The dental management of children with sickle cell disease and beta-thalassaemia: a review

2021 Thalassaemia International Federation Guidelines for the Management of Transfusion-dependent Thalassemia

Beta-thalassemia and particularly its transfusion-dependent form (TDT) is a demanding clinical condition, requiring life-long care and follow-up, ideally in specialized centers and by multidisciplinary teams of experts. Despite the significant progress in TDT diagnosis and treatment over the past decades that has dramatically improved patients’ prognosis, its management remains challenging. On one hand, diagnostic and therapeutic advances are not equally applied to all patients across the world, particularly in several high-prevalence eastern regions. On the other, healthcare systems in low-prevalence western countries that have recently received large numbers of migrant thalassemia patients, were not ready to address patients’ special needs. Thalassaemia International Federation (TIF), a global patient-driven umbrella federation with 232 member-associations in 62 countries, strives for equal access to quality care for all patients suffering from thalassemia or other hemoglobinopathies in every part of the world by promoting education, research, awareness, and advocacy. One of TIF’s main actions is the development and dissemination of clinical practice guidelines for the management of these patients. In 2021, the fourth edition of TIF’s guidelines for the management of TDT was published. The full text provides detailed information on the management of TDT patients and the clinical presentation, pathophysiology, diagnostic approach, and treatment of disease complications or other clinical entities that may occur in these patients, while also covering relevant psychosocial and organizational issues. The present document is a summary of the 2021 TIF guidelines for TDT that focuses mainly on clinical practice issues and recommendations.

Orofacial manifestations of sickle cell disease: implications for dental clinicians

Sickle cell disease is a multisystem disease associated with episodes of acute illness and progressive organ damage. It is one of the most common severe monogenic disorders worldwide and is now the fastest growing genetic disorder in the UK. Dental awareness of orofacial manifestation varies geographically due to the inheritance pattern and patient population affected by the disease. This article details the epidemiology, pathophysiology and the orofacial manifestations in light of current literature.

Evidence-based dental management in the new era of sickle cell disease: A scoping review

BACKGROUND

Sickle cell disease (SCD) is an emerging global health issue with rapid progress in therapy especially since 2017. However, systematic reviews found no clinical trials on dental treatment of SCD.

TYPES OF STUDIES REVIEWED

Using a scoping review approach, the authors examined citations from 13 national SCD guidelines and 10 books spanning 4 decades. The authors also searched the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Scientific Electronic Library Online, and GoogleScholar. Eligibility criteria included SCD, oral health care and dental treatment, related to oral and systemic health, original data, or observations.

RESULTS

Systemic treatment of SCD might have opposing effects on caries, perhaps explaining the conflicting results published. Malocclusion correlates with marrow expansion. Other unusual orofacial findings reflect ischemia. Of 86 full-text articles examined, only 1, a Brazilian esthetic dentistry study, was a randomized clinical trial. No disease-specific data were found on risk of developing bacterial endocarditis, safety of inhaled nitrous oxide, safety of epinephrine with local anesthetic, or the benefit of comprehensive oral health care.

PRACTICAL IMPLICATIONS

In SCD, oral health and systemic health could be strongly linked. Penicillin, vaccines, and hydroxyurea might impact caries and bone. The interaction of SCD treatments and oral health merit study.

Assessment of mandibular characteristics in patients affected with β-thalassaemia major: A retrospective case-control study

OBJECTIVE

Thalassemia is the most common hereditary blood disorder across the world. This study aimed to identify some mandibular features of thalassaemic patients and compare them with unaffected counterparts.

MATERIAL AND METHODS

This retrospective case-control study was carried out on lateral cephalograms of 60 subjects (26 males, 34 females) with class II malocclusion and age range of 11 to 15 years. The control group consisted of 60 non-thalassaemic subjects with class II malocclusion and similar chronological age, gender and vertical facial dimension. Based on the Jarabak index, the case and control subjects were classified into hyperdivergent, normodivergent and hypodivergent growth patterns. Four linear (ramus height, ramus width, mandibular depth, and antegonial notch depth) and 3 angular (symphyseal angle, gonial angle, and mandibular arc angle) cephalometric parameters were measured to represent mandibular morphology. The data were analysed using Chi-square test and Student's t-test.

RESULTS

No significant difference was found in linear measurements between thalassaemic patients and controls. The symphysis angle was significantly greater and the mandibular arc angle was significantly smaller in the total thalassaemic sample than the control individuals (P<0.001 and P=0.004, respectively). The difference in symphysis angle was significant in both hyperdivergent and normodivergent subjects (P=0.004 and P=0.002, respectively), whereas the difference in mandibular arc angle was only significant in the normodivergent subgroup P=0.001).

CONCLUSIONS

The smaller mandibular arc angle in the thalassaemic sample suggests a more superior than posterior growth direction of condyles compared with healthy individuals. The difference in symphyseal angle represents inherent differences in chin morphology between thalassaemic subjects and controls.

