Heterozygous COL17A1 variants are a frequent cause of amelogenesis imperfecta.

BACKGROUND: Collagen XVII is most typically associated with human disease when biallelic COL17A1 variants (>230) cause junctional epidermolysis bullosa (JEB), a rare, genetically heterogeneous, mucocutaneous blistering disease with amelogenesis imperfecta (AI), a developmental enamel defect. Despite recognition that heterozygous carriers in JEB families can have AI, and that heterozygous COL17A1 variants also cause dominant corneal epithelial recurrent erosion dystrophy (ERED), the importance of heterozygous COL17A1 variants causing dominant non-syndromic AI is not widely recognised. METHODS: Probands from an AI cohort were screened by single molecule molecular inversion probes or targeted hybridisation capture (both a custom panel and whole exome sequencing) for COL17A1 variants. Patient phenotypes were assessed by clinical examination and analyses of affected teeth. RESULTS: Nineteen unrelated probands with isolated AI (no co-segregating features) had 17 heterozygous, potentially pathogenic COL17A1 variants, including missense, premature termination codons, frameshift and splice site variants in both the endo-domains and the ecto-domains of the protein. The AI phenotype was consistent with enamel of near normal thickness and variable focal hypoplasia with surface irregularities including pitting. CONCLUSION: These results indicate that COL17A1 variants are a frequent cause of dominantly inherited non-syndromic AI. Comparison of variants implicated in AI and JEB identifies similarities in type and distribution, with five identified in both conditions, one of which may also cause ERED. Increased availability of genetic testing means that more individuals will receive reports of heterozygous COL17A1 variants. We propose that patients with isolated AI or ERED, due to COL17A1 variants, should be considered as potential carriers for JEB and counselled accordingly, reflecting the importance of multidisciplinary care.

Spectrum of pathogenic variants and founder effects in amelogenesis imperfecta associated with MMP20.

Amelogenesis imperfecta (AI) describes a heterogeneous group of developmental enamel defects that typically have Mendelian inheritance. Exome sequencing of 10 families with recessive hypomaturation AI revealed four novel and one known variants in the matrix metallopeptidase 20 (MMP20) gene that were predicted to be pathogenic. MMP20 encodes a protease that cleaves the developing extracellular enamel matrix and is necessary for normal enamel crystal growth during amelogenesis. New homozygous missense changes were shared between four families of Pakistani heritage (c.625G>C; p.(Glu209Gln)) and two of Omani origin (c.710C>A; p.(Ser237Tyr)). In two families of UK origin and one from Costa Rica, affected individuals were homozygous for the previously reported c.954-2A>T; p.(Ile319Phefs*19) variant. For each of these variants, microsatellite haplotypes appeared to exclude a recent founder effect, but elements of haplotype were conserved, suggesting more distant founding ancestors. New compound heterozygous changes were identified in one family of the European heritage: c.809_811+12delinsCCAG; p.(?) and c.1122A>C; p.(Gln374His). This report further elucidates the mutation spectrum of MMP20 and the probable impact on protein function, confirms a consistent hypomaturation phenotype and shows that mutations in MMP20 are a common cause of autosomal recessive AI in some communities.

New missense variants in RELT causing hypomineralised amelogenesis imperfecta.

Amelogenesis imperfecta (AI) is a heterogeneous group of genetic diseases characterised by dental enamel malformation. Pathogenic variants in at least 33 genes cause syndromic or non-syndromic AI. Recently variants in RELT, encoding an orphan receptor in the tumour necrosis factor (TNF) superfamily, were found to cause recessive AI, as part of a syndrome encompassing small stature and severe childhood infections. Here we describe four additional families with autosomal recessive hypomineralised AI due to previously unreported homozygous mutations in RELT. Three families carried a homozygous missense variant in the fourth exon (c.164C>T, p.(T55I)) and a fourth family carried a homozygous missense variant in the 11th exon (c.1264C>T, p.(R422W)). We found no evidence of additional syndromic symptoms in affected individuals. Analyses of tooth microstructure with computerised tomography and scanning electron microscopy suggest a role for RELT in ameloblasts' coordination and interaction with the enamel matrix. Microsatellite genotyping in families segregating the T55I variant reveals a shared founder haplotype. These findings extend the RELT pathogenic variant spectrum, reveal a founder mutation in the UK Pakistani population and provide detailed analysis of human teeth affected by this hypomineralised phenotype, but do not support a possible syndromic presentation in all those with RELT-variant associated AI.

Amelogenesis imperfecta caused by N-terminal enamelin point mutations in mice and men is driven by endoplasmic reticulum stress.

'Amelogenesis imperfecta' (AI) describes a group of inherited diseases of dental enamel that have major clinical impact. Here, we identify the aetiology driving AI in mice carrying a p.S55I mutation in enamelin; one of the most commonly mutated proteins underlying AI in humans. Our data indicate that the mutation inhibits the ameloblast secretory pathway leading to ER stress and an activated unfolded protein response (UPR). Initially, with the support of the UPR acting in pro-survival mode, Enamp.S55I heterozygous mice secreted structurally normal enamel. However, enamel secreted thereafter was structurally abnormal; presumably due to the UPR modulating ameloblast behaviour and function in an attempt to relieve ER stress. Homozygous mutant mice failed to produce enamel. We also identified a novel heterozygous ENAMp.L31R mutation causing AI in humans. We hypothesize that ER stress is the aetiological factor in this case of human AI as it shared the characteristic phenotype described above for the Enamp.S55I mouse. We previously demonstrated that AI in mice carrying the Amelxp.Y64H mutation is a proteinopathy. The current data indicate that AI in Enamp.S55I mice is also a proteinopathy, and based on comparative phenotypic analysis, we suggest that human AI resulting from the ENAMp.L31R mutation is another proteinopathic disease. Identifying a common aetiology for AI resulting from mutations in two different genes opens the way for developing pharmaceutical interventions designed to relieve ER stress or modulate the UPR during enamel development to ameliorate the clinical phenotype.

