Abstract
Objectives:
The study aimed to understand the cause of glossitis that occurred among boarding students in a central school in Chhukha, Bhutan, and the outcome after 15 days of treatment with a vitamin B complex tablet.
Methods:
The researcher extracted data from the treatment records of patients treated for glossitis from 30 September 2020 to 30 October 2020 at the boarding school and conducted a retrospective descriptive study. A total of 97 records were used in the study: the age, gender,date of reporting to school, treatment, dietary preferences, and outcome of treatment.
Results:
In all, 63 (64.9%) patients were females. The students who were staying in the hostel for longer duration were more in proportion among the patients. About 80% of the patients had subjective improvement after treatment with two doses of one tablet of vitamin B complex tablet for 15 days. There were no deaths.
Conclusion:
The study could not ascertain the definite cause of glossitis among boarding students but 80 % of the patients showed subjective improvement after treatment with daily two doses of 32.5 mg of vitamin B complex tablet. The study recommends a prospective study to understand the cause of glossitis among boarding students to prevent similar future outbreaks.
Introduction
Inflammation of the tongue or glossitis is characterised by redness, swelling, altered sensation, pain on the tongue, difficulty in taking meals, excessive salivation, etc. 1 There are different types of glossitis such as benign migratory glossitis, atrophic glossitis, median rhomboid glossitis.2–4 It may be caused by deficiencies of nutrients including riboflavin, niacin, pyridoxine, vitamin B12, folic acid, iron, zinc, and vitamin E, protein-calorie malnutrition, candidiasis, Helicobacter pylori colonisation, xerostomia and diabetes mellitus.5–7
There were reports of outbreak of glossitis among students of some boarding schools in Bhutan during mid-academic sessions in the years 2018 and 2019 and it was mainly seen among boarding students. 8 It has been taken as an issue of concern both by the health and education ministries. 9 Studies in Bhutan mentioned that thiamine (vitamin B1) deficiency was suspected to be the cause of peripheral neuropathy which was seen mostly in boarding students.10,11 This finding of thiamine deficiency led to a change in policy with the introduction and supply of fortified rice in the central schools in 2018 to improve the nutritional content of food. 12 However, due to some unidentified reasons, then started the problem of glossitis in the schools as per reports maintained at the Ministry of Education, Bhutan.
There was an outbreak of glossitis at Paksikha Central School under Bongo Gewog, Chhukha District, Bhutan during the months of September–October 2020. The school reopened in July 2020 for classes 10 and 12 and homemade food was not allowed due to COVID-19 prevention protocol. The students of classes 9 and 11 joined the school in September 2020 in compliance with the prevailing COVID-19 prevention protocol in the school. 13 Three meals for students of boarding schools in the country are provided from a hostel and the food commodities are purchased by the school administration. 14
This study was therefore conducted to understand the cause of outbreak, the response to treatment with vitamin B complex tablets and provide evidence for prevention or management of similar outbreaks in the future.
Methods
The study is a retrospective descriptive analysis of medical records of students who were treated for glossitis during outbreaks in the school from 30 September 2020 to 30 October 2020. There were two groups of patients according to their date of reporting to school due to the need to observe COVID-19 prevention protocol in school. The students of classes 10 and 12 reported to the school on 1st July 2020 due to academic reasons. The other group comprised of students of classes 9 and 11 who reported to school late on 19 September 2020 because they had to appear for examination as per the school`s schedule and not board examinations.
There was no access to outside or home food because students were neither allowed to move out of the school campus nor the parents were allowed to bring in food due to the need to observe COVID-19 protocol in the school.
The diagnostic criteria of glossitis include a smooth, glossy, painful, swollen and red tongue, and excessive salivation with difficulty in speaking, eating or swallowing. We followed the following inclusion criteria for diagnosis as per the symptoms explained by the patients and signs observed by the doctors. The symptoms for inclusion criteria were complaints of redness of the tongue, swelling, excessive salivation and pain on taking meals. The examination findings used were redness of the tongue and swelling with loss of filiform papillae. We also followed inclusion criteria for subjective improvement such as a decrease in redness, swelling, salivation and pain on taking meals. The clinical signs for improvement included a decrease in redness, swelling of the tongue, visible appearance of filiform papillae and no super-added signs of infection.
We included all the records of patients in the study and the sample size calculation was not done for this study. We did not use separate controls in the study because the study is a retrospective review of medical records of all the patients. We did not differentiate among different types of glossitis because of the non-availability of histological diagnosis services at the district hospital.
