JDC CASE REPORT

Severe Gingivitis Associated with Ascorbic

Acid-Deficiency in a Pediatric Patient

Allison J. Brand, DMD 1 Michael B. Lieberman, DDS 2

Evlambia Hajishengallis, DDS, DMD, MSc, PhD 3

ABSTRACT
Plaque-induced gingivitis, a common condition in children, responds well to
proper oral hygiene practices. Persistent severe gingivitis, on the other hand, should
prompt investigation of etiological factors. Nutritional elements are implicated in
periodontal health. This case report describes a pediatric patient with severe persistent
gingivitis caused by vitamin C deficiency. The events that led to a diagnosis of
scurvy and a resolution of the systemic and localized manifestations of the disease,
after vitamin C administration, are presented. It is recommended that vitamin C
deficiency be considered in cases of refractory gingivitis, especially in pediatric patients
with special health care needs who have aversion to foods rich in ascorbic acid.
(J Dent Child 2019;86(2):125-8)
Received February 14, 2019; Last Revision March 23, 2019; Accepted March 25, 2019.
Keywords: vitamin c, scurvy, periodontal disease

P
laque-induced gingivitis, characterized by gingival
inflammation with no attachment or bone loss,
is the most common periodontal disease in chil-
dren. Uncommon in early primary dentition, gingivitis
is found in approximately 50 percent of four- to five-
year-old children and young adults, and 100 percent of
adolescents.1
Inadequate oral hygiene is the most frequent cause
of gingivitis. However, local or systemic factors, includ-
ing malnutrition, can exacerbate the severity of plaque-
induced gingivitis. 2-5 One of the nutritional factors
implicated in periodontal health is vitamin C (ascor-
bic acid).6 Vitamin C-dependent enzymes catalyze the
hydroxylation of lysine and proline, which is necessary
for the folding of collagen into its functional structure.7
Thus, vitamin C deficiency can particularly affect
1
Dr. Brand is a resident, 2Dr. Lieberman is a clinical associate, and 3Dr.
Hajishengallis is a professor, graduate program director and chief, all
in the Division of Pediatric Dentistry, Department of Preventive and
Restorative Sciences, The University of Pennsylvania School of Dental
Medicine, University of Pennsylvania, Philadelphia, Pa., USA.
Correspond with Dr. Hajishengallis at evalmbia@upenn.edu
connective tissues high in collagen, such as the gingiva.
Those at risk for vitamin C deficiency usually include
elderly individuals, adults with smoking or other addic-
tions, individuals from lower-income households or
with stressful lives, pregnant women, and individuals
who are treated in hospitals (e.g., patients on main-
tenance hemodialysis).8
The purposes of this paper are to present an unusual
case of a 10-year-old girl with persistent severe gingi-
vitis caused by vitamin C deficiency, and discuss the
symptoms and events that led to the diagnosis and the
treatment rendered.
CASE REPORT
A 10-year-old Caucasian girl presented to the Dental
Medicine (PDM) Pediatric Clinic of the University of
Pennsylvania, Philadelphia, Pa., USA, one week follow-
ing an anaphylactic reaction to milk proteins. Her chief
complaint was excessive bleeding and swollen and pain-
ful gingiva. A review of the patient’s medical history
revealed extreme prematurity (23-week), ligated patent
ductus arteriosus, bronchopulmonary dysplasia, asthma,

