Initial diagnosis of anemia from sore mouth and improved classification

of anemias by MCV and RDW in 30 patients

Shin-Yu Lu, DDS,a and Hong-Cheng Wu, MD,b Kaohsiung, Taiwan
CHANG GUNG MEMORIAL HOSPITAL, KAOHSIUNG MEDICAL CENTER

Thirty patients with a wide range of sore mouth that led to the diagnosis of iron deficiency in 12 patients,
pernicious anemia in 8 patients, combined deficiency of iron and vitamin B12 in 2 patients, and anemia of chronic
disease in 8 patients were investigated. The oral signs and symptoms included glossitis, glossodynia, angular cheilitis,
recurrent oral ulcer, oral candidosis, diffuse erythematous mucositis, and pale oral mucosa. The values of hemoglobin in
30 patients varied from normal to severe life-threatening levels, but none had developed generalized symptoms
sufficiently advanced to arouse suspicions of anemia before they visited the Oral Medicine Clinic. The aim of this paper
is to describe a retrospective study of 30 patients with oral changes as the initial manifestation of nutritional deficiency or
anemia of chronic diseases. Improved diagnosis and classification of anemia based on the mean and heterogeneity of red
cell size will be discussed. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:679-85)

The oral manifestations of stomatitis and glossitis in

anemia have long been recognized. These oral changes
may occur in the absence of symptomatic anemia or
microcytosis or macrocytosis. The value of hematological studies in the investigation of patients with
stomatitis, glossodynia, or recurrent oral ulceration that
are unexplainable is important. The hematological
screening in these cases should include estimations of
serum ferritin, folate, and B12 levels even at the face of an
apparently normal peripheral blood film. The detailed
oral, physical, and mental investigations and improved
classification of anemia by red cell distribution width
(RDW) and mean corpuscular volume (MCV) can give
dentists and physicians an enhanced ability in diagnosis
and treatment of sore mouth relating to anemia. The
retrospective survey provided additional evidence for the
subject.
MATERIALS AND METHODS
Thirty patients (19 women and 11 men) with a wide
range of sore mouth visiting the Oral Medicine Clinic of
Chang Gung Memorial Hospital, Kaohsiung Medical
Center, and finally diagnosed with anemia of nutritional
deficiency or chronic diseases, were included in this
study. A full medical history was recorded including

Director of Oral Medicine and Oral Diagnosis, Chang Gung

Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan.
b
Hematologist, Department of Hematology-Oncology, Chang Gung
Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan.
Received for publication Jan 14, 2002; returned for revision Dec 9,
2002; accepted for publication Jan 20, 2004.
1079-2104/$ - see front matter
2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.tripleo.2004.01.006

diet, medication, previous operations, and previous care

about sore mouth. Patients were investigated if they
had any generalized symptoms and signs of anemia, including weakness, tiredness, exertional dyspnea, pallor,
tachycardia, postural hypotension, and those suggestive
of neuropathy, for example, (1) paresthesias of extremities, (2) disturbance of gait, (3) motor impairment from
mild clumsiness to a spastic paraplegia, (4) loss of
position or vibration sense, (5) disturbance of taste and
smell, or (6) disturbance of memory and affect, forgetfulness, mental slowing, depression, irritability, or paranoid psychosis.
The oral complaints and the presence of stomatitis and
angular cheilitis were recorded. Microbiological samples
were taken when clinically indicated. All patients
underwent hematological investigations consisting of
complete blood counts (CBC). The reported automated
blood counts include hemoglobin (Hb), hematocrit (Hct),
MCV, and RDW measured as coefficient of variation
(CV) or standard deviation (SD). Proposed classification
of anemia in the study by MCV and RDW of Bessmans
study1 was used (Table I). The assessments of serum
level of ferritin, iron, transferrin and total iron binding
capacity (TIBC), vitamin B12, and folate were made
when nutritional deficiency was highly suspected. The
autoantibody screening tests, including parietal cell
antibodies and antinuclear antibody (ANA), were carried
out in 10 patients with cobalamin (vitamin B12)
deficiency. The bone marrow and blood smear examinations were done in 1 patient with pernicious
anemia. The liver or kidney function tests were undertaken when history and physical examination
suggested anemia of renal disease or liver disease. Each
case had been consulted with a hematologist or medical
doctors for further evaluation and treatment.
679

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680 Lu and Wu

Table I. Proposed classification of anemic disorders based on MCV and RDW from Bessmans study1

