Iron and the oral epithelium: a review

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.

A Study to Assess the Levels of Salivary Ferritin in Iron Deficiency Anemia Subjects and Healthy Subjects

Introduction: Iron deficiency anemia is one of the most widespread disorders in humans. Early diagnosis of iron deficiency anemia is challenged by assessing serum ferritin levels. However, studies across the globe have concluded that ferritin is present in quantifiable amounts in saliva. Thus, in the study, the scope of using salivary ferritin as a diagnostic biomarker in detecting iron deficiency anemia is studied.

Methods: Levels of salivary ferritin in patients with iron deficiency anemia (test group, n=15) and non-anemic subjects (control group, n=15) were assessed by an automated chemilumesent method with a total sample size of 30 volunteers.

Results: The mean level of salivary ferritin in subjects with iron deficiency anemia was 139.37±47.90 µg/dl, which was significantly higher when compared to the level in non-anemic subjects, 94.18±62.90 µg/dl, which was contradictory when compared to the levels of serum ferritin.

Conclusion: The raise in the levels of salivary ferritin in subjects with iron deficiency anemia can be attributed to the iron-dependent enzymatic function of saliva. Thus, salivary ferritin can become a biomarker that helps in the diagnosis of iron deficiency anemia; however, more research is needed for devising a more standard cutoff value for diagnosing iron deficiency anemia.

Oral Candidosis: Pathophysiology and Best Practice for Diagnosis, Classification, and Successful Management

Oral candidosis is the most common fungal infection that frequently occurs in patients debilitated by other diseases or conditions. No candidosis happens without a cause; hence oral candidosis has been branded as a disease of the diseased. Prior research has identified oral candidosis as a mark of systemic diseases, such as hematinic deficiency, diabetes mellitus, leukopenia, HIV/AIDS, malignancies, and carbohydrate-rich diet, drugs, or immunosuppressive conditions. An array of interaction between Candida and the host is dynamic and complex. Candida exhibits multifaceted strategies for growth, proliferation, evasion of host defenses, and survival within the host to induce fungal infection. Oral candidosis presents a variety of clinical forms, including pseudomembranous candidosis, erythematous candidosis, angular cheilitis, median rhomboid glossitis, cheilocandidosis, juxtavermillion candidosis, mucocutaneous candidosis, hyperplastic candidosis, oropharyngeal candidosis, and rare suppurative candidosis. The prognosis is usually favorable, but treatment failure or recurrence is common due to either incorrect diagnosis, missing other pathology, inability to address underlying risk factors, or inaccurate prescription of antifungal agents. In immunocompromised patients, oropharyngeal candidosis can spread to the bloodstream or upper gastrointestinal tract, leading to potentially lethal systemic candidosis. This review therefore describes oral candidosis with regard to its pathophysiology and best practice for diagnosis, practical classification, and successful management.

Oral potentially malignant disorders: A consensus report from an international seminar on nomenclature and classification, convened by the WHO Collaborating Centre for Oral Cancer

Oral potentially malignant disorders (OPMDs) are associated with an increased risk of occurrence of cancers of the lip or oral cavity. This paper presents an updated report on the nomenclature and the classification of OPMDs, based predominantly on their clinical features, following discussions by an expert group at a workshop held by the World Health Organization (WHO) Collaborating Centre for Oral Cancer in the UK. The first workshop held in London in 2005 considered a wide spectrum of disorders under the term "potentially malignant disorders of the oral mucosa" (PMD) (now referred to as oral potentially malignant disorders: OPMD) including leukoplakia, erythroplakia, proliferative verrucous leukoplakia, oral lichen planus, oral submucous fibrosis, palatal lesions in reverse smokers, lupus erythematosus, epidermolysis bullosa, and dyskeratosis congenita. Any new evidence published in the intervening period was considered to make essential changes to the 2007 classification. In the current update, most entities were retained with minor changes to their definition. There is sufficient evidence for an increased risk of oral cancer among patients diagnosed with "oral lichenoid lesions" and among those diagnosed with oral manifestations of 'chronic graft-versus-host disease'. These have now been added to the list of OPMDs. There is, to date, insufficient evidence concerning the malignant potential of chronic hyperplastic candidosis and of oral exophytic verrucous hyperplasia to consider these conditions as OPMDs. Furthermore, due to lack of clear evidence of an OPMD in epidermolysis bullosa this was moved to the category with limited evidence. We recommend the establishment of a global research consortium to further study the natural history of OPMDs based on the classification and nomenclature proposed here. This will require multi-center longitudinal studies with uniform diagnostic criteria to improve the identification and cancer risk stratification of patients with OPMDs, link them to evidence-based interventions, with a goal to facilitate the prevention and management of lip and oral cavity cancer.

