|Year : 2018 | Volume
| Issue : 5 | Page : 256-261
Vitamin C supplementation as an adjunct to nonsurgical therapy in the treatment of chronic periodontitis: A clinical and biochemical study
U Raghavendra1, Anupama Rao2, Shankar Rajesh Kashyap2, Jyothi D'Souza1, Vijaya Kumar2, Bhuvanesh Sukhlal Kalal3, Neevan D'Souza4
1 Department of Biochemistry, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
2 Department of Periodontology, Yenepoya Dental College, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
3 Department of Biochemistry, Yenepoya Medical College; Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
4 Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
|Date of Web Publication||24-Oct-2018|
Dr. Anupama Rao
Department of Periodontology, Yenepoya Dental College, Yenepoya (Deemed to be University), Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: The aim of the present study is to assess the effectiveness of Vitamin C supplementation, a known antioxidant, on periodontal health in patients with chronic periodontitis (CP) and salivary total antioxidant capacity (TAOC) levels. Materials and Methods: A sample of 50 patients diagnosed with CP and 50 healthy controls were selected for the present study. Fifty CP patients were further randomly divided into two groups. CP1 (25 patients received nonsurgical therapy alone) and CP2 (25 patients received Vitamin C supplementation (1500 mg/day) as an adjunct to nonsurgical therapy). Clinical parameters such as plaque index (PI) gingival index (GI), gingival bleeding index (GBI), pocket depth (PD), and clinical attachment level (CAL) were recorded at 1-month and 2-month post therapy. Salivary TAOC levels were measured by Koracevic's method at baseline and 2 months' post therapy. Results: Patients with CP showed lower salivary TAOC compared to control group (P < 0.001). There was a highly significant reduction in all the clinical parameters and salivary TAOC levels in CP1 and CP2 at 1-month and 2-month post therapy. CP2 group showed significant reduction in GBI score (P < 0.001) but failed to report any statistically significant improvement in PI, GI, PD, CAL, and in salivary TAOC levels compare CP1 group. Conclusion: Vitamin C supplementation showed significant reduction in GBI score at 1-month and 2-month post therapy but failed to show any additional benefit in reduction of PI, GI, PD, CAL, and in salivary TAOC levels compare to nonsurgical therapy. Further long-term investigation needs to be conducted to validate the results of the present study.
Keywords: Chronic periodontitis, periodontal health, salivary total antioxidant capacity, Vitamin C
|How to cite this article:|
Raghavendra U, Rao A, Kashyap SR, D'Souza J, Kumar V, Kalal BS, D'Souza N. Vitamin C supplementation as an adjunct to nonsurgical therapy in the treatment of chronic periodontitis: A clinical and biochemical study. J Int Oral Health 2018;10:256-61
|How to cite this URL:|
Raghavendra U, Rao A, Kashyap SR, D'Souza J, Kumar V, Kalal BS, D'Souza N. Vitamin C supplementation as an adjunct to nonsurgical therapy in the treatment of chronic periodontitis: A clinical and biochemical study. J Int Oral Health [serial online] 2018 [cited 2022 Oct 6];10:256-61. Available from: https://www.jioh.org/text.asp?2018/10/5/256/243852
| Introduction|| |
Onset and progression of chronic periodontitis (CP) occur in response to bacterial plaque and toxic products resulting from host-microbe interactions. Over the past few years, strong evidence has emerged to implicate the role of oxidative stress in the pathogenesis of CP.
Increase in production of reactive oxygen species (ROS) due to overactivation of neutrophils in response to dental plaque is detrimental to periodontal health. Most cases of CP are successfully managed by reducing the microbial load. Still due to its multiple and complex contributing factors, successful management of CP can be very challenging.
Several studies have reported possible positive influences of nutritional supplementation on periodontal therapeutic outcomes.,, Vitamin C is a potent antioxidant essential for maintaining the integrity of connective tissue, osteoid tissues, and dentine. Even though low Vitamin C intake does not cause periodontitis, its severe deficiency tends to results in acute spontaneous gingival bleeding seen in scurvy.
