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J Bagh College Dentistry

Vol. 23(2), 2011

Selected salivary constituents

Selected salivary constituents among 16-18 years patients


with thalassemia major in relation to oral diseases
Hanaa S Al-Jobouri, BDS, MSc. (1)
Mohammed Al-Casey, BDS, MPH, MSPH. (2)

ABSTRACT
Background: Thalassemias constitute a form of anemia that has clear problems in relation to oral health.The purpose
of this study was to investigate the occurrence and severity of dental caries among patients with beta-thalassemia
major in relation to salivary physicochemical characteristic and to compare results with healthy subjects.
Materials and Method: 41 -thalassemia major patients (31 male, 10 female) and 41 healthy control subjects
matching in age and gender the -thalassemia patients were examined using the decayed, missing, and filled
surfaces (DMFS) index. Oral health status was recorded by application of plaque index (PlI), gingival index (GI) and
calculus index (Cal I). Stimulated salivary samples were collected for the determination of salivary flow rate and pH
of saliva in addition to the determination of concentration of calcium, phosphorus and magnesium.
Results: results showed that -thalassemia group had higher (DMFS), plaque, gingival, calculus, and phosphorus
values as compared to control group, while -thalassemia group had lower salivary flow rate, pH, calcium and
magnesium values compared to control group with statistically highly significant differences. A negative significant
correlation was found between DMFS with salivary pH and flow rate (p<0.05). A negative highly significant correlation
was found between salivary constituents (calcium, phosphorus, magnesium) and DMFS (p<0.01).
Conclusion: Patients with - thalassemia major showed highly significant differences in dental and periodontal
diseases as compared to control group and therefore a special preventive program needed for this target group.
Key words: -thalassemia, salivary constituents, dental diseases. (J Bagh Coll Dentistry 2011;23(124-127).

INTRODUCTION
The thalassemias are a diverse group of
genetic blood diseases characterized by absent or
decreased production of globulin protein chains,
resulting in microcytic anemia of varying degrees.
Based on their clinical and genetic orders,
thalassemias are classified mainly into major (thalassemia) which exhibits the most severe
clinical symptoms and minor (-thalassemia)
which is mild and considered to be clinically
asymptomatic. An intermediate form of
thalassemia may also occur. Such conditions are
increasingly causing an obvious problem in the
Mediterranean-bounding countries (1,2).
Saliva is the fluid produced by the salivary
glands and it's armed with various defense
mechanisms such as the immunological and
enzymatic defense systems and saliva has the
ability to protect the mucosa against mechanical
insults and to promote its healing via the activity
of epidermal growth factor (3,4). It can influence
the carious process in several ways 1. The flow of
saliva can reduce plaque accumulation on the
tooth surfaces and also increase the rate of
carbohydrate clearance from the mouth 2.

Saliva has another function of major


importance from caries remineralizing effects.
Saliva is supersaturated using the ions which
make up the mineral content of the teeth (calcium,
phosphate and hydroxyl ions) when the pH is
above a critical value, about 5.5. Below this
value (e.g. after an intake of sugar) the saliva and
plaque is unsaturated, and the tooth dissolves.
Above this value, the calcium and phosphate ions
from saliva start to repair the damaged mineral
crystals from the enamel the process of
remineralization (5). A small number of clinical
studies have analyzed the status of the oral
cavities in thalassemic patients, considering both
dental and periodontal conditions (6,7,8) .Delayed
eruption of both deciduous and permanent teeth
and high frequency of caries were observed;
moreover, dental caries disease was related to the
severity of systemic disease. A significant inverse
correlation was observed between transfusion
requirements and caries in mixed dentition (9). The
theoretical risk of oral and dental diseases in
thalassemia major (TM) patients remains high.
For all of above it was decided to conduct
this study to gain knowledge regarding oral health
problems of this target group which may allow
setting a preventive program for these medically
comprised subjects.

