Thalassemia review: features, dental considerations and management

Exploring the Impact of Blood Disorders on Dental Caries

Blood comprises various cellular elements and serves as our immune system's second line of defense. Deviations from its normal composition can have adverse effects on health. At the same time, the oral mucosa in the oral cavity functions as the body's first line of defense, and any anomalies or diseases within it can give rise to both systemic and oral complications. If left untreated, caries can lead to severe tooth damage or extraction, potentially affecting an individual's nutrition and overall health. This review article focuses on the importance of understanding the intricate relationship between blood disorders and oral health. It underscores the profound impact of oral manifestations of blood disorders such as β-thalassemia, sickle cell disease, iron deficiency anemia, leukemia, hemophilia, Plummer-Vinson syndrome, erythroblastosis fetalis, Fanconi anemia, cyclic neutropenia, and acute lymphoblastic leukemia on the overall well-being of an individual.

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

Local Anesthesia Onset and Pain Perception in Hemophilic and Thalassemic Conditions

The study aims to evaluate and compare the onset of local anesthesia (LA) and pain perception during endodontic treatment in hemophilic and thalassemic patients. Methods: The study included 90 patients with symptomatic irreversible pulpitis of the mandibular molars. Three groups (n = 30 in each group) were included. Group 1: hemophilic patients; group 2: thalassemic patients; and group 3: individuals without any systemic diseases. Onset of LA and visual analogue scale (VAS) scores was recorded immediately after the administration of local anesthesia, during the pulp exposure procedure, and during canal instrumentation, and were compared between the three groups. Frequency distribution, ANOVA, and linear regression analysis (p < 0.05) were applied. Results: The mean onset time was 46 ± 34 s in the hemophilic group, 42 ± 23 s in the thalassemic group, and 38 ± 12 s in controls, but the differences were statistically insignificant. After LA administration (LA-VAS), all three groups experienced a statistically significant reduction in pain (p = 0.048). On pulp exposure (PE-VAS) (p = 0.82) and during canal instrumentation (CI-VAS) (p = 0.55), there was no statistically significant difference in pain perception between the groups. The coefficients indicate a positive correlation between the VAS and onset time, indicating a positive reduction in the VAS following the administration of LA. Conclusions: Hemophilic patients exhibited a clinically longer average onset time for LA. However, the difference among the three groups with regard to the overall pain perception after LA administration, during and after pulp exposure, and during canal instrumentation was statistically insignificant.

Thalassemia and Nanotheragnostics: Advanced Approaches for Diagnosis and Treatment

Thalassemia is a monogenic autosomal recessive disorder caused by mutations, which lead to abnormal or reduced production of hemoglobin. Ineffective erythropoiesis, hemolysis, hepcidin suppression, and iron overload are common manifestations that vary according to genotypes and dictate, which diagnosis and therapeutic modalities, including transfusion therapy, iron chelation therapy, HbF induction, gene therapy, and editing, are performed. These conventional therapeutic methods have proven to be effective, yet have several disadvantages, specifically iron toxicity, associated with them; therefore, there are demands for advanced therapeutic methods. Nanotechnology-based applications, such as the use of nanoparticles and nanomedicines for theragnostic purposes have emerged that are simple, convenient, and cost-effective methods. The therapeutic potential of various nanoparticles has been explored by developing artificial hemoglobin, nano-based iron chelating agents, and nanocarriers for globin gene editing by CRISPR/Cas9. Au, Ag, carbon, graphene, silicon, porous nanoparticles, dendrimers, hydrogels, quantum dots, etc., have been used in electrochemical biosensors development for diagnosis of thalassemia, quantification of hemoglobin in these patients, and analysis of conventional iron chelating agents. This review summarizes the potential of nanotechnology in the development of various theragnostic approaches to determine thalassemia-causing gene mutations using various nano-based biosensors along with the employment of efficacious nano-based therapeutic procedures, in contrast to conventional therapies.

