International Journal of Paediatric Dentistry 1992; 2: 93-91
Flow rate and chemistry of parotid saliva related to dental caries and gingivitis in patients with thalassaemia major ANTIGONE SIAMOPOULOU-MAVRIDOU', ANESTIS MAVRIDIS2, EMANUEL GALANAKIS', SPYROS VASAKOS*, HARITINI FATOUROU3 & PETER LAPATSANIS' 'Department of Paediatrics, School of Medicine, University of Ioannina lDepartment of Biological Chemistry, School of Medicine, University of Ioannina 'Division of Dentistry* School of Medicine, University of Ioannina
Summary. Twenty-one child patients with thalassaemic major (TM) and 83 healthy control children were examined for dental caries and gingivitis. Stimulated parotid gland secretions were collected from each child. Parotid saliva flow rate was measured and the saliva samples were tested for calcium, phosphorus, potassium, sodium, urea, lysozyme and immunoglobulin levels (IgA, IgG, IgM). The results showed that dental caries experience was significantly higher in the TM group. Parotid saliva flow rates in TM patients were not signiticantly different from those in the healthy controls. However, the median saliva concentrations of phosphorus and IgA were significantly lower in the patients than in the controls. The concentration of lysozyme was also lower in the TM group, but the difference was not statistically significant. The findings could provide an explanation for the higher dental caries experience and gingivitis observed in the TM group.
Introduction The thalassaemias, a heterogenous group of inherited disorders, are characterized by hypochromic anaemia caused by deficient synthesis of one or more of the polypeptide chains of human haemoglobin. In the homozygous state P-thalassaemia genes result in a severe or total suppression of pchain synthesis, clinically characterized as thalassaemia major (TM) or Cooley's anaemia. Skeletal abnormalities result primarily from hypertrophy and expansion of the erythroid marrow, which results in widening of the marrow space and thinning of the cortex, with consequent osteoporosis. Striking changes appear in the skull and the facial bones. The frontal bone is thickened, with Correspondence and reprint requests to: Dr A. SiamopoulouMavridou. Assistant Professor of Paediatrics. School of Medicine,'Universityof Ioannina, 45 1 10 Ioannina, Greece.
prominent frontal bossing. The maxilla is regularly involved. Pneumatization of the sinusoids is markedly delayed and a marked overgrowth of the maxilla may result in severe malocclusion and jumbling of the maxillary incisors, as well as prominence of the malar eminences. The bony changes result in the classical Cooley's facies [ 11. A small number of relevant clinical studies in children with TM has shown an increased prevalence of dental caries and gingivitis. Most cases of TM in younger patients are likely to have orthodontic or periodontal problems [2]. A study [3] of 50 patients (age 3-28 years) with TM showed a high prevalence (64%) of maxillary deformity and a dental caries experience (decayed, missing and filled teeth) of 8.3 per patient, slightly higher than a comparable group of 5,553 children (age 5-18 with TM showed Some years); 32y0Of the 50 degree of gingival inflammation. Although the
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maxillary deformity was considered to be a consequence of the disease, dental caries and gingival inflammation were thought not be directly related to it. Ventura [4] theorized that the endocrine dysfunction caused by thalassaemia is responsible for an increase in caries prevalence. The purpose of the present study was, first, to determine the dental caries experience and gingival health of a group of TM patients and of healthy controls and, secondly, to determine the flow rate and biochemical composition of their parotid saliva, to search for possible differences that may play a role in the initiation of dental caries and gingivitis.
