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Craniofacial Biology Lecture #30 CC !" #namel $e%elopmental $efects !&'(&)! Slide 1 - Introduction Dr. Page Caufield So enough excuses. I have just one other. ou fly in an air!lane and you"re sitting next to so#eone $ho"s really really healthy% they $or& out% robust% and they"re snee'ing% and they"re telling you they"re not infectious and they"re really healthy. If it"s a !ut'y loo&ing guy it"s just co##on cold or so#ething. (ealthy !erson gets sic& and he"s coughing% you"re gonna get sic&. So% recovering a little bit. So% the title gives this a$ay% but I $anted to #a&e this a sus!ense story for you to get and !artici!ate and &ind of build. )o$ I"# not gonna be able to totally do that because *% you haven"t had #uch on caries% right+ *nd so I didn"t $ant to get too heavily into caries and its etiology. ,ut you have had develo!#ental anato#y% so let"s see if $e can &ind of tease into this. This is a very controversial to!ic by the $ay. *s I s!ea&% I"ll be in )orth -arolina next $ee&. There"s a lot of !ush bac& on so#e of the conce!ts I"# gonna tell you today% it hasn"t% ta&es about 1. years for an idea to really get entrenched in dentistry% it"s !robably about / years% there"s al$ays a lag !eriod% you $ait for evidence based and other things% and so#eti#es it never co#es. Let #e just &ind of tease you a little bit. I &no$ you $ould li&e for us just to co#e u! and tell you the ans$ers to everything as if $e &ne$ the#% and $e really don"t but this is again% so#ething ha!!ening right no$ today% in fact one of the !ro!onents of the #ajor theory of $hat"s causing this disease that I"# gonna tell you about is here at ) 0 today% and he"s the dean in Io$a% David 1ohnson% very good friend of #ine% !ediatric dentist and he"s the !ro!onent of $hat is the !revailing hy!othesis. So $hat a coincidence% $elco#e David 1ohnson% and I"# just gonna tear your $hole thing a!art% but that"s $hat friends are for% right+ Slide 23 -ase 4e!ort So this is the case re!ort% basically this is a% this is not #y case at all% this is fro# ,ellevue% I"# an attending at ,ellevue and -harlie Larson $as good enough to give this% to !rovide this for #e so I give hi# credit for this case% this is a 5.6 year old% 5 and a half year old (is!anic child being treated in the o!erating roo#% you can tell it"s the o!erating roo# fro# the nasal intubation% right+ ,eautiful child% and fro# the #edical record it"s listed as non-contributory% not sure $hat that #eans. It #eans that there"s nothing in the child"s #edical records that indicates there #ight be a !roble#. )o$ that"s usually fro# the anesthesiologist !oint of vie$ because they have to assign a ris& to a child before you intubate the#. So there"s 7 classifications of ris&. )or#ally the !ast #edical history is briefly revie$ed by the attending dentist% the !ediatric dentist% but the anesthesiologist has the #ost to lose if there is so#ething in the history% so it"s non-contributory. *nd the child and its #other did not s!ea& 8nglish% they $ere recent i##igrants. ou can see this do$n belo$% and so it"s difficult to elicit a !ast #edical history. * lot of !eo!le don"t go to the hos!ital $henever they have a !roble#. * lot of children are not born in hos!itals. *nd so $hen you $ant to get a !ast #edical history they"re not co#!lete as you"d li&e. 9ast dental

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history% there $as none. :f course% child"s not gonna be in a !osition to go to a dentist% it"s not $ithin their #eans. In the social history% fro# the social case $or&er% because it $as in ,ellevue% these children are for the #ost !art% are on !ublic assistance% on ;edicaid% and ,ellevue is the <-atch#an+= area hos!ital for ;anhattan and so#e of the boroughs. So recent i##igrant and lo$% do you &no$ $hat S8S #eans+ Socioecono#ic status. *s you can see this child lives in !overty. *nd this is the 0nited States so no one lives in !overty% right+ 2.> of children in the 0nited States% the $ealthiest nation% live in !overty. So this child lives in !overty. Slide 73 9resenting I#age So here"s the% I don"t necessarily $ant to rush into !resentations% but that"s ho$ the child !resented. There are so#e things you #ay and #ay not notice% and that"s o&% you"re not ready for that. :h% you are ready for that% you don"t need years and years of training to &no$ there"s a !roble#. So this $as diagnosed as caries% and it"s gonna be treated% you see there"s an abscess in the u!!er incisor u! there% the little bubble at the to!