Thalassaemia - part 1: a clinical update for the dental team

Thalassaemia is a genetic disorder that affects haemoglobin function. It is an abnormality of haemoglobin caused by mutation of genes related to alpha or beta globin chains that can be further subdivided into categories. These haematological conditions can vary from mild forms, which present as mild anaemia, to severe forms, that can become life-threatening. The window for dental treatment is often limited by several factors involving medical management, such as the need for antibiotic cover or blood transfusions. The lifetime management of the medical conditions are onerous and can place significant physical and psychological burden on the patient. This paper is part of a two-part series on thalassaemia. Part one focuses on the clinical manifestations patients may present with, treatment regimens and dental implications of such presentations. Part two explores the perspectives of thalassaemia patients on their dental experience.

Identifying Gingival Pigmentation Patterns and Skin Color and Its Co-relation With Serum Ferritin Levels in Thalassemic Patients

Background: Patients with β-thalassemia major (β-TM), a genetic issue due to hemoglobin (Hb) synthesis disorder, require life-long erythrocyte transfusion. The purpose of this study is to evaluate and compare gingival pigmentation and skin color with serum ferritin levels of patients with β-TM, using the Dummett's oral pigmentation index (DOPI) and Fitzpatrick skin scale, respectively.

Methods: A total of 100 patients were monitored at a thalassemia care center. Each patient's gingival pigmentation and skin color were matched with DOPI and the skin scale under natural light. Serum ferritin levels, the interval of blood transfusions, and iron chelation medications were studied. A gingival pigmentation score and skin color type were compared with the serum ferritin.

Results: A significant correlation was found between age, serum ferritin, pigmentation score, and skin color, which means as serum ferritin level increases, gingival pigmentation score increases, and skin color darkens.

Conclusion: This study evaluated the correlation between gingival pigmentation and skin color with serum ferritin levels and established gingival pigmentation as a sign of iron deposition in β-TM patients. This is the simplest and least invasive method for evaluating serum ferritin level parameters in β-TM patients.

Anthropometric measurements of peri-oral region in a sample of Iraqi thalassemic patients

OBJECTIVES:

Thalassemia, one of the most widespread autosomal recessive disorders, is characterized by anomalies in the synthesis of hemoglobin beta chains and is frequently coupled with variable craniofacial characteristics. Thalassemic patients suffer from severe anemia, which triggers several defense mechanisms in the body, such as bone marrow expansion, which forces the bones to expand, resulting in craniofacial bone deformities. This study aims to assess and compare the orofacial dimensions of β-thalassemia patients with those of a control group across similar ages and gender.

MATERIALS AND METHODS:

Three hundred Iraqi individuals agreed to participate in this study (150 non-thalassemic and 150 thalassemic patients with an equal distribution of genders). A well-trained researcher carried out five anthropometric measurements by using an electronic digital caliper. Gender and group differences were tested using an independent sample t test.

RESULTS:

Mouth width showed clinical and statistically significant group differences among all measurements in the study group.

CONCLUSIONS:

All measurements except mouth width showed nonsignificant clinical group differences.

Complications of patients with thalassemia major and intermedia in a selected Iranian population

BACKGROUND

Due to anemia in thalassemia major (TM) and thalassemia intermedia (TI) patients, bone changes occur, especially in the broad bones like jaw and skull, which are the main sites of hematopoiesis. Therefore, the dentist should be aware of the disease to prevent complications. The aim of this study was to evaluate the radiographic findings of the jaw and teeth in TM and TI patients and to compare the two groups.

METHODS

50 TM patients and 50 TI patients in Amirkola Thalassemia Center, whose thalassemia were definitively diagnosed by a hematologist, were selected as the study group and the control group consisted of 50 healthy individuals. In patients` panoramic radiographs, dental anomalies (microdontia, root shortening etc.) and bone disorders (bone marrow hyperplasia, maxillary sinus invisibility etc.) were assessed. A p<0.05 was considered.

RESULTS

Dental anomalies were (42.84%) in TI patients and (23.46%) in the control group, the difference was significant. Dental anomalies in TM patients were (38.76%) and in the control group (23.46%) and a significant difference was observed (p<0.001). Bone disorders were (47.94%) in TI patients and in the control group (32.64%). Bone disorders in TM patients were (44.88%) and in the control group was (32.64%) that showed a significant difference.

CONCLUSION

This study showed that in thalassemia patients, bone and dental disorders frequency were higher than healthy individuals. Bone disorders were also more common than dental anomalies. Dental and bone disorders were more common in TI.

