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Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 106-109

Evaluation and association of serum iron and ferritin levels in children with dental caries

Department of Pediatric and Preventive Dentistry, V. S. Dental College, Bengaluru, Karnataka, India

Date of Web Publication10-May-2017

Correspondence Address:
N S Venkatesh Babu
Department of Pediatric and Preventive Dentistry, V. S. Dental College, V. V. Puram K. R. Road, Bengaluru - 560 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_71_16

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Background: Iron deficiency anemia accounts for 90% of all types of anemia in the world. Although the prevalence has declined in recent years, it remains an important pediatric public health problem. Iron deficiency has also been associated with dental caries. It impairs salivary gland function causing reduced salivary secretion and buffering capacity leading to increased caries activity. Aim: The aim of the study is to explore an association between dental caries and serum levels of iron and ferritin in children aged 3–12 years. Subjectsand Methods: The study group included 120 children, hospitalized for uncomplicated medical problems. Blood reports were evaluated to determine serum iron and ferritin levels. Dental caries experience was assessed using deft index. Statistical Analysis Used: The collected data were tabulated and analyzed using Student's t-test and Pearson's correlation coefficient. Results: Out of 120 children, 38 children showed low serum iron levels of which 31 children had dental caries and nine out of 15 children in the high serum iron level group showed dental caries. High ferritin levels were seen in three children among which two children were caries-free and only one child had a low ferritin level who also had a positive deft score. Conclusion: Based on the results, it was concluded that there is an inverse association between serum iron levels and dental caries whereas there is no association between serum ferritin levels and dental caries.

Keywords: Dental caries, serum ferritin, serum iron

How to cite this article:
Venkatesh Babu N S, Bhanushali PV. Evaluation and association of serum iron and ferritin levels in children with dental caries. J Indian Soc Pedod Prev Dent 2017;35:106-9

How to cite this URL:
Venkatesh Babu N S, Bhanushali PV. Evaluation and association of serum iron and ferritin levels in children with dental caries. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2022 Aug 17];35:106-9. Available from: http://www.jisppd.com/text.asp?2017/35/2/106/206040

   Introduction Top

Dental caries is one of the most common unmet health needs of children. It is an irreversible microbial disease of the calcified tissues of teeth characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth which often leads to cavitation.[1] The National Health Survey conducted in 2004 reported the prevalence of dental caries for both coronal and root surfaces as 51.9% in 5-year-old children and 53.8% in 12-year-old children.[2]

The discomfort and pain associated with dental caries can interfere with the nutritional intake including iron which results in iron deficiency anemia.[3] On the other hand, iron deficiency often impairs salivary gland function leading to reduced salivary secretion and low buffering capacity.[4] Thus, it is a two-way effect. According to the World Health Organization (WHO), the most common and widespread form of nutritional deficiency worldwide is iron deficiency affecting millions of people.[5] Despite the epidemic nature of both dental caries and iron deficiency worldwide, not many studies have been done to find if an association exists between the two conditions. Thus, the aim of this study was to explore an association between both serum iron and ferritin levels and dental caries.

   Subjects and Methods Top

One hundred and twenty children (71 boys and 49 girls) aged 3–12 years were included for this double-blind, cross-sectional study. The children hospitalized at the Kempegowda Institute of Medical Sciences Hospital, Bangalore, India, for uncomplicated medical problems (mild viral infection and dehydration and simple bone fractures) whose blood samples were tested for serum iron and ferritin levels were included in the study. However, children with diseases and/or taking medicines that could affect the serum iron or ferritin levels were excluded from the study. Dental examination was carried out using decayed, missing, and filled teeth (DMFT) and dmft index (WHO criteria 1997) to identify DMFT. The examinations were done bedside using a mouth mirror, probe, and torch light. A tooth was diagnosed as decayed (“D/d” component) if its color was changed and there was any evidence of primary caries or recurrent caries. The “M/m” component included extracted teeth and decayed teeth indicated for extraction due to caries, and the “F/f” component included restored teeth without caries. White spots were not considered as decayed. The serum iron and ferritin levels were obtained from the reports prescribed by the consulting pediatrician. The dental examiner was not aware of the serum iron or ferritin levels at the time of clinical examination. Data analysis included Pearson's correlation coefficient and t-test using SPSS 16.0 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant.

   Results Top

The study was conducted to find an association of serum iron and ferritin levels with dental caries. The mean age of the children examined was 6.3 years (6.32 years for boys and 6.25 years for girls).

While examining for dental caries, it was found that 93 out of the 120 children had dental caries. The mean deft score among these children was 1.7 (±1.5) [Table 1].
Table 1: Mean score values

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The normal limit of serum iron level in children is 50–120 μg/dl. In the present study, the mean value of serum iron among the children examined was 70 (±35) μg/dl [Table 1]. Out of 120 children, 67 children had normal serum iron and 53 of these children had dental caries. A high serum iron level was found in 15 children, of which nine children had decayed teeth, whereas 38 children showed a low serum iron level among which 31 children had dental caries.

