QUANTITATIVE CYTOMORPHOMETRIC ANALYSIS OF BUCCAL SQUAMES IN DIABETICS

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Diabetes mellitus has become a major health issue in the entire world. The International Diabetes Federation (IDF) has estimated that 382 million people currently have diabetes all over the world, and by 2035, this will rise to 592 million people. The number of people with type 2 diabetes is increasing in every country and 80% of the people with diabetes live in low-income and middle-income countries. The greatest numbers of people with diabetes are between 40 and 59 years of age and about 175 million people with diabetes are still undiagnosed.¹
Diabetes mellitus is a complex metabolic disorder, characterized by hyperglycemia and abnormalities in carbohydrate, lipid, and protein metabolism. Diabetes may compromise the tissue repair, growth, and regeneration thus adversely affecting the morphology of the oral mucosa.²
The various oral complications of uncontrolled diabetes mellitus can be listed out as xerostomia, candidiasis, increased incidence of dental caries, gingivitis, periodontitis, periapical abscess, and parotid enlargement, burning mouth syndrome, lichen planus, lichenoid reactions, traumatic ulcers, irritational fibromas, glossodynia, median rhomboid glossitis, neurosensory dysesthesias, and taste dysfunctions. Early diagnosis of diabetes mellitus and its associated effects on various parts of the body shall play a major role in its successful management- control and treatment. The present study utilizes the ease and non-invasive technique of oral exfoliative cytology in a systemic disease such as Diabetes Mellitus. Thus highlighting its usefulness as an adjunct to clinical examination and diagnosis of various oral diseases.³
A cytomorphometric study on buccal squames was undertaken on clinically proven 30 diabetic patients and their corresponding control group (n = 30). The fasting blood sugar level was estimated using the glucose oxidase dehydrogenase-pyruvate oxidase dehydrogenase (GOD-POD) method, with the GOD-POD kit and a digital photo colorimeter. The effects of diabetic mellitus were noted on oral exfoliated cells by measuring nuclear area, cytoplasmic area and their resultant nuclear cytoplasmic ratio. Magnus Pro 3.0 a semiautomatic image analysis technique which is a faster, more accurate and more reproducible was used on the Papanicolaou stained cells. The nuclear area (NA) and cytoplasmic area (CA) were obtained by drawing outline around the nuclear and cellular boundaries using digital cursor.
The subsequent values of cytoplasmic ratio and nuclear ratios (CNR) were calculated. The level of fasting blood sugar (FBS) was 92.97 ± 8.89 mg/dl for the control group versus 157.70 ± 16.22 mg/dl for the diabetic patient group. The mean of FBS of the diabetic patient group showed a statistically significant in FBS compared to the control group in their respective age groups. In the present study, The mean NA values obtained from diabetic patient group was 87.271 µm² with statistically significant difference (p < 0.001) from the control group (NA= 67.493 µm²). Similar values were noted by Alberti et al.,⁴ Jajarm et al.,⁵ Shareef et al.⁶

The mean CA of the diabetic patient group was 2642.892 µm² and that of the control group was 2731.431 µm². No significant difference (p > 0.001) was found in the mean CA of the study group as compared to the control group. The mean CNR showed a statistically significant decrease in the study group as compared to the control group (p < 0.001). Various studies especially around the turn of the century stated the cell size is determined by the amount of nuclear chromatin. Two theories on cell proportions of different cellular constituents in the diabetic patients can be discussed as 1) genetic regulation and 2) enzyme regulation. Genetic regulation: in diabetics, atherosclerosis leads to diminished blood flow to the peripheral tissue. The resultant ischemia causes hypoxia and decreased oxidative phosphorylation and thus decreased ATP generation. The lack of ATP and shift to anaerobic respiration results in accumulation of lactic acid and inorganic phosphates lowering the pH. Hence irreversible cellular injury occurs. Enzyme regulation: to compensate for ATP depletion in the cells leads to accumulation of cAMP7 and activation of glycogen splitting enzyme, phosphorylase. This leads to increased breakdown of glycogen reserves of the cell and excess preservation of cAMP as a compensatory mechanism to cell injury. The eventual process of increased nuclear area can be attributed to irreversible cell injury- where cellular adaptation leads to hypertrophied nucleus with much higher DNA content than normal cells.² Diabetes associated decreased salivary flow causing mucosal atrophy could lead false positive results of nuclear enlargement. Cytomorphometry could play a major in assessing early inflammatory and neoplastic diseases of oral cavity in the background of the associated oral cytological changes of diabetes mellitus. The need of the hour is to adopt oral exfoliative cytology as an easy and non-invasive technique for verification of systemic diseases on a routine daily basis.

Bibliografía del artículo
1. International Diabetes Federation (IDF). Diabetes Atlas. Ch. 2, 6th ed.: International Diabetes Federation (IDF) pp. 29-49, 2013.
2. Kumar V, Cotran RS, Robbins SL. Robbins basic pathology. 7th ed. Philadelphia, PA: Elsevier Inc; pp. 12-647, 2005.
3. Nayar AK, Sundharam BS. Cytomorphometric analysis of exfoliated normal buccal musoca cells. Indian J Dent Res 14:87-93, 2003.
4. Alberti S, Spudella CT, Francischone TR, Assis GF, Crstari TM, Taverira LA. Exfoliative cytology of the oral mucosa in type II diabetic patients: Morphology and cytomorphometry. J Oral Pathol Med 32:538-43, 2003.
5. Jajarm HH, Mohtasham N, Moshaverinia M, Rangiani A. Evaluation of oral mucosa epithelium in type II diabetic patients by an exfoliative cytology method. J Oral Sci 50:335-40, 2008.
6. Shareef BT, Ang KT, Naik VR. Qualitative and quantitative exfoliative cytology of normal oral mucosa in type 2 diabetic patients. Med Oral Patol Oral Cir Bucal 13:E693-6, 2008.
7. Koss LG, Melamed MR. Diagnostic Cytology and its histopathological bases. 4th ed, Vol. 1. Philadelphia: Lippincott Williams and Wilkins; pp. 22-53, 2006.