Association of Vitamin D Deficiency with Caries Experience and Recurrent Oral Ulcers in Children: A Case-Control Study

Association of Vitamin D Deficiency with Caries Experience and Recurrent Oral Ulcers in Children: A Case-Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of Vitamin D Deficiency with Caries Experience and Recurrent Oral Ulcers in Children: A Case-Control Study Neeharika Soorneedi, Naga Supraja Atluri, Vatsalya Kommalapati, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8685385/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background Vitamin D plays a critical role in maintaining calcium homeostasis and modulating immune responses, both of which are fundamental to oral and dental health. Recent research indicates that vitamin D deficiency may contribute to an increased susceptibility to dental caries and recurrent aphthous ulcers in pediatric populations. Aim To evaluate the association between serum vitamin D levels, dental caries experience, and recurrent oral ulcers in children aged 6–12 years. Materials and Methods A case-control study was conducted among 100 children. Fifty children with clinically diagnosed vitamin D deficiency (serum 25(OH)D < 20 ng/mL) formed the case group, and 50 healthy children with sufficient vitamin D levels (≥ 30 ng/mL) served as controls. Dental caries experience was recorded using the dmft/DMFT index, and history of recurrent oral ulcers was documented using a structured questionnaire. Independent t-test and chi-square test were applied for statistical analysis, with p < 0.05 considered significant. Results Mean serum vitamin D levels were significantly lower in cases (15.6 ± 2.8 ng/mL) than in controls (32.4 ± 4.1 ng/mL; p < 0.001).The mean dmft/DMFT score was higher among deficient children (5.12 ± 1.4) compared to controls (2.48 ± 1.1) (p < 0.01). Recurrent oral ulcers were reported in 42% of vitamin D–deficient children versus 12% in controls (p < 0.01). Conclusion Vitamin D deficiency shows a significant correlation with greater dental caries experience and a higher occurrence of recurrent oral ulcers among children. Periodic screening for vitamin D levels may aid in preventing these oral conditions. Vitamin D Calcium homeostasis Immune regulation Hypovitaminosis D Figures Figure 1 Figure 2 INTRODUCTION Vitamin D is a fat-soluble secosteroid that acts as a prohormone, playing a crucial role in calcium and phosphate regulation, skeletal development, and bone mineralization. In addition to its traditional function in maintaining bone health, vitamin D has been increasingly identified as a multifaceted regulator involved in modulating immune, endocrine, and epithelial system activities. 1 , 2 Vitamin D deficiency has emerged as a major global public health concern, with epidemiological data suggesting that nearly one billion individuals worldwide exhibit suboptimal serum concentrations of 25-hydroxyvitamin D [25(OH)D]. 3 , 4 The causes of hypovitaminosis D include limited sunlight exposure, darker skin pigmentation, clothing habits, inadequate dietary intake, and urban lifestyle patterns that restrict outdoor activity. 5 In the context of oral health, vitamin D plays a crucial role in maintaining both hard and soft tissue integrity. It’s receptors (VDRs) are seen in oral epithelial cells, gingival fibroblasts, salivary glands, and dental pulp cells, indicating a regulatory role in local immune responses and tissue homeostasis. 6 , 7 Adequate vitamin D levels facilitate calcium absorption and promote enamel and dentin mineralisation, thereby improving the resistance of teeth to acid demineralisation and caries formation. 8 , 9 Vitamin D enhances innate immune defense by upregulating the expression of antimicrobial peptides, including cathelicidin and β-defensins. These peptides exhibit potent bactericidal activity against cariogenic microorganisms such as Streptococcus mutans and Lactobacillus spp., thereby contributing to oral microbial homeostasis.. 10,11 Multiple clinical studies and meta-analyses have reported an inverse association between vitamin D levels and the occurrence of dental caries in pediatric populations. Li et al. 12 reported that children with serum 25(OH)D levels below 20 ng/mL had higher caries experience, with a pooled risk ratio of 1.22 compared to vitamin D-sufficient children. Similarly, Buzatu et al. 13 and Hujoel 14 confirmed that hypovitaminosis D constitutes a modifiable risk factor for both primary and permanent dentitions. Prenatal vitamin D levels have shown to influence early childhood caries, highlighting the nutrient’s role in enamel development even before tooth eruption. 15 Also, vitamin D has been implicated in maintaining the integrity of oral mucosa. The active form, 1,25-dihydroxy-vitamin D, modulates cytokine production, suppresses proinflammatory mediators (e.g., IL-6, TNF-α), and enhances anti-inflammatory cytokines (e.g., IL-10), thereby contributing to mucosal immune tolerance. 16 , 17 Deficiency may therefore predispose to mucosal inflammation and recurrent aphthous ulcers (RAUs), one of the most common oral lesions in children. 18 , 19 Several reports, including those by Akdeniz et al. 20 and Kurnatowska et al. 21 have found decreased vitamin D levels in patients with RAUs than healthy controls, suggesting a possible pathophysiologic link. However, while separate relation of vitamin D deficiency with dental caries and with recurrent oral ulcers have been studied, the dual impact of vitamin D status on both conditions within same pediatric cohort remains under-explored. Understanding this relationship is relevant in regions like India, as vitamin D deficiency is common among children despite abundant sunlight. 