25

Disorders of eruption and

exfoliation
Case 1
SUMMARY
Beth was only 20 days old when it was noticed she
had two teeth at the front of the lower jaw (Fig. 25.1).
What is the correct terminology for these early erupting
teeth?
If the teeth are present at birth, natal is the correct term. If
they are not present at birth but erupt within the rst month
of life, neonatal is correct.
The prevalence rates for both natal and neonatal teeth are
reported as 1 in 20003000 live births. The most commonly
presenting tooth is the lower central incisor. More rarely,
maxillary incisors or rst molars have been reported. The
early eruption is thought to be caused by the ectopic posi-
tion of the tooth germ during fetal life. Natal and neonatal
teeth may follow a sporadic pattern or they may be familial.
However, they can be associated with specic syndromes:
Pachyonychia congenita.
Ellisvan Creveld.
HallermannStrei.
What are the main problems associated with natal and
neonatal teeth?
Mobility.
Ulceration of ventral surface of tongue.
Nipple soreness (breastfeeding mothers).
The teeth are mobile because the development of the tooth
is consistent with age. Only about ve-sixths of the crown is
formed and usually no root. Additionally, the crown is
occasionally dilacerated and the enamel hypoplastic or
hypomineralized.
Excessive mobility is a danger to the airway from aspiration
and the tooth should be removed. Care should be taken to
ensure that the entire tooth including the pulpal tissue is
removed, otherwise dentine and a root will form, which will
require eventual removal. If teeth can be left then continued
root development will occur.
Nipple soreness may occasionally necessitate tooth removal.
Ulceration on the ventral surface of the tongue may respond
to carmellose sodium oral paste. Smoothing of the incisal
edges with sandpaper discs may also help.
What factors can cause generalized premature eruption but
still be considered as normal?
Familial a family history is a common nding.
Children with high birth weights.
Race generally Negroids tend to erupt their permanent
teeth earlier than Mongoloids, who are in turn in advance of
Caucasians. Racial group does not seem to aect eruption
times of primary teeth but eruption patterns can vary in the
primary dentition.
Sex females tend to erupt permanent teeth several months
ahead of males.
The opposite of premature eruption is delayed eruption.
When is generalized delay in eruption of primary
teeth expected?
Preterm infants.
Very low birth weight infants.
What conditions may lead to a generalized
retarded eruption of teeth in both primary and
permanent dentitions?
Chromosomal abnormalities Downs and Turners syndromes.
Gross nutritional deciency.
Hypothyroidism/hypopituitarism.
Hereditary gingival bromatosis (HGF).
Acquired gingival overgrowth (drug-induced).
What specifc condition is associated with grossly delayed
or failed eruption of teeth in the permanent dentition?
Cleidocranial dysplasia this is an autosomal dominantly
inherited condition where, in addition to multiple sup-
ernumerary teeth causing delayed exfoliation of primary
teeth and delayed eruption of permanent teeth, there is
aplasia of commonly the distal end or total absence of the
clavicles. Fig. 25.1 Natal teeth.
25 D I S O R D E R S O F E R U P T I O N A N D E X F O L I AT I O N
111

