Gingival inflammation from lack of vitamin C is well documented from the days of scurvy. Scurvy is a rare condition in developed countris and most dental professionals have not seen it first-hand when treating patients. However, what is seen is periodontal disease and this has led to questions regarding what role, if any, vitamin C plays in the onset and progression of periodontal disease. In a recent systematic review published 2019 in the journal of Environmental Research and Public Health the authors aimed to “systematically review the relationship between the dietary intake and blood concentration of vitamin C and periodontal disease, as well as the preventive ability that vitamin C exerts against periodontal disease.”1
This review included the following study designs cross-sectional, longitudinal, cohort, case-control, and RCT. All of the cross-sectional studies showed periodontal disease was significantly associated with vitamin C intake or blood vitamin C levels. However, there was a lack of causation. Though the studies suggest that vitamin C obtained through diet is transferred to the periodontal tissues via blood, the association could also be deduced as reverse causation. This would mean that the results were due to periodontal disease effecting vitamin C levels rather than vitamin C effecting periodontal disease. The authors call for a longitudinal study to verify the association.
In the randomized controlled trials reviewed improvements in periodontal indices were observed in patients with gingivitis, but not in those with periodontal disease. Vitamin C reduced the cytotoxic and apoptotic activity of p. gingivalis which may be the mechanism by which it improved periodontal indices in patients with gingivitis. It has been speculated that once the inflammatory reaction advances beyond gingival involvement and effects alveolar bone, some factor plays a role in inhibiting the effect of vitamin C.
None of the studies showed an improvement in pocket depth after vitamin C administration. Nonetheless, the studies were sufficient to determine the preventive ability of vitamin C in regard to periodontal disease. Other factors that may influence vitamin C and the association with periodontal disease such as diabetes was also reviewed. These studies showed some evidence that vitamin C did improve gingival bleeding in periodontitis patients with diabetes. This could be associated with the fact that glucose inhibits the transfer of vitamin C to the cells. It is important to note that in diabetic patient’s vitamin C is thought to work less effectively. However, in some studies, vitamin C taken in via food was determined to likely work effectively.
The authors cite several limitations such as studies with inconsistencies in evaluations, for example, only evaluating part of the mouth instead of a full mouth evaluation. Many factors were not addressed such as smoking and diabetes and their influence on vitamin C and periodontal disease. Lastly, the number of articles included in the review was small with only 14 publications meeting the criteria for this review.
The authors conclude by stating, “This review provided an overview and appraisal of studies analyzing the relationship of vitamin C to periodontal disease. It highlights the effects of vitamin C on the prevention of incidence and the development of periodontal disease. Further studies addressing the use of unified periodontal indicators and an elucidation of the implications of other factors should be performed so as to increase knowledge of the relationship between vitamin C and periodontal disease.”
Do you include nutritional counseling to your patients on a regular basis? Do you feel like patients are receptive to nutritional counseling? Have you seen improvements in patients gingival/periodontal health after making nutritional changes?
- Tada A, Miura H. The Relationship between Vitamin C and Periodontal Diseases: A Systematic Review. Int J Environ Res Public Health. 2019 Jul 11;16(14):2472. doi: 10.3390/ijerph16142472. PMID: 31336735; PMCID: PMC6678404.