Oral Conditions in Japanese Infants: a Retrospective Study

PEDIATRIC DENTAL JOURNAL 17(1): 65–72, 2007 65

Oral conditions in Japanese infants: A retrospective study

Mieko Tomizawa*1, Tomiko Sano*2 and Tadashi Noda*2

*1 Department of Oral Health and Welfare, Faculty of Dentistry, Niigata University, *2 Division of Pediatric Dentistry, Department of Oral Health Science, Niigata University Graduate School of Medical and Dental Sciences 2-5274 Gakkocho-dori, Niigata 951-8514, JAPAN

Abstract The present study was carried out to investigate the oral status of Key words 234 Japanese infants, who had registered at the Pediatric Dentistry Clinic of Clinical observation, Niigata University Medical and Dental Hospital over a period of 26 years, from Infant, 1979 to 2005. The 234 infants consisted of 125 males and 109 females and the Oral findings youngest patient was 2 days old. We divided them into 11 groups based on the diagnosis. The groups consisted of 46 oral mucosal lesions (8 patients were counted again with natal teeth), 45 cleft lip and/or palate infants, 28 with normal oral condition, 26 high maxillary frena, 21 natal or neonatal teeth, 21 traumatic injuries, 15 teeth anomalies, 14 ankyloglossia, 11 eruption problems, 8 occlusal problems, and 7 with other conditions. Among the 234 cases, some very rare conditions were noted, including a prematurely exfoliated super- numerary deciduous tooth in a 2-month-old infant, 3 cases of palatal polyps, and 2 cases of epulides. It was shown that infants exhibit many kinds of oral conditions that require professional attention from pediatric dentists.

Introduction Subjects and Methods In the first year of life, dynamic changes occur We included 234 infants out of 18,616 patients, resulting in the physical and functional development who had registered at the Pediatric Dentistry Clinic of infants. The oral cavity of an infant differs from of Niigata University Medical and Dental Hospital that of children belonging to other age groups over a period of 26 years, from 1979 to 2005. The because it includes the pre-eruption stage and clinical records and intra-oral photographs of these onset of primary teeth eruption. Some very peculiar patients were examined retrospectively. Six infants oral lesions such as epithelial pearls, natal teeth, were excluded because of missing records. The Riga-Fede disease, etc. appear only in infants. Such infants included 125 males and 109 females and the lesions have been reported in many articles1–7), youngest patient was 2 days old (Fig. 1). Among however, only a few reports8–10) have addressed the these infants, 70% were self referrals and 30% were oral conditions of newborns or infants as a separate referred by general practitioners, other departments age group. The aim of this study was to clarify of our hospital (oral surgery), or medical doctors the oral findings in Japanese infants attending the (pediatrician, obstetrician, dermatologist). We divided Pediatric Dentistry Clinic of Niigata University patients into 11 groups based on the diagnosis. The Medical and Dental Hospital. groups were oral mucosal lesions, cleft lip and/or palate, normal oral condition, high maxillary frenum, natal or neonatal teeth, traumatic injuries, teeth anomalies, ankyloglossia, eruption problems, occlusal Received on October 5, 2006 problems and others (Table 1). They were classified Accepted on January 15, 2007 by age in months, gender, location and treatment.

65 66 Tomizawa, M., Sano, T. and Noda, T.

Table 1 Distribution of the patients based on the diagnosis Diagnosis Age Male Female Total (%) Oral mucosal lesions 21d–11m 23 23 46 (*8) (19.0) Cleft lip and/or palate 1m–11m 24 21 45 (18.6) Normal oral condition 1m–11m 14 14 28 (11.6) High maxillary frenum 1m–11m 12 14 26 (10.7) Natal or neonatal teeth 2d–10m 10 11 21 (8.7) Traumatic injuries 6m–11m 14 7 21 (8.7) Teeth anomalies 9m–11m 9 6 15 (6.2) Ankyloglossia 1m–11m 8 6 14 (5.8) Eruption problems 3m–11m 6 5 11 (4.5) Occlusal problems 8m–11m 2 6 8 (3.3) Others 25d–11m 6 1 7 (2.9) Total 2d–11m 128 114 242 (*8)(100) *: counted again with natal teeth