Low or normal RDW

MCV \80 fl
(Microcytosis)

MCV = 80;100 fl
(Normocytosis)

MCV [ 100 fl
(Macrocytosis)

a or b thalassemia (minor)

Normal
ACD
Nonanemic hemoglobinopathy
ACD
Mixed deficiency
Early iron or B12 or folate deficiency
Anemic hemoglobinopathy
Sideroblastic anemia

Aplastic anemia
Preleukemia
Myelodysplastic syndrome
Folate deficiency
Vit B12 deficiency
Cold agglutinin disease

ACD
IDA
S-b thalassemia (major)
Red cell fragmentation

High RDW

Most IDA, PA, and ACD patients have low RBC but thalassemia cases always have high RBC.
MCV, mean corpuscular volume; RDW, red cell distribution width; ACD, anemia of chronic disease.

Table II. Oral symptoms and signs and laboratory findings in 12 patients with iron deficiency
Pt no.

Sex/Age

Oral S/S

RBC

Hb

MCV

MCH

Hct

RDW-SD

F/58

4.30

7.2

57.7

16.7

24.8

M/68

3.59

6.6

67.1

18.4

3
4

F/33
F/38

4.69
3.54

8.1
4.4

61.0
56.5

F/48

4.03

6.0

6
7
8

F/45
F/58
F/42

4.90
2.78
2.90

F/42

10

F/26

11
12

F/52
F/56

AG
ROU
POM
AG
POM
AC
AC
AG
POM
AC
EM
AC
OC
OC
POM
AC
AG
AC
OC
BT
AG
AC

RDW-CV

Ferritin

Fe

TIBC

39.2

5.41

25

420

24.1

48.6

3.64

423

17.3
12.4

28.6
20

42.9
48.9

19.8
24.3

\3
\3

12
3

493
503

52.8

14.9

23.3

43.6

21.1

\3

\2

412

14
7.00
3.6

86.9
77.0
60.5

28.6
21.2
12.8

42.6
21.4
19.8

41.0
49.9
45.1

11.0
16.6
25.3

5.0
4.6
\3

29
23
3

260
423
523

4.65

9.1

67.3

19.6

31.3

47.2

19.5

3.09

16

425

4.50

10.2

67.0

21.5

34.9

45.9

15.2

5.5

28

405

4.63
3.68

10.9
6.5

75.2
66.6

23.5
17.7

34.8
24.5

45.7
45.1

16.8
18.9

\3
5.57

15
8

496
410

RBC, red blood cells; Hb, hemoglobin; MCV, mean corpuscular volume; Hct, hematocrit; RDW, red cell distribution width; SD, standard deviation; CV,
coefficient of variation; TIBC, total iron binding capacity; Oral S/S, signs and symptoms; AG, atrophy glossitis; ROU, recurrent oral ulcer; POM, pale
oral mucosa; AC, angular cheilitis; OC, oral candidosis; EM, erythematous mucositis; GD, glossodynia; BT, burning tongue sensation.

Laboratory normal ranges were: Hb 12 g/dL (female),

13.5 g/dL (male), MCV 80;100 fl, MCH 26-34 pg/cell,
Hct 36% to 46 %, RDW-SD 40;45 fl, RDW-CV
11%;14%, RBC count 4-5.2 3 106/m (female), 4.5-5.9
3106/m (male), serum folate >2.5 ng/mL, serum B12
185;710 pg/mL, serum iron 50;160 UG% (male),
40;150 UG% (female), total iron binding capacity
(TIBC) 250;400 UG%, serum ferritin 102 (21;453)
ng/mL (male), 28 (6;142) ng/mL for females less than
50 years old and 94 (16;412) for females more than 50
years old.
The degree of anemia is scaled as mild (Hb 10 g/dL to
normal limits), moderate (Hb 8.0 to 10.0 g/dL), severe
(Hb 6.5 to 7.9 g/dL), and life-threatening anemia (Hb
less than 6.5g/dL) by hemoglobin (Hb) level.

