Gingival Enlargement Caused by Vitamin C Deficiency (Scurvy) in a Boy

Abstract

Localized gingival enlargement associated with vitamin C deficiency (scurvy) is rarely encountered in the modern era. The purpose of this paper is to report a case of extensive inflammatory gingival enlargement in the mandibular anterior region associated with vitamin C deficiency in a 10 year-old boy. There was a significant improvement of the gingival enlargement seven days after starting oral vitamin C supplementation. Vitamin C deficiency should be included in the differential diagnosis of any gingival enlargement, especially in children.

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JDC CASE REPORT
40 Kakade et al. Journal of Dentistry for Children-85:1, 2018
Gingival enlargement caused by scurvy
ABSTRACT
Localized gingival enlargement associated with vitamin C deciency (scurvy) is rarely
encountered in the modern era. e purpose of this paper is to report a case of exten-
sive inammatory gingival enlargement in the mandibular anterior region associated
with vitamin C deciency in a 10 year-old boy. ere was a signicant improvement of
the gingival enlargement seven days after starting oral vitamin C supplementation.
Vitamin C deciency should be included in the dierential diagnosis of any gingival
enlargement, especially in children. (J Dent Child 2018;85(1):40-2)
Received October 11, 2017; Last Revision November 29, 2017; Accepted December
1, 2017.
K:  ,  , ,   
1
Dr. Kakade is a professor and head, and
3
Dr. Santosh is a graduate
student, Department of Pediatric Dentistry; Drs.
2
Raut and
4
Nagar are
graduate students,
5
Dr. Bansal is a professor, and
6
Dr. Desai is a profes-
sor and head, Department of Oral Pathology, all at the Nair Hospital
Dental College, Mumbai, India.
Correspond with Dr. Desai at nansrd@hotmail.com
Vitamin C deficiency (scurvy) was initially ob-
served in sailors with inadequate intake of
ascorbic acid during their lengthy sea voyages,
resulting in spontaneous bleeding associated with ab-
normal gingival enlargement.1-3 Vitamin C, also known
as ascorbic acid, is an essential nutrient obtained from
dietary supplements. Humans are unable to produce
ascorbate due to the absence of the enzyme gulono-
lactone oxidase, which catalyses the last enzymic step in
ascorbate synthesis.3 Vitamin C is involved in various
hydroxylation reactions, redox homeostasis, collagen bio-
synthesis and maturation.3 It is also important for the
eective functioning of the immune system.3 However,
scurvy is rarely encountered in the modern industrialized
era.4,5
Gingival Enlargement Caused by Vitamin C Deficiency
(Scurvy) in a Boy
Adesh Kakade, BDS, MDS1 Mugdha S. Raut, BDS2
Anitha Santosh, BDS3 Saurabh Nagar, BDS4
Shivani Bansal, BDS, MDS5 Rajiv S. Desai, BDS, MDS6
e purpose of this paper is to report a case of exten-
sive gingival enlargement in the mandibular anterior
region associated with vitamin C deciency (scurvy) in
a boy. Oral supplementation with vitamin C (ascorbic
acid) and oral prophylaxis was eective in signicantly
reducing the gingival enlargement, avoiding the need for
surgical excision.
CASE REPORT
An apparently healthy 10 year-old boy of low socioeco-
nomic status was referred by the Department of Pediatric
Medicine, Lokmanya Tilak Municipal General Hospital,
to the Department of Pediatric Dentistry, Nair Hospital
Dental College, both in Mumbai, India, for evaluation of
swollen and bleeding gingiva of one-month duration
during the month of Ramadhan. Gingival swelling pro-
gressed within the last 15 days and was associated with
bleeding and tenderness, especially while brushing the
teeth and eating. His mother reported he had poor dietary
habits, including not eating any fruits or vegetables. She
said he complained about pain in his lower extremities

