LRP5 Disorder: Fork-Shaped Incisors Clinical Report

CLINICAL REPORT
Fork-shaped mandibular incisors as a novel phenotype
of LRP5-associated disorder
Mamiko Yamada
1
| Kazumi Kubota
2,3
| Atsuro Uchida
4
| Tatsuhiko Yagihashi
1
|
Masahito Kawasaki
5
| Hisato Suzuki
1
| Tomoko Uehara
1,6
|
Toshiki Takenouchi
7
| Hiroshi Kurosaka
8
| Kenjiro Kosaki
1
1
Center for Medical Genetics, Keio University
School of Medicine, Tokyo, Japan
2
Department of Plastic and Reconstructive
Surgery, Keio University School of Medicine,
Tokyo, Japan
3
Department of Special Needs Dentistry,
Division of Hygiene and Oral Health, Showa
University School of Dentistry, Tokyo, Japan
4
Department of Ophthalmology, Keio
University School of Medicine, Tokyo, Japan
5
Medical corporation, Kawasaki Dental Clinic,
Kawasaki, Japan
6
Department of Pediatrics, Central Hospital,
Aichi Developmental Disability Center,
Kasugai, Aichi, Japan
7
Department of Pediatrics, Keio University
School of Medicine, Tokyo, Japan
8
Department of Orthodontics and Dentofacial
Orthopedics, Graduate School of Dentistry,
Osaka University, Osaka, Japan
Correspondence
Kenjiro Kosaki MD, Center for Medical
Genetics, Keio University School of Medicine,
35 Shinanomachi, Shinjuku-ku, Tokyo
160-8582, Japan.
Email: [email protected]
Funding information
Initiative on Rare and Undiagnosed Diseases
from the Japan Agency for Medical Research
and Development, Grant/Award Number:
JP20ek0109301
Abstract
The LRP5 gene encodes a Wnt signaling receptor to which Wnt binds directly. In
humans, pathogenic monoallelic variants in LRP5 have been associated with
increased bone density and exudative vitreoretinopathy. In mice, LRP5 plays a role in
tooth development, including periodontal tissue stability and cementum formation.
Here, we report a 14-year-old patient with a de novo non-synonymous variant,
p.(Val1245Met), in LRP5 who exhibited mildly reduced bone density and mild exuda-
tive vitreoretinopathy together with a previously unreported phenotype consisting of
dental abnormalities that included fork-like small incisors with short roots and an
anterior open bite, molars with a single root, and severe taurodontism. In that exuda-
tive vitreoretinopathy has been reported to be associated with heterozygous loss-of-
function variants of LRP5 and that our patient reported here with the p.(Val1245Met)
variant had mild exudative vitreoretinopathy, the variant can be considered as an
incomplete loss-of-function variant. Alternatively, the p.(Val1245Met) variant can be
considered as exerting a dominant-negative effect, as no patients with truncating
LRP5 variants and exudative vitreoretinopathy have been reported to exhibit dental
anomalies. The documentation of dental anomalies in the presently reported patient
strongly supports the notion that LRP5 plays a critical role in odontogenesis in
humans, similar to its role in mice.
KEYWORDS
aberrant teeth morphogenesis, low bone density, LRP5, Wnt signaling pathway
1|INTRODUCTION
The canonical Wnt signaling pathway plays a role in cell proliferation
and differentiation by regulating the amount of transcriptional
coactivator β-catenin, which controls a developmental gene expres-
sion program involving many components (MacDonald et al., 2009).
LRP5 (Low-density lipoprotein Receptor-related Protein 5; OMIM #
603506) is a component in Wnt signaling and an important receptor
to which Wnt binds directly (He et al., 2004). LRP5 plays a particularly
important role in the regulation of bone density, and gains in the func-
tion of LRP5 are known to cause a high bone mass (Roetzer
et al., 2018), while its loss-of-function causes osteoporosis-
pseudoglioma syndrome (OMIM #259770) and familial exudative
vitreoretinopathy (FEVR) (OMIM #601813) (Pekkinen et al., 2017;
Ubels et al., 2020). Dental malformations, including microdontia,
taurodontism, peg-shaped teeth, enamel hypoplasia, and missing
teeth, arising from dysfunction of the Wnt signaling pathway have
been well documented in human patients with Wnt10a variants
Received: 28 September 2020 Revised: 10 January 2021 Accepted: 6 February 2021
DOI: 10.1002/ajmg.a.62132
Am J Med Genet. 2021;1–6. wileyonlinelibrary.com/journal/ajmga © 2021 Wiley Periodicals LLC 1

(Yu et al., 2019a), and patients with LRP6 variants have been reported
to manifest congenital missing permanent teeth and hypohidrotic
ectodermal dysplasia (Yu et al., 2020a). However, dental mal-
formations have not previously been documented in humans with
LRP5 variants.