Zinc, Copper, and Iron in Oral Submucous Fibrosis: A Meta-Analysis

Oral submucous fibrosis (OSF) is a potentially malignant disorder which causes fibrosis and inflammation of the oral mucosa. Studies have reported altered levels of trace elements in oral submucous fibrosis subjects, but findings have been inconsistent. The objective of this research is to perform a meta-analysis to summarize studies that report zinc (Zn), copper (Cu), and iron (Fe) in patients, with and without OSF. A literature search of Embase, PubMed, Cochrane Library, and Web of Science electronic databases was conducted for studies up to January 2017. A total of 34 reports met the inclusion criteria. The standardized mean difference was utilized as the effect size. The robust variance estimation method was chosen to handle dependency of multiple related outcomes in meta-analysis. There was a significant increase in the levels of Cu (effect size = 1.17, p value < 0.05, 95% confidence interval (CI): 0.164–2.171) and a significant decrease in levels of Zn (effect size = −1.95, p value < 0.05, 95% CI: −3.524 to −0.367) and Fe (effect size = −2.77, p value < 0.01, 95% CI: −4.126 to −1.406) in OSF patients. The estimation of Zn, Cu, and Fe levels may serve as additional biomarkers in the diagnosis and prognosis of OSF along with the clinical features.

S, Palaneeswari M. S, Devi A.J. M. Significance of ferritin in recurrent oral ulceration

BACKGROUND

Ferritin is the storage form of iron. Hence, the sensitive test which can be used for diagnosing iron deficiency anaemia is estimation of ferritin in serum. One of the causative factors of oral ulceration is nutritional deficiency, which includes iron also.

AIM

To study the meaningful association between recurrent oral ulcer and ferritin.

MATERIALS AND METHODS

Fifty oral ulcer cases which were diagnosed clinically in the ENT Department of Sree Balaji Medical College and Hospital and Twenty Five controls were included in this study. Serum ferritin was estimated by doing a particle enhanced turbidimetric immunoassay for both cases and controls.

RESULTS

66% of cases had decreased ferritin values and 34% had normal values, which was significant.

CONCLUSION

From this study, it can be concluded that it is mandatory to screen oral ulcer patients for iron deficiency anaemia by estimating serum ferritin and it is also advisable for the patients to have iron supplementation on regular basis, along with diet rich in iron in addition to vitamins.

High concentrations of hexavalent chromium in drinking water alter iron homeostasis in F344 rats and B6C3F1 mice

Hexavalent chromium [Cr(VI)] induces hematological signs of microcytic anemia in rodents. Considering that Cr(VI) can oxidize ferrous (Fe(2+)) to ferric (Fe(3+)) iron, and that only the former is transported across the duodenum, we hypothesize that, at high concentrations, Cr(VI) oxidizes Fe(2+) in the lumen of the small intestine and perturbs iron absorption. Herein we report that 90-day exposure to Cr(VI) in drinking water resulted in dose-dependent decreases in Fe levels in the duodenum, liver, serum, and bone marrow. Toxicogenomic analyses from the duodenum indicate responses consistent with Fe deficiency, including significant induction of divalent metal transporter 1 (DMT1, Slc11a2) and transferrin receptor 1 (TFR1, Tfr1). In addition, at ⩾20mg Cr(VI)/L in drinking water, Cr RBC:plasma ratios in rats were increased and exceeded unity, indicating saturation of reductive capacity and intracellular absorption of Cr(VI) into red blood cells (RBCs). These effects occurred in both species but were generally more severe in rats. These data suggest that high concentrations of Cr(VI) in drinking limit Fe absorption and alter iron homeostasis. Furthermore, some effects observed at high doses in recent Cr(VI) chronic and subchronic bioassays may be explained, at least in part, by iron deficiency and disruption of homeostasis.

Biochemical markers in oral submucous fibrosis: A review and update

Oral submucous fibrosis (OSMF) is a potentially malignant oral condition effectively linked to the causative habit of chewing areca nut. Since its first description in the 1950s, numerous epidemiological, biochemical, histological, and genetic studies have been reported. While most studies point out to the cause and effect of areca nut, co-additive factors are also implicated in the progression and malignant transformation of this condition. Biochemical investigations have concentrated on outlining such changes in the blood, serum or tissues of these patients and have given insights on the possible pathogenesis of OSMF. This article attempts to compile details of biochemical investigations in OSMF and summarize and infer on the findings.

