Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

DIFFERENTIAL DIAGNOSIS AND FOR DETERMINING THE MOLECULAR CAUSES UNDERLYING ORO-DENTAL ANOMALIES IN A SERIES OF PATIENTS

Viorica Radoi1, Andrei Kozma2*, Vasilica Toma3*, Horia Lăzărescu4, Radu Ursu5, Agnes Katherine Lackner6, Laurențiu Camil Bohîlțea7, Norina Forna8

1 Lecturer.PhD. MD – „Carol Davila” University of Medicine and Pharmacy, Bucharest, 2 CS II, PhD, MMD, MDHC – National Institute for Mother and Child Health “Alessandrescu Rusescu”, Bucharest; member of Academy of Romanian Scientists and of Romanian Academy of Medical Sciences 3 Assist.Prof. PhD.MD - University of Medicine and Pharmacy ”Grigore T.Popa”, Iasi 4 Assist.Prof.PhD- University of Medicine and Pharmacy ”Grigore T.Popa”, Iasi 5 CS II, PhD, MD – National Institute for Recovery, Physical medicine and Balneoclimatology, Bucharest 6 Assistant, prof. MD - „Carol Davila” University of Medicine and Pharmacy, Bucharest 7 MD, MD , Medical University Wien, University Dental Clinic, Department of Pediatric Dentistry 8 Univ.Prof.PhD, - „Carol Davila” University of Medicine and Pharmacy, Bucharest 9 Univ.Prof.PhD. – Dean of Faculty of Dental Medicine, University of Medicine and Pharmacy ”Grigore T.Popa”, Iasi; member of Academy of Romanian Scientists and of Romanian Academy of Medical Sciences

*corresponding authors: Andrei Kozma: [email protected]; Vasilica Toma: [email protected] **all authors have same contribution

Abstract: Progress in genetics and molecular biology has resulted in the emergence of new concepts to explain the etiology and pathogenesis of many human disease processes including oro-dental diseases. Recent advances in molecular aspects of odontogenesis indicate that the development of teeth is under strict genetic control. More than 300 genes are involved in determination of the position, number, and shape of the different types of teeth. Currently, there are more than 4,000 genetic disorders identified till date, of which orofacial syndromes form a considerable part. Genetic factors either in isolation or in combination with various environmental factors plays role in causation of these craniofacial anomalies. Early diagnosis is often crucial for the effective treatment of functional and developmental aspects. However, not all syndromes can be clinically identified early, especially in cases of absence of known family history. Moreover, the treatment of these patients is often complicated because of insufficient medical knowledge, and because of the dental and craniofacial developmental variations. The role of the team is crucial for the prevention, proper function, and craniofacial development which is often combined with orthognathic surgery. Clinical phenotyping together with genetic data and pathway information will ultimately pave the way for preventive strategies and therapeutic options in the future. This will improve the prognosis for better functional and aesthetic outcome for these patients and lead to a better quality of life, not only for the patients themselves but also for their families. Keywords: oro-dental anomalies, genetic testing, Kallman syndrome, Noonan syndrome

Background processes including oro-dental diseases. Progress in genetics and molecular biology Technological advances in molecular has resulted in the emergence of new biology have provided tools to study concepts to explain the etiology and alterations in gene structure that are pathogenesis of many human disease associated with a particular disease [1].

