Clin Oral Invest (2002) 6:223–226
DOI 10.1007/s00784-002-0179-y
O R I G I N A L A RT I C L E
P. F. Lugliè · Guglielmo Campus · C. Deiola
M. G. Mela · D. Gallisai
Oral condition, chemistry of saliva,
and salivary levels of Streptococcus mutans in thalassemic patients
Received: 26 June 2002 / Accepted: 22 August 2002 / Published online: 26 October 2002
© Springer-Verlag 2002
Abstract The purpose of this investigation was to deter-
mine the oral status in a group of patients with thalasse-
mia major (TM). Eighteen TM patients (15 M, three F)
and 18 healthy controls randomly matched for age and
sex were examined for dental caries using the decayed,
missing, and filled teeth (DMFT) index and for oral hy-
giene conditions using the oral hygiene index (OHI)-S.
Spontaneous saliva was collected from each subject, and
the biochemical composition (calcium, phosphorous, po-
tassium, sodium, urea) was determined. Furthermore,
salivary Streptococcus mutans levels were evaluated.
Statistical analysis (Student’s t-test) were performed for
means comparison, while independence among categori-
cal variables was assessed using the χ2 test. Fisher’s ex-
act test was used when expected cell values were less
than 5. Dental status (DMFT index) was almost equal in
the two groups (10.3 in TM vs 9.4 in controls, P=0.34).
The occurrence of plaque (OHI-S 2) was higher in the
control group, but no statistically significant association
was observed between oral hygiene conditions in the two
groups (Fisher’s exact test 0.47, P=0.79). Biochemical
saliva composition was very similar in the two groups;
only the urea concentration was lower in TM, and
this difference was statistically significant (P=0.002).
The TM patients had an increased presence of mutans
streptococci at detectable levels. Our findings confirm
that, although no substantial differences were found be-
tween the two observed groups, further investigations are
needed to determine the theoretical risk of oral diseases
in thalassemic patients.
Keywords β-Thalassemia · Dental caries · Oral hygiene ·
Saliva · Streptococcus mutans
P.F. Lugliè · G. Campus (✉) · C. Deiola
Dental Institute, University of Sassari,
Viale San Pietro 43/C, 07100 Sassari, Italy
e-mail: gcampus@uniss.it
Tel.: +39-079-228540, Fax: +39-079-228541
M.G. Mela · D. Gallisai
Pediatric Department, University of Sassari, Sassari, Italy
Introduction
The thalassemias are a diverse group of genetic blood
diseases characterized by absent or decreased production
of globulin protein chains, resulting in microcytic ane-
mia of varying degrees. Thalassemia distribution coin-
cides with areas where P. falciparum malaria is common.
The β-thalassemias are seen primarily in Africa, south-
east Asia, and regions surrounding the Mediterranean
Sea.
β-Thalassemia major (β-TM) was first described by a
Detroit pediatrician, Thomas Cooley, in 1925. Patients
with untreated TM have ineffective erythropoiesis, de-
creased red cell deformability, and enhanced clearance of
defective red cells by macrophages. The result is a very
hypermetabolic bone marrow with thrombocytosis, leu-
kocytosis, and microcytic anemia in the young child pri-
or to splenomegalia. Diagnosis can be confirmed by
demonstrating thalassemia traits in both parents, globin
biosynthetic ratios, or β-gene screening. The latter iden-
tifies the most common and some uncommon, but not all
mutations. Bone marrow hyperplasia is reflected at the
skeletal level in: voluminous head and cut of the eyes of
the mongoloid type with epicanthus, prominence of the
malar eminence, prominence of the frontal drafts, root of
the nose sunken (flat-nosed), and thickening of the crani-
al bones, thus producing the typical aspect of the thalas-
semic patient, facies thalassemica. In previous studies,
Lugliè [10, 11] studied the maxillofacial problems of
