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ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 211-215
 

Vitamin D deficiency as an etiological factor in delayed eruption of primary teeth: A cross-sectional study


1 Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India
2 Department of Pedodontics and Preventive Dentistry, AECS Maaruti College of Dental Sciences and Research Center, Bengaluru, Karnataka, India
3 Department of Pedodontics and Preventive Dentistry, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka, India
4 Department of Pedodontics and Preventive Dentistry, Vydehi Institude of Dental Sciences and Research Center, Bengaluru, Karnataka, India

Date of Submission04-Jul-2018
Date of Decision26-Jul-2020
Date of Acceptance31-Jul-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. Lalitha S Jairam
Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, University House, Gnanagangothri Campus, New BEL Road, M S R Nagar, Mathikere, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_184_18

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   Abstract 


Context: Delayed tooth eruption might be the primary or sole manifestation of local or systemic pathology. Aims: The aim of the study was to correlate Vitamin D level and eruption status of primary teeth. The objectives also included the assessment of the association between Vitamin D levels and socioeconomic status, infant's sun exposure, maternal sun exposure during pregnancy and religion. Settings and Design: A cross-sectional, observational study conducted on 96 infants aged 12–15 months. Materials and Methods: Ninety-six infants, aged 12–15 months were selected after obtaining parental consent. Blood samples were assessed for Vitamin D3 levels using the Vitamin D ELISA Kit. The eruption status of the teeth was recorded in all the 96 infants. The obtained data were subjected to the statistical analysis. Statistical Analysis Used: The obtained data were subjected to relevant statistical analysis such as Analysis of Variance, unpaired t-test, Kruskal–Wallis test, and Mann–Whitney U test, Chi-square Test, Tukey HSD, and Fisher's exact Test. Results: A significant correlation was found in the Vitamin D levels and the eruption timing (P < 0.001). The difference in mean Vitamin D levels among the three socio economic groups was not statistically significant (P = 0.088). A significant association was found between the infant's sun exposure and mother's sun exposure during pregnancy and religion on the Vitamin D levels (P = 0.002, P = 0.042, P = 0.002). Conclusions: Vitamin D deficiency can be considered as an etiological factor for delayed eruption. A strong association exists between the socioeconomic status, infant's sun exposure, maternal sun exposure during pregnancy, and religion with Vitamin D levels.


Keywords: Delayed eruption, sun exposure, Vitamin D deficiency


How to cite this article:
Jairam LS, Konde S, Raj N S, Kumar N C. Vitamin D deficiency as an etiological factor in delayed eruption of primary teeth: A cross-sectional study. J Indian Soc Pedod Prev Dent 2020;38:211-5

How to cite this URL:
Jairam LS, Konde S, Raj N S, Kumar N C. Vitamin D deficiency as an etiological factor in delayed eruption of primary teeth: A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2020 Dec 1];38:211-5. Available from: https://www.jisppd.com/text.asp?2020/38/3/211/296628





   Introduction Top


Eruption is defined as the movement of the tooth from its site of development in the alveolar bone to the occlusal plane in the oral cavity.[1] The eruption time of both primary and permanent teeth have got a specific date and variations of 6 months on either side of the usual eruption date may be considered normal for a given child. Eruption is a continuous process from the start of the development until the functional position is reached. We studied this process from the moment of emergence of tooth through the mucosa. Therefore, in our study, we considered the use of emergence stage, instead of eruption stage. There are several factors which influence the eruption of permanent as well as primary teeth into the oral cavity which include both local and systemic factors. In some cases, delayed tooth eruption could be the first and foremost manifestation of local or systemic disease.[2]

Nutritional deficiencies of Vitamin D, Vitamin C, Vitamin B, and Vitamin A and Protein Energy Malnutrition have been associated with the disturbances in the oral structures.[3]

There is vast literature on the genetic, endocrine disturbances, and nutritional deficiencies such as protein malnutrition as the etiological factors of delayed eruption. Vitamin D has shown to affect the enamel and dentin formation and has also been considered a risk factor for the development of dental caries.[4] However, there is a lack of scientific literature regarding the association of Vitamin D deficiency and delayed eruption of teeth. This study was conducted to assess the Vitamin D levels and correlate it with the eruption of primary teeth among 12–15 months infants. The association between the socioeconomic status, maternal sun exposure during pregnancy, infant's sun exposure, and religion with Vitamin D deficiency was also assessed.


