|Year : 2009 | Volume
| Issue : 2 | Page : 62-66
Salivary coagulopathy and immunoglobulins in oral submucous fibrosis
R Pinakapani1, P Shambulingappa2, MC Shashikanth3
1 Department of Oral Medicine and Radiology, College of Dental Sciences, Davangere, Karnataka- 570 004, India
2 Department of Oral Medicine and Radiology, MM College of Dental Sciences & Research, Mulana (Ambala), Haryana-133 203, India
3 Department of Oral Medicine and Radiology, U P Dental College, Lucknow- 570 004, India
|Date of Web Publication||1-Dec-2009|
Department of Oral Medicine & Radiology, Gitam Dental College & Hospital, Visakhapatnam - 530 045
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim : The etiopathogenesis of oral submucous fibrosis is still obscure. Immunological disorders have been associated with it and as the disease produces changes localized to the oral cavity, it is assumed that saliva may play an important role in the etiopathogenesis. The purpose of this study was to detect salivary coagulopathy, immunologic alterations and their comparison in oral submucous fibrosis patients and controls. Materials and Methods : Salivary coagulopathy procedures and quantitative estimations of serum immunoglobulins were carried out by serial radial immunodiffusion method in 60 oral submucous fibrosis patients and equal age- and sex-matched healthy controls. The obtained data was analyzed using Mann-Whitney and Chi-square tests. Results : The results indicated the presence of a precipitating factor in saliva responsible for salivary coagulopathy, dependent upon the severity of the disease and not on age, sex or duration of the disease. As compared to the controls, serum IgG and IgA, but not IgM levels were raised significantly among patients. IgG levels were increased in all the grades, while IgA levels were increased in Grade II and Grade III cases only. IgM levels in Grade II and Grade III cases showed no significant alterations, however, were reduced in Grade I cases. The serum immunoglobulin levels showed no correlation with the duration of the disease. Conclusion : Alteration in saliva and immunity do indicate an immunological basis in the etiopathogenesis of this complex clinical entity.
Keywords: Immunoglobulins, oral submucous fibrosis, salivary coagulopathy
|How to cite this article:|
Pinakapani R, Shambulingappa P, Shashikanth M C. Salivary coagulopathy and immunoglobulins in oral submucous fibrosis. J Indian Acad Oral Med Radiol 2009;21:62-6
|How to cite this URL:|
Pinakapani R, Shambulingappa P, Shashikanth M C. Salivary coagulopathy and immunoglobulins in oral submucous fibrosis. J Indian Acad Oral Med Radiol [serial online] 2009 [cited 2019 Jun 20];21:62-6. Available from: http://www.jiaomr.in/text.asp?2009/21/2/62/57888
| Introduction|| |
Oral submucous fibrosis (OSMF) is "an insidious, chronic disease affecting any part of the oral cavity and sometimes the pharynx. Although occasionally preceded by and/or associated with vesicle formation, it is always associated with juxta-epithelial inflammatory reaction followed by fibroelastic change of the lamina propria, with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to eat".  OSMF occurs predominantly among Indian and to a lesser extent in other Asian people. One of the serious complications of this disease is the risk of the development of oral carcinoma, estimated to be 7.6% of cases over a 10-year period. 
To date, no conclusive etiological agent has been identified. Various hypotheses have been put forward suggesting a multifactorial origin for this condition. These include chili (capsaicin),  areca nut,  misi,  nutritional deficiencies,  genetic predisposition,  and autoimmunity. 
As the disease produces changes localized to the oral cavity, it is reasonable to assume that saliva may have an important role to play in causation of OSMF. Pathak AG  reported an unusual presence of fibrin precipitating factor (FPF) / coagulum in the saliva of OSMF patients. The saliva precipitate was observed only when OSMF patient's saliva was mixed with equal quantity of OSMF's plasma or control's plasma. Chaturvedi VN, Sharma AK and Chakarbarti S  observed salivary coagulopathy among the majority of OSMF patients, a finding which was similar to that reported by Pathak AG (1979). 
