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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 2  |  Page : 208-212

Vitamin D deficiency and its correlation with coronal pulp morphology changes – A preliminary study

1 Department of Oral Medicine and Radiology, V.S.P.M Dental College, Nagpur, Maharashtra, India
2 Department of Biochemistry, NKP Salve Institute of Medical Science, Nagpur, Maharashtra, India
3 Periodontics and Implantology, Government Dental College, Nagpur, Maharashtra, India

Date of Submission25-Feb-2022
Date of Decision29-May-2022
Date of Acceptance29-May-2022
Date of Web Publication22-Jun-2022

Correspondence Address:
Tapasya V Karemore
Department of Oral Medicine and Radiology, V.S.P.M Dental College and Research Center, Nagpur - 440 019, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_63_22

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Background: Vitamin D deficiency (VDD) is a pandemic and usually under-diagnosed, under-treated nutritional deficiency globally. Among the Indian population, VDD may be due to lower dietary vit D and calcium intake, low socioeconomic status, etc. VDD can manifest as delayed tooth eruption, absence of secondary dentin formation, altered coronal pulp morphology, enlarged pulp space, and high pulp horns. Radiographic changes can be detected by various advanced imaging techniques but with multiple drawbacks. Intraoral radiographs (IOPA) can be an easy, chair-side and routine method of detecting coronal pulp morphology (CPM) changes due to VDD. Aims and Objectives: To assess correlation of vit D deficiency (VDD) and changes in coronal pulp morphology (CPM) using dental radiographs among young adults. Material and Methods: 60 subjects were included in the study and divided into two groups: one with CPM changes and the second group without CPM changes. All the subjects underwent digital intraoral imaging and serum evaluation for vit D. The subjects were classified into deficient, optimal, and overdose categories. At the same time, the tooth morphology was divided into normal and chair/constricted types. Results: The correlation of vitamin D levels with the pulp horn heightof all three molars were negative and statistically insignificant. Pulp chamber height and width showed negligible and insignificant relationships with vitamin D levels. Conclusion: This study could not prove a significant correlation, but the data generated might help carry out advanced research in a related context. Using an Intraoral Periapical radiograph for evaluating VDD can also be a baseline screening in largepopulations in the future.

Keywords: Dentin, enamel, pulp, vit D Key Message: Vitamin D deficiency induced morphological defcets in pulp and/or dentin can help to identify period and threshold of vitamin D deficiency. These morphologic indicators may help to diagnose the deficiency and guide to restore this essential vitamin.

How to cite this article:
Karemore TV, Motwani MB, Gupta M, Karemore V, Banubakode T, Ashtankar KA. Vitamin D deficiency and its correlation with coronal pulp morphology changes – A preliminary study. J Indian Acad Oral Med Radiol 2022;34:208-12

How to cite this URL:
Karemore TV, Motwani MB, Gupta M, Karemore V, Banubakode T, Ashtankar KA. Vitamin D deficiency and its correlation with coronal pulp morphology changes – A preliminary study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 7];34:208-12. Available from: http://www.jiaomr.in/text.asp?2022/34/2/208/347932

   Introduction Top

Although Vitamin D deficiency (VDD) is a pandemic, it is usually an under-diagnosed and under-treated nutritional deficiency globally.[1] It can be seen in individuals irrespective of age, gender, race, and geography. Among the Indian population, VDD may be due to various reasons like lower dietary Vit D and calcium intake, low socioeconomic status, pigmented skin, and the major factor reported being lack of exposure to sunlight. Chronic VDD may remain asymptomatic and undetected but can cause a significant impact on the growth and development of an individual.[2],[3]

In India, the prevalence of VDD is 70–100% in the general population, while, among children between 5–20 years of age, it varies between 37.8–97.5%.[1] The most important function of Vit D is to regulate calcium and phosphorus balance for bone mineralization. At the same time, it is also responsible for regulating various genes responsible for cell differentiation and cell growth.[4],[5] Intraoral manifestations of nutritional deficiency of Vit D can manifest as delayed tooth eruption, absence of secondary dentin formation leading to teeth with enlarged pulp space and high pulp horns that extend beyond the dentin-enamel junction in the coronal portion.[6],[7] Woo SM et al.[8] carried out an in vitro study to evaluate the potential of Vit D as an odontogenic inducer in human dental pulp cells (HDPCs). This study concluded that Vit D promotes odontoblastic differentiation of HDPCs.