Journal of Dentistry for Children-86:2, 2019 Severe gingivitis and scurvy Brand et al. 125
 performed but found to be normal (Table).
Table. Patient’s Blood Test Results Improvement of oral hygiene and utili-
zation of chlorhexidine gluconate mouth-
Date of testing Reference
range rinse would significantly resolve the
1/5/2017 3/29/2018 4/9/2018 4/19/2018 patient’s oral condition; therefore, a diag-
nosis of severe gingivitis due to poor oral
WBC (x103/µL) 8.2 7.0 4.8 5.9 3.7-10.5 hygiene was not excluded.
RBC (x10 /µL)
6
5.06 4.63 3.41 3.16 3.9-5.45 The patient presented with irritability,
Hemoglobin g/dL 13.3 11.8 8.7 8.1 11.7-15.7 left leg limp, petechiae on both legs, and
hematoma on the left thigh in the location
Hematocrit (%) 39.8 36.5 26.7 26.0 34.8-45.8
where an Epi-pen injection was admin-
Platelet (x103/µL) 276 315 232 321 176-407
istered during her allergic reaction. Due
PT/INR (seconds) 13.2 111.6-13.8 to her poor cooperation, a limited intra-
PTT (seconds) 21 22.0-36.0 oral examination revealed edematous,
Factor VIII (%) 184 49-191 spontaneously-bleeding granulomatous
lesions and hematomas on the mandibular
Ferritin (ng/mL) 55.4 10-82
and maxillary anterior gingiva (Figure 1).
Iron Profile (mg/dL) 43 25-140
The patient was diagnosed again with
Vitamin B12 (pg/mL) 413 168 247-1,174 severe gingivitis; oral hygiene, including
Vitamin E (mg/L) 7.6 4.8 5.5- 9.0 the use of chlorohexidine gluconate mouth-
Vitamin A (mg/L) 0.36 0.20-0.50 rinse, was reemphasized.
At the one-week follow up, her deteri-
Vitamin C (µmol/L) <5 23-114
orating oral condition, especially after her
recent stressor event (allergic reaction),
WBC: White blood cells. µL: microliter. RBC: Red blood cells.
g/dL: grams/deciliter. PT/INR: Prothrombin time/International normalized ratio.
suggested diagnosis of acute necrotizing
PTT: Partial thromboplastin time. ng/mL: nanograms/milliliter. ulcerative gingivitis (Figure 2), which
mg/dL: milligrams/deciliter. pg/mL: picograms/milliliter. prompted us to prescribe metronidazole
mg/L: milligrams/Liter. µmol/L:micromoles/Liter.
(200 mg every eight hours) for five days;
however, this did not improve the patient’s condition.
gastroesophageal reflux, milk allergy, autism, develop- Concurrently, the patient’s limping increased and her
mental delay, swallowing difficulty, food aversions, and a pediatrician suggested a leg radiograph and orthopedic
diet consisting of a limited selection of fruits and vegeta- evaluation, both of which were unremarkable. The pa-
bles, soy yogurt, and chicken nuggets. tient’s condition continued to decline, leading to an
A review of the patient’s dental history showed mul- emergency room visit and hospitalization for a hemato-
tiple visits to the PDM, during which she was diagnosed logical evaluation. On that admission, the patient was
with poor oral hygiene and, at times, severe gingivitis. found to have normal factor VIII, ferritin, prothrombin,
To rule out systemic contributing factors, blood meta- partial thromboplastin time, Von Willebrand factor and
bolic and vitamin (excluding vitamin C) testing was iron, and low hemoglobin and hematocrit levels (Table).
An ultrasound exam showed subcutaneous edema and
hemorrhage behind her left knee, probably caused by

Figure 1. Edematous, spontane­o usly bleeding Figure 2. Clinical aspect similar to acute necrotizing ulcerative
granulomatous lesions and hematomas on the gingivitis.
maxillary anterior gingiva.