Also, over the past decade, we have become increasingly aware of immunoglobulin disorders and the wide variety of symptoms and diseases with which they can be associated. Studies conducted on the serum immunoglobulins' (IgG, IgA, IgM) profile of patients with OSMF have shown conflicting results with some demonstrating an increase in all the three immunoglobulins while others have shown an increase in only either of these. ,,,,, Therefore a need for the study arose to assess the salivary coagulopathy and estimation of serum immunoglobulins (IgG, IgA, IgM) in subjects with OSMF.
| Materials and Methods|| |
The present study was conducted in the Department of Oral Medicine and Radiology, College of Dental Sciences, Davangere, India over a period of one year and eight months, from March 2004 to November 2005. The study group comprised 60 OSMF subjects of either sex above 15 years of age satisfying the characteristic clinical features of OSMF with histopathologic confirmation. Age and sex-matched subjects with no adverse habits and no oral lesions constituted controls. All OSMF patients and selected control subjects did not have any past or present systemic disease/s (e.g. diabetes, hypertension, liver disorders or kidney diseases) nor were they taking any medication. OSMF was divided clinically into three grades as per the criteria described by Bhatt AP and Dholakia HM.  A proforma was used to record complete demographic details and clinical history along with details of various chewing habits, its duration and severity.
Salivary coagulopathy procedure
The subjects were asked to expectorate saliva, 10 ml of which was centrifuged immediately at 1000 rpm for 10 min. Plasma was obtained using double oxalate solution with 1:5 ratio of anticoagulant to blood centrifuged at 1000 rpm for 10 min after 1 h refrigeration. The test was conducted as described by Chaturvedi et al. 
The above samples were prepared in duplicate. One set was incubated at 37 0 C and other at 4 0 C. Observations were made for appearance of coagulum after 2, 4 and 24 h. Serum IgG, IgA and IgM were estimated by Serial Radial Immunodiffusion (SRI).  Statistical analysis was done using Chi-square test and Mann-Whitney test to derive the level of significance.
| Results|| |
In the present study the mean age of cases was 29.98 years with an age range of 15 to 50 years. The male to female ratio was 9:1 [Table 1]. Of the 60 OSMF patients 18.33% (11) cases were of Grade I, 35.0% (21) cases of Grade II and 46.67% (28) cases of Grade III severity of OSMF [Table 2].
The formation of coagulum was seen in 78.33% (47) cases of OSMF. The coagulum when present was seen in test tubes 1 and 4 only. It was white or cream in color, variable in size and suspended in the upper part of the tube. No significant relation was observed between age and sex, and formation of coagulum [Table 3] and [Table 4]. A progressive increase in cases showing salivary coagulopathy was observed with increase in severity of the disease and this was statistically significant (P < 0.01) [Table 5]. Although the number of cases showing salivary coagulopathy increased with increase in duration of the disease, this was not statistically significant (P=0.52)[Table 6].
The mean serum IgG and IgA levels among OSMF patients were significantly increased as compared to control group (P < 0.001). Though a slight increase in serum IgM was observed among OSMF patients, this was not statistically significant (P = 0.31) [Table 7].
Serum IgG and IgA levels were increased in all the grades of OSMF and when compared to the control group, the increase was highly significant (P < 0.001). Their levels also showed significant (P < 0.001) increase with the severity of the disease except IgA which showed no significant alteration in Grade I v/s II cases (P = 0.37). A statistically significant decrease in serum IgM level was seen in Grade I cases as compared to control group (P < 0.05). IgM levels in Grade II and Grade III were increased but this was not statistically significant (P = 0.13, P = 0.06 respectively) as compared to the control group. A significant increase in IgM level was seen in Grade II (P < 0.01) and Grade III (P < 0.001) cases as compared to Grade I cases. However, there was no significant alteration seen between Grade II and Grade III cases, (P = 0.94) [Table 8].
None of the serum immunoglobulin fractions showed any significant relationship with increase in duration of the disease (P = 0.20, IgG; P = 0.15, IgA; P = 0.95, IgM respectively) [Table 9].
