Original Article

Evaluation of the Effect of Oral Journal of Advanced Oral Research

1–7
Vitamin D3 Supplement on Orthodontic © 2023 Academy of Advanced
Dental Research
Tooth Movement: A Randomized Article reuse guidelines:
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Clinical Trial Study DOI: 10.1177/23202068231177239
journals.sagepub.com/home/aad

Fahimeh Farzanegan1, Ghazal Ghasemi Nour2, Majid Ghayour Mobarhan3,4

and Abdolrasoul Rangrazi5

Abstract
Aim: One of the problems that orthodontists commonly face is the prolonged duration of the treatment. Therefore, it
is important to find an effective method to increase the rate of orthodontic tooth movement (OTM). This study aimed
to evaluate the effectiveness of oral administration of vitamin D3 on OTM rates in humans.
Materials and Methods: In this randomized clinical trial study, we selected 29 healthy women aged 18–25 years who
sought orthodontic treatment and required bilateral maxillary first premolar extraction. Participants were tested to
measure the blood levels of vitamin D3 and, based on the outcomes, were divided into three groups: control (without
vitamin D3 deficiency; N = 10), placebo (N = 9), and experiment (N = 10), both with vitamin D3 deficiency. Subjects
of the last two groups, who were randomly assigned, received 50,000 IU (International Unit) vitamin D3 pearls (Dana
Pharmaceutical Company, Tabriz, Iran) or a placebo every 2 weeks for 2 months. Inclusion criteria were patients requir-
ing bilateral extraction of the first premolar in the maxilla. The canines were retracted by nickel-titanium (NiTi) coil
springs into the extraction sites. At the beginning, after 1 and 2 months, the distance between canine and lateral teeth on
both sides was measured to calculate OTM.
Results: In the first month (t (1–2)), the mean values of OTM in the placebo group were higher than the other groups.
However, during the second month (t (2–3)) and overall (t (1–3)), the experiment group showed a higher OTM. The
experiment and control groups were statistically different in all three time periods (P-value < .05). The difference between
the experiment and placebo groups was only significant in t (2–3) (P-value < .05). Whereas the placebo and control
groups showed a significant difference in t (1–2) (P-value < .05).
Conclusion: Vitamin D3 deficiency seems to increase OTM. Receiving oral supplements of vitamin D3 may not have
much effect on increasing the level of vitamin D3. The lowest OTM rate was observed in the control group.

Keywords
Calcitriol,Vitamin D3; Orthodontic tooth movement, Cholecalciferol

Abbreviations
1
Oral and Maxillofacial Diseases Research Center, Mashhad University of
1,25,2(OH)D3: 1,25-Dihydroxyvitamin D3 Medical Sciences, Mashhad, Iran
2
School of Dentistry, Mashhad University of Medical Sciences, Mashhad,
BALP: Bone alkaline phosphatase
Iran
HMGB1: High mobility group box 1 3
Metabolic Syndrome Research Center, Mashhad University of Medical
IU: International unit Sciences, Mashhad, Iran
NiTi: Nickel-titanium
4
International UNESCO center for Health-Related Basic Sciences and
Human Nutrition, Department of Nutrition, School of Medicine, Mashhad
NSAID: Non-steroidal anti-inflammatory drugs University of Medical Sciences, Mashhad, Iran
OTM: Orthodontic tooth movement 5
Dental Research Center, Mashhad University of Medical Sciences,
PGE2: Prostaglandin E2 Mashhad, Iran
PTH: Parathyroid hormone
Corresponding author:
RANKL:  Receptor activator of nuclear factor Abdolrasoul Rangrazi, Dental Research Center, Mashhad University
kappa-Β ligand of Medical Sciences, Mashhad 9177948959, Iran.
VGEF: Vascular endothelial growth factor E-mail: [email protected]
2 Journal of Advanced Oral Research

