Journal of Cytology, Vol. 28, No. 2, April-June, 2011, pp.

66-72
Original Article
Quantitative cytomorphometric analysis of exfoliated normal gingival cells
Sheela Kumar1, Veerendra Kumar1, Punit Vaibhav Patel1, GD Vidya2
1

Department of Periodontology, JSS Dental College and Hospital, Contituent College

of JSS University, Mysore - 15, Karnataka, India
2
Department of Oral Pathology and Microbiology, JSS Dental College and Hospital,
Contituent College of JSS University, Mysore - 15, Karnataka, India
Correspondence Address:
Punit Vaibhav Patel
Department of Periodontology, JSS Dental College and Hospital, Mysore - 15,
Karnataka
India
punitvai@gmail.com

PMID: 21713150
DOI: 10.4103/0970-9371.80745
Abstract
Background: The use of oral exfoliative cytology as a diagnostic aid accentuates the
need for establishing an accurate baseline, thereby enabling the comparison of
abnormal oral tissue with established baseline. Aims and Objective: To detect any
changes in the nuclear area (NA), cytoplasmic area (CA), and nuclear:cytoplasmic
ratio (N:C ratio) values for clinically normal gingival smears in relation to age and sex
of apparently healthy subjects. Materials and Methods: Gingival smears were
collected from 80 (40 male, 40 female) apparently healthy subjects belonging to the
age group of 0-20, 21-40, 41-60, and more than 60 years. Smear slides were fixed by
using spray fixative. The smears were stained using Papanicolaou procedure. The
cytoplasmic and NAs were measured using image analysis software. Statistical
analysis of the data was done using one-way ANOVA with Tukey-HSD procedure and
Student's t test. Results: The result showed that there was a significant difference
(P<0.001) in NA, CA, and N:C in males of different age groups. There was a

significant difference (P<0.001) in NA, CA, and N:C in females of different age
groups. The difference in N:C between males and females was significant (P<0.001)
in all the groups. The difference in NA, CA, and N:C with age irrespective of gender
was significant (P<0.05). There was a significant difference (P<0.05) between males
and females with respect to NA, CA, and N:C irrespective of age. Conclusion: Ageand sex-related alterations were observed in gingival smears, which could be a
baseline for these variables to compare identical measurements, made on pathologic
smears of oral premalignant and malignant lesions.
Keywords: Cytomorphometric analysis; cytoplasmic area; exfoliated normal cells;
gingival epithelium; nuclear area; nuclear; cytoplasmic ratio; squamous cell
carcinoma
Introduction
Oral cancer is one of the common cancers and constitutes a major health problem in
developing countries, representing the leading cause of death. Although representing
2-4% of the malignancies in the western part of the world, the oral cancer accounts for
almost 40% of all cancers in the Indian subcontinent. [1] The early diagnosis and the
consequent treatment of precancerous lesions could prevent a large number of deaths
due to this disease. Currently, a wide range of early diagnostic aids, such as toluidine
blue, chemiluminescence, and tissue autofluorescence are being used for early
detection and prompt treatment of the lesion. [2] In spite of all these procedures,
clinical examination and histopathological studies of biopsy material are the classical
diagnostic methods used for precancerous and cancerous oral lesions. [3],[4]
In the last few years the interest for oral exfoliative cytology as a diagnostic and
prognostic methodology and also for monitoring patients in oral precancer and cancer
has re-emerged. However, in general, cytology has relied primarily on the personal
judgement of the cytologist and not on the measurement of cell
parameters. [5] Controversy has surrounded the use of cytology in the diagnosis of oral
cancer. One of the main reasons for this being the occurrence of false-negative
results. [4],[5] A number of authors have suggested reasons for this, including inadequate
sampling, technical error, misinterpretation of the findings, and bias. [6],[7],[8]
To minimise the false-negative results, many authors, such as Cowpe et al, [9],
[10]
Goldsby et al, [11] and Ogd et al. [12] have suggested the utilisation of quantitative
techniques, based on the evaluation of parameters, such as nuclear area (NA),
cytoplasmic area (CA), and nucleus-to-cytoplasmic area ratio (NA/CA). This may
increase the sensitivity of exfoliative cytology for early diagnosis of oral cancers,
since these techniques are precise, objective, and reproducible and non-invasive. [9],[10],
[11],[12]
Although, a number of quantitative cytomorphologic and cytomorphometric