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Tooth development is an excellent example which are under strict genetic control by a for the reciprocal interaction between the number of signaling molecules and their ectoderm and the underlying mesenchyme. downstream signaling pathways. During This results in sequential cell activities like these stages, the continuous interplay of proliferation, condensation, adhesion, inductive signals between epithelia and migration, differentiation, and secretion and mesenchyme in a precisely organized leads to the formation of a functional tooth manner results in the formation of distinct organ [1,2,3]. and highly specialized structures, such as Genetic causes of oro-dental anomalies incisor, canine, premolar and molar teeth Recent advances in molecular aspects of [2,4,9]. Disturbances during any step of odontogenesis indicate that the development tooth development may affect growth, of teeth is under strict genetic control. More differentiation and pattern formation [9]. than 300 genes are involved in Currently, there are more than 4,000 genetic determination of the position, number, and disorders identified till date, of which shape of the different types of teeth orofacial syndromes form a considerable [4,5,6] in those genes encoding part. Genetic factors either in isolation or in transcription factors and signaling molecules combination with various environmental involved in odontogenesis is responsible for factors plays role in causation of these numerous abnormalities of the teeth. The craniofacial anomalies. It becomes a most commonly studied genes in tooth challenge for a dental practitioner to development are homeobox genes [7,8]. diagnose and manage orofacial syndromes Tooth development requires a sequential due to their complexity of multisystem and reciprocal series of signaling involvement [10]. interactions between the oral epithelium and the neural crest-derived mesenchyme, Table 1. - Genetic syndromes with oro-dental anomalies [10, 11,12] Dental defect Genetic syndromes Bardet Biedl syndrome, , Down syndrome, / ectodermal dysplasia, Cleft syndrome, Ellis van Creveland syndrome, Ehler Anodontia Danlos syndrome, , Goltz syndrome, Gorlin syndrome, Hallermann Strieff syndrome, Hypohydrotic ectodermal dysplasia, Johanson Blizzard syndrome, , Lenz microphthalmia syndrome, Maroteaux Lamy syndrome, Orofacialdigital syndrome type 2, Popliteal pterygium syndrome, Rieger syndrome, SHORT syndrome, Sturge Weber syndrome, , Van der Woude syndrome, , Witkop syndrome Hyperdontia , Cleidocranial dysplasia, Craniometaphyseal dysplasia, Crouzon syndrome, Down syndrome, Ehler-Danlos syndrome, Gardner syndrome, Hallermann Strieff syndrome, Klippel Trenaunay syndrome, Sturge Weber syndrome, Microdontia Blepharocheilodontic syndrome, Cleidocranial dysplasia, Crouzon syndrome, Goltz syndrome, Johanson Blizzard syndrome, Median cleft syndrome, Rieger syndrome, SHORT syndrome Macrodontia Crouzon syndrome Enamel Goltz syndrome, Hallermann-Streiff syndrome, Median cleft face syndrome, hypoplasia SHORT syndrome, Trichodento-osseous syndrome, Williams syndrome Dentinal Ehler Danlos syndrome, Osteogenesis imperfect

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defects Impacted / Aarskog syndrome, Cleidocranial dysplasia, Down syndrome, Gardner Unerupted syndrome, Maroteaux Lamy syndrome, Noonan syndrome teeth

Case presentations phosphate levels were detected, ranging up We present the cases of 2 patients with to 200 U/L. orodental anomalies but diagnosed with 2 Intraoral examination revealed multiple significantly different genetic disorders: submerged and retained deciduous teeth (53, Noonan syndrome (NS) and Kallman 54, 63, 64, 65, 73, 74, 75, 84), deep bite, syndrome (KS) high arched palate, gingival overgrowth with Noonan syndrome supernumerary teeth in the lower anterior Noonan syndrome (NS) is an autosomal region with grade I mobility of lower dominant multisystem disorder. Congenital permanent incisors. Many permanent teeth heart deformities, , thoracic were unerupted (12, 15, 22, 24, 25, 33, 34, deformities, short neck with webbing, 43, 44, 45) and all the erupted teeth were , and are some caries free. of the frequently observed clinical features. The included Williams NS is relatively common, with an estimated syndrome (FISH for Williams syndrome incidence of 1 per 1,000 to 1 per 2,500 live 7q11.23 probe was negative), births [13,14,15] Cardiofaciocutaneous syndrome (CFC-skin pathology is more florid; gastrointestinal Case report 1 problems are more severe and long lasting; A 9-year-old boy reported to the dentistry Facial appearance tends to be coarser), fetal clinic with irregularly placed upper and alcohol syndrome (no intrauterine exposure) lower front teeth and unerupted teeth. and - Germline A detailed medical and dental history was pathogenic variants occurring most obtained from the patient and his parents. commonly in exon 2 of the HRAS proto- His medical history showed mild pulmonary oncogene have been shown to cause stenosis and bilateral . Costello syndrome [14,15,16]. Around the age of 8 y.o. he reported having Genetic testing (comprehensive gene panel his lower front teeth extracted due to the for Noonan syndrome – 8 genes) [13] same aforementioned symptomatology. revealed the presence of the pathogenic The patient showed mild dysmorphic c.214G>T / p.Ala72Ser / rs121918453 features (flat nose, hypertelorism, webbed missense in the protein-tyrosine neck), , clubbed fingers. , non- type, 11 gene Radiological examinations were performed, (PTNP11, cytogenetic location 12q24.13), with a normal electrocardiogram and normal mutation reported in patients with autosomal cardiac function but a missing carpal dominant Noonan syndrome type 1. detected through wrist Rx. Elevated alkaline

