Dental Fluorosis

Epidemiology

Dental fluorosis is a developmental disturbance of dental enamel caused by the consumption of excess fluoride during tooth development. It's caused by overexposure to fluoride during the first eight years of life more commonly, the time when most permanent teeth are being formed. 

Dental Fluorosis

Common sources of fluoride includes, toothpaste (if swallowed by young children), drinking water in fluoridated communities, beverages and food processed with fluoridated water, dietary prescription supplements that include fluoride (e.g., tablets or drops) and other professional dental products (e.g., mouth rinses, gels, and foams). Increases in the occurrence of mostly mild dental fluorosis were recognized as more sources of fluoride became available to prevent tooth decay. These sources include drinking water with fluoride, fluoride toothpastes (if swallowed by young children) and dietary prescription supplements in tablets or drops. Moderate-level chronic exposure (above 1.5 mg/litre of water - the WHO guideline value for fluoride in water) to drinking water is typically the most significant source. 

Dental fluorosis can occur among persons in all communities at different severities, even in those with a low natural concentration of fluoride in the drinking water. However fluoride in water is mostly of geological origin. Waters with high levels of fluoride content are mostly found at the foot of high mountains and in areas where the sea has made geological deposits. Known fluoride belts on land include: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In these areas fluorosis has been reported. Various studies from all over the world on the disease burden of different populations reveals different figures. But As of 2005 surveys conducted by the National Institute of Dental and Craniofacial Research in the USA between 1986 and 1987 and by the Center of Disease Control between 1999 and 2002 are the only national sources of data concerning the prevalence of dental fluorosis.

Data from the National Health and Nutrition Examination Survey, 1999-2004 and the 1986-1987 National Survey of Oral Health in U.S. School Children reveals that there were less than one-quarter of persons aged 6-49 in the United States had some form of dental fluorosis. The prevalence of dental fluorosis was higher in adolescents than in adults and highest among those aged 12-15. Adolescents aged 12-15 in 1999-2004 had a higher prevalence of dental fluorosis than adolescents aged 12-15 in 1986-1987. Another survey conducted in Indian subcontinent shows that fluorosis is an endemic disease prevalent in 20 states out of the 35 states and Union Territories of the Indian Republic.

Signs and symptoms

Symptoms of fluorosis range from tiny white specks or streaks that may be unnoticeable to dark brown stains and rough, pitted enamel that is difficult to clean. The severity of the condition depends on the dose (how much), duration (how long), and timing (when consumed) of fluoride intake. Since the 1930s, dentists have rated the severity of fluorosis using the following categories:

·

• Questionable -The enamel shows slight changes ranging from a few white flecks to occasional white spots.
• Very mild      -Small opaque paper-white areas are scattered over less than 25% of the tooth surface.
• Mild               - White opaque areas on the surface are more extensive but still affect less than 50% of the surface.
• Moderate        -White opaque areas affect more than 50% of the enamel surface.
• Severe             -All enamel surfaces are affected. The teeth also have pitting that may be discrete or may run together.

Classification of Dental Fluorosis

Treatment options

Depending upon severity of the disease, treatment option varies. Micro/Macro abrasion, Bleaching, Composite restorations, Veneers, Full crowns are the main options available. These are described in detail in another article.

Disease prevention

Removal of excessive fluoride from drinking-water is difficult and expensive. The preferred option is to find a supply of safe drinking-water with safe fluoride levels. If you rely on well water or bottled water, your public health department or a local laboratory can analyze its fluoride content. Where access to safe water is already limited, de-fluoridation may be the only solution. Methods include: use of bone charcoal, contact precipitation, use of Nalgonda or activated alumina (Nalgonda is called after the town in South India, near Hyderabad, where the aluminium sulfate-based defluoridation was first set up at a water works level).

Health education regarding appropriate use of fluorides and parental vigilance is a key measure to prevent fluorosis. Keeping all fluoride-containing products such as toothpaste, mouth rinses, and supplements out of the reach of young children and monitoring your child’s use of fluoridated toothpaste are key facts. Only place a pea-sized amount of toothpaste on your child’s toothbrush. Also teach your child to spit out the toothpaste after brushing instead of swallowing it. To encourage spitting, avoid toothpastes containing flavors that children may be likely to swallow. Adult supervision of tooth brushing by children younger than 6 years of age and changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.