Table 2 Diagnosis of oral mucosal lesions Diagnosis Number of patients (%) Epithelial pearl 12 (26.1) Riga-Fede disease 11 (*7) (23.9) Eruption cyst 8 (17.4) Eruption gingivitis 4 (8.7) Palatal polyp 3 (*1) (6.5) Epulis 2 (4.3) Mucous retention cyst 2 (4.3) Stomatitis 2 (4.3) Hemangioma 2 (4.3) Total 46 (*8) (100) Fig. 1 Distribution of age and gender *: counted again with natal teeth

Results Seven of the 11 Riga-Fede disease cases were caused by natal or neonatal teeth in 1- to 2-month- Oral mucosal lesions old infants. The other 4 resulted from normally Oral mucosal lesions were observed in 46 cases and erupted primary incisors and the infants were 5, 7, 9 8 of them coexisted with natal teeth. The lesions and 10 months old. A 10-month-old infant suffered were diagnosed as epithelial pearls, Riga-Fede from cerebral palsy. Two cases had also shallow disease, eruption cysts, eruption gingivitis, palatal ulcer formation on the tongue dorsum and upper polyps, epulides, mucous retention cysts, stomatitis anterior gingivae. Treatment was performed by (Herpetic gingivostomatitis and candidiasis), and covering the incisal edges of the primary teeth with hemangioma (Table 2). The age of the infants in light-cure composite resin to reduce irritation. The this group ranged from 21 days to 11 months old. prognosis of Riga-Fede disease was good and the Twelve epithelial pearl cases were located as natal teeth were preserved (Fig. 2). follows: maxilla 1, mandible 5, maxilla and mandible Eruption cysts were located in the lower primary 2 and unknown 4. All cases had been observed central incisor region in 5 subjects, lower primary without any treatment. lateral incisor region in 1, upper primary lateral ORAL CONDITIONS IN JAPANESE INFANTS 67

Fig. 2 a: Riga-Fede disease caused by a natal tooth at the age of 1 month and 8 days, b: covered incisor edge with light-cure composite resin, c: ulcer shrinkage after 3 weeks

One of the 2 mucous retention cyst cases was located on the lower lip and the other was a ranula on the floor of the mouth13). Two cases of hemangioma were located on the lower lip and on the angle of the mouth. They were referred to the Oral Surgery Clinic for further management.

Cleft lip and/or palate There were 45 cases of cleft lip and/or palate, and the age ranged from 1 to 11 months, with 34 of 45 patients of age 10–11 months old. They were referred for dental check-ups from the Oral Surgery Clinic. Four of the 45 cases had already decayed maxillary primary incisors.

Fig. 3 Intra-oral view showing a pedunculated polyp on Normal oral condition the left side of the palate in a 20-day-old newborn Twenty-eight infants were brought to our clinic for oral examination of dental caries, teeth eruption, or for fluoride application. They were diagnosed within incisor in 1 and maxillary primary first molar in 1. the normal range. They were under observation, and later the primary teeth erupted spontaneously. High maxillary frenum Four cases of eruption gingivitis were seen in the There were 26 cases in which the attached position upper primary incisor region. of the upper frenum was at the crest of the alveolar Three cases of palatal polyps were similarly ridges. Treatment consisted of observation in 24 located on the hard palate near the incisive papilla cases and surgical frenectomy in 2 cases due to (Fig. 3). The polyp was surgically removed in 2 persistent gingival inflammation at the upper central cases and the polyp, which was under observation, incisor region. decreased in size in 1 case11). One of the 2 epulis cases was located on the Natal or neonatal teeth palatal gingiva between the upper primary central Twenty-one infants visited our clinic with natal or incisors and the other was located on the maxillary neonatal teeth. The age of patients ranged from 2 primary lateral incisor region12). However, they days to 10 months old. There were 5 newborn infants, were not congenital epulides and were diagnosed 7 cases of 1 month age, 3 cases each of 2 or 3 months as epulis granulomatosa and epulis osteoplastica age and 1 case each of 7, 9, and 10 months age. pathologically. Seven of them involved lower right primary central 68 Tomizawa, M., Sano, T. and Noda, T.