Radiographic Features of the Maxillofacial Anomalies in Beta-Thalassemia Major: With New View

BACKGROUND

Beta- thalassemia major causes the basic skeletal changes due to ineffective erythropoiesis in suffering patients. The aim of the study was to determine the frequency of maxillo-facial anomalies and the hemoglobin and ferritin levels in patients with beta-thalassemia major compared to the healthy control group.

METHODS

The present study was performed on 72 beta- thalassemia major patients and 70 healthy control group in Ahvaz, Southwest Iran, from Jan 2014 to Mar 2015. Panoramic radiographs were taken using a standard procedure. The frequency of abnormalities including enlargement of bone marrow spaces, small maxillary sinuses, thickness of inferior mandibular cortex, prominent antegonial notch, absence of inferior alveolar canal and thin lamina dura, were determined by two Oral and Maxillofacial Radiologist. We also paid to identification of the relationship between abnormalities frequency and hemoglobin and ferritin levels during previous 6 months in thalassemia patients.

RESULTS

The mean age of case and control groups was 18.6±7.25 and 17 ± 6. 55 yr, respectively. The frequency of abnormalities in the case and control groups was as follows, enlargement of bone marrow spaces [69 (95.8%) vs 3 (4.3%)], small maxillary sinuses [45 (62.5%) vs 1(1.4%)], reduced thickness of inferior mandibular cortex [21(29.2%) vs 6 (8.6%)], prominent antegonial notch [10 (13.9%) vs 2 (2.9%)], absence of inferior alveolar canal [68(94.4%) vs 41(58.6%)] and thin lamina dura [40 (55.6%) vs 5 (7.1%)].

CONCLUSION

The all above mentioned abnormalities in patients with beta-thalassemia major was higher than the control group. Moreover, the frequency of maxillo-facial abnormalities decreased by increasing hemoglobin and decreasing ferritin.

The diagnostic protocol for hereditary spherocytosis-2021 update

Background

Hereditary spherocytosis (HS), a commonly encountered hereditary hemolytic disease, is mostly inherited in an autosomal dominant manner. The clinical manifestations in patients with HS show obvious heterogeneity. Moreover, the sensitivity or specificity of some HS diagnostic tests are not ideal and may easily result in misdiagnosis or missed diagnosis in some patients. The objective of this study was to propose a simple and practical diagnostic protocol, which can contribute to the diagnosis of HS and its differential diagnosis with different types of hemolytic anemia such as thalassemia (THAL), autoimmune hemolytic anemia (AIHA), and glucose‐6‐phosphate dehydrogenase (G6PD) deficiency, thus, to provide an alternative simple and reliable method for better clinical diagnosis of HS.

Methods

Through combing our research with existing experimental technologies and studies, we propose a simple and practical protocol for HS diagnosis, which will help clinicians to improve HS diagnosis.

Results

Compared with the existing HS diagnostic protocols, the HS diagnostic protocol we proposed is simpler. In this new protocol, some experimental tests with ideal diagnostic efficiency are added, such as mean reticulocyte volume (MRV), mean sphered cell volume (MSCV), mean corpuscular volume (MCV), in combination with the observation of clinical manifestations, family investigation, routine tests for hemolytic anemia, genetic testing, and other screening tests.

Conclusion

The HS diagnostic protocol we proposed could improve the clinical practice and efficiency of HS diagnosis.

Radiographic Diagnosis of Systemic Diseases Manifested in Jaws

Radiographic changes of the oral and maxillofacial hard tissues can be an indication of an underlying systemic disease. In this article, the range of individual disease entities that have both systemic and dental manifestations are reviewed. Images for many conditions are provided to illustrate the radiographic changes. A summary of the most common jaw affected, radiographic and pathognomonic findings, and management aspects is listed in a table format within this article for quick reference.

Spontaneous osteonecrosis of the jaw in a β-Thalassemia intermedia patient

The resultant anemia in hemoglobinopathies like thalassemia can lead to expansion of the bone marrow cavities due to compensatory hyperplasia. This article reports a case of spontaneous osteonecrosis of the left maxillary alveolus in a patient with β-Thalassemia intermedia. The area affected presented as areas of osteosclerosis on the radiographic examination and sequestrectomy of the left maxillary alveolus was performed after consultation with his hematologist. The exact pathogenesis for the osteonecrosis is unclear. One possible postulation for the cause of osteonecrosis in our case could be that the alveolar bone suffered ischemic infarction secondary to occlusion of the microvasculature within the expanded cancellous bone.

