# Natal & Neonatal Teeth **Dr Jilen Patel** *BDSc (Hons) WA, DClinDent, MRACDS, FADI, FICD* Specialist Paediatric Dentist Senior Lecturer, Clinical Dentistry UWA Dental School **Dr Jilen Patel** *BDSc (Hons) WA, DClinDent, MRACDS, FADI, FICD* Specialist Paediatric Dentist Senior Lecturer, Clinical Dentistry UWA Dental School **Outline** * **THE UNIVERSITY OF WESTERN AUSTRALIA** * Definitions and nomenclature * History * Prevalence * Etiology * Clinical presentation and classification * Histology and ultrastructure * Complications * Diagnosis and differential diagnosis * Management * Conclusion **Outline** * **THE UNIVERSITY OF WESTERN AUSTRALIA** * Definitions and nomenclature * History * Prevalence * Etiology * Clinical presentation and classification * Histology and ultrastructure * Complications * Diagnosis and differential diagnosis * Management * Conclusion < DEFINITIONS > Definers: Massler & Savara, 1950 Spouge & Feasby, 1966 Bodenhoff & Gotlin, 1963 **Definitions** - Massler & Savara, 1950 - Spouge & Feasby, 1966 - Bodenhoff & Gotlin, 1963 **Nomenclature** - Congenital teeth - Fetal teeth - Infancy teeth - Pre-deciduous teeth - Dentitia praecox - Dens connatalis - Precocious dentition (Zhu and King, 1995; Mayhall, 1967; Kates et al. 1984) **Nomenclature** - Congenital teeth - Fetal teeth - Infancy teeth - Pre-deciduous teeth - Dentitia praecox - Dens connatalis - Precocious dentition (Zhu and King, 1995; Mayhall, 1967; Kates et al., 1984) **History** Natal and neonatal teeth have been a **subject of curiosity** and study since the time it was first documented by Titus Livius, in 59 BC Gaius Plinius Secundus (the Elder), in 23 BC, believed that a splendid future awaited male infants with natal teeth. In females it was considered a bad sign and that they bring disaster to their community **Diverse superstition** * Africa, India, Poland | monstrous and bearer of misfortune * China | bad omen for girls * England | grow up into famous soldiers * France & Italy | future conquerors of the worlds (Allwright, 1958; Bodenhoff & Gorlin, 1963; Zhu & King, 1995) Natal and neonatal teeth have been a **subject of curiosity** and study since the time it was first documented by Titus Livius, in 59 BC. Gaius Plinius Secundus (the Elder), in 23 BC, believed that a splendid future awaited male infants with natal teeth. In females it was considered a bad sign and that they bring disaster to their community. #### Diverse superstitions - Africa, India, Poland – monstrous and bearer of misfortune - China – bad omen for girls - England – grow up into famous soldiers - France & Italy – future conquerors of the worlds (Allwright, 1958; Bodenhoff & Gorlin, 1963; Zhu & King, 1995) History History **Prevalence and Incidence** • Natal teeth are **three times** more common than neonatal teeth Rao and Mathad, 2009 • 95%: true primary teeth; **5%**: supernumerary teeth Kates et al. 1984 • The incidence of natal and neonatal teeth has been investigated in multiple studies: – 1:716 to 1:30,000 — Zhu and King, 1995 – 1:2,000 to 1:3,500 — Chow, 1980 **Prevalence and Incidence** • Natal teeth are **three times** more common than neonatal teeth Rao and Mathad, 2009 • 95%: true primary teeth; **5%**: supernumerary teeth Kates et al. 1984 • The incidence of natal and neonatal teeth has been investigated in multiple studies: – 1:716 to 1:30,000 — Zhu and King, 1995 – 1:2,000 to 1:3,500 — Chow, 1980 # Prevalence and Incidence ## Gender predilection - F > M - F : M = 66%: 31% - F = M ## Site - Mandibular incisor region (85%) - Maxillary incisors (11%) - Mandibular canine (3%) - Maxillary canine and molar (<1%) - Multiple neonatal and natal teeth are rare #### Gender Predilection - F > M - F : M = 66% : 31% - F = M #### Site - Mandibular incisor region (85%) - Maxillary incisors (11%) - Mandibular canine (3%) - Maxillary canine and molar (<1%) - Multiple neonatal and natal teeth are rare # Aetiology - **Unknown** - **Superficial position of tooth germ** in alveolar bone during development (Cunha et al. 2001) - **Trauma or infection** - **Osteoclastic activity** within tooth germ area (bone remodelling) (Goncalves, 1998) - **Hereditary transmission** of an autosomal dominant gene, with a familial trait in 8–62% of cases (Hyatt, 1965; Zhu & King , 1995) - Certain **syndromes** and newborns with orofacial clefts (Motoyama et al. 1967) - **Unknown** - **Superficial position of tooth germ** in alveolar bone during development (Cunha et al. 2001) - **Trauma or infection** - **Osteoclastic activity** within tooth germ area (bone remodelling) (Goncalves, 1998) - **Hereditary transmission** of an autosomal dominant gene, with a familial trait in 8–62% of cases (Hyatt, 1965; Zhu & King, 1995) - Certain **syndromes** and newborns with orofacial clefts (Motoyama et al. 1967) # Aetiology * Maternal-related factors - dietary deficiencies (malnutrition) - poor maternal health - endocrine disturbances: pyelitis and hypovitaminosis during pregnancy - excessive secretion of pituitary, thyroid or gonads (Khatib