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Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus
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Journal of the Formosan Medical Association (2014) xx, 1e6
Available online at www.sciencedirect.com
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ORIGINAL ARTICLE
Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus Hsin-Ming Chen a,b,c, Yi-Ping Wang b,c, Julia Yu-Fong Chang b,c, Yang-Che Wu b,c, Shih-Jung Cheng b,c, Andy Sun b,c,* a
Graduate Institute of Oral Biology, School of Dentistry, National Taiwan University, Taipei, Taiwan Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan c Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan b
Received 2 September 2014; received in revised form 12 October 2014; accepted 15 October 2014
KEYWORDS hemoglobin; homocysteine; iron; oral lichen planus; vitamin B12
Background/purpose: A portion of patients with oral lichen planus (OLP) may have nutritional deficiency. This study evaluated whether there was an intimate association of the deficiencies of hemoglobin (Hb), iron, vitamin B12, and folic acid and high blood homocysteine level with OLP. Methods: The blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations in 352 OLP patients were measured and compared with the corresponding levels in 352 age- and sexmatched healthy control participants. Results: We found that 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and one (0.3%) OLP patient had deficiencies of Hb (men < 13 g/dL, women < 12 g/ dL), iron (< 60 mg/dL), vitamin B12 (< 200 pg/mL), and folic acid (< 4 ng/mL), respectively. Moreover, 52 (14.8%) OLP patients had abnormally high blood homocysteine level. OLP patients had a significantly higher frequency of Hb, iron, or vitamin B12 deficiency and of abnormally elevated blood homocysteine level than healthy control participants (all p < 0.001). Upon further dividing OLP patients into those with major erosive OLP (MjEOLP; n Z 67), minor erosive OLP (n Z 202), and nonerosive OLP (NEOLP; n Z 83), we found that MjEOLP patients had a significantly higher mean homocysteine level than NEOLP patients (p Z 0.035).
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Number 1, Chang-Te Street, Taipei 10048, Taiwan. E-mail address: [email protected] (A. Sun). http://dx.doi.org/10.1016/j.jfma.2014.10.004 0929-6646/Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Please cite this article in press as: Chen H-M, et al., Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/ j.jfma.2014.10.004
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H.-M. Chen et al. Conclusion: We conclude that there is a significant association of deficiencies of Hb, iron, folic acid, and vitamin B12 and abnormally high blood homocysteine level with OLP. There may be a close relation of high blood homocysteine level to severity of OLP. Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Introduction Oral lichen planus (OLP) is a chronic immunologic mucocutaneous inflammatory oral mucosal disease that affects 0.2e3% of the population.1,2 Clinically, reticular, papular, erosive, ulcerative, plaque-like, atrophic, and bullous types of OLP can be identified.2 A previous study showed involvement of both antigen-specific and nonspecific mechanisms in OLP. Antigen-specific mechanisms include antigen presentation by basal keratinocytes and antigenspecific keratinocyte killing by CD8þ cytotoxic T lymphocytes. Nonspecific mechanisms include mast cell degranulation and matrix metalloproteinase activation in OLP lesions.1 Through mast cell/T-cell interactions in OLP lesions, mast cell-released cytokines, chemokines, and matrix metalloproteinases can promote T-cell activation, migration, proliferation, and differentiation.3 Histologically, OLP is characterized by liquefaction degeneration of basal epithelial cells and an intraepithelial and subepithelial infiltrate of mononuclear cells, which are predominantly CD8þ. CD4þ cells can be found mainly in the deep lamina propria.4 An increase in histocompatibility leukocyte antigen-DR-positive CD3þ cells in both local lesional tissues and peripheral blood lymphocytes also indicates T-cell activation in OLP.5,6 The aforementioned findings suggest that OLP is a T-lymphocyte-mediated inflammatory disease. Because OLP was considered to be a T-lymphocytemediated immunological disorder, only a few studies evaluated the hematological abnormalities and nutritional deficiencies in OLP patients.7e9 Nevertheless, deficiencies of vitamin B12,7 folate,7e9 iron,7 vitamin B1,9 and vitamin B69 have been reported in a portion of OLP patients. In this study, we assessed whether there was an intimate association of the deficiencies of hemoglobin (Hb), iron, vitamin B12, and folic acid and high blood homocysteine level with OLP.
Materials and methods Study participants The study group consisted of 352 patients (73 men and 279 women; age range, 22e87 years, mean 56.8 14.2 years) with OLP. The normal control group consisted of 352 age- ( 2 years of each patient’s age) and sex-matched healthy control participants (73 men and 279 women; age range, 22e88 years, mean 55.2 13.7 years). All the patients and participants (control) were seen consecutively, diagnosed, and treated in the Department of Dentistry, National Taiwan University Hospital (Taipei, Taiwan) from July 2007 to June 2014. The 352 OLP patients included 269 (51 men
and 218 women) with erosive OLP (EOLP) and 83 (22 men and 61 women) with nonerosive OLP (NEOLP). They were selected according to the following criteria: (1) a typical clinical presentation of radiating grayish-white Wickham striae, papules, and plaques, separately or in combination (NEOLP), and erosion or ulceration on the oral mucosa (EOLP); and (2) biopsy specimens characteristic of OLP, that is, hyperkeratosis or parakeratosis, a slightly acanthotic epithelium with liquefaction degeneration of the basal epithelial cells, a pronounced band-like lymphocytic infiltrate in the lamina propria, and the absence of epithelial dysplasia. The EOLP was further divided into the major (MjEOLP) and minor (MiEOLP) types according to criteria described previously.10e13 However, all OLP patients with areca quid chewing habit, autoimmune diseases (such as systemic lupus erythematosus, rheumatoid arthritis, Sjo ¨gren syndrome, pemphigus vulgaris, and cicatricial pemphigoid), inflammatory diseases, malignancy, or recent surgery were excluded. In addition, all OLP patients with serum creatinine concentrations indicative of renal dysfunction (men, > 131 mmol/L; women, > 115 mmol/L) and who reported a history of stroke, heavy alcohol use, or diseases of the liver, kidney, or coronary arteries were also excluded.14 Healthy control participants had either dental caries or mild periodontal diseases but did not have any oral mucosal or systemic diseases. None of the OLP patients had taken any prescription medication for OLP for at least 3 months prior to entering the study. The blood samples were drawn from OLP patients and healthy control participants for the measurement of blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations. This study was reviewed and approved by the Institutional Review Board at the National Taiwan University Hospital.
