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Byline: Nusrat Ali, Amena Rahim, Sarah Ali and Muhammad Hatif Iqbal


Objective: To compare the levels of vitamin D in children with early childhood caries and children with healthy sound dentition.

Study Design: Cross sectional study.

Place and Duration of study: The study was conducted at Islamic International Medical College from September 2015 to March 2016.

Material and Methods: Eighty children, between 2-8 years of age, were recruited after fulfilling a questionnaire from their parents or caregiver. The sample population was divided into two groups. Group 1 consisted of children suffering from dental caries and was comprised of 60 patients. Group 2 consisted of children with sound healthy teeth and was comprised of 20 children. Questions assessing ch s socioeconomic background, dietary habits particularly frequency of sweet and milk intake, outdoor activity and dental hygiene related behavior were included. The diagnosis of childhood caries was based on oral health diagnostic criteria defined by World Health Organization (WHO). Overall total caries score (decayed missing filled teeth index) was obtained. Levels of 25-hydroxyvitamin D (25(OH) D) was measured from serum samples of the children participating in this study using enzyme linked immunosorbent assay (ELISA). Correlation analysis was done with Pearson correlation and t-test was applied.

Results: Results have established association of Vitamin D levels in children with early childhood caries. Pearson correlation and t-test have revealed that total decayed, missing, filled primary teeth (dmft) caries score was also associated with 25(OH) D concentrations less than 30ng/ml, decreased oral hygiene, lower monthly income, increased sugar consumption, decreased milk intake and decrease outdoor activities. This cross-sectional study showed that carries and lower serum vitamin D are closely related with each other.

Conclusion: Data from this cross-sectional study showed that dental caries and lower serum vitamin D were closely related. Imp ov g ch 's v tam D status may b a a t o a p v t v co s at on to lower the risk for caries.

Keywords: ECC, (Early childhood caries), vitamin D, 25OHD (25 Hydroxy vitamin D), dmft (decayed, missed, filled teeth).


Vitamin D also known as calciferol is fat soluble sterol derived vitamin. It is a prohormone. Its two forms are vitamin D2 and vitamin D31. Vitamin D2 or ergocalciferol is derived from plants, vitamin D3 or cholecalciferol is synthesized in human skin from 7-dehydrocholesterol, on exposure to ultraviolet B irradiation with wavelength 290 to 320 nm convert 7dehydrocholesterol to D32,3. Vitamin D, in its D2 or D3 form, is metabolically inactive. The only difference in the structure of Vitamin D2 and Vitamin D3 is their side chain. This difference has no affect on metabolism and activation, and they are inactive till their activation by two hydroxylases in liver and then in kidney so that it becomes metabolically active. The form of Vitamin D that can exert biological activity is 1,25(OH)2D.

It is basically a hormone obtained after hydroxylation at carbon number 25 by enzyme 25-hydroxylase in the liver to form 25-hydroxyvitamin D, followed by another hydroxylation at carbon number 1 by the enzyme 1a hydroxylase to form, 1,25-dihydroxyvitamin D, active form vitamin D. A reliable assessment of vitamin D status is done by measuring plasma concentration of the circulating 25(OH)D2.

The accepted classification used to determine a pat t's v tam D status is that serum 25 (OH)D levels 4 were considered having excessive caries. Parents completed a questionnaire which revealed information about the child s milk and sugar intake, outdoor activity regarding sun exposure, oral hygiene practices, and their socioeconomic status.

Venipuncture of participants was done to determine serum vitamin D levels. Serum samples were stored in freezers of post graduate laboratory, Biochemistry department of IIMC Rawalpindi. Serum total 25 (OH)D of the study subjects were measured using enzyme linked immunosorbent assay (ELISA). Lab results and questionnaire data were entered into an Excel (Microsoft Office) spreadsheet and analyzed using number codes assigned to each group i.e. Likert scale. SPSS 21 was used for data processing. Analysis included descriptive statistics, frequencies, means +- standard deviations (SD), Pearson correlation and t-test. A p-value <0.05 was considered as significant.

Table-I: Frequency distribution of Vitamin D Levels in study subjects.

Vitamin D levels###Frequency###Percent###Mean serum vitamin D

ng/ml###levels ng/ml

VitD Deficiency44)###8###10.0


Table-II: Correlation of vitamin D with outdoor caries and no caries.