et al. 2005; Vucicevic et al. 2007) * **Feb** *rile state* *:* increased body temperature can affect the normal eruption of teeth, e.g. fever, exanthemata (Massler & Savara, 1959; Vucicevic et al. 2007) * Environmental factors - polychlorinated biphenoyls & bibenzofurans ? (Yamaguchi et al. 1971; Gladen et al. 1990) THE UNIVERSITY OF WESTERN AUSTRALIA - **Maternal-related factors** - dietary deficiencies (malnutrition) - poor maternal health - endocrine disturbances: pyelitis and hypovitaminosis during pregnancy - excessive secretion of pituitary, thyroid or gonads (Khatib et al. 2005; Vucicevic et al. 2007) - **Febrile state**: increased body temperature can affect the normal eruption of teeth, e.g. fever, exanthemata (Massler & Savara, 1959; Vucicevic et al. 2007) - **Environmental factors** - polychlorinated biphenoyls & bibenzofurans? (Yamaguchi et al. 1971; Gladen et al. 1990) Clinical Presentation - **Usually small and conical** - **May resemble** normal primary teeth in size & shape - Usually have an **immature appearance** with poorly-developed, hypoplastic enamel and dentine - **Usually occurs in pair** (Zhu & King, 1995; Galassi et al. 2004; Ziai et al. 2005)  #### Clinical Presentation - **Usually small and conical** - **May resemble** normal primary teeth in size & shape - Usually have an **immature appearance** with poorly-developed, hypoplastic enamel and dentine - **Usually occurs in pair** (Zhu & King, 1995; Galassi et al. 2004; Ziai et al. 2005) This figure shows clinical photos of supernumerary teeth, illustrating their characteristic appearance as small, conical structures with an immature look that resembles normal primary teeth. **Clinical Presentation** * May be attached to the mucosa and are occasionally covered by a pad of soft tissue * Absent or poor root development * Mostly mobile (Zhu & King, 1995; Galassi et al. 2004; Ziai et al. 2005)    #### Clinical Presentation - May be attached to the mucosa and are occasionally covered by a pad of soft tissue - Absent or poor root development - Mostly mobile (Zhu & King, 1995; Galassi et al. 2004; Ziai et al. 2005) Clinical photo showing a mobile, pedunculated mass attached to the oral mucosa, consistent with a soft tissue growth described in the text as being mostly mobile and occasionally covered by a pad of soft tissue. Clinical photo: This figure shows two views of a dental anomaly, likely an ectopic or supernumerary tooth. The top image depicts gloved fingers retracting the lip to reveal a soft tissue pad covering the tooth structure, while the bottom image displays a similar finding with the yellowish crown of the tooth protruding through the gum. Clinical photo: This image displays a dental anomaly, likely an ectopic tooth or supernumerary tooth, situated within the soft tissue of the lower lip. The structure features a visible yellowish crown with a rounded shape and is surrounded by inflamed, pink mucosa. **Classification - Spoug & Feasby 1966** <sub>THE UNIVERSITY OF WESTERN AUSTRALIA</sub> A mature natal or neonatal tooth - a tooth **which is nearly or fully developed** - relatively **good prognosis** for maintenance The immature natal or neonatal tooth - a tooth **with incomplete or substandard** structure - implies a **poor prognosis** #### Classification – Spoug & Feasby 1966 **A mature natal or neonatal tooth** - a tooth **which is nearly or fully developed** - relatively **good prognosis** for maintenance **The immature natal or neonatal tooth** - a tooth **with incomplete or substandard** structure - implies a **poor prognosis** Classification - **Hebling et al. 1997** The appearance of each natal tooth in the oral cavity can be classified into four categories given as follows, as the teeth emerge in the oral cavity: **1. Shell-shaped crown** - poorly fixed to the alveolus by the gingival tissue - absence of a root **2. Solid crown** - poorly fixed to the alveolus by the gingival tissue - little or no root   #### Classification – Hebling et al. 1997 The appearance of each natal tooth in the oral cavity can be classified into four categories given as follows, as the teeth emerge in the oral cavity: **1. Shell-shaped crown** - poorly fixed to the alveolus by the gingival tissue - absence of a root **2. Solid crown** - poorly fixed to the alveolus by the gingival tissue - little or no root Clinical photo showing a natal tooth with a solid crown type, characterized by the tooth being poorly fixed to the alveolus and having little or no root. Clinical photo: A close-up view of a natal tooth with a shell-shaped crown, which appears loosely attached to the gum tissue (alveolus) and lacks a visible root structure. Classification - Hebling et al. 1997 **THE UNIVERSITY OF WESTERN AUSTRALIA** 3. Eruption of the incisal margin of the crown through the gingival tissue 4. Edema of the gingival tissue with an unerupted palpable tooth   #### Classification – Hebling et al. 1997 3. Eruption of the incisal margin of the crown through the gingival tissue 4. Edema of the gingival tissue