Parenteral nutrition in childhood and consequences for dentition and gingivae

Transcription

1 D. Olczak-Kowalczyk*, M. Danko**, E. Banaś**, D. Gozdowski***, K. Popińska**, E. Krasuska-Sławińska****, J. Książyk** *Medical University of Warsaw, Department of Paediatric Dentistry, 18 Miodowa St, Warsaw, Poland **Department of Paediatrics and Nutrition, Children s Memorial Health Institute, Warsaw, Poland ***Department of Experimental Statistics and Bioinformatics, Warsaw University of Life Science, Warsaw, Poland ****Dental Outpatient Clinic, Children s Memorial Health Institute, Warsaw, Poland do-k@o2.pl body mass, antibiotic therapy, and low body mass in the first year of life. Positive dental developmental abnormality Spearman s coefficients: low birth body mass, Apgar score < 7, parenteral nutrition duration, low body mass and antibiotic therapy in the first year of life. Beta-lactam, aminoglycoside, glycopeptide and nitroimidazole treatments were related to enamel hypoplasia. Conclusion Parenteral nutrition in childhood is related to the risk of dental developmental abnormalities, promoted by malnutrition and antibiotic therapy in infancy. Limiting the number of meals and cariogenic snacks, and most probably administration of antibiotics, decreases the risk of caries. Parenteral nutrition in childhood and consequences for dentition and gingivae abstract Aim Assessment of dentition in children under parenteral nutrition, risk factors for caries, and dental developmental abnormalities. Material and method The study involved 63 patients (aged years), i.e. 32 subjects receiving parenteral nutrition for a mean period of 5.6±2.94 years, and 31 healthy control subjects. Oral hygiene (OHI-S, PL-I), gingival (GI), and dentition status (caries, DMFT/dmft, enamel defects, shape alterations), frequency of oral meals and frequency of cariogenic snacks consumption were evaluated. Medical records provided information on parenteral meals per week, age parenteral nutrition started, birth body mass, Apgar score, weight deficiency, and antibiotic therapy until aged 1 year. The Mann- Whitney test, chi-squared test, and Spearman rank correlation coefficient were used (p 0.05). Results Dental developmental abnormalities occurred more often in PN subjects (71.87% vs %). The prevalence of caries in PN (56.25% vs %) and dmft (2.00±3.30 vs. 4.21±3.33) and DMFT (2.47±4.08 vs. 3.33±3.50) were lower. Positive caries Spearman s rank correlation coefficients: frequency of oral meals and frequency of cariogenic snacks consumption, and GI. Negative correlation coefficients: low birth Keywords Caries prevalence; Dental developmental abnormalities; Parenteral nutrition. Introduction For the past 30 years, chronic parenteral nutrition has been granting survival to patients with gastrointestinal impairment [Popi ska et al. 2012]. In Poland, at the beginning of 2012, 165 paediatric patients were under a home parenteral nutrition programme. The most frequent indications of parenteral nutrition in children are: short bowel syndrome, chronic intestinal pseudo-obstruction syndrome, inflammatory bowel disease, and chronic diarrhea. Short bowel syndrome (anatomical or functional loss of more than 50% of small intestine) might be a consequence of congenital gastrointestinal disorders (congenital ileal atresia, volvulus caused by defects in mesenteric attachments), and resection of a part of the gastrointestinal tract in necrotising entercolitis or gastroschisis [Sigalet, 2001]. Parenteral nutrition consists in feeding carbohydrates, lipids, amino acids, and macro- and microelements to a person intravenously through a permanently implanted tunnelled venous port, with its extremity in the superior vena cava, at the right border of the heart [Pittiruti et al. 2009]. Parenteral nutrition can be a lifelong process, and sometimes the only way to provide nutrition, which should be meeting energy needs for various substances. Patients able to intake food by mouth receive partial parenteral nutrition, where the parenteral supply of energy and nitrogen together with electrolytes, calcium, phosphorus, trace elements and vitamins cover no more than 50% of the daily amount [Shulman and Philip, 2003]. Selecting the right products and meals taken by mouth is an individual process, depending on the patient s clinical condition. The recommended diet takes into account age and rational nutrition principles. However, nutrient intake by mouth depends on the European Journal of Paediatric Dentistry vol. 18/

