/home/opencode/cpanel/stomaeduj_hacked/uploads/2017/06/SEJ_2-2017_Articol_Cojanu.pdf ORAL MEDICINE ORAL MANIFESTATIONS IN IRON DEFICIENCY ANEMIA: A CASE REPORTS REPORT OF 40 CASES Original Articles Mihaela Florina Loredana Cojanu,1a* Dana Nicoleta Antonescu,1b Iulia Constantinescu,2c Anca Săsăreanu,3d Sabina Andrada Zurac4e 1 Department of Restorative Odontotherapy, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, Bucharest, Romania 2 Department of Hematology, National Institute of Transfusion Hematology “Prof. Dr. C. T. Nicolau”, Bucharest, Romania 3 Department of Hematology, Institute of Oncology “Prof. Dr. Alexandru Trestioreanu”, Bucharest, Romania 4 Department of Pathology, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, Bucharest, Romania DMD, Clinical Assistant a,b DMD c,d e DMD, Professor Received: June 01, 2017 Received: Revised: June June 30, 15, 2017 2017 Accepted: June 29,Revised: 2017 Accepted: Published: June 30, 2017 Published: Academic Academic Editor: Editor:Constantinus David Wray, Politis MD, DDS,BDS, MD (Honours), MM, MHA, PhD, MB ChB, Professor FDS, RCPS & Chairperson, (Glasgow), FDSOral RCSand Maxillofacial (Edinburgh), Surgery, F Med Sci, University Hospitals Leuven, KUEmeritus, Professor Leuven, Leuven, Belgium Professor, Department of Oral Medicine, Dental School, University of Glasgow, Glasgow, UK Cite this article: Cojanu MFL, MFL,Antonescu AntonescuDN, DN,Constantinescu Constantinescu I, Săsăreanu I, Săsăreanu A, Zurac A, Zurac SA. Oral SA. Oral manifestations manifestations in ironindeficiency iron deficiency anemia: anemia: a reportcase reports. of 40 StomaEdu cases. Stoma EduJ.J. 2017;4(3):114-125. 2017;4(2):114-125. AbstrAct DOI: 10.25241/stomaeduj.2017.4(2).art.4 Introduction: The aim of this work is to reveal the clinical, radiological, immunological, cytological, The aim of this work is to reveal the clinical, radiological, immunological, cytological, microbiological microbiological and histopathological manifestations of oral manifestations taking the form of and histopathological manifestations of oral pathology taking the form of sideropenia, correlations and sideropenia, correlations and interdependence. interdependence. Summary: During a four-year period a study was conducted on patients with different clinical forms Summary: During a four-years period a study was conducted on patients with different clinical forms of of iron deficiency anemia. iron deficiency anemia (IDA) and the prevalence of oral diseases in those patients was highlighted. This The prevalence of oral diseases in patients with sideropenia was also highlighted. This paper paper discusses 24 case results and presents two clinical cases, patients with iron deficiency anemia (by: discussed three cases, patients with iron deficiency anemia (by: bleeding, gum bleeding, colon metrorrhagia, deficiency, gingiva bleeding, colon cancer) and oral symptoms associated. The results are cancer) and oral manifestations associated. The results are meaningful and applicable to the whole meaningful and applicable to the whole group studied. Sampling was done according to the directions of group under study. Sampling was done according to the directions of interest in the study of interest in the study regarding: sex, age, the type of anemia, dental and periodontal lesions. sentence sex, age, the type of anemia, dental and periodontal manifestations. Key learning points: The originality of the study lies in the association of specific examination of the oral The originality of the study lies in the association of specific examination of the oral cavity with cavity with the investigations used in other medical specialties, which led to the creation of a more accurate the investigations used in other medical specialties (clinical gingival periodontal, radiological, diagnosis and the establishment of a connection (sometimes specific issues) between oral diseases and cytological, immunohistochemical, microbiological immunoserological), which led to the creation systemic disease, represented in this study by various forms of sideropenia. of a more accurate diagnosis and to the establishment of a connection (sometimes specific Keywords: oral medicine, iron deficiency anemia, sideropenia, dental and periodontal manifestations. issues) between oral diseases and systemic disease, represented in this study by various forms of sideropenia. Keywords: oral medicine, iron deficiency anemia, sideropenia, dental and periodontal manifestations. 1. Introduction The purpose of this paper developed on patients Anemia represents a world wide health problem with IDA, in collaboration with the “Prof. Dr. 1. Introduction which affects both developing and developed C.T. erythro-kinetic Nicolau” and etio-pathogenic. National Institute of Transfusion countries. It affects all groups of age. Globally Hematology, is to identify isandassociated This study developed over a four-year period on The clinical classification describe with oral patients with various stages of iron deficiency decreased levels of hemoglobin and/or a 24.8% of the population reveal anemia, in Europe manifestation that occurred and also to establish anemia (IDA), in collaboration with the National decreased packed red cell volume (hematocrit).3,4 the percentage being 22.9%. Approximately half of immunoserological values, histopathological, Institute of Transfusion Hematology, and revealed Iron deficiency is also characterized by a reduced the cases with anemia are due to iron deficiency.1,2 microbiological and cytological aspects clinical, x-rays, immunological, cytological, value of the mean corpuscular volume (MCV) and Anemia may be classified clinically, morphologi- associated. microbiological and pathological characteristics the mean corpuscular hemoglobin concentration cally, erythro-kinetic associated to theand etio-pathogenic. underlying disease. The (MCHC), caused by lack of iron.1 The clinical classification is associated correlations and interdependence of these clinical with 2. Methodology Grading: decreased levels of conditions were also identified.hemoglobin and/or a Clinical examination • Mild anemia: Hb 11-9 g/dl,determined Hct 39-30%; intraoral decreased packed red cell volume (hematocrit). 