Assessment of Vitamin C Levels in Periodontal Patients: A Cross-Sectional Study in Palestine

Abstract

Background:

Vitamin C is an essential nutrient for the health of gingival and periodontal tissues due to its antioxidant potential.

Aim:

To assess the levels of vitamin C in different stages and grades of periodontitis.

Materials and Methods:

The present study follows a cross-sectional study design and was conducted in a private dental clinic in Palestine. The present study involves the collection of serum to assess the vitamin C deficiency in patients with existing periodontal diseases. Mann–Whitney U test was used to compare the difference in the vitamin C levels in various stages and grades of periodontitis. P value <0.05 was considered significant.

Results:

There was a significantly lower vitamin C level in patients with Stage IV periodontitis as compared to the early stages of periodontitis. However, there was no difference between the other stages of periodontitis.

Conclusion:

Vitamin C deficiency might be considered as one of the risk factors in periodontitis.

INTRODUCTION

Vitamin C is a form of ascorbic acid and water-soluble vitamin present in our daily dietary consumables. Our human body lacks the ability to produce vitamin C endogenously. Hence, the consumption of vitamin C is of prime importance. Vitamin C is mainly absorbed through intestinal absorption from dietary consumption. The following are the recommended dietary allowance (RDA): 15–75 mg for children, 75 mg for adult women, 90 mg for adult men and 85–120 mg for pregnant and breastfeeding women.[1] In addition to the RDA, the Food and Drug Administration (FDA) recommends a daily intake of vitamin C, denoted as daily value (DV). The DV of vitamin C for children aged 4 and above is 90 mg.[2,3] Citrus fruits, tomatoes, broccoli and bell peppers are considered to be good nutritional sources of vitamin C.

Vitamin C is considered as an essential nutrient for the immune system. It is also required for the metabolism and production of collagen, L-carnitine and neurotransmitters.[4] Collagen production forms a very important component of wound healing which is indirectly governed by the function of vitamin C.[5] Vitamin C also plays the role of an antioxidant that assists in the regeneration of other antioxidants like Tocopherol.[6]

Periodontal disease is associated with a wide number of diseases affecting the periodontium. It is associated with plaque accumulation, which in turn leads to bacterial infiltration and thereby the destruction of tooth-supporting structure and damage to the alveolar bone.[7] American Academy of Periodontology has associated different staging of periodontal disease, wherein Stage I is characterized by simple gingivitis and periodontitis which is associated with early stages of attachment loss.[8] Stage II is moderate periodontitis which shows damage to the supporting periodontium of the tooth.[8] Stage III is associated with severe damage to the periodontium, wherein tooth loss can occur without treatment.[8] Stage IV is regarded as the most severe cases associated with tooth loss and occlusal changes.[9] The risk of progression of the periodontal disease is given as Grades A, B and C, where C is the most severe progressing periodontal disease.

Initiation and management of the periodontal disease are largely affected by the healing of the tissue which is dependent on collagen formation. The pathophysiology of periodontal disease is guided by immune cells like leukocytes, polymorphonuclear neutrophils and mononuclear cells.[10,11] Vitamin C is known to increase the chemotactic response in the leukocyte cells which can be a relevant factor in the initiation of periodontal diseases.[12] Additionally, vitamin C is also known to increase glutathione secretion in mononuclear cells. This tends to provide a protective effect against DNA damage and leads to prevention from periodontal diseases.[13]

Since many molecular studies have shown vitamin C as an essential component of the initiation and progression of periodontal disease, a correlation between vitamin C levels and clinical findings can be pivotal. Hence the present study aims to co-relate the clinical staging of periodontal disease with the vitamin C levels in individuals.

MATERIALS AND METHODS

The present study follows a cross-sectional study design which was conducted in a private dental clinic in Palestine. All the patients who attended a private dental clinic from November 2020 to November 2021 were included in the present study.

Patients visiting the private dental clinic with underlying periodontitis were included in the present study. Only those patients were included who could give written informed consent for participation in the present study. Additionally, patients were asked for their consent to obtain the blood test to determine the serum vitamin C levels. Those patients who did not give consent for participation in the study were excluded.

For all patients with periodontitis included in the study, the stage and the grade of periodontitis were assessed. UNC-15 periodontal probe was used to measure the gingival parameters. Additionally, tooth mobility and furcation levels were assessed for proper staging and grade classification of periodontal disease. The presence of missing teeth due to periodontitis was also noted for each patient. A periapical survey radiograph was taken for each patient to assess the alveolar bone levels to correctly classify and grade the periodontal disease. General gingival and periodontal characteristics like bleeding on probing and the presence of plaque were also noted.