RESULTS
Thirty patients complained about predominantly oral
symptoms that led to the diagnosis of iron deficiency
(ID) in 12 patients (Table II), pernicious anemia (PA) in
8 patients (Table III), combined iron and vitamin B12
deficiency in 2 patients (Table IV), and anemia of
chronic disease (ACD) in 8 patients (Table V). The
patients with IDA or ACD showed a wide range of age,
but none of the PA patients were younger than 40 years
old. IDA was prevalent in females, but the incidences of
PA and ACD had nothing to do with gender. No gross
abnormalities of diet, surgery, or the effect of medication
were detected in the 12 ID patients and 8 PA patients.
Twelve ID patients demonstrated a diverse degree of
anemia, normal to life-threatening condition by Hb level

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Lu and Wu 681

Table III. Oral symptoms and signs and laboratory findings in 8 patients with vitamin B12 deficiency
Pt no.

Sex/Age

1*

M/50

2*
3*
4

M/53
F/47
M/72

5
6*

F/72
F/68

7*
8y

M/72
F/48

Oral
S/S
AG
GD
ROU
AG
AC
OC
AG
AG
EM
GD
AC
OC

RDW-CV

Vit
B12

Folate

Parietal cell
antibody

ANA

36.9

15.5

+
+
+

[20
[2.5

+
+

[20
8.15

+
+

RBC

Hb

MCV

MCH

Hct

RDW-SD

3.13

13.3

115.3

42.5

36.1

59.6

3.41
2.06
3.98

12.9
8.7
13.7

107.6
122.3
103.5

37.8
42.2
34.4

30.7
25.2
41.2

53.7
64.0
73.9

15.1
19.6

37.0
71.8
118

2.74
3.37

10.8
10.4

115.7
95.8

39.4
30.9

31.7
32.3

63.1
57.5

15.0
16.7

91.4
19.5

3.90
5.43

12.9
11.9

97.7
69.2

31.2
21.9

38.4
37.6

45.8
38.0

15.3
13.3

136
92

6.33
5.37
6.60

ANA, antinuclear antibody.

Abbreviations are explained in the footnote to Table II.
*The peripheral neuropathy and disturbance of cerebration existed.
y
The thalassemia minor (with hemoglobin-H) and idiopathic hypothyroidism coexisted.

Table IV. Oral symptoms and signs and laboratory findings in 2 patients with combined iron and vitamin B12
deficiency
Pt no.

Sex/Age

M/76

F/42

Oral
S/S
AC
POM
OC
EM
AC
AG

RBC

Hb

MCV

MCH

Hct

RDW-SD

RDW-CV

Vit
B12

Folate

Ferritin

Fe

TIBC

4.15

7.2

66.0

17.3

27.4

45.1

19.6

157

7.49

\5.0

33

428

4.12

11.6

88.6

28.2

36.5

43.3

13.4

143

\3

28

466

10.8

Abbreviations are explained in the footnote to Table II.

(Table VI). Seven patients were severely anemic and

extremely pale without complaints of symptoms of
anemia except easy fatigue. The oral manifestations
included angular cheilitis (58%), glossitis with different
degree of papillary atrophy (42%), pale oral mucosa
(33%), oral candidosis (25%), recurrent aphthous
stomatitis (8%), erythematous mucositis (8%), and
burning mouth (8%) for several months to 1-year
duration. All had low serum ferritin, low iron, and
normal serum cobalamin and folate. Ten of 11 patients
with high TIBC and low MCV had high RDW, but 1 had
normal RDW (Table VII). Patient 6 had normal TIBC,
MCV, and RDW and was not anemic. Five patients had
low RBC and 7 patients had normal RBC. Eleven of 12
patients showed normal CBC after iron replacement
therapy for 4 to 6 months except patient 6. All oral
symptoms responded more quickly than peripheral
blood and showed complete remission within 1 to 2
months. The antifungal therapy was given initially and
provided much benefit when oral candidosis existed.
All 8 patients with PA had low serum cobalamin,
positive serum antibodies to gastric parietal cells, and

normal serum ferritin and folate. Two patients had positive ANA. The degree of anemia by Hb level showed
mild anemia in 6 patients (75%), moderate anemia in 1
patient (12.5%), and nonanemia in 1 patient (12.5%).
Four of 8 patients underwent panendoscopic examination that confirmed the presence of diffuse atrophy
gastritis. Soreness of tongue (glossitis or glossodynia)
was the most common oral complaint in 5 patients
(62.5%), but smooth tongue was only found in 4 patients
(50%). Two patients showed the typical picture of raw
beefy red tongue while the other 2 only showed redness
at the tongue tip. One patient had normal appearance of
tongue but complained about glossodynia for months.
Other oral features included angular cheilitis (25%), oral
candidosis (12.5%), erythematous mucositis (12.5%),
and recurrent oral ulcer (12.5%). Patient 2 suffered from
recurrent aphthous stomatitis for 2 years and visited
medical consultation once in each year due to vague
general ill health. His serial CBC data revealed MCV
increased from 96.3 to 104.5 fl, RDW increased from
43.6 to 50.3 fl, and Hb decreased from 13.4 to 12.4 g/dL
within 2 years. All of these did not arouse the suspicion

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682 Lu and Wu

Table V. Oral symptoms and signs and laboratory findings in 8 patients with anemia of chronic diseases
Pt no.