The treatment and follow-up were provided by Gedu Hospital. The same hospital team comprising medical officers, dentists and pharmacy technicians visited the school on 30 September 2020, 16 October 2020 and 30 October 2020 and managed the students. The team collected details about age, gender, class, dietary preferences whether taking meat or egg and clinical findings before starting the treatment and after 15 days of treatment. The tongue papillae and colour of the tongue were examined visually and quantitative calculations of the papillae were not done. The same medical officer and dentist examined the students and the pharmacy technician issued medicines that were prescribed by the medical officer.
We examined other somatic status of the patients clinically and for jaundice, pallor, diarrhoea and vomiting. We also asked for history and patients were not smoking, chewing tobacco and taking any other medicines at the time of our study. Tests for bacterial, viral or candidal aetiology could not be conducted due to the limitations of the facility at the district hospital.
The treatment used for glossitis was a vitamin B complex tablet, 32.5 mg one tablet two times per day orally for 15 days. This vitamin B complex tablet was also available over the counter in pharmacies but in Bhutanese health centres, this medicine was supplied by the government and patients were not required to pay the cost. Each 32.5 mg vitamin B complex tablet of government supply contains 1.0 mg of vitamin B1, 1.0 mg of vitamin B2, 15 mg of niacinamide (B3), 1.0 mg of vitamin B6, 0.05 mg of Folic acid and 1.0 mg of vitamin B12, the dose is 1–3 tablets per day depending on deficiency status. 15 There was no history of taking the tablets during the current outbreak. The students treated were aware that vitamin B complex was prescribed in previous outbreaks.
Paracetamol 500 mg was given for 3 days if the patient had pain. Advice was given on oral hygiene, to avoid hot and spicy food if the patients felt hurt on the tongue while taking meals. The patients were identified as improved subjectively if they told in history that the tongue pain was reduced, pain during swallowing of food reduced, redness was reduced and excessive salivation was reduced. The clinical signs included reduced redness of the tongue and there was no added infection on the tongue on clinical examination. The added infection was ruled out clinically from the absence of fever, absence of ulcers on the tongue, and absence of submental, submandibular or cervical lymph nodes. The students were also advised on the importance of maintaining good oral hygiene irrespective of the type of lesion. They were advised to brush their teeth two times daily, rinse their mouth well after eating, remain hydrated and check the colour of their tongue.
Procedure
Prior ethical approval was obtained from the Research Ethics Board of Health (REBH), Bhutan (REBH/Approval/2021/035) dated 3rd March 2021 before commencing the study. The investigators did not contact patients for any additional or individually identifiable information. Waiver of informed consent was obtained during approval and the records were kept secured by the principal investigator.
Statistical analysis
The details of students were recorded during the health team visits to the school and then kept with a medical officer for further follow-up. Data were extracted from the details recorded during patients’ treatment and follow-up. The data were then entered into an Excel sheet and analysed. The variables were described in counts and proportions.
Study variables included age, gender, date of reporting in the hostel, dietary preferences such as whether eating meat or egg and outcome such as subjective improvement after 15 days of treatment. The age was represented in the range, mean age and standard deviation in age, The students who reported on 1 July 2020 were grouped into one and those who reported on 19 September 2020 were grouped into another because of the difference in duration of their stay in the hostel.
Results
In all, 97 students had glossitis during the outbreak and among them 63 (64.9%) were females. In total, 79 (81%) of the patients were the ones who joined the school on 1st July 2020. Sixty-eight (70.1%) patients said they eat eggs and 75 (77.8%) said they eat meat when provided in a hostel. Seventy-eight (80%) students noted subjective improvement when followed after 15 days of treatment and others were improving as per history and clinical examination (Table 1).
Representation by age, gender, class, dietary habits and treatment outcome in the patients during an outbreak of glossitis among boarding students in a school in Chhukha, Bhutan.
Discussion
Our study found that only the boarding students suffered from glossitis and the female patients were more in proportion. The students, who reported to school early on 1st July 2020, were more in proportion than the students who reported to school late on 19th September 2020.