Introduction Overall, there are only a few studies, most of which were
carried out on animals, evaluating the effect of vitamin D3
Orthodontic treatment relies on the clinician’s ability to on tooth movement. In addition, they all focus on the local
produce controlled tooth movement. Since the introduction effects of vitamin D3 rather than oral intake. Therefore, the
of orthodontics, various techniques and devices have been aim of this study was to evaluate the effect of oral vitamin
developed to achieve this. Applying force to a tooth causes D3 supplements on OTM in humans.
certain mechanical, chemical, and cellular events in the
adjacent tissues that result in structural changes and ulti-
mately the movement of the tooth. Even with different Materials and Methods
devices with different mechanisms, one must achieve the
same result at the cellular level, that is, alveolar bone Trial Design
remodeling in the expected direction.1–3
This study used a 1:1 allocation ratio in a randomized clinical
In recent decades, more people have become candidates
trial. The randomization was done for the participants included
for orthodontic treatment. As a result, it is now a new chal-
in the study.
lenge to shorten the treatment time, which is a real concern
for patients, especially adults. An acceleration of the ortho-
dontic tooth movement (OTM) has long been desired Participants, Eligibility, and Setting
because of its various advantages, such as a shorter duration
of treatment and fewer side effects such as problems related This single-center clinical study (XXX University of Medical
to oral hygiene, root resorption, and open gingival embra- Sciences, Dental School, Orthodontic Department) was
sure spaces. Therefore, various methods have been intro- conducted on 29 healthy women aged between 18 and 25 years
duced in recent years to shorten the duration of treatment,4–6 seeking orthodontic treatment. Inclusion criteria were patients
some of which include piezosurgery,7–9 low-level laser ther- requiring bilateral extraction of the first premolar in the
apy,10,11 fiberotomy,12,13 electromagnetic fields,14,15 corticot- maxilla. Exclusion criteria were the presence of any systemic
omy,16 drugs,17 and mechanical stimulation.18 disease, syndrome, or bone malformation, any systemic or
A non-invasive technique involves the use of certain metabolic disease that affects bone metabolism, intake of
drugs that can affect the rate of OTM as well as bone metab- vitamin D or another drug that can influence bone metabolism,
olism.19,20 Several studies have looked into the mechanisms any existing periodontitis or bone loss, and smoking.
and effects of commonly used drugs and systemic factors
such as NSAIDs,21–24 corticosteroids,25,26 thyroid hor-
mones,27 parathyroid hormone (PTH),28,29 and vitamin D30–32 Sample Size Calculation
on tissue changes and OTM.
According to the Al-Attar et al. study,39 the sample size for
Vitamin D and its active metabolite 1,25-dihydroxyvita-
this study was estimated and based on the ability to distinguish
min D3 (1,25,2(OH)D3), together with PTH and calcitonin,
a clinically relevant difference in the orthodontic tooth
regulate the amount of calcium and phosphorus in the
(primary outcome) in the three groups of the trial, with a
body.2,33 Vitamin D deficiency can lead to skeletal disorders
significance level of .05 and 80% power. Based on the
such as osteomalacia as well as non-skeletal effects such as
calculation, at least 23 patients had to be assigned to each
secondary hyperparathyroidism34,35
group. This was rounded up to 25 to compensate for the
A study in 2011 showed that local injection of 1,25,2(OH)
losses during follow-up. However, the number of patients in
D3 was clinically effective in increasing the rate of OTM in
each group was reduced to ten due to the need for a preliminary
humans, and it was demonstrated to be dose-dependent.30
blood test and patient reluctance. To compensate for this,
However, Shetty et al.36 reported in 2015 that local injec-
measurements were taken on both sides.
tions of vitamin D3 significantly reduced the rate and
amount of tooth movement in humans. According to a
study, 1,25,2(OH)D3 stimulates osteoclastic bone resorp- Blinding
tion through a primary hormonal response in osteoblasts.37
In another study, local injection of 1,25,2(OH)D3 was In this triple-blind study, the patient, operator (the second
shown to result in an acceleration of OTM after 21 days in author), and statistician were blinded to the study so that they
adult cats.1 Kale et al. found that 1,25,2(OH)D3 promoted did not know who was receiving placebo or vitamin D3 (the
bone turnover more effectively than PGE2 (prostaglandin pills looked the same). The placebo group was treated after
E2) and supported the balance between formation and the study by an internal medicine specialist for vitamin D3
absorption in alveolar bone remodeling during OTM.38 deficiency.
Farzanegan et al. 3

Randomization Statistical Analysis

Each participant was assigned a random four-digit number, The Shapiro-Wilk test revealed that the data had a normal
and the randomization was completed using the randomizer. distribution. Using SPSS software version 18 (SPSS, Inc.,
org website. The study participants with vitamin D3 defi- Chicago, IL, USA), the one-way ANOVA and Tukey tests
ciency and clinicians were unaware of the allocation into were used to analyze the data. The statistical significance
placebo or intervention groups using opaque envelopes. level was set to .05.