Sex/Age

M/39

2
3

F/56
M/53

4
5
6
7
8

F/50
F/24
M/43
F/30
M/63

Oral
S/S
AG
EM
AG
AG
OC
OC
OC
OC
OC
AG
OC

RBC

Hb

MCV

MCH

Hct

RDW-SD

RDW-CV

Medical diseases

2.00

6.7

92.1

27.0

26.1

63.9

Liver cirrhosis

3.08
2.66

9.7
5.1

90.3
71.1

31.50
19.2

27.80
18.9

61.6
44.4

Liver cirrhosis
Liver cirrhosis

2.45
3.15
2.90
2.59
3.20

7.3
8.2
8.5
9.0
8.7

87.8
84.1
92.1
91.5
85.0

29.8
26.0
29.3
34.7
27.2

21.50
26.5
26.7
23.7
27.2

44.7
47.1
46.0
50.5
40.2

14.0
15.7
14.2

Uremia on H/D
Uremia on H/D
Uremia on H/D
Chronic renal failure
Chronic renal failure

Abbreviations are explained in the footnote to Table II.

Table VI. The degree of anemia by hemoglobin level

in 30 patients
Vit. B12 ID + Vit. B12
ID deficiency
deficiency
ACD Total
Normal
1
Mild anemia
Hb 10.0 to normal
2
Moderate anemia
Hb 8.0 to 10.0
2
Severe anemia
Hb 6.5 to 7.9
4
Life-threatening anemia
Hb less than 6.5
3
Total cases
12

1
6

2
1

9
5

1
8

4
30

ID, iron deficiency; ACD, anemia of chronic disease; Hb, hemoglobin.

of Vitamin B12 deficiency until he visited the Oral

Medicine Clinic. Five PA patients showed combined
peripheral neuropathy and disturbance of cerebration,
including glossodynia, taste degeneration, poor finger
coordination, tingling of fingers, frequent leg cramps
during sleep, forgetfulness, or paranoid psychosis, but
these symptoms varied in severity.
Five of 7 PA patients with high RDW and low RBC
had high MCV, but 2 patients had normal MCV that was
close to the peak of normal range. Patient 8 had low
MCV, normal RDW, and high RBC due to coexisting
minor thalassemia. Patient 1 underwent bone marrow
examination that showed megaloblastic morphology,
hypersegmented neutrophils, and macroovalocytes. All
patients were treated with intramuscular hydroxocobalamin 1000 mg daily for weeks, followed by
monthly injections of 1000 mg for life. After therapy
began, it led to a rapid and dramatic relief of oral
symptoms within 48 hours and subjectively increased
sense of well-being and improved appetite within days.
The smooth tongue recovered with complete re-

Table VII. Classification of 30 anemic patients based

on MCV and RDW
Case no.
30
MCV low, RDW normal
Microcytic homogeneous
MCV low, RDW high
Microcytic heterogeneous
MCV and RDW normal
Normocytic homogeneous
MCV high, RDW high
Macrocytic heterogeneous
MCV normal, RDW high
Normocytic heterogeneous

ID

PA

12

1
10
(83.3%)

1*

ID + PA

ACD

8
1

5
(63%)
2y

ID, iron deficiency; PA, pernicious anemia; ACD, anemia of chronic disease;
MCV, mean corpuscular volume; RDW, red cell distribution width.
*The thalassemia minor coexisted.
y
MCV was close to the peak of normal range.

