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10/8/2013

Premature Exfoliation of Primary Teeth


Dr. Tarun Walia

Exfoliation
The physiologic process in the elimination of deciduous dentition Shedding is due to progressive resorption of deciduous teeth, their supporting tissue & PDL Usually begin with lower anterior teeth, & around the age 5-6 years Resorption of incisors - on lingual side & then with horizontal at apical part Resorption of molars - inner surface of primary root

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Ectopic Eruption

Exfoliation (Contd.)
Exfoliation is symmetrical on either side of arches Girls tend to shed teeth earlier than Boys Resorption process has period of rest & period of repair- explain for intermittent mobility of primary teeth Premature exfoliation leads to either early eruption / delayed eruption

10/8/2013

Premature exfoliation : Primary teeth (Causes)


Toxicities (Acrodynia & Radiation) Metabolic disorders (Acatalasia, Chediak-Higashi disease, Hypophosphatasia) Malignancies (Langerhans cell histiocytosis, leukemia, cyclic neutropenia, agranulocytosis) Dental causes (Caries related infections, trauma, periodontitis, Papillon Lefevre syndrome, Cherubism) Miscellaneous causes (Tumors of jaw, self mutilation,, extreme bruxism)

Acrodynia
Also known as Pink Disease Chronic exposure to mercury, ointments or medications Amalgam restorations do not cause Acrodynia Primarily affects young children Often occurs in infants, age of onset being between 4 months and 8 years Symptoms : Fever, irritability, photophobia, pink discoloration of hands & feet, polyneuritis & painful extremities Orally : Excessive salivation, swelling, loss of alveolar bone, focal gum erosion with subsequent loss of teeth

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Radiation
Xerostomia, increased caries rate enamel hypoplasia, microdontia & abnormal root formation Osteoradionecrosis, leading to changes in trabeculation, bone loss, radiolucency. All these complications lead to increased tooth mobility and subsequent tooth loss

Acatalasia
Characterized by absence of enzyme catalase. Poor oral hygiene or mouth injury leads to bacterial infection. Certain bacteria produce hydrogen peroxide. The peroxide destroys hemoglobin due to lack of catalase thus depriving the infected area of oxygen and causing necrosis. Presents with progressive gangrenous gingivitis and periodontal disease with destruction of alveolar bone and loss of teeth

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Chediak-Higashi disease
Abnormal platelets causes spont. bleeding & easy bruising 85% of children with CHD develop unusual lymphoma-like condition generally leading to death Remaining 15% presents less severe clinical manifestations The oral lesions are consequence of repeated infections Consist of ulcers, markedly hypertrophic gingivitis and severe periodontal destruction Due to recurrent intraoral infections, extensive alveolar bone loss occurs which in most patients leads to tooth exfoliation

Hypophosphatasia
Characterized by diminished serum levels of alkaline phosphatase and phosphoethanolamine in urine 4 groups: perinatal (lethal), infantile, childhood & adult Phenotype range from premature loss of decidious teeth to severe bone abnormality leading to neonatal death. Abnormal cementum or lack of cementum may lead to spontaneous shedding of primary teeth, affecting incisors more than molars Pulp chambers unusually large Dentinal dysplasia is seen Higher incidence of uni-radicular primary teeth is shed

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Histiocytosis
3 variants : Lettere-Siwe disease (most severe form) Hand schuller Christian disease (affects children above 3 yrs & involves mostly bones) Eosinophilic granuloma (affects older children & is benign in nature) Neoplastic proliferation of Langerhans' histiocytes C.M: Scaly erythematous skin rashes : scalp & extremities, fever, anemia, hepatosplenomegaly O.M: Swelling, ulceration, gingival necrosis, radiolucent lesion of mandible & skull. Management: Chemotherapy, radiotherapy, surgical curettage

Leukemia
Immature neoplastic white blood cells in circulation Hyperplastic gingivitis with cyanotic bluish-red discolor. Oral tissues are friable and bleed easily Hyperplastic gingivae may completely cover the teeth In severe cases, purpuric lesions and necrotic ulcers Alveolar bone destruction & necrosis of PDL may occasionally lead to loosening & exfoliation of teeth Treatment : systemic & palliative - chemotherapy, radiation, bone marrow transplant Oral cavity - free of local irritants Child instructed to maintain a high level of oral hygiene