22 , 23 Hence, this case–control study was designed to assess the association between serum vitamin D levels, dental caries experience, and recurrent oral ulcers in children aged 6–12 years. Identifying such links can help integrate nutritional assessment—particularly vitamin D screening—into pediatric dental care and contribute to holistic preventive strategies for oral health. MATERIALS AND METHODS A study was carried out on 100 children of 6–12 years old after obtaining the written informed consent from parents. Fifty vitamin D–deficient children (serum 25(OH)D < 20 ng/mL) constituted the case group, and fifty vitamin D–sufficient children (≥ 30 ng/mL) formed the control group. Children with systemic diseases or on vitamin D supplements were excluded. Serum vitamin D levels were measured using chemiluminescent immunoassay. Dental caries were recorded using dmft/DMFT index, and data on recurrent oral ulcers were collected via parental questionnaire. Analysis of data was done using SPSS v26. Independent t-test and chi-square test were applied, with p < 0.05 considered significant. RESULTS Children with low serum vitamin D levels had significantly more dental caries and higher prevalence of recurrent oral ulcers compared with vitamin D-sufficient peers (Table 1) (Figure 1) (Figure 2). These findings imply that vitamin D has a dual protective role in both tooth mineralisation as well as oral mucosal health (Table 2). Table 1. Serum Vitamin D levels and caries experience Parameter Vitamin D Deficient Vitamin D Sufficient p-value Mean Vitamin D (ng/mL) 15.6 ± 2.8 32.4 ± 4.1 <0.001 Mean dmft/DMFT 5.12 ± 1.4 2.48 ± 1.1 <0.01 Table 2. Association between vitamin D status and recurrent oral ulcers Oral Ulcers Deficient (n=50) Sufficient (n=50) p-value Present 21 (42%) 6 (12%) <0.01 Absent 29 (58%) 44 (88%) DISCUSSION The present study demonstrated a significant association between vitamin D deficiency and increased dental caries experience as well as a higher prevalence of recurrent oral ulcers in children aged 6–12 years. These findings align with accumulating evidence suggesting, vitamin D has an integral role in maintaining both hard and soft oral tissues. Children with lower serum 25(OH)D levels in study had markedly higher dmft/DMFT scores, consistent with the results of previous investigations conducted in diverse populations. 7 , 14 , 22 A meta-analysis conducted by Li and colleagues in 2023 reported that children with vitamin D deficiency had a 22% greater likelihood of developing dental caries (relative risk = 1.22, 95% CI: 1.18–1.25), supporting the link between higher serum 25(OH)D levels and reduced caries risk. 12 Similarly, Buzatu et al. 13 and Hujoel 14 emphasized that inadequate vitamin D intake is risk factor for both primary and permanent dentition. In another large-scale review, Mahmood et al. 15 demonstrated that low maternal vitamin D during pregnancy doubled the risk of early childhood caries, indicating that deficiency may affect enamel development even before tooth eruption. Vitamin D promotes calcium and phosphate absorption and stimulates the expression of dentin and enamel matrix proteins crucial for mineralisation. 8 Deficiency results in hypomineralised enamel, which is more prone to acid dissolution and bacterial colonisation. Moreover, vitamin D has antimicrobial peptides such as cathelicidin and β-defensins, which inhibit cariogenic microorganisms including Streptococcus mutans and Lactobacillus spp. 10 , 11 It’s receptor (VDR) is expressed in odontoblasts, gingival cells, and salivary glands, and polymorphisms in the VDR gene have been associated with altered susceptibility to dental caries. 23 Vitamin D and Oral Mucosal Integrity - In addition to its role in hard-tissue protection, vitamin D contributes to mucosal immunity . It modulates cytokine expression by suppressing proinflammatory mediators, while upregulating anti-inflammatory cytokines. 16 , 17 This immunoregulatory action maintains mucosal integrity and reduces susceptibility to recurrent aphthous ulcers (RAUs). Studies by Akdeniz et al. 18 and Kurnatowska et al. 19 suggested significantly lower vitamin D levels in children with RAUs compared to controls, corroborating the current findings. Low vitamin D may impair epithelial regeneration and barrier function, predisposing individuals to chronic mucosal inflammation. Our results mirror those of Mukhtar et al. 17 who found that vitamin D-deficient children exhibited a significantly higher caries burden compared with vitamin D-sufficient peers. Likewise, a study by Manfredini et al. 24 revealed that vitamin D supplementation was associated with a reduction in caries incidence over a two-year follow-up period. However, some studies have shown inconsistent results. For example, a 2023 Egyptian cohort study found no significant association between vitamin D levels and caries experience, possibly due to confounding effects of fluoride exposure, diet, and oral hygiene practices. 25 These discrepancies underscore the multifactorial etiology of dental caries, where nutritional, microbial, behavioral, and socioeconomic factors interact. PUBLIC HEALTH IMPLICATIONS: The present study have important clinical and preventive implications. In India and other low-latitude countries, vitamin D deficiency remains highly prevalent despite abundant sunlight, largely due to urban lifestyles, indoor activities, and dietary insufficiencies. 