Chronic hyperplastic candidosis/candidiasis (candidal leukoplakia)

Chronic hyperplastic candidosis/candidiasis (CHC; syn. candidal leukoplakia) is a variant of oral candidosis that typically presents as a white patch on the commissures of the oral mucosa. The major etiologic agent of the disease is the oral fungal pathogen Candida predominantly belonging to Candida albicans, although other systemic co-factors, such as vitamin deficiency and generalized immune suppression, may play a contributory role. Clinically, the lesions are symptomless and regress after appropriate antifungal therapy and correction of underlying nutritional or other deficiencies. If the lesions are untreated, a minor proportion may demonstrate dysplasia and develop into carcinomas. This review outlines the demographic features, etiopathogenesis, immunological features, histopathology, and the role of Candida in the disease process. In the final part of the review, newer molecular biological aspects of the disease are considered together with the management protocols that are currently available, and directions for future research.

Antioxidant status of oral mucosal tissue and plasma levels in smokers and non-smokers

The antioxidant status of an individual is thought to be important in the development of potentially malignant oral lesions (PMOL) and oral squamous cell carcinoma (OSCC). To date, little detailed information on mucosal antioxidant status is available in a United Kingdom population and neither has the relationship between smoking and mucosal antioxidant status been established. Furthermore, it has been implied that serum levels of antioxidants and tissue levels in the oral mucosa should be equivalent, but that is unproven. To address these deficiencies in our knowledge we studied 60 individuals, all of whom had an oral mucosal biopsy and simultaneous venous blood sampling. Antioxidant levels were measured using high performance liquid chromatography. Smokers (n= 19) were found to have significantly lower levels of plasma beta-carotene (P<0.05) and significantly lower levels of tissue alpha-carotene (P<0.05) than non-smokers (n=41). Tissue alpha-carotene correlated with plasma levels, but this was not the case with alpha-tocopherol, retinol, lycopene or beta-carotene. This is the first data on oral mucosal antioxidant levels and provides baseline data from which to study patients with potentially malignant oral lesions and oral squamous cell carcinoma.

A comparison of the management of potentially malignant oral mucosal lesions by oral medicine practitioners and oral & maxillofacial surgeons in the UK

This study describes the results of a survey undertaken to assess the management of potentially malignant oral mucosal lesions by oral medicine practitioners and compares their approach with that of oral & maxillofacial surgeons that we have previously described. Significant differences were noted between the two groups in the use of photography to document the lesions and in the use of certain special investigations, which included measurement of serum iron, serum ferritin, serum Vit B12, red cell folate and candidal isolation. The groups also varied in the perceived importance of the age of the patient and anatomical site of the lesion when deciding on the need for further biopsy. There was also significant variation in the use of certain treatment modalities, including excising non-dysplastic and severely dysplastic/carcinoma in-situ lesions and eliminating trauma when treating mild/moderately dysplastic and severely dysplastic/carcinoma in-situ lesions. Significant differences in the frequency and duration of follow-up were noted for non-dysplastic lesions. Finally, the two groups differed significantly when asked to rank the perceived importance of certain factors (the histopathology of the most recent biopsy and the anatomical site of the lesion) when deciding the need to follow-up. Possible reasons for the variation are discussed.

Management of potentially malignant oral mucosal lesions by consultant UK oral and maxillofacial surgeons

This paper describes the results of a recent survey carried out under the auspices of the Professional Education and Evaluation Subgroup of the UK Working Group on Screening for Oral Cancer and Precancer. The aim of this survey was to assimilate information regarding currently used management options of potentially malignant oral lesions as a basis from which to rationalise our future approach to their management. The survey has confirmed that variation exists among oral and maxillofacial consultants in their approaches and a more formal approach to management may therefore be indicated.

Candida and oral candidosis: a review

Candida species are the most common fungal pathogens isolated from the oral cavity. Their oral existence both as a commensal and an opportunist pathogen has intrigued clinicians and scientists for many decades, and recent investigations have revealed many attributes of this fungus contributing to its pathogenicity. In addition, the advent of the human immunodeficiency virus infection and AIDS has resulted in a resurgence of oral Candida infections. Clinicians are witnessing not only classic forms of the diseases but also newer clinical variants such as erythematous candidosis, rarely described hithertofore. Therefore, this review is an attempt at detailing the current knowledge on Candida and oral candidoses together with the newer therapeutic regimes employed in treating these mycoses.

