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 Table of Contents 
Year : 2020  |  Volume : 9  |  Issue : 8  |  Page : 3991-3993  

Association of severe early childhood caries with salivary ferritin

Department of Pedodontics and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India

Date of Submission02-Jan-2020
Date of Decision11-Mar-2020
Date of Acceptance03-Apr-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Mebin George Mathew
Department of Pedodontics and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_9_20

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Aim: To evaluate salivary ferritin levels in children with severe early childhood caries (ECC). Materials and Methods: One hundred twenty participants were split into a study group that consisted of 60 children with severe ECC (dmft ≥5) and a control group that was free of caries. Both groups were age and gender-matched. Saliva was collected from both groups. Salivary ferritin was assessed using chemiluminescence microparticle immunoassay. The data obtained were statistically analyzed. Results: Salivary ferritin levels were higher in children with severe ECC (159.53 ± 18.65 μg/dl) compared to children with no caries (92.16 ± 12.91 μg/dl) and a highly significant statistical difference was seen (P < 0.001). Conclusions: Salivary ferritin levels were high with children having severe ECC.

Keywords: Candida albicans, early childhood caries, iron deficiency anemia, salivary ferritin

How to cite this article:
Rajkumaar J, Mathew MG. Association of severe early childhood caries with salivary ferritin. J Family Med Prim Care 2020;9:3991-3

How to cite this URL:
Rajkumaar J, Mathew MG. Association of severe early childhood caries with salivary ferritin. J Family Med Prim Care [serial online] 2020 [cited 2021 Apr 11];9:3991-3. Available from: https://www.jfmpc.com/text.asp?2020/9/8/3991/293114

  Introduction Top

One of the highest prevailing infectious diseases involving children today is dental caries. Caries in children less than 71 months is known as early childhood caries (ECC) and has been considered as a leading public health epidemic.[1] Severe ECC (S-ECC) is any manifestation of smooth surface caries in children younger than 36 months of age.[2],[3] From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5)surfaces constitutes S-ECC. ECC has been found to produce detrimental psychological and emotional effects often leading to change of diet and nutrition, unaesthetic appearance, and reduction in social activities and school attendance.[1],[3]

Saliva is a complex fluid present that encompasses the tissues of the oral cavity. It consists of various organic and inorganic substances that are required for host protection and can act as a biomarker for detection of dental caries.[4]

Iron is a vital mineral for the human body; it is crucial to maintain intrinsic iron equilibrium since iron derangement in the body can advance into multiple clinical illnesses. Ferritin is the storage protein for iron, which releases/liberates it in a restrained manner for essential cellular processes.[4] Though ECC has been associated with iron deficiency anemia and serum ferritin,[5] no study has been done to see the association of salivary ferritin (SF) with ECC or S-ECC. Hence, this study was initiated to determine the level of SF in S-ECC patients and to assess its reliability as a biomarker for S-ECC.

  Materials and Methods Top

Study was approved by Review Board of Saveetha Dental College, Chennai, India. The study population consisted of patients visiting the Department of Pediatric Dentistry. Inclusion criteria for the study included children aged 4 years with with S-ECC (decayed, missing or filled ≥5) who never underwent dental treatment and did not take any medicines, which could alter ferritin levels and were not medically compromised. Sixty children with S-ECC who fulfilled the inclusion criteria were included in the study group. The control group consisted of 60 children who were free of caries and were age and gender-matched to the test group.

Parents were explained in both English and local languages about the study in detail and were given a chance to clear their doubts and informed consent was obtained. Until sample selection, the children were asked to avoid consuming food or liquids and doing oral hygiene. Children were asked to accumulate saliva in their mouths and transfer into a plastic vessel, which was then transported to a centrifuge tube. Centrifugation was done at 4°C at 13000 rpm for 20 minutes. SF was estimated using chemiluminescence microparticle immunoassay. Blood samples were collected to determine hematological variables. Data were analyzed using Statistical Package for the Social Sciences (SPSS).