The normal level of serum ferritin in children is 7–140 ng/dl. The mean value of serum ferritin in the present study was 53.4% (±34.4) ng/dl [Table 1]. Out of 120 children, 116 children showed a normal serum ferritin level among which 91 children had dental caries. Higher ferritin level was seen in three children of which two children were caries-free and only one child had a low ferritin level who also had a positive deft score. Student's t-test showed no significant differences in the deft index, serum iron, and serum ferritin levels between the genders [Table 1].

Statistical analyses using Pearson's correlation coefficient showed a statistically significant inverse association between caries experience (deft index) and serum iron levels (P = 0.001) [Graph 1], while no association was observed with the serum ferritin levels (P = ns) [Graph 2].

   Discussion Top

Dental caries, a multifactorial, transmissible bacterial infection, is the most common chronic disease of humankind. Diet plays a critical role in the development and clinical features of this infection.[6],[7] In India, not much research has been done in the area of nutritional iron status and caries in children, as per the published literature available. Thus, the present study was conducted to explore an association of serum iron and ferritin levels with dental caries in children.

The prevalence of nutritional anemia and dental caries is still high in some developing countries.[8],[9] The prevalence of anemia in young children continues to remain over 70% in most parts of India and Asia.[10] In this study, 38 out of 120 children had serum iron levels below the normal limits, and an important finding which was observed in the study was that dental caries was present in 31 children out of these 38 children. Statistical analysis showed that there was an inverse significant association between deft index and serum iron levels. Similar results were obtained in a study by Sadeghi et al. that showed a significant inverse association between the serum iron level and early childhood caries.[3] Studies conducted by Schroth et al. and Clarke et al. showed that children with severe early childhood caries had significantly lower hemoglobin levels when compared to caries-free controls.[11],[12] In a cross-sectional study done by Abdallah et al., it was found that children with lower mean hemoglobin levels had significantly higher dmft index.[13]

Fortification of food with iron can help in the prevention of anemia. Iron supplements such as iron–sucrose used for prevention of anemia have shown to reduce the incidence of caries in desalivated rats.[14],[15] Thus, two major public health problems: iron deficiency anemia and dental caries can be alleviated by the addition of iron to sucrose.[15]

Several theories have been proposed as to why the iron levels of a child are associated with the presence of dental caries. One such theory is that the body's inflammatory response, which may accompany rampant forms of dental caries (especially those involving pulpitis or abscesses), results in low hemoglobin levels often observed in severe cases of early childhood caries. This inflammation may trigger a series of events leading to the production of cytokines, which may inhibit erythropoiesis resulting in reduced level of hemoglobin in the blood (and therefore the level of iron).[16] Another theory is that salivary gland function is often impaired in children with iron deficiency, causing reduced salivary secretion and low buffering capacity resulting in dental caries.[4]

The pain and discomfort experienced by children with dental caries may cause difficulty in chewing, which further may negatively affect the absorption of nutrients in the gut due to poorly masticated food.[11] Such altered eating habits may lead to nutritional deficiencies including low iron levels. Thus, a significant proportion of children with severe early childhood caries show malnutrition. The dietary factors that cause reduced iron levels such as high consumption of carbohydrates, beverages, and low meat intake can result in the development of dental caries.[12] Tang et al. in a study observed that among children affected with severe form of early childhood caries, 46% of the children were iron deficient.[17] Shaoul et al. demonstrated that among children affected with both iron deficiency anemia and severe early childhood caries, treatment of dental caries leads to a simultaneous resolution of iron deficiency anemia in most of the cases, even without iron treatment.[18] This can be attributed to the relief from pain and improved eating habits after treatment for dental caries.

Iron ions are precipitated on the enamel surface as thin acid-resistant coatings containing gels and crystals of hydrous iron oxides. These iron ions adsorb salivary calcium and phosphate ions to nucleate the formation of apatites, thus replacing the minerals, which are dissolved during the acid phases of the caries process.[19] Thus, iron could have a significant inhibitory effect on growth of Streptococcus mutans, the early establishment of which directly relates to the severity of dental caries.[20],[21]

Furthermore, a child's iron status is known to have a significant impact on health. For instance, a child suffering from iron deficiency may not only show neurological manifestations such as learning and memory deficits, decreased fine motor skills, increased anxiety but also weakness, poor physical growth, and compromised immune system, making him/her vulnerable to infections.[4],[22]

Serum ferritin is an acute-phase protein and its level is an indicator of body iron stores. However, it is less sensitive since its levels in blood are increased by infection or any type of chronic inflammation, and these conditions could convert what would otherwise be a low level of ferritin from lack of iron into a value in the normal range. Thus, low ferritin level does not totally rule out iron deficiency.[23] In the present study, it was observed that there was no association between serum ferritin levels and deft index. Similar results have been reported by Sadeghi et al. and Clarke et al.[3],[12] However, in a study conducted by Schroth et al., children with severe early childhood caries had significantly lower serum ferritin levels compared to caries-free children.[11]

The concentration of serum iron in children is variable with time. Furthermore, dental caries is a chronic disease, having a multifactorial etiology. Thus, further investigations taking the confounding factors into consideration with a longitudinal study design are recommended.