A work-site nutrition intervention: its effects on the consumption of cancer-related nutrients

OBJECTIVES

In a work-site nutrition intervention targeting fat and fiber, we examined the intervention's effect on specific nutrients implicated in carcinogenesis, including trace metals, vitamins, and categories of fatty acids. The rationale was based on the association observed in a variety of epidemiologic studies between these nutrients and epithelial cancers.

METHODS

Data were taken from eight control companies and five intervention companies that fully implemented the Treatwell intervention. Analyses of variance were used preserving the study's nested design.

RESULTS

Significant intervention-related associations were observed for increased total vitamin A and carotene. Marginal intervention effects were observed for relative decreases in the percentage of calories from both saturated and monounsaturated fatty acids, a relatively smaller increase in the percentage of calories from polyunsaturated fatty acids, and an increase in the consumption of vitamin B6.

CONCLUSIONS

Results indicate a broader effect of the intervention than on fat and fiber only. Increased intake of carotene, the single most important of these other nutrients, is plausibly related to a variety of epithelial cancers.

Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer

Oral submucous fibrosis (OSF) is a chronic disease of the oral mucosa characterized by inflammation and a progressive fibrosis of the lamina propria and deeper connective tissues. It is a condition predominantly seen among people of Indian origin, and an epidemiologic survey done a decade ago showed no less than 250,000 cases in India, a figure that must have increased sharply. OSF is a condition with a high risk of malignant transformation; to date, no conclusive etiologic agent has been identified, although plenty of data have been generated on various aspects of the disease. These include genetic, carcinogenic, immunologic, viral, nutritional, and autoimmune possibilities, all of which also have been implicated in the development of oral cancer. This article reviews existing evidence on the pathogenesis of OSF and its relation to oral cancer and suggests a possible multifactorial model to explain the disease process.

A multivariate study of the prognosis of oral squamous cell carcinomas. Are blood group and hemoglobin new prognostic factors?

Because blood groups and hemoglobin concentration have been associated with the risk of the development of some cancers, this study evaluated the significance of ABO and Rhesus blood groups and hemoglobin concentration as prognostic factors in oral squamous cell carcinoma (SCC). The authors examined all registered primary SCC of buccal and maxillary alveolar mucosa in the Norwegian population between 1963 and 1972. The biopsy specimens from these patients were reevaluated and borderline cases excluded. The remaining 111 cases were included in the study, and features recorded on first admission were included in the survival analyses. ABO and Rhesus blood groups were found in 99 of these patients. Multivariate survival analysis showed that tumor size, hemoglobin concentration, stage, and Rhesus blood groups were significant prognostic factors, but sex, age, treatment, duration of symptoms, ABO blood groups, and clinical appearance of the tumors were not. The prognostic value of Rhesus blood groups and hemoglobin concentration has not been previously reported for oral SCC.

Prognostic value of various molecular and cellular features in oral squamous cell carcinomas: a review

Recent findings of prognostic value for oral squamous cell carcinomas (OSCCs) which may supplement clinical staging are reviewed. Many reports show that histopathologic grading, measurements of tumor-thickness and DNA-content have independent prognostic value and may thus be of clinical value. Features regarding cells at the invading margins of the tumors are probably of higher prognostic value than features within other parts of the tumors. Reportedly, various other cellular and serum markers have prognostic associations worthwhile further research.

The effect of iron deficiency on early oral carcinogenesis in the rat

In order to further investigate the known influence of iron deficiency on 4NQO oral carcinogenesis in the rat, groups of iron-deficient and iron-sufficient Charles River white rats were painted with carcinogen for 8 weeks or 14 weeks and then left untreated for 32 weeks or 26 weeks respectively. Tumour development and epithelial dysplasia were assessed at the time of killing. Animals painted for 14 weeks showed more severe dysplasia than those painted for 8 weeks, but no significant differences were noted between corresponding iron-deficient and iron-sufficient groups.

Nutritional factors and oral candidosis

A variety of nutritional factors including deficiencies of iron, folic acid, vitamins, and diets rich in carbohydrates have been implicated in the pathogenesis of oral candidal infections. The following reviews the growing body of data, from in vivo and in vitro studies, related to each of these implicated factors. Although much disagreement exists as to the specific roles played by these individual factors, there is little doubt that nutritional factors either acting locally or via systemic mechanisms could significantly affect the pathogenesis of oral candidoses. Hence, the role of these less well-characterised predisposing factors should be considered when one is treating patients with intractable oral candidal infections.