Novel DLX3 variants in amelogenesis imperfecta with attenuated tricho-dento-osseous syndrome.

OBJECTIVES: Variants in DLX3 cause tricho-dento-osseous syndrome (TDO, MIM #190320), a systemic condition with hair, nail and bony changes, taurodontism and amelogenesis imperfecta (AI), inherited in an autosomal dominant fashion. Different variants found within this gene are associated with different phenotypic presentations. To date, six different DLX3 variants have been reported in TDO. The aim of this paper was to explore and discuss three recently uncovered new variants in DLX3. SUBJECTS AND METHODS: Whole-exome sequencing identified a new DLX3 variant in one family, recruited as part of an ongoing study of genetic variants associated with AI. Targeted clinical exome sequencing of two further families revealed another new variant of DLX3 and complete heterozygous deletion of DLX3. For all three families, the phenotypes were shown to consist of AI and taurodontism, together with other attenuated features of TDO. RESULTS: c.574delG p.(E192Rfs*66), c.476G>T (p.R159L) and a heterozygous deletion of the entire DLX3 coding region were identified in our families. CONCLUSION: These previously unreported variants add to the growing literature surrounding AI, allowing for more accurate genetic testing and better understanding of the associated clinical consequences.

Environmental influences on the trace element content of teeth--implications for disease and nutritional status.

The aim of this study was to compare the trace element content of children's primary teeth from Uganda and the UK. The Ugandan teeth were from children living in an area where endomyocardial fibrosis (EMF), a cardiac disease, is prevalent. The latter has been putatively linked to insufficient magnesium intake and excess cerium exposure. Primary teeth were collected from 21 Ugandan and 27 UK children. The crowns and roots of the teeth were separated and the former digested and analysed for several major and trace elements by inductively coupled plasma mass spectrometry (ICP-MS) and atomic emission spectrometry (ICP-AES). In addition, the enamel and dentine of eight UK and seven Ugandan primary teeth were isolated via density separation and analysed as above. The data were assessed using non-parametric statistical tests. The Ugandan teeth contained significantly (P < 0.05) greater concentrations of strontium, barium, cerium, lanthanum, praseodymium and significantly less zinc than the UK teeth. No significant difference in the concentrations of aluminium, calcium, copper, magnesium, lead and uranium were found. Analysis of enamel and dentine demonstrated that the former was enriched with several elements including cerium. It is concluded, that the environment, influences the trace element content of primary teeth and this may be useful for monitoring nutritional status. With respect to a geochemical cause for EMF, there is no positive evidence that EMF in Uganda is associated with reduced magnesium and increased cerium uptake in primary teeth. This does not, however, exclude cerium from playing a role in the aetiology of EMF.

The management of traumatically intruded permanent incisors in children.

Trauma to the permanent dentition, particularly the maxillary incisors, is common. Prompt and appropriate management can significantly improve the prognosis for many of these dentoalveolar injuries. Unfortunately, much of this trauma is left untreated. This paper discusses the management of children who present with intruded permanent incisors.

The erosive potential of flavoured sparkling water drinks.

OBJECTIVE: The potential role of acidic drinks in the aetiology of dental erosion is well recognized. Whilst the wide-scale consumption of bottled waters is unlikely to contribute significantly to erosion, the role of flavoured sparkling water drinks is unclear. The aim of this study was to determine the pH, titratable acidity and in vitro erosive potential of a selection of these drinks drawn from the UK market to identify what dietary advice would be appropriate in relation to their consumption. METHODS: pH was measured using a pH electrode and titratable acidity recorded by titration with 0.1-m NaOH. Erosive potential was assessed using an in vitro dissolution assay with hydroxyapatite powder and electron microscopic examination of surface enamel of extracted human teeth, following exposure to the flavoured sparkling waters for 30 min. RESULTS: All of the flavoured waters tested showed appreciable titratable acidity (0.344-0.663 mmol) and low pH (2.74-3.34). In the hydroxyapatite dissolution assay, all of the waters demonstrated erosive potential (89-143%) similar to or greater than that of pure orange juice, an established erosive drink. Exposure of the extracted teeth to the flavoured waters resulted in surface changes consistent with erosive dissolution. CONCLUSIONS: Flavoured sparkling waters should be considered as potentially erosive, and preventive advice on their consumption should recognize them as potentially acidic drinks rather than water with flavouring.

A sampling and analytical methodology for dental trace element analysis.

The role of trace elements in human health and environmental pollution has developed into an extensive field of research. This study describes a sampling and analytical strategy to determine the trace element content of primary (deciduous) teeth and to assess their use in environmental health and nutrition studies. Exfoliated and extracted primary teeth were collected from 21 Ugandan and 27 UK children. The crown and root of the teeth were separated and the former digested and analysed for several elements by inductively coupled plasma mass spectrometry. The influence of country, tooth type, age and gender were statistically investigated in addition to within-person variation. A principal components analysis (PCA) was used to treat the data in a multivariate fashion and facilitated the moderation of outliers. The results demonstrated that country of origin has an important influence on the elemental composition of teeth and that tooth type should be controlled in these types of studies. Given such a restriction, the age and gender of the donor should have no effect and do not need to be controlled. In addition, where country of domicile, age and gender were controlled, the concentrations of most elements within a single tooth type were representative of an individual and therefore may be indicative of health status.