Fanconi's anemia: clinical and radiographic oral manifestations

Fanconi anemia and dyskeratosis congenita/telomere biology disorders: Two inherited bone marrow failure syndromes with genomic instability

Inherited bone marrow failure syndromes (IBMFS) are a complex and heterogeneous group of genetic diseases. To date, at least 13 IBMFS have been characterized. Their pathophysiology is associated with germline pathogenic variants in genes that affect hematopoiesis. A couple of these diseases also have genomic instability, Fanconi anemia due to DNA damage repair deficiency and dyskeratosis congenita/telomere biology disorders as a result of an alteration in telomere maintenance. Patients can have extramedullary manifestations, including cancer and functional or structural physical abnormalities. Furthermore, the phenotypic spectrum varies from cryptic features to patients with significantly evident manifestations. These diseases require a high index of suspicion and should be considered in any patient with abnormal hematopoiesis, even if extramedullary manifestations are not evident. This review describes the disrupted cellular processes that lead to the affected maintenance of the genome structure, contrasting the dysmorphological and oncological phenotypes of Fanconi anemia and dyskeratosis congenita/telomere biology disorders. Through a dysmorphological analysis, we describe the phenotypic features that allow to make the differential diagnosis and the early identification of patients, even before the onset of hematological or oncological manifestations. From the oncological perspective, we analyzed the spectrum and risks of cancers in patients and carriers.

Oral and Dental Manifestations of Fanconi Anemia

Fanconi anemia is a rare disease, which is characterized by decreased production of all blood cell types. Fanconi anemia is the most common inherited form of aplastic anemia. Congenital abnormalities of the eyes, ears, and heart, malformed or absent kidney, urogenital system involvement are common. There is a delay in physical development. Intelligence in patients with Fanconi anemia is usually normal. The most serious problems associated with Fanconi anemia include the gradual development of bone marrow disorders. Many patients with Fanconi anemia develop leukemia or myelodysplastic syndrome, as well as other oncological diseases. Oral manifestations in patients with Fanconi anemia can be classified as gingivitis, periodontitis, dental caries, dental anomalies, soft tissue lesions, oral cancer, and lesions of the tongue. Patients with Fanconi anemia have increased predisposition to squamous cell carcinoma of the head and neck and oral cancer. The interdisciplinary team of medical and dental specialists must be included in the medical and dental treatment of patients with Fanconi anemia. For proper dental care of patients with Fanconi anemia, the close cooperation of dental specialists, including orthodontists, pedodontists, prosthetists, oral surgeons, as well as specialists in periodontology and oral diseases, is of particular importance.

Self-perception of periodontal health status among individuals with Fanconi anemia

Introduction

Fanconi anemia (FA) is a rare genetic disease characterized by congenital malformations and bone marrow failure. One of the most common oral diseases in individuals with FA is periodontitis and adequate self-perception of periodontal status could contribute to its prevention and early detection.

Aim

To compare oral health self-perception, measured by a questionnaire, with the clinical oral condition of patients with FA.

Methods and Results

Fifty-six patients with FA, over 11 years of age, answered a questionnaire about dental history and self-reported oral health. Decayed, missing, and filled teeth (DMFT), Visible Plaque Index (VPI) and Gingival Bleeding Index (GBI) were measured. The median age of participants was 21 years (min 11, max 44), 31 (55%) were females and 25 (45%) males. Thirty-five (62.5%) participants rated their oral condition as satisfactory and 7 (12.5%) participants reported tooth mobility, 10 (17.9%) exposed roots and 21 (37.5%) gingival bleeding. Clinical examination detected average DMFT = 5.23, VPI = 31.36% and GBI = 33.77%. The gingival bleeding report was more frequent among individuals with higher GBI (p =  0.014). The DMFT was higher in those who had already undergone dental treatments (p =  0.031). There was an association between participants who presented dental caries and who rated their oral health as poor (p =  0.03). The question “Do your gums bleed easily?” had good accuracy in the evaluation of periodontal disease (p =  0.68).

Conclusion

Oral health self-perception of individuals with FA about gingival inflammation was associated with their gingival bleeding index.

