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 tooth” 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 dental trauma 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 Cyclic neutropenia Neoplasms (Leukemia, Lymphoma) Localized/generalized aggressive periodontitis Hemifacial hypertrophy Dentin dysplasia (Type 1)
References: 1,2,8 Diseases or Disorders (cont’d)
Chediak-Higashi Acrodynia Facial burns Langerhans Cell Histiocytosis Regional odontodysplasia Dental abscess 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 bones 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 gingivitis / 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 cementum) 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 Dentigerous cyst 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.