Fig. 4 Natal or neonatal teeth and the presence of Riga-Fede disease

Table 3 Diagnosis, location and treatment of traumatic injuries Diagnosis Number of patients Treatment Soft tissue injury (laceration) 7 Upper labial frenum 5 suture 1, observation 4 Lower lip 1 observation Tongue 1 observation

Teeth injury 14 (22 primary incisors*) Luxation 7 fixation 3, extraction 1, observation 3 Avulsion 4 replantation 1 Intrusion 1 observation Concussion 1 observation Tooth fracture 1 extraction Total 21 *: 4 upper primary central incisors, 17 lower primary central incisors, 1 lower primary lateral incisor

incisors, 8 involved lower left primary central Teeth injuries accounted for 14 cases, 4 maxillas incisors, and 6 involved bilateral lower central and 10 mandibles, including 22 primary incisors. primary incisors. Treatment consisted of observation The 14 cases included 7 luxations, 4 avulsions, 1 in 14 cases, extraction in 4, while spontaneous intrusion, 1 concussion, and 1 tooth fracture. The exfoliation occurred in 3 cases. Seven of the 21 cases 22 injured teeth included 4 upper primary central had accompanying Riga-Fede disease (Fig. 4). incisors, 17 lower primary central incisors, and 1 lower primary lateral incisor. Three of the 7 luxation Traumatic injuries cases were fixed with wire and resin or resin shine, There were 21 cases with traumatic injuries (Table 3 were observed, and 1 was extracted. One of the 4 3). Seven of them involved oral soft tissues and avulsion cases was replanted because the avulsed included lacerations on the upper labial frenum in 5 lower primary central incisors were still in the cases, and on the lower lip and tongue in 1 case each. mouth when the patient came to our clinic14). The One case had the upper frenum sutured and the other tooth which had intrusive luxation was observed and 6 cases were observed. it later erupted again spontaneously. Fractured teeth ORAL CONDITIONS IN JAPANESE INFANTS 69

Fig. 5 Impacted straw around the gingival pocket of the lower left primary lateral incisor and the removed straw in an 11-month-old infant were extracted.

Teeth anomalies Teeth anomalies were seen in 15 cases and they consisted of talon cusps, hypoplastic teeth, and fused teeth. Six cases of talon cusps included 4 unilateral maxillary primary central incisors, 1 bilateral maxillary primary central incisor, and 1 unknown. There were 5 cases of hypoplastic teeth. Two cases affected all erupted primary teeth, one with dentinogenesis imperfecta and the other with enamel hypoplasia due to Goltz’s syndrome. Three cases were locally affected. They were enamel hypoplasia of bilateral upper primary central incisors and upper primary lateral incisor, enamel hypoplasia of the primary central and lateral incisors, and hypoplasia of the lower primary central incisor, respectively. Fig. 6 Mandibular melanotic neuroectodermal tumor Fused teeth were seen in 4 cases and they in a 1-month-old infant were fusions of bilateral lower primary central and lateral incisors, upper primary central incisor and a supernumerary tooth, and 2 cases of lower central problems such as eruption disorder, early eruption, and lateral incisors. Fissure sealant was applied to and delayed eruption. Five cases of eruption disorder the fused sulcus to prevent dental caries. were eruption of the maxillary primary lateral incisors before the eruption of maxillary central Ankyloglossia incisors. In the delayed eruption cases, there were Ankyloglossia was seen in 14 patients aged 1 month no evident causes of the disturbed eruption. The ages to 11 months. Treatment was incision of the lingual ranged from 10 months to 11 months old. In early frenum in 1 case, while the other 13 cases were eruption cases, primary teeth began to erupt at 2 observed. Two of them later underwent ankylotomy, months of age. All cases were observed. at the ages of 2 years and 2 years and 2 months, under general anesthesia. Occlusal problems Eight cases had occlusal problems including anterior Eruption problems cross bite in 6 and rotated teeth in 2. They were all Eleven cases visited our clinic because of eruption observed. 70 Tomizawa, M., Sano, T. and Noda, T.