Orthodontic intervention in Fanconi's anemia: A case report

The objective of this case report was to present the orthodontic treatment of an 8-year-old female patient with Fanconi's anemia and Class III skeletal pattern and agenesis of maxillary lateral incisors. Patient presented in the late mixed dentition with a Class III malocclusion with anterior and posterior crossbites. Rapid maxillary expansion and facemask therapy was performed for 12 months. Phase II was simplified with a 6 × 2 fixed appliance only in the mandibular arch for solving the anterior crowding. Maxillary canines were reshaped as lateral incisors and the central incisors were augmented for closing spaces. Although the systemic disease, orthodontic intervention is possible if individual limitations are considered and treatment is simplified.

Gingival Bleeding in a Child with Fanconi Anemia: A Case Report and Literature Review

Fanconi anemia (FA) is a rare autosomal recessive disorder characterized by multiple congenital abnormalities, bone marrow failure, and higher susceptibility to malignancies, especially to head and neck carcinomas. Only few reports about the oral manifestations of FA are available. The main reported oral conditions associated with FA are microdontia and advanced periodontitis. The aim of this paper was to report a case of a 10-year-old patient with FA presenting severe spontaneous gingival bleeding, as well as to discuss the role of the dentist in the management and treatment of this condition.

Risk of Human Papillomavirus Infection in Cancer-Prone Individuals: What We Know

Human papillomavirus (HPV) infections cause a significant proportion of cancers worldwide, predominantly squamous cell carcinomas (SCC) of the mucosas and skin. High-risk HPV types are associated with SCCs of the anogenital and oropharyngeal tract. HPV oncogene activities and the biology of SCCs have been intensely studied in laboratory models and humans. What remains largely unknown are host tissue and immune-related factors that determine an individual's susceptibility to infection and/or carcinogenesis. Such susceptibility factors could serve to identify those at greatest risk and spark individually tailored HPV and SCC prevention efforts. Fanconi anemia (FA) is an inherited DNA repair disorder that is in part characterized by extreme susceptibility to SCCs. An increased prevalence of HPV has been reported in affected individuals, and molecular and functional connections between FA, SCC, and HPV were established in laboratory models. However, the presence of HPV in some human FA tumors is controversial, and the extent of the etiological connections remains to be established. Herein, we discuss cellular, immunological, and phenotypic features of FA, placed into the context of HPV pathogenesis. The goal is to highlight this orphan disease as a unique model system to uncover host genetic and molecular HPV features, as well as SCC susceptibility factors.

Effect of Repeated Antimicrobial Photodynamic Therapy in Treatment of Periodontitis Associated with Fanconi Anemia

BACKGROUND AND OBJECTIVE

Periodontal disease is one of common oral manifestations in patients with Fanconi anemia (FA). The aim of the study was to evaluate the effect of photodynamic therapy (PDT) on periodontal clinical and microbial parameters in a patient with FA.

MATERIALS AND METHODS

For a 16-year-old girl, diagnosed with having FA and periodontal disease, the protocol treatment with duration of 10 months was designed. Every 2 months, thorough oral cavity disinfection was followed by PDT, using photosensitizer phenothiazine chloride activated by a diode laser light. During each visit, periodontal parameters were evaluated: plaque index (PI), gingival index (GI), probing pocket depth (PPD), bleeding on probing (BOP), and clinical attachment level. Simultaneously, the presence of Candida albicans and of five periodontal pathogens was evaluated.

RESULTS

Clinical results showed improvement in GI, BOP, and PPD during this 10-month period. BOP subsequently reduced from 100% to 79%, 72%, and 60% at 6, 8, and 10 months, respectively. The proportion of sites with PPD of ≥4 mm decreased from 38.7% at the baseline to zero after 10 months. Further, all five bacterial species and C. albicans were reduced significantly.

CONCLUSIONS

PDT effectively influences periodontal healing and reduces periodontopathogenic bacteria without damaging the patient's tissues.

Oral health status in children and adolescents with Fanconi anemia

OBJECTIVE

The aim of the study was to investigate the caries experience, dental care level, and oral hygiene in children and adolescents with Fanconi anemia.

