Hindawi

BioMed Research International

Volume 2021, Article ID 9992451, 10 pages
https://doi.org/10.1155/2021/9992451

Research Article
The Association between Nutritional Alterations and Oral
Lesions in a Pediatric Population: An Epidemiological Study

Angela Pia Cazzolla ,1 Michele Di Cosola ,1 Andrea Ballini ,2,3 Luigi Santacroce ,4,5
Roberto Lovero ,6 Nunzio Francesco Testa ,1 Vitantonio Lacarbonara ,7
Annarosa De Franco ,7 Giuseppe Troiano ,1 Stefania Cantore ,4
Mariasevera Di Comite,7 Riccardo Nocini ,8 Lorenzo Lo Muzio ,1 Vito Crincoli ,7
and Mario Dioguardi 1
1
Department of Clinical and Experimental Medicine, Università degli Studi di Foggia, Foggia 71122, Italy
2
School of Medicine, University of Bari “Aldo Moro”, Bari 70124, Italy
3
Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
4
Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari 70124, Italy
5
Department of Clinical Disciplines, School of Technical Medical Sciences, University of Elbasan “A. Xhuvani”,
Elbasan 3001, Albania
6
AOU Policlinico Consorziale di Bari-Ospedale Giovanni XXIII, Clinical Pathology Unit, Policlinico University Hospital of Bari,
Bari 70124, Italy
7
Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari “Aldo Moro”, Bari 70124, Italy
8
Section of Ear Nose and Throat (ENT), Department of Surgical Sciences, Dentistry, Gynecology and Pediatric, University of Verona,
Verona 37126, Italy

Correspondence should be addressed to Andrea Ballini; [email protected]

and Stefania Cantore; [email protected]

Received 30 September 2021; Accepted 21 October 2021; Published 29 October 2021

Academic Editor: Iole Vozza

Copyright © 2021 Angela Pia Cazzolla et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

The oral conditions of an individual are the result of different factors, including the subject’s genotype, oral hygiene habits, the type
of diet, and lifestyle, such as smoking. Nutrition in the first years of life can affect dental health for a long time. To prevent mouth
diseases, it is also important to eliminate unfavorable eating behaviour and to amplify protective ones. Eating habits, especially in
pediatric age, are an easily modifiable and controllable factor, and diet, in addition to influencing the health of the oral cavity, plays
a fundamental role in systemic health. Indeed, a sugar-rich diet can lead to conditions, such as diabetes, being overweight, and
obesity. The present research was an epidemiological study, with the aim of highlighting some of the associations between
nutrition and oral health. In particular, we studied those lesions of hard and soft tissues that are diagnosed most frequently by
dentists: caries, enamel hypoplasia, periodontal disease, and aphotoxic lesions and their associations with nutritional deficiencies
and excesses including proteins, vitamin A, vitamin D, B vitamins, and iron and calcium minerals. To perform this study, we
recruited 70 patients from the pediatric and orthodontic clinics, aged between 3 and 15 years (y), with mean age of 10.4 y.o. The
study was conducted by providing a questionnaire to pediatric patients’ (supported from their parents or guardians) on
individual eating habits, followed by an accurate oral cavity specialistic examination. The nutritional data were processed by
using Grana Padano Observatory (OGP) software, freely provided online by the OPG. The statistical tests performed were the
chi-square (χ2 ) for independence, and Cramér’s V test was used to evaluate the associations between eating habits and oral
pathologies. The results showed that certain nutritional vitamin deficiencies and nutritional excesses were associated with
definite oral pathologies.
2 BioMed Research International

