Type of the Paper (Article Journal of Baghdad College of Dentistry, Vol. 34, No. 4 (2022), ISSN (P): 1817-1869, ISSN (E): 2311-5270 1 Research Article Salivary vitamin D3 in relation to dental caries among pregnant women in Baghdad city Maimonah Tariq Abed1*, Nada Jafer MH Radhi2 1 Master Student, ministry of health, Baghdad. 2 Assist Professor. Department of Pediatric and Preventive Dentistry, College of Dentistry, University of Baghdad, Iraq. *Correspondence Email: maymuna.hassan1901@codental.uobaghdad.edu.iq Abstract: Background: Vitamin D deficiency is a problem for pregnant women, and it affects general and oral health. This problem increases as vitamin D requirements increase during pregnancy. This study was conducted among pregnant women in urban and rural areas in order to assess the relation between salivary vitamin D3 and dental caries. Materials and methods: In this comparative cross-sectional study, all women participating were at- tending the primary Health Care Centers in Baghdad city in AL-Karkh sector, they were with age ranged from (15-44) years old. The total number 90 pregnant women in the second tri- mester only which include: The first group consists of (45) pregnant women attendance seeking dental treatment in urban areas, The second group consists of (45) pregnant women attendance seeking dental treatment in rural areas. Collection of the unstimulated saliva was done according to Tenovuo (1996). After that the clinical examination of Dental caries DMFT/S was performed according to the world health organization in (2013). Results: The findings of this study revealed that the percentage of pregnant women in the age range of 15– 29 years was higher in the rural areas than in the urban areas. While those in the age range of 30–44 years were higher in the urban areas. Regarding the age, the percentage of dental caries experience was increased with age. Regarding the area, the percentage of dental caries was higher in the urban area than in the rural area. The highest mean value of DMFT was found in the urban area, with no significant differences. While the highest mean value of DMFS was found in the rural areas with no statistically significant difference, except the FS, where was statistically significant and higher in the urban areas. The mean value of salivary vitamin D3 was found to be higher in rural areas than in urban areas, although statistically non-significant. The correlation between dental caries experience (DMFT/S) and salivary vitamin D3 level was statistically non-significant among urban and rural pregnant women, except in the urban areas where the DMFS was found to be significant with salivary vitamin D3. Conclusions: According to the results of this study, there was a non-significant negative correlation between dental caries and salivary vitamin D3 among pregnant women in urban and rural areas. Except, the correlation between dental caries experience by surfaces and salivary vitamin D3 was negative and significant among urban pregnant women. Keywords: Dental caries, Pregnant women, Vitamin D3. Introduction ''Dental caries is a localized, chemical dissolution of a tooth surface brought about by metabolic ac- tivity in a microbial deposits (a dental biofilm) overing a at any given time''(1). It affects people of all ages, races, and genders (2). This process was aided by a number of bacteria, especially streptococcus mutans, which are highly cariogenic. Dental caries, on the other hand, is not thought to be a classic infectious disease; rather, it is seen as a multifactorial disease involving a variety of risk factors. It occurs when there is an environmental disturbance inside the oral cavity, which is supplemented by other external influ- ences (3). Received date: 15-01-2022 Accepted date: 26-02-2022 Published date: 15-12-2022 Copyright: © 2022 by the authors. The article is published under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/li censes/by/4.0/). https://doi.org/10.26477/ jbcd.v34i4.3271 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://doi.org/10.26477/jbcd.v34i3.3214 https://doi.org/10.26477/jbcd.v34i3.3214 J. Bagh. Coll. Dent. Vol. 34, No. 4. 