VYDEHI INSTITUTE OF DENTAL SCIENCES AND RESEARCH CENTRE.
Course Of Study & Subject
ORAL MEDICINE AND RADIOLOGY
Date Of Admission To Course
Title Of The Topic
“MEDIAN RHOMBOID GLOSSITIS AND ITS POSSIBLE ASSOCIATION WITH CANDIDA IN TYPE2 DIABETIS MELLITUS PATIENTS :A CASE CONTROL STUDY”
BRIEF RESUME OF THE INTENDED WORK
6.1Need For The Study :
Median Rhomboid Glossitis, first described by Borcq in 1914, occurs in less than 1% of general population. About 70-80% of cases are in men. Its etiology is unknown, although it has been proposed that it may be derived from chronic candidiasis, staphylococcus aureus or that it may be of embryological, inflammation,or even an immunological origin.1This condition was once thought to represent a developmental defect1. Today, however, most authors do not subscribe to the embryogenesis theory. Instead, they believe that median rhomboid glossitis is related to an infection of Candida albicans, which is the most common fungal organism of the oral cavity.2
It typically presents in the posterior region of the dorsum of the tongue, at the midline, anterior to the lingual "V”, however, it sometimes appears in paramedial location. It appears as a round or rhomboid painless plaque with well-defined margin, intense reddish or pinkish in colour due to atrophy or depapillation and firm on palpation.1 When Median Rhomboid Glossitis is concomitant with a palatal inflammation, it is called the kissing lesion.3
Diabetes mellitus is a complex multisystemic metabolic disorder characterised by a relative or absolute deficiency of insulin secretion, concomitant resistance to metabolic action of insulin on target tissue or relative lack of insulin.4 Diabetes can be divided into two types. Type 1 diabetes formally called as juvenile diabetes or insulin dependent diabetes is usually diagnosed in teenagers and young adults. In this type, the b-cells of pancreas are destroyed by autoimmune mechanism. Type 2 diabetes also known as adult onset or non insulin dependent diabetes, can occur at any age even in childhood. In this type, a resistance to insulin is developed.5
Diabetes has variable and sometimes profound effect on oral tissues. Patients with poor glycemic control are particularly prone to severe and/or recurrent oral infections. Studies suggest that diabetics are more susceptible to fungal infections in areas of moisture and trauma. Candidiasis is one of the most common infections we come across in the oral cavity of diabetics.5
Several studies had been conducted regarding the prevalence of Median Rhomboid Glossitis in Diabetic patients in Western population. But only very few studies had been documented regarding the same in Indian population. Hence the aim of the present study is to find an association of Median Rhomboid Glossitis with candida in Type2 diabetes mellitus patients.
By undertaking this study, we as oral diagnosticians can play a critical role in diagnosing Median Rhomboid Glossitis in undiagnosed diabetic patients & further referring the patient for appropriate investigations & management.
Review of Literature:
In a study by James Guggenheimer (1999) prevalence of candidiasis in 405 subjects with IDDM & 268 non diabetic controls were studied.Assessment included evidence of clinical manifestations of candidiasis and a quantitative measure of candida pseudohyphae in a cytological smear from midline posterior dorsal tongue.As per the results, more subjects with IDDM than control were found to have clinical manifestations of candidiasis including Median rhomboid glossitis. IDDM subjects were also more likely to have candidial pseudohyphae in their cytological smears.5
The study by James Guggenheimer et al(2000),prevalence and characteristics of oral soft tissue diseases identified during a comprehensive oral evaluation of 405 adult subjects with diabetes and 268 control subjects without diabetes.tey found that twenty specific oral soft tissue lesions were identified. Nearly twice as many subjects with diabetes than without diabetes were found to have one or more oral soft tissue lesions6
According to a study done by Brenda L Nelson and Lester D R Thompson (2007),Development, clinical and histological feature and treatment of Median Rhomboid Glossitis are dealt with. 3
This study by Nanditha Shenoy,Amar A Sholapurkar, Keerthilatha M Pai,Prabha Adhikari(2010),difference in oral health status between geriatric patients with diabetes and normal population were compared .No significant difference and no pathognomonic lesions were observed in relation to the disease.4
According to the study done by J Gabanchi et al (2011) 202 Iranian patients with diabetes mellitus aged 10-86 years & 261 healthy subjects aged 10-28 years and diagnosis of MRG was made based on clinical features. 6.43% diabetic patients and 1.53% of control group had Median Rhomboid Glossitis , so prevalence of MRG in diabetes was much higher than that in controls1
In the study by Mustafa Goregen et al (2011) the relationship between median rhomboid glossitis (MRG) and Candida and bacteria species, prevalence and possible association with age, gender, smoking, denture wearing, and diabetes mellitus were studied. MRG frequency was detected to be 0.7%. In mycological examination, Candida species were determined in 90.0% of the MRG patients and in 46.6% of the control group.2
OBJECTIVES OF THE STUDY:
To establish an association between Median Rhomboid Glossitis and Type 2 Diabetes Mellitus
To investigate the possible association between Median rhomboid Glossitis and Candida species.