with an unerupted palpable tooth Clinical photo showing the eruption of the incisal margin of a crown through the gingival tissue. Clinical photo: This image shows the lower lip retracted to reveal severe edema of the gingival tissue surrounding the central incisors. The swollen, reddish gum tissue appears tense and glossy, consistent with the caption describing an unerupted palpable tooth. Histology **Enamel** (Ndiokwelu et al. 2004, To 1992) • thin layer of enamel or absence of the enamel • enamel hypoplasia/hypomineralisation **Dentin** (Massler & Savara, 1950; Zhu & King, 1996; Uzamis et al. 1999; Leung & Robson, 2006) • interglobular dentin in the coronal region • **irregular dentin** and cell inclusions in the cervical region • **atypical dentin** (due to the response to irritant stimulus from oral cavity)  Histology **Enamel** (Ndiokwelu et al. 2004, To 1992) • thin layer of enamel or absence of the enamel • enamel hypoplasia/hypomineralisation **Dentin** (Massler & Savara, 1950; Zhu & King, 1996; Uzamis et al. 1999; Leung & Robson, 2006) • interglobular dentin in the coronal region • **irregular dentin** and cell inclusions in the cervical region • **atypical dentin** (due to the response to irritant stimulus from oral cavity) Labelled diagram: A cross-section of a tooth showing the crown and root structures. The outer enamel layer is highlighted in green, while the underlying dentin is stained pink/red. The University of Western Australia # Histology ## Dentino-enamel junction: not scalloped ### Cementum - normal thickness - thickened layers - acellular cementum in some cases (thinner than normal) - circumferential cementum ### Pulp canal and pulp chamber (Howkins 1932, Massler & Savara 1950, Hals, 1957, Clergeau-Guerithault, 1991, Friend et al. 1991) - larger than normal - vascularised pulps along with few inflammatory cells ### Roots (Massler & Savara, 1950, Allwright 1958, Leung & Robson 2006) - lack of root formation (despite the tooth is erupted in the oral cavity) The University of Western Australia Histology Dentino-enamel junction: not scalloped ### Cementum - normal thickness - thickened layers - acellular cementum in some cases (thinner than normal) - circumferential cementum ### Pulp canal and pulp chamber (Howkins 1932, Massler & Savara 1950, Hals, 1957, Clergeau-Guerithault, 1991, Friend et al. 1991) - larger than normal - vascularised pulps along with few inflammatory cells ### Roots (Massler & Savara, 1950, Allwright 1958, Leung & Robson 2006) - lack of root formation (despite the tooth is erupted in the oral cavity) # Structural Characteristics * **Enamel** of the teeth exhibited hypoplastic, depressed areas, and the incisal edge of natal tooth lacked enamel (Jasmin & Clergeau-Guerithault, 1991) * **Thickness of enamel** was around 280 microns compared to up to 1200 microns in normal teeth (Uzamis et al. 1999) * **Enamel** has normal prism structure and mineralization (prism structure can be absent in the cervical part of the enamel) * Cervical and apical **dentin** is tubular * In developing teeth, the **dentin** in these regions changed to an irregularly formed hard tissue of osteodentin character (in which enclosed cells could be observed) (Masatomi et al. 1991) - **Enamel** of the teeth exhibited hypoplastic, depressed areas, and the incisal edge of natal tooth lacked enamel (Jasmin & Clergeau-Guerithault, 1991) - **Thickness of enamel** was around 280 microns compared to up to 1200 microns in normal teeth (Uzamis et al. 1999) - **Enamel** has normal prism structure and mineralization (prism structure can be absent in the cervical part of the enamel) - Cervical and apical **dentin** is tubular - In developing teeth, the **dentin** in these regions changed to an irregularly formed hard tissue of osteodentin character (in which enclosed cells could be observed) (Masatomi et al. 1991) Complications - Dysplastic enamel - Mobility - potential risk of aspiration - Difficulty suckling - interfere with feeding - Traumatic injury to the baby’s tongue and/or to the maternal breast - Riga-Fede disease   - Dysplastic enamel - Mobility – potential risk of aspiration - Difficulty suckling – interfere with feeding - Traumatic injury to the baby’s tongue and/or to the maternal breast - Riga-Fede disease Clinical photo: This image displays the oral cavity, specifically focusing on the tongue and teeth, which illustrates Riga-Fede disease. The visual shows a lesion or ulceration on the tip of the tongue located near the upper incisors. Clinical photo: Complications **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** ### Poor quality enamel * increased risk of caries * chipping and attrition * periapical abscesses (Allwright, 1958) Periapical radiolucencies (Kates et al. 1984)  #### Poor quality enamel - Increased risk of caries - Chipping and attrition - Periapical abscesses (Allwright, 1958) Periapical radiolucencies (Kates et al. 1984) Radiograph: Mobility - “[Natal] teeth are **loose and moveable** in the early stages and there is a