The buccal mucosa in anaemia

Cytomorphometric analysis of buccal mucosal cells in iron deficiency anemia: A cross-sectional study

Background

Worldwide, at any given moment, more individuals have iron deficiency anemia (IDA) than any other health problems. Very few studies have been conducted to evaluate changes in oral mucosa in IDA. The present study is undertaken for cytomorphometric analysis of buccal mucosal cells in IDA. Nuclear diameter (ND), cell diameter (CD), nuclear area (NA), cell area (CA), and nuclear-cytoplasmic ratio (N/C) are measured and compared in buccal mucosal cells of IDA patients and controls.

Aims

To evaluate cytomorphometric changes in epithelial cells of oral mucosa in IDA and to compare these changes with the controls.

Settings and Design

A cross-sectional study.

Methods and Materials

Forty cases of IDA and forty cases of control group were selected for the study. IDA cases were diagnosed with decreased Hb level, MCV, MCH, MCHC and confirmed by decreased serum iron and increased total iron-binding capacity levels. Cytomorphometric analysis of buccal mucosa was performed to study CA, CD, NA, ND, and N/C ratio.

Statistical Analysis Used

Statistical analysis was done using t- test in SPSS software version 4.

Result

Results of our study showed increased cell area, cell diameter, nuclear area, nuclear diameter, and nuclear-cytoplasmic ratio in anemic group as compared to controls.

Conclusion

The study suggests that individuals with IDA regardless of clinically visible oral lesions show cytological changes in oral mucosal epithelium. Knowledge of quantitative alterations in oral epithelial cells of IDA patients is important as these alterations are similar to those seen in precancerous and radiation-induced changes. Cytomorphometry is an efficient tool to understand the extent of cellular changes that occur in oral epithelial cells in IDA.

Iron deficiency anemia and Plummer-Vinson syndrome: current insights

Plummer–Vinson syndrome (PVS), a rare clinical condition, is characterized by a triad of dysphagia, iron deficiency anemia and esophageal web in the post-cricoid region. It was first described over a century ago. However, literature on this condition remains scanty, and its prevalence appears to be declining worldwide, possibly due to improvements in nutrition over time. The condition has been reported most commonly in thin-built, middle-aged, white women. The esophageal webs in PVS are thin mucosal folds, which are best seen either in lateral views at barium swallow or at esophagoscopy. These are usually semilunar or crescentic, being located most often along the anterior esophageal wall, but can be concentric. The exact cause and pathogenesis of PVS remain unclear, though iron and other nutritional deficiencies, genetic predisposition and autoimmunity have all been implicated in formation of the webs. Treatment includes correction of iron deficiency and endoscopic dilation of the esophageal webs to relieve dysphagia. PVS is associated with an increased risk of hypopharyngeal and esophageal malignancies. Correction of iron deficiency may arrest and reverse the mucosal changes and possibly reduces this risk.

Carbohydrates and sulphur-containing compounds in the anaemic buccal epithelium

Mucosal biopsies from the inside of the cheek show epithelial atrophy, glycogen depletion, and an occasional increase in sulphydryl content in both iron-deficiency and megaloblastic anaemias. These changes are the same in the two types of anaemia but are more marked in the latter group.

The tongue and oesophagus in iron-deficiency anaemia and the effect of iron therapy

Biopsies of the tongue and oesophagus were performed on 14 patients with uncomplicated iron-deficiency anaemia before and after treatment with iron. Haemoglobin and serum iron estimations were performed at the same time. Nine patients had clinical evidence of atrophic changes in the tongue before therapy was started. Evidence of regeneration appeared within one or two weeks of starting iron therapy. Two patients showed persistent atrophy. Angular stomatitis and koilonychia were longer in disappearing. Biopsies confirmed that filiform papillae and kerato-hyalin granules are frequently absent from the epithelium of the smooth tongues of iron-deficient patients. Iron therapy is followed by the re-appearance of keratohyalin granules and keratinized filiform papillae. Two patients complained of dysphagia, which disappeared after treatment. No abnormality in the oesophageal epithelium was found in any of the patients either before or after therapy. The relationship of oesophageal carcinoma to antecedent iron-deficiency epithelial changes is considered suspect.

Disaccharidase levels in normal epithelium of the small intestine of rats with iron-deficiency anemia

Iron-deficiency anemia is the nutritional deficiency most frequently occurring throughout the world, which manifests as a complex systemic disease involving all cells, affecting enzyme activities and modifying protein synthesis. In view of these considerations, the objective of the present study was to determine the effects of iron-deficiency anemia on disaccharidases and on the epithelial morphokinetics of the jejunal mucosa. Newly weaned male Wistar rats were divided into 4 groups of 10 animals each: C6w received a standard ration containing 36 mg elemental iron per kg ration for 6 weeks; E6w received an iron-poor ration (5-8 mg/kg ration) for 6 weeks; C10w received an iron-rich ration (36 mg/kg ration) for 10 weeks; E10w received an iron-poor ration for 6 weeks and then an iron-rich ration (36 mg/kg) for an additional 4 weeks. Jejunal fragments were used to measure disaccharidase content and to study cell proliferation. The following results were obtained: 1) a significant reduction (P < 0.001) of animal weight, hemoglobin (Hb), serum iron and total iron-binding capacity (TIBC) in group E6w as compared to C6w; reversal of the alterations in Hb, serum iron and TIBC with iron repletion (E10w = C10w); animal weights continued to be significantly different in groups E10w and C10w. 2) Sucrase and maltase levels were unchanged; total and specific lactase levels were significantly lower in group E6w and this reduction was reversed by iron repletion (E10w = C10w). 3) The cell proliferation parameters did not differ between groups. On the basis of these results, we conclude that lactase production was influenced by iron deficiency and that this fact was not related to changes in cell population and proliferation in the intestinal mucosa.