(1)

MATERIALS AND METHODS

(2)

MSc Preventive dentistry, Department of Preventive


dentistry, College of Dentistry, Baghdad University
Professor, Department of Preventive dentistry, College of
Dentistry, Baghdad University

Orthodontics, Pedodontics and Preventive Dentistry124

In this study 41 TM patients (31 males, 10


females) aged from 1618 years and 41 healthy
controls subjects matching in age and gender the

J Bagh College Dentistry

Vol. 23(2), 2011

TM group were examined for dental caries using


the decayed, missing, and filled surfaces (DMFS)
index following the criteria described by WHO
(10)
, for plaque accumulation using plaque index
by Sillness and Le (11), for gingival inflammation
using the gingival index system by Le and
Sillness (12) and dental calculus using calculus
index component of the simplified oral hygiene
index of Greene and Vermillion (13).
The collection of stimulated salivary samples
was performed under standard condition
following instruction cited by Tenovuo and
Lagerlof (3) and saliva was collected in a sterile
screw capped bottle salivary pH was measured
using an electronic pH meter after adjustment of it
and flow rate of saliva was expressed as milliliter
per minute (ml / min). Samples were centrifuged
at 4000 rpm for 30 minutes; the clear supernatant
was separated by micropipette and was stored at (20C) in a deep freeze. The concentration of
calcium, in addition to phosphorus and
magnesium were determined in the salivary
supernatant samples and this done through
different biochemical tests and according to
manufacturers instructions. The concentration
level of each constituent was expressed as
(mmol/L) unit.
Data processing and analysis were carried
out using SPSS package version 10. Student's ttest was applied for testing the significant
differences between study and control groups and
correlation coefficients were applied at the 0.05
level of significance.

RESULTS
Table 1 illustrates the mean, standard
deviation and statistical difference between TM
and control groups of (DMFS, plaque, gingival
and calculus indices), The TM group had a higher
DMFS compared to control group with
statistically highly significant difference (P<0.01).
Plaque (Pl), gingival (GI) and calculus (Cal)
values were higher in TM group as compared to
control group with statistically highly significant
difference (P<0.01).. In regard to salivary
physicochemical characteristic, salivary flow rate
and pH were found to be lower in TM group with
statistically highly significant difference (P<0.01).
Results showed that salivary calcium(Ca) and
magnesium(Mg) were higher in control group as
compared to TM group with statistically highly
significant difference (P<0.01),while salivary
phosphorus was found to be highly significant
lower in control group as compared to TM group
as seen in Table 2.
In this study an inverse correlation had been
observed between DMFS with both flow rate and
Orthodontics, Pedodontics and Preventive Dentistry125

Selected salivary constituents

pH and this correlations were statistically


significant (P<0.05), also highly significant
inverse correlation had been observed between
DMFS and all salivary constituents and this
correlations were statistically (P<0.01) in TM
group as shown in Table 3.

DISCUSSION
The present study showed that DMFS was
significantly higher in thalassemic patients than in
age matched healthy controls and theresults are in
disagreement with some studies (9,14,15).
Certain oral structural changes that take place
in thalassemic patients due to maxillary
enlargement result in protrusion of anterior teeth,
over-bite or open-bite and varying degrees of
malocclusion, which further predispose to caries
according to Al-Wahadni et al (16).
Colonization with Streptococcus mutans in
thalassemics has been found to be higher which
may also have a role in the higher caries incidence
seen in them (17).
Highly significant plaque, gingival, calculus
indices were recorded among TM group than that
control and these results were in agreement with
other studies (8,16,18). This increase in plaque and
calculus indices among the TM group may be
related to the oral neglected condition present in
the TM group who place a low priority on dental
care and cleansing of their teeth.
The incidence of gingivitis in patients with
thalassemia major seems likely related to local
factors such as poor oral hygiene, malocclusion
and drying of the gingivae through the patients
inability to close his mouth over the protruding
teeth, the chronic anoxemia may in some cases
predispose to gingival disorders (2). Higher
prevalence of gingivitis would be correlating the
maxillofacial characteristics of thalassemic
disease. It is well known that orthodontic
problems such as crowding, extreme maxillary
overjet, crossbite, and oral breathing are mainly
implicated in gingival disease (7).
Flow rate and the pH of saliva were found to
be significantly lower among TM group compared
to control group, this result was disagreed with
Siamopoulou et al (6). This reduction in salivary
flow rate might be due to the fact that iron
deposits in thalassemic patients can directly affect
the salivary glands, causing important and painful
inflammation, with either normal or diminished
salivary flow (19).
There were highly significant reduction in
the concentration of salivary calcium and
magnesium in TM group as compared to control
group, these results agree with Ghasempour et al