The most reliable marker of vitamin D status is the serum concentration of 25-hydroxyvitamin D (25(OH)D). Although there are various methods like High-Pressure Liquid Chromatography, Chemiluminescent Immunoassay (CLIA), and Enzyme-Linked Immunosorbent Assay to assess the levels of Vit D but they require special equipment and are costly for primary screening.[9]

Bone changes representative of VDD can be detected by various imaging techniques like orthopantogram (OPG), cone-beam computed tomography (CBCT), computed tomography (CT), ultrasound sonography test (USG), and magnetic resonance imaging (MRI) and can give some idea about the levels of Vit D. Although useful, these techniques have multiple drawbacks, likeradiation exposure and high cost.[10] Therefore, there is a need to identify simple and relatively less costly methods to assess vitamin D levels. An easy, chair-side, and routine method of detecting changes due to Vit D deficiency can be the use of pulp morphology changes in intraoral radiographs.

Dental radiographs were used by D'Ortenzio L et al.[11] in their study to detect changes in the coronal pulp of permanent molars in living and archaeological individuals that occurred secondary to past VDD. The study stated that VDD could disturb the metabolism of the microstructure of developing tooth dentin. Histologically, this dentin showed clear bands of bubble-like spaces and incremental lines within the dentin matrix, called interglobular dentin (IGD). The deficiency of Vit D can influence the internal environment of the tooth, causing the absence of secondary dentin formation and producing different morphological changes or shape deformities in the coronal pulp.[11]

All the previous studies conducted so far have included archeological cases of rickets to observe VDD-induced dentin or pulp alterations.[8],[11],[12] Vitamin D deficiency has become an issue of concern these days.[1] Hence, it was felt necessary to find the prevalence of VDD among the central Indian population and identify the importance of intraoral radiography to detect pulp morphology changes, if any, due to VDD among otherwise healthy individuals. After D'Ortenzio et al.,[11] this would be the first research conducted among living individuals to analyze VDD and coronal pulp morphology (CPM) correlation.

   Methodology Top

This study was conducted according to the guidelines laid down in the Declaration of Helsinki. The Ethics committee approved all procedures of VSPM academy of Higher education involving human subjects with approval reference as VSPM/IEC/12/18 ODMR. After Instituitional Ethics Committee approval, this cross-sectional study was carried out in the Oral Medicine and Radiology department at VSPM's Dental College and Research Center, Nagpur, India. Written consent was obtained from all the included subjects.

Subjects 18–20 years of age with intact, fully erupted either right/left maxillary and mandibular molars (1st, 2nd, and 3rd), were included. Subjects with current or aprevious history of thyroid or parathyroid diseases, renal disorders, metabolic disorders, bone disorders, mal-absorption syndrome, and chronic diarrhea, or on Vit D supplements and carious, mal-aligned, or partially erupted teeth, were excluded.

The sample size formula for 'r,' i.e., Pearson's correlation coefficient, was:

n= [(Zα+Zβ)/c]2/3

Zα- 1.96 at α error of 5%

Zβ- 0.84 at β error of 20% (power of study = 1- β=80%)

c- 0.5 × ln[(1 + r/1-r)]

r-corelation coefficient of 0.36.

Hence, sample size was calculated as 60 per group using epi info software version 6.

60 subjects were included in the study, and two groups were made: C1–30 subjects showing radiographic CPM changes, and C2 – 30 subjects with no radiographic CPM changes. All the subjects underwent a serum evaluation for vit D. Detail case history including dietary habits and frequency of physical exercises was recorded. Questions were based on consumption of vegetarian or non-vegetarian food items containing Vit D. Frequency and duration of outdoor and indoor games or other intended exercises were noted to know the status of physical exercises. The radiographic image was analyzed with the help of Carestream Radiovisiography (RVG) 5200 software USA, by an attached computer system.

Method of measurement

The RVG software tool was used for all the measurements [Figure 1]. A line was drawn at the base of the coronal pulp chamber for reference. Two vertical lines were drawn from this reference line up-to-pulp horns, named horn 1 (H1) and horn 2 (H2). For width (W), the mesiodistal dimension at the maximum heights of H1 and H2 was considered. Pulp chamber height was measured from the reference line up to the maximum height of the chamber to meet a point between H1 and H2 [Figure 2],[Figure 3],[Figure 4]. The CPM was evaluated for changes by two experienced radiologists usingthe method given by D' OrtenzioL et al.[11] [Figure 5] and [Figure 6].
Figure 1: Radiographic image in RVG software with toolbar

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Figure 2: CPM measurements - PH1 and PH2 – H: pulp horn height, W1 and W2 – W: pulp horn width, PCH - pulp chamber height

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Figure 3: Measurements using RVG software tools. Red line: base of coronal pulp chamber, Blue line: H1 – Distal Pulp horn height, Green line: H2 – Mesial Pulp horn height

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Figure 4: Measurements using RVG software tools. Blue line: Pulp chamber height, Red line: Width of distal pulp horn, Green line: Width of mesial pulp horn

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Figure 5: Chair shaped coronal pulp with constricted horn

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Figure 6: Radiograph showing Chair shaped coronal pulp in first molar

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Selected subjects were analyzed for CPM changes as normal or chair/constricted type and were classified as C1 or C2. Based on vitamin D levels, the subjects were classified into deficient, optimal, and overdose categories.