constant danger of the teeth becoming detached and either swallowed or aspirated, especially during nursing” (Brauer et al 1947 as cited by Massler & Savara 1950) - **No reports of inhalation** of an exfoliated natal tooth (Gardiner 1961) - *“Inhalation of one of these teeth has never been reported in the literature and the danger is probably more imaginary than real”* (Spouge & Feasby 1966) - “[Natal] teeth are **loose and moveable** in the early stages and there is a constant danger of the teeth becoming detached and either swallowed or aspirated, especially during nursing” (Brauer et al 1947 as cited by Massler & Savara 1950) - **No reports of inhalation** of an exfoliated natal tooth (Gardiner 1961) - *“Inhalation of one of these teeth has never been reported in the literature and the danger is probably more imaginary than real”* (Spouge & Feasby 1966) **Difficulty Feeding** - Presence of natal teeth may cause discomfort for the mother when the infant is suckling - interfere with feeding - ulceration - laceration (Bodenhoff & Gorlin 1963, Massler & Savara 1950) - Children with normal primary teeth have often been nursed up to 2-3 years of age without complication (Massler & Savara 1950) - Presence of natal teeth may cause discomfort for the mother when the infant is suckling - interfere with feeding - ulceration - laceration (Bodenhoff & Gorlin 1963, Massler & Savara 1950) - Children with normal primary teeth have often been nursed up to 2-3 years of age without complication (Massler & Savara 1950) Riga-Fedes Syndrome * Benign ulceration of the ventral surface of the tongue of lingual frenum caused by repetitive trauma from the sharp incisal edges of teeth (Choi et al. 2009, Bodenhoff & Gorlin ,1963) * In infants, the tongue rests between the alveolar processes, causing the ventral surface of the tongue to rest against the incisal edges of natal teeth (Massler & Savara 1950) * Discomfort, refusal to feed (Massler & Savara 1950) (Patil and Dixit 2013)  - Benign ulceration of the ventral surface of the tongue or lingual frenum caused by repetitive trauma from the sharp incisal edges of teeth (Choi et al. 2009, Bodenhoff & Gorlin 1963) - In infants, the tongue rests between the alveolar processes, causing the ventral surface of the tongue to rest against the incisal edges of natal teeth (Massler & Savara 1950) - Discomfort, refusal to feed (Massler & Savara 1950) (Patil and Dixit 2013) Clinical photo: A close-up view of a ventral tongue ulceration characterized by a central white, necrotic lesion surrounded by erythematous tissue. This image illustrates the traumatic ulceration of the lingual frenum caused by repetitive friction from the sharp incisal edges of natal teeth. Systemic Conditions - Cleft lip, Palate and cyclopia (Boyd & Miles 1951, de Almeida & Gomide 1996) - Ellis-Van Creveld (Chondroectodermal Dysplasia) (Weiss, 1955) - Pachyonychia Congenital (Jadassohn-Lewandowsky) (Bodenhoff & Gorlin 1963, Leung 1986) - Hallermann-Streiff (Oculomandibulodyscephaly with Hypotrichosis) (Robotta & Schafer, 2011) - Steatocystoma Multiplex (McDonald & Reed 1976, King & Lee 1987) - Pierre-Robin - Pallister-Hall - Short Rib-Polydactyly (type II) - Wiedemann-Rautenstrauch (Neonatal Progeria) - Pfeiffer, Ectodermal Dysplasia, Craniofacial Dysostosis - Rubinstein-Taybi - Sotos - Adrenogenital - Epidermolysis-BulloSa SimPlex including Van der Woude - Down's Syndrome (Ndiokwelu et al. 2004) - Walker-Warburg Syndromes (Venkatesh and Adhisivam, 2011) - Cleft lip, Palate and cyclopia (Boyd & Miles 1951, de Almeida & Gomide 1996) - Ellis-Van Creveld (Chondroectodermal Dysplasia) (Weiss, 1955) - Pachyonychia Congenital (Jadassohn-Lewandowsky) (Bodenhoff & Gorlin 1963, Leung 1986) - Hallermann-Streiff (Oculomandibulodyscephaly with Hypotrichosis) (Robotta & Schafer, 2011) - Steatocystoma Multiplex (McDonald & Reed 1976, King & Lee 1987) - Pierre-Robin - Pallister-Hall - Short Rib-Polydactyly (type II) - Wiedemann-Rautenstrauch (Neonatal Progeria) - Pfeiffer, Ectodermal Dysplasia, Craniofacial Dysostosis - Rubinstein-Taybi - Sotos - Adrenogenital - Epidermolysis-Bullosa Simplex including Van der Woude - Down's Syndrome (Ndiokwelu et al. 2004) - Walker-Warburg Syndromes (Venkatesh and Adhisivam, 2011) ## Diagnosis * History * Clinical examination * Radiograph **?**  #### Diagnosis - History - Clinical examination - Radiograph **?