Methods Twenty-one patients with thalassaemia major (TM) were studied (9 females and 12 males). Their mean age was 11.9k3.68 years and the mean duration of their disease was 7-9years (5.13 years). A group of 83 healthy children, matched for age, sex and socio-economic status, who were not receiving any medication and who were having a similar diet and the same exposure to fluorides, was selected from various schools and used as the control group. All the patients and control subjects were asked by the same doctor (EG) to answer orally a simple questionnaire concerning their daily diet. Patients and controls were evaluated by the same dentist (HF) for dental caries and gingivitis by application of the Decayed, Missing and Filled Index and the Gingival Index according to the World Health Organization’s criteria [5]. The oral examination and the collection of saliva was conducted according to our previous studies [6,7]. Stimulated parotid saliva was collected from both groups of children for 5 minutes in the morning, after a 2-hour fast. The gustatory stimulus (commercial lemon juice) was applied with a cotton swab 3 times per minute to the lateral border of the tongue. A Carlson-Crittenden cup was used unilaterally for saliva collection. Samples were centrifuged at 1500-rpm for 10 minutes and the supernatants were kept frozen at -20°C until analysed. Salivary sodium, potassium and urea were assayed by the Beckman Astra automated starroutine analyser system. Calcium and inorganic
phosphorus levels were determined by the Technicon RA-1000 system serum analyser [8]. Lysozyme activity was estimated by using the Testomar lysozyme kit [9]. Immunoglobulin levels were measured by the single radial immunodiffusion technique [lo], using very sensitive immunodiffusion plates. Assay ranges were 0.008-0-133 g l-l, 0.01 1-0-18 gl-* and0.008-0.13 gl-lforIgA,IgM and IgG, respectively. All patients’ sera were routinely assayed for sodium, potassium, urea, calcium, phosphorus and immunoglobulins. The statistical significance of differences between the two groups were evaluted by the Mann-Whitney U-test [ 1 I].
Results As shown in Table 1, the median number of DMF teeth in TM children was 7.00,almost twice as high as that in the control group, and the median values of GI were 1-225in the TM group and 0.600 in the controls; both these differences were highly significant (P~0.001). Table 1. Decayed, missing and filled teeth (DMFT) and Gingival Index (GI) in 21 thalassaemia major (TM) patients and 83 healthy control children (medians and 95% confidence intervals) TM group
DMFT GI
Control group
Median
95%CI
Median
95%CI
7.000 1.225
4.00-9.50 0.85-1.47
2.900*
1.345-4.70 0.57464
0.600*
*Differences between TM and control groups significant, Pt0.001.
The concentration of electrolytes, urea, lysozyme and immunoglobulins A (IgA) in the stimulated parotid saliva of patients and controls can be seen in Table 2 (salivary IgG and IgM levels are not included because they were not measurable by the method used). Parotid saliva flow rate was not significantly different in the two groups. The concentrations of phosphorus, urea and IgA were significantly lower in the TM group (P
Flow rate and chemistry of parotid saliva related to dental caries and gingivitis in patients with thalassaemia major ANTIGONE SIAMOPOULOU-MAVRIDOU', ANESTIS MAVRIDIS2, EMANUEL GALANAKIS', SPYROS VASAKOS*, HARITINI FATOUROU3 & PETER LAPATSANIS' 'Department of Paediatrics, School of Medicine, University of Ioannina lDepartment of Biological Chemistry, School of Medicine, University of Ioannina 'Division of Dentistry* School of Medicine, University of Ioannina
Summary. Twenty-one child patients with thalassaemic major (TM) and 83 healthy control children were examined for dental caries and gingivitis. Stimulated parotid gland secretions were collected from each child. Parotid saliva flow rate was measured and the saliva samples were tested for calcium, phosphorus, potassium, sodium, urea, lysozyme and immunoglobulin levels (IgA, IgG, IgM). The results showed that dental caries experience was significantly higher in the TM group. Parotid saliva flow rates in TM patients were not signiticantly different from those in the healthy controls. However, the median saliva concentrations of phosphorus and IgA were significantly lower in the patients than in the controls. The concentration of lysozyme was also lower in the TM group, but the difference was not statistically significant. The findings could provide an explanation for the higher dental caries experience and gingivitis observed in the TM group.
Introduction The thalassaemias, a heterogenous group of inherited disorders, are characterized by hypochromic anaemia caused by deficient synthesis of one or more of the polypeptide chains of human haemoglobin. In the homozygous state P-thalassaemia genes result in a severe or total suppression of pchain synthesis, clinically characterized as thalassaemia major (TM) or Cooley's anaemia. Skeletal abnormalities result primarily from hypertrophy and expansion of the erythroid marrow, which results in widening of the marrow space and thinning of the cortex, with consequent osteoporosis. Striking changes appear in the skull and the facial bones. The frontal bone is thickened, with Correspondence and reprint requests to: Dr A. SiamopoulouMavridou. Assistant Professor of Paediatrics. School of Medicine,'Universityof Ioannina, 45 1 10 Ioannina, Greece.