2022 Abed and Radhi 2 Vitamin D plays an important role in calcium absorption and musculoskeletal health regulation(4). It has also been linked to cardiovascular health, immunological response, wound healing, and prevention of cancer (5-9). Teeth are mineralized organs surrounded by alveolar bone and formed by enamel, dentin, and cemen- tum, which are three distinct hard tissues. While tooth mineralization is similar to skeletal mineralization, if mineral metabolism is disrupted, failures similar to those seen in bone tissue will occur.Vitamin D is essential for bone and tooth mineralization, and when levels aren't controlled, it can result in the "rachitic tooth," a deficient and hypomineralized organ that's prone to fracture and decay (10,11). Two mechanisms for vitamin D's effect on caries have been proposed. Vitamin D is thought to work through the vitamin D receptor, and polymorphisms in this gene have been linked to tooth decay(12). Low vitamin D levels can promote topical demineralization of teeth, similar to its known effect on bone, by lowering calcium and phosphate ions concentrations. Vitamin D can influence caries through immuno- logical factors like cathelicidins(13,14). Iraqi study worked among nutritional rickets children revealed the dmfs was lower than control group(15).Pregnancy is a stressful disorder that causes significant changes in metabolic and physiological functions extent(16). As a result, the most significant physiological and hor- monal changes in a woman's life occur during pregnancy(17). And one of the focus areas for these changes is the oral cavity(18). Pregnant women are more likely to develop tooth decay for a variety of reasons, in- cluding a decrease in salivary pH in the oral cavity, sweet food preferences, and a lack of focus on oral health(16,18,19). Unfortunately, becoming pregnant can lead to unhealthy behaviors. These behaviors may include a preference for certain food groups at the expense of others, as well as snacking on harmful foods, such as candy, on a regular basis in order to relieve nausea, Increased consumption of processed carbohydrates will give a favorable environment for cariogenic bacteria, potentially increasing the risk of tooth decay in certain people (20). In Iraq, research compared pregnant women to non-pregnant women and found that pregnant women had more dental caries than non-pregnant women (21-25). As far as, no Iraqi study has been carried out to measure the level of salivary vitamin D3 and its relation to dental caries among pregnant women in urban and rural areas. Therefore, this study was conducted. We suggest the null hypothesis that there is no relation between the salivary vitamin D3 level and dental caries. Materials and Methods The present research was carried out between 13th of April and the 8th of September. The pregnant women were examined during this time; the saliva samples were collected. Before starting the study, approval was achieved from the Ministry of Health for women examinations Verbal consents were ob- tained from all women and the ethical committee had accepted the study's protocol in University of Baghdad, College of Dentistry. In this comparative cross sectional study, all women participating in this study were attending the primary Health Care Centers in Baghdad city in AL-Karkh sector, They were with the age ranged from (15-44) years. The total number 90 pregnant women in the second trimester only which include. The first group consists of (45) pregnant women attendance seeking dental treatment in urban areas, The second group consists of (45) pregnant women attendance seeking dental treatment in rural areas. Collection of the un-stimulated saliva were done according to Tenovuo.(26)The saliva is al- lowed to accumulate in the floor of the mouth and the pregnant woman spits out it into the disposable graduated test tube. Saliva samples were taken to a lab at a primary health care center and centrifuged for 15-20 minutes at (3000) rpm. The clear samples was collected by a micropipette and stored into eppen- drouftubes at (-20 C) in a deep freeze until the time of biochemical analysis. After collection of saliva the clinical examination of Dental caries DMFT/S was performed according to WHO.(27) The concentration of salivary vitamin D3 was detected by an enzyme linked immune-sorbent assay (ELISA) using a salivary vitamin D3 kit. J. Bagh. Coll. Dent. Vol. 34, No. 4. 