"Early baby teeth": Folklore and facts.

Variations in the newborns' oral cavity have been an enduring interest to the pediatric dentist. The occurrence of natal and neonatal teeth is a rare anomaly, which for centuries has been associated with diverse superstitions among many different ethnic groups. Natal teeth are more frequent than neonatal teeth, the ratio being approximately 3:1. The purpose of this case report is to review the literature related to the natal teeth folklore and misconceptions and discuss their possible etiology and treatment.

“Early doing's and sayings” of a child is always flooded with immense pleasure in day-to-day life. Not all the early happenings in the child's life are easily appreciated. One such thing that leads to plethora of reactions is the newborn with the new teeth at birth or too early. The folklore and misconceptions surrounding natal and neonatal teeth varies. To complicate matters further, there are various difficulties like pain on suckling, refusal to feed, traumatic ulceration faced by the mother and the child due to the child's early teeth. These teeth are of enduring interest to both the parents and pediatric dentist because of their clinical characteristics.

Case Report

A 2-day-old male infant was referred with the complaint of two teeth in the lower jaw since birth, continuous crying, and refusal to suck milk. Oral examination revealed two crowns of the teeth in the mandibular anterior region [Figure 1], whitish opaque in color and exhibiting grade III mobility. The crown size was normal; the gingiva was of normal appearance. A diagnosis of natal tooth was made. Since immediate extraction was the treatment of choice, the pediatrician was consulted and vitamin K was administered intramuscularly as a part of immediate medical care to prevent hemorrhage; and the teeth were extracted under topical local anesthesia [Figure 2], which the patient tolerated well. The extracted teeth had a crown but were devoid of roots [Figure 3]. The patient was reevaluated after 7 days, and the recovery was found to be uneventful [Figure 4].

Figure 1

Preoperative view showing mandibular anterior natal teeth

Figure 2

Extracted natal teeth

Figure 3

Postoperative view after extraction

Figure 4

After 1 week

Review of Literature

Folklore and fact

The occurrence of natal and neonatal teeth for centuries has been associated with diverse superstitions among many different ethnic groups. In some cultures like Malaysian communities, a natal tooth is believed to herald good fortune. Chinese community considers presence of these teeth as a bad omen and the affected children are considered to be monsters and beavers of misfortune. Shakespeare contributed his thoughts on natal teeth in “King Henry the Sixth” when he refers to Richard the Third in his quotation, “teeth hadst thou in thy head when thou wast born to riguity thou camest to bite the word.”[1] In England, the belief was that this condition would guarantee the conquest of the world.[2]

Massler and Savara (1950)[3] defined these teeth as natal and neonatal teeth, taking only the time of eruption as a reference. This definition has been widely accepted and followed. Natal teeth are those teeth that are present at the time of birth and neonatal teeth are those teeth that erupt within the first 30 days of life. Terms such as congenital teeth, fetal teeth, predeciduous teeth, and precocious dentition, as well as Dentitia praecox and dens cannatalis, have been used to describe these teeth.

Classification

Spoug and Feasby (1966) have suggested that clinically, natal and neonatal teeth are further classified according to their degree of maturity.[2]

A mature natal or neonatal tooth is the one which is nearly or fully developed and has relatively good prognosis for maintenance.

The term immature natal or neonatal teeth, on the other hand, implies a tooth with incomplete or substandard structure; it also implies a poor prognosis.

The appearance of each natal tooth into the oral cavity can be classified into four categories given below, as the teeth emerge into the oral cavity.[24]

Shell-shaped crown poorly fixed to the alveolus by the gingival tissue and absence of a root.

Solid crown poorly fixed to the alveolus by the gingival tissue and little or no root.

Eruption of the incisal margin of the crown through the gingival tissues.

Edema of the gingival tissue with an unerupted but palpable tooth.

If the degree of mobility is more than 2 mm, the natal teeth of category (1) or (2) usually need extraction.[4].

