Abstract
Background
Given equivocal findings from existing nationally representative studies, the authors sought to determine associations between vitamin D levels and caries experience in US children using updated National Health and Nutrition Examination Survey data.
Methods
The authors used data from 2011-2016 National Health and Nutrition Examination Survey. Vitamin D status was assessed on the basis of the sufficiency thresholds of 50 and 75 nmol/L for serum 25-hydroxyvitamin D (25[OH]D) recommended by the Institute of Medicine (now National Academy of Medicine) and Endocrine Society, respectively. Caries experience was defined as the total number of decayed or filled tooth surfaces (dfs) and decayed, missing, or filled tooth surfaces (DMFS) and a binary measure of any dfs and DMFS. Associations between 25(OH)D and any or total dfs and DMFS were examined in children aged 2 through 5, 6 through 8, 9 through 11, and 12 through 18 years, using multivariable logistic and linear regression models after adjustment for covariates.
Results
Children aged 2 through 5 years with 25(OH)D above 75 nmol/L experienced fewer total dfs (β = –1.94; 95% CI, –3.60 to –0.28) than those with 25(OH)D below 75 nmol/L. Children 6 through 8 years with 25(OH)D above 75 nmol/L had lower presence of any dfs (odds ratio, 0.59; 95% CI, 0.36 to 0.95) than those with 25(OH)D below 75 nmol/L, and those with 25(OH)D above 50 nmol/L had lower presence of any DMFS (odds ratio, 0.38; 95% CI, 0.19 to 0.79) than those with 25(OH)D below 50 nmol/L. There were no associations of 25(OH)D status with either any or total DMFS in children 12 through 18 years
Conclusions
There were no consistent associations of 25(OH)D status with caries experience across age groups.
Practical Implications
Vitamin D status was not associated consistently with reduced caries experience.
Key Words
Abbreviation Key:
25(OH)D (25-hydroxyvitamin D), dfs (Decayed or filled teeth surfaces), DMFS (Decayed, missing, or filled tooth surfaces), IOM (Institute of Medicine), NA (Not applicable), NHANES (National Health and Nutrition Examination Survey), S-ECC (Severe early childhood caries)
,
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- Bailleul-Forestier I.
- Davideau J.L.
and hormone precursor
- Kulie T.
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- Hounshell J.
- Schrager S.
that promotes calcium and phosphate hemostasis, regulates cell maturation and differentiation, and plays a role in the innate immune system
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and prevention of numerous chronic, infectious, and skeletal and nonskeletal disease.
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,
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,
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,
,
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The American Academy of Pediatrics recommends a minimum daily intake of 400 international units of vitamin D for infants, children, and adolescents to maintain innate immunity and prevent disease.
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Vitamin D regulates serum calcium and phosphate.
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- Delgado A.S.
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Reduced amount of calcium or phosphate levels can modify the quality and quantity of enamel and dentin, which start developing earliest in primary teeth in utero during the second trimester,
with calcification of permanent teeth beginning at birth starting with the permanent first molars.
Teeth with defects, such as hypoplasia and hypocalcification, are at increased risk of caries formation as these disturbances can enhance the environment for colonization and adhesion of cariogenic bacteria to teeth.
,
- Almoudi M.M.
- Hussein A.S.
- Abu Hassan M.I.
- Schroth R.J.
,
- Hong L.
- Levy S.M.
- Warren J.J.
- Broffitt B.
,
,
- Reed S.G.
- Voronca D.
- Wingate J.S.
- et al.
,
- Nørrisgaard P.E.
- Haubek D.
- Kühnisch J.
- et al.
,
- Fatturi A.L.
- Menoncin B.L.
- Reyes M.T.
- et al.
,
- Ślebioda Z.
- Szponar E.
- Dorocka-Bobkowska B.
,
- Uwitonze A.M.
- Rahman S.
- Ojeh N.
- et al.
Vitamin D’s role in regulating the innate immune response
also may affect caries formation. Vitamin D can enhance antibacterial activity against various oral bacteria by stimulating antimicrobial peptides, such as cathelicidin and defensins.
- Ślebioda Z.
- Szponar E.
- Dorocka-Bobkowska B.
,
,
- Wang Q.
- Zhang W.
- Li H.
- et al.
,
Conversely, vitamin D deficiency can reduce host response to cariogenic bacteria.
- Almoudi M.M.
- Hussein A.S.
- Abu Hassan M.I.
- Schroth R.J.
- Tanaka K.
- Hitsumoto S.
- Miyake Y.
- et al.
,
- Singleton R.
- Day G.
- Thomas T.
- et al.
