Reasons for Early or Late Loss of Primary Teeth

Amanda Huminicki November 7, 2015 Outline

 What is the “normal” exfoliation time for primary anterior teeth?  Reasons for early exfoliation of primary teeth  Reasons for late exfoliation of primary teeth  What to ask parents  Case studies  The infamous “shark ” scenario

Normal age ranges for primary anterior tooth exfoliation

 Mand cental incisors: 6-7 y  Max central incisors: 7-8 y  Mand lateral incisors: 7-8 y  Max lateral incisors: 8-9 y  Mand canines: 9-11y  Max canines: 11-12 y Image:  Females are often ahead of http://www.aboutyourteeth.com.au/wp- males content/uploads/2013/10/ChildTooth.jpg

 Reference: Nowak AJ and Casamassimo PS. : The Handbook of Pediatric Dentistry, 4th Edition. The American Academy of Pediatric Dentistry, 2011.

Reasons for early exfoliation

 Could be normal for that child  Trauma  Important to ask parents if there’s been a history of  Underlying disease or medical disorder

 References:1,2 Image: http://bestdentistnews.com/wp- content/uploads/lost-tooth-199x300.jpg

Diseases or Disorders

 Hypophosphatasia*  Fibrous dysplasia  Papillon-LeFevre   Neoplasms (Leukemia, Lymphoma)  Localized/generalized  Hemifacial hypertrophy  dysplasia (Type 1)

 References: 1,2,8 Diseases or Disorders (cont’d)

 Chediak-Higashi  Acrodynia  Facial burns  Langerhans Cell Histiocytosis   Vitamin C deficiency (scurvy)

 References: 1,2,8

Reasons for late exfoliation  May be normal for that child  Trauma  Ankylosis  Impacted permanent successor tooth  Supernumerary tooth – PA or pan  Underlying disease or medical disorder http://askanorthodontist.com/braces/wp- content/uploads/2012/10/Ankylosed- Primary-Central-Incisor1.jpg  Reference: 1 Diseases or Disorders

 Cleidocranial dysplasia  Chondroectodermal dysplasia  Achondroplasia  Osteogenesis imperfecta  Gardner syndrome  Down syndrome  Apert syndrome

 References: 1,8

Diseases or Disorders (cont’d)

Hypothyroidism Hypopituitarism Ichthyosis Hunter syndrome Incontinentia pigmenti Hereditary gingival fibromatosis Low birth weight and/or premature baby

 References: 1,8 Questions to ask parents for early loss of a primary incisor

 Was the child early or late to get his or her primary teeth?  You can refer to the normal tooth eruption timeline chart as a guide  Is there a history of trauma?  Did they bring in the tooth?  An exfoliated primary central incisor with a complete root (no root resorption): suspect http://www.cabinetmagazin e.org/issues/36/N0025954_FIN hypophosphatasia AL.jpg Reference: 1,2

Questions to ask parents (cont’d)

 Past medical history  Premature birth or LBW  Existing medical conditions  History of broken  Medications & allergies http://images.wisegeek.com/medical -history-form.jpg  History of recurrent infections

 References: 1,2 Clinical exam

 Are soft tissues normal?  Rule out / periodontitis  Rule out trauma  Are other primary incisors mobile? http://www.columbia.edu/itc/hs/dental/d7710/client_  Is there any edit/AnatomyofPrimaryTeeth_files/slide0001_image013.j pathology? pg

 References: 1,2 Case Study – Early Loss of Primary Teeth  A healthy 20 month old female patient presented at a pediatric dental office  She was referred by her general dentist re: mobility of 71 and 81 that had been increasing over several weeks  Medical and family histories: clear

except for a previous bacterial http://ecx.images- amazon.com/images/I/51vrh5ydT skin infection and a systemic viral 2L._SL1500_.jpg infection Reference: 3 Case Study – Early Loss

 Reference: 3 Case Study – Early Loss (cont’d)

 Clinical examination:  All primary teeth present except E’s  71 and 81 had grade III mobility  All other teeth were WNL  Soft tissues WNL except for gingivitis around 71/81 (mother reports not brushing this area due to the mobility)  Overall, oral hygiene was good

 Reference: 3 Case Study – Early Loss (cont’d)

Reference: 3 Case Study – Early Loss (cont’d)

 Diagnosis: Hypophosphatasia  Made by:  Microscopic examination of 71 and 81 after they exfoliated (no )  Blood testing by physician: would see deficient tissue non-specific alkaline phosphatase  May or may not be a family history

 Reference: 3,4 Case Study – Early Loss (cont’d)