% that #eans the tooth is infected and straining. The lateral% al#ost co#!letely #issing bilaterally. *nd if you can see% I don"t &no$ ho$ good you can see fro# $here you"re at% you can see so#e o!acities in the teeth% they"re chal&y% they"re off color% so the attending $ould list on their list% they $ould say the child has !oor oral hygiene% because if you had great oral hygiene you"d have great $hite shiny teeth right+ That"s $hat $e see on T?% so if you"re in there doing your thing% and if you did that every day you $ouldn"t have this !roble#% you &no$ this child just needs education% and a tube of tooth!aste and a toothbrush and so#ebody telling the# to brush their teeth. ;ean$hile the #other is trying to figure out ho$ she"s gonna feed her fa#ily of four for @7.51 a day but $eAre going to brush these teeth to #a&e the# $ell again% but I"# overstating% because it sets the stage for $hat so#e of the theories are for this disease. Slide 53 9resenting I#age So here is a !icture% not great. )o$ $ithout telling you a lot $hat this entity has been na#ed and ter#ed% and I $ill as $e develo! #ore. If you loo& at the #osaic !attern% clearly caries in the #olar area% so#e #ore than others% but this is confined in general to the anterior teeth% and it"s the #axillary. *nd I"ll tell you $hy in a #inute $hy !eo!le had different theories because $hen you see this% this is a very severe case% so it has #anifestation beyond just the !ri#ary anterior teeth% second !oint again% !ri#ary teeth% not !er#anent teeth. Be"re tal&ing about a disease% caries% that affects !ri#ary dentition% young children. The na#e has been given% several na#es% and $e"ll tal& about it as early childhood caries. That doesn"t give you any infor#ation% does it+ Slide .3 Diagnosis :& so hereAs so#e of the diagnoses that as a !ediatric dentist% $hich I a#% $e learned a long ti#e ago it $as called nursing bottle caries% so thin& that through% nursing bottle caries% $ould a nursing bottle cause caries+ Bell not the bottle but $hat"s inside the bottle. So babies that% the theory goes% so Lou 4i!a $as !robably the first% David 1ohnson% $ho"s visiting fro# Io$a today% $as !robably the second% and then there $ere a series of other !eo!le% #ade the observation that children $ith this disease% es!ecially in

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the u!!er #axillary anteriors% they hy!othesi'ed these babies $ent to bed $ith a bottle% and it $as called bottle !ro!!ing% so fussy baby% canAt go to slee!% !ut so#e a!!le juice% sugar $ater. 9ediatricians% I $as at the *#erican *cade#y of 9ediatrics% and I did a !resentation on this last year% !ediatricians al$ays tell #others of fussy babies to ta&e a to$el% soa& it in sugar $ater% and give it to the baby and there"s a reason for doing that% and that $ill hel! the# slee!. *nd it"s an old conce!t% and so the idea $as that these babies $ent to bed $ith a bottle% and it had sugar $ater and other ty!es of% even #il& and it $ould slee! all night $ith this #il& in constant% #il& or sugar $ater% $hatever% constant contact $ith the #axillary teeth. )o$ because the lo$er teeth are bathed in saliva% no you have to !icture yourself laying in a crib% it"s hard for #e to !icture this% the lo$er teeth are generally not affected% and they theori'ed that they"re !rotected by the !ooling of saliva. So envision a &id $ith a bottle in bed% !ro!!ed $ith constant s$eet contact% !erfect diet for cariogenic bacteria to cause tooth decay% #a&es sense+ Is that !lausible+ ,ecause that"s !revailing theory right no$. So as a resident% and i $as in ,oston% and $e sa$ a lot of this in ,oston% and every ti#e $e sa$ this $e had a chec&list $hich said Cdid baby go to slee! $ith a bottle+C and $e had a little box% yes or no. $ell% it $as al$ays yes% because at so#e !oint baby !robably did go to bed $ith a bottle% not all the ti#e% but so#eti#es% all the ti#e% but once you chec&ed yes% baby $ent to bed $ith a bottle% it then beca#e nursing bottle caries% and then you #ove on to doing #ore i#!ortant things li&e ho$ you"re gonna restore those teeth. *nd so as a clinician% you"re thin&ing #ore about ho$ I can #a&e this child $hole again rather than the cause. So it $as fine to call it that% others ca#e u! $ith different na#es% to be a little different% to have a different na#e% if you"re fro# the $est coast or the east coast% so there"s al$ays this ty!e ofD and the 8uro!eans donAt $ant to be left out% they called that ra#!ant caries% and I li&e that a little bit better because it