Determination of blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations The blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations were determined by the routine tests performed in the Department of Laboratory Medicine, National Taiwan University Hospital.
Statistical analysis Comparisons of the mean blood levels of Hb, iron, vitamin B12, folic acid, and homocysteine between 352 OLP patients and 352 age- and sex-matched healthy control participants and between MjEOLP and MiEOLP or NEOLP patients were performed by Student t test. The differences in frequency of Hb, iron, vitamin B12, or folic acid deficiency and of abnormally high blood homocysteine level between OLP patients and healthy control participants and between
Please cite this article in press as: Chen H-M, et al., Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/ j.jfma.2014.10.004
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Oral lichen planus
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Table 1 Mean blood concentrations of hemoglobin, iron, vitamin B12, folic acid, and homocysteine in 352 patients with oral lichen planus and in 352 age- and sex-matched healthy control participants. Patients with OLP (n Z 352) Mean SD Hb (g/dL) Men (n Z 73) Women (n Z 279) Iron (mg/dL) Men (n Z 73) Women (n Z 279) Vitamin B12 (pg/mL) Folic acid (ng/mL) Homocysteine (mM)
Range
14.4 1.6 12.8 1.2
(9.3e16.8) (7.5e16.4)
(10.0e183.0) (16.0e210.0) (150.0e1000.0) (3.7e24.0) (3.2e23.8)
98.6 86.6 605.4 13.3 8.8
34.3 30.9 266.2 5.9 3.3
Healthy control participants (n Z 352) Mean SD
p
Range
15.2 0.7 13.6 0.7
(13.6e16.6) (12.2e15.4)
<0.001* <0.001*
(62.0e187.0) (60.0e204.0) (259.0e1000.0) (4.1e24.0) (4.3e14.3)
0.527 <0.001* <0.001* 0.008* 0.052
101.8 99.2 686.7 14.5 8.4
26.2 28.0 239.8 6.0 2.0
* Comparisons of the mean blood levels of hemoglobin, iron, vitamin B12, folic acid, and homocysteine between 352 OLP patients and 352 age- and sex-matched healthy control participants by Student t test with p < 0.05. Hb Z hemoglobin; OLP Z oral lichen planus; SD Z standard deviation.
MjEOLP and MiEOLP or NEOLP patients were compared by Chi-square test. The result was considered to be significant if p < 0.05.
Results The mean blood concentrations of Hb, iron, vitamin B12, folic acid, and homocysteine in 352 OLP patients and in 352 age- and sex-matched healthy control participants are presented in Table 1. Because men usually have higher blood levels of Hb and iron than women, these two mean levels were calculated separately for men and women. We found that OLP patients had significantly lower mean Hb (p < 0.001 for both men and women), iron (p < 0.001 for women only), vitamin B12 (p < 0.001), and folic acid (p Z 0.008) levels than healthy control participants (Table 1). In addition, OLP patients had marginally significantly higher mean homocysteine level (p Z 0.052) than healthy control participants. Although male OLP patients also had a lower mean iron level than male healthy control participants, the difference was not significant (p Z 0.527; Table 1). According to the World Health Organization (WHO) criteria for iron-deficiency anemia, men with Hb < 13 g/dL and women with Hb < 12 g/dL were defined as having Hb deficiency or anemia.15 Furthermore, patients with serum iron level < 60 mg/dL,16 serum vitamin B12 level < 200 pg/ mL (148 pmol/L),14 or folic acid level < 4 ng/mL (10 nmol/ L)17 were defined as having iron, vitamin B12, or folic acid deficiency, respectively. In addition, patients with the blood homocysteine level > 12.4 mmol/L (which was the mean blood homocysteine level of healthy control participants plus two standard deviations) were defined as having an abnormally high homocysteine level. Based on the aforementioned definitions, 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and 1 (0.3%) OLP patient were diagnosed as having Hb, iron, vitamin B12, and folic acid deficiencies, respectively (Table 2). Moreover, 52 (14.8%) OLP patients had abnormally high blood homocysteine level (Table 2). OLP patients had a
significantly higher frequency of Hb, iron, or vitamin B12 deficiency and of abnormally elevated blood homocysteine level than healthy control participants (all p < 0.001; Table 2). Defining iron-deficiency anemia as the presence of a Hb concentration < 13 g/dL for men and < 12 g/dL for women,15 a mean corpuscular volume 80 fL, and a low serum iron level (< 60 mg/dL),16 we found that 36 (10.2%) of the 352 OLP patients could be classified as having irondeficiency anemia. In addition, defining pernicious anemia as the presence of a Hb concentration < 13 g/dL for men and < 12 g/dL for women,15 a mean corpuscular volume 100 fL, a low serum vitamin B12 level (< 200 pg/mL), and serum positivity of gastric parietal cell antibody,14,18 we discovered that only six (1.7%) of the 352 OLP patients could be classified as having pernicious anemia. When applying the WHO criteria for iron-deficiency anemia, these findings suggest that approximately 10% of the 352 OLP patients in this study are having iron-deficiency anemia, but pernicious anemia is infrequently found in the 352 OLP patients studied. When the 352 OLP patients were further divided as having MjEOLP (n Z 67), MiEOLP (n Z 202), and NEOLP (n Z 83), we found that MjEOLP patients had a significantly higher mean homocysteine concentration than NEOLP patients (p Z 0.035; Table 3). However, there were no significant differences in the blood levels of Hb, iron, vitamin B12, and folic acid between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients (Table 3). Moreover, there were no significant differences in the frequencies of Hb, iron, vitamin B12, and folic acid deficiencies and of abnormally elevated blood homocysteine level between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients (Table 4).