Comparison of decayed, missing, filled teeth index between thalassemia major patients and control group in Iran: a systematic review and meta-analysis

Introduction

Scientific evidence of the association between Decayed, Missing, and Filled Teeth (DMFT) and thalassemia are conflicting and difficult to establish conclusions. Therefore, this study aimed to determine the relationship between dental caries (using the DMFT index) and thalassemia major using meta-analysis.

Methods

Databases were searched using such keywords as “Thalassemia,” “Caries,” “decay,” “DMFT,” “Iran,” and OR operators, AND, and NOT. After the elimination of duplicate documentation, the articles which met the inclusion criteria were selected. Quality assessment was performed based on the Newcastle-Ottawa Quality Checklist. Thereafter, the standardized mean difference of the DMFT index was estimated.

Results

In eight studies, the mean DMFT was compared between patients with thalassemia major and the control group. In six studies, the mean of this index was higher in patients with thalassemia major than in the control group and in all six of the studies, the differences were statistically significant. The mean standardized difference of DMFT, D, M, and F were reported as 1.36 (0.41, 2.30), 2.63 (0.42, 4.84), 1.65 (−0.14, 3.45), and 0.02 (−1.67, 1.72), respectively.

Conclusion

The results of this meta-analysis indicated that DMFT index was more inappropriate in patients with thalassemia, as compared to the control group which represents the higher incidence of dental caries among patients with thalassemia compared to the control group.

Oral Manifestations of Systemic Diseases

Signs and symptoms representative of a systemic condition can manifest in the oral cavity and orofacial region. Such conditions may be previously diagnosed, or the orofacial manifestation may be the presenting sign of an acute or chronic systemic condition not previously diagnosed. Pathologic processes in the mouth, jaws, and contiguous structures could have a direct and indirect impact on the patient's overall systemic condition. Moreover, systemic conditions may result in compromised function of the orofacial region or impact patients' oral health profile. This article reviews selected systemic conditions that present or impact on the oral cavity and orofacial region.

Craniofacial Deformities in Patients With Beta-Thalassemia: Orthodontic Versus Surgical Correction-A Systematic Review

Rapid blood cell turnover and bone marrow expansion caused by beta-thalassemia (βT) result in craniofacial and dentoalveolar anomalies. This report presents a systematic review of the literature over the past 50 years on orthodontic and surgical considerations in the management of βT-affected patients. Seventeen publications encompassed 24 patients, 11 male individuals and 13 female individuals, 7 to 43 years of age. Eleven patients underwent only surgical treatment, eleven combined orthodontic-surgical treatment, and 2 orthodontic treatment. Surgical treatment primarily addressed typical maxillary overgrowth by maxillary reshaping, premaxillary segmental repositioning, or complete Le Fort I impaction and set back osteotomy. In severe maxilla-mandibular discrepancy and/or increased lower facial height, a bilateral sagittal split mandibular osteotomy is the treatment of choice. Although surgery involves risks of excessive bleeding, morbidity, and impaired nasal esthetics, little attention is given to the orthodontic modality. In conclusion, the current literature recommends early interceptive orthodontics aimed to decrease dentoskeletal deformities, severe malocclusion, and soft tissue imbalance. Treatment includes maxillo-mandibular orthopedic and functional manipulation with dentoalveolar treatment, which might either prevent orthosurgical procedures later or reduce its extent. This suggested a multidisciplinary approach comprising a hematologist, a pediatrician, a pediatric dentist, and an orthodontist, which might also significantly improve the patient's quality of life.