26 The Comprehensive National Nutrition Survey (CNNS) reported that up to 25% of Indian children aged 10–19 years exhibit vitamin D deficiency. 27 Given that both caries and recurrent ulcers are preventable, periodic screening for vitamin D status could be integrated into routine pediatric dental examinations. Encouraging sunlight exposure, dietary modification, and fortification or supplementation could aid in improving oral and systemic health outcomes. 28 , 29 CONCLUSION In summary, this study reinforces vitamin D deficiency is significantly associated with higher caries experience and increased frequency of recurrent oral ulcers in children. These results highlight the importance of optimal vitamin D levels for both dental hard tissues and oral mucosal integrity. Integrating nutritional assessment into pediatric dental care and public-health vitamin D strategies could play a pivotal role in promoting holistic oral health among children. LIMITATIONS AND FUTURE DIRECTIONS The limitations include its cross-sectional design, which precludes causal inference, and the absence of detailed assessment of dietary intake or sun exposure. Future longitudinal and interventional studies should aim to determine optimal serum 25(OH)D thresholds for oral health benefits. Additionally, exploring VDR gene polymorphisms, salivary biomarkers, and the microbiome response to vitamin D supplementation may provide a more comprehensive understanding of its role in oral health. Declarations Funding: No funding was received for this study. Clinical Trial Registration: Clinical trial number: not applicable. Conflict of Interest: The authors declare no conflict of interest. Ethical Approval and accordance: The study protocol was approved by the Institutional Ethics Committee of Malla Reddy Institute of Dental Sciences. The research was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013 revision) for studies involving human participants. Consent to Participate: Written informed consent was obtained from parents/guardians before participation. Data Availability Statement The datasets generated and/or analysed during the current study are not publicly available due to institutional restrictions and participant confidentiality, but are available from the corresponding author on reasonable request. References Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266–81. Bikle DD. Vitamin D metabolism, mechanism of action, and clinical applications. Chem Biol. 2014;21(3):319–29. Cashman KD, et al. Vitamin D deficiency in Europe: pandemic? Am J Clin Nutr. 2016;103(4):1033–44. Kheiri B, et al. Global and regional prevalence of vitamin D deficiency in population: an updated meta-analysis. Front Nutr. 2023;10:1070808. Pal A, et al. Prevalence and correlates of vitamin D deficiency among children and adolescents from a nationally representative survey in India. Indian Pediatr. 2023;60(3):181–90. Dietrich T, et al. Association between serum concentrations of 25-hydroxyvitamin D3 and periodontal disease. Am J Clin Nutr. 2004;80(1):108–13. Khammissa RAG, et al. The role of vitamin D in oral health. S Afr Dent J. 2018;73(3):170–7. Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet. 2007;369(9555):51–9. Grant WB, Boucher BJ. Are Hill’s criteria for causality satisfied for vitamin D and periodontal disease? Dermatoendocrinol. 2010;2(1):30–6. Martineau AR, et al. Vitamin D supplementation and antimicrobial peptide expression. BMJ. 2017;356:i6583. Grant WB. Role of vitamin D in oral and systemic health. J Dent Res. 2019;98(4):351–8. Li X, et al. Correlation between vitamin D levels in serum and the risk of dental caries: a meta-analysis. BMC Oral Health. 2023;23:222. Buzatu R, et al. A systematic review of the relationship between serum vitamin D levels and caries in children. Dent J (Basel). 2024;12(4):117. Hujoel PP. Vitamin D and dental caries in controlled clinical trials: systematic review. Nutr Rev. 2013;71(2):88–97. Mahmood MK, et al. Association between prenatal vitamin D deficiency with dental caries: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2024;24:64. Liu PT, et al. Vitamin D-mediated regulation of the immune system. J Invest Dermatol. 2011;131(6):1167–74. Mukhtar A, et al. The influence of vitamin D levels on dental caries. Nutrients. 2023;16(11):1572. Akdeniz SS, et al. The association between recurrent aphthous stomatitis and vitamin D deficiency. J Oral Pathol Med. 2020;49(4):299–304. Kurnatowska I, et al. Vitamin D deficiency and recurrent aphthous stomatitis in children. Clin Nutr ESPEN. 2020;35:73–7. Thacher TD. The burden of vitamin D deficiency in Indian children: the time is right for vitamin D food fortification. Indian Pediatr. 2023;60(3):181–2. Sadeghi M, et al. Vitamin D supplementation and oral health outcomes in children: a systematic review. Int J Paediatr Dent. 2023;33(1):12–24. Schroth RJ, et al. Prenatal vitamin D and dental caries in infants. Pediatrics. 2016;137(1):e20152136. Zhang T, et al. Vitamin D receptor gene polymorphisms and susceptibility to dental caries: a meta-analysis. Arch Oral Biol. 2022;137:105386. Manfredini M, et al. Vitamin D supplementation and reduction in caries incidence: a prospective cohort study. Clin Oral Investig. 