Teething in Infants

Teething is the phenomena accompanying growth of teeth through the gums. The effect of teething on infant health has been debated for at least 5000 years, and traditional beliefs on the issue have still not been entirely superseded by scientific findings. Sumerians believed teething and worm infestation were associated. Hindu writings, as well as work by Aristotle, Homer, Celsus, and others, describe associations between teething and illness. Many of these authors implicated tooth emergence in childhood mortality. The belief that teething led to childhood mortality, seizures, diarrhea, fever, or other serious conditions was criticized as early as the 17th century by Francois Ranchin. Yet in 1839, 5016 deaths in England and Wales were attributed to teething. Illingworth wrote in 1975 that “teething produces nothing but teeth.” However, as recently as 1979, parents and physicians were identifying teething as a cause of presenting symptoms in children admitted to the hospital. A medical evaluation of 50 of these children showed that in 48 cases the symptoms, ranging from upper respiratory infection to bacterial meningitis. Most medical professionals now agree that teething does not cause life-threatening illness, but they disagree about which symptoms may be associated with tooth eruption.

Teething in Infants

However several studies with different study designs has revealed symptoms believed to be associated with teething such as loss of appetite for solids and liquids, drooling, biting or chewing various objects, congestion or runny nose, cough, sleep disturbances, restlessness and irritability, rash, spitting up or vomiting, and diarrhea and fever or mild temperature elevation. Anyhow It is important to inform parents that none of these symptoms consistently and accurately predict when teething is about to occur and any of other organic disorders should be ruled out in infants with these symptoms.

The recommended intervention for teething is the use of cold items because the cold acts as an anesthetic for the gums. Refrigerated pacifiers, Spoons, Clean wet washcloths, Frozen bagels or bananas, refrigerated teething rings can be offered to the infants at this stage.Topical teething gels sold over-the-counter (OTC) are often used for teething but may carry serious risks, including local reactions, seizures with overdose, and methemoglobinemia. Benzocaine containing teething gels should not be used in infants or children under 2 years of age. If necessary, parents should be instructed on proper dosing of analgesic medications, such as acetaminophen or ibuprofen.

Problem based learning (PBL)

“True learning is based on discovery guided by mentoring rather than the transmission of knowledge.”

John Dewey

Introduction and History

In simple terms Problem-based learning (PBL) is a student centred education in which students learn about a subject through the experience of creating a problem. Problem- based learning or what we simply called PBL is based on research in the cognitive sciences on how we learn.

This educational strategy was developed at the McMaster University Medical School in Canada in the 1960s in medical education. Efficacy of this revolutionary learning method has made it popular among educationists and It is one of the big success stories in the education in the past few years.   But nowadays PBL is developed and implemented in a wide range of domains around the world. This approach empowers learners to conduct research, integrate theory and practice, and apply knowledge and skills to develop a viable solution to a defined problem .In simple words this simple revolutionary idea that problems should come before answers drives PBL.  Beginning with a problem puts you in the driver’s seat.  You can use your previous knowledge, your hunches, and your wildest ideas to try for a solution.  In the process you can develop an inventory of what you know and what you need to know to get to a solution.  Once you know that you can start questioning your instructor or your classmates, plundering the library, surfing the net, or bugging the many excellent experts to fill your needs. 

What is the difference between Subject based learning and Problem Based learning

What is wrong with the old teacher stand up and talk student sit and listen learning?  It doesn’t meet the needs.  It is too slow, too shallow, too inefficient and not much fun.  Students retain little of what they learn after even a few weeks.  Students rarely can apply what they have learned to the unpredictable problems of life and work. Students get little practice in developing their thinking skills and intellectuality or framing problems that interest them. As a result, students come to see learning as something grim to be avoided.

Problem based learning gives you opportunities to examine and try out what you already know; discover what you need to learn; develop your people skills for achieving higher performance in teams; improve your writing and speaking abilities, to state and defend with sound arguments and evidence your own ideas; and to become more flexible in your approach to problems that surprise and dismay others. Despite the work and effort it requires, PBL is never dull and is often fun.

Here is a diagram of the basic difference between subject based and problem based learning.

What is expected in Problem Based Learning?

