Early Childhood Caries

Early childhood caries (ECC) is defined as the presence of 1 or more decayed (non-cavitated or cavitated lesions), missing due to caries, or filled tooth surfaces in any primary tooth in a child 71 months of age or younger (Drury et al., 1999). The consequences of unmanaged ECC and premature tooth loss include pain and infection, impaired speech, and may result in poor weight and height growth (Ayhan et al., 1996 and Low et al., 1999). Due to the rising amount of children presenting with ECC (Tinanoff and Reisine, 2009), preventing the initiation and progression of dental decay is important to the oral health and overall health of children.

Many causative factors exist to play a role in the development of dental decay, including bacteria, diet, oral hygiene, medical conditions and lack of important vitamins and minerals, such as vitamin D. Vitamin D is a steroid hormone essential for bone growth and remodeling, as well as Tooth development, especially the early stages of morphogenesis, differentiation and enamel and pulp development (Glijer et al., 1985). The major physiologic function of vitamin D is to maintain serum calcium and phosphorus levels; without vitamin D, intestinal absorption of dietary calcium and phosphorus is significantly decreased (Holick, 2007). When serum calcium (Ca++) levels are decreased, parathyroid hormone (PTH) levels increase, in turn, increasing tubular resorption of Ca++ and enhancing the action of osteoclasts to mobilize Ca stores from the bone. In addition, PTH stimulates the kidneys to convert 25(OH) D to its active form of vitamin D, 1, 25-dihydroxy vitamin D (Schroth et al., 2012 and Holick, 2006), At least 1 billion people worldwide have vitamin D deficiency or insufficient levels of vitamin D (Holick, 2007). Vitamin D deficiency is defined as a 25-hydroxyvitamin D (25(OH) D) level of less than 20 ng per milliliter (Hujoel, 2013). There are many causes of vitamin D deficiency, including heritable disorders, acquired disorders and reduced synthesis of vitamin D absorbed through the skin (Holick, 2007) (Schwalfenberg, 2011).

Vitamin D deficiency can contribute to a number of conditions including vitamin D resistant rickets, osteoporosis, dental enamel hypoplasia and dental caries. Children who are breastfed are at increased risk for vitamin D deficiency if they are not receiving adequate sunlight exposure or vitamin D supplements. Furthermore, children who receive inadequate vitamin D through sun exposure or diet may be at risk for ECC (Holick, 2007). Some experiments have found that giving a mother vitamin D supplements while she is pregnant can reduce the rate of dental enamel defects in their children. Defects in dental enamel increase the risk of a child developing dental caries (Cockburn et al., 1980). Much of the initial focus on the role of vitamin D in caries occurred during the 1920s and 1930s through the efforts of Mellanby and colleagues (Mellanby et al., 1924; Mellanby, 1928; Mellanby and Pattison 1928).

Several historical reports document the beneficial effects of vitamin D supplementation in reducing dental caries in children (Mellanby et al., 1924; Mellanby and Pattison, 1926; McBeath, 1933; Anderson et al., 1934; Eliot et al., 1934; McBeath and Zucker, 1938; McBeath and Verlin, 1942). Many studies have found that geographic location and sun exposure are related to dental caries. People living closer to the equator with greater amounts of sun exposure are less likely to develop dental caries (Grant, 2011). Studies that give people vitamin D supplements to prevent caries have found that vitamin D is effective at preventing the development of caries (Hujoel, 2013).

Schroth et al., (2012) conducted a pilot study in which 38 participants (19 controls and 19 patients with severe ECC) were assessed for adequate levels of vitamin D and PTH. His study reported that children with severe ECC have lower vitamin D levels compared to cavity-free controls. Hujoel, (2013) hoped to further investigate the link between vitamin D and tooth decay. The findings from this systematic review and meta-analysis reaffirm the importance of Vitamin D for dental health- children who are vitamin D deficient have poor delayed tooth eruption and are prone to dental caries. Schroth et al. (2013) established a research to investigate the association between serum concentrations of 25(OH) D and S-ECC in preschool children. They found Children with S-ECC appear to have relatively poor nutritional health compared to caries-free controls, and were significantly more likely to have low vitamin D, calcium, and albumin concentrations and elevated PTH levels. Maguire et al. (2013) conducted a study to examine the association between cow’s milk intake on both vitamin D and iron stores in healthy urban preschoolers. They Found two cups (500 mL) of cow’s milk per day maintained 25-hydroxyvitamin D >75 nmol/L with minimal negative effect on serum ferritin for most children.