2022;26(9):5637–45. Mohamed R, et al. Association between serum vitamin D and dental caries in preschool children. BMC Oral Health. 2023;23:291. Pal A, et al. Prevalence and correlates of vitamin D deficiency among Indian children. Indian Pediatr. 2023;60(3):181–90. Thacher TD. The burden of vitamin D deficiency in Indian children. Indian Pediatr. 2023;60(3):181–2. Sadeghi M, et al. Vitamin D supplementation and oral health outcomes in children: a systematic review. Int J Paediatr Dent. 2023;33(1):12–24. Grant WB, Boucher BJ. Are Hill’s criteria for causality satisfied for vitamin D and periodontal disease? Dermatoendocrinol. 2010;2(1):30–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviews received at journal 04 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Reviews received at journal 25 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 09 Feb, 2026 Editor invited by journal 08 Feb, 2026 Submission checks completed at journal 07 Feb, 2026 First submitted to journal 07 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8685385","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589911627,"identity":"bfc23c91-91b6-411e-b341-e4a1360e6bb4","order_by":0,"name":"Neeharika Soorneedi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYHCDxMYHQJKHjxQtzQYgLWwkaElgkwBRBLWYM7A/fPBxzx05fvbktsqvOXYybAzMDx/dwKPFsoHH2HDGs2fGkj0P227LbksGOozN2DgHjxaDAzxs0jwHDiduuJHYdltyGzNQC1AEvxb2ZyAt9fuBWoolt9UTo4XBDKQlwUAisY3x47bDRGg5DPLLgcOGM848bJZm3Hach42ZkF+Otz988OHAYXn+9vSHH39uq7bnZ29++BifFgZmZDYPughBwPiDFNWjYBSMglEwYgAAFwFG4Q9+zp4AAAAASUVORK5CYII=","orcid":"","institution":"Malla Reddy Institute of Dental Sciences,Malla Reddy Vishwavidyapeeth","correspondingAuthor":true,"prefix":"","firstName":"Neeharika","middleName":"","lastName":"Soorneedi","suffix":""},{"id":589911628,"identity":"408e4105-e96f-43f5-9161-c36b1216e68b","order_by":1,"name":"Naga Supraja Atluri","email":"","orcid":"","institution":"Malla Reddy Institute of Dental Sciences,Malla Reddy Vishwavidyapeeth","correspondingAuthor":false,"prefix":"","firstName":"Naga","middleName":"Supraja","lastName":"Atluri","suffix":""},{"id":589911629,"identity":"3715776f-a4c9-4a5b-b7c4-112b615448e4","order_by":2,"name":"Vatsalya Kommalapati","email":"","orcid":"","institution":"Sibar Institute of Dental Sciences","correspondingAuthor":false,"prefix":"","firstName":"Vatsalya","middleName":"","lastName":"Kommalapati","suffix":""},{"id":589911631,"identity":"8a3ed079-aade-4866-8126-b5946835666a","order_by":3,"name":"Lakshmi Manojna Nachu","email":"","orcid":"","institution":"Vishnu Dental College","correspondingAuthor":false,"prefix":"","firstName":"Lakshmi","middleName":"Manojna","lastName":"Nachu","suffix":""},{"id":589911635,"identity":"5a4e6470-ac1b-4ee0-a064-d3aaec896ea0","order_by":4,"name":"Harika Rapala","email":"","orcid":"","institution":"GSL Dental College \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Harika","middleName":"","lastName":"Rapala","suffix":""},{"id":589911637,"identity":"70f67723-435b-454f-9cff-f2022bab2087","order_by":5,"name":"Raveen Teja Prathuri","email":"","orcid":"","institution":"GSL Dental College \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Raveen","middleName":"Teja","lastName":"Prathuri","suffix":""}],"badges":[],"createdAt":"2026-01-24 09:23:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8685385/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8685385/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102596297,"identity":"385f647d-72f7-4317-8f00-a32b58d512c3","added_by":"auto","created_at":"2026-02-13 12:15:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15048,"visible":true,"origin":"","legend":"\u003cp\u003eMean dmft/DMFT score by vitamin D status\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8685385/v1/eb3688fad55643360430bb0c.jpeg"},{"id":102596296,"identity":"bcbd6eb4-2f58-4661-bb9c-733d35089914","added_by":"auto","created_at":"2026-02-13 12:15:38","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":11448,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of recurrent oral ulcers (Vitamin D deficient group)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8685385/v1/b82b4b0aa9be91fcb21e81e2.jpeg"},{"id":102596298,"identity":"b38851cf-cdef-4a93-b114-b70141c37fae","added_by":"auto","created_at":"2026-02-13 12:15:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":542232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8685385/v1/2f8268d9-431a-45af-af60-f0d49fb862c4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of Vitamin D Deficiency with Caries Experience and Recurrent Oral Ulcers in Children: A Case-Control Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eVitamin D is a fat-soluble secosteroid that acts as a prohormone, playing a crucial role in calcium and phosphate regulation, skeletal development, and bone mineralization. In addition to its traditional function in maintaining bone health, vitamin D has been increasingly identified as a multifaceted regulator involved in modulating immune, endocrine, and epithelial system activities.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Vitamin D deficiency has emerged as a major global public health concern, with epidemiological data suggesting that nearly one billion individuals worldwide exhibit suboptimal serum concentrations of 25-hydroxyvitamin D [25(OH)D].\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The causes of hypovitaminosis D include limited sunlight exposure, darker skin pigmentation, clothing habits, inadequate dietary intake, and urban lifestyle patterns that restrict outdoor activity.