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 Table of Contents  
Year : 2016  |  Volume : 8  |  Issue : 3  |  Page : 145-149

Analysis of serum copper and iron levels in oral submucous fibrosis patients: A case–control study

1 Department of Orthodontics and Dentofacial Orthopedics, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India
2 Department of Oral Pathology and Microbiology, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India
3 Department of Oral Pathology and Microbiology, R.R. Dental College and Hospital, Umrada, Udaipur, Rajasthan, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Dr. Pramod Kumar
House No. 1, Shakti Nagar, Mal Godam Road, Etawah - 206 001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-4003.191728

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Background: Oral submucous fibrosis (OSF) is a chronic debilitating disease and a potentially malignant disorder of the oral cavity. The pathogenesis of the disease is not well established. Trace elements such as copper and iron play an important role in the pathogenesis of OSF. Estimation of these elements in serum of the patients may be helpful in understanding the pathologic mechanism. Therefore, a study was carried out to analyze the level of serum copper and iron in the population of Central India. Materials and Methods: A case–control study was carried out on 35 patients with clinically diagnosed of OSF and 35 healthy controls. OSF patients were categorized by clinical staging. Serum copper and iron concentrations were measured by atomic absorption spectrophotometry. Results: Results of the study shows that the mean serum copper concentration was greater in study group (133.3 ± 19.2) compared to control group (113.9 ± 22.1) and the mean serum iron was lower in study group (116.0 ± 24.1) compared to control group (128.2 ± 23.4). The result obtained was statistically significant. The serum copper level increases as the clinical staging of OSF progresses, whereas serum iron level decreases as clinical staging progresses. Conclusion: There was an increase in copper level and decrease in iron level in study group compared to control group; this suggests that there is an increase in copper level with the advancement of clinical staging of OSF.

Keywords: Atomic absorption spectrophotometry, clinical staging, oral submucous fibrosis, potentially malignant disorder, serum copper, serum iron

How to cite this article:
Kumar H, Kumar P, Jain S, Suryawanshi H. Analysis of serum copper and iron levels in oral submucous fibrosis patients: A case–control study. Indian J Dent Sci 2016;8:145-9

How to cite this URL:
Kumar H, Kumar P, Jain S, Suryawanshi H. Analysis of serum copper and iron levels in oral submucous fibrosis patients: A case–control study. Indian J Dent Sci [serial online] 2016 [cited 2022 Jul 4];8:145-9. Available from: http://www.ijds.in/text.asp?2016/8/3/145/191728

  Introduction Top

Schwartz (1952) described a disorder of oral mucosa under the term “Atrophia Idiopathica (tropica) Mucosae Oris” characterized by progressive fibrosis of oral mucosa. Later, Joshi (1953) coined the term submucous fibrosis of the palate and pillars.[1]

Oral submucous fibrosis (OSF) is a chronic disease of the oral cavity, which is characterized by a juxtaepithelial inflammatory reaction followed by fibroelastic change in the lamina propria and associated epithelial atrophy. This leads to a restricted mouth opening, resulting as trismus leading to restriction of food consumption, difficulty in maintaining oral health, as well as impairs the ability to speak.[2]

The disease is predominantly seen in India, Bangladesh, Sri Lanka, Pakistan, Taiwan, Southern China, and Polynesia.[3] Worldwide estimates in 1996 indicate that 2.5 million people were affected by the disease.[4] In 2002, the statistics for OSF from the Indian continent alone was about 5 million people (0.5% of the population of India).[5] In an epidemiological study on oral cancer and precancerous lesions in a rural Indian population, the malignant transformation rate of OSF was 7.6% (5 of 66) over a 17-year period.[6]

The disease is multifactorial in origin. The factors that have been discussed as possible etiological factors to date are Areca nut, capsaicin in chillies, micronutrient deficiencies of iron, zinc, and essential vitamins. Data from numerous studies suggest that Areca nut is the main etiological factor for OSF.[2],[3]

The commercially freeze-dried products such as pan masala, Gutka, and mawa (Areca nut and lime) have high concentrates of Areca nut per chew and appear to cause OSF more rapidly than by self-prepared conventional betel quid which contain smaller amounts of Areca nut.[7]

The role of trace elements has been extensively studied in the recent years to find their role in the etiology of oral premalignant and malignant conditions.

