Establishment of a Dental Effects of Registry

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in

the Graduate School of The Ohio State University

By

Jennifer Laura Winslow, DMD

Graduate Program in

The Ohio State University

2018

Thesis Committee

Ann Griffen, DDS, MS, Advisor

Sasigarn Bowden, MD

Brian Foster, PhD

Copyrighted by

Jennifer Laura Winslow, D.M.D.

2018

Abstract

Purpose: Hypophosphatasia (HPP) is a metabolic that affects development of mineralized tissues including the dentition. Early loss of primary teeth is a nearly universal finding, and although problems in the permanent dentition have been reported, findings have not been described in detail. In addition, enzyme replacement therapy is now available, but very little is known about its effects on the dentition. HPP is rare and few dental providers see many cases, so a registry is needed to collect an adequate sample to represent the range of manifestations and the dental effects of enzyme replacement therapy. Devising a way to recruit patients nationally while still meeting the IRB requirements for human subjects research presented multiple challenges.

Methods: A way to recruit patients nationally while still meeting the local IRB requirements for human subjects research was devised in collaboration with our Office of

Human Research. The solution included pathways for obtaining consent and transferring protected information, and required that the clinician providing the clinical data refer the patient to the study and interact with study personnel only after the patient has given permission. Data forms and a custom database application were developed.

Results: The registry is established and has been successfully piloted with 2 participants, and we are now initiating wider recruitment.

Conclusion: The registry provides a mechanism for collecting data from many sources to achieve a sample size that will provide a thorough descriptive analysis of the effects of ii HPP on the mixed and permanent dentition as well as the effects of enzyme replacement therapy on the dentition. The registry has been successfully piloted and we are now initiating a wider recruitment. The registry could also serve as a pilot for data collections on other rare disease with dental implications.

iii Dedication

This document is dedicated to my husband, Chris Winslow, my family, and my research

mentor, Dr. Ann Griffen.

iv Acknowledgments

I would like to thank my husband for supporting me and having endless amounts of patience while I worked countless hours. I would like to thank the members of my committee for their time and support on this project. I would like to thank my sister for allowing me to use pictures of my adorable nieces for the recruitment materials. I would also like to thank Dr. Heidi Steinkamp and Jodee Coldren. Without all of these people, I would not have been able to develop this registry. I hope for things to continue to develop with this registry once I have graduated and help find answers for those with hypophosphatasia.

v Vita

May 2008 ...... Paradise High School

2012…………………………………………B.S. Biology, CSU, Chico

2016…………………………………………D.M.D., Midwestern University, Glendale

2016 to present ...... Dental Resident, Division of Pediatric

Dentistry, The Ohio State University

Fields of Study

Major Field: Dentistry

vi Table of Contents

Abstract ...... ii

Dedication ...... iv

Acknowledgments...... v

Vita ...... vi

Fields of Study ...... vi

Table of Contents ...... vii

List of Tables ...... ix

List of Figures ...... x

Chapter 1. Introduction ...... 1

Chapter 2. Methods ...... 7

Chapter 3. Results ...... 14

Chapter 4. Discussion ...... 21

Chapter 5. Conclusion ...... 26

Bibliography ...... 27

Appendix A. Study Brochure...... 29

vii Appendix B. HPP Forms for the Participant ...... 32

Appendix C. Collection Flyer ...... 40

Appendix D. HPP Forms for the Dentist ...... 42

viii List of Tables

Table 1: Patient Demographics ...... 14

Table 2: HPP History ...... 15

Table 3: Dental History from Participants ...... 17

Table 4: in the primary dentition ...... 18

Table 5: Occlusion ...... 20

ix List of Figures

Figure 1: Radiograph of missing upper ...... 18

Figure 2: Picture of exfoliated lower incisors ...... 18

Figure 3: Tooth Chart...... 19

x Chapter 1. Introduction

Hypophosphatasia (HPP) is a rare inherited metabolic disease that occurs because of a mutation in the gene, ALPL [1]. This results in a loss of function of the enzyme tissue non-specific (TNSALP) [1]. TNSALP plays an important role in the development of mineralized tissues including the dentition [1]. TNSALP loss of function results in accumulation of inorganic pyrophosphate (PPi) and other extracellular phosphorylated substrates, including pyridoxal 5’-phosphate (PLP), and phosphoethanolamine (PEA) [1, 2]. Inorganic pyrophosphate acts as an inhibitor of formation, so failure to hydrolyze PPi impairs skeletal and dental mineralization [1, 3]. HPP can be inherited in an autosomal dominant or recessive fashion

[1]. The mutations that occur are mostly missense mutations [1], and over 300 mutations have been identified [4]. TNSALP is expressed mainly in bone, adrenal glands, liver, teeth, and kidneys [1].