papillation by 3 to 4 weeks (Fig 1). All the oral changes

also showed complete remission. Most of neurological
complications proved to be reversible. Overall, of 7
patients whose RDW fell with therapy, some showed
a steady fall while others had a transient rise followed by
a progressive drop. All blood values returned to normal
after several months except patient 8 who remained little
changed because of thalassemia minor.
Two patients showed low serum ferritin, low serum
iron, high TIBC, low serum cobalamin, and negative
parietal cell antibodies that confirmed the diagnosis of
combined deficiency of iron and vitamin B12 (Table IV).
Patient 1 had subtotal gastrectomy as a result of gastric
cancer 6 years ago and suffered from pale oral mucosa,
oral candidosis, and angular cheilitis. Patient 2, with
recurrent erythema of buccal mucosa and angular
cheilitis, was a strict vegetarian for many years. Patient
1 showed severe anemia, low MCV, and high RDW,
whereas patient 2 had mild anemia, normal MCV, and

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Lu and Wu 683

Fig 1. A 50-year-old man with an 8-month history of painful glossitis and taste disturbance was diagnosed as pernicious anemia
(patient 1 in table III). A, Notice moderate papillary atrophy and lobulation of tongue 8 days before treatment. B, Tongue became
beefy-red 2 days before treatment. C, Dramatic response with resolution of erythema and pain 36 hours after treatment with B12
injection. D, The regeneration of tongue mucosa appeared complete 1 month later.

normal RDW. Both responded well to iron and cobalamin replacement therapy initially but recurred 3 to 4
years later. Therefore maintenance therapy for life was
recommended due to malabsorption in patient 1 and
potential deficiency of micronutrients in patient 2.
The oral changes in 8 ACD patients included oral
candidosis (75%), atrophy glossitis (50%), and erythematous mucositis (12.5%). Medical evaluation revealed 3
patients with liver cirrhosis, 3 patients with uremia on
regular hemodialysis, and 2 patients with chronic renal
insufficiency. Five patients had moderate anemia and
3 patients had severe to life-threatening anemia. All
had normal serum values of ferritin, iron, folate, and
cobalamin. Seven ACD patients showed normocytic
homogeneous or heterogeneous and 1 was microcytic
homogeneous. None had MCV below 70 fl or high RBC
counts (Table VII). All oral changes improved after
supportive medical therapy and supplement with
antifungal therapy when oral candidosis existed, but it
recurred easily because of their immunocompromised
condition. None showed blood values returned to normal.
DISCUSSION
The dietary deficiency or anemia of chronic diseases
should be suspected in every case of glossitis, glossodynia, angular cheilitis, erythematous mucositis, oral
candidosis, recurrent oral ulcer, and burning mouth when

no other obvious causes are found.2-8 In developing a

complete differential diagnosis and considering various
local, systemic, or psychogenic factors and drug complications, it is not hard to tell the differences between the
oral signs and symptoms of anemic patients and the
nonanemic patients with oral complaints.
Iron deficiency can contribute to impaired cellular
immunity, deficient bactericidal activity of polymorphonuclear leukocytes, inadequate antibody response, and
epithelial abnormality that may cause high prevalence of
oral candidosis, angular cheilitis, and atrophy glossitis in
patients with IDA.9 Vitamin B12 and folate are the most
important cofactors necessary for DNA synthesis. When
they are deficient, it causes macrocytic change of RBC,
abnormalities of leukocytes and platelets, and epithelial
changes, particularly in the rapidly dividing epithelium
of the mouth and gastrointestinal tract. The immunocompromised condition in ACD may induce many oral
changes. Because of the overlap of oral manifestations in
different causes of anemia, the top priority of diagnostic
approach to anemic individuals relies on a detailed
medical evaluation of the patients history and defining
the anatomy of the patients complaints. When stomatitis
preceding haematological abnormality is highly suspected, CBC study is necessary. We suggest use of the 6
categories of Bessmans study1 to evaluate the physiologic basis of anemia initially, for it can yield a short and