3,4 assessment of mucosa, Anemia represents a world wide health problem • Moderate anemia: Hb 9-7 g/dl, Hct 30-22%; periodontium and caries which affects both the developing and the • Severe anemia: Hb 7-3 g/dl, Hct 22-10%.14clinical Iron deficiency is also characterized by a reduced lesions. Detection of caries involved both value of thecountries developed mean corpuscular It affects volume (MCV) all groups and (visual and tactile) and radiographic examination. of age. the mean24,8% Globally corpuscular hemoglobin of the population anemia, in Evaluation concentration reveal 2. Methodology of the periodontium consisted of Europe the (MCHC), percent caused by being lack of22,9%, This prevalence iron.1 while in Romania clinical assessment studyofwas carried on levels, attachment a numberboneof 39,8% of the population is affected. Approximately topography Grading: 40 patients with various degrees (radiographs of iron and evaluation) deficiency tooth •half Mildofanemia: the cases with g/dl, Hb 11-9 anemiaHct 39-30%; anemia – 34 are due to iron mobility; females andstatus inflammatory 6 males, between of the tissue,16 and tissue •deficiency. 82 years of age contours, and revealed oral manifestations 1,2 Moderate anemia: Hb 9-7 g/dl, Hct 30-22%; color, texture, edema and sulcular •Anemia Severemay be classified anemia: Hb 7-3clinically, g/dl, Hctmorphologically, 22-10%.14 among 77.5% exudates of them was also (Figures 1,2). noted. *Corresponding author: Clinical Assistant Mihaela Florina Loredana Cojanu, DMD Department of Restorative Odontotherapy, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, Bucharest, Romania, 17-23 Plevnei Street, Bucharest, 1 District, RO-010232 Romania, Tel: +40722766503, Fax: 021.315.85.37, e-mail: loredana.cojanu@gmail.com; lory_cojanu@yahoo.com. 114 Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com ORAL EVALUATION OF MANIFESTATIONS THE THERAPEUTICIN IRON DEFICIENCY BENEFITS ANEMIA: OF GENERAL CASE REPORTS ANTIBIOTIC THERAPY IN PERIODONTAL DISEASE Biological samples The main factors were taken involved from gingival in developing sulcus caries are: Original Articles dental or structures,pockets. periodontal the plaque andthe After dietMGGinfluenced (May- by the immune system, Grünwald-Giemsa) stainingsaliva, timing microscopic cytologic and topical fluoride. In addition, there are general aspects were observed. The samples obtained factors such as: education, socio-economic were also cultivated on specific medium and status, behavior, health attitude, bacterial growthincome. When one characteristics wereofobserved. the risk factors increases, Cell staining is a necessary it produces an imbalance, and useful technique leading to to caries visualize (Fig. 3).5,6 and structure of cells. morphology In the oral cavity there are about 700 species Serology was used to establish Complement of known bacteria, at least 30 species of fungi and Immunoglobulin levels. Gingival biopsy was (especially Candida) and several species of performed, fixation and sectioning of the tissues. protozoa (associated with food bacteria) and some A solution of paraformaldehyde was used to fix intracellular viruses.7,8,9,10 tissues. In a healthy oral cavity, what is normallytechnique IHC is an excellent detection found is Figure 1. Sex prevalence of IDA. and has the between 20-50 advantage bacterialofspecies, being able the to show number exactly going up where a given protein to 200-400, in case isoflocated a disease.within the These tissue examined,are microorganisms in our casesfound always gingival chorion and in communities epithelium. and vary with Thethemarkers used were: CD1a, cavity environment. 11,12,13 CD2O, CD3, CD4, CD5 The most complexcorion,and CD7 accessible corion, MPO, CD138, microbial S100, SMA,ofki67, ecosystem p63, p53, the human bodyAE1-AE3, lies in the CD31 and oral cavity. CD34. The dental surfaces and the mucosa are the arias of microbial This prevalencecolonization. study wasThe constant carried on a production number of of saliva and the intermittent 40 patients with various degrees of iron food feeding with deficiency sugars and amino acids generate anemia – 34 females and 6 males (Fig. 1), between nutrients for microbial growth. 14 16 and 82 years of age and revealed, 24 patients The increased with dental and number of microorganisms, periodontal lesions, gingiva their development on a favorable ground inflammation in 7 patients and lack of symptoms and the association with the on 9 of the cases (Fig. 2). inflammatory response of the host are responsible for caries development on The main factors involved in developing caries are: Figure 2. Oral manifestations among patients diagnosed the plaque (Fig. 4).15,16 dental structures, the plaque and diet influenced with iron deficiency was 77,55%. Immunity is the ensemble of humoral and cellular, by the immune system, saliva, timing and topical specific and nonspecific factors, which protect the Figure 3. Ethological factors influencing the development of caries process and periodontal diseases. Figure 4. Emergence of salivary biofilm with the development of common microbial flora and exacerbation of the pathogen flora under the action of systemic predisposing factors. Stomatology Edu Journal 115 EVALUATION OF THE THERAPEUTIC BENEFITS OF GENERAL ANTIBIOTIC THERAPY ORAL MANIFESTATIONS IN IRON DEFICIENCY ANEMIA: CASE REPORTS IN PERIODONTAL DISEASE Original Articles a b a. b. Figure 8. Chronic marginal periodontitis, active approximal and cervical caries lesions: a. facial aspect; b. lingual aspect. Figure 5. Chronic marginal periodontitis, active approximal and cervical caries lesions: a. facial aspect; b. lingual aspect. 