The copper content of Areca nut is high, and the levels of copper in saliva and serum may rise in volunteers who chew Areca quid.[8] The enzyme lysyl oxidase is found to be upregulated in OSF. This is a copper-dependent enzyme and plays a key role in collagen synthesis and its cross-linkage.[2]

In patients with OSF, iron deficiency anemia is often present. Iron is necessary for the proper functioning of many enzymes and has been recognized as an important element for maturation of epithelium.[1],[9]

Thus, the present study aimed to estimate and compare the levels of serum copper and iron among subjects with OSF and healthy controls. Measurement of copper and iron level in the serum of patients with OSF may help in understanding the pathogenesis and rendering the effective treatment of the disease.

  Materials and Methods Top

A case–control study was carried out in the Department of Oral Pathology and Microbiology. The study consists of seventy patients visited the dental clinic of the Department of Oral Pathology and Microbiology.

The patients were divided into the following groups:

  • Group A: Study group consists of 35 patients who were clinically diagnosed as suffering from OSF
  • Group B: Control group consists of 35 patients with no apparent lesions of oral mucosa and without any habit of Areca nut or tobacco-related habits. Informed consent was obtained from all the subjects.

Subjects suffering from other chronic systemic diseases were excluded. Inclusion criteria comprised subjects diagnosed with OSF (in the study group) and subjects willing to provide written consent.

The staging of the OSF was done according to the criteria of clinical grading by Haider et al. Clinical staging was done depending on topography and extent of distribution of bands [Figure 1].
Figure 1: Clinical photograph of patient showing the presence of blanching and faucial bands.

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  1. Stage 1 - Subjects had faucial bands
  2. Stage 2 - Presented faucial and buccal bands
  3. Stage 3 - Faucial, buccal, and labial bands were involved.

After obtaining the Institutional Ethical Committee clearance, a detailed case history was recorded and clinical examination was performed. A volume of 5ml venous blood was drawn by venepuncture of the median cubital vein under all aseptic conditions. The blood was allowed to clot and then centrifuged at 1000–1500 RPM for 15 min. Subsequently, serum was collected, which was analyzed for copper and iron with Atomic Absorption Spectrophotometer (GF-AAS; Shimadzu Corp., Kyoto, Japan).

The data obtained were tabulated and analyzed using Statistical Package for Social Sciences, version 17.0 (SPSS), IBM Corporation, Armonk, New York, United States. Means and standard deviations were calculated for serum copper and iron in study and control groups.

To compare the mean values of serum copper and iron between the study subjects and control group, independent sample t-test was used. One-way analysis of variance (ANOVA) was used to assess the significance in difference between the mean copper and iron levels based on the staging of OSF.

  Results Top

In the present study, the subjects in study group ranges from 24 to 58 years with mean age of 42.6 years, and in control group, ranges from 22 to 59 years with mean age of 40.3 years. A total of 70 patients participate in the study, of which 35 were in study group and 35 were in control group. Of 70 patients (study and control groups), 62 (88.5%) were male and 8 (11.5%) were female.

Independent sample t-test was used to find out the correlation. The mean serum copper and iron levels differed significantly (P < 0.05) between the OSMF group and control group. Serum copper in OSF group was higher (133.3 ± 19.2) as compared to control group (113.9 ± 22.1), whereas serum iron level was lower in the OSF group (116.0 ± 24.1) as compared to the control group (128.2 ± 23.4) [Table 1] and [Figure 2].
Table 1: Descriptive Statistics of mean serum copper and iron concentrations (μg/100 ml) in OSF and control group

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Figure 2: Mean serum copper and iron values (μg/100 ml) in patients and control group.

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One-way ANOVA was used to find out the correlation between clinical stages of OSF and serum copper and iron levels. Statistically significant differences were observed in mean serum copper levels among patients in three clinical stages of OSF. The mean serum copper level was lowest for Stage 1 (116.2 ± 9.9), followed by Stage 2 (132.9 ± 13.4), and was highest for Stage 3 (152.3 ± 14.0). There was a decrease in mean serum iron concentration as clinical stage advances and the difference observed was statistically significant with the lowest level of serum iron in Stage 3 (106.0 ± 21.7), followed by Stage 2 (111.8 ± 23.0), and highest in Stage 1 (129.3 ± 22.9) [Table 2], [Table 3] and [Figure 3].
Figure 3: Mean serum copper and iron concentrations (μg/100 ml) among oral submucous fibrosis patients in relation to clinical staging.