HISTOLOGICAL FINDINGS IN THE PATERSON-KELLY SYNDROME

Forty-one specimens taken from lesions in the post-cricoid region of patients with the Paterson-Kelly syndrome have been examined. Most webs consist of normal oesophageal mucosa which may be associated with underlying muscle and nerve lesions. Strictures also show a chronic non-specific inflammation often with epithelial changes and sometimes squamous carcinoma. Other lesions observed clinically have also shown malignant change.

Importance of iron repletion in the management of Plummer-Vinson syndrome

Plummer-Vinson syndrome (PVS) is characterized by iron deficiency anemia, upper esophageal stricture, cervical dysphagia, and glossitis. The precise role of iron deficiency in PVS has yet to be defined and remains a subject of much debate. A 29-year-old woman with PVS is presented. The patient had a 4-year history of severe iron deficiency anemia, a 2-year history of progressive dysphagia and weight loss, and a greater than 90% benign upper esophageal stricture. Iron therapy alone resolved her dysphagia and anemia, and a follow-up esophagram 1 year later showed a residual stenosis of less than 30%. The development of severe iron deficiency anemia in this patient 2 years before the onset of dysphagia, as well as the response of the stricture to iron repletion, supports the theory that iron deficiency can cause dysphagia and upper esophageal strictures. The occurrence of glossitis, gastritis, and esophagitis in iron deficiency demonstrates the adverse effects of iron depletion on the rapidly proliferating cells of the upper alimentary tract.

Oral epithelial dysplasia in vitamin B12 deficiency

Widespread soreness and focal ulceration of the oral mucosa developed in a woman with vitamin B12 deficiency shortly after hydroxocobalamin therapy had commenced. An oral mucosal biopsy showed disordered epithelial maturation with marked cytologic atypia. However, during the next month of treatment, the patient's oral mucosa became clinically and histologically normal. Pathologists should be aware that vitamin B12 deficiency may be associated with epithelial changes similar to those associated with premalignancy.

Iron deficiency depresses cell proliferation in hamster cheek pouch epithelium

Iron deficiency anaemia was induced in hamsters by feeding a low iron diet coupled with weekly bleeding. To assess cell proliferation, the stathmokinetic agent vinblastine sulphate was administered and cell birth rates were calculated from cumulative mitotic indices. The rate was significantly reduced in epithelium from iron-deficient animals. The uptake of tritiated thymidine [( 3H]TdR) was also significantly reduced in these animals. Results of both stathmokinetic and labelling experiments indicate that cell production in the cheek pouch epithelium of iron-deficient animals is impaired.

Iron deficiency in the elderly

Iron deficiency in the elderly almost always results from blood loss. The loss of iron can be viewed as occurring in four stages, which are reflected in the different tests used to diagnose iron deficiency. Tests used to diagnose iron deficiency have certain limitations regarding their ability to detect iron deficiency before the overt anaemia occurs. The tests which diagnose iron deficiency most accurately are low serum ferritin and reduced iron staining of a bone marrow aspirate. Because iron is present in many metabolic processes besides the production of haemoglobin, iron deficiency results in a variety of defects which are manifested at biochemical, tissue, and functional levels. Iron is a component of several enzymes in the respiratory electron transport chain. Adequate haem and iron levels are necessary to control cytoplasmic and mitochondrial protein synthesis. Iron deficiency results in tissue defects, including those affecting the gastrointestinal tract, and defects of mitochondria and lymphocytes. Normal iron levels seem to be necessary for normal work capacity. A deficiency of iron, independent of the anaemia, results in reduced exercise capacity that can be measured in both physiological and economic terms. Elderly patients complaining of increased fatigue should therefore be screened for iron deficiency. There is evidence to suggest that iron deficiency may predispose individuals to certain infections. Other information points to the promotion of certain bacterial and parasitic infections after rapid correction of iron deficiency. Thus elderly patients having iron replacement therapy should be followed closely. A deficiency of iron has been shown to result in certain behavioural and learning abnormalities. Iron deficiency has been shown to result in impaired control of body temperature, resulting in an increase in catecholamine levels. The impairment in heat-generating ability was shown to result from reduced conversion of T4 to T3 in the peripheral tissues.