  Results Top

A total of 120 children participated in the study, each group consisting of 60 children. There was no statistically significant difference between groups regarding physical characteristics [Table 1]. The mean age of cases was 4.2 ± 0.9 years and that of controls was 4.1 ± 0.7 years [Table 1]. There was a highly significant statistical difference in SF levels between the study (159.53 ± 18.65 μg/dl) and control groups (92.16 ± 12.91 μg/dl), the data which is presented in [Table 2]. [Table 3] showed that there was significant differences in Hb and mean corpuscular volume (MCV) between two groups.
Table 1: Sample distribution in the study and control group

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Table 2: Salivary ferritin values in the study and control group

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Table 3: Comparison of blood variables between study and control group

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  Discussion Top

An increase in ECC was seen in many countries and significantly affected the socially disadvantaged populations.[1] The association of ECC with various other health problems such as malnutrition, gastrointestinal disorders, pain, and insomnia has made it a major public health problem.[6],[7] The use of saliva as a biomarker for ECC is becoming popular as it is noninvasive, safe, and easy to handle and transport, easy to collect, and economical.[4]

Iron is an essential element, which is required for several biological processes. Iron deficiency is the most common and widespread form of nutritional deficiency worldwide, estimating that one third of world population could be suffering from iron deficiency anemia (IDA).[8] However, the relationship between ECC and anemia is controversial. Sadeghi et al.[9] and Clarke et al.[10] found an inverse relationship between ECC and SF. This was in contrast to Schroth et al.[11] who found significantly low serum levels in children with S-ECC. However, a systematic review by Hashemi et al.[7] concluded that ECC is a risk factor for anemia, thus connecting two major public health problems. The results of blood variables in our study suggest that children in the study could be suffering from IDA, which could be due to tooth pain, which could have restricted dietary consumption.

The role of SF with caries has not yet been explored. Jagannathan et al.[5] stated that SF is a prognostic marker for IDA. This could be due to the fact that conservation of iron for iron-deficient anemic patients was occurring through iron-dependent enzymatic functions. The incidence of oral candidiasis has been found to be markedly increased in iron deficiency anemia patients as the oral epithelial cells are susceptible to damage by Candida albicans (C. albicans), a fungus which has been associated with ECC. C. albicans uses ferritin as an iron source, which could be the reason for high SF levels in SECC but not in the control group. High ferritin levels in cells of the oral epithelium are directly associated to destruction caused by C. albicans.[5],[12],[13] Recent studies have shown that iron is at the center of interaction for C.albicans and ferritin plays a key role in it.[14] C. albicans has shown multiple approaches to acquire iron from the host and ferritin has promoted the process.[15] Children with high C. albicans count have five times higher chance to develop ECC compared to those without C. albicans,[16] suggesting potent cariogenic characteristics, which lead to the development and progression of S-ECC.[17] A recent study has shown that microbial accumulation occurs on preformed crowns, which can lead to development of new carious lesions.[18] Various studies have shown that iron deficiency can be a risk factor for ECC.[19],[20] Iron has a cariostatic effect [20] but the lack of iron due to anemia and C. albicans could hinder the outcome. Thus, C. albicans could be a link in the relationship between ECC and IDA and help in solving these two conditions. Hence, the importance of oral hygiene and proper nutrition should be taught to parents and children by not only dentists but also by primary care physicians and pediatricians. Children with S-ECC often find difficulty in eating due to pain, which leads to malnutrition and even lead to failure to grow and thrive.

This study explored the levels of SF in children with S-ECC. The exact mechanism in which ferritin rises is still not clear. However, the results of this study might suggest that C. albicans may play a role in the association between ECC and IDA. This has never been reported before and only research in this direction in the future will help us to understand this better.

