Vitamin C or Ascorbic Acid Deficiency

What Is Vitamin C?

Vitamin C (ascorbic acid) is a water-soluble vitamin, a potent reducing and antioxidant agent that wards off and protects the body from bacterial infections and toxicants. It is also known as ascorbic acid and is a potent inhibitor of ROS (reactive oxygen species). Apart from detoxication, it is attributed to collagen formation within the connective tissues, bone, capillaries, fibrous tissues, and even the skin. It is not produced within our body and hence can be obtained only through diet.

Dietary supplements of ascorbic acid are commonly recommended by some physicians for patients:

• To improve their antioxidant functions.

• To rectify tissue repair or damage.

• For improving enzymatic sufficiency of neurotransmitters.

Vitamin C deficiency has several adverse effects and links to oral and general health diseases. The enzymatic role of ascorbic acid is highly crucial for a healthy immune defense. Though conflicting research statements have been documented over the effect of vitamin C in the prevention of cardiovascular diseases and various neurovascular diseases like Alzheimer's disease and dementia exists in the literature that ascorbic acid (vitamin C) remains a potent inhibitor of microbial activity and promotes lymphocyte proliferation regulating and boosting the individual's immunity considerably to an extent.

What Is the Pathogenesis of Vitamin C Deficiency or Scurvy?

In ascorbic acid deficiency, the fibroblasts that proliferate and synthesize collagen molecules aiding tissue repair are affected. Immature fibroblasts in this deficiency lead to delayed wound healing because of weak or somewhat affected collagen tissue. Similarly, the bone gets compressed or brittle as osteoblasts or bone-forming cell movement is restricted or non-migratory. Instead, the cartilage pools up and gets calcified in between the rows at the end of long bones. Thus, impaired collagen synthesis and brittle bone formation are significant impediments to wound healing in patients suffering from scurvy.

As per the ultrastructure study, cell organelles like the Er (endoplasmic reticulum) and ribosomal granules are dilated and lost, with fibrillar material spilling into the extracellular matrix. The cellular structures are vital for maintaining the integrity of all the supporting tissues that arise from the mesenchymal origin, such as bone, connective tissue, or dentine. As per research, the clinical manifestations of scurvy are fully established in the individual only after 4 to 6 months, approximately after the pool of ascorbic acid undergoes complete or partial depletion.

Histopathological studies of scurvy patients reveal changes in the microvasculature. With electron microscopy examination, pathologic changes in cell structure are visualized. Low serum ascorbic acid levels (<0.6mg/dL), an increase in hemosiderin pigment deposit, and assessment of the patient's clinical symptoms of fatigue or periodontal disease severity noticed by the dental surgeon on routine examination are all proven diagnostic aids in early detection and the systemic impact of scurvy along with the association oral ulcers lesions (frequently oral mucosal ulcerations), and their management. On examination of the affected tissue, be it skin, or oral mucosa, the maxillofacial surgeon, dentist, or physician can reveal histopathological features of scurvy like extravasated erythrocytes, red blood cells, or extravascular clots.

What Causes Vitamin C Deficiency?

The causes or risk factors for vitamin C or Ascorbic acid deficiency alongside a poor supplementation or lack of vitamin C availability in the patient's immune system are :

• Nutritional or protein deficiencies.

• Anxiety or mental health issues.

• Aging.

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• Depression.

• Alcoholism.

• Substance abuse.

• Anorexia.

• Allergy.

• Gastric disease.

• Smoking.

• Ulcerative colitis.

• Chemotherapy.

What Are the Clinical Features of Vitamin C Deficiency?

Orosystemic Impact:

1. As a disease, scurvy may mimic or instead resemble the clinical symptoms of several other medical or systemic conditions like vasculitis, deep vein thrombosis, or systemic bleeding disorders.

2. In full-fledged or severe scurvy cases, other manifestations like hemarthrosis, purpuras, and rashes may be present and are common.

3. Some patients find that they may be unable to walk or are excessively tired.

4. Also, oral lesions or dental manifestations definitely precede or are initial symptoms of the onset of scurvy before progressing in severity.

5. In dental literature, varying degrees of degeneration in the jaw bone and the pulp chambers of the tooth are linked typically with ascorbic acid deficiency.

The following features related to oral and dental manifestations are seen in patients with vitamin C deficiency:

According to the American Academy of Periodontology (2017), periodontal disease in scurvy patients is characterized typically by:

• Attachment loss around the tooth.

• Bleeding on probing.

• Probing depth clinically.

• Radiographic bone loss and eventual mobility of the teeth.

• Tooth loss.

The patient is assessed usually in 4 stages depending on the presenting grade and stage of clinical symptoms dentally:

Stage 1 - Associated with early attachment loss and gingival recession around the teeth.

Stage 2 - Moderate periodontal disease with attachment loss around the teeth.

Stage 3 - Severe periodontal disease with attachment loss around the teeth.

Stage 4 - Severe damage to the teeth resulting in high-grade mobility, loss of the teeth, and difficulty in chewing and speech.

The given below general clinical features of scurvy are the common systemic manifestations to diagnosis:

• Malaise or fatigue.

• Inflammation of bone or joints accompanied by pain or generalized edema can be present.

• Mood swings or depression.

• Anxiety and irritability.

• Tooth mobility.

• Some patients may be anemic also (low hemoglobin).

• Purpuras (can be spontaneous with bleeding lesions occurring on the skin and oral mucosal membranes).

• Petechiae.

• Ecchymosis.

• Blurred vision.

• Headaches.

• Photosensitivity or light sensitivity.

• Pathologic fracture of bones (ascorbic acid deficiency in the bone matrix).

• Neuropathies and convulsions may be a common feature in severe cases of scurvy.

How Can We Manage Vitamin C Deficiency?

1. The treatment for scurvy typically involves management by the physician through oral or injectable administration of vitamin C supplementation of usually 1000 mg/1g for three days followed by 500 mg for one week and then 100 mg up to 3 months. Though this is the recommended dosage, physician prescription is essential, and the dosage varies based on the clinical severity of scurvy.

2. However, dental management will involve scaling, root planing, and periodontal or gingival surgery followed by prosthetic protocols if needed in patients as attachment loss eventually may result in tooth loss.

3. Also, severe periodontal disease leading to tooth mobility cannot be reversed.

Conclusion:

To conclude, though vitamin C supplementation may help considerably improve the quality of life in these patients, adverse impacts on periodontal and irreversible oral health effects of this deficiency need strict dental management by the dental surgeon.

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