Discussion The majority of previous studies focused on the immunological dysregulation in OLP patients.1e6 Thus, hematological abnormalities and nutritional deficiencies were
Please cite this article in press as: Chen H-M, et al., Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/ j.jfma.2014.10.004
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H.-M. Chen et al. Table 2 Number and percentage of individuals with hemoglobin, iron, vitamin B12, or folic acid deficiency or with abnormally high homocysteine level in the two study groups. Factor
N (%)
Hemoglobin deficiency (men < 13 g/dL, women < 12 g/dL) Iron deficiency (< 60 mg/dL) Vitamin B12 deficiency (< 200 pg/mL) Folic acid deficiency (< 4 ng/mL) High homocysteine levels (>12.4 mM)a
p
Patients with OLP (n Z 352)
Healthy control participants (n Z 352)
77 48 25 1 52
0 0 0 0 11
(21.9) (13.6) (7.1) (0.3) (14.8)
< < < > <
(0) (0) (0) (0) (3.1)
0.001* 0.001* 0.001* 0.99 0.001 *
OLP patients (N ) Z 352; Healthy control participants (N ) Z 352 age and sex matched. * Comparison of frequency of hemoglobin, iron, vitamin B12, or folic acid deficiency and of abnormally high blood homocysteine level between 352 OLP patients and 352 age- and sex-matched healthy control participants by Chi-square test with p < 0.05. OLP Z oral lichen planus. a Patients with high homocysteine level are those with the homocysteine level greater than the mean blood homocysteine level of healthy control participants plus two standard deviations.
Table 3 Mean blood concentrations of hemoglobin, iron, vitamin B12, folic acid, and homocysteine in 67 patients with MjEOLP, in 202 patients with MiEOLP, and in 83 patients with NEOLP.
Hb (g/dL) Men Women Iron (mg/dL) Men Women Vitamin B12 (pg/mL) Folic acid (ng/mL) Homocysteine (mM)
Patients with MjEOLP (n Z 67)
Patients with MiEOLP (n Z 202)
Mean SD
Mean SD
14.7 1.2 (n Z 13) 12.9 1.4 (n Z 54) 97.0 83.5 620.0 13.2 9.5
104.7 87.3 609.8 14.7 8.8
Patients with NEOLP (n Z 83)
p*
Mean SD
14.4 1.3 (n Z 38) 12.8 1.2 (n Z 164)
39.0 (n Z 13) 30.1 (n Z 54) 294.3 6.1 4.1
p*
30.8 (n Z 38) 30.8 (n Z 164) 269.1 6.9 3.2
14.2 2.1 (n Z 22) 12.9 1.3 (n Z 61)
0.468 0.611 0.471 0.430 0.793 0.114 0.151
89.2 87.3 623.7 13.6 8.3
36.7 (n Z 22) 32.1 (n Z 61) 251.6 5.9 2.8
0.439 1.000 0.557 0.516 0.934 0.685 0.035**
* Comparisons of the mean blood levels of Hb, iron, vitamin B12, folic acid, and homocysteine between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients by Student t test. **p < 0.05 by Student t test. Hb Z hemoglobin; MiEOLP Z major erosive oral lichen planus; MjEOLP Z minor erosive oral lichen planus; NEOLP Z nonerosive oral lichen planus; SD Z standard deviation.
Table 4 Number and percentage of individuals with hemoglobin, iron, vitamin B12, or folic acid deficiency and with abnormally high homocysteine level in the MjEOLP, MiEOLP, and NEOLP groups. Factor
Hemoglobin deficiency (men < 13 g/dL, women < 12 g/dL) Iron deficiency (<60 mg/dL) Vitamin B12 deficiency (< 200 pg/mL) Folic acid deficiency (< 4 ng/mL) High homocysteine levelsa (> 12.4 mM)
N (%)
p*
N (%)
p*
Patients with MjEOLP (n Z 67)
Patients with MiEOLP (n Z 202)
11 (16.4)
46 (22.8)
0.352
20 (24.1)
0.341
10 6 0 12
26 16 1 34
0.825 0.992 0.561 0.987
12 3 0 6
0.879 0.306 ND 0.080
(14.9) (9.0) (0) (17.9)
(12.9) (7.9) (0.5) (16.8)
Patients with NEOLP (n Z 83)
(14.5) (3.6) (0) (7.2)
* Comparison of frequency of hemoglobin, iron, vitamin B12, or folic acid deficiency and abnormally high blood homocysteine level between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients by Chi-square test. MiEOLP Z major erosive oral lichen planus; MjEOLP Z minor erosive oral lichen planus; ND Z no difference; NEOLP Z nonerosive oral lichen planus. a Patients with high homocysteine level are those with the homocysteine level greater than the mean blood homocysteine level of healthy control participants plus two standard deviations.
Please cite this article in press as: Chen H-M, et al., Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/ j.jfma.2014.10.004
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Oral lichen planus infrequently investigated in OLP patients. Jolly and Nobile9 found folic acid deficiency (< 3 ng/mL) in five of 34 OLP patients. They also observed widespread deficiencies or marginally low levels of vitamins B1 and B6 in both OLP patients and control participants, suggesting special dietary habits of the local community and an inadequate intake of unrefined cereal products such as whole-wheat bread, which is the main source of vitamins B1 and B6. Challacombe7 studied the hematological abnormalities in 103 OLP patients and demonstrated anemia, low iron, low folate, and low vitamin B12 in nine (8.7%) OLP patients, 13 (12.6%) OLP patients, three (2.9%) OLP patients, and two (1.9%) OLP patients, respectively. Moreover, the prevalence of hematological abnormalities was significantly greater in EOLP patients than in NEOLP patients.7 Thongprasom et al8 identified low red cell folate level in 11 (44%) of 25 OLP patients. However, the serum vitamin B12 levels of OLP patients were within normal range in their study.8 This study found that 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and one (0.3%) OLP patients had deficiencies of Hb, iron, vitamin B12, and folic acid, respectively. OLP patients had a significantly higher frequency of Hb, iron, or vitamin B12 deficiency than healthy control participants. Of 352 OLP patients, 36 (10.2%) had iron-deficiency anemia and six (1.7%) had pernicious anemia. In addition, EOLP patients did not have a significantly higher prevalence of hematinic deficiency than NEOLP patients. The results of previous and present studies indicate that there is a small group of OLP patients definitely having anemia or hematinic deficiencies. Therefore, supplementation of hematinics or multiple B vitamins may be beneficial for this specific group of OLP patients. Actually, Jolly and Nobile9 observed good and some improvement in 20 of 41 and nine of 41 vitamin-deficient OLP patients treated with multiple vitamin supplements, respectively. However, complete remission of the OLP lesions was not seen within 2 months of commencing vitamin therapy.9 This finding suggests that although the frequency of hematinic deficiency is significantly higher in OLP patients than in healthy