Enamel defects on the maxillary premolars in patients with cleft lip and/or palate: a retrospective case-control study

Tooth abnormalities associated with non-syndromic cleft lip and palate: systematic review and meta-analysis

OBJECTIVE

To evaluate the association between orofacial clefts (OFC) and tooth abnormalities (TA).

METHODS

We searched PubMed, Scopus, Web of Science, Cochrane Library, LILACS, and BBO, and in the gray literature and selected observational studies that evaluated the association between TA and OFC. The risk of bias was analyzed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed comparing the presence and absence of OFC, cleft type-cleft palate (CP) and cleft lip with or without palate (CL/P)-and cleft laterality-unilateral and bilateral. The certainty of evidence was evaluated using the GRADE approach.

RESULTS

A total of 99 studies were included in the qualitative analysis, and 37 were included in the meta-analysis. Only four studies were classified as low risk of bias. Significant associations were observed between the presence of OFC and tooth agenesis (OR = 19.46; 95%CI = 4.99-75.96), supernumerary teeth (OR = 4.04; 95%CI = 1.26-12.99), developmental defects of enamel (OR = 3.15; 95%CI = 1.28-7.80), microdontia (OR = 15.57; 95%CI = 1.06-228.51), and taurodontism (OR = 1.74; 95%CI = 1.74-2.86). Individuals with CP had a lower frequency of supernumerary teeth (OR = 0.22; 95%CI = 0.08-0.64), peg-shaped tooth (OR = 0.31; 95%CI = 0.12-0.80), and morphological TA (OR = 0.13; 95%CI = 0.04-0.45) than individuals with CL/P. No TA was significantly associated with cleft laterality (p > 0.05). The quality of the evidence was very low in all analyses.

CONCLUSION

Individuals with OFC had a higher frequency of TA than those without OFC. Individuals with CP had a lower frequency of TA than individuals with CL/P. No TA was associated to cleft laterality.

CLINICAL RELEVANCE

Help to identify the treatment needs of individuals affected by OFC, improving the services provided to this population.

Factors and Mechanisms Involved in Acquired Developmental Defects of Enamel: A Scoping Review

BACKGROUND

Developmental Defects of Enamel (DDE) is a pathology of the teeth that can greatly alter the quality of life of patients (hypersensitivity, esthetic issues, loss of function, etc.). The acquired DDE may occur as a result of a wide range of acquired etiological factors and his prevalence of this pathology may reach up to 89.9%. The main objective of this research was to identify and analyze, in current literature, the factors related to acquired DDE, in order to propose a general theory about the mechanisms involved.

METHODS

The search of the primary literature was conducted until [December 31, 2021]. Our search strategy uses the Pubmed/MEDLINE database and was structured around 3 terms ["Development," "Defect," and "Enamel"]. To be included, references had to be primary studies, written in English. Exclusion criteria were reviews, in vitro, animal, genetic or archeology studies, and studies focused on clinical management of DDE. One hundred and twenty three articles were included in this scoping review: 4 Randomized clinical trials, 1 letter, 5 cases reports, 2 fundamentals studies, and 111 observational studies (33 Cross-sectional studies, 68 Cohort study and 10 Case-control study). The quality of evidence was assessed using the PEDro scale for clinical trials, the Newcastle-Ottawa scale for observational studies, and a published tool to assess the quality of case reports and case series.

RESULTS

A scoping review of the literature identified 114 factors potentially involved in acquired DDE. The most frequently encountered pathologies are those causing a disorder of calcium homeostasis or a perturbation of the ARNT pathway in mother or child. The link between the ARNT pathway and metabolism deficiency in uncertain and needs to be defined. Also, the implication of this mechanism in tissue impairment is still unclear and needs to be explored.

CONCLUSIONS

By identifying and grouping the risk factors cited in the literature, this taxonomy and the hypotheses related to the mechanism allow health practitioners to adopt behaviors that limit the risk of developing aDDE and to set up a prevention of dental pathology. In addition, by reviewing the current literature, this work provides guidance for basic research, clinical studies, and literature searches.