Children with darker skin pigmentation not receiving vitamin D supplementation during the winter required 3 to 4 cups of cow’s milk per day to maintain 25-hydroxyvitamin D >75 nmol/L. Cow’s milk intake among children using a bottle did not increase 25-hydroxyvitamin D and resulted in more dramatic decreases in serum ferritin(Maguire et al., 2013(. Another study by Lee et al. (2014) investigated the association between total daily consumption of non–cow’s milk and serum 25-hydroxyvitamin D levels in a population of healthy urban preschool-aged children and analyzed the association between daily non-cow's milk and cow's milk consumption. They found Drinking non-cow's milk beverages was associated with a 4.2-nmol/L decrease in 25-hydroxyvitamin D level per 250-mL cup consumed among children who also drank cow's milk.Children who drank only non-cow's milk were at higher risk of having a 25-hydroxyvitamin D level below 50 nmol/L than children who drank only cow's milk (Lee et al., 2014). Mothers of children with ECC have lower vitamin D levels during pregnancy than mothers whose children don’t have caries (Schroth et al., 2014).

Another group has recently stated that pregnant women with higher prenatal intakes of vitamin D were more likely to report that their child was caries-free compared with women who had lower vitamin D intakes (Tanaka et al., 2015). Data from a cross-sectional study suggested that there is an association between caries and lower serum vitamin D. improving children’s vitamin D status may be an additional preventive consideration to lower the risk for caries (Schroth et al., 2016). The aim of Study: To determine if there is a relationship between vitamin D deficiency and the development of Early Childhood Caries (ECC).

Methodology: This is a case-control pilot study to determine the relationship of vitamin D deficiency to the prevalence and severity of ECC. Patient selection and examination following inclusion and exclusion criteria, an Informed consent form will obtain from the parent or guardian after explaining the study in detail. Patients have a yearly pediatric medicine exam and blood drawn regardless of their participation in the study. Inclusion Criteria: • Cases: Patients diagnosed with ECC who are treatment planned to receive full mouth dental rehabilitation under General Anesthesia (GA). • Age 71 months or younger. • Patients with an American Society of Anesthesiologists (ASA) Classification of 1 (Healthy person). • Controls: patients who present with no frank cavitated lesions upon visual and radiographic examination who are: • Patients of record at SFH for an annual exam with blood work patients will schedule to undergo an otolaryngology procedure under GA. Exclusion Criteria: • Patients with significant metabolic disorders and/or complex medical issues. • Patients with an ASA Classification of 2 or greater. • Patients received vitamin D supply • Controls: patients who present with frank cavitated lesions upon visual and radiographic examination. Blood Samples: The operating room (OR) staff obtained blood samples while the patient will be under GA prior to the initiation of dental treatment. An intravenous (IV) line will place while the child is in the OR for clinical purposes. No additional needle sticks will incur, as blood will draw from a clinically necessary IV line. The sample will obtain as a maximum fill of a Red topped 4.0 mL BD Vacutainer tube.

Patients will assign a Research Medical Record Number in the Center Hospital database so that blood samples are correct will analyze and tabulate when they will leave the OR. Phlebotomist obtained blood from the caries-free controls, a topical anesthetic (EMLA) was applied to the antecubital fossa one hour prior to minimizing discomfort from the venipuncture during their annual exams also assigned a research-related identification number in the same manner. Vitamin D Analyses: All blood samples were analyzed for 25-OH Vitamin D levels, PTH level, Ca level and Albumin in Medical Laboratory. Total 25-OH Vitamin D was calculated as the sum total of 25-OH Vitamin D3 and 25-OH Vitamin D2. Lab results were entered into a database and chart for data analysis. PTH, Albumin and Ca levels were analyzed with the same blood sample in addition to 25(OH) D levels. PTH is a more sensitive surrogate for mild Vitamin D deficiency and is typically was analyzed in conjunction with Vitamin D.

Analysis and report data are based on the following values: Deficient (< 35 nmol/L), Adequate (= 50 nmol/L), Optimal (= 75 nmol/L). Normal reference ranges were adopted for calcium (2.1-2.6 mmol/L), albumin (35–47 g/L for those < 48 months and 33–39 g/L for those = 48 months), and PTH (7–50 ng/L). Blood work drawn was analyzed and any discrepancy in findings, such as vitamin D deficiency, was reported to the patient so that they will referrer for treatment by their pediatrician. Statistical Analysis: The analysis included descriptive statistics (frequencies, means ± Standard Deviations (SD)), Chi-square analysis, and t-tests. Unadjusted odds ratios (OR) and 95% confidence intervals (CI) were also calculated.

Multiple regression analysis was performed for mean 25(OH)D including independent variables significantly associated with vitamin D levels on bivariate analysis or known to influence vitamin D status. Logistic regression for S-ECC including variables associated at the bivariate level was also performed. In both models, some variables were excluded when there was evidence of multicollinearity. A p-value = 0.05 was significant. All analyses will be done by using SPSS 20 software at p = 0.05.