   Materials and Methods Top


A cross-sectional, observational study was conducted on 96 infants to evaluate and compare the Vitamin D status among 12–15 months infants who visited the Pediatrician in various private and government hospitals of Bangalore. Normal, well-nourished infants aged 12–15 months with parental consent and infants who were advised blood investigations by the pediatrician for diagnostic purpose were included in the study. The exclusion criteria were local conditions such as the presence of mucosal barriers such as scar tissue, gingival hyperplasia, tumors, infants under medication such as phenytoin, radiation damage, oral clefts, and systemic conditions such as HIV infection, cerebral palsy, dysosteosclerosis, anemia, Celiac disease, prematurity/low birth weight, renal failure, endocrine disorders, and infants with genetic disorders.

A questionnaire was distributed to the parents to gather relevant information regarding the general health of the child. The eruption status (emergence status) of the teeth was recorded in all the 96 infants. The blood test was carried using 2 ml of blood. The collected blood sample was then transported to the laboratory where it was stored at −20°C until it was analyzed. The analysis of blood samples was done by using the Vitamin D ELISA Kit (Immunoshop, India). The intensity of the yellow color obtained after processing was inversely proportional to the concentration of 25(OH)-Vitamin D.

The 96 infants were divided into two groups: Group 1 consisted of 48 infants with teeth erupted (emergence of tooth through the mucosa was considered in the erupted group) and Group 2 consisted of 48 infants showing delayed eruption (no tooth in the oral cavity). The Vitamin D levels of the infants in both groups were evaluated and correlated with eruption status. The relation between the socioeconomic status, infant's sun exposure, mother's sun exposure during pregnancy, and religion with Vitamin D levels was evaluated.

The obtained data were subjected to relevant statistical analysis such as Analysis of Variance, Unpaired t-test, Kruskal–Wallis test and Mann–Whitney U-test, Chi-square test, Tukey HSD, and Fisher's exact test.


   Results Top


The results indicate that 54.16% of the infants had Vitamin D deficiency and 14.58% had sub optimal levels of Vitamin D [Figure 1]. Mean Vitamin D deficiency in Group 1 (normal eruption) was 33.84 ng/ml and in Group 2 (delayed eruption) was 12.67 ng/ml. The difference was statistically significant (P< 0.001) [Table 1]. A significant correlation was seen between the time of eruption and Vitamin D deficiency.
Figure 1: Distribution of study subjects according to Vitamin D deficiency and age group

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Table 1: Comparison of mean Vitamin D level and time of eruption

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The mean Vitamin D level in the <10,000₹/month group was 27.07 ng/ml. The Vitamin D levels of other two groups, i.e., 10,000–50,000₹/month and > 50,000 ₹/month were 24.31 ng/ml, 18.07 ng/ml, respectively. The difference between the groups was not significant [Figure 2].
Figure 2: Mean Vitamin D levels based on income

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Infants with a sun exposure of >15 min had a higher mean Vitamin D level (27.95 ng/ml) compared to a sun exposure <5 min (17.68 ng/ml) and a sun exposure of 5–15 min (26.92 ng/ml) which was statistically significant (P = 0.002). On comparing the Vitamin D status and mother's sun exposure during pregnancy, a higher mean Vitamin D level was obtained in mother's with a sun exposure >15 min (27.24 ng/ml) as compared to a sun exposure of 5–15 min (23.60 ng/ml) and <5 min (18.32 ng/ml) which was statistically significant (P = 0.042) [Table 2].
Table 2: Comparison of Vitamin D level based on and Mother's sun exposure/day in mins

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[Table 3] shows the comparison of religion and Vitamin D status which showed a higher mean Vitamin D level among Christians (30.77 ng/ml) followed by Hindus (24.46 ng/ml) and Muslims (12.21 ng/ml). The difference was statistically significant (P = 0.002).
Table 3: Comparison of Vitamin D level in three groups based on religion

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   Discussion Top


Diet and nutrition are the important factors in the promotion and maintenance of good health. Nutrition plays an important role to establish and sustain the structure and function of the body.[5] American Dietetic Association states that nutrition is an integral component of oral health.