METHODS

Decay-missing-filled teeth index, restorative index and simplified oral hygiene index were examined in two groups of children and adolescents: FA, diagnosed with Fanconi anemia (n = 35) and a healthy control group, non-FA (n = 35). Oral hygiene habits were assessed through questionnaires completed by parents.

RESULTS

FA group presents higher decay-missing-filled teeth index values, dental care index, oral hygiene index. Nevertheless, no statistical difference was observed between the groups. Frequency of visits to the dentist was higher in the non-FA group. Frequency of tooth brushing was higher in FA group and it was performed by the subjects without the help of their parents.

CONCLUSIONS

No difference was observed in caries experience, dental care level, and oral hygiene in children and adolescents with FA when compare with non-FA.

Oral leukoplakia in patients with Fanconi anaemia without hematopoietic stem cell transplantation

BACKGROUND

Fanconi anaemia is a genetic disease characterized by congenital abnormalities, progressive bone marrow failure, and a higher predisposition of oral squamous cell carcinoma. The purpose of this study was to evaluate the prevalence of oral mucosa lesions in patients with Fanconi anaemia without hematopoietic stem cell transplantation (HSCT).

PROCEDURE

Patients with Fanconi anaemia who had not undergone HSCT was cross-sectional evaluated for the presence of oral lesions.

RESULTS

The sample was composed of 78 male and 60 female patients, with a median age of 9 years. Of the 138 patients, approximately 45% manifested at least one oral mucosa abnormality: 35 patients (25%) presented with traumatic injuries, and 16 (12%) exhibited leukoplakia. The following lesions were observed in low prevalence: aphthous ulcers, atrophic tongue, petechiae and hematomas, gingival hyperplasia, mucoceles, herpes, hyperpigmentation, haemangioma, non-neoplastic proliferative lesions, neutropenic ulcers, papilloma, and candidiasis.

CONCLUSION

There was a high prevalence of oral leukoplakias in patients with Fanconi anaemia who had not undergone HSCT. It highlights the need of regular oral screenings in this cohort of concern for head and neck malignancies and suggests that oral leukoplakias should be further investigated as part of the syndrome phenotype.

Fanconi Anemia: main oral manifestations

Fanconi Anemia is a recessive and rare genetic disorder, characterized by chromosomal instability that induces congenital alterations in individuals. Aplastic anemia due to the progressive failure of the bone marrow, malignant neoplasias such as acute myeloid leukemia, liver tumors and squamous cell carcinoma are some of the possible evolutions of Fanconi Anemia. Some of these diseases develop mainly after bone marrow transplantation. The aim of this critical review of the literature was to discourse about the main oral manifestations and their involvement in the health of individuals who are ill with Fanconi Anemia. The clinical oral findings described in the literature include periodontal changes, such as gingivitis and aggressive periodontitis, recurrent aphthous ulcers and traumatic lesions. Papillary atrophy, macroglossia, melanic pigmentation and squamous cell carcinoma are the most common oral manifestations on the tongue. An increased risk for the development of malignant neoplasias in individuals with Fanconi Anemia has been reported, and this is progressive after bone marrow transplantation. In radiographs, dental anomalies such as the presence of supernumerary teeth, tooth agenesis, tooth rotation and transposition of teeth are observed. Salivary flow and some salivary components are also altered. Due to the increased susceptibility to the development of cancer in this specific population, it is important for the dentist to know the common oral manifestations and potentially cancerous lesions, in order to make an early diagnosis in individuals with Fanconi Anemia.

[Clinical manifestations of hematological non-neoplastic diseases in Dentistry]

Systemic disease can cause clinical manifestations in the oral and maxillofacial area, which is important to recognize because it could be the first symptom of an undiagnosed illness. There are different oral signs that could suggest the clinician a blood disorder, such as pallor, petechiae, ecchymosis, ulcerations, gingival hypertrophy or spontaneous gingival bleeding. In addition, blood disorders will determine the dental management of these patients and the protocol for limiting possible complications that may arise due to the treatment itself. This paper reviews the oral manifestations and dental management of non-neoplastic alterations of red cells, white cells and hemostasis, with emphasis on two-way relationship that must exist between the dentist and the patient's hematologist for making a treatment plan.