The current evidence is insufficient to support the recommendation of mono-antioxidant vitamin supplements. Supplementation with Vitamin C may result in cost-effective, noninvasive, adjunctive protocol to potentiate most predictable outcome of conventional periodontal therapy. The present study aims to estimate the salivary total antioxidant capacity (TAOC) and to assess the efficacy of Vitamin C as an adjunct to nonsurgical therapy in the treatment of CP.
| Materials and Methods|| |
A total of 100 individuals (50 with CP and 50 healthy controls) were recruited for a single centered investigator blind, prospective, randomized control study from the outpatient department of periodontology over the period of 2 months [Figure 1]. The study protocol was in accordance with the Consolidated Standards of Reporting Trials guidelines. Ethical clearance was obtained from the Yenepoya University Ethics Committee (Ref. No.YUEC/2015/045) before the study. Informed consent was obtained from all the study individuals, and confidentiality of the data was maintained throughout the study.
All the individuals of age group 35–60 were from Dakshina Kannada district, systemically healthy, and had a minimum of 20 scorable teeth present. Individuals were excluded from the study if (1) they use of nonsteroidal anti-inflammatory drugs or antimicrobial drugs, mouthwashes, or vitamin/antioxidant supplements within a 3-month period before the commencement of the study, (2) they are on special dietary requirements, (3) history of any medication affecting salivary secretion during the past 3 months, (4) history of any known intolerance/allergy to Vitamin C supplementation, (5) history of periodontal therapy in the previous 6 months, and (6) pregnant and lactating women.
There were 50 patients with CP (American Academy of Periodontology - 1999) defined as two or more tooth sites with pocket depth (PD) ≥4 mm or clinical attachment level (CAL) of 4 mm that bled on probing. Control group of 50 individuals were having clinically healthy periodontium with no probing PD >3 mm at any site, full mouth bleeding scores <10%, with no evidence of CAL ≤1 mm and also with no history of systemic disease.
After recruitment, a total of 100 individuals (50 with CP and 50 with clinically healthy periodontium) who fulfill the selection criteria were subjected to unstimulated whole salivary sample collection for biochemical estimation of TAOC by Koracevic's method. The American Dental Association approved toothpaste; free of anti-inflammatory, antioxidant agent (200 g) was prescribed to all the participants for brushing the teeth. The modified bass technique was introduced to all the participants as the tooth brushing technique of choice. All the participants received oral instructions for maintaining a good oral hygiene. On the same appointment, CP patients were randomly allocated using computer-generated random numbers into Group I (CP1) and Group II (CP2) and subjected to assess clinical indices such as plaque index (PI), gingival index (GI), and gingival bleeding index (GBI). CAL (from cementoenamel junction to the base of sulcus/pocket) and probing PD (from the crest of gingival margin to the base of the pocket) was recorded using Williams's periodontal probe.
Patients in CP1 were treated only with conventional nonsurgical therapy (scaling and root planing) using hand instruments and ultrasonic scalers, whereas patients in CP2 underwent similar nonsurgical therapy along with daily supplementation of Celin 500 mg chewable Tablet (Ascorbic acid [Vitamin C] Glaxo SmithKline Pharmaceuticals Ltd.,) as a part of routine periodontal therapy, thrice daily for 2 months. Clinical measurements were repeated after 1- and 2-month post therapy. At the end of 2 months, unstimulated whole saliva of the patients of CP1 and CP2 were collected and subjected for estimation of salivary TAOC by Koracevic's method.
Collection of saliva
Individuals were asked not to eat or drink 1 hr before the sample collection. A volume of 2 ml of unstimulated whole saliva was collected by spitting method into a sterile container. The collected sample was centrifuged at 3000 rpm for 15 min and the supernatant was stored at −20°C until the biochemical analysis. The biochemical analysis of TAOC was done using Koracevic's method.