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Table 2: Descriptive Statistics of mean serum copper and iron concentration (μg/100 ml) of OSF patients in relation to clinical staging

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Table 3: Comparison of Mean Scores of serum copper and serum iron in Different Stages of OSF

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Pearson correlation was used to find the correlation between mean serum copper and iron levels and clinical stages of OSF. The results showed that serum copper level is directly proportional to the clinical stages of OSF, i.e., as the severity of OSF increases, the mean serum copper level increases. Whereas mean serum iron level was found to be inversely proportional [Table 4] and [Table 5].
Table 4: Pearson Correlation of mean serum copper with clinical stages of OSF

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Table 5: Pearson Correlation of mean serum iron with clinical stages of OSF

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  Discussion Top

Trace elements such as copper and iron play an important role in disease progression and have been extensively studied in the past.

The normal range of serum copper is 20–70 µg/dL (infants), 80–190 µg/dL (children), 70–140 µg/dL (adult males), and 80–150 µg/dL (adult females).[10] Serum copper has also been found to be altered in epilepsy,[11] eating disorders,[12] obesity,[13] insulin-dependent diabetics,[14],[15] multiple sclerosis, acute and chronic liver diseases, infections, myocardial infarcts, and schizophrenia.[16]

The results of present study showed that the mean serum copper level was significantly higher in study group. Numerous studies in the past have also shown similar results.[17],[18],[19] However, a study conducted by Trivedy et al. showed that serum copper remained normal in OSF patients [20] in contrast to the present study, and a study conducted by Varghese et al. showed a significant reduction in the serum copper in both OSF and oral cancer patients.[21]

High levels of copper in Areca nuts, a major etiological factor in OSF, plays an initiating role in stimulation of fibrinogenesis by upregulation of lysyl oxidase and thereby causing inhibition of degradation of collagen and causing its accumulation thereby causing OSF.[17] The increase in serum copper in premalignancy and malignancies is still a controversy; however, the rise in serum copper may be due to increased turnover of ceruloplasmin (a copper carrying globulin with essential oxidase activity) in the serum of carcinoma patients.[22] Furthermore, there is a gradual increase in serum copper level as the clinical stage of OSF increased. Thus, there could be a direct relation between serum copper and extent of fibrosis.

Normal range of serum iron in newborns: 100–250 µg/dL, children: 50–120 µg/dL, adult men: 65–176 µg/dL, and adult women: 50–170 µg/dL. Decrease in serum iron level causes iron deficiency anemia, learning disabilities, impaired immune function, decreased energy levels, and physical performance.[23]

The mean serum iron concentration in study subjects was lower than the control group. Serum iron levels are considered biochemical indicators for nutritional assessment. Utilization of iron in collagen synthesis by the hydroxylation of proline and lysine leads to decreased serum iron levels in OSF patients. In most cases, clinical anemia may be a contributing factor.[24],[25]

Furthermore, lack of iron in the tissues results in decreased vascularity which facilitates percolation of arecoline.In vitro studies on human fibroblasts observed that arecoline causes increased fibroblastic proliferation and collagen formation which is a hallmark of OSF.[3]

The present findings are drawn by a smaller sample size, so this strongly warrants an in-depth study of serum copper and iron levels involving large sample size and also involving a variety of precancerous and cancerous lesions.

  Conclusion Top

It can be concluded from the present study that serum copper and iron levels play an important role in the pathogenesis of the disease. Higher serum copper level upregulates enzyme lysyl oxidase, an important enzyme in cross-linking of collagen, and makes it in an insoluble form which is resistant to proteolysis. Normal serum iron level is required for the integrity of oral epithelium, so any decrease in serum iron level caused increased penetration of arecoline, which stimulates increased fibroblastic proliferation and increased collagen formation.

Hence, serum copper and iron levels along with the clinical assessment can be a helpful tool not only in diagnosis but also in staging of OSF in near future.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Schwartz MK. Role of trace elements in cancer. Cancer Res 1975;35(11 Pt 2):3481-7.  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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