The recent epidemic of dental caries in children – affecting 23.7% of UK 5-year-olds in 2021-2022 has been linked to a number of factors – socioeconomic status and ethnicity being chief among them.[i] There is also strong evidence of a relationship between maternal and childhood vitamin D deficiency (VDD) and dental caries in primary and permanent teeth.[ii]
Although VDD can arise from inadequate dietary intake of vitamin D, or hereditary metabolic disorders, the primary cause is lack of exposure to sunlight with adequate ultraviolet B rays (UVB).[iii] According to recent figures,[iv] changes to lifestyle and working culture mean the average person in the UK spends approximately 80% to 90% of their time indoors, risking under-exposure to sunlight. Children reportedly now spend less time outdoors than prison inmates.[v]
Apart from the detrimental effect on brain development and mental health,[vi] and the potentially serious impact of the pollutants that accumulate in a closed room,[vii] this phenomenon is believed to have contributed to increases in systemic[viii] and oral disease[ix] related to vitamin D deficiency (VDD).
Vitamin D and oral health
Vitamin D is a fat-soluble hormone with multiple functions, the main one being the regulation of calcium and phosphate levels in the body.[x] Without adequate vitamin D, the body absorbs no more than 10% to 15% of dietary calcium. With sufficient amounts of vitamin D available, the intestinal calcium absorption increases to 30% to 40%. Vitamin D is instrumental in facilitating intestinal calcium absorption, for the mineralisation of bones and teeth.[xi]
A recent study[xii] has shown that supplementing the diets of children under the age of 3 – at least in the autumn and winter – significantly reduced the risk of caries. A higher maternal intake of vitamin D during pregnancy is also associated with a lower risk of dental caries in children after birth.[xiii]
As well as dental caries, VDD has been associated with periodontal disease – including periodontitis and gingival inflammation. Studies have indicated that alveolar bone regeneration procedures performed in baseline VDD patients may be more prone to failure. Vitamin D deficiency may also be linked with certain oral cancers, and osteonecrosis of the jaw.[xiv]
VDD – nutrition and other factors
Vitamin D is obtained mainly from exposure to sunlight, but can also be absorbed through food or dietary supplements.[xv] The recommended daily dietary intake of 10μg/day is unlikely to be met by the average modern UK diet.[xvi] Although some cereals, plant milks and margarines are fortified with vitamin D, there are only a small number of foods naturally containing vitamin D. These include oily fish like salmon, mackerel and sardines – as well as egg yolks, red meat and liver.[xvii]
Food insecurity, combined with the relative costs of nutritious versus processed food, has led to an upsurge in common deficiencies in important nutrients. This has affected the systemic and oral health of people – particularly those living in low-income households – in the UK.[xviii] In 2022, almost 11,000 people in England were hospitalised with malnutrition and 405 children were treated for rickets – a disease caused by insufficient vitamin D and calcium, causing bones to fail to develop properly.[xix]
People with darker skin, containing more melanin pigment, tend to be more prone to VDD.[xx] People with more melanin pigmentation are better able to resist the harmful effects of ultraviolet rays than those with lighter skin – however, darker skin requires longer exposure to ultraviolet radiation to facilitate vitamin D synthesis.[xxi]
Children’s skin is more efficient at synthesising vitamin D than older people, but young skin risks sun damage with over-exposure. As the skin ages, this capacity decreases, and the elderly may need additional exposure to light every day or supplements to reap the benefits.[xxii]
There is currently a lack of evidence to show the effect of high sun protection factor (SPF) sunscreen on vitamin D absorption in natural light.[xxiii] However, the NHS suggests all children should wear a high factor sunscreen and take supplements.[xxiv]
Minimally invasive options – treatment and prevention
If teeth have been affected by VDD, and are at risk of developing caries, a number of minimally invasive treatment options should be considered. Once measures are in place to remineralise teeth and maintain effective biofilm removal, resin-based pit and fissure sealants have shown promising results – arresting dental caries for up to two years in the permanent teeth of children and adolescents.[xxv]
To address all classes of cavity, from incipient to severe, BRILLIANT EverGlow® composite from COLTENE allows highly aesthetic and long-lasting direct restorations to be achieved effortlessly. BRILLIANT EverGlow® has smooth consistency for ideal handling, and is an exceptionally durable solution, suitable for anterior and posterior restorations. When a lower viscosity format is needed, BRILLIANT EverGlow® Flow is the perfect solution. High polishability, translucency and colour matching means BRILLIANT EverGlow® and EverGlow® Flow blend in perfectly.