According to the epistemological literature four types of knowledge can be identified.

• 1     Explanatory knowledge-Theories
• 2.       Descriptive Knowledge-Facts
• 3.       Procedural Knowledge-Knowledge of how to do things
• 4.       Subjective Knowledge- Personal convictions or attitudes of the learner

The PBL problems are in two varieties with regards to acquisition of above mentioned aspects of knowledge.

• 1.       During the course of their study, students acquire different kinds of, or categories of knowledge about relevant aspects of their domain of study.
• 2.       The problem types to be distinguished are meant to guide the learners towards these different knowledge categories.

In a problem based curricula four different kinds of problems have been identified.

• ·         Explanation problems
• ·         Fact-finding problems
• ·         Strategy problems
• ·         Moral dilemma resolution problems

Respectively they are effective in achieving explanatory knowledge, descriptive knowledge, procedural knowledge and subjective knowledge. Teacher, Mentor, or Guiding body has the freedom of designing the problems to drive learners to achieve the desired aspect of knowledge. Ideally it should be the combinations of all.

Characteristics of PBL

According to Barrows in 1996 there are six core characteristics of PBL are distinguished.

• A The first characteristic is that learning needs to be student-centred.
• B Second, learning has to occur in small student groups under the guidance of a tutor.
• C The third characteristic refers to the tutor as a facilitator or guide.
• D Fourth, authentic problems are primarily encountered in the learning sequence, before any preparation or study has occurred.
• E Fifth, the problems encountered are used as a tool to achieve the required knowledge and the problem-solving skills necessary to eventually solve the problem.
• F Finally, new information needs to be acquired through self-directed learning.

It is generally recognized that a seventh characteristic should be added: Essential for PBL is that students learn by analysing and solving representative problems. However authors also describes following features as essential components in PBL as well.

Students must have the responsibility for their own learning. The tutor is only a facilitator in this learning process.

The problem simulations used in problem-based learning must be ill-structured and allow for free inquiry. The real world problems are ill-structured and PBL should allow the trainers to develop their skill to identify the problem and develop realistic solutions.

Learning should be integrated from a wide range of disciplines or subjects. During PBL students should be able to access, study and integrate information from all the disciplines and reach to a more robust solution. The development of information systems and multidisciplinary approach in the present world support this task more than ever before.

Collaboration is essential. PBL provides the platform to share information and work productively with fellow people.

What students learn during their self-directed learning must be applied back to the problem with reanalysis and resolution.

A closing analysis of what has been learned from work with the problem and a discussion of what concepts and principles have been learned are essential.

Self and peer assessment should be carried out at the completion of each problem and at the end of every curricular unit.

The activities carried out in problem-based learning must be those valued in the real world.

Student examinations must measure student progress towards the goals of problem-based learning.

“Problem-based learning must be the pedagogical base in the curriculum and not part of a didactic curriculum.”

Rules in problem design

• ·         Problem should consist of a title
• ·         Well-formed problem consist of a concrete body text
• ·         Each problem needs and instruction as to what to do with it
• ·         A problem should be connected to the prior knowledge base students have
• ·         A problem should raise students curiocity
• ·         A problem should only introduce a limited number of issues for learning
• ·         A problem should not take too much self-directed study time to acquire a fair understanding of the issues at hand

Advantages and Disadvantages of PBL

As in any educational theory there are advantages and limitations found in literature when creating or implementing problem based learning curriculum. Some of the advantages which were perceived by several authors are as follow.

• ·        Students interest and benefit
• ·        Minimizing faculty workload
• ·        Long-term knowledge retention
• ·        PBL provide a more challenging
• ·        Motivating and enjoyable approach to education
• ·        Students become actively engaged in meaningful learning rather than traditional memorization
• ·        Increased responsibility for their learning and self-direction

Higher levels of comprehension and skill development occur than in traditional instruction and develop interpersonal collaboration and team work.

Following disadvantages has been encountered in PBL according to literature.

 Lack of systematic learning as in traditional learning in which the information is delivered in a well arranged manner

Difficulty in allocating time required in a course schedule

Students often express difficulties with self-directed learning whereas the teachers may have difficulties to break their traditional teaching habits.

Also selecting the appropriate question will be critical and challenging too.

However the traditional student assessment systems should be changed in assessing a student who was trained on PBL.