2 Olczak-Kowalczyk D. et al. type and extension of the disease, or on the part of the intestine that was resected. In paediatric patients, prolonged intravenous nutrition is not only to keep them alive, but also to guarantee a physical development as similar as possible to the physiological one. However, parenteral nutrition, as any other treatment, is not devoid of complications. The most common include infections associated with the implanted central venous catheter and requiring antibiotic therapy, deep vein thrombosis, liver impairment (cholestasis), and metabolic complications, including gallstone, renal calculus and metabolic bone disease. Catheter-associated blood stream infections are the most common cause of hospitalisation in children under home parenteral nutrition and might be life-threatening. Treatment of catheter-associated bacterial infection consists of using an antibiotic coated catheter for three days, coupled with a systemic antibiotic therapy for 10 days, and in severe infections for 2 3 weeks. In cholestasis associated with parenteral nutrition, it is necessary to modify the content and often also the intake of lipids. This results in a decrease in the lipid/kg BW/daily dose in parenteral nutrition, which negatively affects the energy supply, but might have a positive effect on liver functions, preventing cirrhosis and its complications. Metabolic bone disease is associated with infectious complications, and therefore requires antibiotic therapy, which might have a negative effect on the bones, and aluminium traces contained in some of the parenteral nutrients also have a toxic influence on the bones. In children under parenteral nutrition, underweight, shorter stature, and delayed bone age often occur [Pittiruti et al., 2009; Shulman and Philip, 2003]. Parenteral nutrition might also influence the oral cavity, where both the systemic consequences of inappropriate nutrition and topical effects of food are visible. Long-term parenteral nutrition, a decreased number of oral meals and a coexistent low body mass at developmental age may contribute to the development of malocclusion [Olczak- Kowalczyk et al. 2014]. Nutrition is commonly known to influence the prevalence of caries. Frequent consumption of cariogenic snacks (containing carbohydrates, especially saccharose), soft (insufficient salivary flow) or sticky (retainable) food, and juices or sweet drinks, are particularly pernicious. Predisposition to caries also occurs in children with prolonged protein-energy malnutrition in early childhood. Delivering nutrients is indispensable for the development of the protein structure of the tooth and its mineralisation. Malnutrition during the foetal period and early childhood might result in dental developmental abnormalities [Alvarez at al., 1993; Alvarez, 1995]. In children under parenteral nutrition, other associated complications, such as frequent and prolonged antibiotic therapy and birth factors, might also influence dentition health. The aim of this work was the assessment of dentition in children under parenteral nutrition, risk factors in caries, and dental developmental abnormalities. Materials and method Patients The research investigated 32 patients aged years (mean age of 6.43±3.61 yrs) and involved in a parenteral nutrition programme. The duration of parenteral nutrition therapy at the time the study started varied from 1.17 to years. In 25 patients, parenteral nutrition was started during the first three months of life. In most patients, chronic parenteral nutrition was a consequence of short bowel syndrome (28 patients). In the remaining patients the following conditions were present: ulcerative colitis (1 patient), chronic intestinal pseudo-obstruction (1 patient), protein-losing enteropathy (1 patient), and chronic secretory diarrhoea (1 patient). Parenteral nutrition received for a period shorter than one year, gastro-oesophageal reflux and asthma precluded the participation in the study. Thirty-one generally healthy patients aged (median 7.08±3.57 years) composed the control group. Chronic diseases and treatments precluded assignment to the control group. Age >18 years, infectious diseases, lack of consent of child and/or parent/legal guardian precluded the assignment to any of the two groups. Table 1 presents both groups, including type of dentition and parenteral nutrition starting age. Method Patients underwent a general medical examination (medical history, physical examination, lab tests), a nutrition history analysis (dietician), a dental evaluation (paediatric dentist), and their medical history was analysed (paediatrician). The results were statistically analysed. General