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Cyclic neutropenia
Can occur at any age Rythemic reduction in PMN in 21 day cycle Risk for opportunistic infection (affected during the interval of neutropenia, in a 21 day cycle, concomitant with oscillation of bone marrow blood cell production) Fever, malaise, sore throat, stomatitis, regional lymphadenopathy, headache, cutaneous infection, conjunctivitis Gingivitis, ulceration, loosening of teeth, loss of supporting bone Repeated insult as gingiva return to normal during the cycle, when neutrophil count is normal

Cyclic neutropenia

10/8/2013

Aggressive Periodontitis
Localized Juvenile Periodontitis: Affects adolescents & young adults. Self limiting affects 1st permanant molars and incisors. Bone loss is 3-4 times faster than adult periodontitis No much accumulation of supragingival plaque or calculus Gingiva appears normal Possible organism: Actinobacillus actinomycetemcomitans, or /and bacteroides species Radiographs show marked destruction of alveolar bone with vertical pocket formation leading to tooth loss

Generalized Juvenile Periodontitis : Also k/n as severe periodontitis & rapidly progressing periodontitis Affects young adults & affects the entire dentition Unlike in localized type, marked gingival inflammation & plaque accumulation. Subgingival plaque harbors Porphyromonas gingivalis Early onset periodontitis : Management includes mechanical debridement of affected site in conjugation with antibiotic therapy. (Tetracycline or Amoxicillin + metronidazole)

10/8/2013

Papillon Lefevre syndrome


Marked destruction of periodontium (periodontoclasia) Unknown cause Depressed peripheral blood neutrophil chemotaxis. Palmar and plantar hyperkeratosis Horizontal bone loss, infected periodontal pockets Loosening of primary teeth leading to premature loss Possible organism: Actinobacillus actinomycetemcomitans, Fusebacterium nucleatum Management: Specific antibiotic therapy, extraction, denture fabrication

Papillon Lefevre syndrome

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Cherubism
Fibro-osseous lesion of jaws involving more than one quadrant Stabilizes after growth period Usually leaving some facial deformity and malocclusion Ground glass appearance RG : Unilocular/multilocular bilateral expansive radiolucenices Faint radiopacities resembling residual bones sometime present at puberty

Self mutilation
Purposeful traumatizing ones own oral structures Local cause, Emotional cause Finger Nails, Bobby pins, Pacifier Lower anterior teeth , Cheeks, lower lip Necrosis of tissue, loosening of teeth Lesch-Nyhan Syndrome : Spastic cerebral palsy, mental retardation, severe motor disability, cognition, ocular motility and behavioral control Self mutilating aggressive behavior - mutilation of lips by constant chewing on them Teeth are lost due to prophylactic extractions

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10/8/2013

Lesch-Nyhan Syndrome

Odontodysplasia
Also k/n as Ghost teeth Affected teeth are poorly mineralized Lack of proper calcification of E, D & C Abnormal pulp chamber & root shape Radiographically appear abnormal in size & shape Permanent teeth affected more frequently then primary teeth Generally fail to erupt but if they do; have consistency of gelatin Often need to be extracted

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10/8/2013

Odontodysplasia

Diagnostic Test - premature exfolioation of primary teeth


CBC Hematrocrit hemoglobin, platelets, RBC, WBC Differential leukocyte count Serum levels - Phosphate, calcium, alkaline phosphatase, blood glucose, ESR Urinalysis - glucose, phosphoethenolamine Skull survey Culture for anaerobic bacteria Gingival biopsy Tooth biopsy Neutrophil chemotaxis

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10/8/2013

Diagnosis of early exfoliation (Contd /-)


Medical History Family history of loss of teeth, systemic disease History of skin infections/lesions, otitis media, or other recurrent infection Hyperkeratosis of palms or soles of feet Exophthalmia Pale mucosa or petechiae Neurologic disorders

Implications of early exfoliation of primary teeth : Change may be necessary, for example : caries, diet, hygiene Precautions may be necessary : radiation, salivary stimulant or substitute If part of a syndrome, need to determine what other issues arise Concerns : Esthetics Speech Eating, nutrition, diet Self-esteem, psyche Health of succedaneous teeth

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