Recent studies on tooth development in mice have shown that
LRP5 plays an important role in periodontal tissue stability and tooth
cementum formation (Tamura and Nemoto, 2016). In β-catenin-
deficient mice, the differentiation of cementoblasts and dentin cells is
suppressed, and the normal growth of tooth roots is inhibited (Kim
et al., 2013). Here, we report a patient with unusual dental features
together with mild exudative vitreoretinopathy and a mildly reduced
bone density.
1.1 |Patient report
The patient was a 14-year-old male with microdontia and FEVR. He
was born at 40 weeks 3/7 days of gestation to unrelated parents with
no significant family history. His birthweight was 3000 g (−0.43 SD),
his body length was 47.0 cm (−1.45 SD), and his head circumference
was 33.0 cm (−0.38 SD).
His facial features included a triangular face, hypoplastic alae nasi,
short columella, narrow forehead, and kinky hair. Because of congeni-
tally missing (4 s premolars) and small permanent teeth, both dental
arches showed a spaced arch with a severe open bite. No remarkable
abnormalities in the primary teeth and no delays in eruption were
observed. However, the crowns of the lower incisors exhibited signifi-
cant notches in both the mesio- and disto-labial developmental
grooves, resulting in a fork-like morphology (Figure 1(a,c)). Addition-
ally, other teeth exhibited a variety of crown morphology defects,
including microdontia, a deep lingual groove, and an ectopic cusp
(Figure 1(b)). The patient did not exhibit oral habits such as finger
sucking or tongue thrust, according to his mother. There were no
remarkable disorders of oral functions, such as eating or speaking dis-
orders. The muscle tension of the lips and tongue seemed to be within
normal limits. According to Angle's classification of the molars, the
patient was classified as showing class I malocclusion (Angle, 1899);
FIGURE 1 Dental and ophthalmological examination of the patient. (a) Prolonged retention of the mandibular primary central incisors
resembling forks that had erupted at the age of 6 years and 5 months. (b) Intraoral photographs obtained at the age of 14 years and 5 months.
The anterior teeth cause an open bite. (c) Close-up view of the mandibular anterior teeth at the age of 14 years and 5 months. The mandibular
anterior teeth were described as showing microdontia resembling forks. (d) Orthopantomogram obtained at the age of 14 years and 5 months.
There are no tooth germs observed except at the third molars. Because of a congenital lack of permanent teeth, the patient has a mix of primary
and permanent teeth. (e) Wide-field angiography of the left eye performed at the age of 14 years and 6 months. Aberrant circumferential
peripheral vessels and an area of capillary nonperfusion in the temporal periphery (arrow) are observed. No evidence of leakage at the site of the
vascular-avascular junction or retinal neovascularization is seen [Color figure can be viewed at wileyonlinelibrary.com]
2YAMADA ET AL.

therefore, the relationship of the maxilla and mandible was also con-
sidered as being within normal limits. An orthopantomogram showed
short roots in all the incisors and a pipette-like root morphology in the
premolars. Narrow pulp chambers were observed in the incisors and
premolars. Both the upper and lower molars showed single roots with
severe taurodontism (Figure 1(d)). The open bite could have been
related to the small crowns and short roots of the teeth, which make
it easier for the teeth to move. The parents had no remarkable abnor-
malities of the teeth. An ophthalmological examination, including a
wide-field angiography, revealed aberrant circumferential peripheral
vessels and an area of capillary nonperfusion in the left eye, but not in
the right eye. No findings suggestive of angiographic leakage at the
site of the vascular-avascular junction or retinal neovascularization
were seen, and the patient was diagnosed as having FEVR stage 1,
avascular periphery (Figure 1(e)). The patient's visual acuity remained
normal. His bone density was normal in the lumbar spine (82%, or
−1.4 SD compared to the same age), but was mildly decreased in the
left femur (78%).
His motor development was normal. He held his head at age
3 months, rolled over at the age of 6 months, sat without support at
age 7 months, and walked independently at age 1 year and 3 months.