Establishing and evaluating an auto-verification system of thalassemia gene detection results

The manual verification of gene tests is time-consuming and error prone. In this study, we try to explore a high-efficiency, clinically useful auto-verification system for gene detection of thalassemia. A series of verification elements were rooted in the auto-verification system. Consistency check was applied initially as one of the essential elements in our study. One hundred twenty-four archived cases were used to choose the consistency-check rules' indices from routine blood examination and hemoglobin electrophoresis by the receiver operating characteristic curves. Rule 1 and rule 2 established by the chosen indices were compared by their passing rate, consistency with manual validation, and error rate. Finally, 748 cases were used for verifying the system's feasibility by evaluating the passing rate, turn-around time (TAT), and error rate. The rule 2 had a higher passing rate (67.7% vs. 50.8%) and consistency (0.623 vs. 0.364) than the rule 1 with an error rate of zero. In a "live" valuation, the auto-verification system can reduce the TAT and error rate of verification by 51.5% and 0.13%, respectively, with a high passing rate of 82.8%. The auto-verification system for gene detection of thalassemia in this study can shorten the validation time, reduce errors, and enhance efficiency.

An evaluation of thyroid autoimmunity in patients with beta thalassemia minor: A case-control study

Objective:

The tendency to autoimmune diseases has been reported to be increased in beta thalassemia minor (BTM). The aim of this study was to evaluate whether thyroid autoimmunity is higher in BTM.

Methods:

Patients with BTM (n=86) and a healthy control group (n=93) were included in this cross-sectional case-control study. The two groups were compared in terms of anti-thyroglobulin (anti-TG) and anti-thyroid peroxidase (anti-TPO) and thyroid hormones.

Results:

In the BTM group, thyroid hormones and serum anti-TG and anti-TPO antibody levels were not statistically different from those of the control group. The BTM and control groups were similar in terms of anti-thyroid antibody (ATA) positivity prevalence. In the BTM group, anti-TG was 11.6% and anti-TPO was 14% positive, while these values were 14% and 12.9% positive, respectively in the control group (p=0.806 and p=0.989, respectively). The proportion of anti-TG and/or anti-TPO antibody positive subjects was found to be 20.9% in the BTM group, and 20.4% in the control group (p=0.919). The ratios of subjects with euthyroidism, hyperthyroidism and hypothyroidism were similar in both groups.

Conclusions:

As the thyroid autoimmunity prevalence in the BTM group was not increased compared to the control group, it can be considered that there is no necessity for routine ATA and thyroid hormone testing in subjects with BTM.

[Rapid detection of alpha-globin gene αααanti-3.7 triplets with droplet digital PCR]

OBJECTIVE

To establish a rapid method for detection of alpha-globin gene αααanti-3.7 based on droplet digital PCR (ddPCR) technique.

METHODS

The differential sequence between the X1 and Y1 box of α1 gene was selected as the amplicon of the target gene with β-actin as the reference gene. The specific primers and TaqMan probes were designed, and then a quantitative method for detecting the copy number was established based on ddPCR technique. The sensitivity and accuracy of the method were evaluated by detecting 28 samples of known genotypes and 60 clinical samples.

RESULTS

The ddPCR-based method accurately identified the genotypes of all the 28 samples with known genotypes and detected 5 cases of αα/αααanti-3.7 from the 60 clinical samples, and the results were verified by MLPA. The sensitivity and accuracy of this method were both 100% for detecting alpha-globin gene αααanti-3.7.

CONCLUSION

This ddPCR-based method for detecting αααanti-3.7 triplet can be applied for population screening and in routine clinical molecular diagnosis with simple operation, rapid analysis and accurate results.

[Rapid detection of alpha-globin gene αααanti-3.7 triplets with droplet digital PCR]

OBJECTIVE

To establish a rapid method for detection of alpha-globin gene ααα^anti-3.7 based on droplet digital PCR (ddPCR) technique.

METHODS

The differential sequence between the X1 and Y1 box of α1 gene was selected as the amplicon of the target gene with β-actin as the reference gene. The specific primers and TaqMan probes were designed, and then a quantitative method for detecting the copy number was established based on ddPCR technique. The sensitivity and accuracy of the method were evaluated by detecting 28 samples of known genotypes and 60 clinical samples.

RESULTS

The ddPCR-based method accurately identified the genotypes of all the 28 samples with known genotypes and detected 5 cases of αα/ααα^anti-3.7 from the 60 clinical samples, and the results were verified by MLPA. The sensitivity and accuracy of this method were both 100% for detecting alpha-globin gene ααα^anti-3.7.

CONCLUSION

This ddPCR-based method for detecting ααα^anti-3.7 triplet can be applied for population screening and in routine clinical molecular diagnosis with simple operation, rapid analysis and accurate results.