An interesting article titled “Bleeding tendency and ascorbic acid requirements: systematic review and meta-analysis of clinical trials” written by P. P. Hujoel et al., appears in the 2021 edition of Nutrition Reviews (Vol. 79, no. 9, pp. 964–975). The authors sought out to conduct a systematic review and meta-analysis of controlled clinical trials on whether ascorbic acid also known as Vitamin C supplementation leads to less bleeding of the gums on gentle probing also described as gingival bleeding tendency and (2) to relate Vitamin C plasma levels to bleeding of the eye known as retinal hemorrhaging.
In the study, the authors investigated 15 prior clinical trials in six: India, Indonesia, Italy, Germany, the United Kingdom, and United States, with 1,140 participants with 97.4% of them being healthy, with measures of gingival bleeding tendency. The authors also looked at data from 8,210 U.S. residents surveyed in the Centers for Disease Control and Prevention’s Health and Nutrition Examination Survey (NHANES) III, with measures of retinal hemorrhaging. The authors found that bleeding of the gums on gentle probing and also bleeding in the eye were both associated with low bloodstream vitamin C levels. Further, the authors found that increasing daily intake of vitamin C in those with low vitamin C plasma levels helped to reverse bleeding of the gums and bleeding in the eye.
In the article the authors discuss how Vitamin C is also used to help prevent scurvy – which is a deadly disease that was more common centuries ago. They discuss how the World Health Organization (WHO) states that 0 mg of Vitamin C intake for 1 month, within the context of 45 mg daily AA supplementation, safely protects against scurvy. The authors present a dose response curve for how Vitamin C supplementation is related to estimate baseline Vitamin C plasma levels in the context of gum bleeding tendency. From this, they say that that a 0 mg Vitamin C intake for 1 month, within the context of a prior 45 mg daily Vitamin C intake, will lead to a most pronounced increase in gum bleeding tendency which is reversible with Vitamin C supplementation. Thus they are confident that preventing scurvy and preventing an increased gum bleeding tendency have different Vitamin C intake requirements. They feel that Vitamin C recommendations, which are in place to protect against scurvy, are too low today, and that such a low vitamin C intake can lead to a bleeding tendency. As such, the authors suggest organizations like WHO should update their suggest daily Vitamin C intake guidance.
The authors also state that both a gum bleeding tendency and eye bleeding could indicate a problem in one’s microvascular system, and specifically of a microvascular bleeding tendency in the brain, heart and kidneys. It is noted that this microvascular bleeding tendency has been associated serious outcomes of having a stroke. The authors do point out that the study does not show that increasing Vitamin C intake will reduce strokes.
The first author of the article suggests that people try to pay attention to their Vitamin C intake by eating foods rich in Vitamin C such as peppers, oranges, kale, or kiwis. If these foods are not able to be eaten, then Vitamin C supplementation of 100 to 200 milligrams a day should occur. The first author expresses concern that people who follow paleo diets may particularly not have these Vitamin C rich foods in their diet and thus need supplementation.
The authors also discuss how an association between gum bleeding and Vitamin C levels was first shown in some work in articles in 1986 and 1991 which identified gum bleeding as a biological marker for vitamin C levels. The authors of the study are concerned that the dental professional as a whole has been recommending brushing or flossing to treat gum bleeding without also mentioning that Vitamin C levels may need to be increased to get at the root cause of the problem. The first author states:
“There was a time in the past when gingival bleeding was more generally considered to be a potential marker for a lack of vitamin C. But over time, that’s been drowned out or marginalized by this overattention to treating the symptom of bleeding with brushing or flossing, rather than treating the cause.”
These studies over 30 years ago pointed out above, showed that even with good oral health and frequent brushing and flossing, an increased gum bleeding tendency could not be reversed without also incorporating increased Vitamin C intake. The authors state:
“A default prescription of oral hygiene and other periodontal interventions to ‘treat’ microvascular pathologies, even if partially effective in reversing gingival bleeding as suggested in this meta-analysis, is risky because it does not address any potential morbidity and mortality associated with the systemic microvascular-related pathologies.”
The article makes clear several points. First is that a lack of enough Vitamin C can cause increased gum bleeding tendency and also increase bleeding of the eye. The second, is that both of these can be reversed with getting enough Vitamin C through the diet or through supplementation (100 to 200 mg a day minimum). The third is that the dental professional as a whole has been overly promoting addressing increased gum bleeding tendency by saying to brush or floss regularly when for some the problem may lie with a lack of Vitamin C intake. Such continued recommendations can have potential deadly or serious consequences as retinal hemorrhaging and cerebral strokes are associated with an increased gum bleeding tendency.
Additional Source:
Jake Ellison, “Bleeding gums may be a sign you need more vitamin C in your diet,” University of Washington News, January 31, 2021.