doesnAt give an etiology% a !riority. So if you tell the #others that they"re baby has baby bottle tooth decay% you"re !retty #uch% the die is cast there"s not a lot of roo# for debate after that% but if you say ra#!ant caries% it &ind of leaves the door o!en a little% o&+ <Student Euestion so#ething about 7rd #olars= Dr. -aufield3 you"re gonna have to sit on your hands and $ait% and then if I don"t ans$er% o&+ ,ut you"re antici!ating% and that"s good. Don"t get too far ahead of #e though% o&+ I"# slo$ today. So that $as good antici!ation% good lead. Bell% *#erican *cade#y of 9ediatric Dentistry and the *#erican Dental *ssociation $anted to co#e in $ith so#ething a little better and they had a conference in 2FFF and it $as called severe early childhood caries% !retty good na#e% its severe% its early% its childhood caries. )o$ that ter# is really getting% after 1. years still hasn"t been $idely e#braced% ta&es a $hile for things to get incor!orated into !ractice. Slide 63 -ause :&. So $hat is the cause% $e say etiology% of this for# of caries% no$ start thin&ing $hat $ould cause this ty!e of caries. I just told you the !revalent theory thatAs been !ublished in guidelines% is baby bottle. 1ust to get your #ind thin&ing a little bit% does everyone have% does every country in every situation in Gyana% in rural -hina% in *frica% in other !arts of the $orld% do they have bottles+ Little ni!!les on the#% and for#ula+ Do they

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have stores that you can buy this stuff+ #ost of the $orld does not have baby bottles% they don"t have this stuff% and i $ill tell you that the disease is very co##on in other !arts of the $orld% and so the baby bottle conce!t is #ore of a $estern% Stony ,roo&% if I can use that% ho!e #any of you are fro#% that"s o&% it"s just that Lou 4i!a $as there and he $as a brilliant #an. ,ut that"s $hat $e thin& of in ter#s of causation% $hen $e say $e thin& of in ter#s of fa#iliarity% o&+ *nd so that ca#e to #ind. *lright IA# biasting you no$. So this $hole idea is to say it"s biological !lausible if you had a nursing bottle and you $ent to bed $ith it and it had s$eets in it% and it $as sustained% you could cause bacteria to go cra'y and dissolve the teeth. ,iologically !lausible. *nd the $ay it affected #ostly the anterior teeth% anterior teeth nor#ally don"t develo! caries% es!ecially on the s#ooth surfaces% it"s unusual% unusual !resentation% so no$ $e see this disease in a fair nu#ber of children% #ore and #ore every day% and attribute it to this. So that #a&es sense% o& good. Bell this is a nice one% !oor diet. So !oor diet $ould be eating food thatAs high in carbohydrates% lo$ in !rotein% high in sugar. There"s a significant nu#ber of !eo!le% and this ca#e fro# S$edish research in the HFAs% that believed that good oral hygiene $ill solve all the dental !roble#s% fro# !eriodontal disease to dental caries% if $e could only teach !eo!le. *nd $hen I $as in school this $as the leading hy!othesis% if $e could only teach !eo!le to clean their teeth% I #ean really clean the# $ith a brush and floss and $e"d !ut so#e fluoride on to! of it and $e do this rigorous% disci!lined $ay% there should be no tooth decay% a clean tooth never decays% that $as one of the slogans% there should be no !eriodontal disease. 8nroll#ent to dental school $ent do$n in the HFAs% late HFs% IFs% no one $as a!!lying to dental school% it just loo&ed li&e that dental disease $as on the decline% that !eriodontal disease could be cured $ith brushing and flossing% et cetera. )o$ the S$edish are very good at executing this% $hat"s called grou! thin&. So in the S$edish syste#% every school $as regi#ented so that children did clean their teeth% but $hat they did% #ore i#!ortantly $as change their diet% because !art of that $hole geshtaldt $as that sugar and $e find carbohydrates needed to be lessened% and once they started doing that% and there $ere so#e studies called the ?i!o#e <+= study% and the $hole history% $e"ll tell you about so#e of it in cariology next year% that oral hygiene $ill solve everything. ,ut also $hat really ha!!ened $as the diet% the diet changed. 9eo!le really $eren"t a$are of $hat refined sugars can do. Today $e &no$ that refined sugars are right u! there $ith alcohol% tobacco% sugar% toxin. *s #ajor toxins they"re tal&ing about taxing sugar. Diabetes% obesity% all because of refined sugar. 