Eruption is a complex process that can be influenced by the number of factors. Delayed eruption is the first appearance of the teeth in the oral cavity at a much later time than what is normally expected. If there is a failure an erupting tooth to unite with the mucosa, it will lead to a delay in the breakdown of the mucosa and thus cause a barrier to emergence.[6] The average time of eruption of lower primary incisor is 6 months.[7] A standard deviation of 6 months for primary dentition is considered normal.[8] Studies conducted on the Indian population show a delayed eruption pattern of primary teeth.[9],[10] Variations for delayed eruption have been attributed to nutrition, socioeconomic status, climate, and environmental factors. A study by Kohli et al.[11] evaluated the effect of feeding practices on timing of eruption of the first primary tooth and found that initiation of soft diet coincided with the eruption of the first tooth. A general pattern of delay was observed in the Indian population considered in this study in accordance with our results. The effect of protein malnutrition on delayed eruption has been established in various studies. However, the effect of Vitamin D deficiency on the eruption of primary teeth has not been reported. Thus, our study aimed to find out the prevalence of Vitamin D status among 12–15 months infants and correlate it to the timing of eruption of primary teeth. In addition, we also tried to assess the association of socioeconomic status, infant's sun exposure, mother's sun exposure during pregnancy, and religion on Vitamin D status of the infants.

The Vitamin D levels were classified based on the Endocrine Society's Clinical Guidelines as levels <20 ng/ml deficiency, 20–29 ng/ml as insufficiency, and 30–100 ng/ml as sufficiency.[12] Among 96 infants in our study, 52 had Vitamin D deficiency (54.16%), 14 had insufficiency (14.58%), and 30 had sufficient levels (31.26%). Similar studies conducted by Jain et al.,[13] Mehrotra et al.,[14] and Agarwal et al.[15] found the prevalence of Vitamin D deficiency to be (66.7%, 90%, and 16.4%, respectively).

Eruption of first primary tooth in the oral cavity teeth at the age of 6–10 months is an important event in a child's development.[16] Eruption timing beyond this was classified as delayed. Out of the 48 infants in Group 1, four infants were Vitamin D deficient. The Vitamin D status of these infants was found to be in the range of 12.45 ng/ml to 49.6 ng/ml with a mean of 31.02 ng/ml. In Group 2, which consisted of 48 infants who showed delayed eruption of teeth; the Vitamin D levels ranged from 4.9 ng/ml to 18.2 ng/ml with a mean of 11.65 ng/ml showing Vitamin D levels below the optimum level (<20 ng/ml). The difference between the groups was statistically significant (<0.001), suggesting that lower Vitamin D levels could be an etiological factor for delayed eruption of teeth. Vitamin D is important to bone and teeth mineralization because of its role in the maintenance of adequate serum calcium and phosphorus concentrations. The presence of rickets during tooth development may result in enamel and dentin hypoplasia, incomplete development, and delayed tooth eruption.[1]

The socioeconomic status was divided into three groups based on the monthly income as Group 1 (<10,000 ₹/month), Group 2 (10,000–50,000 ₹/month), and Group 3 (>50,000 ₹/month). It was found that the mean Vitamin D levels in Group 1, Group 2, and Group 3 were 27.07 ng/ml, 24.31 ng/ml, and 18.70 ng/ml, respectively. However, there was no statistically significant difference between the groups (P = 0.088) which may be due to a low sample size per group. Higher the socio economic status, higher is the prevalence of Vitamin D deficiency was also reported by studies conducted by Puri et al.[17] and Harinarayan et al.[18]

This could be attributed to the fact that higher socioeconomic society dwells mostly in an indoor environment, greater protection from sun exposure by means of sunscreens to avoid the harmful effects of sunlight. There is a shift in recreational activities from outdoor physical activities to indoor activities such as watching television, computer gaming, etc., which could also result in lower Vitamin D levels.