,
- Schroth R.J.
- Lavelle C.
- Tate R.
- Bruce S.
- Billings R.J.
- Moffatt M.E.K.
,
- Wagner Y.
- Heinrich-Weltzien R.
,
,
- Deane S.
- Schroth R.J.
- Sharma A.
- Rodd C.
,
- Schroth R.J.
- Jeal N.S.
- Kliewer E.
- Sellers E.A.
,
- Schroth R.J.
- Levi J.A.
- Sellers E.A.
- Friel J.
- Kliewer E.
- Moffatt M.E.K.
,
- Seminario A.L.
- Jumani K.
- Velan E.
- Scott J.M.
- Latimer J.
- Schroth R.J.
,
- Kim I.J.
- Lee H.S.
- Ju H.J.
- Na J.Y.
- Oh H.W.
,
- Schroth R.J.
- Rabbani R.
- Loewen G.
- Moffatt M.E.
,
- Gyll J.
- Ridell K.
- Öhlund I.
- Åkeson P.K.
- Johansson I.
- Holgerson P.L.
,
- Kühnisch J.
- Thiering E.
- Kratzsch J.
- et al.
,
- Williams T.L.
- Boyle J.
- Mittermuller B.A.
- Carrico C.
- Schroth R.J.
,
- Carvalho Silva C.
- Gavinha S.
- Manso M.C.
- et al.
and others not showing an association.
- Nørrisgaard P.E.
- Haubek D.
- Kühnisch J.
- et al.
,
- Seminario A.L.
- Jumani K.
- Velan E.
- Scott J.M.
- Latimer J.
- Schroth R.J.
,
- Kim I.J.
- Lee H.S.
- Ju H.J.
- Na J.Y.
- Oh H.W.
,
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
,
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
,
- Antonenko O.
- Bryk G.
- Brito G.
- Pellegrini G.
- Zeni S.N.
,
- Dudding T.
- Thomas S.J.
- Duncan K.
- Lawlor D.A.
- Timpson N.J.
Two existing cross-sectional studies (including 1
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
by K.H.) have evaluated associations between vitamin D status and caries using the National Health and Nutrition Examination Survey (NHANES) data. However, these data sets used nondentists for dental examinations and defined caries experience as the presence or absence of 1 or more teeth with active caries or restoration.
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
,
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
Thus, these studies were not able to model caries experience as a continuous variable; count the number of decayed, missing, or filled teeth or surfaces; or distinguish between tooth type or number. Furthermore, they evaluated participants aged 5 through 12 years
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
and 12 through 19 years,
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
excluding the youngest children, and used the Institute of Medicine (IOM) (now National Academy of Medicine) serum 25-hydroxyvitamin D (25[OH]D) threshold of 50 nmol/L.
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
,
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
Our study examines the association between vitamin D status and caries experience, determined via dental examinations conducted by dentists, in nationally representative samples of US children aged 2 through 18 years using NHANES 2011-2016.
Methods
Study design and population
- Dye B.A.
- Afful J.
- Thornton-Evans G.
- Iafolla T.
,
- Chen T.C.
- Parker J.D.
- Clark J.
- et al.
,
- Johnson C.L.
- Dohrmann S.M.
- Burt V.L.
- Mohadjer L.K.
Oral health examinations are conducted by licensed, trained, and calibrated dentists in mobile examination centers,
- Dye B.A.
- Afful J.
- Thornton-Evans G.
- Iafolla T.
and venous blood samples are taken using standardized protocols. For this study, we chose the data sets of 2011 through 2016 with total sample size of 29,902 participants, as they represent the newest released NHANES vitamin D data. A flowchart of study participant inclusion is depicted in the figure. As NHANES data sets are public access, this study was exempt from an institutional review board review.
Caries experience
- Dye B.A.
- Afful J.
- Thornton-Evans G.
- Iafolla T.
Analysis was stratified by primary and permanent teeth because the anatomy, progression of caries, and number of teeth differ in the primary
- Tickotsky N.
- Petel R.
- Araki R.
- Moskovitz M.
and permanent dentitions.
- Hummel R.
- Akveld N.A.E.
- Bruers J.J.M.
- van der Sanden W.J.M.
- Su N.
- van der Heijden G.J.M.G.
The main outcome variables for the analysis of primary dentition were the total number of decayed or filled tooth surfaces (dfs) and the presence (dfs ≥ 1) or absence (dfs = 0) of any caries experience, defined as at least 1 decayed or filled tooth surface.
Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016.