The mean serum IgG level showed a statistically significant increase (P<0.05) in patients with presence of salivary coagulum than in absent cases [Table 10]. However, there was no significant difference in the serum IgA and IgM levels of cases showing presence or absence of salivary coagulopathy.
| Discussion|| |
Salivary coagulopathy was present among the majority of the OSMF patients. No association existed between salivary coagulopathy and the age and sex of the OSMF patients. Similar findings were also reported by Chaturvedi et al.  In the present study there was progressive increase in percentage of cases with increase in the severity of disease showing coagulum formation in saliva. Similar findings were also reported by Chaturvedi et al. 
In our study though the presence of coagulopathy showed an increase with increase in duration of OSMF, it was not statistically significant (P=0.52). This was in contrast to that reported by Chaturvedi et al,  about significantly increased formation of coagulum associated with increase in duration of the disease.
In the present study the mean serum IgG was significantly increased as compared to controls. This was in agreement with Pathak,  Gupta et al,  Chaturvedi and Marathe,  Canniff et al,  and Chaturvedi et al.  In contrast, our findings are not in agreement with Rajendran et al.  While in our study the mean IgA fraction showed a significant increase similar to the observations made by Gupta et al,  Rajendran et al.  and Shah et al,  this was not in agreement with Pathak,  Chaturvedi and Marathe,  Canniff et al.  and Chaturvedi et al.  IgM levels did not show any significant alterations in the present study. Similar observations were reported by Pathak,  Chaturvedi and Marathe,  Canniff et al,  Rajendran et al,  and Chaturvedi et al.  Whereas Gupta et al.  and Shah et al.  reported a significant increase in serum IgM levels in OSMF.
In the present study the mean serum IgG levels were increased in all the grades of OSMF as compared to the control group and this was statistically significant (P<0.001). The above observations were similar to those reported by Chaturvedi and Marathe  and Chaturvedi et al.  A highly significant (P<0.001) increase in serum IgG level was also observed in Grade I v/s II, Grade I v/s III and Grade II v/s III cases of OSMF. In contrast, Chaturvedi and Marathe  observed significant increase in Grade III cases as compared to Grade I cases (P<0.001).
Serum IgA levels in our study were raised significantly in Grade II (P< 0.01) and in Grade III (P<0.001) cases compared to the control group. In contrast Chaturvedi and Marathe  observed significant decrease in levels (P<0.01) in Grade III cases as compared to the control group; Chaturvedi et al.  reported decreased levels, but not significant (P<0.1) in all the grades as compared to the control group. In the present study serum IgA level was significantly increased in Grade III compared to Grade I and Grade II cases (P<0.001). In contrast Chaturvedi and Marathe  observed IgA level significantly less in Grade III compared to Grade I and Grade II (P<0.001) cases of OSMF.
While IgM levels were significantly reduced in Grade I cases, the difference in Grade II and Grade III was not significant as compared to the controls. In contrast Chaturvedi and Marathe  and, Chaturvedi et al.  reported no significant (P>0.1) alterations in IgM levels in various grades of OSMF compared to the control group. Though Chaturvedi and Marathe  observed no significant difference among various grades, the present study showed significant increase in Grade II (P<0.01) and Grade III (P<0.001) cases as compared to Grade I cases.
In our study with respect to duration of the disease no correlation was observed in the levels of serum immunoglobulins (IgG, IgA, IgM) among patients of OSMF (P=0.02, IgG; P=0.15, IgA; P=0.95, IgM). A review of the literature available failed to show any other reference of immunoglobulin in relation to duration of OSMF.
In the present study although all the three fractions of immunoglobulin levels were raised in the OSMF patients, only IgG fraction showed a significant increase (P<0.05). However, Chaturvedi et al.  reported no significant difference in the serum IgG, IgA and IgM levels of cases showing presence and absence of coagulum formation except serum IgG levels showing significant alterations in Grade II and Grade III cases of OSMF showing presence of coagulum formation in saliva.