3-4 mm; the gum color changed from light red to brick red, with aare microorganisms bordure always periphery area (lisere) found in communities and vary with the cavity environment.touch; and ulceration areas; bleedings at slight 12,13,14 the The dental surfaces and the mucosa are theretreat periodontal chart revealed slight gum areas of at the level of the front inferior incisive, microbial colonization. The constant production periodontal pockets of saliva inand11,the12, intermittent 15, 27, 33, 42, food43,feeding 44, 45 with and slight dental mobility (first degree) at the inferior sugars and amino acids generate nutrients for incisive. microbial growth.15 3.2.2. Hematologic diagnosis – iron deficiency The increased number of microorganisms, their anemia due to metrorrhagia (Figures 8,9) development HGB 10.47 g/dL; on HCTa favorable 33.75 %; RBC ground3.61and the 106/μL; association with MCV 79 fL; Fe 23 μg/dl the inflammatory response of the host are responsible for caries development Complementary exams: radiological, cytological, under Figure 9. Panoramic radiograph. the plaque (Fig. 4).16,17 immunohistochemical, microbiological, Immunity is the ensemble of humoral and cellular, immunoserological environment and aspects Figure 6. Panoramic image. of cultivation consisting specific and nonspecific factors, which protect the 3.2.3. Serology – slight modification of minimum three types of colonies both in aerobic human CRP 3.0body g/dL;against IgA 3.63 infectious diseases, g/l; IgG 11.84 g/l; parasites IgM 1.82 and anaerobic fluoride. In addition,environment. there are general The isolation factors such in aggressions g/l; C3 1.2 g/l;and C4 0.4malignant g/l proliferation. The anaerobic environment was practically impossible, as: education, socio-economic status, behavior, 3.2.4. Radiological presence of microorganisms– generalized and their horizontal products although some bacterial species had developed health attitude, income. When one of the risk minimal bone initiating loss; radiotransparency and producing caries causeswith different an immunity in this environment too. Anyway, there were found factors increases, it produces an imbalance, site: cervical response on 43,on44,specific based 45; approximately and nonspecific on 47 Gram negative bacilli, perhaps Enterobacteriaceae leading to caries (Fig. 3).5,6,7perhaps Streptococcus and 48; factors. vertical 18,19,20 bone resorption on 13 (Figure 10). and Gram positive cocci, The 3.2.5. Cytological – the following were observed: sp. most complex and accessible microbial A systemic disease can influence the effectiveness ecosystem of the human body microbial loadedresponse epithelial cells; connective 3.2. Case no. 2: M.Ş., f, age 25lies in the oral cavity, of the immunity which can lead to an there inflammatory cells; macrophages, granulocytes, 3.2.1. are Oralabout 700 species diagnosis – active of approximal known bacteria, at caries: intense microbial activity consequently with dental least 30 on species of fungi lymphocytes; cocci, diplococci, Treponema mesial 12 and 22; (especially Candida) cervical caries and lesions or periodontal manifestations. several species of protozoa (associated denticola, fusobacterium, yeasts. distal on 43 and 44, facial on 45 with food ; chronic Cytological exam revealed: epithelial cells loaded bacteria) marginal and some intracellular periodontitis. The exam viruses. of the8,9,10,11 marginal 3. Cases reports with germs, polymorphic microbial flora, important In a healthy oralrevealed: periodontium cavity, whattartar is normally indexfound 34.48is 3.1. Case no. 1: M.Ș., f, age 25 granulocyte infiltrate. The immune-histochemical percent; gum between 20-50 inflammation index 11.20 bacterial species, the percent; number 3.1.1. Oralrevealed: diagnosis – activeof approximal diagnosis fragments pavement periodontal going up to inflammation 200-400, in case index 6.03 percent; of disease. These caries: mesial on 12 and 22; cervical caries stratified mucosa, presenting important acanthosis periodontal pockets with dimensions between with epithelial cristae irregularly elongated. In a b c Figure 10. Laboratory aspects: a. inflammatory infiltrate, macrophages, frequent cocci, bacilli, candida filaments; b.Figure 7. Laboratory abundant aspects: inflammatory a. inflammatory infiltrate infiltrate, macrophages, in the corium (IHC-CD3); c. mild vascularfrequent cocci, hyperplasia bacilli, candida filaments; b. (IHC-CD34). abundant inflammatory infiltrate in the corion (IHC-CD3); c. mild vascular hyperplasia (IHC-CD34). 116 Stomatology Edu Journal Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com 117 ORAL EVALUATION OF THE THERAPEUTIC MANIFESTATIONS BENEFITS IN IRON OF GENERAL DEFICIENCY ANTIBIOTIC ANEMIA: CASE REPORTS THERAPY EVALUATION OF THE THERAPEUTIC BENEFITS OF GENERAL ANTIBIOTIC THERAPY IN PERIODONTAL DISEASE IN PERIODONTAL DISEASE Original Articles Articles Original Articles a b a b Figure Figure 8. 11.Chronic Chronicperiodontitis, periodontitis,active active cervical lesions:a.a.facial cervical lesions: facialaspect; aspect;b.b.lingual lingual aspect. aspect. Figure 11. Chronic periodontitis, active cervical lesions: a. facial aspect; b. lingual aspect. front incisive; 3.1.2. Hematologic moderate dental –mobility diagnosis (second iron deficiency front incisive; moderate dental mobility (second degree). anemia degree).due to metrorrhagia: HGB 10.47 g/dL; 3.3.2.33.75 HCT Hematologic %; RBC 3.61 diagnosis 106/μL; ––MCV iron79deficiency fL; Fe 23 3.3.2. Hematologic diagnosis iron deficiency Original anemia μg/dL. (Figures 11,12) anemia (Figures 11,12) HGB 10.8 g/dL; HCT 38 %; RBC 4.79 106/μL; MCV HGB 10.8 g/dL; HCT Complementary exams:38 %; RBC 4.79 106/μL; radiological, MCV cytological, 73.1 fL; Fe 21 μg/dl. 73.1 fL; Fe 21 μg/dl. immunohistochemical, microbiological, immuno- Complementary exams: radiological, cytological, Complementary exams: radiological, cytological, serological. immunohistochemical, microbiological, immunohistochemical, 3.1.3. Serology – slight modification: microbiological, CRP 3.0 g/dL; immunoserological immunoserological IgA 3.3.3. Serology – increase of the IgM g/L; C3 1.2 3.63 g/L; IgG 11.84 g/L; IgM 1.82 3.3.3. g/L; Serology – increase of the IgM CRP C4 5.50.4 g/L.IgA g/dL; 1.93 g/l; IgG 12.4 g/l; IgM 2.40 CRP 3.1.4. 