The main outcome variables for the analysis of permanent teeth were the total number of decayed, missing, or filled tooth surfaces (DMFS) and the presence (DMFS ≥ 1) or absence (DMFS = 0) of any caries experience, defined as at least 1 DMFS.
Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016.
Missing primary teeth were not included owing to the difficulty in differentiating between natural exfoliation and carious tooth extraction.
National Health and Nutrition Examination Survey (NHANES): Oral Health Examiners Manual.
Third molars and unerupted, congenitally missing, or supernumerary teeth also were not included. Analyses of primary teeth were stratified further by children aged 2 through 5, 6 through 8, and 9 through 11 years, and the analyses of permanent teeth were stratified by children aged 6 through 8, 9 through 11, and 12 through 18 years. Other NHANES oral health data sets have used similar age cutoffs.
Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016.
,
,
- Gupta N.
- Vujicic M.
- Yarbrough C.
- Harrison B.
Vitamin D measurements and thresholds
The National Academies Collection: reports funded by National Institutes of Health.
and the Endocrine Society defines sufficiency as 75 nmol/L and above.
- Holick M.F.
- Binkley N.C.
- Bischoff-Ferrari H.A.
- et al.
Vitamin D was also analyzed as a continuous variable for an increase in 1 nmol/L. Season of measurement of 25(OH)D was not available; thus, adjustment for seasonality was not possible.
Covariates
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
Total sugar consumption data from the first 24-hour dietary recall interview in NHANES was used in the analysis. Total sugar consumption as a percentage of energy intake was calculated as the total sugar intake divided by the total energy intake multiplied by 100 and categorized as 10% or less or more than 10% on the basis of the World Health Organization’s recommended threshold for sugar consumption at 10% of total energy intake.
In addition, the presence of a sealant, defined as having 1 or more teeth with pit-and-fissure sealants as assessed by a dentist during the oral health examination,
Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016.
,
- Griffin S.O.
- Wei L.
- Gooch B.F.
- Weno K.
- Espinoza L.
was included as an oral health measure.
Statistical analysis
- Chen T.C.
- Parker J.D.
- Clark J.
- et al.
We reported descriptive statistics including weighted percentages and means with corresponding 95% CIs.
,
- Schroth R.J.
- Rabbani R.
- Loewen G.
- Moffatt M.E.
,
- Slade G.D.
- Grider W.B.
- Maas W.R.
- Sanders A.E.
,
- Blostein F.A.
- Jansen E.C.
- Jones A.D.
- Marshall T.A.
- Foxman B.
We considered demographic confounding variables and caries risk factors as covariates in multivariable models similar to previously published studies.
- Kim I.J.
- Lee H.S.
- Ju H.J.
- Na J.Y.
- Oh H.W.
,
- Schroth R.J.
- Rabbani R.
- Loewen G.
- Moffatt M.E.
,
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
,
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
We adjusted the models by the demographic confounding variables age (continuous), sex (binary), race or ethnicity (4 categories: non-Hispanic White, non-Hispanic Black, Hispanic, and other), and ratio of family income to federal poverty threshold (continuous) as well as caries risk factors of dental visit in the past year (yes/no), toothbrushing times (≥ 2 times per day or P value below .05 as statistically significant.
Results
FigureFlowchart of study participants.
Table 1Characteristics of US children aged 2 through 18 years by age and dentition subgroups in National Health and Nutrition Examination Survey 2011-2016.
Logistic regression findings
Multivariable logistic regression analysis adjusted by demographic confounding variables of age, sex, race or ethnicity, and ratio of family income to federal poverty threshold as well as caries risk factors of dental visit in the past year, toothbrushing times, sealant presence, total sugar consumption as a percentage of energy intake, and milk consumption.
Multivariable logistic regression analysis adjusted by demographic confounding variables of age, sex, race or ethnicity, and ratio of family income to federal poverty threshold as well as caries risk factors of dental visit in the past year, toothbrushing times, sealant presence, total sugar consumption as a percentage of energy intake, and milk consumption.
Linear regression findings
Multivariable linear regression analysis adjusted by demographic confounding variables of age, sex, race or ethnicity, and ratio of family income to federal poverty threshold as well as caries risk factors of dental visit in the past year, toothbrushing times, sealant presence, total sugar consumption as a percentage of energy intake, and milk consumption.
Multivariable linear regression analysis adjusted by demographic confounders of age, sex, race or ethnicity, and ratio of family income to federal poverty threshold as well as caries risk factors of dental visit in the past year, toothbrushing times, sealant presence, total sugar consumption as a percentage of energy intake, and milk consumption.