Sardinian TM patients and noticed the positive influence
of intensive transfusion therapy and the pretransfusion
hemoglobin concentration on oral status, underlining that
conditions in the oral cavity varied remarkably according
to the onset of therapy.
A small number of clinical studies have analyzed the
status of the oral cavities in thalassemic patients, consid-
ering both dental and periodontal conditions [4, 5, 13,
14, 15]. Delayed eruption of both deciduous and perma-
nent teeth and high frequency of caries were observed;
moreover, caries disease was related to the severity of
systemic disease. A significant inverse correlation was
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observed between transfusion requirements and caries in
mixed dentition [2].
The purpose of this study was to assess the preva-
lence and distribution of dental caries and oral hygiene
conditions in a group of patients affected by TM. Fur-
thermore, salivary biochemical composition and the
mean number of colony-forming units (CFU) of Strepto-
coccus mutans in the total saliva were evaluated.
Materials and methods
Selection of the sample
The patients were collected from a sample that had un-
dergone previous studies for the maxillofacial aspects of
thalassemia 20 years ago [10, 11]. The current study
group was composed of 18 subjects (15 male and three
female, age range 23–31 years). Matched controls (1:1)
were randomly paired for age and sex and selected from
a sample of the population living in the town of Sassari.
The patients were treated in the Pedodontic Department
of the Dental Institute of the University of Sassari.
Clinical parameters
A clinical record was filled out for each patient: one part
for gathering personal data and a second one specific to
dental examination. The present number of teeth was re-
corded and the decayed, missing, and filled teeth
(DMFT) index was quantified. Oral hygienic conditions
were recorded using the oral hygiene index (OHI)-S [7].
Saliva samples
Spontaneous saliva was collected from each patient,
placed in test tubes (Eppendorf Bel-Art, USA), and pre-
served at –80°C before chemical analysis. The samples
were centrifuged at 1,500 rpm for 10 min. Concentra-
tions of calcium, phosphorous, potassium, sodium, and
urea were assayed with a Serum Technicon RA-1000 an-
alyzer system.
Wooden tongue depressors with enlarged extremity
were pressed against the subjects’ tongues for 30 s and
then onto Rondac plates containing mitis salivarius agar
with bacitracin (0.2 U/ml) and sucrose (200 g/l) selective
for mutans streptococci [12]. The plates were incubated
for 48 h in anaerobiosis (BBI gas Pak, Anaerobic Sys-
tems) and 24 h in aerobiosis at 37°C. Then the colonies
with S. mutans morphology were detected and counted,
following Emilson’s suggestions [3]. Colonies with un-
clear aspect were verified by sorbitol and mannitol fer-
mentation and by adhesive growth on tubes containing
trypticase soy broth with 0.1 g/l sucrose. Based on the
presence of at least one presumptive S. mutans colony on
the plate, corresponding to an estimated salivary S. mu-
tans level of 1×104 cfu/ml, patients were divided into S.
mutans-positive and S. mutans-negative groups.
Comparison of quantitative variables among the
groups was carried out using Student’s t-test. Indepen-
dence among qualitative variables was tested with the χ2
test. The data were processed with Nanostat software,
version 1.0 (Adelso, Italy).
Results
The TM group had a mean DMFT score of 10.3±7.3
with a median of 9.5 (25%–75% 5.5–15.0), while in the
control group DMFT was 9.4±4.4 with a median of 10
(25%–75% 6.3–11.0) (statistical t value 0.42, P=0.34).
The mean values of DMFT components were: TM 2.8±
4.1, controls 1.6±1.5 for DT; TM 0.8±1.4, controls
0.7±1.4 for MT; and TM 6.7±5.7, controls 0±3.8 for FT
(Table 1). No statistically significant difference was not-