Maxillary incisor enamel defects in individuals born with cleft lip/palate

Cleft lip with or without cleft palate (CLP) is considered the most frequent congenital malformations of the head and neck, with cleft individuals exhibiting more chances of presenting abnormalities such as developmental defects of enamel (DDE). Matrix metallopeptidase 2 (MMP2) is a membrane-bound protein with collagen-degrading ability and has important roles in tooth formation and mineralization. The aim of this study was to evaluate the frequency, location, severity and extent of DDE found in the maxillary incisors for groups of individuals born with CLP, as well as understanding their relationship with the cleft side. Besides, this study addresses the hypothesis that DDE can be influenced by variation in the MMP2 genes (rs9923304). Individual samples, clinical history, intraoral photographs and panoramic radiographs were obtained from 233 patients under treatment at the Cleft Lip and Palate Service of the University Hospital Lauro Wanderley at the Federal University of Paraíba. Digital images were examined by the same evaluator using the Classification of Defects According to the Modified DDE Index, and then loaded into the Image Tool software, where two measurements were made: total area of the buccal surface (SA) and the area of the DDE (DA), obtaining the percentage of the surface area affected (%SAD) (ICC = 0.99). Genomic DNA was extracted from saliva samples from 124 participants. Genotyping was carried out using TaqMan chemistry for one marker in MMP2 (rs9923304). Statistical analyses were performed by The Jamovi Project software. The Shapiro-Wilk test was applied, followed by the Student’s t-test and the Mann-Whitney test. Chi-square and Fisher’s exact tests, and odds ratio (OR) with 95% confidence interval (CI) calculations were used to determine Hardy-Weinberg equilibrium and statistically significant differences with an alpha of 0.05. No significant differences in the prevalence and extent of enamel defects were found between male and female individuals born with CLP (p = 0.058256). The frequency of individuals presenting teeth with DDE, in relation to the cleft and non-cleft side, was statistically different (p <0.001; OR = 7.15, CI: 4.674> 7.151> 10.942). However, the averages of %SAD were similar (p = 0.18). The highest means of the %SAD were found in individuals with bilateral cleft lip with or without cleft palate (BCLP) when compared to individuals with unilateral cleft lip with or without cleft palate (UCLP), for the teeth inside (IA) and outside the cleft area (OA) (p <0.001). Regardless of the cleft side, individuals with BCLP were 7.85 times more likely to have more than one third of the tooth surface affected, showing more frequently defects in the three thirds (OA: p <0.001) (IA: p = 0.03), as well as a higher frequency of more than one type of defect (OA: p = 0.000358) (IA: p = 0.008016), whereas in UCLP, defects were isolated and restricted to only one third, more frequently, the incisal third (OA: p = 0.009) (IA: p = 0.001), with greater frequency of milder defects, such as demarcated (p = 0.02) and diffuse (p = 0.008) opacities. A higher frequency of the T allele, less common, was observed in the group of CLP individuals who had all the affected teeth or at least two teeth with %SAD greater than 20% (p = 0.019843). Our results suggest that MMP2 may have a role in the cases that presented DDE and genotyping rs9923304 could serve as the basis for a genomic approach to define risks for individuals born with CLP. Frequency and severity of DDE is strongly related to the CLP phenotype, since the highest values were found for BCLP. However, the extent of the DDE is independent of its relationship with the side of the cleft.

Association between Dental Anomalies and Orofacial Clefts: A Meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis to assess whether individuals with nonsyndromic orofacial clefts (OCs) display a higher frequency of dental anomalies (DAs) when compared with individuals without OCs.

METHODS

A literature search of indexed databases (PubMed, Cochrane, Web of Science, Embase, Scopus, and LILACS) was conducted without language restriction up to and including February 1, 2020. Cross-referencing was used to further identify articles. Several cleft teams across the United States and Europe were contacted to obtain unpublished data. The eligibility criteria were observational studies with original data that statistically compared individuals with OC without syndromes and those without OC on any type of DA in primary and/or permanent dentition. Random effects meta-analysis through the Mantel-Haenszel estimator was used to evaluate the association between OC and DA based on odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The literature search generated 933 records, and 75 full-text articles were reviewed. Twenty-six studies encompassing 15,213 individuals met the inclusion criteria. The meta-analysis revealed statistically significant associations between OC and agenesis (OR, 14.2; 95% CI, 9.4 to 21.3), supernumerary teeth (OR, 5.7; 95% CI, 3.3 to 9.7), developmental enamel defects (OR, 5.6; 95% CI, 3.5 to 9.0), microdontia (OR, 14.8; 95% CI, 4.0 to 54.6), peg-shaped anterior teeth (OR, 12.2; 95% CI, 3.6 to 41.2), taurodontism (OR, 1.7; 95% CI, 1.0 to 2.7), tooth malposition and/or transposition (OR, 5.6; 95% CI, 2.8 to 11.5), tooth rotation (OR, 3.2; 95% CI, 1.3 to 8.2), and tooth impaction (OR, 3.6; 95% CI, 1.1 to 12.2). The OR estimates of the reviewed studies exhibited significant heterogeneity (P < 0.0001). No association was observed between OC and fusion and/or gemination.