Study area : Department of Oral Medicine & Radiology,
Vydehi Institute Of Dental Sciences & Diabetic clinic, Vydehi Institute of Medical Sciences
Study population : Patients reporting to OPD of Vydehi Institute of Dental sciences & Diabetic clinic ,Vydehi Institute of Medical Sciences, White Field ,Bangalore
Duration of the Study : 2012-2014
Case history proforma.
Mouth mirror and probe.
Periodic Acid Schiff stain
Tourniquet and Disposable syringes
METHOD OF COLLECTION OF DATA: (including sampling procedure if any).
Sample Size: 500 subjects will be included in the study. They will be divided into 2 categories
Group 1- 250 Type 2 Diabetes Mellitus patients.
Group 2- 250 Healthy patients who are age and sex matched (control group ) with no signs and symptoms of any disease.
Known diabetic patients with a history of Type 2 Diabetes Mellitus.
Patients with any other systemic diseases.
Patients with recent history and/or currently on medications which affect oral microbial flora
(eg: Antibiotics, Corticosteroids, Immunosupressants )
Data collection methodology: 250 diabetic patients and 250 healthy control patients will be selected after a written consent is obtained.
A detailed case history will be recorded with special importance to age, sex, smoking habits, duration of diabetes mellitus, drug used and paraclinical data including Random blood sugar, Fasting blood sugar ,Post prandidal blood sugar , Hb A1c.
A detailed intra oral examination will be done. The diagnosis of Median rhomboid Glossitis will be made based on WHO guidelines. 2ml of peripheral blood will be collected from every patient for the estimation of random blood sugar. In patients diagnosed with Median Rhomboid Glossitis ,Fasting ,Post prandial & Glycosylated haemoglobin assay will be done in diabetics and controls. Candida assessment will be done using the scraping from the dorsal aspect of the tongue in Median Rhomboid Glossitis patients. Cytological samples for candidial pseudo hyphae assessment obtained by scraping a wooden spatula across the posterior midline dorsal tongue where the lesion is present. Material is spread on a glass slide approximately 2cm2. The slide is immediately fixed with spray fixative and is allowed to air dry. Slides are stained with Periodic acid Schiff stain, and the pseudohyphae detection is done.
Candidal hyphae count assessment done on the cytological smear.
Results will be analyzed by
Test for proportion
Does the Study require any investigation or intervention to be conductedon patients or other human subject or animals? If so, please describe briefly.
2ml of peripheral blood will be taken for screening of diabetes in controls and in Type 2 diabetic patients for Random, Fasting ,post prandial blood sugar & Glycosylated haemoglobin assay.
Smear for candidial assessment will be taken from dorsal aspect of tongue in patients with Median Rhomboid glossitis.
Has Ethical Clearance been obtained from your Institution?
List of references:
J Ghabanchi, A Andisheh Tadbir, R Darafshi, M Sadegholvad. The prevalence of median rhomboid glossitis in Diabetic patients:A case control study.Iranian Red Crescent Med J 2011;13(7):503-506.
Brenda L. Nelson, Lester D.R. Median Rhomboid Glossitis.2007 ENT journal
Mustafa Goregen,Ozkan Miloglu, Mustafa Cemil Buyukkurt, Fatma Caglayan, Ayse Esin Aktas-Median Rhomboid Glossitis.A clinical and microbiological study.2011;Vol5:367-372.
James Guggenheimer, Paul A Moore,Karen Rossie,Daniel Myers,Mary Beth Mongelluzzo,Harvey M block, Robert Weyant,Trevor Orchard. Insulin dependent diabetes mellitus and oral soft tissue pathologies-Prevalence and charesteristics of non candidial lesions: Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:563-569.
James Guggenheimer , Paul A Moore, Karen Rossie ,Daniel Myers,Mary BethMongelluzzo,Harvey M block,Robert Weyant,Trevor Orchard. Insulin dependent diabetes mellitus and oral soft tissue pathologies-Prevalence & characteristics of candida and candidial lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:570-576.
Nandita Shenoy, Amar A. Sholapurkar, Keerthilatha M. Pai, Prabha Adhikari. Oral health status in geriatric Diabetics;Rev Clin Pesq Odontol.2010 jan;6(1)63-69
Sujata.M.Byahatti , Mohammed. S. H. Ingafou-The Prevalence of Tongue Lesions in Libyan Adult Patients,Oral Medicine and Pathology,J Clin Exp Dent,2010;2(4):163-168
Azmi-Mohammad-Ghaleb Darwazeh 1, Amna-Abdulla Almelaih. Tongue lesions in a Jordanian population. Prevalence, symptoms, subject’s knowledge and treatment provided. Med Oral Patol Oral Cir Bucal. 2011 Sep 1;16 (6):e745-9.
Signature of the Candidate
Remarks of the Guide
I am willing to guide DR.LEKSHMY J in her dissertation entitled “MEDIAN RHOMBOID GLOSSITIS AND ITS POSSIBLE ASSOCIATION WITH CANDIDA IN TYPE2 DIABETIS MELLITUS PATIENTS :A CASE CONTROL STUDY”