   Results Top

Statistical analysis was done where descriptive statistics like mean, standard deviation, and median were obtained for different coronal pulp measurements, corresponding to first, second and third molar. The morphology for each molar tooth type was expressed in terms of frequencies and percentages. The association of vitamin D categories and morphology type was tested statistically using Pearson's Chi-square test. The correlation of vitamin D levels with various dimensions was obtained using Pearson's correlation coefficient. All the analyses were performed using SPSS version 26.0 (IBM Corp, USA) software and the statistically significance was tested at 5% level.

The mean age of subjects in the study was 19.9 years, with a median of 20 years. The age ranged between 18 to 21 years. There was a female preponderance with 34 (56.7%) females and 26 (43.3%) males. Coronal pulp morphology and the vitamin D status of included individuals showed non-significant correlation [Table 1]. Comparing the association of change in tooth morphology among both groups and their vitamin D status was statistically insignificant [Table 2]. For all the molars, the association was statistically insignificant [Table 3]. There was an insignificant influence on the subject's type of nutrition and vitamin D status. Association of physical activity and sun exposure with vitamin D levels was also non-significant.
Table 1: Shows the overall association of vitamin D status with tooth morphology

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Table 2: Shows the association between vitamin D status and tooth morphology changes in subjects

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Table 3: Provides the association between the vitamin D status of subjects and the type of tooth morphology

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   Discussion Top

This preliminary study was carried out to identifythe correlation of Vit D deficiency with changes in tooth coronal pulp morphology. The historical background for this correlation was generated because VDD causes hypo calcification of dentin and delayed tooth eruption. At the cellular level, mitogen-activated protein kinases (MAPKs), like ERKs, i.e., extracellular signal-regulated kinases, were responsible for odontoblastic differentiation of human dental pulp stem cells (DPSCs).[8] Woo SM et al.[8] investigated the effect of 1α, 25(OH)2D3 on odontoblastic differentiation and mineralization of DPSCs. These results demonstrated that 1α,25(OH) 2D3 promoted odontoblastic differentiation of HDPCs via modulating ERK activation. This theory was used to experiment the effect of Vitamin D levels on tooth formation that was thought to introduce therapeutic ways to prevent tooth pulp injury.

Brickley MB et al.[12] studied past VDD and its effects on dentin. The authors discussed ancient Vit D deficiency and its long-term effects. VDD was thought to form interglobular dentin, which helped to provide important information about intrauterine and early infant deficiency that occurred in the past. This study recommended that there is potential to fill in many important gaps in understanding past and present aspects of vitamin D deficiency.

Along with changes at the cellular and developmental levels, studies have also found the radiographic and histologic presentation of nutritional and hereditary deficiencies of Vit D as large pulp chambers, hypoplastic enamel, and dentin mineralization defects, clinically, short roots, malocclusion, and persistent periodontal disease.[6] The large or altered coronal pulp morphology of living and archeological individuals secondary to VDD was confirmed radiographically by D' Ortenzio L et al.[11] in 2018. Radiological examination of the pulp can aid in determining the timing of deficiency in individuals who have pulp changes in their teeth. The present study also evaluated CPM changes among subjects 18–21 years of age. Usually, all three permanent molars are developed and have erupted in the oral cavity at this age. Hence, this age group was considered to detect VDD-induced changes.

The overall association of vitamin D status with tooth morphology within the comparative group was not significant [Table 1] and [Table 2]. Individual molars and CPM were not found to be significant with variable Vit D levels [Table 3]. These findings are not in coordination with the previous study by D' Ortenzio et al.[11]or could not prove a significant correlation between VDD and CPM changes.

Dietary intervention with Vit D has been shown to improve dental (as well as skeletal) formation and mineralization when implemented early in development.[4],[7] But it is also stated that the majority of circulating Vit D is provided by ultraviolet B (UVB) radiation, and <10% is through dietary sources.[4] The present study did not show an association between physical activity, sun exposure, nutrition and vitamin D status.