HPP ranges from mild to severe, with greater severity occurring with earlier onset, [1] which is reflected in lower levels of serum alkaline phosphatase (ALP) activity

[3]. It is now recognized that HPP severity is a spectrum, but it has historically been classified into six different forms, mostly based on the age of onset of systemic symptoms. The six different forms of HPP are: perinatal, benign prenatal, infantile, childhood, adult, and odontohypophosphatasia (odonto-HPP) [3]. Perinatal occurs in utero or at birth [2]. This form is the most severe form and results in , as it is 1 fatal due to almost complete absence of bone mineralization [2]. Benign prenatal also occurs in utero and can be detected through bone-related symptoms in the prenatal stage.

This results in poor skeletal mineralization, but is not fatal [2]. The infantile form occurs before six months of age [2]. Severe bone deformities, , respiratory issues, , hypercalcemia, and nephrocalcinosis occur in this form [2]. Epileptic seizures may develop due to the inability to dephosphorylate pyridoxyl phosphate, and indicates a poor prognosis of survival [2]. The mortality rate is approximately 50% in the infantile form due to respiratory failure [5]. The childhood form of HPP ranges in presentation from minor, with premature primary tooth loss as the only symptom, to moderate HPP-related rickets, short stature, delayed walking, and pain in the lower limbs

[2]. The adult form of HPP was originally described as developing during middle age with the onset of skeletal symptoms [2]. However, more recent reports indicate that nearly all patients diagnosed with the adult form of HPP report a history of early primary tooth loss and even skeletal symptoms that occurred during childhood, such as fractures, chronic muscle pain, and rickets [2, 5]. It appears that despite the childhood dental history, HPP was not recognized in these patients [5]. Permanent tooth loss, multiple fractures, , chondrocalcinosis, osteoarthropathy, and stress fractures have all been reported in patients with adult HPP [2]. A sixth classification, odontohypophosphatasia, was described to include children who experience early loss of primary teeth in the absence of apparent systemic symptoms [2]. Recent evidence, however, has linked odontohypophosphatasia to later development of the adult onset form [5]. It has been suggested odonto-HPP should be used to describe dental effects in early childhood but reserved for a diagnostic criteria only later in life if extra-dental 2 effects have not been observed with long-term follow up, since available data suggests later symptoms of adult-onset disease may occur [5]. Therefore, both early diagnosis when the first symptoms occur is important, but also long-term follow up for these patients is essential [5].

HPP has been considered a rare disease, although it is unclear what fraction of cases go undiagnosed. In Europe, the prevalence of severe HPP has been estimated at

1:300,000 individuals, and the prevalence of the moderate forms is estimated to be greater at 1:6,730 [2]. In Japan, the prevalence of severe perinatal is believed to be 2-

3:100,000 births [2]. In Canada, the severe forms are believed to be 1:100,000, though this data is from a study done over 50 years ago [2]. HPP is believed to be more common in Caucasians than African-Americans [4]. The mild form of HPP is the most prevalent and believed to be underdiagnosed [4].

Systemic symptoms of HPP are somewhat nonspecific, and can be difficult to distinguish from those of rickets, osteomalacia, , and several other .

For this reason diagnosis based on systemic symptoms alone can be difficult. In contrast, the dental pattern in young children, early loss of primary incisors with intact roots and no history of trauma, is unique to HPP. Since the first skeletal symptoms may not manifest until adulthood, the identification of early tooth loss can provide an important diagnostic clue. However, recognition of this abnormality requires knowledge of normal tooth exfoliation times and patterns, and it requires that the patient remember the phenomenon many years later. Pediatric dentists can play an important role in identifying the disease early and informing families. Failure to diagnose HPP has resulted in therapy

3 with that worsened symptoms, so accurate diagnosis is not only important for timely therapy, but also to prevent harm.

Diagnosis relies upon medical and dental history, clinical examination of the patient and laboratory testing. Genetic testing is also available [2]. Total serum ALP is the crucial value and is low in all forms of HPP. Normal levels of ALP vary by age and sex, and laboratory results must be compared to specific gender- and age-specific references [2]. Normal ALP levels are higher in childhood, so if adult reference ranges are used the diagnosis may be missed. Appropriate pediatric reference ranges [6] have not been widely adopted even in pediatric hospitals, so reference ranges should be confirmed against the CALIPER standards. Plasma PLP, and urinary PPi and PEA will also be elevated in HPP [2, 4], with PLP being a specific HPP biomarker [4]. Any of these can be used as additional tests. A low ALP can be followed up with studies and analysis of the

ALPL gene through genetic testing [2].

Enzyme replacement therapy for HPP has been available in the United States since 2015. Asfotase alfa (StrensiqTM; Alexion Pharmaceuticals Inc., New Haven, CT,

USA) is recombinant TNSALP, and the only form of replacement therapy available for

HPP [2]. This recombinant form includes a highly negatively charged “tail” that allows the TNSALP to be transferred to bone, as compared to unaltered TNSALP, which has been determined to be ineffective [2]. There have been substantial improvements in skeletal mineralization for those who have undergone treatment [2]. Currently, this drug is only approved for perinatal/infantile and childhood HPP forms in the USA, Canada,

Europe, and Japan [2]. Clinical trials for adolescent and adult HPP are being conducted

[5]. A history of early tooth loss can aid in making a diagnosis of childhood HPP in 4 adults whose first skeletal symptoms occur later in life, and this diagnosis can be critical to obtaining insurance coverage for therapy.