1. Introduction informed consent was obtained from the patients’ parents or

guardians to publish this paper.
The oral conditions of an individual are the result of various The inclusion criteria were as follows:
factors, such as the subject’s genotype, oral hygiene habits
(i.e., toothbrushing), type of diet, and any smoking habits (i) Age from 3 to 15 years, with a mean age of 10.4
[1–3]. Unhealthy eating habits adversely affect both oral years, a standard deviation of 2.75, and a median
and general health. Nutrition in the early years of life can (value that leaves 50% on the left and 50% on the
influence long-term dental health [4–7]. Foods that are right of a series of data sorted in a nondecreasing
harmful to general health can also damage teeth and vice way) of 10
versa. Research has been focusing on the effect of nutrition (ii) Gender: both male and female
on mucous membranes and hard dental tissues, which can
be a systemic effect or a local effect, such as the effect of (iii) The absence of situations requiring special diets
acidic foods and drinks on the teeth, which can be responsi-
ble for dental erosion in patients with good oral hygiene The exclusion criteria include all situations that required
[8–11]. Changing one’s eating habits and lifestyle can lead specific diets, including diabetes and hereditary metabolic
to the improvement of oral and systemic conditions [12–15]. diseases such as phenylketonuria, glycogenosis, galactosemia,
To prevent mouth diseases, it is, therefore, advisable to celiac disease, severe food intolerances, and chronic inflam-
change the modifiable factors, eliminating unfavorable ones matory bowel diseases.
and amplifying the protective ones. Eating habits represent During the first phase of the study, we administered a
an easily modifiable and controllable factor, knowing that questionnaire to patients that inquired about their eating
diet, in addition to influencing the health of the oral cavity, habits. To obtain more reliable answers, we typically asked
plays a fundamental role in systemic health, acting also in for the help of the parents. For the purposes of this research,
the autologous self-renewal stem cell niche, related to the oral the software freely available online, following registration at
mucous membrane trophism [16, 17]. It is well known that a the website http://www.osservatorio.granapadano.it (OGP),
diet rich in sugars can lead to conditions, such as diabetes, was used (i) to evaluate if the patients’ food intake was
being overweight, and obesity [18]. The present research appropriate and (ii) to provide them personalized nutri-
was an epidemiological study, with the aim of highlighting tional advice, highlighting any nutritional deficiencies or
some of the associations between nutrition and oral health. excesses caused by their ordinary diet [19].
In particular, our attention was directed towards those The first phase, that of the interview, allowed an active
lesions of hard and soft tissues more frequently diagnosed healthcare professional- (dentist) patient relationship,
by a dental practitioner: caries, enamel hypoplasia, peri- strengthened by the emotional elements linked to nutrition
odontal disease, and aphthous lesions. The nutrients we (nourishing means, first of all, “taking care” of someone),
assessed for excesses or deficits in pediatric patients, based and the subsequent phase of delivery of the press of the
on the frequency of intake of certain foods, were proteins, nutritional advice involved communicating things never said
vitamin A, vitamin D, vitamins of group B, and the minerals before, and do this in a way where the patient feels empathy
iron and calcium. Our main questions were as follows: (1) from the healthcare professional, facilitated by the “counsel-
“What eating habits can influence the onset of these sta- ing” approach. Through this, thanks to the healthcare pro-
tuses?” and (2) “At what point can a correct diet act on the fessional, the patient becomes the protagonist of the
maintenance of a good trophism of the oral mucous mem- change process, acquiring awareness of their own eating
branes and on the formation and safeguarding of dental habits and lifestyle. This was a useful and powerful tool of
structures?” improving compliance and achieving expected results more
easily.
For the calculation of nutritional needs, the software
2. Materials and Methods refers to age groups expressed as follows:

This research was conducted in collaboration with Elbasan (i) From 3 to 6 years, male and female
University “A. Xhuvani” (School of Technical Medical Sci- (ii) From 7 to 10 years, male and female
ences), Elbasan, Albania, a dental community cabinet (Sor-
riso & Benessere—Ricerca e Clinica SRL, Bari, Italy), the (iii) From 11 to 15 years, male and female
University of Bari Aldo Moro (Italy), and the University (iv) From 11 to 15 years, female
of Foggia (Italy).
To perform this study, we recruited 70 pediatric patients Data collection was conducted with the help of an elec-
from the pediatric and orthodontic private practice clinics. tronic questionnaire to evaluate the frequency of weekly or,
The Institutional Ethics Committee of the Faculty of Techni- alternatively, monthly intake of the most common foods of
cal Medical Sciences of Elbasan “Aleksandër Xhuvani” the interviewee’s diet, whose nutrient content was “weighed.”
approved the application to conduct the clinical trial in the The data collected by the questionnaire were as follows:
faculty (protocol identification: INTL_ALITCOOP/Dent-
Path/2020_SLK). Informed consent was obtained from all (i) Essential personal data for the inclusion of the sub-
subjects’ parents or guardians involved in the study. Written ject within a specific cluster
BioMed Research International 3