What local factors can account for delayed eruption of

permanent teeth?
Supernumerary teeth or odontomes.
Ectopic crypt positions of permanent teeth.
Cystic change in the follicle of permanent teeth.
Crowding.
Thickened mucosa due to early primary tooth removal.
Generally teeth may be lost early because of:
Metabolic disturbances.
Severe periodontal disease.
Loss of alveolar bone support.
Self-injury or non-accidental injury.
George will continue to have regular dental care and
supervision of brushing. Even in the presence of immaculate
plaque control we can expect that his neutrophil defect will
predispose him to periodontal disease and premature loss of
some if not all his permanent teeth.
The opposite of premature exfoliation is delayed
exfoliation.
What causes delayed exfoliation of primary teeth?
Double primary teeth.
Hypodontia aecting permanent successors.
Ectopically placed permanent successors.
Trauma or periradicular infection of primary teeth causing
interruption of physiological resorption.
Infraocclusion or ankylosis.
Double primary teeth are associated in 40% of cases with an
abnormality of number of the permanent dentition. Parents
should be advised of this and a dental panoramic tomogram
should be taken around the age of 6.
Key point
Natal and neonatal teeth may need to be removed if:
Mobility causes concern about inhalation.
Ulceration under the ventral surface of the tongue
persists.
Nipple soreness is signifcant.
Exfoliation of teeth (like eruption) can be either prema-
ture or delayed.
Case 2
SUMMARY
George was 3 years of age when his mother frst
noticed that his lower primary incisors were loose.
History
George was born after a normal pregnancy and delivery but
had problems after birth with recurrent coughs and colds,
upper and lower respiratory tract infections, and oral ulcer-
ation. He was extensively investigated and was conrmed
as having a cyclic neutropenia.
Dental history
George and his mother had regular toothbrush instruction
and his oral hygiene was excellent. He also used 0.2% chlor-
hexidine gel at night instead of uoridated toothpaste.
Despite these efforts his lower primary incisors exfoliated
between age 4 and 5 years and by his sixth birthday he had
erupted his lower permanent central incisors and rst per-
manent molars ( Fig. 25.2A, B ).
Premature loss of primary teeth is an important diagnos-
tic event, as most conditions causing it are potentially
serious and warrant immediate investigation ( Box 25.1 ).
Fig. 25.2 (A) Cyclic neutropenia.
Box 25.1 Dierential diagnosis of causes of premature exfoliation of
primary and permanent teeth
Neutropenias and qualitative neutrophil defects:
Cyclic neutropenia.
Congenital neutropenia (Kostmann disease).
Pre-pubertal periodontitis.
Juvenile periodontitis.
Leucocyte adhesion defect.
Papillon Lef vre syndrome.
Chediak Higashi disease.
Langerhans cell histiocytosis leading to bony destruction.
Hypophosphatasia with aplasia or hypoplasia of cementum.
Self-injury in either a psychotic disorder or the congenital insensitivity to pain
syndrome.
Ehlers Danlos syndrome (type VIII) disorder of collagen formation causing
progressive periodontal destruction.
Scurvy loss of tooth due to failure of proline hydroxylation and collagen
synthesis.
Neutropenias and qualitative neutrophil defects:
Cyclic neutropenia.
Congenital neutropenia (Kostmann disease).
Pre-pubertal periodontitis.
Juvenile periodontitis.
Leucocyte adhesion defect.
Papillon Lef vre syndrome.
Chediak Higashi disease.
Langerhans cell histiocytosis leading to bony destruction.
Hypophosphatasia with aplasia or hypoplasia of cementum.
Self-injury in either a psychotic disorder or the congenital insensitivity to pain
syndrome.
Ehlers Danlos syndrome (type VIII) disorder of collagen formation causing
progressive periodontal destruction.
Scurvy loss of tooth due to failure of proline hydroxylation and collagen
synthesis.
Fig. 25.2 (B) Cyclic neutropenia.
25 D I S O R D E R S O F E R U P T I O N A N D E X F O L I AT I O N

112
How is infraocclusion graded?
Grade I Occlusal level above contact point of adjacent
tooth.
Key point
Infraocclusion:
Mandibular frst primary molar most commonly afected.
More common in primary teeth than in permanent teeth.
Equal sex ratio.
Higher incidence of absent permanent successors.
Grade II Occlusal level at contact point of adjacent
tooth.
Grade III Occlusal level below contact point of adjacent
tooth.
Grade III infraocclusions, if progressive, may be com-
pletely reincluded by the surrounding hard and soft tissues.
Radiographs of infraoccluded teeth show blurring or
absence of the periodontal space.
Treatment options in infraocclusion
These are considered in Chapter 6.
Recommended reading
Crawford PJM, Aldred MJ 2005 Anomalies of tooth
formation and eruption. In: Welbury RR, Duggal MS,
Hosey MT (eds) Paediatric Dentistry, 3rd edn. Oxford
University Press, Oxford, pp 297318.
For revision, see Mind Map 25,
page 187.
Infraocclusion is the preferred term for either submerged
teeth or ankylosis when describing teeth that have failed
to achieve or maintain their occlusal relationship to
adjacent or opposing teeth. Most commonly, primary
teeth have reached a normal occlusal level before becoming
infraoccluded. Rarely there may be primary failure of eruption
of primary and permanent teeth in the same quadrant in the
same person.
The tooth most commonly aected is the mandibular rst
primary molar. Males and females are aected equally.
Infraoccluded primary teeth are associated with a higher
incidence of absent permanent successors.
41
187

MI N D MA P 2 5
primary teeth
pre-term
very low birth weight
generalized
cleidocranial dysplasia
supernumerary / odontome
ectopic
cystic follicular change
crowding
thickened mucosa
localized
chromosomal
nutritional
hypothyroid
hypopituitarism
acquired gingival overgrowth
hereditary gingival
fibromatosis (HGF)
primary and permanent teeth
permanent teeth
Generalized delay in eruption
familial
high birth weight
race
sex
Generalized
premature eruption
of permanent teeth
aetiology
spontaneous
familial
syndromic
mobility
tongue ulceration
tongue ulceration
nipple soreness
mobility
extract
extract
extract
smooth tooth
carmellose paste
nipple soreness
problems
treatment
Natal / neonatal teeth
neutropenia
neutrophil defect
histiocytosis
hypophosphatasia
scurvy
EhlersDanlos syndrome
psychosis
Metabolic
periodontal disease
self injury
non-accidental injury
congenital insensitivity to pain
Premature loss
of primary teeth
double primary teeth
ectopic successor
abnormal physiological resorption
infraocclusion / ankylosis
hypodontia affecting
permanent successor
Delayed exfoliation
of primary teeth
Disorders of Eruption and
Exfoliation