CONCLUSION

Within the limitations of this study, the available evidence suggests that individuals with OCs are more likely to present with a range of DAs than their unaffected peers.

KNOWLEDGE TRANSFER STATEMENT

The findings of the current review suggest that individuals with orofacial clefts (OCs) are more likely to present with a range of dental anomalies than their unaffected peers. Understanding the association between OCs and dental anomalies is essential in guiding clinicians during treatment-planning procedures and is important in raising our awareness of the possible need for future dental treatment for patients with OCs.

Enamel defects in permanent teeth of patients with cleft lip and palate: a cross-sectional study

OBJECTIVE

This study investigated the prevalence, type, and location of enamel defects in the permanent teeth of patients with complete unilateral or bilateral cleft lip and palate (CLP), and compared the prevalence and characteristics of defects between CLP patients and non-CLP individuals.

METHODS

We examined completely erupted permanent dentition, except for third molars, of CLP patients and non-CLP individuals of both sexes, 9-36 years of age, and analyzed corresponding panoramic radiographs. Two independent examiners performed clinical examinations in accordance with the Modified Developmental Defects of Enamel index.

RESULTS

A total of 210 (87.9%) CLP patients and 194 (41.4%) non-CLP individuals had at least one enamel defect; these were more prevalent in the CLP group than in the non-CLP group. Upper teeth were primarily affected by enamel defects associated with the cleft; defects were most prevalent on the cleft side in CLP patients, followed by the non-cleft side in CLP patients, and then by non-CLP individuals.

CONCLUSION

Enamel defects were more common in CLP patients than in non-CLP individuals. Among CLP patients, enamel defects were more prevalent in the cleft side of the maxilla; the central incisor was the most commonly affected tooth in this quadrant.

Structural color changes in permanent enamel of patients with cleft lip and palate: a case-control study

OBJECTIVES

White spots are more common in patients with cleft lip and palate (CLP) than in the normal population. Whether these are due to the cleft itself or concomitant circumstances (e.g., surgical procedures, orthodontic treatments, systemic fluoridation, increased caries risk) remains unclear. This case-control study evaluated both their prevalence in CLP patients versus control subjects and associated risk factors.

PATIENTS AND METHODS

A total of 73 CLP patients (average age 8.7 years, range 6-18 years, 42 % male) and a control group of 73 age- and gender-matched non-CLP patients were included. Enamel color changes, subsuming mineralization defects (DDE index), mild dental fluorosis (Dean's index), and initial caries (ICDAS score 2), were recorded. Caries index (dmf-t/DMF-T) scores were also recorded to distinguish between high or low caries risk as defined by the Deutsche Arbeitsgemeinschaft für Jugendzahnpflege criteria. Histories of systemic fluoridation, trauma to primary teeth, surgery, and orthodontic treatment were obtained using a questionnaire. Statistical analysis included t test, χ (2) test, and multivariable logistic regression.

RESULTS

Enamel color changes were observed three times more often in the CLP group than in the control group (39.7 vs. 12.3 %; p < 0.001). Significantly more patients in the CLP group had a history of orthodontic treatment (38.4 vs. 15.1 %; p < 0.05). An increased risk for enamel color changes was associated with CLP itself [OR (odds ratio) 3.6; 95 % confidence interval (CI) 1.3-9.9] and table salt plus tablets combined for systemic fluoridation (OR 2.7, 95 % CI 1.1-6.9). No increased risks were identified for increased caries risk, history of primary-tooth trauma, or history of orthodontic treatment.

CONCLUSION

The higher prevalence of enamel color changes in the CLP group (more than threefold compared to the control group) was not related to previous orthodontic treatments; however, systemic fluoridation (table salt and tablets) constituted a risk factor for the enamel color changes seen in the CLP patients.