studies have been carried out on precancerous and cancerous lesions presenting in the
oral cavity but few studies have been performed on clinically normal oral mucosa
matched for age and sex. Moreover, authors, such as Morrison et al[13]and Cowpe et
al, [10] have also clearly stressed the need of a baseline cytomorphologic data of
normal oral squamous cells prior to the examination of pathological squamous cells,
for comparison and evaluation of malignant epithelial cells. The aim of this study was
to detect any changes in NA, CA, and nuclear:cytoplasmic ratio (N:C ratio) values, for
clinically normal gingival smears in relation to age and sex. Thus, an attempt is made
to establish a baseline for these variables with which, to compare identical
measurements, made on pathological smears.
Materials and Methods
A total of 80 apparently healthy subjects were selected randomly from the OPD of the
college. A prior written consent was taken based on "Declaration of Helsinki" (1964)
from all included subjects. [14] The study was approved by ethical committee at the
University.
Subjects were divided accordingly [Table - 1]:
40 Male: further to age group of (10 each) 0-20, 21-40, 41-60, more than 60 years
40 Female: further to age group of (10 each) 0-20, 21-40, 41-60, more than 60 years
Subjects were included who were clinically healthy and presented normal gingival
tissue with gingival index [15] (Loe and Silness) score less than 1.
Subjects were excluded who presented with history of alcohol intake, tobacco, or its
products abuse in any form (present or past), any clinical pathological findings on the
gingiva (acute or chronic in nature), history of anemia, diabetes mellitus, hepatitis,
tuberculosis, acquired immune deficiency syndrome and leukemia or any other
systemic or hormonal condition, which predisposes the gingival manifestation, and
who were receiving or had received prior to study entry, systemic corticosteroids,
immunosuppressive agents, radiation therapy, and/or chemotherapy.
Screening/baseline
At baseline for each subject name, age, gender, occupation, and relevant medical
history were recorded. A thorough clinical examination was performed to rule out any
pathologic changes in oral cavity, especially on gingival tissue. A thorough scaling
(tooth cleaning) was performed to eliminate any inflammation from the gingival
tissue. Subjects were recalled after 2-week intervals and gingival index [15](Loe and

