Introduction
Dental enamel is highly mineralized tissue occupied by large hydroxyapatite crystals that are organized into prisms [
1]. Enamel formation (amelogenesis) is the result of a complex biomineralization process, which is coordinated reciprocal interactions between ectoderm and mesenchyme [
2]. Ameloblasts are differentiated from inner enamel epithelium cells and secrete multiple extracellular matrix proteins into the developing enamel layer [
3]. As the crystals ribbons undergo nucleation and elongation, the matrix proteins are cleaved and degraded by proteases and reabsorbed by ameloblasts to allow the mineral ribbons to thicken and widen, finally achieving fully mineralization with remarkable hardness [
4]. Any genetic or environmental disturbances can cause developmental enamel defects in a localized or generalized pattern [
5].
Amelogenesis imperfecta (AI) is an inherited disorder affecting tooth enamel formation which is genetically and phenotypically heterogeneous [
6]. AI exhibit diverse clinical phenotypes depending on the stages of disturbance occurrence [
7]. Based on clinical appearance, cases of enamel malformation are categorized as hypoplastic, hypomaturation and hypocalcified types [
8]. Identifying the genes that causing isolated AI provide the molecular clues for dental enamel formation. To date, more than 27 genes are known to be involved in the molecular pathogenesis of AI, in which amelogenin (
AMELX, Xp22.3-Xp22.1), enamelin (
ENAM, 4q21), ameloblastin (
AMBN, 4q21), kallikrein related peptidase 4 (
KLK4, 19q13), matrix metallopeptidase 20 (
MMP20, 11q22) are common candidate genes reported [
5,
9,
10]. The disease-causing mutations are usually characterized as missense, nonsense, or frameshift mutations [
11]. Moreover, mutation at exon-intron boundaries can leads to retention of the intron, or exon skipping [
12]. To date, around 10% mutations occurred in exon-intron boundary were reported to cause AI, including
AMBN (1),
CNNM4 (1),
COL17A1 (1),
ENAM (7),
FAM20A (8),
LAMB3 (1),
LTBP3 (1),
MMP20 (4),
ODAPH (1),
RELT (1),
SLC10A7 (3), and
TP63 (1) [
13].
Amelogenin is the most abundant extracellular matrix protein mainly expressed by preameloblasts and ameloblasts, which plays a vital role in hydroxyapatite crystal elongation and growth [
2].
AMELX has 7 exons and multiple isoforms resulting from conserved alternative splicing in the mRNA transcripts [
14].
AMELX mutations lead to X-linked AI, which is often manifested as thinner enamel and hypomatured teeth with brown discoloration [
15]. At present, more than 28 pathogenic
AMELX mutations have been reported [
16]. It is reported that exon 4 is usually skipped during pre-mRNA splicing and internal splicing sites can be observed in exon 6 [
17]. Silent mutation in exon 4 was reported to cause generalized pitted hypoplastic AI by inclusion of exon 4 during transcription process [
14]. The phenotypes varied from a deficiency in the thickness (hypoplasia) to mineralization (hypomineralization/hypomaturation) [
10]. Characterization in domains of AMELX help to provide the clues to understanding diverse phenotypes.
Enamelin is the largest and accounts for about 5% of the enamel matrix proteins, which is mainly expressed in the secretory ameloblasts and participates in nucleation and extension of enamel crystals during enamel formation [
18,
19]. Mutations of
ENAM lead to hypoplasitc AI by an autosomal dominant or recessive inheritance pattern. Up to now, 24 pathogenic mutations of
ENAM have been reported [
13]. Human enamelin gene contains 10 exons, in which exon 2 is usually skipped during pre-mRNA splicing. Splicing donor site mutation (NM_031889.3: c.-61 + 1G > A) was reported to result in a retention of intron 1 and exon 2, presumably disturbing regulation transcription of 5’UTR of enamelin gene [
20]. However, the mechanism of AI caused by splicing mutations is still unclear.
In the current study, we performed a mutational analysis in 2 Chinese families presenting with hypoplastic and hypomaturation AI. We identified two novel splicing mutations in AMELX and ENAM, respectively. Splicing assay confirmed the effects of pre-mRNA splicing mutation to further reveal the genotype-phenotype correlation with AI causative genes.
Discussion
In this study, we identified two novel splicing mutations in AMLEX and ENAM causing hypoplastic/hypomaturation AI and hypoplastic AI, respectively. The intron-exon boundary mutation on AMLEX in proband 1 resulted in a partial inclusion of intron 6, which would change the secondary structure of amelogenin. The proband 2 with a typical hypoplastic AI phenotype, mapped the disease-causing mutation to a novel mutation in intron 4 of ENAM. Furthermore, the minigene splicing assay revealed that the mutation also influenced mRNA splicing by skipping of exon 4, which was predicted to destruct the signal peptide.
Through selective inclusion or exclusion of exons or introns during pre-mRNA processing, alternative splicing generates distinct mRNA variants and is essential for development, homeostasis, and renewal [
24]. Sixteen alternative splicing transcripts can be observed in murine
Amelx [
25,
26]. Splicing mutations can create new splice sites or enhancer sequences, which create aberrant transcripts and contribute to disease [
12]. In this study, for the first time, we reported a splicing mutation of
AMELX gene could cause intron retention. It is well-known that mRNAs with retained introns are generally restricted from exiting the nucleus [
27]. Most intron retention in mammalian mRNAs was considered to downregulate gene expression by RUST (regulated unproductive splicing and translation) or NMD (nonsense mediated decay) [
28,
29]. As we all know, amelognenin participates in enamel matrix deposition and mineralization [
30,
31]. The lack of normal transcripts would prevent the elongation of the crystal, and promotes apoptosis of ameloblasts, leading to severe defects of enamel bio-mineralization [
32]. Consistently, decreased enamel thickness and hypomineralization could be observed in the dentitions of proband 1, indicating that the splicing mutation of
AMELX results in enamel malformation and hypomineralization.
Exon skipping is the most common alternative splicing, which is reported in genetic diseases such as Duchenne muscular dystrophy [
24,
33]. Splicing mutations in
ENAM was predicted to cause intron retention or exon skipping [
34,
35]. In our study, the splicing mutation in proband 2 led to exon 4 skipping. Human
ENAM encodes 1142 amino acids, including a 39-amino-acid length signal peptide encoded by exon 3 and exon 4 [
20]. Exon 4 skipping would delete 23 amino acids and interrupt the signal peptide as result. The c.123 + 4 A > G mutation was predicted to alter the secondary structure of enamelin and downregulate the ENAM expression.
Dose-dependent effect can be investigated in the enamel phenotypes caused by
ENAM mutations. In vitro experiment showed that the secretion of mutant protein caused by a splicing mutation was reduced [
20]. When only one allele is mutated, the phenotype may be slight or not obvious, and when both alleles are mutated, the phenotype is significant [
9]. Exon skipping was predicted to cause a more severe phenotype [
36]. Meanwhile, the proband in family 2, who was a heterozygous mutation, presented a phenotype with generalized thinner enamel thickness and localized enamel pitting, which was consistent with the previous reports. Haploinsufficiency would result in hypoplastic enamel.
In summary, we characterized two novel splicing mutations in AMELX and ENAM in two Chinese pedigrees. The splicing mutation in AMELX caused the partial retention of intron 6 during pre-mRNA splicing. The mutation in intron 4 of ENAM resulted in exon 4 skipping. Splicing mutations in AMELX and ENAM lead to AI. These results expand the spectrum of gene mutations causing amelogenesis imperfecta, and broaden our understanding of pathologic mechanisms of splicing mutations causing AI.
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