5.5 g/dL; IgA 1.93 g/l; IgG horizontal 12.4 g/l; IgM 2.40 g/l ;C33Radiological 1 g/l ;C44 0,2 –generalized g/l minimal g/l bone ;C 1 g/l ;C 0,2 g/l 3.3.4. loss; 3 radiotransparency Radiological 4 – generalwith differentbone horizontal site: 3.3.4. Radiological – general horizontal bone Figure 12. Radiograph aspect –– horizontal 9. Radiograph horizontal bone atrophy with cervical minimal on 43.44.45; loss; proximalapproximately demineralization on 47 onand 48; 34 and Figure 12. Radiographaspect boneatrophy aspect – horizontal bone atrophywith minimal loss; proximal demineralization on 34 and localized with vertical localized resorption. vertical resorption. vertical recurrent bone resorption caries lesion on 13 (Fig. under 6). restoration on 37 localized vertical resorption. recurrent caries lesion under restoration on 37 3.1.5. (Fig. 13).Cytologic appearance: microbial loaded (Fig. 13). lesions distal on 43 and the under-epithelial 44, facial connective on 45; tissue chronic there was 3.3.5. Cytological epithelial cells were – microbial observed loaded macrophages, interspersed in a the under-epithelial connective tissue there was 3.3.5. Cytological – microbial loaded macrophages, an abundant marginal inflammatory periodontitis. The lymphoplasmacytic exam of the marginal mixed cellular background of componentcells: inflammatory (epithelial macrophages, and an abundant inflammatory lymphoplasmacytic mixed cellular component (epithelial and infiltrate. periodontium There revealed: was a moderatecalculus edema index of the 34.48 conjunctive), cocci, granulocytes, bacilli, candida lymphocytes filaments. with microbial infiltrate. There was a moderate edema of the conjunctive), cocci, bacilli, candida filaments. epithelium and percent; gingival moderate spongiosis inflammation with erosive 3.3.6. Histologically – severe inflammatory epithelium and moderate spongiosisindex 11.20 with erosive elements: cocci, diplococci, 3.3.6. Histologically Treponema – severe denticola, inflammatory and ulcerative percent; areas. inflammation index 6.03 periodontal infiltrate was fusobacterium, observed; yeasts (Fig. the immunohistochemical and ulcerative areas. infiltrate was observed; the 7-a). immunohistochemical 3.3 Case percent; no. 3: S. M., f, age periodontal pockets41 with dimensions diagnosis The revealed: fragments histopathologic examination of pavements revealed 3.3 Case no. 3: S. M., f, age 41 diagnosis revealed: fragments of pavements 3.3.1. between Oral diagnosis 3-4 – mm; gingiva on teeth color diagram: changed,activefrom mucosa, fragments stratified of squamous presenting acanthosis mucosa acanthosis with prominent and 3.3.1. Oral diagnosis – on teeth diagram: active mucosa, stratified presenting and cervical light lesions redlesions to brickon 13, 31, 41 and 43; arrested parakeratosis with diffuse spongiosis and minimal cervical onred, 13, with a bordure 31, 41 and 43;periphery arrested acanthosis parakeratosis with withdiffuseirregularly spongiosis and elongated minimal brown area lesionsandon 37 and 48; on periodontal chart: hyperemia and important interstitial edema. brown(lisere) lesions on 37 ulceration and 48; on areas; bleedings periodontal at chart: hyperemia cristae epithelial and importantand abundant interstitial edema. inflammatory chronic periodontitis with tartar index of 25.89%; In the under-epithelial connective tissue, there chronic periodontitis slight touch; with tartar the periodontal index chart of 25.89%; revealed slight In the under-epithelial lymphoplasmacytic connective infiltrate in lamina tissue, there propria. gum inflammation index of 10.71%; periodontal was a minimal lymphoplasmocytic inflammatory gum gingivainflammation recession atindex of 10.71%; the level periodontal of the front inferior was a minimal Moderate edema lymphoplasmocytic within the lamina inflammatory propria and inflammation index of 7.14%; generalized infiltrate, with rare and small debris of odontogenic inflammation index of 7.14%; incisive, periodontal pockets in 11. 12. 15. 27. generalized infiltrate, with moderate rare and small debris of odontogenic gum retraction, with Stillman’s clefts on 16, 26; gum retraction, tissue in the epithelial chorion. spongiosis were noted; 33. 42. 45with 43. 44.exudateandStillman’s atslight cleftsmobility dental on 16,(first 26; tissue focally, in the chorion. erosive and ulcerative seropurulent seropurulent exudate at pressure pressure on the sides on the sides of of 3.3.7. Microbiological – on a areas were present rich macrophages degree) at the inferior incisive 3.3.7.7-b;Microbiological – on a rich macrophages the periodontal pockets at 13,(Fig. 12, 5-a; b). 43, 44; 23, 37, (Fig. c). inflammatory infiltrate ground, intercellular the periodontal pockets at 13, 12, 23, 37, 43, 44; inflammatory infiltrate ground, intercellular bleedings when touching gum level of the inferior cocci and bacilli phagocytosis, the presence of bleedings when touching gum level of the inferior cocci and bacilli phagocytosis, the presence of a b c a b c Figure 13. Figure 10.Laboratory Laboratoryaspects: aspects:a.a. inflammatory inflammatory lymphoplasmocytic lymphoplasmocytic infiltrate infiltrate with with macrophages macrophages loaded loaded with germs; with germs; b. b. acanthosis Figure 13. Laboratoryepithelium acanthotic aspects: a. inflammatory lymphoplasmocytic infiltrate with macrophages loaded withchronic germs;infiltrate b. acanthosis pavements squamous withelongation epithelium with important important elongation of the of the papillary interpapillary cristae cristaechronic and abundant and abundant infiltrate in chorion; in of islands pavements corion; epithelium islands of with important odontogenic elongation epithelium in of the corion; c. papillarymacroscopic aerobic cristae and abundant aspect. chronic infiltrate in chorion; islands of odontogenic epithelium in chorion; c. mild vascular hyperplasia (IHC-CD34). odontogenic epithelium in chorion; c. mild vascular hyperplasia (IHC-CD34). 