Incidence and prevalence

The incidence of natal and neonatal teeth has been estimated to be 1:1000 and 1:30,000[56] Reports about significant difference in males and females are conflicting, with females, in general, being more affected. Natal teeth are more frequent, approximately three times more common than neonatal teeth,[1] with the most common localization being the mandibular region of the central incisors (85%), followed by maxillary incisors (11%), mandibular cuspids or molars (3%) and the maxillary cuspids and molars (1%).[3] Natal or neonatal cuspids are extremely rare.[7] As has been noted, the natal and neonatal teeth are more frequently seen in the mandibular incisor regions and are more frequently bilateral. Most commonly, these teeth are precociously erupted from the normal complement of primary teeth (90–99%). Only 1-10% of natal and neonatal teeth are supernumerary.[89]

Etiology

The variety of natal and neonatal descriptions suggests the lingering controversy regarding this condition and its etiological aspect. In fine the law in this regard is yet to be resolved.

The rate at which baby's teeth comes through will depend on its “genetic blueprint,”[4] i.e. hereditary transmission of a dominant autosomal gene appears to be an important factor.[210]

Endocrine disturbances: It is thought to be because of excessive secretion of pituitary, thyroid, or gonads.

Eruption of natal and neonatal teeth could be dependant on osteoblastic activity within the area of the tooth germ.[210]

Infection: For example, congenital syphilis appears to have varying effect. In some cases, the teeth has erupted early, while in others the eruption has been retarded.[10]

Nutritional deficiency, for example, hypovitaminosis (which in turn is caused by poor maternal health, endocrine disturbances, febrile episodes, pyelitis during pregnancy, and congenital syphilis).[110]

Febrile status: Fever and exanthemata during pregnancy tend to accelerate eruption as they do in various other processes.

Superficial position of the tooth germ.

Environmental factors: Polychlorinated biphenyls (PCBs) and dibenofuran[11] seem to increase the incidence of natal teeth. These children usually show other associated symptoms such as dystrophic finger nails, hyperpigmentation, etc.

The most acceptable theory is based upon the result of a superficial localization of the dental follicles, probably related to the hereditary factor.[5812]

Natal teeth and neonatal teeth are frequently found associated with developmental abnormalities and recognized syndromes. These syndromes include Ellis–van Creveld, pachyonychia congenita, Hallerman–Streiff, Rubinstein–Taybi, steatocystoma multiplex, Pierre–Robin, cyclopia, Pallister–Hall, short rib-polydactyly type II, Wiedeman–Rautenstrauch, cleft lip and palate, Pfeiffer, ectodermal dysplasia, craniofacial dysostosis, multiple steacytoma, Sotos, adrenogenital, epidermolysis bullosa simplex including van der Woude and Walker–Warburg syndromes.[113]

Complications

Potential risk of the infant inhaling the tooth into his/her airway and lungs if the tooth becomes dislodged during nursing, due to its great mobility.

Ulceration to ventral surface of the tongue: Coldrallin first described this condition in 1857. Riga and Fede histologically described the lesion, which was then started to be called Riga–Fede disease.[214]

Difficulty in feeding or refusal to feed due to pain.

Ulceration to the nipple of the mother and interference with breast feeding.

Clinical aspects

Clinically, the natal teeth are small, or of normal size, conical, or of normal shape. They may reveal an immature appearance with enamel hypoplasia and small root formation. Natal teeth may exhibit a brown-yellowish/whitish opaque color. They are attached to a pad of soft tissue above the alveolar ridge, occasionally covered by mucosa, and as a result, have an exaggerated mobility, with the reason of being swallowed or aspirated, in most of the cases.[515] Bigeard et al. revealed that the dimensions of the crown of these teeth are smaller than those for the primary teeth under normal conditions.

Histological features

In this study, ground section of natal and neonatal teeth demonstrated varying thickness of enamel and almost straight dentino-enamel junction. Dentin demonstrated irregular branching of dentinal tubules and Tomes granular layer [Figures 5–7].