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the context of oral health, vitamin D plays a crucial role in maintaining both hard and soft tissue integrity. It\u0026rsquo;s receptors (VDRs) are seen in oral epithelial cells, gingival fibroblasts, salivary glands, and dental pulp cells, indicating a regulatory role in local immune responses and tissue homeostasis.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Adequate vitamin D levels facilitate calcium absorption and promote enamel and dentin mineralisation, thereby improving the resistance of teeth to acid demineralisation and caries formation.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Vitamin D enhances innate immune defense by upregulating the expression of antimicrobial peptides, including cathelicidin and β-defensins. These peptides exhibit potent bactericidal activity against cariogenic microorganisms such as \u003cem\u003eStreptococcus mutans\u003c/em\u003e and \u003cem\u003eLactobacillus\u003c/em\u003e spp., thereby contributing to oral microbial homeostasis..\u003csup\u003e10,11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMultiple clinical studies and meta-analyses have reported an inverse association between vitamin D levels and the occurrence of dental caries in pediatric populations. Li et al.\u003csup\u003e12\u003c/sup\u003e reported that children with serum 25(OH)D levels below 20 ng/mL had higher caries experience, with a pooled risk ratio of 1.22 compared to vitamin D-sufficient children. Similarly, Buzatu et al.\u003csup\u003e13\u003c/sup\u003e and Hujoel\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e confirmed that hypovitaminosis D constitutes a modifiable risk factor for both primary and permanent dentitions. Prenatal vitamin D levels have shown to influence early childhood caries, highlighting the nutrient\u0026rsquo;s role in enamel development even before tooth eruption.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlso, vitamin D has been implicated in maintaining the integrity of oral mucosa. The active form, 1,25-dihydroxy-vitamin D, modulates cytokine production, suppresses proinflammatory mediators (e.g., IL-6, TNF-α), and enhances anti-inflammatory cytokines (e.g., IL-10), thereby contributing to mucosal immune tolerance.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Deficiency may therefore predispose to mucosal inflammation and recurrent aphthous ulcers (RAUs), one of the most common oral lesions in children.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Several reports, including those by Akdeniz et al.\u003csup\u003e20\u003c/sup\u003e and Kurnatowska et al.\u003csup\u003e21\u003c/sup\u003e have found decreased vitamin D levels in patients with RAUs than healthy controls, suggesting a possible pathophysiologic link.\u003c/p\u003e \u003cp\u003eHowever, while separate relation of vitamin D deficiency with dental caries and with recurrent oral ulcers have been studied, the dual impact of vitamin D status on both conditions within same pediatric cohort remains under-explored. Understanding this relationship is relevant in regions like India, as vitamin D deficiency is common among children despite abundant sunlight.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHence, this case\u0026ndash;control study was designed to assess the association between serum vitamin D levels, dental caries experience, and recurrent oral ulcers in children aged 6\u0026ndash;12 years. Identifying such links can help integrate nutritional assessment\u0026mdash;particularly vitamin D screening\u0026mdash;into pediatric dental care and contribute to holistic preventive strategies for oral health.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e A study was carried out on 100 children of 6\u0026ndash;12 years old after obtaining the written informed consent from parents. Fifty vitamin D\u0026ndash;deficient children (serum 25(OH)D\u0026thinsp;\u0026lt;\u0026thinsp;20 ng/mL) constituted the case group, and fifty vitamin D\u0026ndash;sufficient children (\u0026ge;\u0026thinsp;30 ng/mL) formed the control group. Children with systemic diseases or on vitamin D supplements were excluded. Serum vitamin D levels were measured using chemiluminescent immunoassay. Dental caries were recorded using dmft/DMFT index, and data on recurrent oral ulcers were collected via parental questionnaire. Analysis of data was done using SPSS v26. Independent t-test and chi-square test were applied, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eChildren with low serum vitamin D levels had significantly more dental caries and higher prevalence of recurrent oral ulcers compared with vitamin D-sufficient peers (Table 1) (Figure 1) (Figure 2). These findings imply that vitamin D has a dual protective role in both \u003cstrong\u003etooth mineralisation\u003c/strong\u003e as well as \u003cstrong\u003eoral mucosal health\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Table 2).