medical examination and medical history analysis In both groups the body mass was evaluated. Low body mass was defined as BW < 3 percentile). Based on medical history, birth body mass (low birth body mass < 2500g), low body mass (BW < 3 percentile) and antibiotic use in the first year of life, including chemical groups of administered antibiotics, and the parenteral nutrition starting age and duration, were analysed. Nutrition history analysis The patients parents were asked questions about their dietary history, including oral meals/day and consumption of cariogenic snacks, sweet drinks and fruit juices. Nutrient values of food intake (oral) and parenteral nutrition (PN) were computed based on 7-day food records (household measures were used for oral intake) and the percentage of energy from oral intake was calculated (Dieta 4.D version 4.1, Polish software based on Polish food tables, Institute of Food and Nutrition, Warsaw). The children were under standard nutrition, and nutrient supply was monitored through nutrient serum levels. The research protocol was developed as part of nutritional support monitoring. 70 European Journal of Paediatric Dentistry vol. 18/1-2017

3 Children with special health care needs Type of dentition Number of patients Mean age in years±sd Parenteral nutrition starting age 1 year of age >1 year of age mean±sd in years kg number of patients Body birth mass Parenteral nutrition deciduous ± ± ±0.99 mixed ± ± ±0.87 permanent ± ± ±0.46 total ± ± ±0.92 Control group deciduous ± ±0.59 mixed ± ±0.57 permanent ± ±0.28 total ± ±0.56 table 1 Group characteristic including nutrition type, parenteral nutrition starting age and type of dentition. Dental evaluation Gingivae, teeth and oral hygiene levels were evaluated. The examining physician did not have any information on the patients general health. Löe and Silness plaque index (PLI) and Greene and Vermillion oral hygiene index (OHI-S) were used to evaluate oral hygiene [Loe, 1967; Green and Vermillion, 1964]. The PLI assessed the presence and amount of soft debris and mineralised deposits at the cervical margin of 6 teeth: 16, 12, 24, 36, 32, 44 (in case of deciduous teeth 55, 51, 63, 75, 71, 83), according to the scales: 0 = no plaque, 1 = thin film of plaque seen only on probing at the gingival margin, 2 = moderate accumulation which can be seen with the naked eye, 3 = abundance of soft matter in the interdental space. The index is the quotient of values obtained for all the teeth (buccal, lingual, mesial and distal) surfaces and the number of surfaces scored [Löe, 1967]. The OHI-S was scored after disclosing dental plaque with a 3% aqueous erythrosine solution (after PLI and gingiva score). Calculus index (CI-S) and debris index (DI-S) were scored for the buccal surface of teeth 16, 11, 26, 31 (55, 51, 65, 71) and the lingual surfaces of teeth 36 and 46 (75 and 85). Degree of tooth coverage: 0 = no calculus present, 1= calculus covering not more than one third of the tooth surface, 2 = calculus covering more than one third, but not more than two thirds of the exposed tooth surface, 3 = calculus covering more than two thirds of the exposed tooth surface. The value for every index component was the median for all scored surfaces. The OHI-S score is the sum of DI-S and CI-S [Green and Vermillion, 1964]. Löe and Silness Gingival Index (GI) is used to assess the gingival condition of all examined teeth as follows. 0= No inflammation; healthy looking gingiva. 1= Slight change in gingiva colour and slight tissue structure changes; no bleeding on probing. 2= Slight glazing, redness, slight oedema and enlargement; bleeding on probing. 3= Marked redness and oedema; tendency to spontaneous bleeding; ulceration. The GI is the quotient of the numbers scored for gingiva surrounding every evaluated tooth surface and the number of surfaces [Loe, 1967]. Teeth evaluation All tooth surfaces were scored in quadrants (upper right, upper left, lower left, lower right). Caries, fillings, teeth missing because of caries, anatomical anomalies (shape, size) and enamel defects were scored. The number of scored teeth and the dmft and DMFt indexes, where d/ D indicates a carious tooth, m/m a tooth missing because of caries, f/f a filled tooth, were determined. Enamel defects were classified according to the DDE Index [Clarcson and O Mullane, 1989]. Discolouration brown or greenish spots, demarcated and diffuse enamel opacities and hypoplasia (enamel deficient in amount) were scored. Statistical analysis The Mann-Whitney test, the chi-squared test, the Spearman coefficient, univariate