   Conclusion Top

Based on the results of the study, it is concluded that there is an inverse association between the serum iron level and dental caries whereas there is no association between serum ferritin levels and dental caries. Dental caries can act as an early warning sign of low iron levels and may allow the patient to receive necessary interventions before the severe sequelae of iron deficiency take root. Since iron plays a significant role in normal physical and neurological development, preoperative assessments for children requiring treatment for severe early childhood caries should include evaluation of iron and hemoglobin levels.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Shafer WG, Hine MK, Levy BM. A Text Book of Oral Pathology. 5th ed. Philadelphia: W. B. Saunders Company; 1993. p. 567-658.  Back to cited text no. 1
National Oral Health Survey and Fluoride Mapping. An Epidemiological Study of Oral Health Problems and Estimation of Fluoride Levels in Drinking Water. Dental Council of India, New Delhi; 2004.  Back to cited text no. 2
Sadeghi M, Darakhshan R, Bagherian A. Is there an association between early childhood caries and serum iron and serum ferritin levels? Dent Res J (Isfahan) 2012;9:294-8.  Back to cited text no. 3
Mahantesha T, Parveen Reddy KM, Kamavaram Ellore VP, Ramagoni NK, Iitagi V, Anitha KS. Evaluation and association of iron deficiency anemia with salivary pH and buffering capacity in children aged 6-12 years. Natl J Physiol Pharm Pharmacol 2014;4:229-32.  Back to cited text no. 4
World Health Organization. Worldwide prevalence of anaemia 1993–2005. In: De Benoist B, McLean E, Egli I. WHO Global Database on Anaemia. Geneva, Switzerland: World Health Organization; 2008.  Back to cited text no. 5
Preethi BP, Pyati A, Dodawad R. Evaluation of flow rate, pH, buffering capacity, calcium, total protein and total antioxidant levels of saliva in caries free and caries active children – An in vivo study. Biomed Res 2010;21:289-94.  Back to cited text no. 6
Berkowitz RJ. Causes, treatment and prevention of early childhood caries: A microbiologic perspective. J Can Dent Assoc 2003;69:304-7.  Back to cited text no. 7
Killip S, Bennett JM, Chambers MD. Iron deficiency anemia. Am Fam Physician 2007;75:671-8.  Back to cited text no. 8
McDonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent. 6th ed. St. Louis, Missouri: Mosby Co.; 2004. p. 261.  Back to cited text no. 9
Kotecha PV. Nutritional anemia in young children with focus on Asia and India. Indian J Community Med 2011;36:8-16.  Back to cited text no. 10
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Schroth RJ, Levi J, Kliewer E, Friel J, Moffatt ME. Association between iron status, iron deficiency anaemia, and severe early childhood caries: A case-control study. BMC Pediatr 2013;13:22.  Back to cited text no. 11
Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ, Judd P. Malnourishment in a population of young children with severe early childhood caries. Pediatr Dent 2006;28:254-9.  Back to cited text no. 12
Abdallah MA, Abed HH, Hamza G, Alsahafi EN. The association between dmft index and haemoglobin levels in 3-6 year-old Saudi children with anaemia: A cross sectional study. J Taibah Univ Med Sci 2016;11:72-6.  Back to cited text no. 13
World Health Organization. Oral Health Surveys: Basic Methods. 3rd ed. Geneva: WHO; 1997.  Back to cited text no. 14
Miguel JC, Bowen WH, Pearson SK. Effects of frequency of exposure to iron-sucrose on the incidence of dental caries in desalivated rats. Caries Res 1997;31:238-43.  Back to cited text no. 15
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Shaoul R, Gaitini L, Kharouba J, Darawshi G, Maor I, Somri M. The association of childhood iron deficiency anaemia with severe dental caries. Acta Paediatr 2012;101:e76-9.  Back to cited text no. 18
Flink H. Studies on the prevalence of reduced salivary flow rate in relation to general health and dental caries, and effect of iron supplementation. Swed Dent J Suppl 2007;192:3-50.  Back to cited text no. 19
Ribeiro NM, Ribeiro MA. Breastfeeding and early childhood caries: A critical review. J Pediatr (Rio J) 2004;80 5 Suppl: S199-210.  Back to cited text no. 20
Berlutti F, Ajello M, Bosso P, Morea C, Petrucca A, Antonini G, et al. Both lactoferrin and iron influence aggregation and biofilm formation in Streptococcus mutans. Biometals 2004;17:271-8.  Back to cited text no. 21
Fretham SJ, Carlson ES, Georgieff MK. The role of iron in learning and memory. Adv Nutr 2011;2:112-21.  Back to cited text no. 22
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