\u003c/p\u003e\n\u003cp\u003eTable 1. Serum Vitamin D levels and caries experience\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVitamin D Deficient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVitamin D Sufficient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMean Vitamin D (ng/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e15.6 \u0026plusmn; 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e32.4 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMean dmft/DMFT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5.12 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2.48 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Association between vitamin D status and recurrent oral ulcers\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOral Ulcers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeficient (n=50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSufficient (n=50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e21 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e29 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e44 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study demonstrated a significant association between vitamin D deficiency and increased dental caries experience as well as a higher prevalence of recurrent oral ulcers in children aged 6\u0026ndash;12 years. These findings align with accumulating evidence suggesting, vitamin D has an integral role in maintaining both hard and soft oral tissues. Children with lower serum 25(OH)D levels in study had markedly higher dmft/DMFT scores, consistent with the results of previous investigations conducted in diverse populations.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA meta-analysis conducted by Li and colleagues in 2023 reported that children with vitamin D deficiency had a 22% greater likelihood of developing dental caries (relative risk\u0026thinsp;=\u0026thinsp;1.22, 95% CI: 1.18\u0026ndash;1.25), supporting the link between higher serum 25(OH)D levels and reduced caries risk.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Similarly, Buzatu et al.\u003csup\u003e13\u003c/sup\u003e and Hujoel\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e emphasized that inadequate vitamin D intake is risk factor for both primary and permanent dentition. In another large-scale review, Mahmood et al.\u003csup\u003e15\u003c/sup\u003e demonstrated that low maternal vitamin D during pregnancy doubled the risk of early childhood caries, indicating that deficiency may affect enamel development even before tooth eruption.\u003c/p\u003e \u003cp\u003eVitamin D promotes calcium and phosphate absorption and stimulates the expression of dentin and enamel matrix proteins crucial for mineralisation.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Deficiency results in hypomineralised enamel, which is more prone to acid dissolution and bacterial colonisation. Moreover, vitamin D has antimicrobial peptides such as cathelicidin and β-defensins, which inhibit cariogenic microorganisms including \u003cem\u003eStreptococcus mutans\u003c/em\u003e and \u003cem\u003eLactobacillus spp.\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e It\u0026rsquo;s receptor (VDR) is expressed in odontoblasts, gingival cells, and salivary glands, and polymorphisms in the VDR gene have been associated with altered susceptibility to dental caries.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eVitamin D and Oral Mucosal Integrity -\u003c/b\u003e In addition to its role in hard-tissue protection, vitamin D contributes to \u003cb\u003emucosal immunity\u003c/b\u003e. It modulates cytokine expression by suppressing proinflammatory mediators, while upregulating anti-inflammatory cytokines.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This immunoregulatory action maintains mucosal integrity and reduces susceptibility to \u003cb\u003erecurrent aphthous ulcers (RAUs).\u003c/b\u003e Studies by Akdeniz et al.\u003csup\u003e18\u003c/sup\u003e and Kurnatowska et al.\u003csup\u003e19\u003c/sup\u003e suggested significantly lower vitamin D levels in children with RAUs compared to controls, corroborating the current findings. Low vitamin D may impair epithelial regeneration and barrier function, predisposing individuals to chronic mucosal inflammation.\u003c/p\u003e \u003cp\u003eOur results mirror those of Mukhtar et al.\u003csup\u003e17\u003c/sup\u003e who found that vitamin D-deficient children exhibited a significantly higher caries burden compared with vitamin D-sufficient peers. Likewise, a study by Manfredini et al.\u003csup\u003e24\u003c/sup\u003e revealed that vitamin D supplementation was associated with a reduction in caries incidence over a two-year follow-up period. However, some studies have shown inconsistent results. For example, a 2023 Egyptian cohort study found no significant association between vitamin D levels and caries experience, possibly due to confounding effects of fluoride exposure, diet, and oral hygiene practices.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e These discrepancies underscore the multifactorial etiology of dental caries, where nutritional, microbial, behavioral, and socioeconomic factors interact.\u003c/p\u003e\n\u003ch3\u003ePUBLIC HEALTH IMPLICATIONS:\u003c/h3\u003e\n\u003cp\u003eThe present study have important clinical and preventive implications. In India and other low-latitude countries, vitamin D deficiency remains highly prevalent despite abundant sunlight, largely due to urban lifestyles, indoor activities, and dietary insufficiencies.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The Comprehensive National Nutrition Survey (CNNS) reported that up to 25% of Indian children aged 10\u0026ndash;19 years exhibit vitamin D deficiency.