Summary

PBL has becoming a revolutionary method of leaning in the context of student centred learning. At the heart of PBL stands a problem. PBL process can be designed in the way the students achieve the different aspects of knowledge. As in any learning method PBL also has its own advantages and disadvantages.

Work place based assessments

What is Work place based assessment (WBA)?

The primary purpose of WPBA is to provide short loop feedback between trainers and their trainees – a formative assessment to support learning. They are designed to be mainly trainee driven but may be triggered or guided by the trainer.

What is the Purpose of WBA?

Several purposes of WBA has been identified. WBA helps to form a comprehensive assessment system, blueprinted to important curriculum requirements. It also provides educational feedback on which to reflect and develop practice. Another purpose of WBA is it provides a reference point on which to compare past, current and future levels of competence. WBA also supports remedial / targeted training and Provides evidence of progression. At the end of WBA it informs summative assessment

Benefits of WBA

Main benefit of WBA is it has a strong educational impact. Availability of clinical materials and skilled teachers are other benefits of WBA. Some other benefits of WBA are,

•       WBA is Based on observable performance and specific criteria

•       Encompasses skills, knowledge, behaviour and attitudes including judgement and leadership

•       Provides descriptors to aid the assessor’s judgement

•       Samples across important workplace tasks

•       Encourages trainee/trainer dialogue

•       Can identify those in need of additional support

•       Encourages reflection to improve practice

•       Provides a personal trajectory of progress

•       Indicates readiness for summative tests

Position of work place based assessment in Miller’s Pyramid

Preparation for WBA

First most important fact in WBA is Patient consent and safety must be assured by the assessor. Also the assessors should be trained in the tool and have expertise in the area being assessed. Reliability of assessing can be improved by using on a range of different assessors. It Should be used in different settings with different cases.

Use of WBA

•       Trainee led and  trainer guided

•       Structured forms should inform debriefing

•       Feedback immediately after observation

•       Written feedback should describe performance

•       WBA should be followed by reflection by the trainee

•       Use more often for trainees who need remedial support

•       Judge the trainee against the standard at the end point 

•       The interaction between trainee and trainer is key

Trainee role

•       Triggers WBA, in line with the LA

•       Puts the safety of the patient first

•       Agrees case and time with assessor in advance

•       Ensures sufficient WBAs are completed throughout placement

•       Uploads to the portfolio comments accurately within 2  weeks of assessment

•       Respects confidentiality of patients and colleagues

•       Reflects on feedback

•       Follows up action plans

 

Assessor role

•       Must be appropriately qualified in the relevant discipline

•       Must be trained on  the WBA method

•       Ensures consent and safety of patient

•       Carries out observation and provides feedback

•       Completes / checks online form and signs to validate

•       Keeps the AES informed of issues or concerns

Criteria for feedback

There should be a written record describing performance to look back on.

Good quality feedback should:

•       Reinforce what was done well

•       Explain areas for development

•       Suggest appropriate corrective action

Barriers to WBA

•       Unintentionally seen as threatening (e.g. as mini-exams)

•       Low ratings are seen as failures by trainees (and some trainers)

•       Lack of trainer time, especially senior trainers

Actions to overcome barriers

•       Provide faculty development  and trainee induction

•       Promote WBA as opportunities for learning

•       Written feedback puts ratings in context

•       Low scores should be seen as the norm early on

•       Provide time in job plans for those in key roles to use WBAs and discuss concerns

Utility of assessment

Refers to the relative value of using a type of assessment.

The criteria are:

•       Reliability

•       Validity

•       Acceptability to users

•       Feasibility of use

•       Educational impact

It is unlikely that one assessment type will cover all these areas

The challenge is to improve the utility of all types of assessment to enhance the overall assessment system.