Sillness) was recorded to include the subjects with a score of less than 1. Following
confirmation of score less than 1, each subject was asked to rinse with normal saline
(0.91% isotonic solution) to maintain the normal tonicity of superficial gingival
epithelial cells. A sterilised disposable interproximal brush (STIM Interprox Brushes,
DENT-AIDS, New Delhi, India) was used to scrap the attached gingiva in upper
anterior region [Figure - 1]. Scrapings were smeared onto the slide. A minimum of 4
smear samples were taken from each subject that would be sufficient to give 200 cells
per subject (50 cells per smears). In order to obtain cells from all the layers of the
epithelium, a moderate pressure was applied while taking the smear. The smears were
immediately fixed using spray fixative (RAPID PAP Spray fixative, Biolab
Diagnostics (I) Pvt Ltd, India) to avoid air drying. Papanicolaou technique (RAPID
PAP stain, Biolab Diagnostics (I) Pvt. Ltd., India) was used to stain the smear. The
stained smears were examined under a microscope equipped with a 40 objective
(Olympus WPlanFL 160/0, Tokyo, Japan) and a 2.25 video projection lens (Nikon
CCTV/Microscope Adapter, Yokohama, Japan). The acquired images were transmitted
to a video camera (CCD 72; Dage MTI, Michigan City, IN, USA) for display on a
video monitor (Sony HR Trinitron, Tokyo, Japan). A screen shot of each slide was
captured saved and transferred to the computer for image analysis.{Figure 1}
Image analysis
Two hundred cells per subject, which were unfolded with clear outline were selected
for the study. Cells were analysed for CA, NA, and nucleocytoplasmic (N/C) ratio
using a software (SCION image for window v.4.0.3.2, Scion Corporation, Frederick,
MD, USA). The sampling was done in a stepwise manner, moving the slide from left
upper corner to right and then down in order to avoid measuring the same cells again.
For measurement, the software was calibrated and scale setting was changed from
square pixels to square micrometers (m2). The instructions were followed, as given
in the manual of the software for measuring the cell sizes. The nucleus and the cell
outline were traced using digital cursor on the screen and the software automatically
calculated the cell and NA [Figure - 2]. The N:C ratio was calculated manually. All
the recorded data underwent statistical analysis.{Figure 2}
Statistical analysis
The various parameters were used to analyse the NA, CA, N:C ratio of each cells in
relation to age and sex of apparently healthy subjects. One-way ANOVA test was used
for analysis of CA, NA, and N:C ratio in relation of age and sex. Tukey-HSD
procedure was used to identify the significance between various age groups and sex.
Students t test was used to evaluate the difference in CA, NA, and N:C ratio in male
and female in various age groups. The level of significance was set at P0.05. Data
was reported as mean and standard deviations.

Results
The nuclei of epithelial cells of healthy subjects was normal with no signs of
morphological alterations.The statistical result showed that the difference in NA, CA,
and N:C ratio in males of different age groups was statistically significant
(P<0.001) [Table - 2]. There was a significant difference (P<0.001) in NA, CA, and
N:C ratio in females in different age groups [Table - 3]. The difference in NA between
males and females was significant (P<0.001) in 0-20, 21-40, and 41-60 age groups,
whereas difference in CA was significant (P<0.001) in 0-20, 21-40, and >60 age
groups and the difference in N:C was significant (P<0.01) in all the age groups [Table
- 4]. The difference in NA, CA, and N:C ratio with age irrespective of gender was
significant (P<0.05) [Table - 5]. There was a significant difference (P<0.05) between
males and females in the terms of NA, CA, and N:C ratio irrespective of age [Table 6].
Discussion
The present study represents a quantitative technique applied to the smears collected
from clinically normal gingival mucosa, matched for age and sex in an attempt to
define a baseline for comparison with pathological smears. We hoped that if this was
achieved, the diagnostic potential of exfoliative cytology in the diagnosis of early
gingival malignancy would be greatly enhanced.
In recent years, there has been increasing interest in the role of exfoliative cytological
technique as a screening aid for the oral malignancy and pre-malignancies. A growing
body of literature has also accumulated regarding the role of exfoliative cytology as a
standard technique in screening of oral pathologies. Moreover, cytomorphometric
analysis or image analysis of exfoliated cells has also been suggested as a key
approach to define and identify the cellular and nuclear changes in such cytological
smears. [10],[11]
Previously, cytomorphometric analysis was done by using planimetric methods but
with time, planimetric methods have been replaced by computer-assisted image
analysis techniques, which are faster, more accurate, and more reproducible. In this
regard authors, such as Ogden et al[12] suggested that this computer-assisted analysis
of images formed by a microscope may increase the sensitivity of exfoliative cytology
for early diagnosis of oral cancers, since these techniques are precise, objective, and
reproducible. Similarly, Cowpe et al[9],[10] also demonstrated that exfoliative cytology
is capable of detecting malignant changes, through estimation of NA:CA ratio using
the planimetric method in Papanicolaou-stained smears. This study concluded that 50
cells were sufficient to provide indication of malignant changes. [10] Since then, a
number of studies have been carried out using this technique to evaluate the influence