J Bagh College Dentistry

Vol. 23(2), 2011

(18)

and disagree with the results obtained by


Luglie et al (17) which found them very similar in
both groups, while concentration of phosphorus
found to be significantly higher in the TM group
as compared to the control and this result agree
with Ghasempour et al (18) and disagree with
Luglie et al (17) which found that there was no
difference in concentration of phosphorus
between two groups and with Siamopoulou et al
(6)
which found salivary phosphorus lower in the
TM group. These differences in salivary
constituents among thalassemic patients might be
related to differences in their level in serum as a
result of disease process since frequent blood
transfusion for thalassemic patients can lead to
iron overload which may result in hypogonadism,
diabetes
mellitus,
hypothyroidism,
hypoparathyroidism
and
other
endocrine
abnormalities (20).
In present study there was significant
negatively correlation between salivary flow rate
and dental caries. Salivary flow rate may play an
important role in relation to dental caries in which
the physiological function of saliva namely the
cleansing activity is very important in the
clearance of not food but also bacteria (21). There
is reasonably good evidence that the risk for
caries is significantly increased when salivary
flow rate is pathologically low (hyposalivation
and xerostomia) and this evidence indicates that
clinically relevant chronic reduction in salivary
flow rate is a strong risk factor for caries
prevalence and incidence (22).
The other important physicochemical
characteristic in saliva in relation to dental caries
is its constituents. Saliva mainly composed of
water in addition to a low percentage of
electrolytes (23). Calcium and phosphorus are the
main component of teeth; their presence in saliva
may greatly affect remineralization of teeth. The
caries process involves a progressive and an
ultimately irreversible alteration in the
hydroxyapatite structure of the affected tooth. In
this regard it seems logical to expect that the
salivary concentrations of ions that comprise
hydroxyapatite should be correlated with caries
status in some way (3). In the present study, there
were strong and highly significant negative
correlations between salivary calcium and
phosphorous with dental caries in both groups
which was agree with EL-Samarrai(24) . studies
which agree with present study. The higher caries
experience among TM patients could be explained
by reduction in concentration of electrolytes in
saliva that was shown to negatively associate with
dental caries in present study as well as others (24).
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Selected salivary constituents

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Vol. 23(2), 2011

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Selected salivary constituents

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Table 1: Oral health status (mean and standard deviation) between TM and control groups
Parameters
DMFS
PlI
GI
CalI

TM group Control group


MeanSD MeanSD
9.297.66 2.542.44
1.350.50 0.940.35
1.460.56 0.860.38
0.070.03 0.000.01
** Highly significant

t-value P-value
5.38
4.16
5.54
7.84

0.000**
0.000**
0.000**
0.000**

Table 2: Salivary parameters (mean and standard deviation) between TM and control groups
Salivary parameters
Flow rate
pH
Calcium
Phosphorus
Magnesium

TM group Control group


MeanSD MeanSD
0.530.20 0.810.12
7.170.96 8.230.30
1.720.50 2.410.45
4.102.05 2.290.60
0.420.16 0.980.58
** Highly significant

t-value P-value
7.61
6.70
6.50
5.42
5.93

0.000**
0.000**
0.000**
0.000**
0.000**

Table 3: Correlation coefficient between salivary physicochemical characteristic and caries


experience
DMFS
TM group
Control group
r-value P-value r-value P-value
-0.343 0.028* -0.309 0.049*
Flow rate
-0.327 0.037* -0.371 0.017*
pH
-0.620 0.000** -0.398 0.010*
Calcium
-0.539 0.000** -0.433 0.005**
Phosphorus
-0.634 0.000** -0.347 0.026*
Magnesium
* Significant ** Highly significant

Salivary parameters

Orthodontics, Pedodontics and Preventive Dentistry127

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