(ii) The weight and height for calculating the body mass (v) Information reported on the possible appearance of
index (BMI) aphthous lesions
(iii) The abdominal circumference (the weight, height, We collected the data acquired through the OGP soft-
and abdominal circumference data can be reported ware, the anamnesis, and the physical examination, and, in
by the subject or detected by the healthcare profes- particular, for each of the 70 patients, we assessed the pres-
sional, and the software automatically checks ence or absence of the following:
“therefore if the healthcare professional decides to
detect the data, the corresponding item must be (i) Excesses of proteins, carbohydrates, lipids, saturated
ticked”) fats, and cholesterol
(iv) Lifestyle data (hours spent close to television and/or (ii) Deficiencies of carbohydrates, lipids, vitamin C,
at personal computer/notebook for free time, smok- vitamin A, vitamin D, calcium, iron, and omega 3
ing habits, physical activity, etc.)
(iii) The presence of four types of lesions: caries, gingivi-
Before moving on to the analysis of individual foods, we tis, enamel hypoplasia, and aphthosis
asked for the weekly frequency of intake of certain food fam-
ilies (side dishes, fruits, dairy products, meats, and salami). The above elements were the variables available to us to
The collected data were compared with those collected dur- conduct a study on the association between nutritional alter-
ing the administration of the detailed questionnaire, in order ations and oral lesions.
to reduce the risk of underestimating/overestimating the The statistical analysis between the variables was per-
consumption of relevant foods. formed with the chi-square test (χ2 ) for the evaluation of
During the detailed interview, a number was inserted for the significance of the association or independence. The
each food that responds to weekly or monthly assumptions; if degree of association between the nominal variables was ver-
the food in question was not taken, the corresponding space ified with Cramér’s V index (C).
was left blank. The single intake refers to the quantity of food,
expressed in grams, which represents the standard portion
for age and sex, which was automatically extrapolated from
3. Results
the dedicated software. When the questionnaire reports more The results showed the following deficiencies in the diet
than one food in the same row (for example, beans, lentils, (expressed as percentages): calcium (67%), vitamin D
fava beans, chickpeas, and boiled/canned cooked soybeans), (66%), iron (56%), vitamin A (30%), carbohydrates (23%),
it was necessary to sum the intake of the individual foods omega 3 (20%), lipids (17%), and vitamin C (16%). The
and report their total value in the box with the relative excessive amounts of nutrients introduced with diet were
frequency. cholesterol (64%), saturated fats (63%), proteins (58.56%),
Once the data were acquired through the questionnaire, lipids (44%), and carbohydrates (20%) (Tables 1(a)–1(c)).
it was possible to proceed to the oral cavity specialist patho- As reported in Table 2, it shows the average ages, and most
logical anamnesis. We asked patients if they suffered from of the alterations (9 out of 13) were present at a slightly lower
particular mucous diseases, almost always not detectable at average age. The excesses of carbohydrates and saturated fats
the time of the visit, as in the case of vesicular-bullous and the deficiencies of carbohydrates, lipids, vitamin C, vita-
lesions or aphthous lesions. We investigated the onset of min D, calcium, iron, and omega 3 were present in subjects
any burning or painful symptoms associated with the inges- with a lower average age compared with those who were not
tion of particular foods and the possible remission of the characterized by such alterations. Only the excesses of pro-
symptoms when avoiding the intake. teins, lipids, and cholesterol and deficiency of vitamin A were
The third step consisted of the objective examination found in patients with a higher average age compared to
of the patients’ oral cavity to assess the presence of caries, patients who did not have these alterations.
earlier restorative treatments, endodontic therapies, dental From this, we consider that the diet tended to improve
erosions, missing teeth, enamel hypoplasia, and calcifica- with advancing growth. Clearly, we are talking about chil-
tions, as well the gingival status and the presence of dren who, having an age greater than 3 years, begin to select
plaque/calculus. foods of their preference, avoiding quality (Table 3).
Therefore, the information available for each patient Regarding the sample’s oral lesions, the following were
included the following: found:
(i) The nutritional status (i) 50% had caries
(ii) The nutritional deficiencies or excesses (ii) 34% had periodontal disease, represented by mild or
(iii) The clinical history moderate gingivitis

(iv) The current presence of caries, already restored (iii) 33% had hypoplasia of the enamel
teeth, enamel hypoplasia, enamel erosion, gingivitis, (iv) 20% reported the more or less frequent onset of
and periodontal disease canker sores
4 BioMed Research International