Group on basis of###N###Mean vitamin D###Std. Deviation###Std. Error Mean###p-value

Caries###conc. (ng/ml)

No Caries###20###47.2###14.0###3.14###0.001


Table-III: Correlation of children having outdoor activities with serum vitamin D levels.

Correlation of Variables###Outdoor Activity###Vitamin D###Caries###Significance

Outdoor Activity###1###.803**###-.738**###.000




Results have established association of Vitamin D levels in children with early childhood caries. A total of 80 children were selected to participate in the study and of these 43were male and 37 were female. The mean age of the patient was 5 years and 3 months with SD +- 1.3.

The mean serum vitamin D level in the study was 26.8 +- 14.6. It was found that 52% children had vitamin D deficiency, 16% children had vitamin D insufficiency, 21% children had vitamin D sufficiency and 10% children had optimal vitamin D levels (table-I).

Vitamin D and caries level (dmft) were significantly associated with each other, with 25 OH vitamin D levels child were deficient (4, shown as yellow and magenta colors, means more decayed, carious ,missed and filled teeth. Similarly with 25 OH vitamin D levels of a adequate (>44ng/ml) had low caries score i.e. dmft <1 which was shown in blue and gray colors.

T-test has showed that childhood caries has significant association with Vitamin D levels. Statistically significant difference (p-value=0.001) was found in vitamin D levels of sample population with caries and without caries.

This study has showed that vitamin D deficiency, insufficiency and sufficiency was strongly correlated with caries score (dmft) (table-II), serum vitamin D levels between 10-20 ng/ml is associated with excessive dental caries and serum vitamin D levels above 40ng/ml was associated with healthy teeth without caries.

The correlation analysis has also revealed that there was direct correlation present between serum 25 OH vitamin D levels and outdoor activity (table-III) (figure).

Outdoor activity of children and their exposure to sunlight was also examined and it was seen that it had a beneficial effects on dental health.

Children having outdoor activities had positive correlation with serum vitamin D, whereas children having outdoor activities had reverse correlation with caries score (table-III).

The results of our study revealed statistically significant difference (p-value=0.001) of vitamin D levels in sample population with caries and without caries (population with sound dentition).


The current study examined different aspects of early childhood caries and effect of serum vitamin D levels on extent of caries in children. Outdoor activity of children and their exposure to sunlight was also included in our study.

In a study conducted by Grant et al in 2011, It was also assumed that vitamin D deficiency and insufficiency was also due to decrease sun light exposure17, It had also been suggested that this vitamin D deficiency and insufficiency plays main role in development of dental caries in children. These findings match with results of our study. A cross sectional study was conducted in Qatar over a period from August 2009 to June 2010 by Bener et al, also concluded that exposure to sun was necessary for the synthesis of vitamin D and decreased sun light exposure was responsible for vitamin D deficiency and a cause for extensive dental caries in children18. These results were similar to findings our study. A meta-analysis on role of vitamin D on the onset and progression dental caries by Hujoel 2013 showed that with vitamin D supplementation chances of dental caries were reduced to 47%. Hujoel et al had also concluded that vitamin D has topical fluoride like characteristics19.

These results were in accordance with our findings. A cross-sectional study performed in Canadian schools in 2015 by Schroth et al, showed that hypovitaminosis D was closely related with extensive dental caries. The results of this study matches with our findings20. A case-control study conducted in the city of Winnipeg, Manitoba, Canada from 2009 to 2011 by Schroth et al, concluded that statistically significant difference in vitamin D and calcium levels between children with severe dental caries and caries free children. This finding was in line with our results for children with extensive childhood caries. Nowadays sugar consumption is increased a lot in the form of sweets and chocolates and children were less aware of brushing techniques and oral hygiene practices. It was also suggested by different studies that despite of all the facts described above, decreased oral hygiene and increased consumption of sugar in diet and drinks were prominent risk factors for caries18,21.

In most of the cross-sectional, case control and prospective studies, vitamin D deficiency had been considered to be associated with increased risk of dental caries. It was important to note that vitamin D deficiency in individuals might result from lack of sun exposure or it might be due to malnutrition or some gene polymorphism are involved.


Data from this cross-sectional study showed that dental caries and lower serum vitamin D were closely related. Improving ch 's vitamin D status may be an additional preventive consideration to lower the risk for caries.


This study has no conflict of interest to declare by any author.


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Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Jun 30, 2017

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