In addition to skeletal mineralization, TNSALP plays an important role in the dentition. TNSALP is expressed in the cells associated with formation and mineralization of enamel, , and [2]. Dental findings in medical reports have been only vaguely described, although a high prevalence of dental problems has been reported.

Dental effects are found in infantile, childhood, adult, and odonto-HPP forms [2]. A nearly universal finding in all forms of HPP is primary tooth loss before the age of five with roots intact and undeveloped or abnormal formation of cementum [5]. Primary tooth loss can affect the entire dentition, but most commonly involves the single rooted teeth, and most often the incisors [2, 4]. In general, the severity of HPP is correlated with more premature primary tooth loss [4]. Hypomineralization of the primary dentition within the enamel and dentin have been reported [3]. Other reported dental findings in the primary dentition are increased spaces and reduced thickness of dentin [2, 4, 5]. This causes the appearance of “shell” teeth [4]. Severe dental caries has also been reported [2, 5].

Other dental effects that have been reported include: bulbous crowns with cervical constriction, taurdontism of the molars, shorts roots, hypoplastic enamel, and eruption disorders such as delayed eruption, ankylosis of primary teeth, and permanent tooth retention or impaction [2]. Little is known about the mixed and permanent dentitions in

HPP, other than loss of [5]. A recent HPP review by Whyte, who has followed the medical status of a large cohort of patients for an extended period of time, summarized dental findings as “permanent teeth fare well early on, but poorly characterized dental problems and skeletal disease manifesting as osteomalacia can 5 eventually re-emerge” [4]. More detailed characterization of the dental problems is clearly needed. It seems especially important that we learn more about the long-term effects of milder odonto-HPP forms that had previously been assumed not to affect the permanent dentition.

The systemic effects of enzyme replacement therapy have been carefully documented, but very little is known about its effects on the dentition. Anecdotal reports have suggested “tightening” of loose teeth, but this warrants closer study. It is not known whether replacement therapy will prevent or correct the dental effects or if timing is critical. In summary, there is a need to expand knowledge about the dental effects of HPP and the dental effects of Asfotase alfa therapy. The objective of this thesis was to establish a registry to expand the knowledge of information about the dental effects of

HPP in the mixed and permanent dentition as well as the effects of enzyme replacement therapy on the dentition.

6 Chapter 2. Methods

This study was approved by Human Subjects Committee of Nationwide Children’s

Hospital, Columbus, Ohio (IRB17-0084) with a Reliance Agreement with The Ohio State

University IRB.

1. Research design and sampling:

Inclusion Criteria: The primary participants will be children diagnosed with or suspected to have HPP (age birth to 18 years of age). Their affected family members will be invited to participate as well (no age criteria).

Exclusion Criteria: Parent/guardian or participant (over the age of 18) who is non-

English speaking.

Sample size: The analysis will be descriptive, and HPP is a rare disease, so there is no target sample size. Efforts will be made to recruit as many participants as possible.

2. Recruiting Patients:

Participants will be recruited both at NCH and nationally. NCH patients will be recruited from the Dental Clinic where a bimonthly clinic for periodontal problems has a wide referral base. A referral pathway for patients with HPP from the Bone Clinic at NCH to the Dental Clinic is also established, contributing to the pool of potential participants.

Patients who attend the Dental Clinic will receive dental examinations and radiographs as indicated. We are likely to identify only a small number of cases at NCH, so it will be 7 necessary to recruit nationally to accrue sufficient numbers of participants to characterize the range of HPP effects. A study brochure and website https://u.osu.edu/hppstudy have been developed to publicize the study to health care professionals and potential participants. The role of the outside dental/medical professionals will be to inform their patients who have HPP about the registry and provide information on how to contact us to participate. The study brochure and website provide contact information and briefly explain the study. Study information materials will be distributed to personal contacts of the investigators, will be made available at American and Ohio Academy of Pediatric

Dentistry meetings, and through Soft Bones site at www.SoftBones.org, a national patient organization.

3. Consent/assent and strategy for data collection:

Recruitment and consent: Patients treated at NCH will be informed of the opportunity to participate by their dental or medical provider. Patients who agree to participate will be consented/assented and enrolled by study personnel. For participants outside the NCH system, recruiting materials that instructed potential participants to contact study personnel by phone or email will be widely distributed as described above. After potential participants contact us the study will be briefly explained, and if they wish to participate a packet containing consent/assent forms and data collection forms will be mailed or emailed to them. The consent forms will be reviewed by phone with the participants, who will sign and return them by mail or fax.