Table 1 Table 2

(a) Population and distribution of subjects (total = 70), with an (a) Ratio of the number of individuals with the presence (P) or
excess of each of the variables considered absence (A) of excesses for each nutritional variable into the
sample size (70 patients). Upper (U.L.) and lower (L.L.) limits can
Excess n % differ, within the sample population
Protein 41 58.6
Excess A (n) P (n) U.L. L.L.
Lipids 31 44.3
Protein 0.41 0.59 0.70 0.47
Carbohydrates 14 20.0
Lipids 0.56 0.44 0.56 0.33
Saturated fats 44 62.9
Carbohydrates 0.80 0.20 0.29 0.11
Cholesterol 45 64.3
Saturated fats 0.71 0.63 0.74 0.52
Cholesterol 0.36 0.64 0.76 0.53
(b) Population and distribution of subjects (total = 70), with a
deficiency of each of the variables considered
(b) Ratio of the number of individuals with the presence (P) or
Deficiency n % absence (A) of deficiencies for each nutritional variable into the
Carbohydrates 16 22.9 sample size (70 patients). Upper (U.L.) and lower (L.L.) limits can
Lipids 12 17.1 differ, within the sample population
Vitamin C 4 5.7 Deficiency A (n) P (n) U.L. L.L.
Vitamin A 21 30.0 Carbohydrates 0.77 0.23 0.33 0.13
Vitamin D 46 65.7 Lipids 0.83 0.17 0.26 0.08
Calcium 47 67.1 Vitamin C 0.94 0.06 0.14 0.02
Iron 39 55.7 Vitamin A 0.70 0.30 0.41 0.19
Omega 3 14 20.1 Vitamin D 0.34 0.66 0.77 0.55
Calcium 0.33 0.67 0.78 0.56
(c) Population and distribution of subjects (total = 70), with a Iron 0.44 0.56 0.67 0.44
deficiency of each of the variables considered
Omega 3 0.80 0.20 0.29 0.11
Oral lesions n %
Caries 35 50.0 (c) Ratio of the number of individuals with the presence (P) or
Gingivitis 24 34.2 absence (A) of specific oral lesions to the sample size (70
patients). Upper (U.L.) and lower (L.L.) limits can differ, within
Hypoplasia 23 32.9 the sample population
Aphthae 14 20.0
Oral lesions A (n) P (n) U.L. L.L.
Caries 0.50 0.50 0.62 0.38
Gingivitis 0.66 0.34 0.45 0.23
The rejection region for the χ2 test of independence
Hypoplasia 0.67 0.33 0.44 0.22
(Table 4), between the explanatory variable (presence or
absence of nutritional alteration) and dependent variable Aphthae 0.80 0.20 0.29 0.11
(presence or absence of a lesion), showed dependence
between the following:
(2) Excess carbohydrates and caries (C = 0:35)
(i) Caries and excess lipids and carbohydrates
(3) Vitamin C deficiency and periodontal disease
(ii) Periodontal disease and excess saturated fats and
(C = 0:34)
carbohydrates
(4) Iron deficiency and periodontal disease (C = 0:28)
(iii) Periodontal disease and deficient vitamin C and
iron (5) Excess lipids and caries (C = 0:258)
(iv) Enamel hypoplasia and deficient vitamin D (6) Excess of saturated fat and periodontal disease
(C = 0:254)
(v) Aphthae and deficient vitamin A
(7) Carbohydrate deficiency and periodontal disease
Through Cramér’s V index, these associations were clas- (C = 0:251)
sified based on their degree of significance (Table 5).
(8) Vitamin D deficiency and enamel hypoplasia
(1) Vitamin A deficiency and canker sores (C = 0:37) (C = 0:24)
BioMed Research International 5

