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Association of Vitamin B12, Serum Ferritin and Folate Levels with Recurrent Oral Ulceration

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Association of Vitamin B12, Serum Ferritin and Folate Levels with Recurrent Oral Ulceration Pak J Med Res Original Article Vol. 51, No. 4, 2012 Association of Vitamin B12, Serum Ferritin and Folate Levels with Recurrent Oral Ulceration Farkhanda Ghafoor1, Ayyaz A Khan2 National Health Research Complex1 , Department of Dentistry2 , Shaikh Zayed Medical Complex, Lahore. Abstract Background: The pathophysiology of recurrent aphthous stomatitis or aphthous ulcers remains obscure but malnutrition is one of its contributory factors. There is some role of vitamin B12, ferritin and folate in the development of these lesions. Objectives: To determine the relationship between recurrent aphthous stomatitis and levels of ferritin, folate and vitamin B12. Study type settings: This case control study was conducted at Immunoassay lab, NHRC and Department of Dentistry, Shaikh Zayed Hospital, Lahore. Patients and Methods: Sixty patients of all ages and both genders having history of recurrent ulcers over the past period of 3-6 months. Similar number of healthy controls were chosen who were either attendants of the patients or staff of the hospital and did not have any history of aphthous ulcers. Proforma was filled for each participant and 5ml blood was drawn and tested for complete picture blood by Sismex, serum ferritin by ELISA (Biocheck), vitamin B12 and RBC folate by IBL kits from USA. Results: Fifty seven (57) age and gender matched patients with recurrent aphthous ulcers and 57 normal healthy controls were studied. Anemia was present in 24(42.1%) patients and 18(31.6%) controls. Hematocrit levels were normal in 45(79%) patients and 40(70.2%) controls. Low levels of RBC folate was seen in 26(45.6%) patients and 26(45.6%) controls. Vitamin B12 deficiency was present in 29(50.1%) patients and none of the controls. The low levels of ferritin was seen in 6(10.5%) patients and 18(31.5%) controls. Conclusions: Patients with recurrent aphthous ulcers had more hematinic deficiencies, particularly of vitamin B12 as compared to controls. Key words: Recurrent aphthous ulcers, RBC folate, vitamin B12, serum ferritin. Introduction and no laboratory procedure exists to confirm the diagnosis5,9. ecurrent Aphthous Stomatitis (RAS) is as old as Studies have reported that globally 20% of R humanity itself. “Aphthai” is a Greek term world population is affected by the condition with 7,10 meaning to set on fire in relation to focal painful prevalence as high as 66 % in certain populations . inflammation of oral mucosa1,2. Other commonly used Since 1949 World Health Organization, has names of RAS are Canker Sores, Oral Ulcers, Mouth recognized public health importance of nutritional anemia Ulcers3. as a major health problem throughout the world 11 The exact pathophysiology of Aphthous ulcers especially, in the developing countries . The nutritional remains obscure, many factors are considered to surveys in a number of countries have highlighted the contribute to the pathogenesis of these lesions, such as wide-spread prevalence of nutritional anemia in immunological factors, local trauma, smoking, stress, developing countries. It has been found that in Pakistan hormonal imbalance, infections, vitamin and trace 1.3% are anemic and among them 11.4% are suffering element deficiencies, hereditary and genetic factors, from pernicious anemia, a variant of megaloblastic microbial factor, food hypersensitivity drug allergy, anemia which, is caused by deficiency or defective hematinic deficiencies and human immunodeficiency absorption of vitamin B12 in adults and folate deficiency virus infection4 -8 . Since the etiology is unknown, in children resulting into oral ulceration, mucosal diagnosis is entirely based on history and clinical criteria bleeding and glossitis12,13. Since malnutrition is a common contributing factor of RAS, therefore, it is Corresponding Author: useful to specify prevalence of vitamin B12, ferritin and Farkhanda Ghafoor folate in RAS determinants in the development of lesions. National Health Research Complex A considerable amount of research has been Shaikh Zayed Medical Complex carried out on the etiological significance of stress, Lahore . 