control participants, hematinic deficiency is probably not the main etiology causing the OLP. Homocysteine, a sulfur-containing amino acid, is formed during methionine metabolism.19 Both vitamin B12 and folic acid function as coenzymes that are required for the conversion of homocysteine to methionine.20 It is important to monitor the blood homocysteine level because higher blood homocysteine levels can cause oxidative stress, damage endothelium, and enhance thrombogenicity, and are thus associated with increased rates of coronary heart disease and stroke.19,21e24 In addition, measurement of both serum methylmalonic acid and homocysteine levels is found to be a more sensitive method of screening for vitamin B12 deficiency (sensitivity Z 99.8%), and thus can be used for detecting subclinical vitamin B12 deficiency.25,26 In this study, an abnormally higher blood homocysteine level was detected in 14.8% of OLP patients, whereas only 3.1% of healthy control participants had a higher blood homocysteine level. The high blood homocysteine level in OLP patients could be due to deficiencies in folic acid and vitamins B12 and B6, because previous studies have shown that a supplementation with folic acid and vitamins B12 and B6 can
5 reduce blood homocysteine levels.21,27,28 In this study, the mean vitamin B12 and folic acid levels were significantly lower in OLP patients than in healthy control participants. Furthermore, the frequency of vitamin B12 (but not folic acid) deficiency was significantly higher in OLP patients than in healthy control participants. Our study also showed a significantly higher mean blood homocysteine level in MjEOLP patients than in NEOLP patients. Because patients with MjEOLP often have more severe and larger recurrent ulcerative OLP lesions than NEOLP patients, the result of our study indicates that the severity of OLP may be related to the elevated homocysteine level in OLP patients. In our oral mucosal disease clinic, a portion of patients with atrophic glossitis, burning mouth syndrome, recurrent aphthous ulcerations, OLP, or antithyroid autoantibodies are found to have hematinic deficiencies, high blood homocysteine level, iron-deficiency anemia, or thalassemia.29e34 Supplementation of multiple B vitamins including B1, B2, B6, and B12, calcium pantothenate, nicotinamide, and folic acid may cause significant reductions in blood homocysteine level and improvements of oral symptoms or signs in patients with atrophic glossitis or burning mouth syndrome.27,28 These findings suggest that it is very important to check complete blood count and blood levels of iron, vitamin B12, and folic acid for patients with atrophic glossitis, burning mouth syndrome, recurrent aphthous ulcerations, or OLP. For those patients with hematinic deficiencies, high blood homocysteine level, or anemia, immediate treatment with multiple B vitamins or specific deficient hematinics usually results in prompt improvement of the associated oral diseases. Our results demonstrated that 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and one (0.3%) OLP patient had deficiencies of Hb, iron, vitamin B12, and folic acid, respectively. Moreover, 52 (14.8%) OLP patients had abnormally high blood homocysteine level. In addition, we showed significantly higher frequencies of Hb, iron, and vitamin B12 deficiencies and of abnormally elevated blood homocysteine level in our 352 OLP patients than in the 352 healthy control participants. These findings suggest there is a significant association of deficiencies of Hb, iron, and vitamin B12 and abnormally high blood homocysteine level with OLP. The present study also found that MjEOLP patients had a significantly higher mean blood homocysteine level than NEOLP patients. This finding also indicates a close relation of high blood homocysteine level to severity of OLP.
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6 5. Hirota J, Osaki T, Tatemoto Y. Immunohistochemical staining of infiltrates in oral lichen planus. Pathol Res Pract 1990;186: 625e32. 6. Yamamoto T, Yoneda K, Ueta E, Osaki T. Cellular immunosuppression in oral lichen planus. J Oral Pathol Med 1990;19: 464e70. 7. Challacombe SJ. Haematological abnormalities in oral lichen planus, candidiasis, leukoplakia and non-specific stomatitis. Int J Oral Maxillofac Surg 1986;15:72e80. 8. Thongprasom K, Youngnak P, Aneksuk V. Folate and vitamin B12 levels in patients with oral lichen planus, stomatitis or glossitis. Southeast Asian J Trop Med Public Health 2001;32: 643e7. 9. Jolly M, Nobile S. Vitamin status of patients with oral lichen planus. Aust Dent J 1977;22:446e50. 10. Lin HP, Wang YP, Chia JS, Sun A. Modulation of serum antinuclear antibody levels by levamisole treatment in patients with oral lichen planus. J Formos Med Assoc 2011;110:316e21. 11. Kuo RC, Lin HP, Sun A, Wang YP. Prompt healing of erosive oral lichen planus lesion after combined corticosteroid treatment with locally injected triamcinolone acetonide plus oral prednisolone. J Formos Med Assoc 2012;112:216e20. 12. Chiang CP. Levamisole is an effective immunomodulator for patients with oral lichen planus. J Formos Med Assoc 2012; 111:661. 13. Wu KM, Wang YP, Lin HP, Chen HM, Chia JS, Sun A. Modulation of serum smooth muscle antibody levels by levamisole treatment in patients with oral lichen planus. J Formos Med Assoc 2013;112:352e7. 14. Morris MS, Jacques PF, Rosenberg IH, Selhub J. Folate and vitamin B-12 status in relation to anemia, macrocytosis, and cognitive impairment in older Americans in the age of folic acid fortification. Am J Clin Nutr 2007;85:193e200. 15. WHO/UNICEF/UNU. Iron deficiency anaemia assessment, prevention, and control: a guide for programme managers. Geneva, Switzerland: World Health Organization; 2001. 16. Shine JW. Microcytic anemia. Am Fam Physician 1997;55: 2455e62. 17. de Benoist B. Conclusions of a WHO technical consultation on folate and vitamin B12 deficiencies. Food Nutr Bull 2008;29(2 Suppl.):S238e44. 18. Lahner E, Annibale B. Pernicious anemia: new insights from a gastroenterological point of view. World J Gastroenterol 2009; 15:5121e8. 19. Spence JD. Homocysteine-lowering therapy: a role in stroke prevention? Lancet Neurol 2007;6:830e8. 20. Chanarin I, Deacon R, Lumb M, Perry J. Cobalamin-folate interrelations. Blood Rev 1989;3:211e5.