Principle behind Koracevic's method
Standardized solution of Fe–ethylenediaminetetraacetic acid complex interacts with hydrogen peroxide by a Fenton-type reaction, leading to the formation of hydroxyl radicals (•OH). These ROS dissolute benzoate, leading to liberation of thiobarbituric acid reactive substances (TBARS), Antioxidants from the added sample of saliva cause suppression of the production of TBARS. The analysis of this reaction is done spectrophotometrically. Statistical analysis was performed using IBM Statistical Program for Social Sciences IBM® SPSS® Statistics V22.0 (SPSS Inc., Chicago Illinois, USA). The descriptive statistics mean, standard deviation, were calculated and presented in [Table 1] and [Table 2]. Within the group comparisons of PI, GI, GBI, PD, CAL at baseline, 1-month post therapy, 2-month post therapy between CP1 and CP2 were analyzed by repeated measures ANOVA. The Bonferroni correction was done to adjust probability (P values) to avert the increased risk of Type I error when making multiple comparison. The Salivary TAOC level at baseline between CP1, CP2, and control group were compared using one way ANOVA and Tukey HSD post hoc test. Intergroup comparisons of and PI, GI, GBI, PD, CAL, and TAOC were analyzed by Student's t-test. P < 0.05 was considered statistically significant.
|Table 1: Intergroup comparison of mean scores of plaque index, gingival index, gingival bleeding index, pocket depth, clinical attachment level between chronic periodontitis 1 and chronic periodontitis 2 at 1 and 2 months post therapy|
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|Table 2: Mean salivary total antioxidant capacity levels between chronic periodontitis 1 and chronic periodontitis 2 and control group|
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| Results|| |
The mean PI, GI, GBI, PD, CAL of CP1 and CP2 groups at baseline, 1- and 2-month post therapy are shown in [Table 1]. There was no statistically significant difference in clinical measures when compared with CP1 and CP2 except PI and GBI which showed statistically significant improvement in CP2 group compared to CP1 group at 1- and 2-month post therapy [Table 1].
At baseline, 1- and 2-month post therapy, there was no significant difference in plaque scores between CP1 and CP2.
Gingival bleeding index
There was a significant difference observed in mean scores of GBI between CP1 and CP2 at 1- and 2-month post therapy between CP1 and CP2. Two-month post therapy GBI score for CP1 was 24.09 ± 7.17 compare to CP2 score of 18.26 ± 4.20. It significantly reduced in CP2 group compare to CP1 group.
Gingival index, pocket depth, and clinical attachment level
There was no significant difference observed in mean scores of GI, PD, and CAL between CP1 and CP2 at baseline, 1- and 2-month post therapy between CP1 and CP2.
Intragroup comparison of clinical parameters
There was significant improvement PI, GI, GBI, PD, CAL scores at 1- and 2-month post therapy in both groups (CP1 and CP2) compared to baseline scores (P < 0.001).
The mean salivary TAOC levels for all study groups at baseline and 2-month post therapy are presented in [Table 2].
Inter group comparison of salivary total antioxidant capacity
At baseline, there was statistically significant difference observed among CP1 (535.64 ± 75.67) and control group (793.97 ± 34.02) as well as in CP2 (502.78 ± 59.05) and control group (793.97 ± 34.02) (P < 0.001), but there was no significant difference in mean salivary antioxidant levels between CP1 and CP2 (P = 0.053). At 2-month post therapy comparison of mean salivary antioxidant levels between CP1 and CP2 was statistically nonsignificant (P = 0.343).
Intragroup comparison of salivary total antioxidant capacity
Mean salivary TAOC levels increased from baseline to 2-month post therapy in both CP1 and CP2. It was statistically significant (P < 0.001).
| Discussion|| |
The role of Vitamin C as an antioxidant and immune-modulatory factor has been proven in many chronic inflammatory diseases. Vitamin C as an antioxidant controls excessive production of ROS in chronic inflammatory diseases. Low levels of Vitamin C in blood may exacerbate preexisting periodontitis. The premise for the current study is based on the hypothetical association for the requirement of additional Vitamin C to counter increased oxidative stress resulting from CP.