His speech development was delayed. He expressed his first meaning-
ful words at about 22 months. At age 13 years, his Wechsler Intelli-
gence Scale for Children-Fourth edition (WISC-VI) score was
82, which was within borderline intellectual functioning. He was
attending classes for students with special needs in addition to his
regular classes.
2|MOLECULAR STUDIES
This study was approved by the local institutional review board.
Informed assent from the patient and informed consent from the
patient's parents were obtained for the molecular studies. An exome
analysis was performed as previously reported (Takenouchi
et al., 2015). Genomic DNA was extracted from peripheral blood sam-
ples from both the patient and his parents. Exome analyses were per-
formed using the SureSelectXT Human All Exon V6 (Agilent
Technologies, Santa Clara, California) and the NovaSeq platform
(Illumina, San Diego, California). The sequence reads were mapped to
the human reference genome (GRCh37) according to the best-
practice guidelines for Burrows-Wheeler Aligner (BWA) (Li and
Durbin, 2009) and the Genome Analysis Tool Kit (GATK) (McKenna
et al., 2010) and the integrated analysis suite variant tools (San Lucas
et al., 2012). The filtered variants were annotated with SnpEff
(Cingolani et al., 2012).
The patient had a de novo heterozygous variant of the LRP5
gene: Chr11(GRCh37):g.68197138G > A, NM_002335.2:c.3733G > A,
p.(Val1245Met) (rs1215728276). This variant was confirmed by Sanger
sequencing and is extremely rare: c.3733G > A was not encountered in
any of a 3552-person cohort of normal Japanese individuals (Tadaka
et al., 2019) and had a minor allele frequency of 0.001% in the gnomAD
database (Lek et al., 2016). The gnomAD database included three
patients with the LRP5 variant, c.3733G > A, and all three were hetero-
zygous for the variant. The phenotype of these individuals remains
unknown. Since dental/ophthalmologic abnormalities of adult onset
would not affect the reproductive fitness, observation in the gnomAD
cohort would not negate pathogenic role of this variant in the patient
reported herein. This variant was also absent in pathogenic variant data-
bases such as the ClinVar and HGMD databases (Landrum et al., 2014;
Stenson et al., 2017).
The pathogenicity of the variant was predicted as follows: Poly-
phen2 HumDiv/Var predicted the variant to be probably damaging
(Adzhubei et al., 2010), MutationTaster (v2013) predicted the variant
to be disease-causing (Schwarz et al., 2014), and the combined
annotation-dependent depletion (CADD) score corresponded to a del-
eterious result (Kircher et al., 2014). Overall, the allele c.3733G > A
was scored as “likely pathogenic”(PS1, PM1, PM2, and PP3)
according to the standards and guidelines for the interpretation of
sequence variants by the American College of Medical Genetics and
Genomics (Richards et al., 2015). The non-synonymous variant,
c.3733G > A (NM_002335.2), was located within the highly con-
served epidermal growth factor (EGF)-like domain per the CLUSTALW
program (Larkin et al., 2007). The amino acid residues surrounding
variants HLVLLQNLL are conserved down to zebrafish (Figure 2).
A trio exome analysis detected no de novo or biallelic putatively
pathogenic variants within the coding regions of any genes other than
LRP5. No pathogenic variants in known dental-anomalies-associated
genes, including WNT10A [MIM: 606268], WNT10B [MIM: 601906],
MSX1 [MIM: 142983], PAX9 [MIM: 167416], LRP6 [MIM: 603507],
AXIN2 [MIM: 604025], EDA [MIM: 300451], EDAR [MIM: 604095],
EDARADD [MIM: 606603], LTBP3 [MIM: 602090], SMOC2 [MIM:
607223], TFAP2B [MIM: 601601] and GREM2 [MIM: 608832], were
detected in the patient (Fournier et al., 2018; Kantaputra et al., 2015;
Tanasubsinn et al., 2017; Yu et al., 2019b).
