Dental and Periodontal Health Status of Beta Thalassemia Major and Sickle Cell Anemic Patients: A Comparative Study

Abstract

Background: This study aimed to assess the dental and periodontal health status of beta thalassemia major and sickle cell anemic patients in Bilaspur, Chattishgarh, India.

Materials & Methods: A total of 750 patients were included in the study. The patients were randomly divided into three groups I (n=250), II (n=250) and III (n=250), ranging from 3-15 years. After performing a thourough general examination, including their demographic data, intraoral examination was done using Decayed-Missing-Filled Teeth Index (DMFT Index), Plaque index (PI) and Gingival index (GI). Statistical analysis was done using statistical software SPSS 17.5 version. Chi square test & student t test was used for the comparison of study and control groups. The level of significance was set at P<0.05.

Results: In the present study, it was found that, prevalence of dental caries and periodontal diseases was significantly more in beta thalassemic patients followed by sickle cell anemic patients than control group. However, when group I (beta thalassemia) was compared with group II (sickle cell anemia), results were found to highly significant (P<0.001) only for decayed missing filled tooth.

Conclusion: Appropriate dental and periodontal care improves a patient's quality of life. Preventive dental care is must for thalassemic and Sickle cell disease patients.

How to cite this article: Singh J, Singh N, Kumar A, Kedia NB, Agarwal A. Dental and Periodontal Health Status of Beta Thalassemia Major and Sickle Cell Anemic Patients: A Comparative Study. J Int Oral Health 2013; 5(5):53-8.

Introduction

Haemoglobinopathies, mainly thalassaemias and sickle-cell anemia, are globally widespread. About 5% of the world's population carries genes responsible for haemoglobinopathies1. Each year about 3,00,000 infants are born with major hemoglobin disorders – including more than 2,00,000 cases of sickle-cell anemia in Africa. Globally, there are more carriers (i.e. healthy people who have inherited only one mutant gene from one parent) of thalassemia than of sickle-cell anemia, but the high frequency of the sickle-cell gene in certain areas leads to a high rate of affected newborns.1-2

Sickle-cell anemia is particularly common among people whose ancestors come from sub-Saharan Africa, India, Saudi Arabia and Mediterranean countries. 2-3

Worldwide, patients with hemoglobin E-beta-thalassemia (Hb E/β-thalassemia) represent approximately 50 per cent of those affected with severe beta thalassemia. The highest frequencies are observed in India, Bangladesh and throughout Southeast Asia, particularly in Thailand, Laos and Cambodia, where it is common for individuals to inherit alleles for both hemoglobin E (Hb E) and beta-thalassaemia.3-6

Sickle cell disease (SCD) 7 and thalassemia 8 is an inher-ited autosomal recessive blood disease.

Sickle cell disease is a chronic disorder has been linked to hypoxia. The pathophysiology of Sickle Cell Disease is thought to result from polymerization of hemoglobin S in red blood cells (RBCs) under hypoxic conditions, which results in the occlusion of blood vessels. The single amino-acid change in the beta subunit causes sickle hemoglobin to polymerize, especially under low oxygen tension. Polymerization causes the RBCs to deform into the characteristic sickle shape, thus plugging blood vessels.7

Whereas thalassemia results in reduced rate of synthesis of one of globin chains that form hemoglobin which in turn causes anemia. No hemoglobin chains are produced or only a very small amount is produced which prevents the synthesis of normal adult hemoglobin and severe damage the red blood cells capacity to transport oxygen. The oral structural changes occurs in thalassemic patients are due to maxillary enlargement resulted into protrusion of anterior teeth, increased space between teeth, overbite and open bite and varying degree of malocclusion which further predisposed to dental carries.9

Not much information is available on the association of dental & periodontal health status with sickle cell anemic and Beta thalassemic patients separately and comparison of the two former mentioned diseases, which affects both general & oral health, related quality of life. Therefore, there is a need to assess the oral health status of such patients, which poses a major health problem to the society.

Therefore this study was aimed to assess the dental and periodontal health status of beta thalassemia major and sickle cell anemic patients in Bilaspur, Chattishgarh, India.

Materials & Methods

A cross sectional study was conducted in the CIMS medical college Bilaspur, Chattishgarh, India. A total of 750 patients were included in the study. The patients were randomly divided into three groups I, II and III. Group I comprised of beta thalassemic patients (n=250) and Group II comprised of sickle cell anemic patients (n=250) of both sex and varying age groups. These selected 500 patients were regularly attending the Out Patient Department (OPD) or blood bank for repeated blood transfusion or admitted in the wards of Department of Pediatrics, CIMS medical hospital, Bilaspur, Chattishgarh. Group III was a healthy control group (n=250) of similar age and gender, taken from three different schools in Bilaspur. Ethical committee of hospital approved the study & consent was obtained from the parents of all patients. Study was conducted for a period of one year (June 2011 to May 2012).