prominent frontal bossing. The maxilla is regularly involved. Pneumatization of the sinusoids is markedly delayed and a marked overgrowth of the maxilla may result in severe malocclusion and jumbling of the maxillary incisors, as well as prominence of the malar eminences. The bony changes result in the classical Cooley's facies [ 11. A small number of relevant clinical studies in children with TM has shown an increased prevalence of dental caries and gingivitis. Most cases of TM in younger patients are likely to have orthodontic or periodontal problems [2]. A study [3] of 50 patients (age 3-28 years) with TM showed a high prevalence (64%) of maxillary deformity and a dental caries experience (decayed, missing and filled teeth) of 8.3 per patient, slightly higher than a comparable group of 5,553 children (age 5-18 with TM showed Some years); 32y0Of the 50 degree of gingival inflammation. Although the
93
94
A. Siamopoulou-Mavridou et al.
maxillary deformity was considered to be a consequence of the disease, dental caries and gingival inflammation were thought not be directly related to it. Ventura [4] theorized that the endocrine dysfunction caused by thalassaemia is responsible for an increase in caries prevalence. The purpose of the present study was, first, to determine the dental caries experience and gingival health of a group of TM patients and of healthy controls and, secondly, to determine the flow rate and biochemical composition of their parotid saliva, to search for possible differences that may play a role in the initiation of dental caries and gingivitis.
Methods Twenty-one patients with thalassaemia major (TM) were studied (9 females and 12 males). Their mean age was 11.9k3.68 years and the mean duration of their disease was 7-9years (5.13 years). A group of 83 healthy children, matched for age, sex and socio-economic status, who were not receiving any medication and who were having a similar diet and the same exposure to fluorides, was selected from various schools and used as the control group. All the patients and control subjects were asked by the same doctor (EG) to answer orally a simple questionnaire concerning their daily diet. Patients and controls were evaluated by the same dentist (HF) for dental caries and gingivitis by application of the Decayed, Missing and Filled Index and the Gingival Index according to the World Health Organization’s criteria [5]. The oral examination and the collection of saliva was conducted according to our previous studies [6,7]. Stimulated parotid saliva was collected from both groups of children for 5 minutes in the morning, after a 2-hour fast. The gustatory stimulus (commercial lemon juice) was applied with a cotton swab 3 times per minute to the lateral border of the tongue. A Carlson-Crittenden cup was used unilaterally for saliva collection. Samples were centrifuged at 1500-rpm for 10 minutes and the supernatants were kept frozen at -20°C until analysed. Salivary sodium, potassium and urea were assayed by the Beckman Astra automated starroutine analyser system. Calcium and inorganic
phosphorus levels were determined by the Technicon RA-1000 system serum analyser [8]. Lysozyme activity was estimated by using the Testomar lysozyme kit [9]. Immunoglobulin levels were measured by the single radial immunodiffusion technique [lo], using very sensitive immunodiffusion plates. Assay ranges were 0.008-0-133 g l-l, 0.01 1-0-18 gl-* and0.008-0.13 gl-lforIgA,IgM and IgG, respectively. All patients’ sera were routinely assayed for sodium, potassium, urea, calcium, phosphorus and immunoglobulins. The statistical significance of differences between the two groups were evaluted by the Mann-Whitney U-test [ 1 I].
Results As shown in Table 1, the median number of DMF teeth in TM children was 7.00,almost twice as high as that in the control group, and the median values of GI were 1-225in the TM group and 0.600 in the controls; both these differences were highly significant (P~0.001). Table 1. Decayed, missing and filled teeth (DMFT) and Gingival Index (GI) in 21 thalassaemia major (TM) patients and 83 healthy control children (medians and 95% confidence intervals) TM group
DMFT GI
Control group
Median
95%CI
Median
95%CI
7.000 1.225
4.00-9.50 0.85-1.47
2.900*
1.345-4.70 0.57464
0.600*
*Differences between TM and control groups significant, Pt0.001.
The concentration of electrolytes, urea, lysozyme and immunoglobulins A (IgA) in the stimulated parotid saliva of patients and controls can be seen in Table 2 (salivary IgG and IgM levels are not included because they were not measurable by the method used). Parotid saliva flow rate was not significantly different in the two groups. The concentrations of phosphorus, urea and IgA were significantly lower in the TM group (P
