Case report: the importance of oral

manifestations in diagnosing
iron deficiency in childhood
V.S.S. PIERRO*, L.C. MAIA*, L.G. PRIMO*, F.D. SOARES**

ABSTRACT. Aim The aim of this article is to report a case of iron deficiency diagnosed in a child after routine oral
examination. Case report A 5-year-old male child of African descent was brought to the paediatric dental clinic
of a public university in Rio de Janeiro, Brazil. His mothers main complaint was her childs decayed teeth and
sensitivity in the tongue every time he ate spicy or hot food. Anamnesis revealed chronic respiratory problems due
to allergy, two previous episodes of anaemia and hospitalization about 15 months before the dental visit because
of severe primary herpetic gingivostomatitis. Soft tissue examination revealed his tongue had various patches of
atrophic mucosa characterizing absence of papillae in these areas. The childs dietary assessment indicated that
he never ate meat or vegetables. Haematological investigation showed that the child probably had an iron
deficiency, although the full blood count was not totally compatible with anaemia. A rapid initial recovery was
quite noticeable after the beginning of oral therapy with ferrous sulphate, as remission of tongue sensitivity as
well as papillae neoformation were observed.

KEYWORDS: Iron deficiency diagnosis, Tongue pathology, Child, Preschool.

Introduction cases worldwide [Derossi and Raghavendra, 2003].

Many systemic diseases have oral manifestations
that must be properly recognized if the patient is to
receive appropriate diagnosis and referral for
treatment [Long et al., 1998]. These diseases
frequently include many types of anaemia that are
widely recognized by their oral lesions [Neville et al.,
1995; Drossy and Raghavendra, 2003]. Anaemia
results from a decrease in the normal amount of
circulating haemoglobin. A variety of factors can
cause this condition, including iron deficiency,
haemolysis, deficit in red blood cell production,
vitamin B12 and folic acid deficiency, or a
combination of these factors [Derossi and
Raghavendra, 2003].
Iron deficiency is the most common cause of
anaemia throughout the world [Massey, 1992; Neville
et al., 1995]. It affects approximately 30% of the
world population and accounts for up to 500 million
Departments of *Paediatric Dentistry and Orthodontics, School of Dentistry,
Federal University of Rio de Janeiro, **Pathology, Federal Fluminense University,
Rio de Janeiro, Brazil
In infancy, the major causes of iron deficiency
anaemia are a dilution of body iron by rapid growth
and an iron poor diet [Behrman and Kliegman,
1994], and its progression is usually insidious [Farley
and Foland, 1990].
Oral manifestations of iron deficiency anaemia
include angular cheilitis and atrophic glossitis or
generalized oral mucosal atrophy [Neville et al.,
1995]. The atrophic tongue is a result of
depapillation and loss of filliform and fungiform
papillae. Moreover, glossodynia is a common
complaint [Derossi and Raghavendra, 2003].
The aim of this article is to report a case of iron
deficiency diagnosed in a child after routine oral
examination.
Case report
A 5-year-old male child of African descent was
brought to the paediatric dental clinic of a public
university in Rio de Janeiro, Brazil. His mothers
main complaint was the presence of decayed teeth.
Anamnesis revealed chronic respiratory problems
due to allergy, two previous episodes of anaemia and

EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 2/2004 115

V.S.S. PIERRO ET AL.
a b
FIG. 1 - Atrophic aspect of the patients tongue along with the two hyper-pigmentated lesions on initial intraoral examination.
hospitalization about 15 months before the dental
visit because of severe primary herpetic
gingivostomatitis. His mother also reported that he
stayed in hospital for approximately 14 days in order
to receive parenteral nutrition because of numerous
oral ulcers, including lesions on the tongue,
oropharynx and others in the oesophagus, which did
not allow food to be ingested.
Intraoral clinical examination revealed dental
caries in some primary teeth as well as poor oral
hygiene. During soft tissue examination, it was
observed that the tongue showed various patches of
atrophic mucosa characterizing absence of papillae
in these areas. Along with the depapillated areas
there were two hyper-pigmented flat lesions
measuring about 5 mm in diameter, resembling two
macules (Figs. 1a, 1b). The mother said that the
macules appeared during patients recovery from
gingivostomatitis and had never changed in colour or
size since then. She also seemed to believe that the
atrophic tongue was due to the cicatrisation process
of the ulcerations present during the herpetic
infection that had occurred about a year before.
In order to discard the possibility of vascular lesions,
the hyper-pigmented lesions were submitted to
diascopy, which presented a negative response (Fig. 2).
In consultation with an oral pathologist, it was decided
to watch whether they showed any change in colour or
size, in which case a biopsy would be performed. It was
suggested that the patient should undergo a
haematological investigation, consisting of a full blood
and serum vitamin B12 count. Furthermore, the mother
was asked about the patients diet and revealed that he
never ate meat or vegetables and that feeding the child
was always quite an annoying task for her. She added
that he had also been complaining about sensitivity in
the tongue every time he ate spicy or hot food.
The haematological investigation results showed
that the serum level of vitamin B12 was in the normal
116
FIG. 2 - Diascopy of the hyper-pigmentated lesions showing
a negative response.
range (392.0 pg/mL: 174.0-878.0), and the
haemoglobin level was at the lowest limit (11.6 g/dL,
normal > 11.5 g/dL) along with microcytic
hypochromic cells on a peripheral blood smear. Red
cell distribution width (RDW) was 13.8% (6.5-
14.5%), haematocrit 35.7% (> 34%), and mean
corpuscular volume 77.6 fl (82 fl). These values
showed that the child probably had an iron deficiency,
although the full blood count was not totally
compatible with anaemia. The child was then referred
to his paediatrician, who also suspected iron
deficiency and started a therapeutic trial of iron
(ferrous sulphate - 3 mg/kg/day) in order to confirm
the diagnosis without submitting the child to an
invasive examination again. After 14 days of therapy,
the tongue had already begun to show areas of
papillae neoformation (Figs. 3a, 3b) and the patients
mother reported that he had no longer complained
about tongue sensitivity during the past week.
One month after starting iron therapy, the child
showed continuous neoformation and maturation of
papillae but, when compared with changes observed
in the beginning of the treatment, the process seemed
to be slower. For this reason, it was decided to
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 2/2004

