“A Rarity–Cases of Natal Teeth”
Prematurely erupted teeth present at birth have been described as “natal teeth/ congenital teeth or fetal teeth”. Such teeth are of great concern to the parent because of several superstitions and beliefs. Other related inconveniences or dangers to the infants and mothers are the displacement and aspiration of such teeth causing injuries to the oral cavity along with the disturbance during breast feeding.
The aim of this case report is to discuss the typical clinical features and special management and counselling of the parent for such teeth.
Natal teeth, Neonatal teeth, Hypoprothrombinemia, Rega Fege disease
Teeth that are present at the time of birth are known as natal teeth while the teeth that erupt during the neonatal period (from birth to 30days) are referred as neonatal teeth . Such teeth have been designated as congenital teeth, fetal teeth, predeciduous teeth, dentitia praecox. The incidence of natal and neonatal teeth varies from 1:1000 to 1:30,000 [2-5] and the mandibular incisors(85%), maxillary incisors(11%), mandibular canines and molars(3%), maxillary canines and molars(1%), and in pairs(38-76%) [1,3,6,7]. Superstitions concerning these prematurely erupted teeth have varied from claims that such infants are exceptionally favored by fate. This condition usually is an unpleasant experience to the child as well the mother.
Case-1: A 4-day old male neonate was brought to the Department of Pedodontics and Preventive Dentistry, K.D Dental hospital Mathura (UP) by the parent with the complaint of the presence of a black tooth in the lower front region of jaw since birth. The mother also complained about the child having difficulty in suckling and highly irritable. On intraoral examination revealed the presence of a tooth in the mandibular anterior region which showed blackish discolouration of the crown portion and a morphological characteristic of an incisor. The tooth was loosely attached to the underlying soft tissue and displayed grade-3 mobility (Figure-1). Based on the clinical findings this case was diagnosed as a Natal tooth.
Case-2: A 7-day old male neonate was brought to the Department of Pedodontics and Preventive Dentistry, K D Dental hospital ,Mathura(U P) by the parents with the complaint of mobile tooth in the lower front region of the jaw and also the presence of an ulcer on the inner surface of the tongue. On intraoral examination the tooth appeared yellowish in colour, mobile and resembled morphologically to the mandibular incisor (Figure-2). The soft tissue surrounding the tooth was inflamed and appeared swollen. The ventral surface of the tongue revealed a solitary ulcer probably due to trauma from the tooth. Based on history and clinical examination this case was diagnosed as Riga – Fede disease because of the presence of Natal tooth.
The cases were managed by extracting the teeth under topical anaesthesia with the aim to prevent inadvertent risk of being swallowed the teeth because of their loose attachment to the underlying soft tissue. Haemostasis was achieved by digital as well as pressure pack. Both the extracted teeth exhibited short crowns with no roots indicating immature type of natal tooth (Figure-3 and Figure-4). In the second case the ulceration on the ventral surface of the tongue was also completely healed after 10days of extraction of the teeth.
The occurrence of natal and/or neonatal teeth was reported since prehistoric period, which for centuries has been associated with diverse superstitions among many different ethnic groups. “Babies born with erupted teeth were known to the Greeks and Romans” . Titus livias, in 59 B.C. considered natal teeth to be prediction of disastrous event. Malaysian communities however believed neonatal teeth to be a good omen. Some other communities like the Chinese thought presence of these teeth as a bad omen. Some Indian communities look upon this as an unlucky baby, bad omen or devil’s incarnation. In England, the belief was that this condition would guarantee the conquest of the world [7-9].
Natal and Neonatal teeth have been reported as being predeciduous or supernumery teeth . According to Brauer et al, supernumerary natal or neonatal teeth are characterized by their looseness and lack of root formation  and the lower primary central incisors were mainly affected .
Various etiological factors have been reported. Some of them is noted ie, 1)familial pattern or inheritance, 2)endocrinal disturbances especially of the thyroid, gonads, and thymus 3)superficial position of the tooth germs, 4) infections like congenital syphilis. Further some systemic conditions or syndromes associated with such teeth are;- Hallerman-streiff syndrome (occlusomandibulodyscephaly with hypotrichosis), Ellis-Van creveld syndrome (chondroectodermal dysplasis), Craniofacial dysostosis syndrome, Multiple steacystoma, Cleft palate, Pierre Robin syndrome, Adrenogenital syndrome, Epidermolysis bullosa simples etc are reported.
Presence of these teeth causes several possible complications to the child and mother. Some of them include the traumatic injuries to ventral surface of tongue. This condition is called as Riga-Fede disease. The lesion was first described by Antonio Riga, an Italian physician in 1881. Histologic studies and additional cases were subsequently published by F. Fede in 1890 . It has been subsequently been known as “Riga-Fede” disease. Other complications include the possibility of swallowing the greatly mobile teeth by the infant during sucking. Inconvenience like unable to place the nipple in position during suckling, irritability lead to frequent crying, and refusal of feeding, also injury to the breast.
Timely management of natal teeth is important depending upon the clinical situation. Most prematurely erupted teeth are hypermobile up to the extent which may require extraction so as to avoid displacement and aspiration during suckling because of the limited root development. Exceptionally rare cases in which the sharp incisal edges of the tooth may cause trauma to the surrounding soft tissue, therefore the teeth have to be extracted. If the tooth is not causing any disturbances to the infant or mother they are left alone and the importance of the tooth in the growth of the infant should be explained to the parent. Teeth causing trauma need conservative treatment which of consists of smoothing rough incisal edges, or placing round, smooth composites over the incisal edges. Generally the gingival tissues surrounding natal teeth are normal but some time the tissue is edematous and hemorrhagic. Therefore, the inflamed gingival tissue around the teeth can be controlled by applying chlorhexidine gluconate gel three times a day . Otherwise usually extraction should be delayed for at least 10 days after birth because of fear of hemorrhage due to hypoprothrombinemia. Nowadays delaying of surgical procedure on newborns is no longer considered because of prophylactic administration of vitamin K as a standard procedure in most hospitals . If necessary, hemostasis may be enhanced by using topical hemostatic agents in combination with direct pressure.
CONCLUSION As natal teeth may present with different clinical manifestations, a proper evaluation and sound clinical experience is very important for the management of such teeth and also strong counselling for the parent to remove the strong beliefs and superstitions from the parents` mind . Then the infant will be of normal behaviour with normal milestone and the parent particularly the mother will accept the infant as one of the loveliest.
The authors would like to acknowledge Dr. A. K. Munshi, Senior Professor, Head of Dept. of Pedodontics & Preventive Dentistry, Dean, Principal and Director K. D. Dental College & Hospital, Mathura, India for contributing his valuable ideas and guidance in the process of managing such cases.
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Figure-1: Case 1- Intraoral photograph showing a natal tooth in the mandibular anterior region.
Figure-2: Case 2- Intraoral photograph showing a natal tooth in the mandibular anterior region.
Figure-3: Case 1- Extracted immature natal tooth.
Figure-4: Case 2- Extracted immature natal tooth