Dentinogenesis imperfecta


Dentinogenesis imperfecta is a genetic disorder of tooth development. It is inherited in an autosomal dominant pattern, as a result of mutations on chromosome 4q21, in the dentine sialophosphoprotein gene. It is one of the most frequently occurring autosomal dominant features in humans. Dentinogenesis imperfecta affects an estimated 1 in 6,000-8,000 people.
People with this condition have abnormal enamel, short and narrow roots, and can lack nerves. This condition can cause teeth to be discolored and translucent, giving teeth an opalescent sheen. Teeth are also less mineralized than normal, making them prone to rapid wear, breakage, and loss. These problems can affect primary teeth alone, or both baby teeth and permanent teeth, with the primary teeth usually more severely affected.
Although genetic factors are the main contributor for the condition, any environmental or systemic changes that impede calcification or metabolization of calcium can also result in anomalous dentin.

Classification

Shield classification (1973)

This is the most widely used classification for dentinogenesis imperfecta, and subdivides the condition into 3 types:

Type I

DI associated with Osteogenesis Imperfecta . Type of DI with similar dental abnormalities usually an autosomal dominant trait with variable expressivity but can be recessive if the associated osteogenesis imperfecta is of recessive type.
Recent genetic studies have identified that mutations in the genes coding for the collagen type 1 proteins, COL1A1 and COL1A2, are associated with this type of DI.
Not all individuals with OI have dentinogenesis imperfecta, and the prevalence of DI varies depending on the subtype of OI:
  • Higher prevalence of DI among individuals with OI type III and IV at 43-82% and 37-100%, respectively
  • Lower prevalence of DI among individuals with OI type I at 8-40%
  • No data available for other OI subtypes

    Type II

DI not associated with OI. Occurs in people without other inherited disorders. It is an autosomal dominant trait. A few families with type II have progressive hearing loss in addition to dental abnormalities. Also called hereditary opalescent dentin.

Type III

Brandywine isolate. This type is rare with occurrences only in the secluded populations in Maryland, USA. Similar to DI type II, this type is also not associated with OI. Its predominant characteristic is bell-shaped crowns, especially in the permanent dentition. Unlike Types I and II, it involves teeth with shell-like appearance and multiple pulp exposures.
Mutations in the gene coding for the dentine sialophosphoprotein are associated with DI type II and III. DSPP is a polypeptide which gives rise to 3 proteins; dentine sialoprotein, dentine glycoprotein, and dentine phosphoprotein. The DPP protein is thought to contribute to hydroxyapatite crystal formation and growth, a fundamental crystal which is widely distributed in mineralized dentin and enamel. The function of the DGP and DSP proteins is not well understood.
Genetic studies have shown that type II and III may be the same subtype of dentinogenesis imperfecta, differing only by the severity.

de La Dure-Molla, Foruner and Berdal (2015)

de La Dure-Molla, Foruner and Berdal have proposed a new classification to supersede the Shield Classification. This new classification is designed to overcome the shortcomings of its predecessor, mainly the clinical difficulty in using the Shield classification due to the overlapping signs and symptoms between the subtypes.
In this classification, the authors propose that the DSPP diseases, that is dentinogenesis imperfecta and dentin dysplasia, are jointly named "Dentinogenesis imperfecta", and sub-types are determined according to the severity of the condition. There are a few exceptions:
  • Shields' Dentine Dysplasia type I - this condition is unique in that it only affects root development, and is separately termed "radicular dentin dysplasia" in the new classification.
  • Shields' Dentinogenesis Imperfecta type I - this subtype is not acknowledged in this new classification as the authors deem it a different condition since it is a syndrome of osteogenesis imperfecta

    Mild type

Primary teeth are moderately affected.
Permanent teeth are not discolored, or the discoloration is mild. Little or no attrition is evident. The crown of the teeth may be bulbous and markedly constricted at the CEJ.
Radiographically, evidence of partial pulp obliteration with a "thistle-shaped appearance".

Moderate type

Teeth are moderately discolored. More attrition is evident with shortening of crown height. Crowns may appear bulbous with prominent constriction at the CEJ.
Radiographically, the pulp is small or is totally obliterated. Roots appear thinner and shorter than average. There may be periapical pathology.

Severe type

Teeth are markedly discolored. The crowns are very short due to severe attrition. Crowns may appear bulbous with prominent constriction at the CEJ.
Radiographically, pulp appears large and the dentin layer is thin. Roots are thin and short. There may be multiple periapical pathologies.