H.-M. Chen et al. 21. Lonn E, Yusuf S, Arnold MJ, Sheridan P, Pogue J, Micks M. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med 2006;354:1567e77. 22. Welch GN, Loscalzo J. Homocysteine and atherothrombosis. N Engl J Med 1998;338:1042e50. 23. Harker LA, Harlan JM, Ross R. Effect of sulfinpyrazone on homocysteine-induced endothelial injury and arteriosclerosis in baboons. Circ Res 1983;53:731e9. 24. Harker LA, Slichter SJ, Scott CR, Ross R. Homocysteinemia: vascular injury and arterial thrombosis. N Engl J Med 1974;291: 537e43. 25. Oh RC, Brown DL. Vitamin B12 deficiency. Am Fam Physician 2003;67:979e86. 26. Savage DG, Lindenbaum J, Stabler SP, Allen RH. Sensitivity of serum methylmalonic acid and total homocysteine determinations for diagnosing cobalamin and folate deficiencies. Am J Med 1994;96:239e46. 27. Sun A, Wang YP, Lin HP, Chen HM, Cheng SJ, Chiang CP. Significant reduction of homocysteine level with multiple B vitamins in atrophic glossitis patients. Oral Dis 2013;19:519e24. 28. Sun A, Lin HP, Wang YP, Chen HM, Cheng SJ, Chiang CP. Significant reduction of serum homocysteine level and oral symptoms after different vitamin-supplement treatments in patients with burning mouth syndrome. J Oral Pathol Med 2013;42:474e9. 29. Sun A, Lin HP, Wang YP, Chiang CP. Significant association of deficiency of hemoglobin, iron and vitamin B12, high homocysteine level, and gastric parietal cell antibody positivity with atrophic glossitis. J Oral Pathol Med 2012;41:500e4. 30. Lin HP, Wang YP, Chen HM, Kuo YS, Lang MJ, Sun A. Significant association of hematinic deficiencies and high blood homocysteine levels with burning mouth syndrome. J Formos Med Assoc 2013;112:319e25. 31. Sun A, Chen HM, Cheng SJ, Wang YP, Chang JY, Wu YC, et al. Significant association of deficiencies of hemoglobin, iron, vitamin B12, and folic acid and high homocysteine level with recurrent aphthous stomatitis. J Oral Pathol Med 2014. http: //dx.doi.org/10.1111/jop.12241. 32. Wang YP, Lin HP, Chen HM, Kuo YS, Lang MJ, Sun A. Hemoglobin, iron, and vitamin B12 deficiencies and high blood homocysteine levels in patients with anti-thyroid autoantibodies. J Formos Med Assoc 2014;113:155e60. 33. Wu YC, Wang YP, Chang JY, Cheng SJ, Chen HM, Sun A. Oral manifestations and blood profile in patients with iron deficiency anemia. J Formos Med Assoc 2014;113:83e7. 34. Wang YP, Chang JYF, Wu YC, Cheng SJ, Chen HM, Sun A. Oral manifestations and blood profile in patients with thalassemia trait. J Formos Med Assoc 2013;112:761e5.
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Journal of the Formosan Medical Association (2014) xx, 1e6
Available online at www.sciencedirect.com
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ORIGINAL ARTICLE
Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus Hsin-Ming Chen a,b,c, Yi-Ping Wang b,c, Julia Yu-Fong Chang b,c, Yang-Che Wu b,c, Shih-Jung Cheng b,c, Andy Sun b,c,* a
Graduate Institute of Oral Biology, School of Dentistry, National Taiwan University, Taipei, Taiwan Graduate Institute of Clinical Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan c Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan b
Received 2 September 2014; received in revised form 12 October 2014; accepted 15 October 2014
KEYWORDS hemoglobin; homocysteine; iron; oral lichen planus; vitamin B12
Background/purpose: A portion of patients with oral lichen planus (OLP) may have nutritional deficiency. This study evaluated whether there was an intimate association of the deficiencies of hemoglobin (Hb), iron, vitamin B12, and folic acid and high blood homocysteine level with OLP. Methods: The blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations in 352 OLP patients were measured and compared with the corresponding levels in 352 age- and sexmatched healthy control participants. Results: We found that 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and one (0.3%) OLP patient had deficiencies of Hb (men < 13 g/dL, women < 12 g/ dL), iron (< 60 mg/dL), vitamin B12 (< 200 pg/mL), and folic acid (< 4 ng/mL), respectively. Moreover, 52 (14.8%) OLP patients had abnormally high blood homocysteine level. OLP patients had a significantly higher frequency of Hb, iron, or vitamin B12 deficiency and of abnormally elevated blood homocysteine level than healthy control participants (all p < 0.001). Upon further dividing OLP patients into those with major erosive OLP (MjEOLP; n Z 67), minor erosive OLP (n Z 202), and nonerosive OLP (NEOLP; n Z 83), we found that MjEOLP patients had a significantly higher mean homocysteine level than NEOLP patients (p Z 0.035).
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Dentistry, National Taiwan University Hospital, College of Medicine, National Taiwan University, Number 1, Chang-Te Street, Taipei 10048, Taiwan. E-mail address: [email protected] (A. Sun). http://dx.doi.org/10.1016/j.jfma.2014.10.004 0929-6646/Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
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H.-M. Chen et al. Conclusion: We conclude that there is a significant association of deficiencies of Hb, iron, folic acid, and vitamin B12 and abnormally high blood homocysteine level with OLP. There may be a close relation of high blood homocysteine level to severity of OLP. Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Introduction Oral lichen planus (OLP) is a chronic immunologic mucocutaneous inflammatory oral mucosal disease that affects 0.2e3% of the population.1,2 Clinically, reticular, papular, erosive, ulcerative, plaque-like, atrophic, and bullous types of OLP can be identified.2 A previous study showed involvement of both antigen-specific and nonspecific mechanisms in OLP. Antigen-specific mechanisms include antigen presentation by basal keratinocytes and antigenspecific keratinocyte killing by CD8þ cytotoxic T lymphocytes. Nonspecific mechanisms include mast cell degranulation and matrix metalloproteinase activation in OLP lesions.1 Through mast cell/T-cell interactions in OLP lesions, mast cell-released cytokines, chemokines, and matrix metalloproteinases can promote T-cell activation, migration, proliferation, and differentiation.3 Histologically, OLP is characterized by liquefaction degeneration of basal epithelial cells and an intraepithelial and subepithelial infiltrate of mononuclear cells, which are predominantly CD8þ. CD4þ cells can be found mainly in the deep lamina propria.4 An increase in histocompatibility leukocyte antigen-DR-positive CD3þ cells in both local lesional tissues and peripheral blood lymphocytes also indicates T-cell activation in OLP.5,6 The aforementioned findings suggest that OLP is a T-lymphocyte-mediated inflammatory disease. Because OLP was considered to be a T-lymphocytemediated immunological disorder, only a few studies evaluated the hematological abnormalities and nutritional deficiencies in OLP patients.7e9 Nevertheless, deficiencies of vitamin B12,7 folate,7e9 iron,7 vitamin B1,9 and vitamin B69 have been reported in a portion of OLP patients. In this study, we assessed whether there was an intimate association of the deficiencies of hemoglobin (Hb), iron, vitamin B12, and folic acid and high blood homocysteine level with OLP.