4efined sugars every$here% dental caries is also !art of that. So refined sugar is !robably the biggest !roble#% not the oral hygiene. ou #ay or #ay not &no$ that #ost of the children in the $orld have no caries% they don"t have toothbrushes% they never did% and they have beautiful teeth because they don"t have the carbohydrates% the sugar There $as a study done by this guy ;antee $ho actually found a case of severe caries in an *frican child% and $hen $e $ent to *frica $e loo&ed at several thousands% oh boy% about 6%FFF in -entral *frican 4e!ublic% and didn"t find any caries% !ractically none. The !yg#ies has 'ero cavities% beautiful teeth% never had a toothbrush% never had a bottle% they had beautiful teeth. So this S$ede guy sees this *frican &id% and this child has these severe ty!e of caries I sho$ed you fro# the ,ellevue study% so he $ent% did the history and $hat have you% the

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only thing he could co#e u! $ith% he couldnAt find a bottle% of course% there"s no bottle% so he as&ed and as&ed and he found out that in his o!inion% the #other breastfed too #uch and so he attributed the caries to too #uch breastfeeding. )o$ I don"t &no$ anything about breastfeeding% I"# not an ex!ert on it% but I don"t thin& you can do too #uch% but any$ay that $as the re!ort% &ind of farfetched% but that $as the nature of the re!ort% and so things get !ublished in the literature% because the $ay he $as thin&ing he needed to have a carbohydrate lactose in breast #il& $hich so#eho$ causes because that"s the $ay he $as thin&ing. Bell $hat if these children had teeth that already had develo!#ental defects+ ,ased on their environ#ent and in-utero ex!erience% and these teeth already $ere da#aged structurally before they ca#e even into the #outh% and then structurally da#aged teeth% $ould they be then #ore susce!tible to caries+ *nd there"s a na#e for this% and anthro!ologists% and if you"re an anthro!ologist and you"re digging u! re#ains fro# an extinct !rehistoric grou! of hunter gatherers% all you have basically are the s&eletal re#ains % and of the s&eletal re#ains you have basically teeth% teeth survive #ost everything .and the anthro!ologists have &no$n forever% long% long ti#e that $hen you"re loo&ing at a tooth long enough you can actually read so#e of the life history of that individual based on the defects in those teeth. So if there $as a !rolonged !eriod of nutritional starvation% lac& of rain% $hatever% you can loo& at a tooth and if it $as the right s!eci#en you can see these so called hy!o!lastic lesions. *nd so anthro!ologists have al$ays been able to correlate ;ayan decline $ith the !oc&s on the teeth. )o$% I"# a #icrobiologist% so the $ay $e s!ent 11 years of ti#e and tax!ayer dollars $as to loo& at this as an acute infectious disease. *nd that $as also another !ossibility. Slide H3 Severe early childhood caries *nd let #e just sho$ you% and this is just another !icture of this disease severe early childhood caries% ra#!ant caries. Be gave it another na#e% and you see the anteriors% and if you sho$ this ty!e of !icture to a !hysician $ho"s in infection in infectious disease% and here at ) 0 $e have so#e very excellent infectious disease !eo!le% ;arty ,laser for exa#!le% and $hen I !resent at rounds% and I sho$ this I say $o$ you got so#e really severe infection here% and these children are just over$hel#ed $ith a bacterial strain that is hy!er virulent% it goes cra'y #a&ing acid% and dissolving teeth. *nd that these bacteria are !robably s!read in the co##unity% and so if you go to the La&ota Indian reservation in 9ine 4idge and you see that .F> of the children in the co##unity have this &ind of disease% you start thin&ing e!ide#ic% you start thin&ing indigenous bacteria that are in their co##unity causing the disease% that"s ho$ an infectious disease !erson $ould vie$ this. *nd as !recedent for this are her!es si#!lex% for exa#!le. It has an acute for# in children% for exa#!le% !ri#ary gingival sto#atitis% I don"t &no$ if you"ve loo&ed at that yet% but it has #anifestation in young children% and so itAs not un!lausible% and so you start thin&ing of bu'' $ords li&e this because if you"re trained in infectious diseases !oint of vie$ you"re thin&ing it"s an infectious disease% it #ay be contagious% #ay be trans#itted% co##unicable a#ong #e#bers of say% La&ota Indian. They #ay be clonal% no$ $eAll do these conce!ts later but certain strains of these bacteria tend to have virulence that is uniEue to a s!ecific clone% so there"s a sub!o!ulation that develo! a !onderance to cause disease% that"s called clonality. So those $ere our thoughts at one ti#e.