Kakade et al. 41
Gingival enlargement caused by scurvy
Journal of Dentistry for Children-85:1, 2018
and had a tendency to limp while walking. e patient’s
medical and family history was noncontributory and
gave no history of medication known to provoke gin-
gival enlargement. His body mass index was 18.7, which
was within the normal range (18.5 to 24.9). Extraoral
examination was non-signicant. No lymphadenopathy
was observed.
An intraoral examination revealed bluish-red, soft,
tender, hemorrhagic gingival enlargement extending from
the distal aspect of the primary left rst molar to the
mesial aspect of the primary right canine covering one
third to one half of the crown portion of the teeth (Fig-
ure 1). Bleeding on slight provocation was also observed.
Oral hygiene was fair and local factors, such as plaque
and calculus, were minimal. A panoramic radiograph did
not reveal bone loss in the mandibular anterior area asso-
ciated with the gingival enlargement (Figure 2). Hema-
toma, hamartoma, drug-induced gingival enlargement,
hereditary gingival bromatosis, plaque-induced gingi-
vitis, acute necrotizing gingivitis, peripheral giant cell
granuloma, periodontitis as a manifestation of systemic
disease such as leukemia, acquired gingival enlargement
such as ascorbic acid-deciency gingivitis, and oral squa-
mous cell carcinoma were considered in the dierential
diagnosis.
A laboratory blood analysis revealed a low hemoglobin
level (11.4 g/dL; reference level: 12.5 to 16.5 g/dL) and
elevated erythrocyte sedimentation rate (53 mm/hr; re-
ference level: 0 to 20 mm/hr). Bleeding time and clotting
time were within normal limits. Bleeding time was 2.30
minutes (reference level: 1 to 9 minutes); clotting time
was 5.45 minutes (reference level: 3 to 11 minutes). A
peripheral blood smear revealed no abnormalities of the
leukocytes. Based on hematological ndings and peri-
pheral blood smear, leukemic gingival enlargement was
ruled out. Poor dietary habits, pain in the lower extremi-
ties, limping while walking, and rapidly progressing gin-
gival growth in the present case suggested an underlying
systemic condition consistent with vitamin C deciency.
e patient underwent a plasma vitamin C level test,
which was found to be 1.42 ug/mL (normal range: 2 to
14 ug/mL). Based on these test results, the patient was
diagnosed with gingival enlargement caused by vitamin
C deciency.
e patient and his parents were instructed to change
his dietary habits and he was prescribed oral vitamin C
supplementation (500 mg per day) for one month. Oral
hygiene was maintained without any surgical periodontal
treatment, and supragingival and subgingival ultrasonic
scaling were done. e patient’s response to the treatment
was dramatic within seven days (Figure 3). After one
month of oral supplementation of ascorbic acid, the gin-
gival overgrowth was signicantly reduced (Figure 4).
e pain in the lower extremities disappeared and no
limping was observed after one month. e patient was
kept under observation for six months; he revealed no
recurrence of gingival enlargement, and his plasma vita-
min C level was 6.1 ug/mL at the last visit.
Figure 1. Intraoral photograph showing bluish-red, soft, tender,
hemorrhagic gingival enlargement on the mandibular anterior
region on the first visit.
Figure 4. Significant gingival improvement after one month
of oral vitamin C supplementation.
Figure 3. Significant gingival improvement after seven days
of oral vitamin C supplementation.
Figure 2. Panoramic radiograph revealing absence of bone
loss in the mandibular anterior region associated with gingival
enlargement.

42 Kakade et al. Journal of Dentistry for Children-85:1, 2018
Gingival enlargement caused by scurvy
DISCUSSION
Scurvy is the nutritional deciency state associated with a
reduced level of vitamin C, which leads to defective col-
lagen synthesis and maturation along with other meta-
bolic derangements.5,6 Ascorbic acid is readily available,
mainly from citrus fruits, green vegetables, potatoes, and
tomatoes.7,8 According to the World Health Organiza-
tion, a serum vitamin C level less than two ug/mL is
considered deficient and associated with a high risk
of scurvy.9 Although gingival bleeding associated with
enlargement is a common oral manifestation of both
scurvy and periodontal disease, these two conditions are
each distinct entities.10 Gingival bleeding and enlarge-
ment in scurvy are due to the defective collagen synthesis
and maturation associated with avitaminosis-C; similar
manifestations in various periodontal diseases are the
result of inammatory response against localized etio-
logical factors like plaque and calculus.7,4,10 Thus,
vitamin C should not be used prophylactically for cure
of periodontal disease in otherwise healthy, well-
nourished pediatric patients.10
Similar to our ndings, high inammatory markers in
the form of elevated erythrocyte sedimentation rate and
musculoskeletal problems in vitamin C deciency has
been reported.11 Under physiological conditions, ascorbic
acid facilitates the absorption of iron from the gastro-
intestinal tract by converting the ferric state (plus three)
to the ferrous state (plus two). In vitamin C deciency,
this process gets hampered, which explains the anemic
status of our patient.12,13
Treatment of scurvy involves ingesting approximately
6.5 mg of vitamin C daily, but a dose that both corrects
the decit and rapidly replenishes the body stores ra-
pidly is 100 mg three times a day.14 e prognosis of
scurvy is excellent with this treatment, and manifesta-
tions of scurvy tend to resolve rapidly, disappearing
completely within a few weeks.4,7
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