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December 2004

684 Lu and Wu
improved differential diagnosis of anemia by MCV,
RDW, and RBC. It is easy to practice and many unnecessary medical examinations can be saved. In the
study, the correct identification of ID, PA, or ACD can be
achieved to 63%;100% (Table VII). Some patients with
early iron, B12, or mixed deficiency or coexisting thalassemia may have either nonanemic normocytosis or
significant red cell abnormalities. This represents a balance or imbalance between a potential microcytosis as
a result of ID or thalassemia and a potential macrocytosis
resulting from folate or B12 deficiency. Therefore macrocytosis or microcytosis alone appears to be an
inadequate indicator of such deficiencies.10-12 Furthermore, an increase of MCV to 100;150 fl in PA patients
often precedes the actual anemia by several years. Some
PA patients can even present neurologic manifestations
without prominent peripheral blood abnormalities.13-17
Therefore, the 2 classic features of PA, macrocytosis
and anemia, cannot be overstressed in our diagnostic
approach. The absence of macrocytosis in 37% of PA
patients is consistent with findings described by
others.15,16
The symptoms of anemia cannot be predicted by Hb
level alone because of the great difference in tolerance
and multiple presentations. In the study, fatigue was the
most common complaint. Generally, young and otherwise healthy people experience much fewer symptoms
than older, multimorbid ones. Slowly developing anemia occurring in a young person may remain asymptomatic until a significant decrease in Hb or episodes of
exertional stress occur.17-18 The Hb in PA patients
often has a biphasic course of change that will begin to
decrease when serum cobalamin is very low. Therefore
it is hard to find any PA patient at the degree between
severe and life-threatening anemia. When Hb is not too
low or MCV is not high or low enough, the latent
anemia of dietary deficiency is often neglected by
physicians and dentists. Therefore it is a misconception
that normal hemoglobin or normal peripheral blood test
excludes such a diagnosis of ID or PA. In this situation,
the change of oral mucosa is a more important diagnostic indicator than the CBC test and further checkup
of serum ferritin and cobalamin is suggested. The
antiparietal cell antibodies in the sera of 90% of cases
of PA suggest that an autoimmune mechanism may be
involved in the pathogenesis of adult-type PA and are
considered to play a pathogenetic role in the cause of
intrinsic factor deficiency and also provide additional
clues for the diagnosis of PA.19-22
As a general rule, an MCV of less than 70 fl and
a transferrin saturation of less than 16% are found only in
IDA.23 They are quite different from ACD with a transferrin saturation more than 16% and MCV rarely below
70 fl.23 The MCV value of less than 70 fl was found in 8

of 12 ID patients but none was found in 8 ACD patients.

All of 12 ID patients showed low serum ferritin and
a transferrin saturation of less than 16%. Therefore the
measurement of serum ferritin and transferrin saturation
(Fe/TIBC) is the most useful and important test of ID
after CBC study.
ACD is the most common type of anemia among
hospitalized patients, and it can mimic or coexist with
other common anemias. Because the etiologies,
mechanisms, and pathogenesis of ACD are not clearly
delineated, its boundaries are indefinite. The RDW in the
patients with ACD has been found normal in some
reports and increased in others, possibly reflecting
differences in patient populations.24-27 Therefore the
anemia of ACD is not well classified by either MCV or
RDW.28-29 There is no specific therapy for ACD but oral
complaints can be ameliorated by successful treatment of
the underlying diseases and aid with antifungal therapy.
Under a high degree of diagnostic astuteness and
a good grasp of basic pathophysiology of anemia, we
demonstrate clearly that the diagnosis of PA and ID can
be established in the preanemic stage. Whenever
possible, hemoglobin concentration should be assessed
in comparison to a previous, reliable value for the same
individual. Obviously, in many clinical situations this is
not possible. We suggest that measuring Hb level should
be included in a routine physical examination in order to
establish the normal value for a given individual.
Because of the narrow intra-individual variation of Hb,
even minor deviations from this value may be a first sign
of a more severe disease. The study reflects the
sensitivity of the oral mucosa in many (but not all) cases
to nutritional deficiency and anemia of chronic diseases
definitely. Improved classification of anemias by MCV,
RDW, and RBC from initial blood count can provide
a rapid and useful guide in our daily practice.
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2. Naylor GD, Hall EH. Differential diagnosis of glossodynia.
J Oral Med 1987;42:85-8.
3. Hjrting-Hansen E, Bertram U. Oral aspects of pernicious
anemia. Br Dent J 1968;17:266-70.
4. Greenberg MS. Clinical and histologic changes of the oral
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1981;52:38-42.
5. Lamey PJ, Lewis MAO. Oral medicine in practice: angular
cheilitis. Br Dent J 1989;167:15-8.
6. Field EA, Speechley JA, Rugman FR, Varga E, Tyldesley WR.
Oral signs and symptoms in patients with undiagnosed vitamin
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10. Breedveld FC, Pieger R, van Wermeskerken RKA. The clinical
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Reprint requests:
Shin-Yu Lu, DDS
Dental Department of Chang Gung Memorial Hospital, Kaohsiung
123, Ta-Pei Road
Niaosung
Kaohsiung, Taiwan, ROC
Helmsmam@ms21.hinet.net