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Slide I3 -artoon (ave you heard the !arable of the $ise #en% the six blind $ise #en+ They"re blind% in case you"re $ondering $hat they"re doing% they can"t see. So no$ thereAs this ele!hant% you can see it but they can"t% and each one is as&ed to described $hat this thing is. and this guy over here feeling% says it"s a $all% and he"s describing the $all and all the features of it% and you"re laughing because obviously it"s an ele!hant du##y% loo& at it. Bell he doesn"t &no$ that% he"s blind. ou !ut hi# there. There"s another guy% he"s a dentist over there% he"s feeling the tus&% see hi# over there+ So% de!ending on your !oint of vie$ and $here you"re standing% so if you"re an infectious disease bacteriologist% you #ay be loo&ing at this differently% you see the #eta!hor% the caries is loo&ed at fro# different% if youAre an anthro!ologist you #ay be seeing this another $ay. *nd so everyone has an o!inion based on their o$n ex!erience and bias% but to describe the entire entity reEuires #ore. Slide /3 Jirst 1FFF Days )o$ let #e get bac& to $hat you"ve learnt so far in this course% in a so#e$hat different $ay in ter#s of develo!#ent overall %and so $e"re #a&ing a seg$ay no$ on develo!#ent. This is called the first thousand days of a child"s life. *nd so#e !eo!le $ould say% and it"s gro$ing% that the first thousand days of a childAs life dictates their entire life"s health history. Jirst 1FFF days% no$ $hen does the first day start+ S: you start at conce!tion% and the last of the 1FFF days co#es out to about 2 years of age. So start thin&ing about conce!tion% for#ing an e#bryo% the in-utero ex!erience is for ladies right+ (o$ long+ <inaudible student= It"s actually 52 $ee&s. So / #onths% or 52 $ee&s. *nd during that !eriod to t$o years of age there are #any things that ha!!en% so here"s the !renatal !eriod of a baby"s first 1FFF days in utero% #other"s health% nutrition% all influence develo!#ent% you"ve had this. ,irthing co#!lications% at birth% several things ha!!en at birth that are really Euite interesting and a $hole series of events occur. Thin& about $hat birth is% you"re #a&ing a transition fro# being in a liEuid environ#ent% $ar#% nurturing% and you get your oxygen nutrients for# the !lacenta% right+ )o$ you"re born% and you have to co#!letely change ho$ youAre gonna co!e $ith this ne$ environ#ent. *nd so% $hat also occurs at birth is the trans#ission of bacteria% indigenous bacteria fro# #other to child. *nd it"s% $e"ve s!ent a good deal of ti#e studying that. *nd #others trans#it their bacteria to their baby at the ti#e of birth% and it"s a natural !rocess. *nd so the first line of !rotection for ne$borns% it"s not the i##unoglobulins fro# the !lacenta% it"s the bacteria that the #other is covered in $ith. That"s the first line of !rotection% that"s $hat"s called the indigenous bacteria. *fter birth% the child"s susce!tible% the child"s i##une syste# is develo!ing% it"s i##ature% the child still relies on the #otherAs i##une syste# for about the first six #onths until it develo!s its o$n% it gets its i##unoglobulins fro# breast #il&% Ig; for exa#!les% and after six #onths the !eriod bet$een six #onths and t$o years of age% the child is very susce!tible to a lot of different infectious diseases. :titis #edia for exa#!le is very co##on in urban situation% but there"s other infectious diseases. In so#e areas children don"t live !ast that six #onths to t$o years !eriod because they are susce!tible to all those infectious diseases% $e have antibiotics% vaccines% $hatever% all that"s ha!!ening in the first... So there"s a lot going on in the child"s develo!#ent during the first 1FFF days.