In our study, we found that there was a significant improvement in intragroup comparison of PI, GI, GBI, PD, CAL at 1- and 2-month post therapy in both CP1 and CP2. At the end of 2 months, GBI showed significant improvement with Vitamin C supplementation (1500 mg/day) as an adjunct to nonsurgical therapy in CP2 group (P > 0.001) compared to nonsurgical therapy in CP1. However, it failed to show significant improvement in PI, GI, PD, CAL in CP2 compared to CP1. Our result was substantiated by the study of Leggott et al., which showed Vitamin C supplementation improved gingival bleeding and depletion of the same increased percentage of sites with gingival bleeding. The reason behind the reduction of GBI score without any change in PI score in CP2 compared to CP1 could be due to known role of Vitamin C in formation and maintenance of endothelial collagen and intercellular elements of entire vasculature including capillaries. Study results by Staudte et al., showed significant reduction of the sulcus bleeding index without any change in PI and PD after grapefruit consumption for 2 weeks' period was also consistent with our results. In contrast, a study by Abou Sulaiman and Shehadeh, and Vogel et al., did not find statistical significance in any clinical parameters including GBI when megadoses of Vitamin C supplementation was given as an adjunct to scaling and root planing.
In the present study, salivary TAOC was measured instead of individual antioxidant level as it offers the accumulative effect of all antioxidants in saliva and protects against free radicals during chronic inflammation rather than individual AO alone. To measure salivary TAOC levels in the current study, we used Koracevic method of salivary TAOC assessment as it is easy, rapid, reliable, and practical for the routine measurement of total antioxidant activity in all the body fluids.
The result of the present study showed a significant reduction in salivary TAOC value in patients with CP compared to healthy controls. This is in accordance with the results of the study by Brock et al., which showed a reduction in systemic and local antioxidant capacity in CP. This reduction in the levels of salivary TAOC could be due to increased production of ROS by PMN cells and decreased antioxidant defenses in patients with CP. At the end of 2-month post therapy, CP1 and CP2 showed higher TAOC in saliva from baseline level, but intergroup comparison failed to show statistically significant difference among CP1 and CP2. It is accordance with Abou Sulaiman and Shehadeh, study who found that TAOC levels improved 1- and 3-month post therapy but did not show statistically significant difference with or without Vitamin C supplementation to nonsurgical therapy.
The reason for not showing statistically significant difference in salivary TAOC levels with Vitamin C supplementation at 1- and 2-month post therapy in spite of showing significant improvement in GBI may be due to lack of gold standard method in determining total AO status of saliva. It is suggested to use many comparable methods to achieve accurate measurement of TAOC., It is also known that Vitamin C is a weak antioxidant in vivo, and it has specific role in certain reactions in specific location which may not be detected by laboratory investigations. It will also be useful to carry out the measurement of Vitamin C rather than TAOC levels alone in saliva.
Limitation of the present study includes the inability to control the daily intake of Vitamin C through diet in the patients of both test groups and also to assess drug compliance by patients in the test group. Our results should be interpreted with caution, as our study included small sample size, and they were from a coastal part of Dakshina Kannada; and hence, it is not possible to extrapolate the results to the entire population. Further multicentric, longitudinal studies with larger sample size should be undertaken to investigate the additional role of Vitamin C supplementation in CP.
| Conclusion|| |
Our study shows obvious lower levels of salivary TAOC in CP compared to healthy periodontium. Nonsurgical therapy with and without Vitamin C significantly improves salivary TAOC. Moreover, additional supplementation of Vitamin C for 2 months reduced gingival bleeding in spite of no change in PI compared to nonsurgical therapy alone. The role of Vitamin C in reducing gingival bleeding does substantiate the need for Vitamin C systemic supplementation to potentiate most predictable outcome of conventional periodontal therapy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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