Clinicians can be confident in advising patients to ‘get out more’, as the risks to mental, physical and oral health of not having enough time outdoors are clear. At the very least, it is important for people at risk of VDD to consider daily supplements – especially in the winter months – to maintain optimal health and reduce the risk of dental caries.
To find out more visit www.coltene.com, email info.uk@coltene.com or call 0800 254 5115
Author: Nicolas Coomber, National Account & Marketing Manager
[i] Levine RS. Childhood caries and hospital admissions in England: a reflection on preventive strategies. Br Dent J. 2021 May;230(9):611-616. doi: 10.1038/s41415-021-2945-8. Epub 2021 May 14. PMID: 33990749; PMCID: PMC8120769.
[ii] Durá-Travé T, Gallinas-Victoriano F. Dental caries in children and vitamin D deficiency: a narrative review. Eur J Pediatr. 2024 Feb;183(2):523-528. doi: 10.1007/s00431-023-05331-3. Epub 2023 Nov 15. PMID: 37966493; PMCID: PMC10912272.
[iii] Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients. 2020 May 19;12(5):1471. doi: 10.3390/nu12051471. PMID: 32438644; PMCID: PMC7285165.
[iv] Bunn S, Duffield G. Indoor air quality. UK Parliament research briefing. September 2023. Available at: https://post.parliament.uk/research-briefings/post-pb-0054/#:~:text=People%20spend%2080%2D90%25%20of,complex%20and%20variable%20than%20outdoors. Accessed July 2024.
[v] Scott S, Gray T, Charlton J, Millard S. The Impact of Time Spent in Natural Outdoor Spaces on Children’s Language, Communication and Social Skills: A Systematic Review Protocol. Int J Environ Res Public Health. 2022 Sep 23;19(19):12038. doi: 10.3390/ijerph191912038. PMID: 36231338; PMCID: PMC9566327.
[vi] Scott S, Gray T, Charlton J, Millard S. The Impact of Time Spent in Natural Outdoor Spaces on Children’s Language, Communication and Social Skills: A Systematic Review Protocol. Int J Environ Res Public Health. 2022 Sep 23;19(19):12038. doi: 10.3390/ijerph191912038. PMID: 36231338; PMCID: PMC9566327.
[vii] Bunn S, Duffield G. Indoor air quality. UK Parliament research briefing. September 2023. Available at: https://post.parliament.uk/research-briefings/post-pb-0054/#:~:text=People%20spend%2080%2D90%25%20of,complex%20and%20variable%20than%20outdoors. Accessed July 2024.
[viii] PRUSZYŃSKI, Jacek, CIANCIARA, Dorota, WŁODARCZYK-PRUSZYŃSKA, Inga, GÓRCZAK, Małgorzata and PADZIŃSKA-PRUSZYŃSKA, Irena. Indoor Generation Era. Risks and challenges. Journal of Education, Health and Sport. 2023;48(1):23-40.eISSN 2391-8306. Available at:
https://www.researchgate.net/publication/374777958_Indoor_Generation_Era_Risks_and_challenges Accessed July 2024
[ix] Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients. 2020 May 19;12(5):1471. doi: 10.3390/nu12051471. PMID: 32438644; PMCID: PMC7285165.
[x] Bârsan M, Chelaru VF, Râjnoveanu AG, Popa ȘL, Socaciu AI, Bădulescu AV. Difference in Levels of Vitamin D between Indoor and Outdoor Athletes: A Systematic Review and Meta-Analysis. Int J Mol Sci. 2023 Apr 20;24(8):7584. doi: 10.3390/ijms24087584. PMID: 37108748; PMCID: PMC10147028.