The blood samples were collected for each patient and immediately stored at lower temperatures. From the sample collected from the patient, 100 μL were diluted with 100 μL of antioxidant tris phosphine hydrochloride. The samples were filtered through a protein removal column, followed by centrifuge action for 30 min. This was followed by the addition of 100 μL of acetonitrile to 100 μL of supernatant. The serum vitamin C was analyzed using hydrophilic interaction chromatography. The pathological lab considered the normal vitamin C level between 40 and 100 μmol/L.

All the data collected from the patients were entered into the spreadsheet. The data obtained were statistically analyzed using the SPSS version 22. Mann–Whitney U test was used between the two groups. P value <0.05 is considered significant.

RESULTS

A total of 29 patients visiting the dental clinic were reported to have periodontal disease. Out of the 29 patients, only 25 patients gave consent for blood sample collection and were included in the present study.

Out of the 25 patients included in the present study, 13 were males and 12 patients were females. All the patients included in the present study have a mean age group of 55 years with a standard deviation of 9 years [Table 1].

Table 1.

Demographic characteristics

Demographic characteristics	n
Number of patients	25
Male	13
Female	12
Age	55±9

Out of all the participants, 12 participants had Stage IV periodontitis, 11 participants had Stage III periodontitis and only 2 participants had Stage II periodontitis. Three participants out of 12 in Stage IV periodontitis had Grade C periodontitis, seven had Grade B periodontitis and two had Grade A periodontitis. In participants with Stage III periodontitis, two were classified as Grade C [Table 2].

Table 2.

Vitamin C levels in different stages and grades of periodontitis

Periodontal staging	Grade A	Grade B	Grade C
Stage I	0	0	0
Stage II	2 (0 deficient)	0	0
Stage III	1 (0 deficient)	8 (4 deficient)	2 (1 deficient)
Stage IV	2 (1 deficient)	7 (3 deficient)*	3 (1 deficient)

*P<0.05 is considered significant.

In participants with Stage IV and Grade C periodontitis, only one out of three had lower levels of vitamin C, which were below 40 μmol/L. However, three participants out of seven with Grade B and one participant out of two with Grade A had lower levels of vitamin C. In Stage III periodontitis, one participant out of two with Grade C and four participants out of eight with Grade B had lower levels of vitamin C [Table 2].

According to Mann–Whitney U test, there is a significant difference in the vitamin C level between Stage I periodontitis and Stage IV periodontitis (P < 0.05). However, there was no significant difference between the other groups.

DISCUSSION

Vitamin C is a known antioxidant that reduces intracellular oxidative stress in patients with gingival and periodontal disease. Vitamin C also causes a reduction in the cytotoxic activity of the Porphyromonas gingivalis which reduces the progression of the gingival disease to periodontal disease.[14] Vitamin C is also known to improve gingival and periodontal health in patients with underlying systemic conditions like diabetes.[15] Since vitamin C can have an influence on immunity, it affects the initiation and progression of periodontal diseases.[16] A study by Mathias et al.[17] suggests that the presence of vitamin C in the serum can have a good impact on the periodontal health of the patients. Since vitamin C largely influences periodontal health, the present study was conducted with an aim to assess the real-time presence or absence of vitamin C levels in existing periodontal conditions.

The present study follows a cross-sectional study design which can be an essential method to provide preliminary data of real-time assessment of vitamin C levels in patients with periodontitis. This can provide evidence for a risk factor of periodontitis which can be addressed in the prevention of the disease.

The present article shows significant low vitamin C levels in patients with periodontal diseases. The vitamin C levels are lower in patients with Stage IV of periodontitis as compared to the early stages of periodontitis. Similar results of low serum vitamin C levels in patients with periodontitis were seen in another study by Munday et al.[18] Another long-term cohort study by Iwasaki et al. has shown a negative relationship between the dietary antioxidants including vitamin C levels and periodontal health.[19]

Despite decreased vitamin C levels being one of the risk factors for periodontal conditions, administration of vitamin C levels is not proved to improve periodontal status in other studies. A study by Gokhale et al.[15] has shown that administration of vitamin C levels does not improve periodontal pocket levels. Another study has also shown that vitamin C administration does not improve the pocket depth and recover attachment loss.[20]

The present study was conducted using a cross-sectional study design which provides lower evidence of vitamin C deficiency as a risk factor. However, further cohort study in the Palestine population can be beneficial to achieve the cause–effect relationship of decreased vitamin C as a risk factor in periodontal diseases.

CONCLUSION

The present study shows that patients with Stage IV periodontitis have significant vitamin C deficiency as compared to those in the early stages of periodontitis. Thus, it may be considered as a risk factor for periodontitis among Palestinians. A further correlation is recommended to confirm such relationship.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.