Radicular dentin dysplasia

This subtype is used in place of Shields' dentine dysplasia type I, in which only the roots of the teeth are affected.
Both primary and permanent teeth are affected.
The teeth appear normal clinically. Radiographically, the roots are shorter and fused together with a rounded apex.

Presentation

Clinical presentation

Clinical features include:
  • Discolored teeth - teeth may be amber, brown, blue or opalescent
  • Bulbous shape to the tooth crown due to cervical constriction
  • Tooth wear/Non-carious tooth surface loss - due to the poorly mineralized dentin, the enamel of the tooth is unsupported and subsequently shears or chips off as it is subjected to occlusal forces. This exposes the underlying less mineralized dentin which is less resistant to wear. Therefore, features of abrasion and attrition may become apparent.
  • Reduction in occlusal vertical dimension - this is secondary to the tooth wear/NCTSL. A reduced OVD can lead to craniofacial dysgnathia, poor tooth aesthetics, and disorders during chewing, swallowing, speaking and eating.
The primary teeth are usually more severely affected than permanent teeth.
Enamel is usually lost early because it is further inclined to attrition due to loss of scalloping at the dentinoenamel junction. It was suggested that the scalloping is beneficial for the mechanical properties of teeth as it reinforces the junction between enamel and dentin. However, the teeth are not more susceptible to dental caries than normal ones.
Periodontal disease, or gum disease, is a common finding amongst individuals with dentinogenesis imperfecta despite no clinical findings of tooth decay. The reason for this is currently not well understood.
Certain patients with dentinogenesis imperfecta will have multiple periapical abscesses apparently resulting from pulpal strangulation secondary to pulpal obliteration or from pulp exposure due to extensive coronal wear. They may need apical endontics to save the involved teeth.
Note that, although dentin exposure is a common clinical finding, individuals with dentinogenesis imperfecta usually do not experience tooth sensitivity as the exposed dentin is typically sclerosed, thereby appearing glassy/shiny.

Radiographic presentation

Radiographic features include:
  • Bulbous shape of tooth crown with pronounced cervical constriction
  • Small pulp, or total pulp obliteration
  • Small or obliterated root canal
  • Presence of pulp stones
  • Narrow and small roots
  • Periapical radiolucency without any evidence of clinical pathology such as tooth decay

    Presentation by subtype of Dentinogenesis Imperfecta

Clinical and radiographic features can be categorised by the subtype of dentinogenesis imperfecta :

Type I

Clinically, both the primary and permanent teeth often appear amber colored and translucent, and show signs of severe attrition. Primary teeth have a more obvious appearance as they have a thinner layer of enamel overlying dentin, thus the abnormal color of dentin is more noticeable.
Radiographically, affected teeth have short and narrow roots, and obliterated pulps due to dentin hypertrophy before or shortly after tooth eruption.
The severity of these features is variable, with some teeth presenting with total obliteration of the pulp, while other teeth appear to have normal, healthy dentin
Some type I cases present with no clinical findings, with only radiographic abnormalities.

Type II

Type II has a similar clinical and radiographic appearance to type I with some distinguishing features:
  • Bulbous crowns are common with pronounced cervical constriction
  • All teeth in the mouth are affected, with severe abnormalities present in both the primary and permanent teeth. This is in contrast to type I where the presentation is more variable
  • Rarely, individuals exhibit sensorineural hearing loss. It is proposed this hearing loss is a secondary feature to attrition; this type of tooth wear can cause jaw overclosure with subsequent changes to the shape of the inner ear, thus causing hearing loss. However, the true cause remains unknown.

    Type III

Similar clinical and radiographic features to that of type I and II are apparent for the permanent teeth. The main distinguishing feature is "shell teeth", a term used to describe the unique appearance of the primary teeth; the primary teeth have multiple pulp exposures and radiographically appear hollow as the dentin layer is thin and the pulp chamber is very large.

Histology

The enamel has a regular structure, however, there are abnormalities in the structure of dentin and at the amelo-dentinal junction. These abnormalities include:
  • Fewer dentinal tubules
  • Dentinal tubules may be of smaller diameter, irregular in shape, and may also be obliterated
  • Abnormal morphology of apatite crystals
  • Higher water and collagen content in the organic component of dentin