** Clinical photograph showing two extracted teeth with the crowns removed, exposing the root structures against a blue surgical background. # Differential Diagnosis * Supernumerary teeth (Zhu & King, 1995) * Bohn’s nodules (Leung and Robson, 2006) * Dental lamina cysts (gingival cyst of newborn) (Leung and Robson, 2006) * Inclusion cysts (Kumar et al. 2008) * Congenital epulis * Odontogenic hamartomas * Lymphangioma of the alveolus (Leung, 1986; Leung and Robson, 2006)    #### Differential Diagnosis - Supernumerary teeth (Zhu & King, 1995) - Bohn’s nodules (Leung and Robson, 2006) - Dental lamina cysts (gingival cyst of newborn) (Leung and Robson, 2006) - Inclusion cysts (Kumar et al. 2008) - Congenital epulis - Odontogenic hamartomas - Lymphangioma of the alveolus (Leung, 1986; Leung and Robson, 2006) Clinical photo: This image displays the upper alveolar ridge of an infant, showing multiple small, whitish-yellow papules on the gingiva. The visual presentation is consistent with Bohn's nodules, which are cystic epithelial rests found in the oral cavity. Clinical photo showing a close-up view of the oral cavity, specifically highlighting a soft tissue mass on the alveolar ridge consistent with a congenital epulis. Clinical photo showing a localized, bluish swelling on the infant's gingiva consistent with an eruption cyst. The image illustrates a fluid-filled sac overlying a tooth germ as it attempts to penetrate the gum tissue. **Radiographs** **What can you see?** **When does calcification of primary incisors begin?** **When does calcification of permanent incisors begin?** ---  **Radiographs** **What can you see?** **When does calcification of primary incisors begin?** **When does calcification of permanent incisors begin?** Radiograph showing a close-up of primary incisors with the developing permanent successors visible in the bone below. The image illustrates the relationship between the calcifying roots of the primary teeth and the crowns of the underlying permanent teeth. Radiographs - A radiographic verification of the relationship between a natal and/or neonatal tooth and adjacent structures, nearby teeth, and the presence or absence of a germ in the primary tooth area - Differentiate the **premature eruption** of a primary tooth from a **supernumerary tooth** - Provides **information about root development** - Shows tooth's relationship to underlying structures (Massler & Savara 1950; Leung, 1986; Almeida al 1997; Cunha et al. 2001)  - A radiographic verification of the relationship between a natal and/or neonatal tooth and adjacent structures, nearby teeth, and the presence or absence of a germ in the primary tooth area - Differentiate the **premature eruption** of a primary tooth from a **supernumerary tooth** - Provides **information about root development** - Shows tooth's relationship to underlying structures (Massler & Savara 1950; Leung, 1986; Almeida al 1997; Cunha et al. 2001) Radiograph: Radiographs **ALARA principle...** **Diagnostic quality of radiograph** **Risk / benefit** THE UNIVERSITY OF WESTERN AUSTRALIA **ALARA principle...** **Diagnostic quality of radiograph** **Risk / benefit** Management The University of Western Australia The treatment planning of these natal or neonatal teeth depends on various factors including: - **degree of mobility** - if the tooth is *supernumerary* or is part of the normal dentition - *inconvenience during suckling* - problems associated with breastfeeding - If the erupted tooth is diagnosed as a tooth of the **normal dentition** – maintenance of these teeth in the mouth is the first treatment option (Chow, 1980; Roberts, 1992) The treatment planning of these natal or neonatal teeth depends on various factors including: - **Degree of mobility** - If the tooth is *supernumerary* or is part of the normal dentition - *Inconvenience during suckling* - Problems associated with breastfeeding - If the erupted tooth is diagnosed as a tooth of the **normal dentition** – maintenance of these teeth in the mouth is the first treatment option (Chow, 1980; Roberts, 1992) # **bold** The University of ## **bold** WESTERN ## **bold** AUSTRALIA # Management ## No treatment * if the tooth is **asymptomatic** * breastfeeding is not impaired (Boyd and Miles, 1951) * Application of a corticosteroid in orabase (such as kenalog) can aid in relieving the symptoms of the ulcer (Slayton, 2000; Choi et al. 2009)   #### No treatment - If the tooth is **asymptomatic** - Breastfeeding is not impaired (Boyd and Miles, 1951) - Application of a corticosteroid in orabase (such as kenalog) can aid in relieving the symptoms of the ulcer (Slayton, 2000; Choi et al. 2009) Management # Grinding Smoothing of the tooth by grinding should be carried out if tooth is causing - Mild subgingival ulceration or mild discomfort to the mother - Trauma to the infant’s tongue Finishing burs, sandpaper disc, softflex disc can be used for smoothing (Allwright 1958, Choi et al 2009, Slayton 2000) Choi et al. 2009   #### Grinding Smoothing of the tooth by grinding should be carried out if tooth is causing: - Mild subgingival ulceration or mild discomfort to the mother - Trauma to the infant’s tongue Finishing burs, sandpaper disc, softflex disc can be used for smoothing (Allwright 1958, Choi et al 2009, Slayton 2000) Choi et al. 2009 Clinical photo showing the oral cavity of an infant with a visible ulceration on the tongue caused by trauma from a sharp neonatal tooth. The image illustrates the specific injury mentioned in the slide's context regarding management of subgingival ulceration. Clinical photo showing an infant's open mouth with the tongue retracted, displaying a healed oral lesion on