Reliability

Enhanced by:

•       Assessor training

•       Use of a range of assessors

•       Use of all WBA methods

•       Use of WBA frequently

•       Triangulation with other assessments

Validity

Enhanced by:

•       Blueprinting to curriculum and GMP

•       Linking WBA with clear objectives within a structured a learning agreement

•       Direct observation of workplace tasks

•       Increasing complexity of tasks in line with progression through the training programme

Acceptability

Enhanced by:

•       Providing assessor training and trainee induction to enhance understanding of criteria, standards and methods

•       Interaction between trainee and trainer

Feasibility

Enhanced by:

•       Linking WBA with clear objectives, standards and a structured learning agreement

•       Assessing what trainees would normally do in training situations

•       Working feedback into normal dialogue

Educational Impact

Enhanced by:

•       Supervised training and appraisal

•       Clear objectives and learning agreement

•       Learning opportunities

•       Good quality feedback

•       Reflection on feedback

The Learning Environment

An environment that supports learning will:

•       Ensure everyone understands and values their role and that of others in the educational process

•       Provide faculty development and trainee induction

•       Make time for training and assessment

•       Encourage performance beyond competency; an aspiration to excellence

•       Encourage the development of reflective practitioners

•       Provide professional educational support

•       Support trainers in making difficult decisions or negative judgements

•       Support for trainees in difficulty

Types of Work place based assessments

Mini  Clinical Examination (CEX)

The CEX traditionally involved observation of the trainee carrying out a thorough history taking and physical examination and presenting their findings and diagnosis, and a written report of conclusions for the supervising clinician to evaluate.

—

Case-based discussions

Case-based discussion (CbD) in medical Foundation Training is a structured discussion with an assessor of clinical cases managed by the foundation doctor. Its strength is assessment and discussion of clinical reasoning. The foundation doctor selects two case records from patients they have seen recently, and in whose notes they have made an entry. The assessor selects one of these for the CbD session. The discussion starts from and is centred on the foundation doctor’s own record in the notes. CbD assesses medical record keeping, clinical assessment, investigation and referral, treatment rationale, follow up and future planning, professionalism and overall clinical care. Feedback is provided to the trainee immediately following the discussion.

—  

Direct Observation of Procedural Skills (DOPS)

Direct observation of procedural skills (DOPS) has been defined as the observation and evaluation of a procedural skill performed by a trainee on a real patient. Procedural skills are also known as technical or practical skills. Evaluation by an experienced practitioner is carried out using either a checklist of defined tasks, a global rating scale, or a combination of both.

—  

360 Degree assessment

Multiple assessors Including senior colleagues, nurses, AHPs is done. This includes the self assessment as well. Student would be assessed for their routine performance. Ultimately the feedback is reviewed with trainee and supervisor on agreed action plan.

—Portfolios

Snadden (1998) describes a portfolio as “a collection of evidence that learning has taken place which in practice includes documentation of learning and progression, an articulation of what has been learned, and a reflection on these learning events/experiences.” Portfolios are used both as a learning tool to stimulate reflective, experiential and deep learning and as an assessment method to judge progression towards or achievement of specific learning objectives, competencies or fitness to practice. Depending on the specialised purpose of the portfolio, its content including evidence required, and assessment criteria vary from context to context. Any portfolio that is used for assessment purposes should clearly articulate the amount, type and quality of evidence required to establish proof of competence and the marking criteria used to evaluate the quality of the evidence.

Vitamin D-What, Where, When, How, Why?

Vitamins are not generally considered to be endocrine substance, but it is a organic dietary factors essential for healthy life. The term ‘ vitamin D ’ refers to two steroid like chemicals, namely ergocalciferol and cholecalciferol . Vitamin D is important for good health, growth and strong bones and may also help to prevent other diseases such as cancer, diabetes and heart disease. A lack of vitamin D is very common. Vitamin D is mostly made in the skin by exposure to sunlight.  A mild lack of vitamin D may not cause symptoms but can cause generalised aches and pains and tiredness. A more severe lack can cause serious problems such as rickets (in children) and osteomalacia (in adults), described below. Treatment is with vitamin D supplements. Some people are more at risk of vitamin D deficiency, and so are recommended to take vitamin D supplements routinely. These include all pregnant women, breast-fed babies, children under 5, and people aged 65 and over. Also, people who do not get much exposure to the sun, people with black or Asian skin types, people who do not go out in the sun and people with certain gut, liver or kidney diseases.  We have checked our own patients and found that 9/10 adults of South Asian origin are vitamin D deficient and something like 60% of our white patients are vitamin D deficient.  Most people present with aches and pains and tiredness.

What is vitamin D?