Intervention Results
All patients were treated with stainless steel brackets Participant Flow
with Roth prescriptions (0.018 Discovery, Dentaurum,
Germany). The initial leveling and alignment were carried A total of 29 subjects aged between 18 and 25 years partici-
out with a 0.014 nickel-titanium (NiTi) wire, followed by a pated in this study: 10 subjects with vitamin D3 deficiency
0.016 NiTi. received dietary vitamin D3 capsules (intervention group),
After the initial leveling and alignment, the blood level nine subjects with vitamin D3 deficiency received placebo
of vitamin D3 was determined by radioimmunoassay capsules (placebo group), and ten subjects with normal vita-
(Biosource, Europe, Nivelles, Belgium). Subjects whose min D3 levels were considered baseline (control group). No
blood level of vitamin D3 was between 20 and 30 ng/mL subject left the trial during follow-up. The distance between
(vitamin D3 insufficiency) or below 20 ng/mL (vitamin D3 the canine and the lateral incisor was measured at the begin-
deficiency) were allocated at random to either the placebo ning as well as 1 and 2 months after initiating the treatment
(N = 9) or the intervention group (N = 10, normal range: to calculate the amount of tooth movement. According to
30–100 ng/mL). Patients with normal vitamin D3 levels the Shapiro-Wilk test, all of the data were normally distrib-
were assigned to the control group (N = 10). uted (P > .05).
Patients in the intervention group received gelatin cap-
sules containing 50,000 IU (international unit) vitamin D3
pearls (Dana Pharmaceutical Company, Tabriz, Iran) (based Tooth Movement
on Demetriou et al.40) every 2 weeks, while the placebo group
received empty gelatin capsules for blinding. The control Table 1 shows the descriptive statistics of the tooth move-
group, which had no vitamin D3 deficiency, was considered ment of the groups at three time periods. Based on the
a parallel to the other two groups in order to carry out the results of the one-way ANOVA test, there was a significant
required measurements at predetermined times. difference in terms of tooth movement between the groups
Finally, the placebo group was treated for vitamin D3 in all three time periods (Table 2).
deficiency. The Tukey test (Table 2) indicated that during the first
period (t (1–2)), there was a significant difference between
the control and intervention groups as well as between the
control and placebo groups (P < .05). However, there was
Canine Retraction
Space closure was performed by retracting the canine using Table 1. The Tooth Movement of the Groups at Three Time
a 0.016-inch stainless steel wire (Remanium, Dentaurum, Periods.
Germany) and a NiTi coil spring (100 g) (American Tooth Movement
Ortodontics, USA). The distance between the lateral incisor
Standard Deviation
and the canine on either side of the maxilla was measured Time Group Mean (mm) (mm)
once a month for 2 months in order to determine the move-
t (1–2) Intervention 1.39 0.23
ment rate of the canine. For this purpose, a computerized Placebo 1.40 0.13
calliper was used to measure the distance between the Control 1.19 0.11
canine and the lateral incisor’s prominent point with an t (2–3) Intervention 1.96 0.28
accuracy of 0.01 mm. The mean movement on either side Placebo 1.67 0.14
Control 1.64 0.17
was taken as the amount of movement for each patient. The t (1–3) Intervention 3.35 0.41
retraction rate of the canine was defined as the amount of Placebo 3.07 0.12
tooth movement per unit of time. Control 2.83 0.22
4 Journal of Advanced Oral Research