of systemic and local factors on normal cells. Cowpe et al[9] found that tissues
undergoing malignant transformation typically show a reduction in CA before the
reduction in NA. They also suggested that samples of healthy mucosa from the same
patient provide the best control. [9],[10]
The cytomorphometric result of the present study revealed an age-related significant
variation in NA, CA, and N:C ratio, irrespective of gender. Age-related variation,
irrespective of gender can be ascribed to cellular senescence. [16],[17] A basal cell can
only divide for a set of number; then the renewal capacity of tissues declines with age,
resulting in the accumulation of senescent cells. The cells which stay for a longer
duration in the oral cavity succumb to the effect of various local environmental
factors. [17]
Our result suggested that there was a significant difference in NA, CA, and N:C ratio
in different age groups of female. This may be attributed to the variations in the
hormonal levels in female throughout the life time. Both estrogen and progesterone
promote protein anabolism and growth of the organ system, including oral cavity.
Estrogen influences the cytodifferentiation of stratified squamous epithelium [18],[19] as
well as the synthesis and maintenance of fibrous collagen. [19]
Our result showed a statistically significant comparative variation in CA and NA,
between males and females in 0-20 age groups. These changes could be ascribed to
the hormonal changes occurring at puberty. Data suggest that at puberty there is a
significant increase in sex hormone in both male and female life. Changes in hormone
levels have been related to an increased prevalence of gingivitis followed by
remission. [18],[20] Increase in gingival inflammation is one of the factors that can
increase NA and lead to a poorly preserved cytoplasm. However, these characteristics
are typically found only in young cells and are not representative of cellular atypia.
In the second age group (21-40 years), there was a significant comparative variation in
NA and N:C ratio between males and females. This may be attributed to the hormonal
imbalances occurring during 21-40 years of age. [18] Mostly women in this age group
are on oral contraceptives and often experience hormonal changes associated with
pregnancy. [21],[22],[23] In the present study, the detailed history of oral contraceptives
intake and pregnancy was not established. Therefore, these factors might have shown
age-related variations in females in the age group of 21-40 years.
In the age group of 41-60 years there was statistically significant comparative
variation in NA and N:C ratio between males and females. The observed variations
could be ascribed to hormonal changes occurring during or after menopause in women
s life. [25] The time frame between regular menstrual cycles and the cessation of
menstrual periods, called perimenopausal transition, is 2-7 years. During this period,

the concentration of circulating estrogen decreases, while follicle-stimulating

hormone and luteinizing hormone concentrations increase. [24],[25] Consequently, the
effects of estrogen on gingival tissue are reduced, therefore compromising the antiinflammatory effect of this hormone on the gingival tissue and ultimately resulting in
cytological variation in the gingival tissues.
There was a significant variation of NA and CA with respect to gender and
irrespective of age. The result showed that NA and CA were significantly greater in
females than in males of all age groups except in >60 age group. However, the
difference in N:C ratio between males and females was not statistically significant.
The variation of NA and CA with respect to gender can be ascribed to sexual
dimorphism observed in human [26] and hormonal difference in individuals. Hormonal
influence happens to be the differentiating factor for the cytomorphometric trends of
males and females. Testosterone has been frequently associated with metabolism and
maintenance of bone and connective tissue matrix unlike the female sex hormones,
which have their effect on the epithelium. [18]
On comparing our results with the results of previous studies, our study results
showed a similar result as shown by Anuradha and Sivapathasundharam [27] where
similar age-related and sex-related alterations are observed in gingival smears. Our
results are also similar to the findings of Ramaesh et al, [28] where they found that
smears from normal buccal mucosa of healthy subjects display a wide variation in the
size of the cells and nuclei.
Moreover, our result are also in agreement with results of Scott et al.[29] They showed
a reduction in N:C ratio with advancing age at a similar rate in both males and
females. Similarly Cowpe et al also showed a significant variation in nuclear diameter
(ND) with age but there was no variation in cell diameter (CD), whereas the ND and
CD varied significantly in various regions in the oral cavity. [10] In the current study,
we found statistically significant maximum CA and NA values for age group of 21-40
years followed by 41-60, 0-21, and >60 years age group.
Our results also confirm the findings of Zitwack et al,[30] where animals treated with
estrogen showed larger and more active cells in the vagina with similar changes in
gingiva and buccal mucosa. Similarly, our results also confirm the findings of Nayar
and Sivapathasundharam [31] where the ND was reported to increase with age and CD
to decrease with age. The cell diameter in the age group 40-59 years, particularly was
less in females than in males. Our result also showed similar trend but in the age
group of 41-60 and >60 years, the NA was lesser than that in the 21-40 years age
group. However, our result is not in agreement with the results of Lee et al[32] where
no significant variations in ND and CD with age has been reported.