the lower gingiva following the grinding of a sharp incisor edge. # Management ## Coverage - Composite build-up Initial photograph of 8 month old boy with a sublingual ulcer caused by primary lower anterior teeth Final photograph 2 months after a resin composite build up was placed on the teeth Choi et al 2009 THE UNIVERSITY OF WESTERN AUSTRALIA   #### Coverage - Composite build-up Initial photograph of 8 month old boy with a sublingual ulcer caused by primary lower anterior teeth Final photograph 2 months after a resin composite build up was placed on the teeth Choi et al 2009 Clinical photograph showing the oral cavity of an 8-month-old boy, specifically focusing on the sublingual area and primary lower anterior teeth. The image illustrates the condition two months after a resin composite build-up was placed on the teeth. Clinical photo showing the oral cavity of an infant with lips retracted, revealing a sublingual ulcer located on the floor of the mouth directly behind the primary lower anterior teeth. # Management THE UNIVERSITY OF WESTERN AUSTRALIA **Management** Khandelwal et al. 2013    Clinical photo showing the oral cavity of an infant with a healing extraction site on the lower gum, illustrating postoperative haemostasis. Clinical photo showing the oral cavity of a neonate, highlighting prominent natal teeth in the lower gum line. Clinical photo of two extracted natal teeth placed on a blue surgical background. The specimen on the left shows the tooth attached to a fragment of gingival tissue, while the specimen on the right displays the isolated tooth structure. # Management ### Extraction – Precautions If the treatment option is extraction only, certain precautions should be taken: * **Considering the general health condition of the infant** prior to extraction * **Avoiding extraction up to the 10th day of life** to prevent hemorrhage ? * **Assessing the need to administer vitamin K before extraction** (0.5-1.0 mg IM) * **Avoiding unnecessary injury** to the gingiva * **Socket should be curetted following extraction** to prevent continued development of the cells of the dental papilla Leung & Robson 2006, Zhu & King 1996 * **Being alert to the risk of aspiration** during removal # Management ## Extraction – complication * Potential increased risk of space loss following extraction * Gardiner, 1961 reported 9 cases with space loss following extraction of natal teeth, however the space was regained when the permanent teeth erupted Gardiner, 1961  A series of dental casts (labeled A-F) illustrating the progression of incisal space changes over time, specifically showing the initial closure of space followed by its gradual reopening as a child ages from 4 months to 7 1/2 years. ## Case: Natal Tooth in a Preterm Newborn ### Question Have a look at these images from a case report showing a natal tooth in a preterm newborn. You can see a 7.1 that is erupted intraorally. Looking at the radiograph, what can you determine about this tooth? ### Findings * **Identification:** The radiograph confirms this is the actual 7.1 primary tooth, not a supernumerary tooth. * **Adjacent Structures:** The underlying permanent teeth 3.1 and 4.1 are visible. * **Additional Findings:** There is an 8.1 tooth also close to erupting in the area. * **Clinical Context:** Most natal teeth (95%) are primary teeth rather than supernumerary. ## Case: Riga-Fede Disease ### Question Observe the ulceration on the ventral surface of this infant's tongue. What is the cause of this presentation? ### Findings * **Diagnosis:** This is Riga-Fede disease (or syndrome), which is not a systemic disease but a traumatic ulceration. * **Cause:** It is caused by the sharp edges of natal teeth rubbing against the ventral surface of the tongue during feeding. * **Clinical Impact:** The ulceration can be quite severe and painful, leading to discomfort and difficulty with breastfeeding or bottle-feeding. ## Case: Bohn's Nodules and Epstein Pearls ### Question A parent presents with a newborn showing multiple small white spots on the gums and palate. What are these anomalies? ### Findings * **Bohn's Nodules:** These are white, keratin-filled cysts found on the alveolar ridges. They are residual bits of dental lamina and are very common (approx. 60% prevalence). * **Epstein Pearls:** Similar white spots found specifically in the palate along the mid-palatal suture line where the palatal shells fused. * **Management:** No treatment is required; they typically exfoliate on their own. ## Case: Natal Tooth in a Cleft Lip and Palate Patient ### Question Look at this case of a child with a unilateral cleft lip and palate. You can see a natal tooth, the cleft, the nose, and the vomer. There is also a feeding ulcer on the tongue. How is this managed? ### Findings * **Anesthesia:** Local anesthetic is delivered via a "ligna jet" (intraligamentary syringe) to precisely control the dose (0.2 ml per click) and avoid toxicity in a small infant. * **Extraction Technique:** The tooth must be removed carefully to