Data collection: Participants (or parents) will complete questionnaires regarding their dental and medical history and sign a Dental Records Release Form to allow their dentist 8 to send us their records and copies of radiographs and photos. Participants will return their completed forms by mail or fax to OSU or in person if they are seen at NCH. Study personnel will contact the dentist to provide study forms and the Records Release Form.

The dentist may either complete our forms or copy existing dental records. All forms and records will be faxed or mailed to us in pre-paid postage first class envelopes.

4. Information to be collected:

Data forms were developed and reviewed for content and clarity by multiple pediatric dental practitioners. These forms were designed to provide the following information. We do not expect all requested information to be available for every participant, and depending on the completeness of data, some records will not be included for certain analyses.

● Demographics:

o Contact information

o Gender, race, DOB, height, weight

● Medical history

o HPP disease classification/diagnosis

o HPP Symptom Tracker

o ALP laboratory values

o HPP genetic testing information

o Therapeutic treatment history including dates:

▪ Strensiq (Asfotase Alfa)

▪ Bisphosphonates 9 ▪ Other

● Dental records

o Dental exam records

o Dental treatment and progress notes

o Photographs and radiographs

5. Protection of information:

The only known risk is the loss of confidentiality. Only approved study personnel have access to personally identifying information including images (photographs and radiographs). Photos and radiographs will be scored by the investigators and findings summarized for analysis. Participants will be assigned a unique numeric identifier to be used in all data analyses. Paper records containing personally identifying information will be stored in a locked cabinet, and electronic information will be stored in a password- protected file in a custom application on the FileMaker (Santa Clara, CA) platform on a secure server password-protected computer in a locked office. All protected information will be transmitted by fax or 1st class mail.

Participants are able to withdraw their information from the registry at any time by contacting the PI.

Tooth samples will be coded and de-identified, so personally identifiable information will not be provided to laboratory personnel.

6. Clinical Data Analysis: 10 Information from questionnaires, medical history, and dental history will be entered into a FileMaker database, and descriptive summary data will be aggregated.

Information that will be examined for patterns and departures from normal includes:

 Age of primary and secondary tooth

o eruption

o loss

o mobility

 Caries and periodontal health

 Clinical or radiographic dental anatomic abnormalities

o enamel

o dentin

o cementum

o pulp chamber

 Soft and/or hard tissue cephalometric measures

 Changes in dental findings after treatment with Asfotase alpha therapy was

aggregated and summarized

i. Tooth mobility

ii. Tooth loss

iii. Other findings by report of patient or dentist

7. Collected teeth:

11 Participants will be asked to contribute any exfoliated or extracted primary or permanent teeth for laboratory analysis. Postage paid envelopes will be provided to mail teeth to the investigators.

8. Collection of control Teeth:

Teeth extracted in the NCH Dental Clinic from patients who do not have HPP will be collected to serve as controls. These teeth would normally be discarded. No personally identifying information will be obtained or retained with these teeth, but age in years at the time of extraction and sex will be recorded. Only teeth from patients who do not have

HPP will be included. These teeth will be compared to teeth donated by participants with

HPP in a laboratory analysis.

9. Laboratory Analysis of Collected Teeth:

Following extraction at Nationwide Children’s Hospital, or upon receipt if mailed by participants, teeth will be fixed in 10% formalin for at least 24 hours. Samples will be transported to the laboratory at OSU where they will then be transferred to 70% ethanol and stored at 4°C. Teeth will be analyzed by (Faxitron digital x-ray cabinet) to allow an overview of the shape and mineralized structure. Teeth will be analyzed by a micro-computed tomography (micro-CT) scanner, a radiographical approach that allows for three-dimensional (3D) reconstruction of mineralized tissue structures in the teeth.

The 3D image reconstructions will be analyzed to determine physical dimensions

(volume, thickness) and material properties (mineral density, or mg hydroxyapatite per cubic mm) of , dentin, and cementum. After x-ray and micro-CT scanning, 12 samples will be decalcified, embedded in paraffin wax, and made into thin (5-6 micrometers) histological sections on glass slides. Standard histological staining will be performed to examine morphology (hematoxylin and eosin), protein

(immunohistochemistry), and gene expression (mRNA localization and signal strength).

These assays are distinct from genetic or DNA testing, as they provide no information about the subject’s genetic status or DNA sequence.

10. Reporting Procedures:

Participants will be given the option of receiving a summary of the results by contacting the primary investigator.

13 Chapter 3. Results

Demographic information for two participants that are currently enrolled in the study is shown in Table 1.

Table 1: Patient Demographics

Demographic Variable Subject 1 Subject 2

Sex Male Female

Age 17 5

Hair Color Brown Blonde

Race White White

Information regarding HPP History for these two participants can be found in

Table 2. The first signs of HPP presented at age 2 for the subject one and 13-14 months for subject two. The age of diagnosis was age 4 for subject one and 19-20 months for subject two. Subject one has been diagnosed with childhood HPP and subject two with odonto-HPP. Subject one is currently undergoing drug treatment therapy while subject two has had no history of drug therapy. Laboratory values for ALP is shown in table 2, and genetic testing has been collected for both subjects.