Materials and methods Study participants The study group consisted of 352 patients (73 men and 279 women; age range, 22e87 years, mean 56.8 14.2 years) with OLP. The normal control group consisted of 352 age- ( 2 years of each patient’s age) and sex-matched healthy control participants (73 men and 279 women; age range, 22e88 years, mean 55.2 13.7 years). All the patients and participants (control) were seen consecutively, diagnosed, and treated in the Department of Dentistry, National Taiwan University Hospital (Taipei, Taiwan) from July 2007 to June 2014. The 352 OLP patients included 269 (51 men
and 218 women) with erosive OLP (EOLP) and 83 (22 men and 61 women) with nonerosive OLP (NEOLP). They were selected according to the following criteria: (1) a typical clinical presentation of radiating grayish-white Wickham striae, papules, and plaques, separately or in combination (NEOLP), and erosion or ulceration on the oral mucosa (EOLP); and (2) biopsy specimens characteristic of OLP, that is, hyperkeratosis or parakeratosis, a slightly acanthotic epithelium with liquefaction degeneration of the basal epithelial cells, a pronounced band-like lymphocytic infiltrate in the lamina propria, and the absence of epithelial dysplasia. The EOLP was further divided into the major (MjEOLP) and minor (MiEOLP) types according to criteria described previously.10e13 However, all OLP patients with areca quid chewing habit, autoimmune diseases (such as systemic lupus erythematosus, rheumatoid arthritis, Sjo ¨gren syndrome, pemphigus vulgaris, and cicatricial pemphigoid), inflammatory diseases, malignancy, or recent surgery were excluded. In addition, all OLP patients with serum creatinine concentrations indicative of renal dysfunction (men, > 131 mmol/L; women, > 115 mmol/L) and who reported a history of stroke, heavy alcohol use, or diseases of the liver, kidney, or coronary arteries were also excluded.14 Healthy control participants had either dental caries or mild periodontal diseases but did not have any oral mucosal or systemic diseases. None of the OLP patients had taken any prescription medication for OLP for at least 3 months prior to entering the study. The blood samples were drawn from OLP patients and healthy control participants for the measurement of blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations. This study was reviewed and approved by the Institutional Review Board at the National Taiwan University Hospital.
Determination of blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations The blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrations were determined by the routine tests performed in the Department of Laboratory Medicine, National Taiwan University Hospital.
Statistical analysis Comparisons of the mean blood levels of Hb, iron, vitamin B12, folic acid, and homocysteine between 352 OLP patients and 352 age- and sex-matched healthy control participants and between MjEOLP and MiEOLP or NEOLP patients were performed by Student t test. The differences in frequency of Hb, iron, vitamin B12, or folic acid deficiency and of abnormally high blood homocysteine level between OLP patients and healthy control participants and between
Please cite this article in press as: Chen H-M, et al., Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/ j.jfma.2014.10.004
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Oral lichen planus
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Table 1 Mean blood concentrations of hemoglobin, iron, vitamin B12, folic acid, and homocysteine in 352 patients with oral lichen planus and in 352 age- and sex-matched healthy control participants. Patients with OLP (n Z 352) Mean SD Hb (g/dL) Men (n Z 73) Women (n Z 279) Iron (mg/dL) Men (n Z 73) Women (n Z 279) Vitamin B12 (pg/mL) Folic acid (ng/mL) Homocysteine (mM)
Range
14.4 1.6 12.8 1.2
(9.3e16.8) (7.5e16.4)
(10.0e183.0) (16.0e210.0) (150.0e1000.0) (3.7e24.0) (3.2e23.8)
98.6 86.6 605.4 13.3 8.8
34.3 30.9 266.2 5.9 3.3
Healthy control participants (n Z 352) Mean SD
p
Range
15.2 0.7 13.6 0.7
(13.6e16.6) (12.2e15.4)
<0.001* <0.001*
(62.0e187.0) (60.0e204.0) (259.0e1000.0) (4.1e24.0) (4.3e14.3)
0.527 <0.001* <0.001* 0.008* 0.052
101.8 99.2 686.7 14.5 8.4
26.2 28.0 239.8 6.0 2.0
* Comparisons of the mean blood levels of hemoglobin, iron, vitamin B12, folic acid, and homocysteine between 352 OLP patients and 352 age- and sex-matched healthy control participants by Student t test with p < 0.05. Hb Z hemoglobin; OLP Z oral lichen planus; SD Z standard deviation.
MjEOLP and MiEOLP or NEOLP patients were compared by Chi-square test. The result was considered to be significant if p < 0.05.