Discussion
Summary of findings
In this large nationally representative cross-sectional analysis of US children aged 2 through 18 years, we found no consistent associations of 25(OH)D status with caries experience across age groups. However, after adjustment for relevant demographic variables and caries risk factors, we found lower total dfs scores in children aged 2 through 5 years with 25(OH)D above 75 nmol/L and lower presence of any dfs or DMFS scores in children aged 6 through 8 years with 25(OH)D above 75 and 50 nmol/L.
Comparison with the literature
- Deane S.
- Schroth R.J.
- Sharma A.
- Rodd C.
,
- Schroth R.J.
- Jeal N.S.
- Kliewer E.
- Sellers E.A.
,
- Schroth R.J.
- Levi J.A.
- Sellers E.A.
- Friel J.
- Kliewer E.
- Moffatt M.E.K.
,
- Seminario A.L.
- Jumani K.
- Velan E.
- Scott J.M.
- Latimer J.
- Schroth R.J.
,
- Williams T.L.
- Boyle J.
- Mittermuller B.A.
- Carrico C.
- Schroth R.J.
Dean and colleagues
- Deane S.
- Schroth R.J.
- Sharma A.
- Rodd C.
found a significant association between severe early childhood caries (S-ECC) and 25(OH)D below 50 nmol/L or below 75 nmol/L in Canadian children. Schroth and colleagues
- Schroth R.J.
- Jeal N.S.
- Kliewer E.
- Sellers E.A.
found that Canadian children with S-ECC had significantly lower 25(OH)D and twice the odds of having 25(OH)D below 75 nmol/L. Schroth and colleagues
- Schroth R.J.
- Levi J.A.
- Sellers E.A.
- Friel J.
- Kliewer E.
- Moffatt M.E.K.
found that more Canadian children with S-ECC had 25(OH)D levels below 75 nmol/L and below 50 nmol/L than caries-free children. Williams and colleagues
- Williams T.L.
- Boyle J.
- Mittermuller B.A.
- Carrico C.
- Schroth R.J.
combined case-control studies from 261 Canadian and 90 American children and found that children with 25(OH)D below 35 nmol/L were significantly more likely to have S-ECC than children with 25(OH)D above 75 nmol/L and that children with 25(OH)D below 50 nmol/L were significantly more likely to have S-ECC than children with 25(OH)D above 75 nmol/L. Furthermore, Seminario and colleagues
- Seminario A.L.
- Jumani K.
- Velan E.
- Scott J.M.
- Latimer J.
- Schroth R.J.
found a significant association between 25(OH)D below 75 nmol/L and early childhood caries in children 1 through 6 years of age with neurologic or genetic conditions residing in the Pacific Northwest of the United States. These studies, conducted in children residing in primarily northern latitudes, compared children with S-ECC
- Deane S.
- Schroth R.J.
- Sharma A.
- Rodd C.
,
- Schroth R.J.
- Jeal N.S.
- Kliewer E.
- Sellers E.A.
,
- Schroth R.J.
- Levi J.A.
- Sellers E.A.
- Friel J.
- Kliewer E.
- Moffatt M.E.K.
,
- Williams T.L.
- Boyle J.
- Mittermuller B.A.
- Carrico C.
- Schroth R.J.
or children with early childhood caries who had complex medical conditions and special health care needs
- Seminario A.L.
- Jumani K.
- Velan E.
- Scott J.M.
- Latimer J.
- Schroth R.J.
undergoing dental treatment under general anesthesia with caries-free children. These study populations do not reflect the general population and differ from our study population of US children.
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
found no significant association between 25(OH)D thresholds of below 50 nmol/L and any caries experience in US children aged 5 through 12 years. Kim and colleagues
- Kim I.J.
- Lee H.S.
- Ju H.J.
- Na J.Y.
- Oh H.W.
also found no significant association between 25(OH)D below 50 nmol/L and any caries experience in South Korean children aged 10 through 12 years. Dudding and colleagues
- Dudding T.
- Thomas S.J.
- Duncan K.
- Lawlor D.A.
- Timpson N.J.
found no convincing evidence of a relationship between 25(OH)D and any caries experience or severity (decayed, missing, and filled primary teeth) in children 85 through 163 months of age residing in South West England. However, Schroth and colleagues
- Schroth R.J.
- Rabbani R.
- Loewen G.
- Moffatt M.E.
found that any caries experience among Canadian children 6 through 11 years of age was associated significantly with 25(OH)D below 75 nmol/L and below 50 nmol/L, and total decayed, missed, and filled primary teeth and decayed, missing, and filled permanent teeth were also associated with 25(OH)D below 75 nmol/L. Gyll and colleagues
- Gyll J.
- Ridell K.