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Slide 1F3 Jirst 1FFF Days )o$ let #e Seg$ay over to the dental develo!#ent over to the !ri#ary dentition. so hereAs that sa#e ti#eline F-1FFF days% nine #onths% in utero% birth% first year% second year% o&% this is the !eriod $e"re tal&ing about. *nd so initial calcification of the !ri#ary teeth occurs aroundD $ell% itAs right there% itAs 1F7 days. So central incisors% these are #axillary and #andibular% #andibular start for#ing first% #axillary second% you &no$ this% you"ve had tooth e#ergence% laterals% cus!ids% second #olars. ,y day 177 you !retty #uch have #inerali'ation under$ay $ith all the !ri#ary teeth. :&% so that"s going on during this 1FFF days. *t birth% the teeth go into a rest the for#ation of a#eloblasts sto!% co#!letely% and $hen they sto!% there"s reasons% and $e"ll go through $hy they just sto!. ,irth is an extre#ely trau#atic event. ItAs visited by extre#e !eriods of hy!oxia% hy!oxia #eans lac& of oxygen. So i#agine youAre a scuba diver and all of a sudden your tan& runs out of air% $ell that"s $hat ha!!ens $ith birth. *s the u#bilical cord detaches% the lifeline to your #other is gone% and no$ you"re forcing your lungs to start $or&ing extre#ely. *nd I can tell fro# so#e of you fro# the $ay you loo& in the #ornings you !robably had a really hard ti#e at birth% $hen you $ere born the doctor sla!!ed your #other and said of you% you $ere so ugly% I $as gonna do #y 4odney Dangerfield% but I"# not in the #ood today% that $as a !oor atte#!t. So% very trau#atic. This leaves a very distinct defect in the for#ing ena#el of !ri#ary teeth% it"s called neonatal line% sounds very benign. *ll of you have one% all of you had one% you"ve lost those teeth. So#e of you had bigger lines than others% $e"ll tell you $hy. ;inerali'ation% the second #olars% there are 2F teeth in the !ri#ary dentition% second #olars are the last of those t$enty% they co#!lete by year 1. :&% so this is a thousand days% and then% $hile all these events are going on the a#eloblasts and the odontoblasts are laying do$n tissue. *nd anyti#e anything interru!ts or there is any &ind of disturbance $hile the a#eloblasts are laying do$n their bric&s% and I"ll sho$ you a better #eta!hor% it"s recorded in the tooth. )o$% bone is ca!able of recording trau#a and #alnutrition% but bone is constantly re#odeled. ,ut you can dig u! s&eletal re#ains and you can cut bones in half% and you can see lines of disturbances% they"re called (arris lines% but if the child recovers and goes on to adulthood those lines are erased because they"re constantly re#odeling. Teeth do not re#odel so if there is a disturbance% or defect% or trau#atic birth for exa#!le it"s all recorded in these !ri#ary teeth% it"s not re#odeled. So if you"re clever% if you can section teeth and you can loo& at the history% and I"ll #a&e this case% you can reconstruct the first 1FFF days. )o$% the nor#al in his office is not going to be able to ta&e a tooth out% section it% !olish it and loo& at it $ith !olari'ed light% so this is outside the sco!e of $hat you can do in your office% but it"s so#ething that"s done routinely here at ) 0 for exa#!le. Jirst 1FFF days% develo!#ental records. Slide 113 D8D )o$ because the title is ena#el defects% ena#el hy!o!lasia% these are ter#s that co#e fro# the historical literature% and they"re ter#s that describe #acrosco!ic visions of $hat"s going on $ith teeth. ;acrosco!ic% #eaning not $ith #icrosco!ic section% #acrosco!ic is $hat you see $ith your eye% so this is often ti#es hy!o!lasia% no$ hy!o!lasia #eans there"s not enough tissue. So if you had a tooth and there $as a defect%