Vitamins are a group of chemicals that are needed by the body for good health. Foods that contain vitamin D include the following though many foods do not contain much vitamin D and exposure to the sun is a better source of vitamin D than foods. Vitamin D is a fat-soluble vitamin. Most foods contain very little vitamin D naturally , though some are fortified (enriched) with added vitamin D.  Foods that contain vitamin D include:

                -Oily fish (such as sardines, pilchards, herring, trout, tuna, salmon and mackerel).

                -Egg yolk.

                -Fortified foods (this means they have vitamin D added to them) such as margarine, some cereals, infant formula milk.

Action of Vitamin D

The 1,25 - (OH)2 -D 3 receptor belongs to a superfamily of nuclear hormone receptors, which bind to their ligand and alter transcription. The hormone travels in the bloodstream in equilibrium between bound and free forms. The latter form is freely able to enter cells, due to its lipophilic nature. The plasma 1,25 - (OH) 2 - D 3 - binding protein (DBP) recognizes the hormone specifi cally. 1,25 - (OH) 2 - D 3 binds to the nuclear receptor; the complex binds to specifi c hormone response elements on the target gene upstream of transcriptional activation sites, and new mRNA and protein synthesis result.

New proteins synthesized include osteocalcin, an important bone protein whose synthesis is suppressed by glucocorticoids. In the GIT, a calcium - binding transport protein (CaBP) is synthesized in response to the hormone – receptor activation of the genome.

Physiological actions of vitamin D

Bone-Vitamin D stimulates resorption of calcium from bone as part of its function to maintain adequate circulating concentrations of the ion. It also stimulates osteocalcin synthesis.

Gastrointestinal tract-1,25 - (OH) 2 - D 3 stimulates calcium and phosphate absorption from the gut through an active transport process. The hormone promotes the synthesis of calcium transport by enhancing synthesis of the cytosolic calcium – binding protein CaBP, which transports calcium from the mucosal to the serosal cells of the gut.

Kidney- 1,25 - (OH) 2 - D 3 may stimulate reabsorption of calcium into the tubule cells while promoting the excretion of phosphate. The tubule cells do possess receptors for vitamin D and CaBP.

Muscle-Muscle cells have vitamin D receptors, and the hormone may mediate muscle contraction through effects on the calcium fl uxes, and on consequent adenosine triphosphate (ATP) synthesis.

Pregnancy-During pregnancy, there is increased calcium absorption from the GIT, and elevated circulating concentrations of 1,25 - (OH) 2 - D 3 , DBP, calcitonin and PTH. During the last 6 months prior to birth, calcium and phosphorus accumulate in the fetus. The placenta synthesizes 1,25 - (OH) 2 - D 3 , as does the fetal kidney and bone. Nevertheless, the fetus still requires maternal vitamin D.

Other roles- Vitamin D may be involved in the maturation and proliferation of cells of the immune system, for example of the haematopoietic stem cells, and in the function of mature B and T cells.

Our main source of vitamin D is that made by our own bodies. 90% of our vitamin D is made in the skin with the help of sunlight.

Ultraviolet B (UVB) sunlight rays convert cholesterol in the skin into vitamin D. Darker skins need more sun to get the same amount of vitamin D as a fair-skinned person. The sunlight needed has to fall directly on to bare skin (through a window is not enough). 2-3 exposures of sunlight per week in the summer months (April to September) are enough to achieve healthy vitamin D levels that last through the year. Each episode should be 20-30 minutes to bare arms and face. This is not the same as suntanning; the skin simply needs to be exposed to sunlight.

So, vitamin D is really important for strong bones. In addition, vitamin D seems to be important for muscles and general health. Scientists have also found that vitamin D may also help to prevent other diseases such as cancer, diabetes and heart disease.

Who gets vitamin D deficiency?

Vitamin D deficiency means that there is not enough vitamin D in the body. Broadly speaking, this can occur in three situations:

1. Increased need for vitamin D

Growing children, pregnant women, and breast-feeding women.

2. Situations where the body is unable to make enough vitamin D

People who get very little sunlight on their skin are also at risk of vitamin D deficiency. This is more of a problem in the most northern parts of the world where there is less sun. In particular:

                 People who stay inside a lot or cover up when outside or use strict sunscreen

                 People with pigmented (dark coloured) skins and elderly people  

                 Some medical conditions can affect the way the body handles vitamin D.