[xi] Khazai N, Judd SE, Tangpricha V. Calcium and vitamin D: skeletal and extraskeletal health. Curr Rheumatol Rep. 2008 Apr;10(2):110-7. doi: 10.1007/s11926-008-0020-y. PMID: 18460265; PMCID: PMC2669834.
[xii] Sobiech P, Olczak-Kowalczyk D, Hosey MT, Gozdowski D, Turska-Szybka A. Vitamin D Supplementation, Characteristics of Mastication, and Parent-Supervised Toothbrushing as Crucial Factors in the Prevention of Caries in 12- to 36-Month-Old Children. Nutrients. 2022 Oct 18;14(20):4358. doi: 10.3390/nu14204358. PMID: 36297042; PMCID: PMC9607142.
[xiii] Durá-Travé T, Gallinas-Victoriano F. Dental caries in children and vitamin D deficiency: a narrative review. Eur J Pediatr. 2024 Feb;183(2):523-528. doi: 10.1007/s00431-023-05331-3. Epub 2023 Nov 15. PMID: 37966493; PMCID: PMC10912272.
[xiv] Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients. 2020 May 19;12(5):1471. doi: 10.3390/nu12051471. PMID: 32438644; PMCID: PMC7285165.
[xv] Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients. 2020 May 19;12(5):1471. doi: 10.3390/nu12051471. PMID: 32438644; PMCID: PMC7285165.
[xvi] Webb AR, Kazantzidis A, Kift RC, Farrar MD, Wilkinson J, Rhodes LE. Colour Counts: Sunlight and Skin Type as Drivers of Vitamin D Deficiency at UK Latitudes. Nutrients. 2018 Apr 7;10(4):457. doi: 10.3390/nu10040457. PMID: 29642423; PMCID: PMC5946242.
[xvii] Fortifying foods and drinks with vitamin D: summary. Independent report. Office for Health Improvement and Disparities Gov.uk. Available at: https://www.gov.uk/government/publications/fortifying-food-and-drink-with-vitamin-d-a-sacn-rapid-review/fortifying-foods-and-drinks-with-vitamin-d-summary Accessed July 2024
[xviii] https://www.bapen.org.uk/malnutrition/introduction-to-malnutrition/what-are-the-consequences-of-malnutrition/
[xix] https://www.thetimes.com/uk/healthcare/article/times-health-commission-thousands-of-people-admitted-to-hospital-suffering-from-malnutrition-n23hqgzjr
[xx] Martin CA, Gowda U, Renzaho AM. The prevalence of vitamin D deficiency among dark-skinned populations according to their stage of migration and region of birth: A meta-analysis. Nutrition. 2016 Jan;32(1):21-32. doi: 10.1016/j.nut.2015.07.007. Epub 2015 Aug 8. PMID: 26643747.
[xxi] Webb AR, Kazantzidis A, Kift RC, Farrar MD, Wilkinson J, Rhodes LE. Colour Counts: Sunlight and Skin Type as Drivers of Vitamin D Deficiency at UK Latitudes. Nutrients. 2018 Apr 7;10(4):457. doi: 10.3390/nu10040457. PMID: 29642423; PMCID: PMC5946242.
[xxii] Webb AR. Who, what, where and when—influences on cutaneous vitamin D synthesis,
Progress in Biophysics and Molecular Biology, Volume 92, Issue 1, 2006, Pages 17-25, https://doi.org/10.1016/j.pbiomolbio.2006.02.004.
[xxiii] Neale RE, Khan SR, Lucas RM, Waterhouse M, Whiteman DC, Olsen CM. The effect of sunscreen on vitamin D: a review. Br J Dermatol. 2019 Nov;181(5):907-915. doi: 10.1111/bjd.17980. Epub 2019 Jul 9. PMID: 30945275.
[xxiv] Sunscreen and sun safety. NHS.uk. December 2022. Available at: https://www.nhs.uk/live-well/seasonal-health/sunscreen-and-sun-safety/ Accessed July 2024.
[xxv] Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Mäkelä M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev. 2004;(3):CD001830. doi: 10.1002/14651858.CD001830.pub2. Update in: Cochrane Database Syst Rev. 2008 Oct 08;(4):CD001830. doi: 10.1002/14651858.CD001830.pub3. PMID: 15266455.