3|DISCUSSION
Here, we report a patient with de novo, heterozygous missense vari-
ant p.(Val1245Met) in LRP5 who had reduced bone density and exu-
dative vitreoretinopathy together with a previously unreported
FIGURE 2 Protein multiple sequence alignment of LRP5. Amino
acid residues surrounding the Val1245 residue, which is mutated to
Met. Note the high degree of evolutionary conservation among five
species, including zebrafish [Color figure can be viewed at
wileyonlinelibrary.com]
YAMADA ET AL.3

phenotype: dental abnormalities. The documentation of dental
anomalies in the presently reported patient strongly supports the
notion that LRP5 plays a critical role in the development of teeth in
humans as well as in mice (Tamura and Nemoto, 2016). During tooth
root formation, many Wnt ligands are continuously expressed
(de Lau et al., 2014). Wnt10a has recently been shown to be impor-
tant for proper proliferation of epithelial and mesenchymal cells
(Yu et al., 2020b). In other words, tooth root formation is under the
control of a signaling network that regulates tooth epithelial-
mesenchymal interactions (Jing et al., 2019; Li et al., 2017). The
improper patterning of the crowns and dentition (Ahn et al., 2017)
and the abnormal root formation and taurodontism (Yang
et al., 2015) observed in the presently reported patient can be
ascribed to the essential role of fine-tuning the canonical Wnt signal-
ing during tooth development performed by the Lrp family of genes
in mice.
A genotype–phenotype correlation of LRP5 variant has been pre-
viously observed. Variants associated with high bone mineral density
which represents the gain-of-function phenotype (Bollerslev
et al., 2013; Costantini et al., 2017; Gregson et al., 2016; Little
et al., 2002; Van Wesenbeeck et al., 2003) are confined to the first
YWTD β-propeller domain, whereas variants associated with FEVR,
which represents the loss-of-function phenotype (Chen et al., 2020;
Chen et al., 2019; Tian et al., 2019; Wang et al., 2019) are confined to
the second to fourth YWTD β-propeller domain and the LDL domain
(Figure 3). Currently, no variants in the fourth EGF domain have been
reported to date other than the p.(Val1245Met) variant described
herein.
The functional effect of the p.(Val1245Met) substitution remains
unknown. The clinical observation that the patient presented with
exudative vitreoretinopathy, which has been described as a hypo-
morphic phenotype, suggests that the variant conferred a loss-of-
function effect. On the other hand, the observation that no dental
anomalies have been previously reported among patients with LRP5
variants and exudative vitreoretinopathy suggests that the
p.(Val1245Met) variant may confer a neomorphic effect. We suggest
that patients with LRP5 variants should be screened for dental
abnormalities.
In conclusion, we suggest that LRP5 plays a critical role in
odontogenesis in humans, similar to its role in mice. More patients
need to be evaluated thoroughly from a dental standpoint to clarify
whether variants other than p.(Val1245Met) are associated with teeth
abnormalities.
AUTHORS' CONTRIBUTIONS
All authors contributed to the study conception and design. Material
preparation, data collection and analysis: Mamiko Yamada, Tomoko
Uehara, Toshiki Takenouchi, Kazumi Kubota, Atsuro Uchida,
Tatsuhiko Yagihashi, Masahito Kawasaki, Hisato Suzuki, and Hiroshi
Kurosaka.
Mamiko Yamada and Kenjiro Kosaki wrote the first draft of the
manuscript. All authors commented on previous versions of the manu-
script and approved the final manuscript.
ACKNOWLEDGMENTS
We thank Ms. Chika Kanoe, Ms. Mineko Fujiwara, Ms. Yumi Obayashi
and Ms. Keiko Tsukue who have provided technical assistance. This
work was supported by Initiative on Rare and Undiagnosed Diseases
(grant number JP20ek0109301) from the Japan Agency for Medical
Research and Development.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are openly available in
Database of Pathogenic Variants at https://dpv.cmg.med.keio.ac.jp/
dpv-pub/variants/12033, reference number DPV:12033.
FIGURE 3 Genotype–
phenotype correlation of LRP5.
Agenotype–phenotype
correlation may exist for LRP5.Red
letters: High bone mineral density,
which represents the gain-of-
function phenotype of LRP5, is
confined to variants occurring in
the first YWTD β-propeller
domain. Blue letters: FEVR, which
represents the loss-of-function
phenotype of LRP5, is confined to
variants occurring in the second to
fourth YWTD β-propeller domain
and the LDL domain. Black arrows
and letters: No variants in the
fourth EGF domain have been
reported to date [Color figure can
be viewed at
wileyonlinelibrary.com]
4YAMADA ET AL.

ORCID
Mamiko Yamada https://orcid.org/0000-0002-4039-8899
Hisato Suzuki https://orcid.org/0000-0002-8122-7180
Tomoko Uehara https://orcid.org/0000-0002-1497-7686
Toshiki Takenouchi https://orcid.org/0000-0002-7311-4135
Kenjiro Kosaki https://orcid.org/0000-0002-6798-8151
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