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you $ould say it didn"t have enough tissue% that"s hy!o!lastic% these are co##on na#es% these are na#es a!!lied to other ty!es of tissue% so it $as natural to call it that. Bell others called it% 8uro!eans called it develo!#ental ena#el defects% D8D% so there"s been several na#es a!!lied to this so there"s a little confusion in ter#s of the ter#inology% it"s based on #acrosco!ic observation so $hat you see $ith your eyes% in an intact dentition% it does not involve ta&ing histology. So defects in ena#el% but itAs also dentin% these are definition based on events that occurred during those 1FFF days. So they $ould say if there $as defect in the a#ount it $ould be called hy!o!lasia% and if there $as a deficiency in the Euality of the #ineral% hy!ocalcification% hy!ocalce#ia% not enough calciu# for exa#!le% then the #ineral is deficient% this is hy!o#inerali'ation. )o$ these $ere basically based on eyeball esti#ations of $hat"s going on% so if it didn"t have a defect% it $asn"t hy!o!lastic% then it $as caused #inerali'ation. *nd the reason I tell you this% and you"ll see this and they"ll say $ell $hat is this% is it this or that. ou don"t really &no$ unless you have an eye on !robe% or you have a section. So !eo!le have been s!itballing this for Euite a $hile based on observation. ,ut here"s $hat you see clinically% and I"ll sho$ you so#e !ictures% o!acities% chal&y $hite teeth. (y!o!lasia $ould be $hatAs called linear hy!o!lasia% grooves% $e"ll sho$ you% fluorosis% dental fluorosis in the !er#anent teeth is a for# of a#eloblasts being da#aged. Jractured chi!!ed a$ay !lates of ena#el these are all different ty!es of hy!o!lasia. Slide 123 Definitions *nd let #e give you a cou!le of #ore definitions before I go on. I"# gonna go through this really Euic&ly because it"s not really ger#ane to $here you"re at right no$ and shouldn"t be% but again% early childhood caries% severe early childhood caries% again% these $ill be things that !eo!le refer to it. Be gave it a ne$ na#e% $e thin& is going on% that"s called hy!o!lasia associated severe early childhood caries. Slide 173 Dental e#bryology Let #e just seg$ay into% no$ this is just a cartoon of ho$ a !ri#ary tooth for#s. It doesn"t really but it"s &ind of the right conce!t. ou see% the rings of the onions for#ing% the !attern% so starting at the incisive ti!% this is a lo$er incisor and then the a#eloblasts build u!on this% you"ve seen this. *nd then those little lines that you see% you re#e#ber that those are called+ Those little develo!#ental lines. 9eri&y#ata are exterior re!resentations of those lines. <inaudible student=. eah% $hat a funny na#e. $hen I $as a dental student and they said striae of 4et'ius% heh% o& $hat"s the next class% that"s great. So &ind of interesting% but you &no$% and if you see the sa#e incre#ental lines in dentin% do you &no$ $hat those are called+ ?on 8bner. I didn"t &no$ until recently. So these $ere just again% #en and $o#en #a&ing different observations based on $hat they had available at the ti#e% and of course if you see so#ething you na#e it after yourself% right+ That"s natural% right+ Bhy $ouldn"t you+ 0nless you have so#e stu!id na#e% I"# sorry% I don"t $ant to use so#e exa#!le of a stu!id na#e. :& so that"s done less and less today% $e try not to na#e things. Slide 153 4elationshi!