126 Brand et al. Severe gingivitis and scurvy Journal of Dentistry for Children-86:2, 2019
the Epi-pen injection. The patient was released and
prescribed iron supplements based on the fact that the
patient’s hematocrit and hemoglobin levels were low.
Five days later, the patient was readmitted to the hos-
pital due to spontaneous oral bleeding, increase in
petechiae on both legs (Figure 3), inability to ambulate,
and bruising on her arms and elbows. At that time, the
differential diagnosis included scurvy, Von Willebrand
disease, Glanzmann’s thrombasthenia, and Henoch-
Schoniein purpura. A complete vitamin-panel testing,
including vitamin C, was ordered, and the patient was
released and prescribed vitamin C supplements due to a
high suspicion of scurvy based on the symptoms, clini-
cal manifestations and the fact that any other disease on
the differential diagnosis the medical team considered
was eliminated upon testing.
Figure 3. Petechiae and hematomas in legs.
Test results confirmed the diagnosis of scurvy (Table).
The patient’s vitamin C supplementation was increased,
and she was placed on a strawberry-sweet potato-banana-
chicken diet as a way to reintroduce fruits and vegetables
Figure 4. Significant improvement of perio-
dontal health after vitamin C supplementation.
Journal of Dentistry for Children-86:2, 2019
into her diet. At 10 days post-admission, the patient’s
periodontal health (Figure 4), temperament, leg move-
ment, leg hematoma, and petechiae had improved
significantly. The patient is now monitored regularly
by hematologists and our dental team for her systemic
and oral health.
DISCUSSION
Ascorbic acid is a water-soluble vitamin synthesized by
plants and most animals but not by humans; it is found
mainly in citrus fruits and vegetables.8,9 Vitamin C is an
electron donor/reducing agent; thus, it is considered an
antioxidant.7 It acts as an enzyme co-factor/co-substrate
for 15 mammalian enzymes involved in important meta-
bolic pathways, such as the norepinephrine biosyn-
thesis, collagen hydroxylation, tyrosine metabolism,
carnitine biosynthesis, and histone demethylation.9 The
reducing action of ascorbic acid in the small intestine
appears to be involved in iron absorption, whereas in
the stomach it may prevent formation of N-nitroso
compounds.9 Intracellularly, vitamin C regulates gene
expression, mRNA translation, and prevention of oxida-
tion damage to DNA and proteins. In plasma, it increases
endothelium-dependent vasodilation, reduces extracellular
oxidants from neutrophils and oxidation of low-density
lipoproteins, and quenches aqueous peroxyl radicals and
lipid peroxidation products.9 Following ingestion, vitamin
C is absorbed from the small intestine and distributed
quickly to extracellular spaces, predominantly in the liver,
brain, and skeletal muscles.9
While vitamin C deficiency is considered at a blood
concentration below 23 µmol per liter, the critical level
for development of scurvy is 10 µmol per liter.10 Latent
scurvy symptoms include fatigue, irritability, vague/dull
aching pains, and weight loss, which often lead to mis-
diagnosis such as myopathy, neuropathic conditions, or
hematological malignancy.10 After one to three months
of severe vitamin C deficiency, the potentially lethal
disease scurvy may develop. The sign/symptoms of
scurvy include depression, confusion, anemia, fever,
shortness of breath, infections, coiled hair, severe gingi-
vitis, petechiae, erythema, purpura, arthralgia, bleeding
into the skin, subcutaneous tissues, muscles, and joints.11
Patients may present with only some symptoms/signs of
scurvy, making the diagnosis difficult. Some, but not all,
of the signs/symptoms can be explained based on the
enzyme malfunction caused by vitamin C deficiency. For
example, the tiredness and signs of autonomic dysfunc-
tion might be due to impaired norepinephrine biosyn-
thesis and the breakdown of wounds and the bleeding
gingiva might be due to impaired hydroxylation of
collagen.7 Moreover, the role of vitamin C in the synthesis
of carnitine, which is involved in the oxidation of fatty
acids, may account for the muscle weakness observed in
scurvy.8,12 Additionally, since ascorbic acid is important
in iron absorption, its deficiency may lead to anemia.13
Severe gingivitis and scurvy Brand et al. 127
 In our patient, blood levels of vitamin C were not
tested initially, as deficiency of this vitamin is extremely
rare. Furthermore, our patient did not have and could
not express other symptoms (i.e., muscle weakness) sug-
gestive of vitamin C deficiency. In addition to that, her
poor oral hygiene was consistent with the diagnosis of
severe gingivitis. It was not until her allergic reaction
that other signs/symptoms of scurvy (bruising, petechiae,
limping) surfaced and led to the correct diagnosis and
treatment. Therefore, in the search of systemic factors4,5,14
that could account for the persistence of gingivitis, the
patient’s diet should be considered. If it is restrictive,
vitamin C blood analysis is important.
The recommended dietary daily allowance (RDA)
for vitamin C is 15 mg at one to three years of age,
25 mg at four to eight years of age, 45 mg at nine to
13 years of age, and 75 mg for boys and 65 mg for girls
at 14 to 18 years of age.15 For adults, the RDA is 90 mg
per day for males and 75 mg/day for females. Con-
sumption of the daily-recommended five servings of
fruits and vegetables provides plenty of vitamin C (210
to 280 mg).8,15
Although scurvy is rare in healthy children, its preva-
lence is rising in those with chronic diseases (e.g.,
patients with iron overload following many transfusions),
neurological conditions (e.g., autism and developmental
delay associated with food selectivity), and a history of
chemotherapy or hematopoietic stem cell transplant.10 In
this context, vitamin C deficiency should be considered
in cases of persistent gingivitis in children who have
aversion to foods rich in ascorbic acid. In these pa-
tients, severe gingivitis may be a sign of scurvy. Vitamin
C supplementation in deficient patients can quickly
restore tissues affected and prevent further deleterious
effects.
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