2022 Abed and Radhi 3 Exclusion criteria: The pregnant women should be: • Free from any systemic diseases • Not receiving any multivitamins, calcium and vitamin D3 supplements • Non smokers Statistical analysis: The Statistical Package for Social Science was used to conduct the statistical analysis (SPSS version -22, Chicago, Illionis, USA). The mean and standard error were calculated using descriptive analysis with a simple chart bar. The difference between two groups was tested using inferential analysis as an inde- pendent sample T test parametric test. For the linear correlation between two quantitative variables, the Pearson correlation parametric test was used. Results The results showed that the percentage of pregnant women in the age range of 15–29 years was higher in the rural areas than in the urban areas. While those in the age range of 30–44 years were higher in the urban areas. As shown in the table 1. Table 1: The distribution of pregnant women according to the age and area Area Age (years) Urban Rural 15-29 30 44.78% 37 55.22% 30-44 15 65.21% 8 34.78% Regarding the descriptive and statistical tests of age by area, the mean value of age in urban pregnant women was found to be 26.20 and the mean value of age in rural pregnant women was found to be 23.4 as shown in table (2). Table 2: Descriptive and statistical tests of pregnant women in the second trimester regarding age by area Pregnancy Area Mean SE 2nd trimester Urban 26.20 1.041 Rural 23.41 0.774 The results of the distribution of caries among pregnant women by age and area were reported that pregnant women in the age range of 30–44 were found to have higher percentages of caries than those in the age range of 15–29. Regarding area, the percentage of caries was higher in the urban area than in the rural area table 3. Table 3: Distribution of Caries status by age and area Vars. N. % Age (years) 15-29 53 79.10 30-44 22 95.65 Area Urban 41 91.11 Rural 34 75.56 J. Bagh. Coll. Dent. Vol. 34, No. 4. 2022 Abed and Radhi 4 The results demonstrated that the highest mean value of DMFT was found in the urban area, with no significant differences as shown in the table 4. Table 4: Descriptive and statistical tests of dental caries experience (DMFT) among pregnant women by area Pregnancy Area Urban Rural Mean ±SE Mean ±SE T test P value 2nd tri- mester DT 0.696 0.234 1.614 0.440 1.864 0.066 MT 0.717 0.169 0.614 0.244 0.352 0.726 FT 2.065 0.435 1.068 0.267 1.935 0.056 DMFT 3.478 0.499 3.295 0.640 0.226 0.821 Concerning dental caries experience by surfaces the results show that the highest mean values of DMFS were found in the rural areas with no statistically significant difference, except the FS, where was sta- tistically significant and higher in the urban areas. Descriptive and statistical tests of caries experience by surfaces and areas are shown in Table 5. Table 5: Descriptive and statistical tests of dental caries experience (DMFS) among pregnant women by area. Pregnancy Area Urban Rural Mean ±SE Mean ±SE T test P value 2nd trimester DS 2.304 0.993 4.864 1.746 1.289 0.201 MS 3.543 0.829 3.068 1.219 0.325 0.746 FS 3.543 0.721 1.750 0.517 2.005 0.048* DMFS 9.391 1.555 9.682 2.484 0.100 0.921 *=significant statistically at p<0.05. In reference to vitamin D3 the findings revealed that the mean values and standard error of salivary Vitamin D3 were found to be higher in rural areas than in urban areas, although statistically non-significant, as shown in Figure 1. Figure 1: Descriptive and statistical tests of Vitamin D3 among area. 10 15 20 Urban Rural S.Vit D3 Urban Rural M e a n J. Bagh. Coll. Dent. Vol. 34, No. 4. 2022 Abed and Radhi 5 The correlation of salivary vitamin D3 with all variables in the urban and rural areas was negative and weak, but not significant. Except in the urban areas, the DMFS was found to be significant with vitamin D3 as shown in table 6. Table 6: Correlation between dental caries experience by teeth, dental caries experience by surfaces and Sali- vary vitamin D3. Area VitD3 r P value Urban DT -0.186 0.216 MT -0.111 0.463 FT -0.184 0.220 DMFT -0.285 0.055 DS -0.240 0.108 MS -0.109 0.472 FS -0.205 0.171 DMFS -0.306 0.038* Rural DT 0.051 0.742 MT -0.172 0.264 FT -0.097 0.531 DMFT -0.071 0.647 DS -0.073 0.639 MS -0.172 0.264 FS -0.051 0.744 DMFS -0.146 0.344 Discussion This study looked at the relation between salivary vitamin D3 and dental caries among pregnant women in urban and rural areas. Regarding the personal characteristics, most pregnant women were un- der 30 years of age. Dental caries was measured by DMFT/S and they were grouped according to WHO.(27)In terms of age, the present study's findings revealed that dental caries increase with age, which was consistent with Iraqi study.(28) this could be explained by the fact that age is the major risk factor for dental caries.(29) also be related to the accumulative and irreversible nature of dental caries.