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

Females are often ahead of males

Reference: Nowak AJ and Casamassimo PS. : The Handbook of Pediatric Dentistry, 4th Edition. The American Academy of Pediatric Dentistry, 2011.

Image:

http://www.aboutyourteeth.com.au/wp-

content/uploads/2013/10/ChildTooth.jpg

Reasons for early exfoliation

Image: http://bestdentistnews.com/wp-

content/uploads/lost-tooth-199x300.jpg

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

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

Reference: 1

http://askanorthodontist.com/braces/wp-

content/uploads/2012/10/Ankylosed-

Primary-Central-Incisor1.jpg

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 hypophosphatasia

Reference: 1,2

http://www.cabinetmagazin

e.org/issues/36/N0025954_FIN

AL.jpg

Questions to ask parents

(cont’d)

Past medical history

Premature birth or LBW

Existing medical

conditions

History of broken bones

Medications & allergies

History of recurrent

infections

References: 1,2

http://images.wisegeek.com/medical

-history-form.jpg

Clinical exam

Are soft tissues

normal?

Rule out gingivitis /

periodontitis

Rule out trauma

Are other primary

incisors mobile?

Is there any

pathology?

References: 1,2

http://www.columbia.edu/itc/hs/dental/d7710/client_

edit/AnatomyofPrimaryTeeth_files/slide0001_image013.j

pg

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

skin infection and a systemic viral

infection Reference: 3

http://ecx.images-

amazon.com/images/I/51vrh5ydT

2L._SL1500_.jpg

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 exhibit delayed eruption (+/- retained primary incisors)

Maxillary permanent incisor erupts ectopically References: 6,7

http://www.jisppd.com/articles/2011/29/

1/images/JIndianSocPedodPrevDent_201

1_29_1_34_79928_f9.jpg

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

chance for spontaneous

eruption of the incisors Reference: 6

https://s3.amazonaws.com/r

apgenius/1365193232_Guy-

with-Question-Mark-over-his-

headFotolia_102829_XS.jpeg

“Shark teeth”

Image: http://www.drrenginnalbantoglu.com/resimler/klinigimizde-uygulanan-tedaviler-21.jpg

o Common

concern of

parents

(10%) o Reference 9

o What

advice

should you

give them?

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.