Table 1 Results in the DMFT

index and its components TM group Controls Statistical
analysis
Mean±SD Median Mean±SD Median t, P values
(25%–75%) (25%–75%)

DMFT 10.3±7.3 9.5 (5.5–15.0) 9.4±4.4 10.0 (6.3–11.0) 0.42, 0.34

DT 2.8±4.1 2.0 (0.0–3.0) 1.6±1.5 1.0 (1.0–2.0) 0.18, 0.12
MT 0.8±1.4 0.0 (0.0–1.0) 0.7±1.4 0.0 (0.0–0.8) 0.10, 0.45
FT 6.7±5.7 6.5 (1.5–9.8) 7.1±3.8 7.0 (5.0–9.8) 0.28, 0.39

Table 2 Sialochemistry in
18 TM patients and healthy TM Controls Statistical
controls analysis
Median 25%–75% Median 25%–75% t, P values

Calcium (mmol–1) 3.5 2.0–4.8 3.5 2.3–5.0 0.28, 0.39

Potassium (mmol–1) 25.0 21.0–28.75 27.0 21.3–28.8 0.31, 0.38
Sodium (mmol–1) 23.0 20.0–25.0 23.5 205–25.8 0.69, 0.25
Urea (mmol–1) 18.5 16.0–19.0 21.5 18.0–24.8 3.00, 0.002
Phosphorus (mmol–1) 17.9 15.3–19.0 17.5 14.0–19.0 0.42, 0.34

Fig. 1 Distribution of DMFT and its components (DT, MT, FT) in
the TM and control groups
Fig. 2 Oral hygiene status (OHI-S) in the two groups
ed. The DMFT analysis showed a similarly skewed dis-
tribution of the disease in both groups (Fig. 1). Plaque
presence was higher in the control group (OHI-S 2), but
no statistically significant association was observed be-
tween oral hygiene levels in the two groups (Fisher’s ex-
act test 0.47, P=0.79) (Fig. 2). Concentrations of electro-
lytes and urea in the stimulated saliva pools in the TM
and control groups can be seen in Table 2. Concentra-
tions of phosphorus, sodium, calcium, and potassium
were very similar in the two groups, while the urea con-
centration was lower in the TM group. This difference
was statistically significant (t=3.00, P=0.002).
225
Fig. 3 Salivary levels of S. mutans (<1×104 and >1×104) in the
two groups
The salivary levels of S. mutans are displayed in
Fig. 3. There was a difference between the two groups:
six patients (33.3%) in the TM group showed lower SM
levels (1×104 CFU/ml) than seven patients (38.8%) in
the control group. The TM patients showed higher de-
tectable levels of mutans streptococci, with an odds ratio
(OR) of 3.14, but the OR null value was included in the
confidence intervals (0.80–12.28).
Discussion
The main purpose of our investigation was to determine
relationships between the oral and chemical conditions
of saliva in TM patients. The DMFT index showed a
slightly higher mean value in the TM group, but no sta-
tistically significant difference was observed between the
two populations.
The oral hygiene status observed was similar in the
two groups. Previous studies [1, 4, 15] suggest that a
higher prevalence of gingivitis would be seen in TM pa-
tients and correlate to local factors or the maxillofacial
characteristics of thalassemic disease. It is well known
that orthodontic problems such as crowding, extreme
maxillary overjet, crossbite, and oral breathing are main-
ly implicated in gingival disease [8, 14]. We suppose that
the maxillofacial characteristics of TM patients can lead
to serious gingival problems, especially in the presence
of bad oral hygiene habits. These characteristics are
strictly related to the onset of transfusional therapy, as
described in previous studies [10, 11]. Our patients with
TM underwent transfusional therapy at very early ages,
thus reducing the typical facial characteristics and relat-
ed problems.
Concentrations of the biochemical components in sa-
liva play an important rule in oral diseases, but few stud-
ies examine this in connection with TM [15]. The saliva-
ry urea concentration was statistically significantly lower
in the TM group. Urea is secreted continuously in the
range of 3–10 mM in saliva and crevicular fluids of heal-
thy individuals [6] and is rapidly hydrolyzed by the ure-
ase enzymes of oral microflora. Existing data indirectly
226
support a major role for ureolysis in plaque pH homeo-
stasis. Elevated salivary urea and ammonia concentra-
tions correlate with marked reductions in the extent and
duration of plaque acidification following a carbohydrate
challenge [9]. Urea hydrolysis can neutralize plaque ac-
ids and may positively influence plaque ecology by pre-
venting the pH from falling to levels that select for the
outgrowth of aciduric, cariogenic micro-organisms. In
addition, ammonia released by ureolysis can promote re-
mineralization of the tooth enamel [13]. The lower sali-
vary urea concentration detected in the TM group is sim-
ilar to results previously described [15].
Salivary levels of S. mutans were statistically higher
in the TM group, and no paper about these levels in TM
patients is available in literature. So the clinical, salivary,
and microbiological data allow us to affirm that TM pa-
tients might be considered at risk for caries. However, it
is very questionable to state whether this difference is re-
lated to the systemic disease. De Mattia et al. [2] corre-
lated decay level and thalassemia parameters (mean fer-
ritin value, splenectomy, etc.), but statistically significant
results were found only for mixed dentition.
In conclusion, the theoretical risk of oral disease in
TM patients remains high, and prevention against oral
disease is very important, taking into account the higher
life expectancy of these patients and the role of good
oral status in better quality of life.
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