14 Table 2: HPP History

HPP Hx Subject 1 Subject 2

Age of first signs of 2 Years Old 13-14 Months HPP

Age of diagnosis 4 Years Old 19-20 Months

Diagnosis Known Known

Form of HPP Childhood Odonto-HPP

Drug Treatment Strensiq None

History of Bone Yes No Fractures Age of first fracture 6 Years Old N/A

Which Bone? N/A

Other Bone Hx  Frequent N/A fractures  Fractures that heal poorly  Fractures that occurred with minimal or no trauma

Hx of muscle weakness Yes, a little No or low muscle tone?

Hx of being easily No No fatigued or having generally low energy?

Hx of chronic pain? No No

15 Taking meds for N/A N/A chronic pain?

Location of pain N/A N/A

Misc. HPP Hx • Knock knees None • • Gait problems • Calcifications of eyes

HPP Laboratory Tests • 11/19/15: <20 • 3/22/2016: for ALP • 2/22/16: 6808 82 (On Strensiq) • 4/7/18: 77 • 4/11/17: <20 (Stopped taking Strensiq) • 4/11/18: <20

Genetic Testing Yes Yes

Information for dental history from the participants is shown in Table 3. The age of first tooth lost occurred at less than one year of age for both subjects. Subject one also reported crooked teeth, cavities, soft teeth, and stained teeth, and mother and grandfather who got dentures at a young age.

16 Table 3: Dental History from Participants

Dental Hx Subject 1 Subject 2

Age of first tooth 6 Months Did not answer erupted

Age when first Less than 1 Less than 1 tooth was lost

Dental Problems • Lost teeth • Lost teeth • Crooked teeth • Cavities • Soft teeth • Other: stained teeth

Family Hx of • Mother: dentures • Mother: none Problems • Father: none • Father: root • Siblings: none canals • Children: N/A • Siblings: none • Grandfather: • Children: N/A dentures • Other: none

The dental history has been collected from subject two. The age of primary tooth loss can be found in table 4. Figure 1 is a radiograph that was provided showing that the participant had exfoliated #E and #F when the participant was only 2 years old. Figure 2 is a picture taken by the dental provider of the lower incisors from this patient due to the following: extracted (#N), avulsed (#O), or exfoliated (#P).

17 Table 4: Tooth loss in the primary dentition

Figure 1: Radiograph of missing upper incisors

Figure 2: Picture of exfoliated lower incisors

18

Figure 3 is the current tooth chart for this participant. Patient does not have a history of caries or restorations, but is currently missing two upper incisors and four lower incisors. The dental provider did not list any tooth abnormalities or any other pathology.

This participant reported a history of trauma to the lower incisors according to the dental provider. The patient fell when they were around one year of age, avulsing #O. A short time later #P exfoliated, and shortly after that #N was noted to be class III mobile and extracted by the dentist. Tooth #Q exfoliated a few months later. A few years later, #E and #F exfoliated without a history of trauma. Most recently, #D is recorded as being class I mobile. The occlusion for this participant can be found in table 5 and is within normal limits.

Figure 3: Tooth Chart

19

Table 5: Occlusion

Crowding None

Spaced Dentition No

Midline Diastema No

Overjet Average

Overbite Average

Crossbite None

Rotated Teeth No

Molar Relationship R: Mesial Step/Class I L: Mesial Step/Class I

Canine R: Class I L: Class I

20 Chapter 4. Discussion

Since few details have been reported about the dental manifestations of HPP, and

HPP is rare enough that few dental providers see more than a handful of cases in an entire career, a mechanism such as a registry is needed to collect an adequate sample to represent the range of manifestations. Devising a way to recruit patients nationally while still meeting the IRB requirements for human subjects research presented multiple challenges. For most registries the clinical examiners are part of a research team within an institution or network, but with a rare disease this model would not provide an adequate sample size. There is little in the literature to provide guidance on IRB issues and national registries conducted outside major health systems. Electronic Health Record

(EHR) systems in large corporations with national networks, for example Kaiser

Permanente, can provide ample information for registries [7]. Large institutions like this may also have systems in place to obtain informed consent and de-identify personal protected information [7]. This is critical to meeting ethical standards on protecting personal information in disease registries [7]. However, this option was not appropriate for our purposes since the level of detail and type of information needed to track the dental manifestations of HPP are not routinely stored in medical/dental or insurance records. Guidance from the literature on multi-site data collection for registries recommended that, “Registries involving multiple institutions require multiple ethical committee approvals [8].” But assembling a research team by enrolling a large number of 21 geographically and institutionally independent dentists to serve as co-investigators is not feasible. For private practitioners it would require credentialing each practitioner with the

IRB at the registry home institution and registering each practice as a site. For practitioners affiliated with an institution it would require separate IRB approval or a reliance agreement. So the challenge was enrolling and obtaining dental data on a geographically scattered cohort and multiple dentists within the requirements of the IRB, and we had to come up with a unique approach to establishing this registry.