Oral manifestations and dentofacial anomalies in β-thalassemia major children in Dubai (UAE)

AIMS

The purpose of this study was to identify special oral and dentofacial manifestations of β-thalassemia major (ΒTM) in Emarati children in Dubai (UAE).

MATERIALS AND METHODS

A total of 38 (ΒTM) and 76 healthy Emirati children were recruited. An oral examination was conducted to determine dmft/DMFT indices, Simplified Oral Hygiene Index, occlusal anomalies, dentofacial, and soft-tissue abnormalities.

RESULTS

ΒTM children had significantly higher DMFT compared to the healthy controls (p-value, 0.017). The Met Need Index (MNI) and the Restorative Index (RI) were lower in the ΒTM group but without statistical significance. Calculus Index (CI) was found to be significantly higher in ΒTM children (p-value, 0.002). The proportion of gingivitis was significantly lower in the ΒTM group (p-value, 0.009). ΒTM children had significantly higher proportion of retained primary teeth (p-value, 0.001) and gingival pigmentation compared with healthy controls (p-value, 0.001). BTM children did not have any statistically significant difference in the Angle molar classiication compared to the control. Interestigly, a significantly higher proportion of transverse cross bite was found in the control subjects compared to the BTM group (p-value, 0.004).

CONCLUSIONS

Significantly higher DMFT, retained primary teeth, gingival pigmentation, and CI was found in the BTM group compared to the controls while significantly lower gingivitis index and transverse cross bite was seen in the BTM group.

Sickle cell disease, dentistry and conscious sedation

The features of sickle cell disease (SCD) are described. Two case reports of patients treated in a Dental Institute are presented and the dental management of patients with SCD discussed. Since infection is one of the major risk factors for sickle cell crisis, the prevention of oral disease and infection is vital for this group of patients and there is no contra-indication to the delivery of dental treatment under local anaesthetic with inhalational sedation if required in the primary care setting. Since patients with sickle cell disease are particularly vulnerable to the effects of periods of hypoxia, which may produce significant morbidity, and because of the additional practical challenges in sedating this group of patients, intravenous sedation should be undertaken in a specialist unit.

CLINICAL RELEVANCE

The increasing prevalence of sickle cell disease highlights the importance of dentists practising in multi-cultural communities having an understanding of this condition and its implications on their clinical practice. This will facilitate the safe management of patients with sickle cell disease.

Craniofacial parameters of Syrian children with β-thalassemia major

AIM

To investigate cephalometric craniofacial parameters (skeletal and dental) of β-thalassemic-major patients and to compare findings with a group of healthy patients in the same age group.

METHODS

Fifty-one Syrian thalassemic-major patients aged 8-12 years were recruited. Lateral cephalometric radiographs were taken. Linear and angular cephalometric measurements were recorded and compared with Syrian controls (n=50) in the same age group.

RESULTS

Thalassemic patients, when compared with controls, showed significant retrognathia in the mandible (reduced sella [mid-point of sella turcica]-nasion [most anterior point on the frontonasal suture] B-point [deepest point on the concavity of the mandibular profile between the alveolar crest and the point of the chin] angle, and decreased sella-nasion-pogonion [most anterior point on the bony chin] angle, P<0.0001), a significant decrease in ramus height (articulare-gonian=36.51 ± 3.87 mm, P<0.0001). They also exhibited a significant class II skeletal pattern (P<0.0001) and a convex facial profile as the nasion A-point (deepest point on maxillary profile between the anterior nasal spine and the alveolar crest) pogonion angle and maxillomandibular A-point-nasion P-point angle increased. They also showed a highly-significant decrease in the total posterior facial height (sella gonion [most posterior, inferior point on the angle of the mandible]=64.24 ± 5.73 mm, P<0.0001) and significant increase in the total anterior facial height (N-Me = 110.78 ± 6.66 mm, P=0.009) when compared to controls.

CONCLUSION

Thalassemic patients exhibited a skeletal class II malocclusion, retrognathia of the mandible, a short height of the ramus, an increase in anterior facial height, and a decrease in posterior facial height.

Orthodontic management of traumatic avulsion of permanent incisors in a child with sickle cell anaemia: a case report

Introduction

Avulsion of permanent teeth in children resulting from trauma is an acute emergency presentation. When not adequately managed, it may result in functional and aesthetic disturbances, with implications for more complicated and prolonged treatment which require planning and biocompatibility in terms of forces used in moving the teeth orthodontically. Literature is scarce on a reported case of this nature and this is the first report in the literature in Nigeria.

Case presentation

We report on a case of avulsion of both maxillary central incisors in an 8-year-old male child of Sub-Saharan African ethnicity with sickle cell anaemia. One of the incisors produced by the parents was replanted at the clinic. The replanted tooth was later traumatized during the course of treatment which resulted in mobility and subsequent extraction of the tooth. At a later presentation at the clinic, orthodontic therapy was instituted. While orthodontic therapy has been considered to be completely noninvasive, special precautions should be taken in the clinical management of sickle cell anaemia patients to prevent local vaso-occlusive events.