Results The mean blood concentrations of Hb, iron, vitamin B12, folic acid, and homocysteine in 352 OLP patients and in 352 age- and sex-matched healthy control participants are presented in Table 1. Because men usually have higher blood levels of Hb and iron than women, these two mean levels were calculated separately for men and women. We found that OLP patients had significantly lower mean Hb (p < 0.001 for both men and women), iron (p < 0.001 for women only), vitamin B12 (p < 0.001), and folic acid (p Z 0.008) levels than healthy control participants (Table 1). In addition, OLP patients had marginally significantly higher mean homocysteine level (p Z 0.052) than healthy control participants. Although male OLP patients also had a lower mean iron level than male healthy control participants, the difference was not significant (p Z 0.527; Table 1). According to the World Health Organization (WHO) criteria for iron-deficiency anemia, men with Hb < 13 g/dL and women with Hb < 12 g/dL were defined as having Hb deficiency or anemia.15 Furthermore, patients with serum iron level < 60 mg/dL,16 serum vitamin B12 level < 200 pg/ mL (148 pmol/L),14 or folic acid level < 4 ng/mL (10 nmol/ L)17 were defined as having iron, vitamin B12, or folic acid deficiency, respectively. In addition, patients with the blood homocysteine level > 12.4 mmol/L (which was the mean blood homocysteine level of healthy control participants plus two standard deviations) were defined as having an abnormally high homocysteine level. Based on the aforementioned definitions, 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and 1 (0.3%) OLP patient were diagnosed as having Hb, iron, vitamin B12, and folic acid deficiencies, respectively (Table 2). Moreover, 52 (14.8%) OLP patients had abnormally high blood homocysteine level (Table 2). OLP patients had a
significantly higher frequency of Hb, iron, or vitamin B12 deficiency and of abnormally elevated blood homocysteine level than healthy control participants (all p < 0.001; Table 2). Defining iron-deficiency anemia as the presence of a Hb concentration < 13 g/dL for men and < 12 g/dL for women,15 a mean corpuscular volume 80 fL, and a low serum iron level (< 60 mg/dL),16 we found that 36 (10.2%) of the 352 OLP patients could be classified as having irondeficiency anemia. In addition, defining pernicious anemia as the presence of a Hb concentration < 13 g/dL for men and < 12 g/dL for women,15 a mean corpuscular volume 100 fL, a low serum vitamin B12 level (< 200 pg/mL), and serum positivity of gastric parietal cell antibody,14,18 we discovered that only six (1.7%) of the 352 OLP patients could be classified as having pernicious anemia. When applying the WHO criteria for iron-deficiency anemia, these findings suggest that approximately 10% of the 352 OLP patients in this study are having iron-deficiency anemia, but pernicious anemia is infrequently found in the 352 OLP patients studied. When the 352 OLP patients were further divided as having MjEOLP (n Z 67), MiEOLP (n Z 202), and NEOLP (n Z 83), we found that MjEOLP patients had a significantly higher mean homocysteine concentration than NEOLP patients (p Z 0.035; Table 3). However, there were no significant differences in the blood levels of Hb, iron, vitamin B12, and folic acid between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients (Table 3). Moreover, there were no significant differences in the frequencies of Hb, iron, vitamin B12, and folic acid deficiencies and of abnormally elevated blood homocysteine level between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients (Table 4).
Discussion The majority of previous studies focused on the immunological dysregulation in OLP patients.1e6 Thus, hematological abnormalities and nutritional deficiencies were
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H.-M. Chen et al. Table 2 Number and percentage of individuals with hemoglobin, iron, vitamin B12, or folic acid deficiency or with abnormally high homocysteine level in the two study groups. Factor
N (%)
Hemoglobin deficiency (men < 13 g/dL, women < 12 g/dL) Iron deficiency (< 60 mg/dL) Vitamin B12 deficiency (< 200 pg/mL) Folic acid deficiency (< 4 ng/mL) High homocysteine levels (>12.4 mM)a
p
Patients with OLP (n Z 352)
Healthy control participants (n Z 352)
77 48 25 1 52
0 0 0 0 11
(21.9) (13.6) (7.1) (0.3) (14.8)
< < < > <
(0) (0) (0) (0) (3.1)
0.001* 0.001* 0.001* 0.99 0.001 *
OLP patients (N ) Z 352; Healthy control participants (N ) Z 352 age and sex matched. * Comparison of frequency of hemoglobin, iron, vitamin B12, or folic acid deficiency and of abnormally high blood homocysteine level between 352 OLP patients and 352 age- and sex-matched healthy control participants by Chi-square test with p < 0.05. OLP Z oral lichen planus. a Patients with high homocysteine level are those with the homocysteine level greater than the mean blood homocysteine level of healthy control participants plus two standard deviations.
Table 3 Mean blood concentrations of hemoglobin, iron, vitamin B12, folic acid, and homocysteine in 67 patients with MjEOLP, in 202 patients with MiEOLP, and in 83 patients with NEOLP.
Hb (g/dL) Men Women Iron (mg/dL) Men Women Vitamin B12 (pg/mL) Folic acid (ng/mL) Homocysteine (mM)
Patients with MjEOLP (n Z 67)
Patients with MiEOLP (n Z 202)
Mean SD
Mean SD
14.7 1.2 (n Z 13) 12.9 1.4 (n Z 54) 97.0 83.5 620.0 13.2 9.5
104.7 87.3 609.8 14.7 8.8
Patients with NEOLP (n Z 83)
p*
Mean SD
14.4 1.3 (n Z 38) 12.8 1.2 (n Z 164)
39.0 (n Z 13) 30.1 (n Z 54) 294.3 6.1 4.1
p*
30.8 (n Z 38) 30.8 (n Z 164) 269.1 6.9 3.2
14.2 2.1 (n Z 22) 12.9 1.3 (n Z 61)
0.468 0.611 0.471 0.430 0.793 0.114 0.151
89.2 87.3 623.7 13.6 8.3
36.7 (n Z 22) 32.1 (n Z 61) 251.6 5.9 2.8
0.439 1.000 0.557 0.516 0.934 0.685 0.035**
* Comparisons of the mean blood levels of Hb, iron, vitamin B12, folic acid, and homocysteine between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients by Student t test. **p < 0.05 by Student t test. Hb Z hemoglobin; MiEOLP Z major erosive oral lichen planus; MjEOLP Z minor erosive oral lichen planus; NEOLP Z nonerosive oral lichen planus; SD Z standard deviation.
Table 4 Number and percentage of individuals with hemoglobin, iron, vitamin B12, or folic acid deficiency and with abnormally high homocysteine level in the MjEOLP, MiEOLP, and NEOLP groups. Factor
Hemoglobin deficiency (men < 13 g/dL, women < 12 g/dL) Iron deficiency (<60 mg/dL) Vitamin B12 deficiency (< 200 pg/mL) Folic acid deficiency (< 4 ng/mL) High homocysteine levelsa (> 12.4 mM)
N (%)
p*
N (%)
p*
Patients with MjEOLP (n Z 67)
Patients with MiEOLP (n Z 202)
11 (16.4)
46 (22.8)
0.352
20 (24.1)
0.341
10 6 0 12
26 16 1 34
0.825 0.992 0.561 0.987
12 3 0 6
0.879 0.306 ND 0.080
(14.9) (9.0) (0) (17.9)
(12.9) (7.9) (0.5) (16.8)
Patients with NEOLP (n Z 83)
(14.5) (3.6) (0) (7.2)
* Comparison of frequency of hemoglobin, iron, vitamin B12, or folic acid deficiency and abnormally high blood homocysteine level between 67 MjEOLP patients and 202 MiEOLP patients or 83 NEOLP patients by Chi-square test. MiEOLP Z major erosive oral lichen planus; MjEOLP Z minor erosive oral lichen planus; ND Z no difference; NEOLP Z nonerosive oral lichen planus. a Patients with high homocysteine level are those with the homocysteine level greater than the mean blood homocysteine level of healthy control participants plus two standard deviations.