14 Email: [email protected] allergy and immunological factors . There is relatively Pakistan Journal of Medical Research, 2012 (October - December) 132 Farkhanda Ghafoor, Ayyaz A Khan less data available on the role of vitamin-B12, ferritin and Haemoglobin level of 14 grams for males and 12 RBC folate deficiencies. This study was planned to see grams for females was taken as normal15, hematocrit of the possibility of deficiency of these nutritional values <36% was taken as low15, folate levels of <280ng/ml was 16 acting as etiological factors in recurrent oral ulceration. taken as low and for vitamin B12 cutoff <220pg/ml was taken as low levels16. Patients and Methods The data from the coded proforma was entered and analyzed using SPSS-11, descriptive frequencies were Sixty patients from all ages of both genders, calculated in relation to various study parameters. The who had been suffering from recurrent aphthous ulcers variables included demographic data (age, gender) and over the past 3-6 months and were visiting the oral health history of aphthous ulcers. The data being quantitative department of Shaikh Zayed Medical Hospital were therefore, student’s t test was applied for testing the included in the study. For each ulcer case a matched significance and a value of p<0.05 was taken as significant. control who was either attendants of the patients or staff of the hospital without history of aphthous ulcers was Results selected on the same day. Pregnant women and those taking supplements were not included. Objectives of the Initially sixty patients with history of recurrent study were explained to all study participants and written aphthous ulcers were included in the study, age and informed consent was obtained for their enrollment. A gender matched, sixty controls were also enrolled on the proforma was used to record demographic parameters same day from the outpatient department of Shaikh and frequency for occurrence of aphthous ulcers. Five Zayed Hospital. Demographic information of three mls of venous blood was drawn from each participant and patients was incomplete, therefore, their matched controls stored in two aliquots, one aliquot with EDTA for were also not included for analysis, however, the blood complete blood picture and RBC folate, whereas, serum reports were communicated to them. Both groups was separated from the second aliquot and stored at comprised of 24 males and 33 females, with the mean age -20°C for the estimation of serum ferritin and vitamin of 31.3 yrs. B12. Hemoglobin and hematocrit was done using Sismex Anemia was found in 24(42.1%) patients (mean instrument on the same day. Serum ferritin levels were 11.3 gm + 1.5gm) and in 18(31.6%) controls (mean 11.0 estimated using ELISA kits from Biocheck USA, RBC gm + 1.0 gm) and the difference was not significant. folate and vitamin B12 with IBL kits from USA. Sample In both patients and controls the hematocrit handling and temperature conditions were strictly levels did not differ statistically. Normal hematocrit was observed for all procedures according to manufacturer’s seen in 45(79%) patients (mean 42.9 gm + 3.5gm) and in protocol. For precision of assay, calibrated 40(70.2%) controls (mean 42.8gm + 4.8 gm) and the micro/multichannel pipettes from Gilson were used difference was not significant. throughout the assay procedures and washing was Table shows that the levels of RBC folate were performed with automatic plate washer. For diagnostic lower in patients than in controls. The values in patients assurance of results all investigations were carried out in ranged from 141.8 ng/ml ±36.6 ng/ml to 454.7 ng/ml duplicate with 6 calibrants, 2 quality control pools along ±50.4 ng/ml while in controls the values ranged from with patient samples. Results were calculated using 200.8 ng/ml ±31.7 ng/ml to 974.7 ng/ml ±16.9 ng/ml. stingray package for statistical analysis and were reported The difference was significant (p<0.01). at 10% coefficient of variation (CV). Table : Comparison of RBC folate, vitamin B12 and ferritin levels in patients and controls. Patients Normal controls (Aphthous Ulcers) n=57 (Non-Aphthous Ulcers) n=57 Low Normal Low Normal RBC Folate n 26 31 26 31 Mean±SD (ng/ml) 141.8±36.6 454.7±50.4 200.8±31.7 974.7±16.9 Vitamin B12 n 29 28 0 57 Mean±SD (pg/ml) 124.12±46.5 258.91±111.6 - 899.8±156.2 Ferritin n 6 51 18 39 Mean±SD (ng/ml) 9.0±3.2 74.3±26.9 8.9±3.3 69.01±24.1 Cutoff values for low levels RBC Folate <280ng/ml Ferritin Male <10ng/ml Vitamin B12 <220pg/ml Female <20ng/ml Pakistan Journal of Medical Research, 2012 (October - December) 133 Association of Vitamin B12, Serum Ferritin and Folate Levels with Recurrent Oral Ulceration Vitamin B12 levels were below <220pg/ml in 29 In present study it was seen that vitamin B12 (50.1%) patients (mean 124.1pg/ml +46.5 pg/ml) while levels were significantly low in patients, whereas, none of none of the controls had low vitamin B12 levels (p<0.001) the participants in control group had low levels of (Table). vitamin B12. This finding is consistent with other 20,23,25,26 Low ferritin levels were seen in 6 patients and studies . It was reported that 73% patients with B12 18 controls (p<0.05). However, the mean estimates of deficiency when given B12 therapy recovered completely both low and normal levels of ferritin did not differ while, 70% patients with recurrent apthous ulcers statistically (Table). improved with hematinic replacement therapy8,14,21 . This study also tried to classify the patients and Discussion controls into subjects with normal values or low values by specified cut-off values of kits used.
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