  Conclusions Top

The results of our study highlight that a relationship exists between SF and S-ECC. Dental caries experience was directly proportional to SF levels. Within the limitations of our study, we can conclude that a relationship exists between SF and S-ECC. Further studies will be needed to understand the mechanisms that determine high SF levels.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Angelopoulou MV, Shanti SD, Gonzalez CD, Love A, Chaffin J. Association of food insecurity with early childhood caries. J Public Health Dent 2019;79:102-8.  Back to cited text no. 1
Early childhood caries: IAPD Bangkok declaration. Int J Paediatr Dent 2019;29:384-6.  Back to cited text no. 2
Nakayama Y, Ohnishi H, Mori M. Caries Res 2019;53:268-74.  Back to cited text no. 3
Hemadi AS, Huang R, Zhou Y, Zou J. Salivary proteins and microbiota as biomarkers for early childhood caries risk assessment. Int J Oral Sci 2017;10;9:e1.  Back to cited text no. 4
Jagannathan N, Thiruvengadam C, Ramani P, Premkumar P, Natesan A, Sherlin HJ. Salivary ferritin as a predictive marker of iron deficiency anemia in children. J Clin Pediatr Dent 2012;37:25-30.  Back to cited text no. 5
Venkatesh Babu NS, 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.  Back to cited text no. 6
Hashemi A, Bahrololoomi Z, Salarian S. Relationship between early childhood caries and anemia: A systematic review. Iran J Ped Hematol Oncol 2018;8:126-38.  Back to cited text no. 7
Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet 2016;387:907-16.  Back to cited text no. 8
Sadeghi M, Darakhshan R, Bagherian A. Is there an association between early childhood caries and serum iron and serum ferritin levels? Dent Res J 2012;9:294-8.  Back to cited text no. 9
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. 10
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
Almeida RS, Brunke S, Albrecht A, Thewes S, Laue M, Edwards JE, et al. The hyphal-associated adhesion and invasion of Candida albicans mediates iron acquisition from host ferritin. PLoS Pathog 2008;4:217-25.  Back to cited text no. 12
Fletcher Mather J, Lewis MJ, Whiting G. Mouth lesions in iron deficiency anemia relationship to Candida albicans in saliva and to impairment of lymphocyte transformation. J Infect Dis 1975;131:44-50.  Back to cited text no. 13
Fourie R, Kuloyo OO, Mochochoko BM, Albertyn, J, Pohl CH. Iron at the centre of Candida albicans interactions. Front Cell Infect Microbiol 2018;8:185.  Back to cited text no. 14
Duval C, Macabiou C, Garcia C, Lesuisse E, Camadro J-M, Auchère F. The adaptive responseto iron involves changes in energetic strategies in the pathogen Candida albicans. Microbiologyopen 2020;9:e970.  Back to cited text no. 15
Xiao J, Huang X, Alkhers N, Alzamil H, Alzoubi S, Wu TT, et al. Candida albicans and early childhood caries: A systematic review and meta-analysis. Caries Res 2018;52:102-12.  Back to cited text no. 16
Fakhruddin KS, Perera Samaranayake L, Egusa H, Chi Ngo H, Panduwawala C, Venkatachalam T, et al. Candida biome of severe early childhood caries (S-ECC) and its cariogenic virulence traits. J Oral Microbiol 2020;12:1724484.  Back to cited text no. 17
Mathew MG, Samuel SR, Soni AJ, Roopa KB. Evaluation of adhesion of Streptococcus mutans, plaque accumulation on zirconia and stainless steel crowns, and surrounding gingival inflammation in primary molars: Randomized controlled trial. Clin Oral Invest 2020. doi: 10.1007/s00784-020-03204-9.  Back to cited text no. 18
Bansal K, Goyal M, Dhingra R. Association of severe early childhood caries with iron deficiency anemia. J Indian Soc Pedod Prev Dent 2016;34:36-42.  Back to cited text no. 19
[PUBMED]  [Full text]  
Koppal PI, Sakri MR, Akkareddy B, Hinduja DM, Gangolli RA, Patil BC. Iron deficiency in young children: A risk marker for early childhood caries. Int J Clin Pediatr Dent 2013;6:1-6.  Back to cited text no. 20


  [Table 1], [Table 2], [Table 3]


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