The increased levels of the serum IgG and IgA fractions of immunoglobulins in the experimental group of patients highlighted the role of active immune phenomenon at work in OSMF. The significant increase in the levels of these major immunoglobulins is also suggestive of accelerated body defense at work among such patients. These elevated levels of immunoglobulins (IgG and IgA) are also in favor of polygammapathy, which are non-specific and non-diagnostic objective reflections of an underlying disease. Increase in immunoglobulin levels is typically associated with three main chronic disease classes: those affecting the liver, collagen and chronic infections. It is also observed from the present study that the severity of OSMF was directly proportional to the estimated elevated levels of the major immunoglobulins IgG and IgA. The latter finding may be taken as an indicator of the gravity of this oral condition, and also for evaluating the various related gammopathies and their management. A need is also felt for the knowledge of immunoprofile estimation in etiology and pathogenesis that would prove a great asset in the proper assessment of this condition.
The fundamental reaction in the clotting of blood is conversion of the soluble plasma protein fibrinogen to insoluble fibrin. The conversion of fibrinogen to fibrin is catalyzed by thrombin which is a serine protease formed from its circulating precursor prothrombin. In order to know whether a similar enzyme is involved in OSMF, Chaturvedi et al.  in their study added a very specific inhibitor of serine protease-Aproteinin in Tube 1 (OSMF plasma + OSMF saliva) which was otherwise showing formation of coagulum. The addition of this enzyme inhibited the process of formation of salivary coagulum, thus indicating the role of some enzyme, the exact nature of which could not be known.
The multifactorial origin of the disease thus appears quite clear, as is the case with oral cancer and most of the precancerous lesions. It also appears that people in whom OSMF develops have a genetic predisposition which could render the oral mucosa more susceptible to chronic inflammatory changes on exposure to carcinogens.
| Conclusion|| |
From the present study it is observed that a salivary coagulation factor and an altered immunity are seen among OSMF patients as compared to healthy controls. Further research must be directed in assessing the exact nature of this unusual feature of salivary coagulopathy among OSMF patients and its role in the causation of this disease. Identification of this factor will not only help in localizing the etiological agent but will also help in arresting OSMF and it carcinomatous development in the oral cavity. Research into the immunological aspect and behavior should also be conducted in such subjects providing valuable information about the disease, its onset, progression and treatment outcome.
| References|| |
|1.||Pindborg JJ, Murthi PR, Bhonsle RB, Gupta PC, Daftary DK, Metha FS. Oral submucous fibrosis as a precancerous condition. Scand J Dent Res 1984;92:224-9. |
|2.||Cox SC, Walker DM. Oral submucous fibrosis: A review. Aust Dent J. 1996;41:294-9. |
|3.||Gupta SC, Yadav YC. "MISI" an etiologic factor in oral submucous fibrosis. Indian J Otolaryngol 1978;30:5-6. |
|4.||Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: Its pathogenesis and management. Brit Dent J 1986;21:429-34. |
|5.||Pathak AG. Fibrin producing factor in oral submucous fibrosis. Ind J Otolaryngol 1979;31:103-4. |
|6.||Chaturvedi VN, Sharma AK, Chakrabarati S. Salivary coagulopathy and humoral response in oral submucous fibrosis. JIDA 1991;62:51-9. |
|7.||Chaturvedi VN, Marathe NG. Serum globulins and immunoglobulins in oral submucous fibrosis. The Indian Practitioner 1988;41:399-403. |
|8.||Gupta DS, Gupta M, Oswal RH. Estimation of major immunoglobulin profile in oral submucous fibrosis by radial immunodiffusion. Int J Oral Surg 1985;14:533-7. [PUBMED] [FULLTEXT] |
|9.||Pathak AG. Serum proteins and immunoglobulins in oral submucous fibrosis. Ind J Otolaryngol 1978;30:1-4. |
|10.||Rajendran R, Sugathan CK, Remani P, Ankathil R, Vijaykumar T. Cell mediated and humoral responses in oral submucous fibrosis. Cancer 1986;58:2628-31. |
|11.||Shah N, Kumar R, Shah MK. Immunological studies in oral submucous fibrosis. Indian J Dent Res 1994;5:81-7. [PUBMED] |
|12.||Bhatt AP, Dholakia HM. Mast cell density in oral submucous fibrosis. J Ind Dent Asso 1977;49:187-91. |
|13.||Ingild A. Single radial immunodiffusion. Scand J Immunol 1983;17:41-56. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]