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Oral lichen planus infrequently investigated in OLP patients. Jolly and Nobile9 found folic acid deficiency (< 3 ng/mL) in five of 34 OLP patients. They also observed widespread deficiencies or marginally low levels of vitamins B1 and B6 in both OLP patients and control participants, suggesting special dietary habits of the local community and an inadequate intake of unrefined cereal products such as whole-wheat bread, which is the main source of vitamins B1 and B6. Challacombe7 studied the hematological abnormalities in 103 OLP patients and demonstrated anemia, low iron, low folate, and low vitamin B12 in nine (8.7%) OLP patients, 13 (12.6%) OLP patients, three (2.9%) OLP patients, and two (1.9%) OLP patients, respectively. Moreover, the prevalence of hematological abnormalities was significantly greater in EOLP patients than in NEOLP patients.7 Thongprasom et al8 identified low red cell folate level in 11 (44%) of 25 OLP patients. However, the serum vitamin B12 levels of OLP patients were within normal range in their study.8 This study found that 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and one (0.3%) OLP patients had deficiencies of Hb, iron, vitamin B12, and folic acid, respectively. OLP patients had a significantly higher frequency of Hb, iron, or vitamin B12 deficiency than healthy control participants. Of 352 OLP patients, 36 (10.2%) had iron-deficiency anemia and six (1.7%) had pernicious anemia. In addition, EOLP patients did not have a significantly higher prevalence of hematinic deficiency than NEOLP patients. The results of previous and present studies indicate that there is a small group of OLP patients definitely having anemia or hematinic deficiencies. Therefore, supplementation of hematinics or multiple B vitamins may be beneficial for this specific group of OLP patients. Actually, Jolly and Nobile9 observed good and some improvement in 20 of 41 and nine of 41 vitamin-deficient OLP patients treated with multiple vitamin supplements, respectively. However, complete remission of the OLP lesions was not seen within 2 months of commencing vitamin therapy.9 This finding suggests that although the frequency of hematinic deficiency is significantly higher in OLP patients than in healthy control participants, hematinic deficiency is probably not the main etiology causing the OLP. Homocysteine, a sulfur-containing amino acid, is formed during methionine metabolism.19 Both vitamin B12 and folic acid function as coenzymes that are required for the conversion of homocysteine to methionine.20 It is important to monitor the blood homocysteine level because higher blood homocysteine levels can cause oxidative stress, damage endothelium, and enhance thrombogenicity, and are thus associated with increased rates of coronary heart disease and stroke.19,21e24 In addition, measurement of both serum methylmalonic acid and homocysteine levels is found to be a more sensitive method of screening for vitamin B12 deficiency (sensitivity Z 99.8%), and thus can be used for detecting subclinical vitamin B12 deficiency.25,26 In this study, an abnormally higher blood homocysteine level was detected in 14.8% of OLP patients, whereas only 3.1% of healthy control participants had a higher blood homocysteine level. The high blood homocysteine level in OLP patients could be due to deficiencies in folic acid and vitamins B12 and B6, because previous studies have shown that a supplementation with folic acid and vitamins B12 and B6 can
5 reduce blood homocysteine levels.21,27,28 In this study, the mean vitamin B12 and folic acid levels were significantly lower in OLP patients than in healthy control participants. Furthermore, the frequency of vitamin B12 (but not folic acid) deficiency was significantly higher in OLP patients than in healthy control participants. Our study also showed a significantly higher mean blood homocysteine level in MjEOLP patients than in NEOLP patients. Because patients with MjEOLP often have more severe and larger recurrent ulcerative OLP lesions than NEOLP patients, the result of our study indicates that the severity of OLP may be related to the elevated homocysteine level in OLP patients. In our oral mucosal disease clinic, a portion of patients with atrophic glossitis, burning mouth syndrome, recurrent aphthous ulcerations, OLP, or antithyroid autoantibodies are found to have hematinic deficiencies, high blood homocysteine level, iron-deficiency anemia, or thalassemia.29e34 Supplementation of multiple B vitamins including B1, B2, B6, and B12, calcium pantothenate, nicotinamide, and folic acid may cause significant reductions in blood homocysteine level and improvements of oral symptoms or signs in patients with atrophic glossitis or burning mouth syndrome.27,28 These findings suggest that it is very important to check complete blood count and blood levels of iron, vitamin B12, and folic acid for patients with atrophic glossitis, burning mouth syndrome, recurrent aphthous ulcerations, or OLP. For those patients with hematinic deficiencies, high blood homocysteine level, or anemia, immediate treatment with multiple B vitamins or specific deficient hematinics usually results in prompt improvement of the associated oral diseases. Our results demonstrated that 77 (21.9%) OLP patients, 48 (13.6%) OLP patients, 25 (7.1%) OLP patients, and one (0.3%) OLP patient had deficiencies of Hb, iron, vitamin B12, and folic acid, respectively. Moreover, 52 (14.8%) OLP patients had abnormally high blood homocysteine level. In addition, we showed significantly higher frequencies of Hb, iron, and vitamin B12 deficiencies and of abnormally elevated blood homocysteine level in our 352 OLP patients than in the 352 healthy control participants. These findings suggest there is a significant association of deficiencies of Hb, iron, and vitamin B12 and abnormally high blood homocysteine level with OLP. The present study also found that MjEOLP patients had a significantly higher mean blood homocysteine level than NEOLP patients. This finding also indicates a close relation of high blood homocysteine level to severity of OLP.
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Please cite this article in press as: Chen H-M, et al., Significant association of deficiencies of hemoglobin, iron, folic acid, and vitamin B12 and high homocysteine level with oral lichen planus, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/ j.jfma.2014.10.004