- Öhlund I.
- Åkeson P.K.
- Johansson I.
- Holgerson P.L.
found a weak association between having a baseline 25(OH)D below 50 nmol/L at age 6 years and increased caries, assessed 2 years later, in 8-year-old Swedish children. Kuhnisch and colleagues
- Kühnisch J.
- Thiering E.
- Kratzsch J.
- et al.
found that higher serum 25(OH)D concentrations were associated with fewer caries-related restorations and number of caries-affected permanent teeth in children 10 years of age residing in Germany. Silva and colleagues
- Carvalho Silva C.
- Gavinha S.
- Manso M.C.
- et al.
found that serum 25(OH)D below 75 nmol/L was associated significantly with advanced caries in permanent teeth of Portuguese 7-year-olds. Overall, these studies included comprehensive adjustments for covariates but differed by type of covariate assessed, definition of caries experience, how caries was diagnosed, and categorization of vitamin D status. Given that some studies have found associations between caries experience and 25(OH)D status in children aged 6 through 11 years and other studies have not, further studies or meta-analyses are needed to shed more light on the relationship in this age group.
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
found no significant association between any caries experience and 25(OH)D below 30 nmol/L or from 30 through less than 50 nmol/L compared with 50 nmol/L or greater in US children aged 12 through 19 years. Antonenko and colleagues
- Antonenko O.
- Bryk G.
- Brito G.
- Pellegrini G.
- Zeni S.N.
also found no significant association between total caries experience (decayed, missing, or filled permanent teeth) in women 20 through 30 years of age in Argentina and IOM 25(OH)D categories of sufficient (≥ 50 nmol/L), insufficient (≥ 30 nmol/L through
- Singleton R.
- Day G.
- Thomas T.
- et al.
In addition, variability in body fat composition associated with growth may decrease the effectiveness of 25(OH)D, which is sequestered by adipose tissue,
- Wortsman J.
- Matsuoka L.Y.
- Chen T.C.
- Lu Z.
- Holick M.F.
in preventing caries in the older age groups.
Strengths and limitations
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
,
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
Furthermore, these studies evaluated only those aged 5 through 12
- Herzog K.
- Scott J.M.
- Hujoel P.
- Seminario A.L.
and 12 through 19 years
- Akinkugbe A.A.
- Moreno O.
- Brickhouse T.H.
using the IOM 25(OH)D thresholds.
Our study was limited by lack of knowledge of participants’ exposure to sun, geographic location, and season of measurement of 25(OH)D. These factors could have affected participants’ vitamin D levels because vitamin D levels are higher with increased exposure to sun, geographic locations closer to the equator, and measurement of 25(OH)D during the summer. The threshold of 25(OH)D below 30 nmol/L was not evaluated because few participants had 25(OH)D levels below 30 nmol/L. We did not include water fluoridation as a caries risk factor in this analysis as it was not measured in NHANES 2011-2012. Subanalysis using NHANES 2013-2016 that included water fluoridation exposure did not change significantly the findings presented in our study. Other limitations of our study include the potential for recall and nonresponse biases in NHANES, as sugar intake was based on dietary recall and participants can elect to not respond to questionnaires. Furthermore, as a cross-sectional study, this study determines association but not causality.
Conclusions
Given the lack of consistent association across different definitions of vitamin D status, caries experience, and dentition types, we cannot conclude that vitamin D status influences caries experience in children. Larger epidemiologic studies should be conducted to confirm potential associations seen in our study in some of the age groups.
Appendix
Multivariable logistic regression analysis adjusted by demographic confounding variables of age, sex, race or ethnicity, and ratio of family income to federal poverty threshold as well as caries risk factors of dental visit in the past year, toothbrushing times, sealant presence, total sugar consumption as a percentage of energy intake, and milk consumption.
Multivariable linear regression analysis adjusted by demographic confounding variables of age, sex, race or ethnicity, and ratio of family income to federal poverty threshold as well as caries risk factors of dental visit in the past year, toothbrushing times, sealant presence, total sugar consumption as a percentage of energy intake, and milk consumption.
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Biography
Dr. Herzog is a pediatric dentist and researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Dr. Ordóñez-Mena is a medical statistician, Nuffield Department of Primary Care Health Sciences, University of Oxford, and National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
Article Info
Publication History
Published online: May 19, 2022
Publication stage
In Press Corrected Proof
Footnotes
Disclosures. Drs. Herzog and Ordóñez-Mena did not report any disclosures.
Identification
DOI: https://doi.org/10.1016/j.adaj.2022.03.008
Copyright
© 2022 American Dental Association. All rights reserved.
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