We collaborated with the NCH Office of Research in devising a strategy that would overcome these challenges, and allow us to recruit participants nationally while meeting the guidelines of the IRB. The solution required that the clinician who would provide the clinical data refer the patient to the study and interact with study personnel only after the patient had given permission. We created recruiting materials (i.e. brochure, website) that practitioners could use to inform potential participants with HPP about the study. The recruiting materials direct the potential participant to contact the study team at NCH/OSU, and the NCH/OSU team obtains consent for participation. The participant may then sign a release allowing the study team to obtain dental records from the participant’s dentist and allow the dentist to complete the study data forms. The logistics are more involved than if the dentists were approved co-investigators, but this pathway for enrollment avoided the need to credential multiple providers or multiple IRB approvals, and so greatly increased the feasibility of the registry. The additional burden of the process includes the requirement that 1) the patient contact study personnel, 2) the study team obtain informed consent (and assent) from the patient over the telephone, 3) the patient transmit protected information including a signed consent form, data forms, 22 and a signed Records Release Form back to the study team by an approved method, either fax or 1st class mail, 4) then the study team contact the dental provider and transmit the

Records Release form securely to the dentist, and 5) the dentist securely transmit clinical information to the study team. Although this is certainly more complicated than simply enrolling on-site patients, it allows the operation of an open registry with a single IRB, and for a rare disease this is essential to achieve adequate enrollment.

IRB approval has been obtained for the registry, it is operational, and has been successfully piloted with two participants. Data from these participants was entered in a custom database application on the FileMaker platform on a secure server. Subject one has not received recent dental care, so recent dental records were not available.

Arrangements are being made for him to be seen in the NCH dental clinic where up-to- date data will be obtained. He has been on treatment with enzyme replacement therapy, so efforts will be made to track down any previous dental records prior to going on enzyme replacement therapy.

With only two participants enrolled in the study, there is not enough data to draw any conclusions, and efforts will now focus on recruiting participants. In addition to describing the range and incidence of dental manifestations of HPP, the registry may allow us to elucidate the relationship of dental findings to laboratory ALP values. Since there are over 300 mutations that have been discovered to date leading to HPP, a very large dataset may be required to make conclusions regarding specific mutations HPP dental phenotype, and it may take years to accrue sufficient data for these questions.

There are limitations to this registry that are important to note. The most important is that HPP is a rare disease, so there is only a small population base to draw from. Another 23 limitation is that we must remain in compliance with IRB requirements, so the protocol is a bit complicated with multiple back-and-forth contact requirements among the participant, the study team, and the dentist. This may prove prohibitively inconvenient for some potential participants or clinicians. Another limitation of this registry that is that we are relying on the participant to self-report their medical and dental history in a questionnaire, and past events such as early tooth loss and family history may not be clearly recalled. Although we will send dental data forms to clinicians, we also offer the option of simply copying and sending dental records allowing us to extract the data.

Since the information is extracted retroactively we anticipate considerable missing data on some the areas of interest. Also at this time the study is not setup to obtain access to medical records, and we will consider adding this.

For the future of this registry, despite no longer being in the residency program at

NCH and OSU I will remain actively involved in recruiting participants. Dr. Griffen will continue to support the registry and collection of data. Dr. Bowden will continue to recruit participants as she provides medical care for them and supervises their enzyme replacement therapy. We hope to obtain exfoliated teeth from participants and once those have been collected, Dr. Foster will provide hard tissue analysis. We also plan to attempt to recruit the adult relatives of children with HPP who have enrolled in the study. Ideas for future recruitment efforts include requesting the Coordination of Rare Diseases at

Sanford (CoRDS) database to contact patients with HPP to inform them of the study, to pay to send study information to all members of the American Academy of Pediatric

Dentistry, and posting study information on the pediatric dental Facebook page iPedo.

The ultimate goal is to accrue enough data to characterize the effects of HPP in the 24 primary, mixed and permanent dentition and the effects of enzyme replacement therapy on the dentition.

25 Chapter 5. Conclusion

The dental effects of untreated HPP are not currently well documented, and little is known about the dental effects of replacement therapy. HPP is rare and few dental providers see many cases, so a registry provides a mechanism to collect an adequate sample to represent the range of manifestations. In collaboration with our Office of

Human Research we devised a way to recruit patients nationally while still meeting the local IRB requirements for human subjects research. Enrolling a large number of participants in the registry will allow us to look in depth at the effects of untreated HPP and also at the dental effects of replacement therapy. Data forms and a custom database application were developed. The registry has been successfully piloted with 2 participants and we are now initiating wider recruitment. The registry could also serve as a pilot for data collections on other rare disease with dental implications.

.