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Figure 1. – PTNP11 gene location on in autosomal dominant Noonan syndrome type 1.

Kallman syndrome Case report 2 Kallmann syndrome (KS) is a rare genetic We present the case of a 23 year old female disorder characterised by central patient with hypodontia, cleft lip, bifid with a lack of sense of smell uvula, hypogonadotropic hypogonadism, and in some cases renal aplasia, deafness, uteral and ovarian hypoplasia, and , cleft lip/palate, and dental distinct facial features (facial asymmetry, agenesis. To date, five genes for KS have hypertelorism, abnormal nose shape). been identified: KAL1, located on the X Family history of the patient revealed 2 chromosome (X-linked inheritance), and other members possibly with the same FGFR1, PROKR2, PROK2 and FGF8, pathology, but without a clinical diagnosis which are involved in of KS (with or any genetic test performed. The pedigree autosomal patterns of inheritance) [17,18] was indicative of an autosomal dominant Most Kallmann cases are diagnosed during pattern of inheritance. infancy in males with cryptorchidism, Considering the patient’s clinical features , or associated non-reproductive and the family history, genetic testing was signs or at the time of due to lack of recommended. The test of choice was next sexual development in combination with generation sequencing using an extended hyposmia or anosmia in both sexes. gene panel for Kallman syndrome (33 genes Tooth agenesis occurs in about 50% of associated with KS)[21]. The result turned KAL-1 syndrome [19,20] both in cleft and out to be positive for the heterozygous non-cleft patients. It is highly variable, pathogenic c.8803G>T / p.Glu2935X ranging from one to multiple congenitally mutation in exon 38 of the chromodomain missing teeth. The most frequently missing helicase DNA-binding protein 7 gene teeth are the lateral mandibular incisors, (CHD7, located at 8q12.2), a single second mandibular and maxillary premolars, nucleotide deletion at position 61775202 and lateral maxillary incisors. Apart from causing frameshift of the entire coding tooth agenesis microdontia, typical region and an abnormal CHD7 protein “screwdriver”-shaped mandibular incisors, production. and thin molar roots have also been observed in these patients [18,20]

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Figure 2. – CHD7 gene location on in Kallman syndrome

Pathogenic mutations in the CHD7 gene are function, and craniofacial development known to be the genetic cause for the which is often combined with orthognathic autosomal dominant hypogonadotropic surgery. hypogonadism 5 with or without anosmia, Clinical phenotyping together with genetic which was the final diagnosis for our patient data and pathway information will [19,20,21] ultimately pave the way for preventive Genetic testing for the identified mutation strategies and therapeutic options in the was performed in both the patient’s future. This will improve the prognosis for relatives, with positive results in both cases. better functional and aesthetic outcome for these patients and lead to a better quality of life, not only for the patients themselves but also for their families

In addition to the traditional specialists, Conclusions specialists with a more basic research profile Early diagnosis is often crucial for the in molecular life sciences become more effective treatment of functional and frequently involved in refined genomics developmental aspects. However, not all diagnostic processes; moreover the syndromes can be clinically identified early, therapeutic planning is expected to further especially in cases of absence of known evolve toward the direction of precision family history. Moreover, the treatment of medicine aided by pharmacogenomics these patients is often complicated because approaches, with familial transgenerational of insufficient medical knowledge, and counselling and personalized preventive because of the dental and craniofacial strategies ahead. developmental variations. The role of the team is crucial for the prevention, proper

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