Figure 5

Photomicrograph showing irregular dentin (1), irregular branching of dentinal tubules (2), and thin enamel (3)

Figure 7

Photomicrograph showing irregular dentinal tubules (1) and Tome's granular layer (2)

Photomicrograph showing irregular branching of dentinal tubules (1), straight dentino-enamel junction (2), and thin enamel (3)

The first report on microscopic observation of natal and neonatal teeth was given by Howkins in 1932. Histological investigations of natal teeth have been well detailed by Boyd and Miles.[16] The histological aspect shows a thin enamel layer, with varying degrees of mineralization and/or hypoplasticity to total absence of enamel in some regions. Friend et al. demonstrated that the alteration in amelogenesis was detected due to premature exposure of the tooth to oral cavity, which resulted in metaplastic alteration of the epithelium of the normally columnar enamel to a stratified squamous configuration.[4] Atubular osteodentin, such as that observed in the occlusal central fossa, is equivalent to the irregular tertiary dentin deposited in response to untoward stimuli such as caries or attrition.[14] This suggests that odontoblasts in the central fossa were exposed to the oral environment before developing a covering enamel and normal tubular dentin and responded by depositing the atubular substance. The dentin may show alterations with atypical deposition of dentinal tubules, chiefly in the cervical third, and occasionally of osteodentin, which is attributed to stimulation by movement of the teeth. It has been further postulated that the mobility may cause degeneration of Hertwig's sheath, thus preventing root development and stabilization.[21517]

The usually increased mobility causes histological changes in the cervical dentin and cementum.[8] The pulp cavity and radicular canals are wider, although the pulp shows normal development.[1] Weil's zone and cell-rich zone are missing.[16] Absence of root formation, lack of cementum formation, lack of pulp chamber, and an irregular dentin formation are also observed. In the polarized light and micro-radiographic studies, these teeth showed enamel hypoplasia and dentinal disturbances including the formation of osteodentin and irregular dentin in the cervical portions and interglobular dentin in the coronal region.[18] Natal teeth with no enamel formation are extremely rare; there has been only one case reported, in which cartilage-like teeth erupted prematurely at birth.[17]

Diagnosis

The diagnosis of the teeth is done based on a complete history, physical examination of the infant, and by the clinical and radiographic findings to rule out being the part of normal dentition or supernumerary, so that indiscriminate extractions would be performed. A proper examination can reveal the relationship between a natal/neonatal tooth and adjacent structures, nearby teeth, and presence or absence of a tooth germ in the primary dentition would determine whether or not later belongs to normal dentition. Investigators have observed that most of these teeth are primary teeth of normal dentition and not supernumerary teeth. According to the citations, diagnosis is important to plan treatment, keeping in view the maintenance of the normal dental occlusion.[2]

Treatment and management

In confronting a typical variation in the newborn's oral cavity, the pediatric dentist must decide between “early treatment” and the other extreme “should never be treated.” If the erupted natal and neonatal tooth is diagnosed as a tooth of normal dentition, the maintenance of these teeth in the mouth is the first treatment option, unless this would cause injury to the baby or mother.[1920] Spouge and Feasby[21] have pointed out that prematurely erupted teeth are often well formed and normal in all respects except that they may be somewhat mobile.

Grinding or smoothening the incisal edges of the teeth was advocated by Allwright in[22] and Martins et al. in 1998.[23] To prevent the injury to the maternal breast, feeding splint was the option reported by Bjuggren (1973).[24] Goho (1996)[25] reported his treatment of natal teeth by covering the incisal margin with composite resin. Tomizawa et al. (1989)[23] reported two cases of treatment of Riga–Fede disease by covering the incisal margin with photopolymerizable resin, which aided rapid healing of the ulcers. This petty tooth can sometimes become pretty serious. Removal of natal teeth is indicated when they are poorly developed, interfere with feeding, highly mobile, and associated with soft tissue growth.

Kates et al.[23] suggested extraction as a treatment as they thought despite initial space loss, the space was regained and crowding of permanent mandibular incisors was not apparent. If extraction is carried out, it is necessary to ensure that the underlying dental papilla and Hertwig's epithelial root sheath are removed by gentle curettage as root development can continue if these structures are left in situ. The prophylactic administration of vitamin K (0.5–1.0 mg i.m.) is advocated because of the risk of hemorrhage as the commensal flora of the intestine might not have been established until the child is 10 days old and since vitamin K is essential for the production of prothrombin in the liver.

Conclusion

Pediatric dentists should make every effort to educate the parents and the medical community on the preferred treatment for the natal teeth. If the extraction of the natal tooth is indicated, then it should be performed by the pediatric dentist to avoid unnecessary trauma to the area. Periodic follow-up by a pediatric dentist to ensure preventive oral health is very essential. Hence, to avoid any complication, early diagnosis and adequate treatment should be a prime concern in the management of natal teeth.