Table 3: Patients’ mean age in the presence (P) or absence (A) of Murty et al. reported in their study that saliva played a
each nutritional alterations and oral lesions. The table also very important role in the prevention and development of
highlights whether the alteration characterizes a trail of greater or tooth decay in enamel [35]. The study involved a compari-
lower age (P major/minor). son between two samples, one with caries-resistant subjects
and the other with caries-sensitive subjects, showing that
A P P major/minor
lipid concentration in the parotid saliva was higher in sub-
Excess jects with caries susceptibility [35].
Protein 9.93 10.12 +0.19 Special cases are represented by the baby bottle syn-
Lipids 9.31 10:97 +1.66 drome: in the context of pathologies affecting deciduous
Carbohydrates 10.09 9.86 -0.23 teeth, we refer to the baby bottle tooth decay syndrome,
Saturated fats 10.08 10.02 -0.05 which derives from incorrect use of the bottle [37–39].
For instance, letting the child fall asleep with the bottle
Cholesterol 9.92 10.11 +0.19
by sucking milk or other sweet substances, or leaving the
Deficiency child for hours with a pacifier soaked in cariogenic sub-
Carbohydrates 10.09 9.88 -0.22 stances (i.e., honey or sugar), is strongly discouraged as
Lipids 10.26 9.00 -1.26 it often causes the formation of caries so extensive as to
Vitamin C 10.18 7.75 -2.43 reduce the tooth to a small dark stump with consequent,
Vitamin A 9.98 10.19 +0.21 painful abscesses, leading in this way to extracting the
Vitamin D 10.42 9.85 -0.57 decayed dental elements. Statistically, children under 3
years of age are the most affected (in particular the incisor
Calcium 10.48 9.83 -0.65
area) [40–43].
Iron 10.10 10.00 -0.10 For the association between canker sores and vitamin A
Omega 3 10.57 7.93 -2.64 deficiency, the control function of vitamin A in the keratini-
Oral lesions zation, maturation, and hydration of mucous membranes
Caries 10.20 9.89 -0.31 and skin was implicated [44–47]. Various studies confirm
Gingivitis 9.98 10.17 +0.19 the association between aphthosis and nutritional deficien-
Hypoplasia 10.11 9.91 -0.19 cies; however, they principally concerned deficiencies of
iron, folate, and vitamins of the B group [48–51].
Aphthae 10.05 10.00 -0.05
In the literature, we did not find clinical studies in
which the association between the onset of aphthosis and
the low vitamin A diet was highlighted [52–55]. In our
4. Discussion findings, this association was established. Only Scully and
Boyle describe, in 1992, in a review, the role of vitamin
The results obtained in this study regarding the association A in the prevention of potentially malignant lesions by
between nutritional alterations and oral manifestations have indicating the protective effects but do not describe their
found confirmation in various studies [19–21]. Several stud- pathogenic mechanisms [56].
ies have shown the existence of an association between Associations between vitamin C and D deficit and peri-
nutritional alterations and tooth decay: studies that have odontal disease are described in the literature [56–59]. In
evaluated the distribution of the body mass index (BMI) our study, only four patients demonstrated a deficit of vita-
and the D(3+4)MFT index in a sample of children and have min C (contained deficit), but all had a sustained degree of
compared the different regression models by analyzing the gingivitis [60, 61]. These were patients who had undergone
association between these two indices [22–24]. Chen et al. more than one oral hygiene session due to the increased sus-
in a cross-sectional study stated that an excess of fats does ceptibility to plaque buildup and inflammatory responses of
not predispose to caries [25], data confirmed by subsequent the gums that led to edema and bleeding on probing more
studies [26–28]. easily [62–64].
Bowen, on the other hand, reported how the significant Regarding the association between a high-fat diet and
presence of fats in the diet influenced cariogenicity, as fats periodontal disease, we can reiterate that, as adipose tissue
would increase the clearance of sugars in the oral environ- is a source of inflammatory cytokines, an increase in body
ment. It would also be conceivable that many fatty acids fat increases the risk of an increased inflammatory response
would exhibit a powerful antibacterial effect [24]; also, in periodontitis [65, 66]. Several studies have shown the
changes in the lipid levels and fatty acid composition could, association between obesity and periodontitis [67–69].
therefore, be associated with caries development [29–32]. Obesity is characterized by abnormal or excessive depo-
Earlier studies confirmed the association between caries sition of fat in the adipose tissue. The consequences go far
and a sugar diet in accordance with the results of our study beyond negative metabolic effects on health, causing an
[33–36]. Gerdin et al. in a study aimed at evaluating the increase in oxidative stress, which leads not only to endothe-
association between dental caries, body mass index, and lial dysfunction but also to negative effects in relation to
socioeconomic status in Sweden concluded that the preva- periodontitis, due to the increase in the inflammatory cyto-
lence of being overweight and having caries was (weakly) kines that are produced [70]. Thus, obesity appears to partic-
associated in Swedish children [33]. ipate in the multifactorial phenomenon of the causality of
6 BioMed Research International

Table 4: Chi-square test. Values rejecting the null hypothesis of independence supportive alternative association (∗).