118 Stomatology Edu Journal Stoma Edu J. 2017;4(2): 114-125 Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com http://www.stomaeduj.com 117 ORAL MANIFESTATIONS IN IRON DEFICIENCY ANEMIA: CASE REPORTS 3.2 Case no. 3: S. M., f, age 41 lesion; secondary caries; plaque and calculus; Original Articles 3.2.1. Oral diagnosis – on teeth diagram: active general marginal gingivitis; chronic periodontitis; cervical lesions on 13.31.41 and 43; arrested aggressive periodontitis with localized and general brown lesions on 37 and 48; on periodontal bone loss. Gathering this information, a graphic chart: chronic periodontitis with calculus index of image of the oral manifestations distribution in 25.89%; gingival inflammation index of 10.71%; associated systemic disease (IDA in these cases) periodontal inflammation index of 7.14%; was obtained (Fig. 11). generalized gingiva retraction, with Stillman’s clefts 4.2. Immunohistochemical analysis on 16.26; seropurulent exudate when exercising On the patients included in the studied lot gingival pressure on the sides of the periodontal pockets at biopsy was performed. The harvest was made 13.12.23.37.43.44; bleedings on gingival pressure from the affected periodontal structure. The iron level of the inferior front incisive; moderate dental deficiency anemia from metrorrhagia (13 cases) is mobility (second degree) (Fig. 8-a; b). characterized by: 5 cases with lack of T helper cells 3.2.2. Hematologic diagnosis – iron deficiency and PMNs, 3 cases with absence of T helper cells, anemia: HGB 10.8 g/dL; HCT 38 %; RBC 4.79 106/ 1 case with absence of PMN, frequent Langerhans μL; MCV 73.1 fL; Fe 21 μg/dL. cells, T and B lymphocytes in 4 cases. The following Complementary exams: radiological, cytological, was noticed with respect to IDA (11 cases): the immunohistochemical, microbiological, immuno- absence of T helper cells in 2 cases, the absence serological. of PMNs in 3 cases and in 4 cases the absence of 3.2.3. Serology – increase of the IgM: CRP 5.5 g/ both T helper cells and PMNs. In 2 cases frequent dL; IgA 1.93 g/L; IgG 12.4 g/L; IgM 2.40 g/L; C3 1 Langerhans cells, melanocytes and B-lymphocytes g/L; C4 0.2 g/L. were noticed (Table 1). 3.2.4. Radiological – general horizontal bone The 24 patients with dental and periodontal minimal loss; proximal demineralization on 34 and manifestations showed: the absence of T helper recurrent caries lesion under restoration on 37 cells and PMNs in 9 cases; PMNs absence in 4 (Fig. 9). cases and in 5 cases the absence of T helper cells 3.2.5. Cytology – microbial loaded macrophages, (which implies the lack of bacterial component in mixed cellular component (epithelial and 13 cases, as well a decrease of the cellular immune conjunctive), cocci, bacilli, candida filaments (Fig. line in 14 cases); frequent Langerhans cells, T and 10-a). B lymphocytes in 6 cases (Fig. 12). 3.2.6. Histopathologic appearance: squamous 4.3. Serology mucosa with hyperkeratosis with parakeratosis, Generally, in the case of anemia there are no acanthosis, diffuse spongiosis; mild lymphoplas- patent systematic changes of immunoglobulin mocytic inflammatory infiltrate, mild hyperemia and/or Complement, and, when present, there is and important interstitial edema within the corion; an associated cause (Table 2). minute remnants of odontogenic epithelium are This study showed: identifiable within the corion (Fig. 10-b). • high levels of IgM (associated to dental and 3.2.7. Microbiological – on a rich macrophages periodontal manifestations) in 2 cases; inflammatory infiltrate ground, intercellular • decreased IgG level in 2 cases (possibly due to cocci and bacilli phagocytosis, the presence of hypogammaglobulinemia); some large, creamy, half-transparent colonies • low values of C3 (due to chronic periodontics belonging to Gram-negative bacteria, considered infections) in 6 cases; as Klebsiella was noticed (Fig. 10-c). Also, smaller • decreased C4 in 2 cases (SLE, macrophages iron colonies, also with mucoid aspect, that could storage) (Fig. 13). be considered by their aspect, as belonging to 4.4. Microbiology the germs of Pseudomonas sp. Colony culture Samples were taken from gingival sulcus or anaerobically developed revealed a very abundant periodontal pockets. After the Gram staining, growth, non differentiated regarding the aspect bacterial cultures were obtained. Bacterial of the colonies; the colonies were in confluence, investigations were limited, due to the given creating a creamy aspect and above them some conditions of their metabolical cultivation and other types of colonies developed with different activity testing. A series of observations started forms and aspects, difficult to identify. from lesion peculiarities of some of the cases. The investigation was limited only to morphology and 4. Results characteristics of the cultivation of the growth of 4.1. Oral aspects the respective bacteria, in aerobic and anaerobic The study noticed the following by clinical environment. A rich bacterial polymorphism was examination, periodontal chart and radiographs found, which could not be significantly correlated on patients: active caries lesions; arrested brown with the lesion aspects encountered. Among lesions; defective restoration; cervical lesions; the isolated major