 Management:  Referral to physician for blood testing  Radiographic screening of long bones  Genetic screening and counseling for family members  Maintain excellent oral hygiene  Often only the primary teeth are affected  Will likely have early loss of other primary teeth  Prosthetic replacement of exfoliated permanent teeth References: 3,4 Case Study – Late Loss of Primary Teeth  A 10 year old boy presented to the pediatric dentist with a chief concern of retained 51 / 61  Medical and family histories: clear  Clinical exam: class I mixed dentition, unerupted 11 / 21  Occlusal and panoramic radiographs taken Reference: 5 http://content.mycutegraphics.com/graphics/dete ctive/boy-detective-with-magnifying-glass.png Case Study – Late Loss (cont’d)

 Reference: 5 Case Study – Late Loss (cont’d)

 Reference: 5 Case Study – Late Loss (cont’d)

 Reference: 5 Case Study – Late Loss (cont’d)

 Diagnosis: supernumerary teeth  Management: referral to OMFS for surgical removal of the 2 supernumerary teeth  After removal, wait and monitor to allow 11 and 21 to spontaneously erupt  If no spontaneous eruption after 6-12 months, surgical exposure and orthodontic repositioning should be considered

 References: 5,6 Case Study – Late Loss (cont’d)

 Reference: 5 Case Study – Late Loss (cont’d)

 Reference: 5

Case Study – Late Loss (cont’d)

 Reference: 5

Case Study – Late Loss (cont’d)

 Reference: 5

When to suspect a mesiodens?  Mesiodens: a supernumerary tooth in the maxillary anterior midline  Suspect a mesiodens if:  Maxillary permanent incisors have an asymmetric eruption pattern  Maxillary permanent incisors http://www.jisppd.com/articles/2011/29/ exhibit delayed eruption (+/- 1/images/JIndianSocPedodPrevDent_201 retained primary incisors) 1_29_1_34_79928_f9.jpg  Maxillary permanent incisor

erupts ectopically References: 6,7 Complications of a mesiodens  Delayed eruption of perm incisors  Crowding  Root / crown resorption of adjacent teeth   Removal usually necessary Reference: 6

http://isdent.org/ArticleImage/2080ISD/isd-42- 255-g006-l.jpg When to extract a mesiodens?

 AAPD recommends extracting a mesiodens no earlier than the time of 2/3 root development of the adjacent incisors  This reduces the risk to the developing adjacent teeth posed by surgical

extraction but there is still a https://s3.amazonaws.com/r apgenius/1365193232_Guy- chance for spontaneous with-Question-Mark-over-his- eruption of the incisors headFotolia_102829_XS.jpeg Reference: 6 “Shark teeth” o Common concern of parents (10%) o Reference 9 o What advice should you give them?

 Image: http://www.drrenginnalbantoglu.com/resimler/klinigimizd e-uygulanan-tedaviler-21.jpg Questions?

 Thank you for your attention! References

 1. Nowak AJ and Casamassimo PS. : The Handbook of Pediatric Dentistry, 4th Edition. The American Academy of Pediatric Dentistry, 2011.  2. Sonis AL. “Oral Pathology / Oral Medicine / Syndromes.” An audio recording from the AAPD Comprehensive Review of Pediatric Dentistry. 2008.  3. Hollis A, Arundel P, High A, Balmer R. Current concepts in hypophosphataisa: case report and literature review. Int J Paediatr Dent 2013 May;23(3):153-9.  4. Moursi AM. Clinical Cases in Pediatric Dentistry. 2012, Blackwell Publishing Ltd: West Sussex UK.  5. Manuja N, Nagpal R, Singh M, Chaudhary S, Suresh BS. Delayed eruption of maxillary permanent central incisors due to bilateral tuberculate supernumerary teeth: case report. J Dent Child 2010 May-Aug:77(2):106-10.  6. American Academy of Pediatric Dentistry. Guideline on Pediatric Oral Surgery. Revised 2014. http://www.aapd.org/media/policies_guidelines/g_oralsurgery.pdf.  7. AAPD Reference Manual. Guideline on Prescribing Dental Radiographs for Infants, Children, Adolescents, and Persons with Special Health Care Needs. Revised 2009.  8. Flaitz CM and Donis AL. Oral Pathology / Oral Medicine / Syndromes. AAPD Comprehensive Review. 2008.  9. Gellin ME, Haley JV. Managing cases of overretention of mandibular primary incisors where their permanent successors erupt lingually. ASDC J Dent Child 1982 Mar-Apr;49(2):118-22.