(a)

Excess Protein Lipids Carbohydrates Saturated fats Cholesterol

∗ ∗
Caries 0.0589 4.6898 8.9286 0.2448 0.5600
Gingivitis 0.2323 0.0355 0.2536 4.5335∗ 0.0507
Hypoplasia 3.3226 0.3690 1.0361 0.0580 0.0130
Aphthae 0.5299 1.7514 1.8080 0.0153 0.0000

(b)

Deficiency Carbohydrates Lipids Vit. C Vit. A Vit. D Calcium Iron Omega 3

Caries 0.0000 3.6207 1.0606 0.0680 2.2826 1.6189 2.8371 3.2143
Gingivitis 4.4410∗ 0.3502 8.1313∗ 0.4348 1.3977 0.0038 5.5054∗ 0.5707
Hypoplasia 0.5804 0.0015 0.5651 0.2498 4.3395∗ 1.9193 0.1740 0.0648
Aphthae 1.6406 1.6092 0.0663 9.7959∗ 0.0159 1.0361 3.7055 2.7009

Table 5: Cramér’s V index values (∗ indicates significant association).

(a)

Excess Protein Lipids Carbohydrates Saturated fats Cholesterol

∗ ∗
Caries 0.0290 0.2588 0.3571 0.0591 0.0894
Gingivitis 0.0576 0.0225 0.0602 0.2545∗ 0.0269
Hypoplasia 0.2179 0.0726 0.1217 0.0288 0.0136
Aphthae 0.0870 0.1582 0.1607 0.0148 0.0000

(b)

Deficiency Carbohydrates Lipids Vit. C Vit. A Vit. D Calcium Iron Omega 3

Caries 0.0000 0.2274 0.1231 0.0312 0.1806 0.1521 0.2013 0.2143
Gingivitis 0.2519∗ 0.0707 0.3408∗ 0.0788 0.1413 0.0073 0.2804∗ 0.0903
Hypoplasia 0.0911 0.0046 0.0899 0.0597 0.2490∗ 0.1656 0.0499 0.0304
Aphthae 0.1531 0.1516 0.0308 0.3741∗ 0.0150 0.1217 0.2301 0.1964

periodontitis through an increase in the production of reac- last association between vitamin D deficiency and enamel
tive oxygen species [70, 71]. hypoplasia, we can confirm this strong association widely
Another association that emerged from our study was described in the literature [74]. Vitamin D is strongly impli-
between a low-iron diet and periodontal disease. Enhos cated as it is a direct protagonist of the deposition of calcium
et al. led a study aimed at assessing the periodontal health and phosphorus in the bones and teeth [75–78].
status in patients with iron deficiency anemia, through the Throughout physical/oral examinations and the study of
detection of ferritin levels in the crevicular fluid before and each patient’s medical records, we collected data regarding
after periodontal therapy and concluded that iron deficiency the presence of oral lesions.
was not a factor of direct risk for periodontal disease. There Statistical analysis confirmed many associations already
are, however, many other lesions associated with iron reported in literature so far, introducing new original data.
deficiency, such as atrophy of the lingual papillae, atrophic In this study, being a preliminary study, the results can be
glossitis, angular cheilitis, and hyposalivation [72]. used as a baseline data for future studies with similar study
Regarding the association we found between periodontal design. For the issues related to “excess carbohydrates and
disease and the low introduction of carbohydrates, the liter- caries,” “vitamin C deficiency and periodontal disease,”
ature does not provide us with much data. Merchant et al.’s and “vitamin D deficiency and enamel hypoplasia,” the asso-
study showed an inverse correlation between the intake of ciations already established were confirmed [79–82]. There-
whole grains and periodontitis [73]. Finally, regarding the fore, in these three specific investigations, our findings have
BioMed Research International 7

the role only to strengthen and confirm current concepts. In the manuscript. Angela Pia Cazzolla, Michele Di Cosola,
contrast, the issues related to “vitamin A deficiency and can- and Andrea Ballini contributed equally as co-first authors.
ker sores,” “iron deficiency and periodontal disease,” and Vito Crincoli and Mario Dioguardi contributed equally as
“carbohydrate deficiency and periodontal disease,” more co-last authors.
attractive results are introduced. In particular, association
between “vitamin A deficiency and canker sores” not only
confirmed but also showed a higher statistical significance. References
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