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Venner, A.A et al. Closing the Gaps in Pediatric Laboratory Reference Intervals:

A CALIPER Database of 40 Biochemical Markers in a Healthy and Multiethnic

Population of Children. Clinical Chemistry 2012. 58(5): 854-868.

27 7. Gliklich RE, Dreyer NA. Registries for Evaluating Patient Outcomes: a User

Guide. Rockville, MD: U.S. Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2014.

8. Cameron, P. A., Finch, C.F., Gabbe, B.J., Collins, L.J., McNeil, K. McNeil, J.J.

2004. Developing Australia’s First Statewide Trauma Registry: What are the

lessons? ANZ J. Surg 2004. 74: 242-428.

28 Appendix A. Study Brochure.

29

30

31 Appendix B. HPP Forms for the Participant

Dental Effects of HPP Registry

Please complete this form and return it to us.

Instructions for sending it back to us:

Fax to 614-292-1125

OR

Mail to Dr. Ann Griffen Division of Pediatric Dentistry 305 W. 12th Avenue Columbus, OH 43210.

32

Information about person with HPP

Last Name First Name Eye color Hair color

Date of Birth □ Female Person completing Relationship to □ Male form patient

Height Weight □ American Indian or Alaska Native □ Asian □ Black or African American Race □ Native Hawaiian or Other Pacific Islander □ White □ Other (please specify: ______)

Street address

Zip Postal City, State Phone Email HPP HISTORY

Age at first signs of HPP Age at diagnosis

□ Known □ In Progress □ Probable □ Other Diagnosis If known, please specify form

□ perinatal

□ infantile

□ childhood

□ adult

□ odontohypophosphatasia

33

Drug Treatment(s) for HPP

□ No

□ Yes* *If yes please specify below: □ Replacement Therapy: Asfotase alfa (Strensiq®)

□ Bisphosphonates (For example: Fosamax, Zomata, Reclast, Alendronate)

□

□ Other (Please specify: ______)

History of Bone Fractures

□ No

□ Yes* *If yes please specify below:

Age of 1st fracture: ______

Which Bone? ______

Check all that apply: □ Frequent fractures □ Fractures that heal poorly or recur □ Stress fractures □ Fractures that occurred with minimal or no trauma □ Other (Please specify: ______)

34

History of muscle weakness or low muscle tone

□ No

□ Yes, a little

□ Yes, a lot

History of being easily fatigued or having generally low energy

□ No

□ Yes, a little

□ Yes, a lot

History of Chronic Pain

□ No

□ Yes* *If yes, how often do you take for your chronic pain? □ Never

□ Sometimes

□ Always What sorts of pain do you have? Check all that apply: □ Bone pain □ Joint pain □ Muscle pain □ Other pain (Please specify: ______)

35

Miscellaneous HPP History (please check all that apply)

□ (bone easily breaks) □ Osteopenia (low )

□ Headaches □ Back problems

□ Foot problems □ Short arms or legs

□ Depression □ Knock-knees

□ Bowed legs □ Gait problems (limping)

□ Seizures □ Calcification of eyes, kidneys, or other organs or glands □ other (please describe below)

36

HPP Laboratory Tests for ALP (serum alkaline phosphatase): (You may fill out the form below or attach laboratory reports.) Date Levels

HPP Genetic Testing: □ No

□ Yes (Please describe in the space below or attach a copy of the report.)

37

DENTAL HISTORY Age when first tooth Age when first tooth lost: erupted: Dental problems (please check all that apply)

□ Lost teeth □ Crooked teeth □ Cavities □ Tooth Pain

□ Jaw Pain □ Bite looks/feels “off” □ Trouble Chewing □ Dark Teeth

□ Soft teeth □ Chalky White Teeth □ Worn teeth □ other (please describe)

FAMILY DENTAL HISTORY Relationship Please Describe Below

Mother

Father

Siblings

Children

Other

38

Dental Effects of Hypophosphatasia Study Dental Records Release Form Please complete and sign this Release Form. Your signature gives us permission to contact your dentist and gives your dentist permission to send us your dental records. A Notice of Privacy Practices is included in your information packet. I, ______hereby authorize Dr.______(name of parent or patient) (name of dentist)

Dentist address: ______

City, State ZIP: ______

Phone number: ______

to release the following information for ______,______. (name of patient) (date of birth)

 Dental records

 X-Rays

 Photos

 Information requested on the HPP Study Dental Form

 Laboratory test results

 Other (please specify) ______

Please release and furnish information to: Dr. Ann Griffen Division of Pediatric Dentistry 305 W. 12th Avenue Columbus, OH 43210

Purpose of Disclosure: Dental Effects of Hypophosphatasia Research Study

I understand and acknowledge that this authorization extends to all or any part of the information designated above. I expressly consent to the release of information designated above. This consent is valid unless revoked by my written notice, provided said notice is received prior to release of the above information.