avoid it slipping into the nasal cavity (due to the cleft). * **Post-Extraction:** It is critical to curette the socket to remove Hertwig's epithelial root sheath and follicle cells; otherwise, a root fragment may continue to form, requiring a second surgery later. ## Case: Highly Mobile Natal Tooth ### Question In this case of a healthy child, look at the mandibular alveolus. There is a tooth "floating" on the tissue. What is the clinical observation here? ### Findings * **Mobility:** The tooth is not firm in the bone; it is essentially floating on its follicle and flapping around as the child moves their tongue. * **Management:** Because it is only attached by soft tissue and cannot "firm up," extraction is indicated. * **Post-Op:** Hemostasis must be checked (ensuring the child has had Vitamin K injections). The extracted specimen shows the crown and the entire associated follicle. ## Case: Natal Tooth in a Preterm Newborn ### Question Have a look at these images from a case report showing a natal tooth in a preterm newborn. You can see a 7.1 that is erupted intraorally. Looking at the radiograph, what can you determine about this tooth?  ### Findings * **Identification:** The radiograph confirms this is the actual 7.1 primary tooth, not a supernumerary tooth. * **Adjacent Structures:** The underlying permanent teeth 3.1 and 4.1 are visible. * **Additional Findings:** There is an 8.1 tooth also close to erupting in the area. * **Clinical Context:** Most natal teeth (95%) are primary teeth rather than supernumerary. ## Case: Riga-Fede Disease ### Question Observe the ulceration on the ventral surface of this infant's tongue. What is the cause of this presentation?  ### Findings * **Diagnosis:** This is Riga-Fede disease (or syndrome), which is not a systemic disease but a traumatic ulceration. * **Cause:** It is caused by the sharp edges of natal teeth rubbing against the ventral surface of the tongue during feeding. * **Clinical Impact:** The ulceration can be quite severe and painful, leading to discomfort and difficulty with breastfeeding or bottle-feeding. ## Case: Bohn's Nodules and Epstein Pearls ### Question A parent presents with a newborn showing multiple small white spots on the gums and palate. What are these anomalies?    ### Findings * **Bohn's Nodules:** These are white, keratin-filled cysts found on the alveolar ridges. They are residual bits of dental lamina and are very common (approx. 60% prevalence). * **Epstein Pearls:** Similar white spots found specifically in the palate along the mid-palatal suture line where the palatal shells fused. * **Management:** No treatment is required; they typically exfoliate on their own. ## Case: Natal Tooth in a Cleft Lip and Palate Patient ### Question Look at this case of a child with a unilateral cleft lip and palate. You can see a natal tooth, the cleft, the nose, and the vomer. There is also a feeding ulcer on the tongue. How is this managed?    ### Findings * **Anesthesia:** Local anesthetic is delivered via a "ligna jet" (intraligamentary syringe) to precisely control the dose (0.2 ml per click) and avoid toxicity in a small infant. * **Extraction Technique:** The tooth must be removed carefully to avoid it slipping into the nasal cavity (due to the cleft). * **Post-Extraction:** It is critical to curette the socket to remove Hertwig's epithelial root sheath and follicle cells; otherwise, a root fragment may continue to form, requiring a second surgery later. ## Case: Highly Mobile Natal Tooth ### Question In this case of a healthy child, look at the mandibular alveolus. There is a tooth "floating" on the tissue. What is the clinical observation here?    ### Findings * **Mobility:** The tooth is not firm in the bone; it is essentially floating on its follicle and flapping around as the child moves their tongue. * **Management:** Because it is only attached by soft tissue and cannot "firm up," extraction is indicated. * **Post-Op:** Hemostasis must be checked (ensuring the child has had Vitamin K injections). The extracted specimen shows the crown and the entire associated follicle. Case: Natal Tooth in a Preterm Newborn Periapical radiolucencies (Kates et al. 1984) Sublingual ulceration of a 27 day old male resulting from natal teeth Bohn's nodules Congenital epuli Eruption cyst A clinical photograph showing a close-up view of an infant's mouth with a unilateral cleft lip and palate, featuring a natal tooth and visible vomer. A clinical demonstration of local anesthetic being administered to an infant's mouth using a specialized intraligamentary syringe. A close-up view of a dental professional using a tool to carefully extract a tooth from an infant with a cleft palate. A clinical photograph showing a close-up view of an infant's mouth with a natal tooth visible on the mandibular alveolus. A close-up clinical photograph showing a highly mobile, displaced tooth in a child's mouth, appearing to float on the gingival tissue. A close-up clinical photograph showing a mobile neonatal tooth in an