and multivariate Poisson regression were used (statistical significance was set at p<0.05). Results General medical condition On the day of the examination, only patients under parenteral nutrition presented low body mass (59.37%). According to the medical records, 37.5% of patients from the PN group presented a low birth body mass. Everyone from the control group had a birth body mass > 2,500 g. Twenty-three children under parenteral nutrition and two from the control group presented low body mass in their first year of life; 87.5% of patients under parenteral nutrition underwent antibiotic therapy during that period, including beta-lactams (penicillins, cephalosporins), European Journal of Paediatric Dentistry vol. 18/

4 Olczak-Kowalczyk D. et al. carbapenem aminoglycosides (amikacin, gentamycin, netilmicin) (65.6%), glycopeptide antibiotics (vancomycin) (53.12%), nitroimidazoles (metronidazole) (46.87%), quinolones (12.5%). Only 12.9% of the patients from the control group underwent antibiotic therapy in their first year of life, and only beta-lactams (penicillins, cephalosporins, and carbapenems) were used. Nutrition type In the group under parenteral nutrition, the median number of oral meals/day, sweet snacks, and juices/ sweet drinks consumption was statistically considerably lower than in the control group. Sixteen patients under parenteral nutrition neither consumed cariogenic snacks nor drank juices/sweet drinks. Two patients were under total parenteral nutrition. In the control group, all patients consumed them (Table 2). Status of oral hygiene and gingivae PLI and GI were higher in the parenteral nutrition group Nutrition type Parenteral nutrition Control group P mean±sd Nutrition by mouth mean oral meals/day 4.64± ±1.37 <0.001* mean intake of sweet snacks/day 0.67± ±0.87 <0.001* mean intake of juices/sweet drinks/day 0.67± ±0.95 <0.001* Parenteral nutrition age when parenteral nutrition was started 0.87±2.66 yrs - - parenteral nutrition duration 5.6±2.94 yrs - - mean weekly parenteral delivery 5.03± * statistically significant difference (P<0.05) table 2 Nutrition type in parenteral and control groups. Evaluated parameters Parenteral nutrition Control group P (Mann-Whitney U test) Mean ±SD Hygiene level ODI-S 1.90± ±0.63 <0.001* OCI-S 0.31± OHI-S 2.21± ±0.63 <0.001* PLI 1.47± ± Gingival health GI 0.69± ± Number of deciduous teeth 16.65± ± dmft 2.00± ± * d 1.38± ± m ± f 0.62± ± * Number of permanent teeth 13.86± ± DMFT 2.47± ± D 2.00± ± M 0 0,06± F 0.47± ± Developmental abnormalities n / % n / % P (chi-squared test) 23 / / <0.001* Enamel defects opacities 4 /12.5 7/22, hypoplasia 9 / / * opacities and hypoplasia 10/ /0.00 <0.001* Change in dental crown shape 5/ / * * statistically significant difference (P<0.05) table 3 The status of oral hygiene, gingivae and dentition in parenteral and control groups. 72 European Journal of Paediatric Dentistry vol. 18/1-2017

5 Children with special health care needs Parameters Parenteral nutrition group All patients dmft DMFT dmft DMFT Number of oral meals/day 0.544* * Sweet drink intake/day 0.595* * Sweet snack intake/day 0.507* * GI * Preterm birth/low birth mass * Low birth weight in the first year of life * * Antibiotic therapy in the first year of life (any antibiotic) * Beta-lactams * Aminoglycosides * Glycopeptide antibiotics * * Nitroimidazoles * * statistically significant difference (P<0.05) table 4 Statistically significant Spearman s rank correlation coefficient between dmft and DMFT and eating habits, gingivitis, antibiotic therapy use and type in the first year of life and preterm birth. than in the control group. However, those were not statistically significant differences. Gingivitis also occurred more often (80.64% vs %; P=0.179 chi-squared test). ODI-S and OHI-S were significantly different. Calculus was found only in patients under parenteral nutrition (28.12%) (Table 3). The Spearman coefficient confirmed a positive correlation between severity of gingivitis in all patients and ODI-S, OHI-S and PLI (statistically significant coefficients, respectively: 0.328, 0.356, 0.511). There was no statistically significant correlation between severity of gingivitis and parenteral nutrition and factors such as low body mass, antibiotic therapy (the Spearman coefficient, multivariate Poisson regression). Caries In the parenteral nutrition group caries occurred significantly less frequently (56.25%) than in the control group (90.32%) (P=0,002 chi-squared test). DMFT and dmft were also lower (only dmfts presented significant differences) (Table 3). Both patients