Table 2. Comparison of Tooth Movement between the which is not only painful but also cannot explain the systemic
Groups Over Three Periods of Time. effects of vitamin D3. In our research, we studied for the first
Time Sig.* Group (I) Group (J) Sig.** time the effect of dietary vitamin D3 on OTM in humans. The
results suggested that higher amounts of vitamin D3 can sys-
t (1–2) .01 Intervention Placebo 0.97
Control 0.03 temically reduce OTM.
Placebo Intervention 0.97 According to Al-Hasani et al., a 25 pg dose of vitamin
Control 0.02 D3 accelerated the experimental canine movement by
Control Intervention 0.03 nearly 51% compared to the control group, while each of
Placebo 0.02
t (2–3) .001 Intervention Placebo 0.01
the 15 and 40 pg doses resulted in an approximately 10%
Control 0.006 acceleration of OTM. They therefore concluded that local
Placebo Intervention 0.01 injection of vitamin D3, in a dose-dependent pattern, is a
Control 0.94 cost-effective way to increase OTM in humans.30
Control Intervention 0.006 In their investigation on cats, Collins et al.1 found that
Placebo 0.94
t (1–3) .04 Intervention Placebo 0.10
individuals who got weekly intraligamentous injections of
Control 0.001 a solution of 1,25,2(OH)D3 in dimethyl sulfoxide saw a
Placebo Intervention 0.10 60% faster movement of their teeth than the matching con-
Control 0.16 trol teeth. In addition, an increased number of mononuclear
Control Intervention 0.001 osteoclasts was reported in histological evaluations, which
Placebo 0.16
can lead to an increase on the pressure side of the periodon-
Note: *One-way ANOVA test; **Tukey test.
tal ligament in alveolar bone resorption.1
In 2019, Narmada et al.32 found that intramuscular
Table 3. Vitamin D3 Levels in Three Groups. administration of vitamin D could increase the number of
osteoclasts and receptor activator of nuclear factor kappa-β
Group Mean ± SD Min. Max. ligand (RANKL) in pregnant rats while going through
Intervention 19.05 ± 3.53 16.51 21.58 OTM. However, according to Nareswari et al.,31 there was
Placebo 17.90 ± 4.42 14.49 21.30 no significant increase in angiogenesis or vascular endothe-
Control 57.35 ± 19.89 43.11 71.58
lial growth factor (VGEF) expression in the Wistar rat after
intramuscular vitamin D injection. Another 2019 study
no noticible difference between the control and placebo evaluated the effects of intramuscular injection on OTM in
groups during this period. rats. The results showed no significant growth in the num-
There was also a significant difference between the ber of osteoblasts or bone alkaline phosphatase (BALP)
intervention and placebo groups as well as between the expression compared with the control group.43
intervention and control groups during the second period Kale et al.38 compared the effects of 1,25,2(OH)D3 and
(t (2–3)) (P ≤ .01). Overall, only the difference between the prostaglandin E2 on OTM. They showed that both PGE2
control and intervention groups was significant in both and 1,25,2(OH)D3 significantly increased the amount of
periods (t (1–3)) (P = .001). tooth movement compared to the control group. Additionally,
there were considerably more osteoblasts on the alveolar
bone’s external surface on the pressure side in the 1,25,2(OH)
Vitamin D3 Level D3-injected group than in the PGE2 group. They therefore
concluded that 1,25,2(OH)D3 is effective in modulating
The preferred range for vitamin D3 is 30–60 ng/mL.41 bone turnover during OTM in rats.
According to our results, 19 out of the 29 patients (65.5%) In 2016, Cui et al.44 suggested that local administration of
had vitamin D3 deficiency. Table 3 gives the levels of vita- 1,25,2(OH)D3 might provide a suitable periodontal liga-
min D3 in the three groups. No serious harm or side effects ment environment for OTM in rats. This was due to a
were observed during the entire treatment. decrease in the expression of HMGB1 (High Mobility Group
Box 1); an inflammatory cytokine that can act as a regulator
in remodelling of periodontal tissue and bone resorption dur-
Discussion ing OTM.
Based on a study by Takano-Yamamoto et al.,45 the number
Vitamin D is a potent inducer of bone resorption and forma- of osteoclasts triggered by the insertion of an elastic band can
tion and is one of the factors that can affect the rate of OTM.19,42 be increased with daily injections of 1,25,2(OH)D3. It was
However, it has only been examined and administered locally, synergistic with mechanical stimuli and resulted in higher
Farzanegan et al. 5

counts of osteoclasts compared to mechanical stimuli alone. of vitamin D3 supplements (2 months) did not have a major
These results suggest that local application of 1,25,2(OH)D3 influence on the rate of tooth movement.
can increase osteoclast counts as well as osteoclastic bone
resorption activity induced by mechanical stimuli. Ethics Approval and Consent to Participate
In a study by Baran et al.46 on rats, it was shown that After primary case selection, the study phases were explained to
areas with local administration of 1,25,2(OH)D3 had a sig- the patients, and signed informed consent was obtained from each
nificantly higher unilateral apposition compared to the of them (no changes were made to the methods after the start of
control group. the study).
The study protocol was approved by the research ethics
In another study, Takano-Yamamoto et al.47 reported that
committee of the XXX (hidden for anonymity).
in young rats who received 10–10 mol/L of 1,25,2(OH)D3
injections every three days, tooth movement increased by
Declaration of Conflicting Interest
245%. Moreover, upon receiving 10–8 mol/L injections,
tooth movement increased by 154% compared to that The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
observed in the control group by the end of the experiment.
However, Shetty et al.36 showed in 2015 that local injec-
Funding
tion of vitamin D3 can significantly reduce the rate and
amount of tooth movement in humans after a 60-day trial This study is funded by the Research Chancellor of the XXX
(hidden for anonymity).
period, contradicting previous results.
The findings of our research suggested that higher lev-
els of vitamin D3 in the blood can reduce the rate of OTM. ORCID iD
Abdolrasoul Rangrazi https://orcid.org/0000-0002-8345-4707

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