There were outbreaks in other boarding schools in the past but the reports were inconclusive due to which definitive intervention could not be done as evidenced by repeated outbreaks for the last 3 years. 16 Also, there was no evidence to ascertain whether the glossitis incidences had any link with food fortification or any contamination because the investigations from the samples collected from some of these schools did not show any link with the outbreaks. 16 However, we found that more than 80% of the patients had subjective improvement when treated with vitamin B complex tablets for 15 days. Microscopic examination of the papillae was not done due to the limitation of the facility but only visual inspection by the treating team was done. The only difference we observed between the fortified rice and vitamin B complex tablet was the presence of 2 mg of riboflavin (vitamin B2) in each tablet of the vitamin B complex; the fortified rice had vitamin B1, B3, B6, B9, B12, vitamin A, iron and zinc but there was no vitamin B2. 17 When a deficiency of riboflavin does occur, it is almost invariably in association with multiple nutrient deficits but this may have been prevented by consumption of fortified rice supplied in the hostel. Also, the food intake recall assessment by the nutritionists of ministries of health and education found that the students were getting only 0.2 mg of riboflavin (B2) through food per day but the recommended daily allowance (RDA) of riboflavin in adolescents (age 10–18 years) is 0.9–1.3 mg and in adults (19–70 years), it is 0.9–1.1 mg. The deficiency is more prominent in girls because of increased metabolic demand. 18
In past investigations, the riboflavin (vitamin B2) content in the body of the students suffering from glossitis was not tested. The main dietary sources of riboflavin are meat and dairy products; only small amounts are found in grains and seeds. Leafy green vegetables are also a good source of riboflavin and in developing countries tend to be the main source of the vitamin. However, the definite causes of such illness remain poorly characterised, largely due to limited diagnostic and microbiological facilities at district hospitals like Gedu.
More than 80% of students with glossitis had subjective improvement after treatment with vitamin B complex tablets for 15 days. The treatment of glossitis with a vitamin B complex tablet two times daily provided 4 mg of vitamin B2 per day as each tablet contains 2 mg of vitamin B2. 19 This quantity of riboflavin ingested through vitamin B complex tablet had met the RDA of riboflavin. This treatment contributed to subjective improvement in the symptoms and signs because one of the indications of the use of vitamin B complex is the treatment and prophylaxis of riboflavin deficiency. 20 Among the students with glossitis more than 70% had taken meat or egg that was served in the school. However, the quantity of meat or eggs served to the students may not have been enough to meet the required intake to prevent the glossitis because riboflavin deficiency is likely to be more prevalent among those who take less quantity of animal-source foods. The meat or egg consumption is important to understand that the cause of glossitis may not be purely due to a lack of meat or eggs in the diet.
This study has certain limitations as being a record-based study with a limited number of patients. The diagnosis was only clinical and patients were not subjected to any blood investigation. The study could not explain the reasons for more proportions of females among the patients. The power analysis for sample size calculation was not done because all the patients suffering from glossitis were included in the study.
Conclusion
The study could not ascertain a definite cause of glossitis among boarding students but there was subjective improvement in 80% of patients after 15 days of treatment with 32.5 mg one tablet two times per day. The role of riboflavin (vitamin B2) which is present in vitamin B complex tablets that are used in the treatment but missing in fortified rice that is served to students may further be explored. Therefore, a prospective study may be needed to identify the causes of glossitis outbreaks among some of the boarding students in the schools.
What we already know
Nutritional disorders related to vitamins and minerals can occur in people who are devoid of adequate nutrition in the diet and they can be prevented by food fortification with minerals and vitamins
What this article adds
Glossitis was seen in boarding students when they were served rice fortified with vitamins and minerals except Riboflavin (vitamin B2)
The role of riboflavin (vitamin B2) in the prevention of glossitis which is absent in the fortified rice may be further explored
Footnotes
Acknowledgements
We acknowledge the contributions made by Mr Leela Bdr Thara, Principal, health in charge of the school for assisting us in management and following up on the sick students and pharmacy technician of Gedu hospital in assisting in dispensing medicines to the patients.
Author contributions
TN managed the patients, designed the research protocol, sought approval, coordinated the research and drafted the manuscript. DG helped in patient management, data entry and finalised the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics approval
Prior ethical approval was obtained from the Research Ethics Board of Health (REBH), Bhutan (REBH/Approval/2021/035) dated 3rd March 2021.
Informed consent
Informed consent was not sought for the present study because this study was a retrospective analysis of the hospital data and patients were not contacted during this study. No identifiable data were mentioned in the study. Waiver of consent was also sought approval from the REBH.
Trial registration
The study is not a randomised controlled trial because vitamin B complex, 32.5 mg is already in use in Bhutan for the treatment of vitamin deficiencies. The treatment in the patients was prescribed as per standard clinical practice. Therefore, registration of clinical trials was not done.