Morphometric analysis of atrophic changes in human lingual epithelium in iron deficiency anaemia

A stereological analysis of epithelial structure at the lateral surface of the tongue showed that iron deficiency anaemia was associated with reduced epithelial thickness despite the absence of overt mucosal abnormalities. The epithelial atrophy was entirely due to a reduction in the size and number of cells in the maturation compartment. By contrast, the progenitor cell compartment was increased in thickness due to an increase in the number of cells. This hyperplastic reaction may be a trophic response to the overall loss of epithelium in this condition.

An example of the use of quantitation in histological diagnosis by a comparison of normal human cheek mucosa and cheek mucosa affected by lichen planus

As an example of the use of quantitation in histological diagnosis the features of normal human cheek mucosa (NHCM) and non-ulcerative lichen planus of the cheek mucosa (LPCM) have been systematically studied and quantified in order to establish normal and pathological features which are constant. The technique enabled the quantitative verification of previously held concepts relating to NHCM and LPCM. A number of interesting features which have been given little attention in past literature were also noted. It is proposed that a reliable quantifiable range of characteristic histological features should be established for use in diagnosis where possible rather than relying on the subjective approach currently employed.

Iron deficiency and iron overload

An up to date review of our knowledge of human iron metabolism is given including problems of iron balance, internal transport, and intracellular mechanisms. Current knowledge of the iron proteins is summarized and this background is used in discussing the pathophysiology of iron deficiency and overload, together with the internal derangements such as sideroblastic anemia which form much of the clinical practice associated with disorders of iron metabolism. The therapeutic approach to these problems will be described.

Effects of iron deficiency on respiration of hamster cheek-pouch epithelium in vitro

Iron-deficiency anaemia was induced in hamsters by feeding a low-iron diet coupled with weekly bleeding. Respiration, assessed by measuring oxygen uptake, was significantly reduced (p less than 0.002) in cheek-pouch epithelia from iron-deficient animals. To relate data on oxygen consumption to cell numbers, the cell densities of the basal and maturation compartments were measured. The cell density of the maturation compartment in iron-deficient animals was significantly reduced (p less than 0.05), whereas that of the basal cell compartment was marginally higher than in control animals. However, the cell density of the tissue as a whole was similar in both groups. Thus, the reduced oxygen consumption in iron deficiency was not due to a reduction in cell numbers. Although there was a significant reduction in epithelial volume in the iron-deficient group, this was not sufficient to account for the reduced oxygen uptake in cheek-pouch epithelia from these animals. It is concluded that iron-deficiency anaemia affects cell respiration directly, probably by interfering with the amounts and/or functions of iron-containing enzymes or cytochromes in the electron-transport chain.

Cell kinetics of hamster ventral tongue epithelium in iron deficiency

The cell-kinetic parameters of labelling index and duration of the S phase of the cell cycle (Ts) were investigated in the ventral tongue epithelium of hamsters with experimentally-induced iron deficiency. The labelling indices in animals with iron-deficiency anaemia and iron deficiency without anaemia did not differ from normal, but the Ts values were significantly shorter indicating an increased cell-production rate. The epithelial cell-kinetic parameters of iron-depleted animals did not differ from normal, but the labelling index was greater than in animals with the more severe stages of iron deficiency.

Oral mucosal changes in iron deficiency anemia in a Sri Lankan female population

The oral mucosal changes in iron deficiency anemia were studied in a selected hospital population. A high incidence of oral lesions was present in the anemic group as compared to age- and sex-matched controls. Atrophic changes of the tongue were quite characteristic clinically, and a significant reduction in the mean epithelial thickness of the buccal mucosa was determined histologically.

Quantitative histological analysis of the epithelium of the ventral surface of hamster tongue in experimental iron deficiency

Quantitative analysis of the ventral tongue epithelium of iron-deficient hamsters revealed significant progressive alterations in epithelial compartment thickness. As iron deficiency developed there was an initial increase in the proportion of the epithelium made up by progenitor cells and a decrease in the proportion formed by maturing cells. With increasing degree of deficiency, the maturation compartment formed less, and the keratinized compartment more, of the epithelium until, at the stage of anaemia, there was a significant reduction in the maturation compartment and a significant increase in the keratin thickness.

Experimental oral infection with the yeast Candida albicans in mice with or without inherited iron-deficiency anaemia (sla)

The role of iron deficiency in the development of oral candidosis was investigated using the mouse mutant sex-linked anaemia (sla). Susceptibility was assessed in terms of the recovery of organisms, particularly from oral swabs, and histological evidence of infection approximately 10 days after the last exposure to Candida albicans. The influence of three factors was studied in mixed groups of normal and anaemic mice: mode of inoculation, treatment with tetracycline and treatment with hydrocortisone. The most susceptible group had received drinking water containing tetracycline (1 mg/ml), hydrocortisone (0.1 mg/ml) and candida (5 X 10(4) c.f.u./ml for 6 days). Anaemic mice showed a rather higher rate of recovery of organisms and more frequent histological evidence of infection than normal mice in certain groups. Neither of these tendencies was statistically significant alone but, taken together, they suggest that some small difference of susceptibility may exist between normal mice and mice with sla. The mouse model could be of value in studying the influence of several other inherited disorders on susceptibility to candidosis.