groups, the following can be fissures; tooth fractures; matte white active cervical mentioned: Gram positive cocci from Micrococcus 118 Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com ORAL MANIFESTATIONS IN IRON DEFICIENCY ANEMIA: CASE REPORTS sp. and Staphylococcus sp. genres (nonhemolytic); Original Articles Klebsiella Gram negative bacillus (colonies with characteristics: big, mucoid); spiral shape bacteria and morphological aspects specific for yeasts, labeled as Candida. It should have been surely necessary to expand the bacterial investigations with molecular biology tests. There are studies about the preponderance of some bacteria from the genres of: Actynomices sp.; Fusobacterium nucleatum; Bacteroides sp.; Prevotella intermedia, Aggregatibacter actynomicetemcomitans; Porphyromonas gingivalis; Tannerella forsythia; Treponema denticola; Prevotella intermedia; Fusobacterium nucleatum; Eikenella corrodens; Eubacterium nodatum; Peptostreptococci; Selenomonas noxia; Capnocitophaga; Klebsiella, more frequently met in caries and periodontal pathology.13 From the group of aerobic and anaerobic bacteria cultures were developed, whose Figure 11. Distributiom of dental and periodontal cultivation rate suggested the presence of certain manifestations in types of anemia. bacterial groups. Seven of the cases indicated the presence of homogeneous cultures, especially of positive gram cocci, which can be associated with the aggressiveness of ecological dominance, selected under the action of local pressure factors and even constitutional general factors (anemia determines growth in monocultures). The frequent cultures were the associated ones, associations of at least 2 bacterial groups, which could have been distinguished through their morphological characteristics. In one single case, the presence of Candida was identified, frequently mentioned in oral conditioned pathology, associated with small, round scattered colonies, with homogeneous shape and dimensions, which suggests a bacterial presence. The presence of a polymorph microbial flora correlated with the dental and periodontal affections was also found. 4.5. Cytology Figure 12. Graphic representation of cases with low Gathering samples at the level of gingival sulcus cellular defense. and periodontal pockets from the studied patients revealed: • The morphology of exfoliating cells in the inflammatory process (hyperplasia, parakeratosis, hyperkeratosis and acanthosis), epithelial cells microbial filled, with a various flora: cocci, bacilli, candida filaments, fusobacterium species; • The presence of inflammatory infiltrate of several types of cells (neutrophils, monocytes, lymphocytes, leukocytes, macrophages) histiocytic proliferation; morphologic and erythrokinetic characteristics of the cellular factors of the immunity system were correlated with the type of anemia (acquired or genetic); • Microbial polymorph flora characteristic to the acute or chronic degree of dental and periodontal manifestations (coccus Gram positive, bacillus Gram negatives, fusobacterium spp., candida filaments). Figure 13. Immunogram graphic representation. Stomatology Edu Journal 119 ORAL MANIFESTATIONS EVALUATION IN IRON DEFICIENCY OF THE THERAPEUTIC BENEFITSANEMIA: CASEANTIBIOTIC OF GENERAL REPORTS THERAPY IN PERIODONTAL DISEASE Original Articles table 1. Specific markers values on patients with IDA and oral manifestations Hematologic No. Name sex Age diagnosis Etiology of anemia Oral diagnosis 1 L.A. F 25 IDA Chronic gastrointestinal Chronic gingivitis blood loss Numerous stained class 5 caries lesions 2 E.R. F 35 IDA Chronic gastrointestinal Chronic gingivitis Colon cancer blood loss Cervical lesions consistent with brown arrested lesions 3 G.I. F 32 IDA Metrorrhagia Chronic gingivitis Cavitated active cervical lesions 4 P.D. F 35 IDA Metrorrhagia Chronic gingivitis Matte, white, active cervical lesions 5 I.F. F 29 IDA Metrorrhagia Generalized marginal gingivitis Multiple adjacent defects that fit the description of abfraction lesions 6 M.Ş. F 39 IDA Metrorrhagia Chronic marginal periodontitis Active approximal and cervical caries lesions 7 N.V. F 35 IDA Metrorrhagia Chronic marginal periodontitis Multiple active caries lesions 8 Ş.G. F 30 IDA Metrorrhagia Chronic marginal periodontitis Thrombocytopenia Extensive active caries 9 Ş.A. F 25 IDA Metrorrhagia Chronic marginal periodontitis Active recurrent caries lesions 10 C.A. F 30 IDA Metrorrhagia Chronic marginal periodontitis Smooth surface caries lesions presenting microfractures in the surface 11 C.V. F 27 IDA Metrorrhagia Chronic gingivitis active root-surface caries lesions 12 T.A. F 34 IDA Metrorrhagia Chronic periodontitis Systemic lupus erythematosus Chronic inflammation Inactive or arrested caries lesions 13 T.C. F 28 IDA Metrorrhagia Chronic periodontitis Cavitated active cervical lesions 14 B.L. F 21 IDA Deficiency Aggressive periodontitis Extensive active cervical caries 15 B.R. M 22 IDA Deficiency Chronic gingivitis Matte, white, active cervical lesions 16 V.M. F 26 IDA Deficiency Chronic gingivitis, Arrested lesions and active localized caries 17 G.C. F 25 IDA Deficiency Chronic periodontitis Arrested caries lesions 18 M.R. F 23 IDA Deficiency Chronic periodontitis Arrested non-cavitated lesions 19 I.B. F 20 IDA Deficiency Aggressive periodontitis, Extensive active root-surface caries lesions 20 R.A. M 29 IDA Deficiency Chronic periodontitis Non-cavitated lesions and fissures 21 S.A. F 43 IDA Deficiency Chronic periodontitis, Active caries lesions with small and large cavities 22 R.M. F 31 IDA Deficiency Chronic periodontitis generalized Cavitated lesions 23 I.M. F 24 IDA Deficiency Chronic periodontitis Active discolored lesions 24 S.M. F 41 IDA Deficiency Chronic periodontitis Active cervical lesions 120 Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com ORAL EVALUATION OF MANIFESTATIONS THE THERAPEUTICIN