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Given that both caries and recurrent ulcers are preventable, periodic screening for vitamin D status could be integrated into routine pediatric dental examinations. Encouraging sunlight exposure, dietary modification, and fortification or supplementation could aid in improving oral and systemic health outcomes.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn summary, this study reinforces vitamin D deficiency is significantly associated with higher caries experience and increased frequency of recurrent oral ulcers in children. These results highlight the importance of optimal vitamin D levels for both dental hard tissues and oral mucosal integrity. Integrating nutritional assessment into pediatric dental care and public-health vitamin D strategies could play a pivotal role in promoting holistic oral health among children.\u003c/p\u003e\n\u003ch3\u003eLIMITATIONS AND FUTURE DIRECTIONS\u003c/h3\u003e\n\u003cp\u003eThe limitations include its cross-sectional design, which precludes causal inference, and the absence of detailed assessment of dietary intake or sun exposure. Future longitudinal and interventional studies should aim to determine optimal serum 25(OH)D thresholds for oral health benefits. Additionally, exploring VDR gene polymorphisms, salivary biomarkers, and the microbiome response to vitamin D supplementation may provide a more comprehensive understanding of its role in oral health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and accordance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Ethics Committee of Malla Reddy Institute of Dental Sciences. The research was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013 revision) for studies involving human participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from parents/guardians before participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to institutional restrictions and participant confidentiality, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHolick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBikle DD. Vitamin D metabolism, mechanism of action, and clinical applications. Chem Biol. 2014;21(3):319\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCashman KD, et al. Vitamin D deficiency in Europe: pandemic? Am J Clin Nutr. 2016;103(4):1033\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKheiri B, et al. Global and regional prevalence of vitamin D deficiency in population: an updated meta-analysis. Front Nutr. 2023;10:1070808.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePal A, et al. Prevalence and correlates of vitamin D deficiency among children and adolescents from a nationally representative survey in India. Indian Pediatr. 2023;60(3):181\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDietrich T, et al. Association between serum concentrations of 25-hydroxyvitamin D3 and periodontal disease. Am J Clin Nutr. 2004;80(1):108\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhammissa RAG, et al. The role of vitamin D in oral health. S Afr Dent J. 2018;73(3):170\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet. 2007;369(9555):51\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant WB, Boucher BJ. Are Hill\u0026rsquo;s criteria for causality satisfied for vitamin D and periodontal disease? Dermatoendocrinol. 2010;2(1):30\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartineau AR, et al. Vitamin D supplementation and antimicrobial peptide expression. BMJ. 2017;356:i6583.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant WB. Role of vitamin D in oral and systemic health. J Dent Res. 2019;98(4):351\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, et al. Correlation between vitamin D levels in serum and the risk of dental caries: a meta-analysis. BMC Oral Health. 2023;23:222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuzatu R, et al. A systematic review of the relationship between serum vitamin D levels and caries in children. Dent J (Basel). 2024;12(4):117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHujoel PP. Vitamin D and dental caries in controlled clinical trials: systematic review. Nutr Rev. 2013;71(2):88\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmood MK, et al. Association between prenatal vitamin D deficiency with dental caries: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2024;24:64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu PT, et al. Vitamin D-mediated regulation of the immune system. J Invest Dermatol. 2011;131(6):1167\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukhtar A, et al. The influence of vitamin D levels on dental caries. Nutrients. 2023;16(11):1572.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkdeniz SS, et al. The association between recurrent aphthous stomatitis and vitamin D deficiency. J Oral Pathol Med. 2020;49(4):299\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurnatowska I, et al. Vitamin D deficiency and recurrent aphthous stomatitis in children. Clin Nutr ESPEN. 2020;35:73\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThacher TD. The burden of vitamin D deficiency in Indian children: the time is right for vitamin D food fortification. Indian Pediatr. 2023;60(3):181\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi M, et al. Vitamin D supplementation and oral health outcomes in children: a systematic review. Int J Paediatr Dent. 2023;33(1):12\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchroth RJ, et al. Prenatal vitamin D and dental caries in infants. Pediatrics. 