The FAO/WHO expert consultation states that in most locations in the world around the equator (between latitudes 42°N and 42°S) the most physiologically relevant and efficient way of acquiring Vitamin D is to synthesize it endogenously in the skin from 7-dehydrocholesterol present in the subcutaneous fat, by 30 min of skin exposure (without sunscreen) of the arms and face to sun (ultraviolet spectrum of wavelength 290–310 nm).[19] In our study, we evaluated the association between sun exposure and Vitamin D levels in the infants and mothers separately. Sun exposure was divided into three main groups. Group 1 (<5 min/day), Group 2 (5–15 min/day), and Group 3 (>15 min/day). There was a statistical significant difference between the Vitamin D deficiency states and the sun exposure among the three groups (P = 0.002). This shows that lesser the sun exposure, lesser is the mean Vitamin D levels. This finding is due to a decline in the traditional practice of exposing the infants to sunlight.

With regard to the mother's sun exposure during pregnancy and Vitamin D deficiency, it was found that the mean Vitamin D levels were lower in mothers who were exposed to sunlight for <5 min/day (18.32 ng/ml) when compared to the Vitamin D levels of mothers who were exposed to sunlight for 5–15 min/day (23.06 ng/ml) or >15 min/day (27.24 ng/ml). The difference was statistically significant (P = 0.042). We can conclude that higher the mother's sun exposure during pregnancy, greater was the level of Vitamin D in the infant. The influence of mother's Vitamin D level on the infant's Vitamin D level is proven through various fetomaternal Vitamin D studies.[20],[21],[22],[23]

The influence of clothing on the Vitamin D status is well documented. To find the association between the clothing and Vitamin D levels, we included religion as a part of our questionnaire. We divided the 96 infants into three main religions, i.e., Hindus, Christians, and Muslims. The mean Vitamin D levels among Hindus, Muslims, and Christians were 24.46 ng/ml, 12.21 ng/ml, and 30.77 ng/ml, respectively. The difference was statistically significant (P = 0.02). The lower Vitamin D levels among the Muslim group in our study could be due to the veil/purdah system that was followed religiously by the Muslim group. The veiled clothing does not allow the photoproduction of previtamin D3 from 7-dehydrocholesterol. There is greater attenuation by black coloured clothing which supports the lower levels of Vitamin D among the Muslims who resort to black veiled clothing which prevents adequate sun exposure of even the areas of the body that is normally exposed to sunlight such as the face and hands.[24] There is substantial evidence correlating the Vitamin D deficiency to veiled clothed practices.[25],[26]

The present study shows a definite relation between Vitamin D deficiency and delayed eruption. In India, the Vitamin D deficiency could be the result of predominantly vegetarian diet and inadequate exposure to the available abundant sunshine. A strong association between the socioeconomic status, infant's sun exposure, maternal sun exposure during pregnancy, and religion with Vitamin D levels was also noted.


   Conclusions Top


The following conclusions were drawn from the present study:

  • The prevalence of Vitamin D deficiency was 54.16% and 14.58% of infants had suboptimal levels of Vitamin D
  • A strong association exists between the timing of eruption of primary teeth and Vitamin D deficiency, and it can be concluded that Vitamin D deficiency could be an etiological factor for delayed eruption
  • Socioeconomic status was a contributing factor for Vitamin D deficiency. Higher the socioeconomic status, higher was the Vitamin D deficiency which could be due to the sun protective factors and urbanization
  • Infant sun exposure played a pivotal role in Vitamin D levels of the infant showing that infants who had a sun exposure >15 min had higher Vitamin D levels
  • The effect of mother's sun exposure is the mainstay for infant's Vitamin D levels soon after birth, and hence, is an important factor determining the Vitamin D levels. Higher the maternal sun exposure during pregnancy, greater the infant's Vitamin D levels
  • The effect of clothing which we measured in terms of religion was a significant factor in Vitamin D deficiency. Muslims who resort to veiled clothes as a traditional practice show a very high incidence of Vitamin D deficiency.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Kohli MV, Patil GB, Kulkarni NB, Bagalkot K, Purohit Z, Dave N, et al. A changing trend in eruption age and pattern of first deciduous tooth: Correlation to feeding pattern. J Clin Diagn Res 2014;8:199-201.  Back to cited text no. 11
    
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Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of Vitamin D deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96:1911-30.  Back to cited text no. 12
    
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Mehrotra P, Marwaha RK, Aneja S, Seth A, Singla BM, Ashraf G, et al. Hypovitaminosis d and hypocalcemic seizures in infancy. Indian Pediatr 2010;47:581-6.  Back to cited text no. 14
    
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