under total PN (4.0 and 9.25 year olds; PN from second month of life) were free of dental caries despite of the dental plaque presence (OHI-S respectively 3.0 and 0.66). The Spearman coefficient confirmed a significant correlation between the prevalence of caries and the average number of oral meals/day (correlation coefficient: 0.403), sweet drink/ snack consumption (coefficients: 0.516, 0.389), and severity of gingivitis (GI) (coefficient: 0.256). Eating habits were also positively correlated with dmft, and GI with DMFT. However, GI did not influence the dmft/ DMFT in the PN group (Table 4). No correlation was established between caries and oral hygiene indexes. For all patients, the correlations between dmft and low birth body mass, and antibiotic therapy were negative. Body mass in the first year of life was negatively correlated to both dmft and DMFt. There was no statistically significant correlation between these factors in the parenteral nutrition group (Table 4). The univariate Poisson regression confirmed a significant correlation between dmft and pareneral nutrition (coefficient: 0.000), antibiotic therapy in the first year of life (coefficient: 0.000), beta-lactams (coefficient: 0.000), aminoglycosides (coefficient: 0.000), glycopeptides (coefficient: 0.003) as well as between DMFT and aminoglycoside (coefficient: 0.043). The multivariate Poisson regression confirmed a significant correlation between the DMFT and antibiotic therapy in the first year of life (coefficient: 0.000), beta-lactams (coefficient: 0.000), aminoglycosides (coefficient: 0.005). Developmental teeth abnormalities Statistically, enamel defects occurred more often in children under parenteral nutrition (71.87%) than in those in the control group (25.80%) (Table 3). In deciduous teeth respectively 46.87% vs. 3.2% (statistically significant); in permanent teeth 40.62% vs % (statistically insignificant). Enamel opacities mainly occurred in the control group (22.58% of patients). Enamel hypoplasia was found in one child in this group on tooth 21. In children under parenteral nutrition enamel opacities occurred less often as a single defect than in the control group but hypoplasia or a complex defect, i.e. enamel opacities and hypoplasia, occurred most often (31.25% vs. 0%) (statistically significant). Enamel defects in deciduous teeth occurred in 57.12% of patients with deciduous or mixed teeth in the PN group, and 3.6% in the control group (statistically significant, p <0.001, chi-squared test). Both enamel opacities and hypoplasia occurred in patients under parenteral nutrition, and in the control group only opacities prevailed. Similarly, enamel defects in permanent teeth occurred statistically significantly more often among patients with mixed or permanent teeth in the PN group (86.67% vs 46.67) (statistically significant, p <0.020, chi-squared test). Enamel opacities and hyperplasia occurred in both groups. Mean values for teeth with enamel defects were European Journal of Paediatric Dentistry vol. 18/

6 Olczak-Kowalczyk D. et al PN group deadalous teeth Control group deadalous teeth 0.07± ±5.77 (*) 0.07± (*) PN group permanent teeth Control group permanent teeth 1.1±1.71 (z) 0.06±0.76 (y) opacities 2.4±7.26 (y) hypoplasia 6.87±7.607 (z) FIG. 1 Mean number of deciduous and permanent teeth with enamel defects in the PN and control groups. Statistical significance of differences: p<0.001 for hypoplasia in deciduous teeth (*), hypoplasia (y) and opacities (z) in permanent teeth; p = for opacities in deciduous teeth (M-W U test) FIG. 2 The developmental abnormalities in crown shape in 14.2 year-old patient (parenteral nutrition was started in 5 month of life); rounded cutting edges of incisors (oval shape) (A) and additional cusps on molars (B). considerably higher in the PN group as well (Fig. 1). In five children under parenteral nutrition, developmental abnormalities in crown shape occurred, i.e. rounded cutting edges of incisors (oval shape), additional or decreased in number cusps on molars (Fig. 2). In two patients they occurred in deciduous teeth, in three patients in permanent teeth. The Spearman s correlation is positive between enamel defects, and low birth body mass, Apgar score <7, parenteral nutrition duration, current low body mass, low body mass and antibiotic therapy in the first year of life. Beta-lactam, aminoglycoside, glycopeptide and nitroimidazole treatments were related to enamel hypoplasia. Low birth body mass, current low body mass and beta-lactam antibiotic use in the first year of life were correlated with abnormalities in