finding from a cohort study. Caries Res. 2001 Jul-Aug;35(4):235-9.              

 

4 McDerra EJ, Pollard MA, Curzon ME.: The dental status of asthmatic British school children. Pediatr Dent. 1998 Jul-Aug;20(4):281-7.              

 

5 Ryburg M., Moller C., Ericson T : Saliva composition and caries development in asthmatic patients treated with B- adrenoceptor agonists: a 4 year follow up study. Scan J Dent Res 1991 99(3): 212-8.  

 

6 del-Rio-Navarro BE, Corona-Hernandez L, Fragoso-Rios R, Berber A, Torres-Alcantara S, Cuairan-Ruidiaz V, Sienra-Monge JJ.: Effect of salmeterol and salmeterol plus beclomethasone on saliva flow and IgA in patients with moderate-persistent chronic asthma.: Ann Allergy Asthma Immunol. 2001 Nov;87(5):420-3.            

 

7 Kargul B, Tanboga I, Ergeneli S, Karakoc F, Dagli E.: Inhaler medicament effects on saliva and plaque pH in asthmatic children . J Clin Pediatr Dent. 1998 Winter;22(2):137-40.              

 

8 Sivasithamparam K, Young WG, Jirattanasopa V, Priest J, Khan F, Harbrow D, Daley TJ.: Dental erosion in asthma: a case-control study from south east Queensland.: Aust Dent J. 2002 Dec;47(4):298-303.  

 

9 Rance F, Micheau P, Marchac V, Scheinmann P.: Food allergy and asthma in children: Rev Pneumol Clin. 2003 Apr;59(2 Pt 1):109-13.              

 

10 Corradi M, Folesani G, Andreoli R, Manini P, Bodini A, Piacentini G, Carraro S, Zanconato S, Baraldi E.: Aldehydes and glutathione in exhaled breath condensate of children with asthma exacerbation.: Am J Respir Crit Care Med. 2003 Feb 1;167(3):395-9.    

 

11 Nadeem A, Chhabra SK, Masood A, Raj HG.: Increased oxidative stress and altered levels of antioxidants in asthma: .

J Allergy Clin Immunol. 2003 Jan;111(1):72-8.              

 

12 Vural H, Uzun K.: Serum and red blood cell antioxidant status in patients with bronchial asthma.: Can Respir J. 2000 Nov-Dec;7(6):476-80.    

 

13 Britton J, Pavord I, Richards K, Wisniewski A, Knox A, Lewis S, Tattersfield A, Weiss S.:

Dietary magnesium, lung function, wheezing, and airway hyperreactivity in a random adult population sample: Lancet. 1994 Aug 6;344(8919):357-62

 

14 Nafstad P, Nystad W, Magnus P, Jaakkola JJ.: Asthma and allergic rhinitis at 4 years of age in relation to fish consumption in infancy: . J Asthma. 2003 Jun;40(4):343-8.                

 

15 Okamoto M, Mitsunobu F, Ashida K, Mifune T, Hosaki Y, Tsugeno H, Harada S, Tanizaki Y.:

Effects of dietary supplementation with n-3 fatty acids compared with n-6 fatty acids on bronchial asthma.:

Intern Med. 2000 Feb;39(2):107-11.  

 

16 Calder PC: Dietary modification of inflammation with lipids .Proc Nutr Soc. 2002 Aug;61(3):345-58.  

 

17 Massey.L., Journal of Agricultural and Food Chemistry, Sept 2001  

 

18 Lozupore E.F.: Morphometric analysis of the deposition and mineralisation of enamel and dentine from the incisor during the recovery phase following a low calcium regimen. Arch Oral Biol 1994. May. 39(5): 4009-16.  

 

19 Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 1991. HMSO 1991  

 

20 National Digestive Diseases Information Clearinghouse: 2 Information Way, Bethesda, MD 20892-3570  

 

21 Surgeon General Report: Mental health: a report of the Surgeon General Chapter :www.surgeongeneral.gov

 

22 Siemon JG, Wiggens DM: Pharmacotherapy of attention-deficit hyperactivity disorder. Can J Psychiatry

1993 Aug;38(6):442-8.

 

23 Dental Practitioners Formulary: British Medical Association, Pharmaceutical Press pp181 1996  

 

24 Brue AW,Oakland TD: Alternative treatments for ADHD: does evidence support their use? Altren Ther health Med 2002 Jan-Feb;8(1):68-70, 72-4.  

 

25 Carter CM, et al : Effects of a few food diet in attention deficit disorder. Arch Dis Child 1993 Nov;69(5):564-8  

 

26 Starobrat HB eta al: The effects of magnesium physiological supplementation on hyperactivity in children with ADHD. Positive response to magnesium oral loading test. Mag Res 1997 Jun;10(2):149-56.  

 

27 Richardson AJ, Puri BK:

A randomised double-blind, placaebo controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD related symptoms in children with specific learning difficulties. Prog Neuro Biol Psych 2002 Feb;26(2):233-9.

​

​

​