infant's lower jaw, appearing loosely attached to the gum tissue. ## Case: Abscess Associated with Natal Tooth ### Question Look closely at this natal tooth. If you don't lift the lip out far enough, what might you miss? ### Findings * **Observation:** Upon lifting the lip, a small abscess (swelling) is visible above the tooth. * **Tooth Morphology:** The tooth is yellow, indicating a qualitative enamel defect. * **Structural Defects:** After extraction, a significant defect/groove is visible on the lingual surface that was not apparent during the initial exam. * **Clinical Significance:** Because natal teeth often have thin, dysplastic enamel and large pulps, they are highly susceptible to rapid breakdown, caries, and subsequent infection/abscess formation. ## Case: Abscess Associated with Natal Tooth ### Question Look closely at this natal tooth. If you don't lift the lip out far enough, what might you miss?   ### Findings * **Observation:** Upon lifting the lip, a small abscess (swelling) is visible above the tooth. * **Tooth Morphology:** The tooth is yellow, indicating a qualitative enamel defect. * **Structural Defects:** After extraction, a significant defect/groove is visible on the lingual surface that was not apparent during the initial exam. * **Clinical Significance:** Because natal teeth often have thin, dysplastic enamel and large pulps, they are highly susceptible to rapid breakdown, caries, and subsequent infection/abscess formation. Case: Abscess Associated with Natal Tooth A clinical examination of an infant's mouth using a dental tool to retract the lip, revealing a natal tooth and an adjacent abscess on the gum. A close-up clinical photograph showing an extracted tooth with significant yellow discoloration and attached soft tissue, likely related to an abscess. [^1]: Original PDF page 1: [[L1 Natal Teeth 2020.pdf#page=1|L1 Natal Teeth 2020, p.1]] [^2]: Original PDF page 2: [[L1 Natal Teeth 2020.pdf#page=2|L1 Natal Teeth 2020, p.2]] [^3]: Original PDF page 3: [[L1 Natal Teeth 2020.pdf#page=3|L1 Natal Teeth 2020, p.3]] [^4]: Original PDF page 4: [[L1 Natal Teeth 2020.pdf#page=4|L1 Natal Teeth 2020, p.4]] [^5]: Original PDF page 5: [[L1 Natal Teeth 2020.pdf#page=5|L1 Natal Teeth 2020, p.5]] [^6]: Original PDF page 6: [[L1 Natal Teeth 2020.pdf#page=6|L1 Natal Teeth 2020, p.6]] [^7]: Original PDF page 7: [[L1 Natal Teeth 2020.pdf#page=7|L1 Natal Teeth 2020, p.7]] [^8]: Original PDF page 8: [[L1 Natal Teeth 2020.pdf#page=8|L1 Natal Teeth 2020, p.8]] [^9]: Original PDF page 9: [[L1 Natal Teeth 2020.pdf#page=9|L1 Natal Teeth 2020, p.9]] [^10]: Original PDF page 10: [[L1 Natal Teeth 2020.pdf#page=10|L1 Natal Teeth 2020, p.10]] [^11]: Original PDF page 11: [[L1 Natal Teeth 2020.pdf#page=11|L1 Natal Teeth 2020, p.11]] [^12]: Original PDF page 12: [[L1 Natal Teeth 2020.pdf#page=12|L1 Natal Teeth 2020, p.12]] [^13]: Original PDF page 13: [[L1 Natal Teeth 2020.pdf#page=13|L1 Natal Teeth 2020, p.13]] [^14]: Original PDF page 14: [[L1 Natal Teeth 2020.pdf#page=14|L1 Natal Teeth 2020, p.14]] [^15]: Original PDF page 15: [[L1 Natal Teeth 2020.pdf#page=15|L1 Natal Teeth 2020, p.15]] [^16]: Original PDF page 16: [[L1 Natal Teeth 2020.pdf#page=16|L1 Natal Teeth 2020, p.16]] [^17]: Original PDF page 17: [[L1 Natal Teeth 2020.pdf#page=17|L1 Natal Teeth 2020, p.17]] [^18]: Original PDF page 18: [[L1 Natal Teeth 2020.pdf#page=18|L1 Natal Teeth 2020, p.18]] [^19]: Original PDF page 19: [[L1 Natal Teeth 2020.pdf#page=19|L1 Natal Teeth 2020, p.19]] [^20]: Original PDF page 20: [[L1 Natal Teeth 2020.pdf#page=20|L1 Natal Teeth 2020, p.20]] [^21]: Original PDF page 21: [[L1 Natal Teeth 2020.pdf#page=21|L1 Natal Teeth 2020, p.21]] [^22]: Original PDF page 22: [[L1 Natal Teeth 2020.pdf#page=22|L1 Natal Teeth 2020, p.22]] [^23]: Original PDF page 23: [[L1 Natal Teeth 2020.pdf#page=23|L1 Natal Teeth 2020, p.23]] [^24]: Original PDF page 24: [[L1 Natal Teeth 2020.pdf#page=24|L1 Natal Teeth 2020, p.24]] [^25]: Original PDF page 25: [[L1 Natal Teeth 2020.pdf#page=25|L1 Natal Teeth 2020, p.25]] [^26]: Original PDF page 26: [[L1 Natal Teeth 2020.pdf#page=26|L1 Natal Teeth 2020, p.26]] [^27]: Original PDF page 27: [[L1 Natal Teeth 2020.pdf#page=27|L1 Natal Teeth 2020, p.27]] [^28]: Original PDF page 28: [[L1 Natal Teeth 2020.pdf#page=28|L1 Natal Teeth 2020, p.28]] [^29]: Original PDF page 29: [[L1 Natal Teeth 2020.pdf#page=29|L1 Natal Teeth 2020, p.29]] [^30]: Original PDF page 30: [[L1 Natal Teeth 2020.pdf#page=30|L1 Natal Teeth 2020, p.30]] [^31]: Original PDF page 31: [[L1 Natal Teeth 2020.pdf#page=31|L1 Natal Teeth 2020, p.31]] [^32]: Original PDF page 32: [[L1 Natal Teeth 2020.pdf#page=32|L1 Natal Teeth 2020, p.32]] [^33]: Original PDF page 33: [[L1 Natal Teeth 2020.pdf#page=33|L1 Natal Teeth 2020, p.33]] [^34]: Original PDF page 34: [[L1 Natal Teeth 2020.pdf#page=34|L1 Natal Teeth 2020, p.34]] [^35]: Original PDF page 35: [[L1 Natal Teeth 2020.pdf#page=35|L1 Natal Teeth 2020, p.35]] [^36]: Original PDF page 36: [[L1 Natal Teeth 2020.pdf#page=36|L1 Natal Teeth 2020, p.36]]