Another important method of quantifying cytological smears is to apply the technique

of DNA cytophotometry. This technique has been used extensively in the past to
characterize the proliferative activity of cell populations. However, with the
occurrence of aberrant diploid DNA distributions in malignancy, the value of DNA
measurement as a single diagnostic criterion of malignancy has reduced to some
extent. Therefore, authors, such as Cowpe and Longmore [33] have expressed a need
for the measurement of more variables than just DNA content, in order to increase the
accuracy of cytology in the diagnosis of oral malignancy. [3],[4] Goldsby et al[11] in their
study on normal human exfoliative oral cells concluded that the measurement of
nuclear and cell size and N:C ratio are the 3 most important factors to be considered
while producing a baseline for normal oral squamous cells. Whereas Cowpe and
Longmore [33] concluded that NA provides an accurate baseline against which future
measurements on abnormal tissue can be compared. Therefore, only these factors are
considered in the present study.
Several authors, such as Miller et al, [34] Montgomery, [35] and Cowpe et al, [10] have
evaluated different sites in clinically healthy oral cavity that included buccal mucosa,
floor of the mouth, hard and soft palate, lower labial mucosa, and dorsum of tongue.
However, data on gingival tissue is scarce. Therefore, gingival tissue is considered in
the present study to provide some initial experimental baseline data.
Data suggest that inflammation is one of the factors that can increase NA and lead to a
poorly preserved cytoplasm, but these characteristics are typically found only in
young cells and are not representative of cellular atypia. [36] Therefore, in the present
study we performed a thorough scaling (tooth cleaning) to control the inflammatory
factors. Moreover, we took the smears from attached gingiva of upper anterior teeth
region to reduce the effect of localized inflammation on our results. We also detected
a range of cellular age in the smears, and cytomorphometric measurements were
generalized rather than restricted to a certain generation of cells, suggesting that the
changes we observed are not just related to inflammation.
Our study is a preliminary attempt to define a baseline for pathological smears
obtained from gingival tissue. The data presented in our study can be of more
diagnostic value, if future pathological samples are obtained and processed in a
similar manner to the present study. As each study differs in the number of cells being
counted per slide, type of fixatives used, time lapse of staining following smear
preparation and time lapse of collection of specimen, and cytomorphometric analysis.
Therefore, there is a need to establish a guideline for cytological procedure and to
standardize the cytological and image analysis procedures.
Conclusion

The present study shows age- and sex-related variations of NA, CA, and N:C in
normal exfoliated gingival cells, which could be considered as a preliminary attempt
to provide a baseline of quantitative cytomorphometric data, with which pathological
smears can be compared. Thereby enhancing the diagnostic and screening potential of
the oral exfoliative cytological technique. Moreover, the data presented in the present
study can be utilised for the identification of premalignant/malignant gingival lesion
in a more objective manner.
Acknowledgment
The present study was financially supported in part by the JSS University, SS Nagar,
Mysore, Karnataka (Order Number;REG/EST-1(3)DCH/109/2010-11). The Authors
express their sincere gratitude to the Registrar, JSS University, Mysore and Principal,
Dr. B. Nandlal, JSS Dental College & Hospital, Mysore, Karnataka for their support.
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