|Non syndromic multiple erupted natal teeth with gingival swelling. A rare case report.
Presence of Multiple natal teeth is a rare. Case of six weeks old infant is presented here with refusal to suckle milk, crying constantly and three erupted natal teeth with gingival swelling. Two more teeth were seen with pre eruption blanching. Oral muscular forces in early infancy can act unfavorably on natal teeth. Immature and unsupported natal teeth can act as foci of infection in infants and should be promptly managed by pediatric dentist to avoid any complications.
Key words: Natal teeth, Gingival swelling, Multiple natal teeth
Non syndromic multiple erupted natal teeth with gingival swelling. A rare case report.
Teeth present at the time of birth are termed natal teeth and those within 30 days after birth are termed neo natal teeth. 1 The incidence of natal teeth ranges from 1:2,000 to 1:3,500 live births.2 Natal teeth were reported during Roman times by Titus Livius (59 BC) and Caius Plinius Secundus (23 BC) and were described in the cuneiform inscriptions found at Nineveh.3 The condition is slightly more common in females. 4 Almost 85% of natal or neonatal teeth are mandibular primary incisors and only small percentages are supernumerary teeth. It is common for natal and neonatal teeth to occur in pairs.5 Various synonyms for natal and neonatal teeth given in literature are congenital teeth, fetal teeth, predeciduous dentition, dentition praecox and dens connatalis. 5-7 Based on maturity of the tooth, it is classified into mature (which is nearly or fully developed and has a relatively good prognosis) and immature (a tooth with incomplete or substandard structure and has poor prognosis) 8
Mother of a one and half month old male infant reported to the department at afternoon with complain of infant refusing to suckle milk since morning. Parent reported the teeth to be present since birth. The mother had problem in feeding the infant and would experience pain occasionally .The infant was born through normal vaginal delivery. There was no history of systemic disease or ill health of mother during the period of pregnancy. Family history for teeth present at birth was negative.
On examination there was presence of single tooth in maxillary arch and two teeth in mandibular anterior arch. Maxillary left central incisor (61) and mandibular left and right central incisors (71, 81) were erupted.(fig 1) Blanching was seen in region of mandibular right first molar (84) and maxillary right central incisor (51) and the area was hard on palpation (consistency of tooth). The maxillary left central incisor was hypoplastic and mobile, labially gingival swelling was observed which was inflamed, red in colour and soft and edematous in consistency (fig 2). The tooth appeared to be slightly extruded and had grade II mobility. On palpation it was tender and the infant cried. The lower incisors showed slight mobility. Incisal edge of the lower right central incisor had notching.
. A radiograph was advised, but the parents did not give consent for it and thus it was not taken. Considering the problem in feeding and the mobility of the tooth, a decision was taken to extract the maxillary central left incisor and retain the mandibular teeth and keep it under observation.
Under topical spray anesthesia, (Nummit Spray) the extraction was done (Fig 3). Small wool of cotton was taken in a tweezer and sprayed with the anesthesia and placed around the tooth to be removed for 90 seconds followed by removal of the tooth. Curettage of the soft tissue remnants and socket was performed. Hemostasis was achieved by placing gauze soaked in saline for 2 minutes compressing the socket. Post operative instructions were given and analgesic drops were prescribed for the infant. A follow up after a week was recommended. The patient came after a month. There was no post operative discomfort or problems reported. On examination the lower central incisors had increased mobility. It was decided to extract them. The incisal edge of the right central incisor and cuspal tip of lower right first primary molar was seen. Following extraction the parents were advised to report after a week. However the patient was lost to follow up.
The given ground section of mandibular incisors showed enamel, dentine, neonatal line (fig 4 ) and straight dentinoenamel junction with accentuated dentinal tubules (fig 5) The maxillary primary teeth ground section showed increased interglobular dentine suggestive of hypoplasia (fig 6). This confirms it was a true natal tooth.
Multiple erupted natal teeth are rare and majority reported in literature are associated with syndromic conditions or systemic illness.9 The present case was seen in a healthy infant. The exact etiology is unknown. Heredity, endocrine disturbances, infection, febrile illness, nutritional deficiencies and exposure to environmental factors like poly chlorinated biphenols and dibenzofurans have been suggested.1,8,10 Other authors have suggested superficial positioning of the tooth germ and increased osteoblastic activity with excessive development during initiation and proliferation of tooth germ during developmental period as the probable etiology of natal and neonatal teeth. 10, 11 In the present case no known etiology was found and cause could be the superficial positioning of the tooth germ.
Hebling (1997) 12 has classified natal teeth into 4 clinical categories:
1. Shell-shaped crown poorly fixed to the alveolus by gingival tissue and absence of a root; 2. Solid crown poorly fixed to the alveolus by gingival tissue and little or no root;
3. Eruption of the incisal margin of the crown through gingival tissue; 4. Edema of gingival tissue with an unerupted but palpable tooth. All the three teeth were of type II category with less than one third of root formation. Clinically the natal/neonatal teeth are poorly developed and are small and cone shaped. They have a yellowish-brown or whitish opaque color and have hypoplastic enamel or dentin.10 Occasionally they may be of normal size and shape. In the present case maxillary primary left central incisor was hypoplastic with loss of enamel and dentine exposed and yellowish in colour. The mandibular central incisors were of normal shape and size with intact enamel and notch on the incisal ridge which gave the appearance of mammeleons. Gum pad of mandibular right primary first molar and maxillary right central incisor showed blanching suggestive of erupting tooth. Majority of natal teeth are mobile13,14. Mobile natal teeth can lead to dangerous complications. Respiratory distress due to Natal teeth associated with swelling of chin with high grade fever and pus in a 15 day infant has been reported in the literature. Emergency drainage and removal was performed under general anesthesia. 15
. The first year of infancy corresponds to the oral stage of psychological development and the infant explores his environment though his mouth, tongue, lips and cheek. The strong oromuscular forces during first few months of life may act unfavourably during suckling and other movements on the immature tooth with less root support. This can lead to increased mobility of the natal neonatal tooth and risk of aspiration or ingestion. Although there have been no reported cases of actual aspiration or ingestion of natal / neonatal teeth in literature, they definitely do not have good prognosis in the first few months of life. Ulceration of the ventral surface of tongue1,8,10, pulp polyp like condition16, pyogenic granuloma17, gingival hyperplasia18 and myxoid calcified hamartoma 19 like complications has been reported to be associated with retention and/or improper removal(without curettage of the socket) of natal teeth in literature. Presence of infection in infancy can lead to disastrous effect. Thus extraction of mobile natal neonatal teeth should be considered. Early removal of primary teeth has been thought to lead to crowding of permanent teeth due space loss. To found no appreciable space loss following extraction of natal primary teeth.20
Presence of multiple natal/neonatal teeth is rare. The teeth may show variations in size, shape, mobility and lead to difficulties in feeding. General medical practitioners and pediatricians should be made aware of its examination and referral to pediatric dentist for its prompt management.
Figure 1 – Three erupted natal teeth 61, 71, 81. Pre eruption of blanching in region of 84
Figure 2 – Extruded hypoplastic 61 with gingival swelling
Figure 3 – Extracted 71 & 81
Figure 4 – Ground section showing neonatal line, enamel and dentine.
Figure 5 – Straight dentinoenamel junction with accentuated dentinal tubules
Figure 6 – Interglobular dentine
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