(30)Regarding to the area where the percentage of dental caries was higher in the urban area and this disagreed with study by Siddiqui et al. (2018) where the highest percentage of dental caries was in the rural areas. (31)And this may be related to the low level of vitamin D3 in urban areas in this study. As a result, a deficiency in this vitamin causes a variety of issues, including changes in the composition and mineralization of teeth and bones. (32) Regarding to the caries experience by teeth and surfaces where the DMFT higher in urban pregnant women and this could be related to the FT mean value which was higher than other components of DMFT and this good indication that the women visit the dentist for filling. While the DMFS was higher in the rural pregnant women and this may be related to the DS mean value where was higher than other J. Bagh. Coll. Dent. Vol. 34, No. 4. 2022 Abed and Radhi 6 components of DMFS. Rural women's negative attitudes toward dental treatment during pregnancy re- lated to a reduced use of dental services and a high frequency of untreated dental caries.(33)despite this the dental caries is remains a multifactorial disease.(34)In reference to Vitamin D3. The findings reported that the mean value in the rural areas was higher than those in the urban areas, but statistically non-significant. This may be explained by their exposure to the sun more than those in the urban areas, the sun is considered the main source of vitamin D3.(35) Regarding the correlation between salivary vita- min D3 and dental caries experience in urban pregnant women, there was a statistically significant nega- tive correlation between DMFS and salivary vitamin D3, and this agreed with Botelho et al. (36). This could be explained by that when the vitamin D3 level decreases, it leads to an increase in dental caries because it is essential for bone and tooth mineralization, and when levels aren't controlled, it can result in hypomineralized teeth and decay.(37,38) Conclusion The findings of the present study concluded that there were negative correlation of dental caries with salivary vitamin D3 levels among pregnant women in urban and rural areas. Pregnant women need more education and encouragement for oral health care and visiting the dentist during pregnancy. Conflict of interest: None. 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Endocrine reviews, 35, 1-34. بغداد مدينة في الحوامل النساء لدى االسنان بتسوس وعالقته اللعابي 3 د فيتامين العنوان: الشيخ راضي جعفر ندى, عبد طارق ميمونة الباحثون: المستخلص: هذه أجريت. الحمل أثناء د فيتامين متطلبات زيادة مع المشكلة هذه تزداد. الفم وصحة العامة الصحة على ويؤثر ، الحامل للمرأة مشكلة د فيتامين نقص:الخلفية .األسنان وتسوس اللعابي 3 د فيتامين بين العالقة تقييم أجل من والريفية الحضرية المناطق في الحوامل النساء بين الدراسة قطاع في بغداد مدينة في األولية الصحية الرعاية مراكز على يترددن المشاركات النساء جميع كانت ، المقارنة المقطعية الدراسة هذه في:العمل وطرق المواد ( 45) من تتكون األولى المجموعة -: تشمل والتي فقط الثاني الفصل في حامل سيدة 90 اإلجمالي العدد بلغ . سنة( 44-15) بين أعمارهن وتراوحت ، الكرخ تم . الريفية المناطق في أسنان عالج عن تبحث حامل امرأة( 45) من الثانية المجموعة وتتكون ، الحضرية المناطق في األسنان عالج عن تبحث حامل امرأة العالمية الصحة لمنظمة وفقًا DMFT / S األسنان لتسوس السريري الفحص إجراء تم ذلك بعد (. 1996) عام Tenovuo لـ وفقًا المحفز غير اللعاب جمع .(2013) عام كانت بينما . الحضرية المناطق في منها الريفية المناطق في أعلى كانت سنة 29-15 العمرية الفئة في الحوامل النساء نسبة أن الدراسة هذه نتائج كشفت: النتائج بالمنطقة يتعلق فيما . العمر تقدم مع تزداد األسنان تسوس لتجربة المئوية النسبة فإن ، بالعمر يتعلق فيما . الحضرية المناطق في أعلى سنة 44-30 العمرية الفئة مع ، الحضرية المنطقة في DMFT قيمة متوسط أعلى على العثور تم. الريفية المناطق في منها الحضرية المناطق في أعلى األسنان تسوس نسبة كانت ، ، إحصائياً به معتد فرق وجود عدم مع الريفية المناطق في DMFS متوسط قيمة أعلى على العثور تم حين في. إحصائية داللة ذات فروق وجود عدم المناطق في أعلى لتكون اللعابية3د لفيتامين المتوسطة القيمة على العثور تم. الحضرية المناطق في وأعلى إحصائية داللة ذات كانت حيث ، FS باستثناء فيتامين ومستوى (DMFT / S) األسنان تسوس تجربة بين العالقة كانت. غيرإحصائية داللة ذات أنها من الرغم على ، الحضرية المناطق في منها الريفية بفيتامين معنوي DMFS أن وجد حيث الحضرية المناطق باستثناء ، والريفية الحضرية المناطق في الحوامل النساء بين غيرإحصائية داللة ذات اللعابي3د .اللعابي3د الحضرية المناطق في الحوامل النساء بين اللعابي 3د وفيتامين األسنان تسوس بين معنوية غير سلبية عالقة هناك كان ، الدراسة هذه لنتائج وفقا :االستنتاجات .الحضرية المناطق في الحوامل النساء بين ومعنوية سالبة اللعابي3د وفيتامين األسطح طريق عن األسنان تسوس تجربة بين العالقة كانت ، عدا فيما . والريفية