2016;137(1):e20152136.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang T, et al. Vitamin D receptor gene polymorphisms and susceptibility to dental caries: a meta-analysis. Arch Oral Biol. 2022;137:105386.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManfredini M, et al. Vitamin D supplementation and reduction in caries incidence: a prospective cohort study. Clin Oral Investig. 2022;26(9):5637\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed R, et al. Association between serum vitamin D and dental caries in preschool children. BMC Oral Health. 2023;23:291.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePal A, et al. Prevalence and correlates of vitamin D deficiency among Indian children. Indian Pediatr. 2023;60(3):181\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThacher TD. The burden of vitamin D deficiency in Indian children. Indian Pediatr. 2023;60(3):181\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi M, et al. Vitamin D supplementation and oral health outcomes in children: a systematic review. Int J Paediatr Dent. 2023;33(1):12\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant WB, Boucher BJ. Are Hill\u0026rsquo;s criteria for causality satisfied for vitamin D and periodontal disease? Dermatoendocrinol. 2010;2(1):30\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Vitamin D, Calcium homeostasis, Immune regulation, Hypovitaminosis D","lastPublishedDoi":"10.21203/rs.3.rs-8685385/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8685385/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVitamin D plays a critical role in maintaining calcium homeostasis and modulating immune responses, both of which are fundamental to oral and dental health. Recent research indicates that vitamin D deficiency may contribute to an increased susceptibility to dental caries and recurrent aphthous ulcers in pediatric populations.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo evaluate the association between serum vitamin D levels, dental caries experience, and recurrent oral ulcers in children aged 6\u0026ndash;12 years.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA case-control study was conducted among 100 children. Fifty children with clinically diagnosed vitamin D deficiency (serum 25(OH)D\u0026thinsp;\u0026lt;\u0026thinsp;20 ng/mL) formed the case group, and 50 healthy children with sufficient vitamin D levels (\u0026ge;\u0026thinsp;30 ng/mL) served as controls. Dental caries experience was recorded using the dmft/DMFT index, and history of recurrent oral ulcers was documented using a structured questionnaire. Independent t-test and chi-square test were applied for statistical analysis, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean serum vitamin D levels were significantly lower in cases (15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 ng/mL) than in controls (32.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1 ng/mL; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).The mean dmft/DMFT score was higher among deficient children (5.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4) compared to controls (2.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Recurrent oral ulcers were reported in 42% of vitamin D\u0026ndash;deficient children versus 12% in controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eVitamin D deficiency shows a significant correlation with greater dental caries experience and a higher occurrence of recurrent oral ulcers among children. Periodic screening for vitamin D levels may aid in preventing these oral conditions.\u003c/p\u003e","manuscriptTitle":"Association of Vitamin D Deficiency with Caries Experience and Recurrent Oral Ulcers in Children: A Case-Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 12:15:33","doi":"10.21203/rs.3.rs-8685385/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-06T13:07:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T08:44:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T03:50:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37187572592033605671649526109880080298","date":"2026-03-05T03:31:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22941688959990064900279623681289671573","date":"2026-03-01T19:52:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T07:09:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319315007982156532807516637884254577905","date":"2026-02-24T03:50:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290200353058476230457058792368044155717","date":"2026-02-12T01:19:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T06:46:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92124597230697848029500726402920628771","date":"2026-02-10T06:29:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T17:30:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-09T17:21:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-08T13:35:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-07T10:23:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-07T10:12:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26ff120d-85ce-478f-b67b-edf7d66db2b9","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-09T04:08:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 12:15:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8685385","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8685385","identity":"rs-8685385","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}