Conclusion

The sequeale of traumatic avulsion in a medically compromised patient with sickle cell anaemia is presented. Prompt and early presentation for dental management is very important; while prevention and management of dental trauma should be recognized as a public health issue. Dental trauma in sickle cell anaemia can be minimized by practicing preventive measures with the use of mouth guard which is an effective device for preventing dental injuries, and patients should be advised to wear them during activities to prevent dental injuries.

Radiographic features of the jaws and teeth in thalassaemia major

OBJECTIVES

This investigation aimed to compare the radiographic changes and root and crown-body lengths of the mandibular first permanent molar in a group of thalassaemic patients with a control group, matched for age and sex.

METHODS

Panoramic radiographs of 50 thalassaemic patients and 50 controls were examined for the presence of radiological changes. Crown body and root lengths were determined using the method of Seow and Lai. The average lengths were calculated and compared between the two groups.

RESULTS

The mean crown-body and root lengths of the mandibular first molar of patients with thalassaemia major were 9.58+/-0.83 mm and 11.89+/-1.33 mm, while those for the control group were 10.45+/-0.78 mm and 12.78+/-1.67 mm, respectively. A significant difference (P<0.05) was found between the mean crown-body and root values of the two groups. A significant difference (P<0.05) was also found between thalassaemic patients and controls in the occurrence of spiky-shaped roots, root and crown lengths, taurodontism, attenuated lamina dura, enlarged bone marrow spaces, small maxillary sinuses, faint inferior alveolar canal and thin cortex of the mandible.

CONCLUSIONS

While thalassaemia major may not be associated with the occurrence of either vascular canals or prominent antegonial notch, spiky-shaped and short roots, taurodonts, attenuated lamina dura, enlarged bone marrow spaces, small maxillary sinuses, absence of inferior alveolar canal and thin cortex of the mandible were found to be reliable diagnostic criteria for thalassaemia major.

Dental arch morphological and dimensional characteristics in Jordanian children and young adults with beta-thalassaemia major

OBJECTIVE

The aim of this study was to examine the arch dimensions of Jordanian patients with beta-thalassaemia major in comparison with an unaffected control group.

METHODS

The sample consisted of 24 patients who suffered from beta-thalassaemia major (mean age = 13.9 +/- 3.1 years) and an unaffected control group (mean age = 13.5 +/- 2.9 years) matched for dental age, sex, and incisor and molar relationships. The unaffected control group was randomly selected from four public schools in the Governate of Irbid-Jordan. Alginate impressions were taken of the maxillary and mandibular dental arches of all participants. All measurements of the arch dimensions were made on the casts using an electronic digital sliding calliper.

RESULTS

In the mandibular arch, when compared with the patients with thalassaemia, the unaffected control group subjects showed a (statistically) significantly larger incisor width, larger arch depth, and larger left and right anterior arch lengths (1.18, 2.58, and 1.85 and 1.12 mm, respectively). In the maxillary arch, there was a statistically significant difference in the mean incisor width (+/- 2.16 mm), arch depth (+/- 3.14 mm), inter-molar width (+/- 1.21 mm) and in the left anterior arch length (+/- 1.97 mm). The canine widths, premolar widths, left and right posterior arch length, and curve of Spee of both arches showed no statistically significant differences between the two groups.

CONCLUSION

When compared to unaffected subjects, patients with beta-thalassaemia major exhibited: a narrower maxilla; a shorter maxilla and mandible; and smaller incisor widths for the maxillary and mandibular arches.

Caries risk in patients with thalassaemia major

AIM

The aim of this study was to assess the prevalence and distribution of dental caries in subjects with thalassaemia major.

DESIGN

Clinical examination for dental caries, diagnosed according to the WHO criteria.

PARTICIPANTS

A total of 54 thalassaemic patients, 23 aged 6-9 (14 males and 9 females) and 31 aged 12-18 (17 males and 14 females) were examined.

OUTCOME MEASURES

dmft, DMFT and plaque scores.

RESULTS

The mean dmft was 6.92 for 6-7 year olds and 4.72 for 8-9 year olds. The DMFT values were 6.57 and 5.95 for ages 12-14 and 15-18, respectively. There was no statistically significant difference in caries prevalence (dmft/DMFT) between gender or between primary and permanent teeth. Only 17.4 per cent of the children aged 6-9 and 21.4 per cent of 12-18 years olds were caries free. The prevalence of dental caries in the thalassaemia patients was considerably higher (22.7 per cent) than that reported in a normal Jordanian sample (DMFT 6.26 vs 4.84). Very few fillings (1.4 per cent of the examined teeth) were observed, indicating a negligible rate of conservative treatment. More than half (61.1 per cent) of the patients had poor oral hygiene (plaque score > or = 2.0).

CONCLUSIONS

The need for effective preventive measures, education and dental treatment need to be stressed for this caries risk group.