Patients who were earlier diagnosed with sickle cell anemia and beta thalassemia, of age ranging from 3-15 years, were only included in the study. Those suffering from other diseases known to influence dental caries or severity of periodontal disease were excluded from the study.

After performing a thorough general examination, including their demographic data, intraoral examination was done using;

1. Decayed-Missing-Filled Teeth Index (DMFT Index), separately for permanent teeth10 and deciduous teeth.11

2. Plaque index given by Silness & Loe.12

3. Gingival index given by Loe & Silness.13

Autoclaved Plane mouth mirror & pig tail explorer were used to examine the oral cavity. Single examiner & single recorder were maintained throughout the study period. Intra examiner variability was 0.89.

Statistical analysis was done using statistical software SPSS 17.5 version. Chi square test & student t test was used for the comparison of study and control groups. The level of significance was set at P<0.05.

Results

Table 1 shows distribution of study population in different groups according to gender (total males were 56.5% and females were 43.5%).

Table 1. Demographic data of study population.

Group	Gender		Total (%)
	Male (%)	Female (%)
Beta thalassemia	115 (46)	135 (54)	250 (100)
Sickle cell anemia	116 (46.4)	134 (53.6)	250 (100)
Control group	193 (77.2)	57 (22.8)	250 (100)
Total	424 (56.5)	326 (43.5)	750 (100)

In the present study, prevalence of dental caries and periodontal diseases was found to highly significant (P<0.001) among all the three groups, (Table 2).

Table 2. Prevalance of dental caries, periodontal diseases in study population.

Indicies	Groups	Mean ± SD	F value	P value
DMFT*	Beta thalassemia Sickle cell anemia Control group	13.33± 6.813 6.59±3.494 1.131±.072	316.036		0.0001£
PI**	Beta thalassemia Sickle cell anemia Control group	3.66±2.115 3.33±2.105 3.28±1.901	12.512		0.0001£
GI***	Beta thalassemia Sickle cell anemia Control group	2.53±1.152 2.64±1.071 2.04±2.410	9.347		0.0001£

*DMFT- decayed missing filled tooth

**PI- Plaque index

***GI- Gingival index

£ Highly significant

When, group I (beta thalassemia) was compared with group III (control group), the mean±standard deviation for decayed missing filled tooth was (DMFT=13.33±6.813, 3.51±1.131), plaque index (PI= 3.66±2.115, 2.83±1.407) and gingival index (GI=2.83±1.152, 2.04±1.410).

Similarly, when group II (sickle cell anemia) was compared with group III (control group), the mean±standard deviation for decayed missing filled tooth (DMFT=6.59±3.494, 3.51±1.131), plaque index (PI=3.33±2.015, 2.83±1.407) and gingival index (GI=2.64±1.071, 2.04±2.410).

Results were found to be highly significant (P<0.001) when comparison was made between above groups (Table 3 & 4).

Table 3. Prevalance of dental caries and periodontal diseases between beta thalassemia patients and control group.

Variables	Groups	Mean ± SD	F value	T value	P value
DMFT*	Beta thalassemia Control group	13.33±6.813 3.51±1.131	563.746	22.490	0.0001£
PI**	Beta thalassemia Control group	3.66±2.115 2.83±1.407	68.883	5.179	0.0001£
GI***	Beta thalassemia Control group	2.83±1.152 2.04±1.410	18.715	3.912	0.018
Gender	Beta thalassemia Control group	0.54±0.499 0.23±0.420	0.23±0.420	7.557	0.0001£

*DMFT- decayed missing filled tooth

**PI- Plaque index

***GI- Gingival index

£ Highly significant

Table 4. Prevalance of dental caries and periodontal diseases between sickle cell anemic patients and control group.

Variables	Groups	Mean ± SD	F value	T value	P value
DMFT*	Sickle cell anemia Control group	6.59±3.494 3.51±1.131	207.158	13.259	0.0001£
PI**	Sickle cell anemia Control group	3.33±2.015 2.83±1.407	45.200	3.216	0.0001£
GI***	Sickle cell anemia Control group	2.83±1.152 2.04±2.410	3.680	3.612	0.056
Gender	Sickle cell anemia Control group	0.54±0.500 0.23±0.420	98.586	7.458	0.0001£

However, when group I (beta thalassemia) was compared with group II (sickle cell anemia), results were found to highly significant (P<0.001) only for decayed missing filled tooth (DMFT=6.59±3.494, 13.33±6.813) (Table 5).

Table 5. Prevalance of dental caries and periodontal diseases between sickle cell anemic and beta thalassemia patients.