It is stated that certain severity in the threshold of deficiency is required before morphological changes develop in the pulp chamber and later to appear radiographically.[11] Majority of the subjects had Vit D levels within the normal range that probably have not affected the coronal pulp radiographically.

Defining Vit D status is still debatable due to its variable levels given by many authors. Few have defined toxicity of Vit D over 50ng/dl, whereas other toxicity levels mentioned are beyond 150 ng/dl. In developed countries, levels of 20ng/dl are considered to be sufficient for utilizing Vit D in nearly 97% of the population across all age groups.[13] 82%of subjects in this study had optimal serum Vit D levels, i.e., 20–70ng/dl, which could be attributed to the central Indian geographic condition and one of the reasons for insignificant association in VDD and CPM changes. These findings also suggest a multicenter evaluation of serum Vit D levels across various geographical regions.

Limitations and future prospective

Limitations of this study include the small sample size and the short duration of the observation to analyze CPM changes with advancing age. The study recommends a larger sample size, emphasizing on the period of CPM changes once they become evident. Histological evaluation can also be coupled with the radiographic investigation to study the correlation between VDD and CPM.

   Conclusion Top

Vit D deficiency is observed as an upcoming challenge in the Indian scenario. The only in vivo study conducted so far by D' ortenzio L et al.[11] among few known rachitic living subjects compared to archaeological data to analyzeVDD induced tooth changes indicates need of further research study could be the first to e in this field. The present study could be the first to experiment changes in CPM secondary to Vit D among the living, young, healthy individuals. Although the significant correlation could not be proved; this data would help carry out advanced research in a related context.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ritu G, Gupta A. Vitamin D deficiency in India: Prevalence, causalities, and interventions. Nutrients 2014;6:729-75.  Back to cited text no. 1
Lhamo Y, Chugh PK, Gautam SR, Tripathi CD. The epidemic of Vitamin D deficiency and its management: Awareness among Indian medical undergraduates. JEnvironPublic Health 2017;1-7. doi: 10.1155/2017/2517207.  Back to cited text no. 2
From Indian Academy of Pediatrics 'Guideline for Vitamin D and Calcium in Children' Committee, Khadilkar A, Khadilkar V, Chinnappa J, Rathi N, Khadgawat R, et al. Prevention and treatment of vitamin D and calcium deficiency in children and adolescents: Indian Academy of Pediatrics (IAP) Guidelines. Indian Pediatr 2017;54:567-73.  Back to cited text no. 3
Surve S, Chauhan S, Amdekar Y, Joshi B. Vitamin D deficiency in children: An update on its prevalence, therapeutics and knowledge gaps. Indian J Nutr 2017;4:1-8.  Back to cited text no. 4
Khan KA, Akram J, Fazal M. Hormonal actions of vitamin d and its role beyond just being a vitamin: A review article. Int J Med Med Sci 2011;3:65-72.  Back to cited text no. 5
Foster BL, Nociti Jr FH, Somerman MJ. The rachitic tooth. Endocr Rev 2013;35:1-34.  Back to cited text no. 6
Ngangom A, Jain M, Verma S. Need of early dental intervention in vitamin D deficiency rickets. Indian J Dent Sci 2018;10:229-32.  Back to cited text no. 7
  [Full text]  
Woo SM, Lim HS, Jeong KY, Kim SM, Kim WJ, Jung JY. Vitamin D promotes odontogenic differentiation of human dental pulp cells via ERK activation. MolCells 2015;38:604-9.  Back to cited text no. 8
Pal M, Datta S, Pradhan AK, Biswas L, Ghosh J, Mondal P, et al. Comparison between different methods of estimation of vitamin D. AdvBiol Chem 2013;3:501-4.  Back to cited text no. 9
Bignotti B, Cadoni A, Martinoli C, Tagliafico A. Imaging of skeletal muscle in vitamin D deficiency. World J Radiol 2014;6:119-24.  Back to cited text no. 10
D'Ortenzio L, Ribot I, Kahlon B. The rachitic tooth: The use of radiographs as a screening technique. Int J Paleopathol 2018;23:32-42.  Back to cited text no. 11
Brickley MB, D'Ortenzio L, Kahlon B, Schattmann A, Ribot I, Raguin E, et al. Ancient vitamin D deficiency: Long-term trend. CurrAnthropol 2017;58:420-7.  Back to cited text no. 12
Balasubramanian S, Dhanalakshmi K, Amperayani S. Vitamin D deficiency in childhood- A Review of current guidelines on Diagnosis and management. Indian Pediatr 2013;50:669-75.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3]


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