tooth shape (Table 5). Discussion The results of the present study confirm the importance of appropriate nutrition and eating habits for the teeth developmental processes. Parenteral nutrition started in early childhood promoted developmental abnormalities in deciduous and permanent teeth. Low body mass and antibiotic use in the first year of life, low birth body mass and asphyxia (Apgar score <7) were crucial. Digestive diseases leading to parenteral nutrition are associated with nutrient malabsorption and malnutrition. Low body mass in children under parenteral nutrition detected in the present study indicates that malnutrition can be prolonged. This could explain the occurrence of enamel defects not only in deciduous teeth, permanent incisors and first molars, but also in other groups of permanent teeth. There is no doubt that prepubertal malnutrition and low body mass in early childhood play a role in developmental teeth abnormalities. Animal studies showed that enamel hypoplasia could be caused by general malnutrition; microelement, vitamin A, D or calcium deficiencies [Alvarez, 1995]. Enamel defects were also observed in children with protein-energy malnutrition in early childhood [Alvarez et al., 1993; Alvarez, 1995] and coeliac disease [Cheng et al., 2010]. Nutritional deficiencies in coeliac disease patients most often occur in the first year of life, i.e. when a gluten free diet is not yet implemented. Hypoplasia in children with coeliac disease occurs mainly in permanent incisors and first molars, and for those teeth the secretory stage of amelogenesis starts during pregnancy, and the maturation stage around birth [Beentjes at al. 2002]. According to Fagrell, nutritional conditions during the first 6 months of life may promote the risk of developing severe demarcated opacities in the first permanent molars [Fagrell et al., 2011]. Malnutrition accompanies different diseases, such as liver cirrosis or inflammatory bowel disease. These diseases may be connected with enamel defects of permanent tooth, but they are rarely observed in early childchood. The present study, similarly to those of Aine et 74 European Journal of Paediatric Dentistry vol. 18/1-2017

7 Children with special health care needs Enamel defects Change in tooth shape hypoplasia or opacities opacities hypoplasia Preterm birth/low birth mass 0.331* * 0.306* Apgar score < * * Underweight in the first year of life 0.369* * Parenteral nutrition duration 0.516* * Current underweight 0.391* 0.269* 0.518* 0.447* Antibiotics in the first year of life 0.366* * 0.280* Beta-lactam antibiotics 0.405* * 0.253* Aminoglycosides * Glycopeptide antibiotics 0.260* * Nitroimidazoles 0.270* * * statistically significant difference (P<0.05) table 5 Statistically significant Spearman s rank correlation coefficient between developmental teeth abnormalities and preterm birth, Apgar score, low body mass and antibiotic therapy in the first year of life (for parenteral nutrition duration, coefficients were only calculated for the parenteral group). al. [2000], and Cruvinel et al. [2012], emphasised the correlation between the prevalence of enamel defects and preterm birth/low birth body mass. The developmental defects of enamel could be caused by disorders of calcium homeostasis related to a systemic disease [Aine et al., 2000]. In the present study, as much as 25/32 digestive diseases resulted from the introduction of parenteral nutrition during the first three months of life, and in 23 patients low body mass occurred during the first year of life. In the children who were part of the present study, malnutrition seemed to play a crucial role in odontogenesis abnormalities. That was illustrated by the correlation between enamel defects and abnormalities in tooth shape, and both low body mass at birth, during the first year of life and at the moment of this study, and the duration of parenteral nutrition. The present study also showed the correlation between enamel defects and birth asphyxia, which had already been reported [Jonhsen et al., 1984; Bansal et al., 2012]. Johansen et al. [1984] noticed the higher frequency of severe respiratory distress syndrome in children with enamel hypoplasia in deciduous teeth who had a very low birth body mass, than in children with healthy tooth enamel. According to the statistical analysis of the present study, antibiotic therapy during the first year of life, especially betalactams, aminoglycosides, glycopeptides, nitroimidazoles, have a negative influence on odontogenesis. Other authors indicated a correlation between amoxicillin use in infancy