Variables	Groups	Mean ± SD	F value	T value	P value
DMFT*	Sickle cell anemia Control group	6.59±3.494 13.33±6.813	161.413	13.925	0.0001£
PI**	Sickle cell anemia Control group	3.33±2.015 3.66±2.115	1.787	1.787	0.182
GI***	Sickle cell anemia Control group	2.64±1.071 2.53±1.152	1.925	1.126	0.166
Gender	Sickle cell anemia Control group	0.54±0.500 0.54±0.499	.032	.090	.032

Gender distribution of findings

When, group I (beta thalassemia) was compared with group III (control group), the mean±standard deviation was 0.54±0.499, 0.23±0.420 and when group II (sickle cell anemia) was compared with group III (control group), the mean±standard deviation was 0.54±0.500, 0.23±0.420. Comparison between above mentioned groups were highly significant (P<0.001) (Table 3 & 4).

In contrast, when group I (beta thalassemia) was compared with group II (sickle cell anemia), the mean±standard deviation was 0.54±0.500, 0.54±0.499. Prevalence of dental caries and periodontal diseases, between group I and II was not statistically significant. In the present study, it was found that, prevalence of

dental caries and periodontal diseases was significantly more in beta thalassemic patients followed by sickle cell anemic patients than control group.

Discussion

Present study was probably among first attempts in India to compare the prevalence of dental caries and periodontal diseases among beta thalassemic and sickle cell anemic patients in a systematic way.

Navpreet Kaur et al. (2012)8 and Dr. Veena R. (2006)14 concluded that the patients with Beta thalassemia had higher caries experience (DMFT=3.45 ± 4.20, 3.14±1.92) prevalence than the healthy controls (DMFT=1.82 ± 2.51, 1.52±1.55). In their study, no significant increased levels of gingivitis or plaque accumulation were seen in Beta thalassemia patients than in controls as compared to our study. We found significant higher prevalence of both dental caries and periodontal diseases among beta thalassemic patients (DMFT=13.33±6.813, 3.51±1.131), plaque index (PI= 3.66±2.115, 2.83±1.407) and gingival index (GI=2.83±1.152, 2.04±1.410).

However, Mean DMFT score was significantly higher in group I (beta thalassemic patients) compared to group III (control group) (DMFT=13.33±6.813, 3.51±1.131) which is similar to study conducted by Navpreet Kaur et al. (2012)7, Al- Wahadni A M, Taani D Q, Al- Omari M O15 and in another study conducted by Sunil Gomber and Pooja Dewan16 and Dr. Veena R.14

The patients with Beta thalassemia had higher caries experience than the normal children. Level of dental caries may be explained on the basis of chronic nature of thalassemia. Patients preoccupied with their main, life threatening problem, neglect basic preventive dental care.7

Another reason could be because of the increased sensitivity to local factors (oral hygiene, tooth brushing habit and frequency of sugar intake).14

A study conducted Esra Guzeldemir (2011)6 had found plaque and gingival indices were significantly higher in sickle cell anemic patients than in healthy individuals (Peridontal Disease and Gingival Index (P=0.02; r=0.299), Peridontal Disease and Plaque Index (P=0.01; r=0.343); Bleeding on probing and Gingival Index (P < 0.0001; r=0.503). These results are similar to our study, when comparison was made between sickle cell anemic patients and control group as follows, plaque index (PI=3.33±2.015, 2.83±1.407) and gingival index (GI=2.64±1.071, 2.04±2.410).

Oral health is not a primary concern of Sickle Cell Disease patients. Various studies had now found that, no significant differences existed regarding the periodontal diseases between patients with Sickle Cell Disease and healthy individuals.6, 17, 18, 19

Our results were disagreeing with the findings of Crawford17, Arowojolu and Savage18 and Arowojolu.19 Crawford17 suggested that Sickle Cell Disease is not associated with increased levels of gingivitis and periodontitis in patients with Sickle Cell Disease. In agreement with the results of a study by Crawford,17 Arowojolu and Savage18 found no significant difference in alveolar bone loss patterns between patients and controls. In the same study group, Arowojolu19 found no clinical periodontal disease or attachment loss in patients with Sickle Cell Disease.

However our study has some limitations. Firstly, sample size of the study population was small and taken from only CIMS hospital, Bilaspur and secondly, the cross sectional nature of the study prevents drawing inferences about casual relationships. Hence more studies are required in this field with increased sample sizes and considerably longer durations to validate our findings.

Conclusions

Appropriate dental and periodontal care improves a patient's quality of life by preventing eating difficulties, oral diseases, and esthetic concerns, and facilitates the management of the disease by the hematologist. Preventive dental care is must for thalassemic and SCD patients.