primary central incisors. Of the 8 cases of eruption Others cysts in our study, 5 were also observed in the lower Seven cases which were classified in the ‘others’ primary central incisors. group were 2 cases with tumors, 1 with a prema- Cleft patients made up the second biggest group turely exfoliated supernumerary primary tooth in the and this could be attributed to the public knowledge maxillary canine region15), a hemophilia A patient that there is a cleft team in our hospital. Our Cleft diagnosed from gingival bleeding, fibroepithelial Palate Team includes members from the departments hyperplasia of the lower primary first molar region, of Oral Surgery, Orthodontics, Preventive Dentistry an impacted straw around the gingival pocket of the and Pediatric Dentistry. The patients were referred lower primary lateral incisor (Fig. 5) and a feeding from the Oral Surgery Clinic. Four cleft patients problem due to cerebral palsy. already had dental caries; however, in the other The tumor patients were referred to the Oral groups, there were no patients who had dental caries. Surgery Clinic and later diagnosed with Histiocytosis It was shown that intensive care for caries prevention X and melanotic neuroectodermal tumor of infancy16) was necessary for cleft patients before the primary (Fig. 6), respectively. teeth began to erupt. As for a high maxillary frenum, the attached Discussion position of the maxillary frenum usually changes from the crest of the alveolar bone with bone The patients usually attending the Pediatric Dentistry development. Therefore, we generally observe such Clinic are 3–5 years old17). The infant group is small cases until the permanent maxillary incisors begin to and our study population was only 1.3% (234 erupt. At that time, if the frenum is still attached to infants) of all the 18,616 patients registered in the the crest, frenectomy is performed. Frenectomy was Pediatric Dentistry Clinic over a period of 26 years. performed in 2 cases because of persistent gingival There have been many reports on epithelial inflammation in the maxillary incisor region. pearls1,8–10), natal teeth2–5), and Riga-Fede disease2,5–7), As for natal or neonatal teeth, 5 cases had which are usually seen in the oral cavity of infants. extractions because of severe mobility. One extrac- However, there have been few reports on the oral tion was done on the second day of life and there findings of newborns or infants as a separate age was no episode of prolonged bleeding. However, group8–10). Infants differ from others because dynamic it is recommended that tooth extraction should be changes are continuously occurring in their bodies postponed up to the 10th day of life to prevent and the oral cavity is in the initial stage of life. hemorrhage5). Pediatric dentists should be aware of what happens Traumatic injury was seen on the soft tissue and in the oral cavities of infants. This report showed primary teeth. Oral soft tissue injury in infants many kinds of oral conditions other than dental is frequently seen in the maxillary frenum and caries, which require professional attention from tongue19). In this report, 5 of the 7 cases of soft tissue pediatric dentists. injuries were on the maxillary frenum and the other We divided them into 11 groups based on 2 were on the tongue and lower lip. The most the diagnosis. The group of oral mucosal lesions frequently injured primary teeth have been reported constituted the biggest group, while epithelial pearls to be maxillary central incisors, however, in infants and Riga-Fede disease accounted for 50% of them. the lower primary central incisors were affected As for Riga-Fede disease, treatment methods involve most frequently. grinding incisor edges or extraction of the involved Teeth anomalies involved talon cusps, fused teeth, although we usually cover the incisor edge teeth, and hypoplastic teeth. Talon cusps are seen with light-cure resin to reduce irritation. This method more frequently in the permanent than in the primary was very easy to apply in the small mouths of infants dentition. A predilection of the maxilla over the and was effective2). Oral mucosal lesions associated mandible has been noted, with more than 90% of the with primary teeth eruption were seen as eruption reported cases in maxilla20). 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