This outbreak is apparently the first outbreak of Glossitis among the students with none having reported before. Other cases of nutritional deficiency syndrome such as the outbreak of Peripheral Neuropathy has been reported before in number of schools within Bhutan. (4) The first cases of oral sores were detected among the students of Tsirangtoe Central School on 3rd September 2018 in the outpatient department of Tsirangtoe BHU. Upon interception, it was found that two other central schools in the district were affected with similar lesions. Glossitis may appear as a result of early signs of nutritional deficiency. This lesion is common among a large group of people cohabiting together in one environment and sharing one kitchen meal. Such an outbreak is known to have occurred in a population of 400 prisoners cohabiting a prison in Assam in 1931.
(5) In another study done on a Libyan population on the prevalence of tongue lesions, Fissured Tongue (Scrotal Tongue) was accorded to have highest prevalence which was in consistent with our findings in this study.
(6)
Epidemiological studies have shown high frequency of tongue diseases among mucosal lesions of the oral cavity with variable prevalence in different parts of the world. (7)(8) These variations are due to the differences in sociodemographic variables of the studied samples and the use of different diagnostic criteria, methodology and procedures to study the sample. (8) This paper suggests similar variations in the incidence of different kinds of tongue lesion in the affected central schools among different socio demographic groups.
Iron and Vitamin B complex constituents notably B9 (Folate) and B12 (Cyanocobalamin) are among the important nutritional components that affect oral and general health. (9) Various oral symptoms such as glossitis, glossodynia, Recurrent Aphthous Ulcers, cheilitis, dysgeusia, lingual paresthesia, burning sensations and pruritus have been reported among individuals having decreased levels of Iron and vitamin B12 intake. (9) (10) It is reported that certain diseases such as pernicious anaemia, gastritis and thyroid diseases are related to the absorption process of vitamin B12 and may thus manifest oral lesion. (11), (12) & (13)
Examination of the affected students revealed the presence of a beefy, red depapillated, sores on tongue. The laboratory blood investigations for Iron and vitamin B complex assay on a few selected samples yielded normal levels on Iron, vitamin B1, B6 and B12 whereas vitamins B2 and B9 have been reported below normal range of 39.8-240ng/ml and 2.7-17ng/ml respectively.
Nutritional Survey analysis revealed reduced vitamin rich dietary intakes among all the three schools. All three schools' diet menus were lacking of green leafy vegetables. From the Typical Day 24-Hour Recall from the cases, it was found that the diet on that particular Day didn’t meet Recommended Daily Allowance(RDA) for Vitamin B2 (Riboflavin), B9 (Folic Acid), B12 (Cyanocobalamin) and Iron.
Of the 40 cases accrued for Exfoliative Cell Cytology Testing to see fungal elements, 31 students were tested positive for the fungal elements. Only clinically evident cases were made available for the test. The fungal infection could be due to poor oral hygiene, caused secondary to nutritional deficiency. Poor Oral Healthcare habit among the school going children is one of the highest risk factors for concomitant fungal infection of the oral cavity which can be aggravated by the mild nutritional deficiency syndrome.
This is the first documented outbreak of Glossitis disease in the boarding Schools in Tsirang and in Bhutan. The findings from this study suggests underlying nutritional deficiency in affected schools. The fortified rice provided from the school feeding program contains vitamin A, B1, B3, B6, B9, B12, Iron and Zinc. Since the laboratory investigations revealed low levels on B2(Riboflavin) and B9(Folic Acid), it is suggested that the cooking methods on fortified rice and hazard analysis of the fortified rice manufacturers to be analysed. Further to increase the dietary intake of B2 and B9, the school’s menu is suggested to improve. The need to monitor and follow strict and inclusive balanced diets for the school feeding program with extended green and leafy vegetables in the diet is being suggested.