and developmental enamel defects [Hong et al., 2005; Laisi at al., 2009; Whatling and Fearne, 2008]. Amoxicillin might decrease the expression of extracellular matrix proteins (such as amelogenin) or the activity of proteases that hydrolyse extracellular proteins [Simmer and Hu, 2002]. The Whatling and Fearne study [2008] confirmed the role of amoxicillin in molar-incisorhypomineralisation (MIH) development, but it did not show correlations with any other antibiotics [Whatling and Fearne, 2008]. According to Laisi et al. [2009], enamel defects can also result from erythromycin use [Laisi et al., 2009]. However, other antibiotics analysed in the present study, not administered to small children as often as beta lactams, did not seem to influence the odontogenesis process. Their role in the development of enamel defects needs to be monitored. The pathogenesis of enamel defects is complex. In children under parenteral nutrition, hypoplasia or/and enamel opacities are most probably caused by numerous factors, also infections treated with antibiotics [Cruvinel et al., 2012]. Many authors confirmed the role of infections in the development of enamel defects in permanent teeth: otitis media, upper and lower respiratory tract infections [Beentjes et al., 2002], episodes of high fever, and urinary tract infections [Tapias- Ledesma et al., 2003]. There are also studies denying any correlation between odontogenesis abnormalities and frequent infectious diseases in childhood and antibiotic therapy [Muratbegovic et al., 2007]. Parenteral nutrition reduces caries. The present study confirmed that the frequent consumption of cariogenic food and juices/sweet drinks had a negative influence on teeth [Ribeiro and Ribeiro, 2004]. According to a study in Peru, mild and moderate prolonged malnutrition during the first year of life predisposed to caries in deciduous teeth and increased the risk of its prevalence in permanent teeth [Alvarez et al., 1993; Alvarez, 1995]. According to the present study, the effect of topical food on caries is more important than malnutrition in early childhood. Low birth body mass was not a key factor. There are divergent opinions on whether low birth body mass has an influence on caries. According to Fadavi et al. [1993], in prematurely born children, a low birth body mass predisposed to caries. Others failed to notice more frequent caries prevalence in prematurely born children than in those born out of a fullterm pregnancy [Gravina et al., 2006]. Low body mass on the day of the examination was not an important factor for dental and gingivae status. This was suprising because as it is generally known malnutrition may be the cause of salivary gland hypofynction and gingivitis. Abrams and Romberg [1999] compared the prevalence and severity of European Journal of Paediatric Dentistry vol. 18/

8 Olczak-Kowalczyk D. et al. gingivitis among 291 well- and malnourished children between the ages of 4 to 7 years. Their reserch showed that there was no significant difference in severity of gingivitis between the well-nourished and malnourished groups, which is in agreement with our results. According to Psoter et. al. [2008] the salivary flow rate was reduced in teenagers who had experienced severe malnutrition in their early childhood or who had continuing nutrition stress. In our study, patients with BMI < 3 had low birth body mass too but it does not provide evidence of longterm malnutrition over a number of years. Antibiotic therapy during the first year of life has a positive influence on caries. That confirms the Fukuda et al. study [2005], which proved that frequent antibiotic use hindered oral colonisation by cariogenic bacteria. Conclusion Parenteral nutrition in childhood is related to the risk of dental developmental abnormalities. They are promoted by malnutrition reflected in a lowered body mass, and the use of antibiotics in the first year of life. A decreased risk of caries results from a limited number of oral meals and cariogenic snacks consumption and frequent use of antibiotics, despite caries risk factors, such as low body mass in infancy, dental plaque and gingivitis. References Popi ska K, Szlagatys-Sidorkiewicz A, Spodaryk M. et al. Home Parenteral Nutrition in Polish paediatric patients in Clin Nurtr 2012;7 (suppl. 1): 138. Sigalet DL. Short bowel syndrome in infants and children: an overview. Semi Pediatr Surg 2001;10(2): Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28(4): Shulman RJ, Phillip S. Parenteral Nutrition in Infants and Children. 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