______(Relationship to Patient) (Printed name)

______(Signature of Patient or Parent/Legal Guardian if Patient under the age of 18) (Date)

39

Appendix C. Tooth Collection Flyer

40

41

Appendix D. HPP Forms for the Dentist

42

HPP Tooth Loss Questions Tooth loss in the primary dentition:

Age Lost

Tooth A B C D E F G H I J

Tooth T S R Q P O N M L K

Age Lost

Tooth loss in the permanent dentition:

Age Lost

Tooth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Tooth 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Age Lost

Have you submitted a lost tooth to an oral pathologist for analysis? **If your patient has any more teeth that you would like to submit, we are collecting teeth for analysis and will be able to provide you and your patient with the results! Please contact us for more information**

□ No □ Yes* *If yes please specify tooth number and provide and description below (Please also include any available pathology reports):

43

Tooth Chart (*You may either use the provided form or provide your own)

44

45

Tooth Abnormalities (Please provide any level of detail you can.) Abnormalities of tooth number: Missing teeth □ No () □ Yes* *If yes please specify tooth number(s) and provide and description below:

Supernumerary □ No teeth □ Yes* () *If yes please specify tooth number(s) and provide and description below:

Other/Comments:

Abnormalities of tooth shape: Invagination/ □ No Dens in dente □ Yes* *If yes please specify tooth number(s) and provide and description below:

Gemination □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Talon Cusp □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

46

Taurodontism □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Fusion □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Other/Comments:

Abnormalities of tooth size:

□ No □ Yes* *If yes please specify below:

Microdontia □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

47 □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Other/Comments:

Abnormalities of tooth mineralization: Enamel Abnormalities Hypoplasia □ No □ Localized (Please specify where: ) □ Generalized Hypocalcification □ No □ Localized (Please specify where: ) □ Generalized Deep Fissures □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

48 Thin enamel □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Enamel Wear □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Other/Comments:

Dentin Abnormalities □ No □ Yes* *If yes please specify below:

Other/Comments:

Cementum Abnormalities □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

49 Hypoplasia or defects □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Other/Comments:

Radiographic findings of Pulp Abnormalities: Enlarged Pulp volume □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Small or obliterated pulp □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Pulp calcification □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

50 Other/Comments:

Abnormalities of tooth eruption/position: Early eruption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Delayed Eruption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Failure of eruption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Impacted teeth □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

51

Ankylosis/Infraoccluded Teeth □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Ectopic Eruption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Other/Comments:

Abnormalities of tooth color: Intrinsic staining □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Extrinsic staining □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

52 Tooth Shade □Average □Yellowish □Grayish □Other (Please specify: ) Other/Comments:

Occlusion: Crowding □ None □ Mild □Moderate □Severe Spaced Dentition □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Midline Diastema □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

53 □Average □ Large/ Increased □Negative/ Underbite □Average □Deep □Anterior Open bite □Posterior Open bite □None □Anterior *If yes please specify tooth number(s) and provide and description below:

□Posterior *If yes please specify tooth number(s) and provide and description below:

Rotated Teeth □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Molar Relationship Right Left □Class I Molar (If primary: □Class I Molar (If primary: Mesial Step) Mesial Step) □Flush Terminal Plane/ End- □Flush Terminal Plane/ End-to- to-End End □Class II Molar (If Primary: □Class II Molar (If Primary: Distal Step) Distal Step) □Class III Molar □Class III Molar

54 Canine Relationship Right Left □Class I Canine □Class I Canine □Class II Canine □Class II Canine □Class III Canine □Class III Canine

Other/Comments:

Abnormalities of : Exfoliation without root resorption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Premature resorption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Small/Obliterated pulp chamber □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

55 Internal Resorption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

External Resorption □ No □ Yes* *If yes please specify tooth number(s) and provide and description below:

Other/Comments

Abnormalities of the periodontium (Please provide periodontal charting if available):

Plaque Level (Please mark all that apply) □None □Localized (Please specify where: □Light ) □Moderate □Generalized □Heavy

Gingivitis □None □Localized (Please specify where: ) □Generalized

56 Periodontitis (Please mark all that apply) □None □Aggressive □Localized (Please specify □Chronic where: ) □Other (Please specify: ) □Generalized Gingival Hyperplasia □None □Localized (Please specify where: ) □Generalized Tooth Mobility (Please provide □ No periodontal charting Yes* if available) □ *If yes please specify tooth number(s) and provide and description below:

Calculus (Please mark all that apply) □None □Light □Localized (Please specify □Moderate where: □Heavy ) □Generalized

Recession □ No □ Yes* *If yes please specify tooth number(s) and provide and description below: Bone loss □ No □ Yes* *If yes please specify tooth number(s) and provide and description

57 below:

Other/Comments:

Other Pathology Not Mentioned Above

58

Miscellaneous Dental History Questions Hx of involving the face/teeth:

□ No □ Yes* *If yes please specify tooth number and provide and description below:

Other Significant Dental History Not Mentioned Above

59