a b
FIG. 3 - Aspect of the tongue after 14 days of therapy with ferrous sulphate, presenting areas of papillae neoformation.
FIG. 4 - Cytopathology showing absence of Candida sp. and
oral smears with predominance of intermediate squamous
cells identified by their increased nuclei (compatible with
atrophic mucosa).
perform an exfoliative cytological examination of the
depapillated tongue areas to check if there was
concomitant Candidal infection in these regions.
Cytopathology did not reveal Candida species,
showing oral smears with predominance of
intermediate squamous cells, which was compatible
with atrophic mucosa (Fig. 4). It is noteworthy to
report that hyper-pigmented macules continued to
remain unchanged up to this examination.
After eliminating the possibility of candidiasis
associated with the atrophic mucosa, iron therapy
was maintained, as it was the only possible treatment
for the condition that seemed to be solely due to iron
deficiency.
Follow-up. The patient continued to follow a
schedule of appointments in order to finish his dental
treatment and to check the condition of his tongue.
After 12 months of follow-up the tongue still
presented areas of depapillation and, according to the
patients mother, he had not improved his diet. For
this reason, the paediatrician continued to maintain
the ferrous sulphate intake.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 2/2004
ORAL MANIFESTATION OF IRON DEFICIENCY
Discussion
It is worthwhile considering that iron deficiency
occurs on a sequential basis in three stages of
progression. The first one is a negative oral balance,
in which the demands for iron (or iron losses) exceed
the bodys ability to absorb iron from the diet. As
long as iron stores are present, and can be mobilized,
red cell morphology and indices are normal in this
phase. The next stages are the iron deficient
erythropoiesis, characterized by the first appearance
of microcytic cells on peripheral blood smear, and
the iron-deficiency anaemia itself, presenting as low
levels of haemoglobin and haematocrit [Braunwald et
al., 2001]. In the case reported here, the child seemed
to be in the second phase, because although his blood
smear presented microcytic and hypochromic cells,
there was no evidence of marked alterations in
haemoglobin level or haematocrit. So, even in the
absence of anaemia, iron deficiency was sufficient to
promote oral manifestations.
Glossitis is significantly more common in anaemic
patients than in healthy ones, especially in those
individuals who are deficient in vitamin B12 and
folate. Thus, it is suggested that glossitis remains a
valuable sign of vitamin-B12 and folate deficiency
[Dawson et al., 1969]. With regard to this, the first
approach in the reported case was based only on an
initial suspicion of vitamin B12 deficiency. However,
haematological investigation results ruled out the
possibility of this type of deficiency.
Iron deficiency glossitis has been described as a
diffuse or patchy atrophy of the dorsal tongue
papillae, often accompanied by tenderness or a
burning sensation. As such findings are also evident
in oral candidiasis, some investigators have
suggested that iron deficiency predisposes the patient
to candidal infection, which results in the changes
seen at the corners of the mouth and on the tongue
[Neville et al., 1995]. For this reason, it was decided
117
V.S.S. PIERRO ET AL.
to perform the exfoliative cytological examination of
the depapillated areas, especially because of the
patients complaint about tongue sensitivity during
the ingestion of some types of food. Presence of
Candida would also involve an antifungal therapy to
treat the condition [Neville et al., 1995].
To diagnose iron deficiency anaemia, serum ferritin
levels can be evaluated along with the haemoglobin
level in routine blood counts [Derossi and
Raghavendra, 2003]. However, as ferritin is an acute
phase reactant, it is known to be unreliable as a sole
marker of iron deficiency. Ferritin may be elevated in
individuals affected at the time of giving blood and
therefore these individuals may have ferritin in the
normal range in spite of being iron deficient (false
negatives) [Fawcett et al., 1998]. On the other hand, the
red cell distribution width (RDW) is a measure of iron
deficiency that retains its diagnostic usefulness when
inflammation is present. It measures the heterogeneity
of red cell size distribution and it is increased in iron
deficiency, but not in thalassaemia trait nor in chronic
inflammatory illness. Thus an elevated RDW is the
earliest haematological manifestation of iron deficiency
[Wilson et al., 1999] and a full blood count alone is
probably the screening test of choice for iron deficiency
anaemia [Crampton et al., 1994]. With regard to the
present case, serum ferritin was not initially evaluated
because it was thought that the patient had vitamin B12
deficiency and not iron deficiency. As a full blood count
showed a way into the latter condition, presenting
microcytic and hypochromic red cells and RDW values
close to the highest acceptable, the patients
paediatrician decided to confirm diagnosis with a
therapeutic trial of iron, preventing the child from being
submitted to another blood test.
Therapeutic trial of iron is indicated to establish the
diagnosis of iron deficiency if the suspicion index is
high and laboratory results are equivocal [Reeves et al.,
1983]. In the reported case a therapeutic trial could be
justified, as dietary history suggested iron deficiency.
Most patients with iron deficiency anaemia
respond to oral iron therapy. Oral ferrous sulphate is
the standard therapy and is very cost-effective
[Derossi and Raghavendra, 2003]. More than 10%
absorption should occur in the first weeks of
treatment, decreasing as the iron stores are
replenished [Farley and Foland, 1990]. In the present
case, a rapid initial recovery was quite noticeable
after the beginning of oral therapy with ferrous
sulphate, as remission of tongue sensitivity as well
as papillae neoformation were observed. However,
the effects of therapy were gradually stabilized
during the course of treatment.
118
Increasing evidence has shown that mild iron
deficiency in infancy may be associated with later
cognitive deficits [Behrman and Kliegman, 1994].
Therefore, diagnosis of this condition is especially
important in children, because it has profound effects
on the central nervous system and has been associated
with impaired mental and motor development [Derossi
and Raghavendra, 2003]. In the case reported here, the
dentist had an important role in diagnosing this
condition by observing the atrophic tongue.
Conclusion
Some systemic conditions have oral manifestations
that dentists must be able to recognize, especially in
children, who need to be in good health for ideal
development. Early and proper diagnosis of these
problems could make a difference to the prognosis of
many conditions and, to a greater extent, to the
childs life.
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