IRON DEFICIENCY BENEFITS ANEMIA: OF GENERAL CASE REPORTS ANTIBIOTIC THERAPY IN PERIODONTAL DISEASE Original Articles Plasmatic MPO MPO cD3 cD3 cD5 cD5 cD7 cD7 sMA s100 s100 cD20 cells cD4 chorion epith chorion epith chorion epith chorion epith gran tissue 2 2 1 1 1 1 1 2 1 2 1 1 1 - 1 1 1 1 1 1 1 2 1 2 1 1 1 - 1 1 - - 0 0 0 0 1 1 1 1 1 - 1 1 2 1 0 1 0 2 1 1 1 1 1 gran tissue 1 1 - - 0 0 0 0 0 0 1 - - gran tissue 1 1 1 2 0 2 1 1 1 2 1 1 1 gran tissue 1 1 1 1 1 0 0 2 1 2 1 1 1 - 1 1 1 2 0 1 1 2 1 2 1 1 1 - 2 2 1 1 0 1 1 1 1 1 1 1 1 - 2 2 - - 0 1 0 1 1 2 1 1 1 gran tissue 1 1 - - 1 1 0 2 1 1 1 1 1 - 1 1 1 1 1 1 2 2 2 2 1 1 1 gran tissue 1 1 - - 1 2 2 2 1 2 1 1 1 gran tissue 2 2 1 2 0 2 1 1 1 1 1 1 1 - 2 2 - - 0 0 0 2 1 2 1 1 1 - 1 1 2 1 1 - - - - - - - - gran tissue 1 1 1 1 0 2 1 1 1 1 1 1 1 - 1 1 2 1 1 1 0 1 1 1 1 1 1 - 2 2 2 1 1 1 0 2 1 1 1 1 1 - 2 2 1 1 0 1 0 2 1 2 1 1 1 - 2 2 - - 1 0 0 2 1 1 1 1 1 - 1 1 - - 1 1 0 2 1 1 1 1 1 gran tissue 1 1 1 1 1 1 2 1 1 1 1 1 1 - 1 1 1 1 0 1 0 2 1 2 - - - Stomatology Edu Journal 121 ORAL MANIFESTATIONS EVALUATION IN IRON DEFICIENCY OF THE THERAPEUTIC BENEFITSANEMIA: CASEANTIBIOTIC OF GENERAL REPORTS THERAPY IN PERIODONTAL DISEASE Original Articles table 2. Serological values on patients with IDA and oral manifestations. Hematologic No. Name sex Age diagnosis Etiology of anemia Oral diagnosis 1 L.A. F 25 IDA Chronic gastrointestinal Chronic gingivitis blood loss Numerous stained class 5 caries lesions 2 E.R. F 35 IDA Chronic gastrointestinal Chronic gingivitis Colon cancer blood loss Cervical lesions consistent with brown arrested lesions 3 G.I. F 32 IDA Metrorrhagia Chronic gingivitis Cavitated active cervical lesions 4 P.D. F 35 IDA Metrorrhagia Chronic gingivitis Matte, white, active cervical lesions 5 I.F. F 29 IDA Metrorrhagia Generalized marginal gingivitis Multiple adjacent defects that fit the description of abfraction lesions 6 M.Ş. F 39 IDA Metrorrhagia Chronic marginal periodontitis Active approximal and cervical caries lesions 7 N.V. F 35 IDA Metrorrhagia Chronic marginal periodontitis Multiple active caries lesions 8 Ş.G. F 30 IDA Metrorrhagia Chronic marginal periodontitis Thrombocytopenia Extensive active caries 9 Ş.A. F 25 IDA Metrorrhagia Chronic marginal periodontitis Active recurrent caries lesions 10 C.A. F 30 IDA Metrorrhagia Chronic marginal periodontitis Smooth surface caries lesions presenting microfractures in the surface 11 C.V. F 27 IDA Metrorrhagia Chronic gingivitis active root-surface caries lesions 12 T.A. F 34 IDA, Systemic lupus Metrorrhagia Chronic periodontitis erythematosus Chronic inflammation Inactive or arrested caries lesions 13 T.C. F 28 IDA Metrorrhagia Chronic periodontitis Cavitated active cervical lesions 14 B.L. F 21 IDA Deficiency Aggressive periodontitis Extensive active cervical caries 15 B.R. M 22 IDA Deficiency Chronic gingivitis Matte, white, active cervical lesions 16 V.M. F 26 IDA Deficiency Chronic gingivitis Arrested lesions and active localized caries 17 G.C. F 25 IDA Deficiency Chronic periodontitis Arrested caries lesions 18 M.R. F 23 IDA Deficiency Chronic periodontitis Arrested non-cavitated lesions 19 I.B. F 20 IDA Deficiency Aggressive periodontitis Extensive active root-surface caries lesions 20 R.A. M 29 IDA Deficiency Chronic periodontitis Non-cavitated lesions and fissures 21 S.A. F 43 IDA Deficiency Chronic periodontitis Active caries lesions with small and large cavities 22 R.M. F 31 IDA Deficiency Chronic periodontitis generalized Cavitated lesions 23 I.M. F 24 IDA Deficiency Chronic periodontitis Active discolored lesions 24 S.M. F 41 IDA Deficiency Chronic periodontitis Active cervical lesions 122 Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com ORAL EVALUATION OF MANIFESTATIONS THE THERAPEUTICIN IRON DEFICIENCY BENEFITS ANEMIA: OF GENERAL CASE REPORTS ANTIBIOTIC THERAPY IN PERIODONTAL DISEASE 5. Conclusions 4.4. Microbiological Original Articles Microbiological macroscopic aspects the patients • The microbial macroscopic determinations showed which were dealt with: showed Biological species samples were of: taken Streptococcus from gingival mutans, sulcus or periodontal Lactobacillus, pockets. After Porphyromonas the Gram coloration, gingivalis, serum immunoglobulins complement through the described technique, bacterial Tannerella cultures were forsythia etc. correlated obtained. Bacterialwith the degree investigations IgA IgG IgM c3 c4 crP were of limited, due impairment to oral of the the given conditions of their structures; 325 1401 102 100 14,3 ++ metabolical cultivation and activity testing. A series •of The evolutionstarted observations of thefrom caries andpeculiarities lesion other oral 133 876 70 60 20 ++ of some of the manifestations can cases, be slow theor investigation rapid depending was limited only to morphology and characteristics 158 1450 234 110 30 ++ on of thethecultivation patient’sof background, the growth of the microbial the respective bacteria, in aerobic component and the and anaerobic systemic factors environment. (anemia in 228 1010 65 123 23,2 ++ Due to the investigations studied, a rich bacterial this case), which can change the general state; polymorphism was found, which could not be 192 1500 142 140 20 - •significantly A reduced or abundant correlated with the lesion inflammatory aspects encountered. Among the major groups isolated, polymorphous infiltrate was also revealed, mention can be made of: Gram positive cocci 363 484 182 120 40 ++ depending from Micrococcus on the sp. degreeand of the inflammation Staphylococcus sp. genres (nonhemolytic); Klebsiella and tissue destruction (neutrophils, macrophages,Gram negative 166 1100 124 100 60 ++ bacillus (colonies with characteristics: big, histiocytes, mucoid); spiral lymphocytes, shape bacteria plasma and cells) and also morphological 205 1100 150 130 30 ++ aspects specific for yeasts, labeled related to the epithelial