                     People with Crohn's disease, coeliac disease, and some types of liver                                                     and kidney disease, are all at risk of vitamin D deficiency.

                 Vitamin D deficiency can also occur in people taking certain medicines -                                                  examples include: Carbamazepine, Phenytoin, prim done, barbiturates and some anti-HIV                    medicines

3. Not enough dietary vitamin D

Vitamin D deficiency is more likely to occur in people who follow a strict vegetarian or vegan diet, or a non-fish-eating diet.

How common is vitamin D deficiency?

It is very common. This is why we recommend a regular supplement to our patients.  A recent survey in the UK showed that more than half of the adult population in the UK had low vitamin D. This level is found to be greater in people who have dark skin.  In the winter and spring about 1 in 6 people has a severe deficiency. It is estimated that about 9 in 10 adults of South Asian origin may be vitamin D-deficient. Most affected people either don't have any symptoms, or have vague aches and pains, and are unaware of the problem.  80% of our Asian patients have been found to be deficient and 60% of our white patients have found to be deficient.

What are the symptoms of vitamin D deficiency?

Symptoms of vitamin D deficiency are tiredness or general aches.  Because symptoms of vitamin D deficiency are often very vague, the problem is often missed.

How is vitamin D deficiency diagnosed?

Vitamin D deficiency can be diagnosed by a blood test.  However, on balance if you have dark skin and live in the UK you should take supplements. It may be suspected from your medical history, symptoms, or lifestyle. A simple blood test for vitamin D level can make the diagnosis.

RECOMMENDATIONS – Your doctor will advise you if you have deficiency or insufficient vitamin D.  If you have a minor level of vitamin D deficiency we recommend patients buy vitamin D tablets equivalent to 10ug or 12.5ug.  Most are made from vegetables.   If you have been found to be deficient we would recommend you stay on this dose for life as treatment is often needed long-term because the cause of the deficiency, such as dark skin or not enough sunlight, is unlikely to be corrected in the future.  We have observed that it takes at least 6 months taking regular vitamin D for symptoms to resolve and the level of vitamin D to return to normal.  It should be noted that if you have severe deficiency the doctor may recommend that you take a higher dose of vitamin D for a limited time, often equivalent to 25ug for the first 3 months.  Please discuss this with your own doctor.  We recommend that patients buy vitamin D tablets as we are unable to prescribe vitamin D without calcium on the NHS and calcium prescriptions have been associated with increased kidney stones and it is for this reason that we recommend that our patients buy vitamin D.

Maintenance therapy after deficiency has been treated

The dose needed for maintenance maybe lower than that stated.  We advise patients to buy 10ug and take 2 a day.   When the body's stores of vitamin D have been replenished. maintenance treatment is often needed long-term, to prevent further deficiency in the future. This is because it is unlikely that any risk factor for vitamin D deficiency in the first place, will have completely resolved. The dose needed for maintenance may be lower than that needed to treat the deficiency.

Cautions when taking vitamin D supplements

Care is needed with vitamin D supplements in certain situations:

 1. If you are taking certain other medicines that can interact such as  Digoxin (for an irregular         heartbeat – atrial fibrillation),  Thiazide or diuretics (water tablets).                                                   

2. If you have medical conditions such as kidney stones, some types of                                                     kidney disease, liver disease or hormonal disease.

3. Vitamin D should not be taken by people who have high calcium levels.

4. You may need more than the usual dose if taking certain medicines such as Carbamezapine, Phenytoin. HRT or barbiturates. Multivitamins are not suitable for long-term high-dose treatment because the vitamin A which can be harmful in large amounts.

Are there any side-effects from vitamin D supplements?

It is very unusual to get side effects from vitamin D if taken in the prescribed dose. However, very high doses can raise calcium levels in the blood. This would cause symptoms such as thirst, passing a lot of urine, nausea or vomiting.

Prognosis (outlook) in vitamin D deficiency?

The outlook for vitamin D deficiency is usually excellent. Both the vitamin levels and the symptoms generally respond well to treatment. However, it can take time (months) for symptoms to resolve and for bones to recover.  Generally after 6 months of using Vitamin D tablets the patient feels a lot better and symptoms have improved.  This does not mean you need to stop taking the medication.  Vitamin D supplementation is for life.