alterations (hyperplasia, as Candida. It should have been surely necessary to expand the acanthosis, parakeratosis);with molecular biology bacterial investigations 255 1030 496 110 20 ++ •tests. TheThere are studies about the immunohistochemical preponderance exam showed a of some bacteria from the genres of: Actynomices 372 1060 124 80 30 ++ chronic inflammatory nucleatum; sp.; Fusobacterium process consisting Bacteroides of sp.; Prevotella numerous intermedia, T cells (pan T markersAggregatibacter CD3 and CD5 actynomicetemcomitans; Porphyromonas 332 1250 120 70 30 ++ positive) retaining CD7 expression and belonging gingivalis; Tannerella forsythia; Treponema mostly to T helper denticola; phenotype Prevotella (CD4+). intermedia; inflammatory Fusobacterium 77 1540 108 126 14,3 - nucleatum; Eikenella corrodens; Eubacterium infiltrate includes also B-lymphocytes (expressing nodatum; Peptostreptococci; Selenomonas noxia; 274 1160 123 110 30 - CD20), neutrophils, Capnocitophaga; Langerhans Klebsiella, more cells (expressing frequently met in caries and periodontal pathology. CD1a and S100); it also revealed a moderate From the 184 1002 100 110 50 ++ group of aerobic and anaerobic bacteria cultures vascular hyperplasia were developed, whosewithcultivation significantrate angiogenesis suggested 185 1210 90 110 20 - the presence (revealed withofCD34 certain bacterial groups. Seven of marker); the cases indicated the presence of homogeneous •cultures, The immunoserological especially of positive examgramdemonstrated cocci, which 78 1220 129 100 20 ++ can be associated with the modifications of the Immunogram values and ofaggressiveness of 144 983 182 110 40 ++ ecological dominance, selected under the action the Complement of local system;and pressure factors these findings even are not constitutional 156 1410 176 100 30 ++ general factors characteristic for (anemia the systemic determines affection, growth in but for monocultures). The frequent cultures were the infections; associated ones, associations of at least 2 bacterial 136 68 154 160 40 ++ •groups, The results whichlead couldto ahavebetter understanding been distinguished of through their morphological characteristics. 271 1210 122 90 30 ++ the determining factors of oral pathology (in In one single case, the presence of Candida clinical types of anemia); was identified, frequently further studies involving mentioned in oral 158 1340 168 70 30 - conditioned pathology, associated with small, larger groups of subjects are necessary in order to round scattered colonies, with homogeneous 164 1200 122 90 30 - definitely shape andestablish a causal dimensions, relation which between suggests these a bacterial presence. entities. What was also found was the presence 216 1230 139 110 20 ++ of a polymorph microbial flora correlated with the dental periodontal affections. 193 1240 240 100 20 ++ 4.5. Cytological Acknowledgments Gathering samples at the level of gingival sulcus The and authors declare periodontal no conflict pockets fromofthe interest related 40 patients studied revealed: to this study. There are no conflicts of interest and • The morphology of exfoliating cells in the no financial interests to be disclosed. Stomatology Edu Journal 123 ORAL MANIFESTATIONS IN IRON DEFICIENCY ANEMIA: CASE REPORTS References Original Articles 1. Greer JP, Arber DA, Glader B, et al. Editors. 11. Roberson TM, Heymann HO, Swift Jr EJ. Editors. Wintrobe's clinical hematology, 13th Edition. Sturdevant’s Art and Science of Operative Dentistry, Philadelphia, PA: Lippincott, Williams & Wilkins; 2009. Fifth edition. St. Louis, MI: Mosby Elsevier Inc.; 2006. Google Scholar(4115) 12. Gao B, Gupta RS. Phylogenetic framework and 2. Nørskov-Lauritsen N, Kilian M. 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Scopus(51) EVALUATION OF THE THERAPEUTIC BENEFITS OF GENERAL ANTIBIOTIC THERAPY Google Scholar(85) IN PERIODONTAL DISEASE Mihaela Florina Loredana COJANU DMD, DMSc, Teaching Assistant Restorative Odontotherapy Department Faculty of Dental Medicine “Carol Davila” University of Medicine and Pharmacy Bucharest Bucharest, Romania Clinical Dentist in Bucharest, Romania CV Loredana Cojanu is a clinical dentist with experience and passion for aesthetic dentistry who graduated from the Dental Medicine “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; PhD in Periodontology; Competence in Implantology. She is currently a Teaching Assistant in Restorative Odontotherapy Department of Dental Medicine “Carol Davila”. She is a member of ESCD, SSER. An author of scientific articles, she also has collaboratively authored book chapters in academic textbook. Questions What means the acronym IDA? 124 qa. Immune disorder activity; qb. Iron deficiency anemia; Stoma Edu J. 2017;4(2): 114-125 http://www.stomaeduj.com ORAL MANIFESTATIONS IN IRON DEFICIENCY ANEMIA: CASE REPORTS What means the acronym IDA? Original Articles qa. Immune disorder activity; qb. Iron deficiency anemia; qc. Increased data analyses; qd. Iron disease autoimmune. Anemia is associated with: qa. Decreased levels of hemoglobin (Hb); qb. Increased values of hematocrit (Hct); qc. High levels of hemoglobin (Hb); qd. Developing countries only. Oral manifestations can appear due to: qa. A healthy diet; qb. An imbalance immune system; qc. Lack of risk factors; qd. Normal dental structures. Increased number of microorganisms in the oral cavity, the inflammatory reaction of the host and immunity response based on specific and nonspecific factors in the previous clinical cases are revealed by: qa. Normal microbial macroscopic aspects; qb. Epithelial cells with no trace of cocci, bacilli, candida filaments and fusobacterium species; qc. Lack of inflammatory infiltrated; qd. Immunohistochemical exam that showed a chronic inflammatory process. 14 - 16 September 2017, Las Vegas, NV, USA https://www.dentsplysironaworld.com Stomatology Edu Journal 125