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)o$ here"s a better dra$ing of that% and again% this is revie$. This is a #olar% and you can see the incre#ental lines% see the !eri&y#ata on the outside% and these are just ter#s% and again% $hen I $as a student% I couldn"t relate it to anything !articularly. *nd if you loo& very very closely and you have the right section% you can loo& at these and see this% really% and these are li&e a calendar% they"re little incre#ental lines of daily incre#ents and $hat they"re doing is they"re recording a child"s history% you just have to be able to read the#. Slide 1.3 -hrono#eter So here"s no$% and I thin& Dr. Bishe used this #eta!hor in his lecture on Jriday% Thursday% the rings of a tree% so as a tree gro$s% everything that"s ha!!ening to that tree% if you had a su##er $ith a lot of rain you have thic& bands% if it $as a bad season you have thin bands% right+ The forest fire. Bell teeth are the sa#e $ay. Trees don"t re#odel% and so everything that"s ha!!ened in the history of that tree are recorded. If you go to the *#erican ;useu# of )atural (istory% on the first floor% and you see the cross section of the red$ood tree that they have% it goes bac& to 6FF ,.-. and I don"t $ant to use ,.-. but all of history% everything $e &no$ about recorded history $as that tree $as still develo!ing. So if you count those rings% it"s #assive% I thin& it"s interesting. Slide 163 Layer of an :nion (ereAs #y favorite and nobody li&es this% unless you"re a coo&% it too& #e a year to find an onion that actually% a !erfectly good onion% you buy this at the local store% loo&s good to #e. ou cut it in half% it"s loo&ing great. Let"s go inside. )o$ $hy a# I sho$ing you an onion because teeth are for#ing li&e an onion in these layers and if you have a !articularly bad% too #uch rain for exa#!le in develo!#ent of an onion you end u! $ith these interior !arts that are rotten. (as this ever ha!!ened to anyone besides #e+ G-d% I"# going #etrosexual and I don"t even &no$ it. :&% you get the idea. I try to #a&e the #eta!hor hit different !eo!le% it"s &illing you% right+ our $ife does all the coo&ing at ho#e% right+ )o+ yea&% o&. *lright% ta&e it or leave it. Slide 1H3 9eriodicity (o$ about this one% o&% #aybe $e can do this one. So I found this% I don"t &no$% internet. So here is the a#eloblasts% here are the three a#igos the three a#eloblasts% they"re laying do$n ena#el% and the odontoblasts are do$n at the botto# !art doing dentin% and so you"re building this $all in incre#ents% and so each day% a layer of bric& is laid. :ur a#eloblasts% $hen you $ere a child% and in utero% each day there $as a layer% and that"s an incre#ental line% in a 25 hour circadian rhyth#. (u#ans have a seven day !eriodicity% called !eriodicity of hu#ans. )o$% so#e $ill say eight days% so#e $ill say six and a half. ;ales are a little bit different than fe#ales. 9ri#ates% chi#!an'ees% they% six day !eriodicity% but it"s a circadian rhyth#. So these bric&s are laid% this ena#el is laid in layers% and so if you count 1%2%7%5%.%6%H% after six days of laying bric&s% the a#eloblasts rest% it #ust be reading exodus or so#ething% I don"t &no$ $hat"s going on $ith these a#eloblasts% but they sto!% and there is a reason. *nd they !ause. *nd $hen they !ause after laying bric&s for six days% seventh day they rest% it for#s a de#arcated line called the striae of 4et'ius. )o$ $hat they do and I"# not gonna do it% I donAt feel li&e it today% but $hat they do is a shift% change direction% just slightly% and start laying

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these bric&s again in a slightly different !attern. The reason for this is that sheer !ressure% it"s i#!ortant for the a#eloblasts% it"s li&e !ly$ood% you $ant to build a structure that doesn"t have sheer !lanes all the $ay do$n$ard% so they #ove and they turn a little bit% and then they do this !attern% o&% IA# not gonna do the dance. So is that clear+ So the little incre#ental lines% there $ill be six incre#ental lines and there $ill be the lines of 4et'ius. )o$% if $hile the a#eloblasts are laying do$n the bric&s there is so#e tre#endous event that occurs $hile they are laying do$n the bric&s li&e a hailstor# or a fire or so#ething li&e that the bric&s aren"t gonna be laid in a very good !atter. In this case% can you guys tell $hat they"re doing+ They"re drin&ing. )o$ actually% alcohol $ill cause alcohol fetal syndro#e% and so #others $ho are !regnant $ho do lots of drin&ing% and loo&ing at so#e of you guys here if I $ere your #other I $ould"ve dran& too% !robably after$ards% that $a&es !eo!le u!. *nd so if you"re drin&ing% so#e adverse effect% drug effect% infectious disease% anything that $ould affect those bric& layers% on that $ould affect the for#ation of these bric&s% these incre#ental lines and there $ould be a defect. So#eti#es the defects are huge. Slide 1I3 )eonatal Line *nd so the biggest defect is the neonatal line% $hat a nice na#e% it has li&e !oetry% but this is an extre#ely% it"s a #ar&er of an extre#e event. Slide 1/3 )eonatal Line *nd if you loo&% and this is the textboo&% see the neonatal line+ So this is !re and that"s !ost. *nd this is fro# textboo&% I thin& I do$nloaded this fro# your vitalboo&% and you can read it it"s fro# ,ath% it"s a nice !icture% and I $ould say that that"s ty!ical neonatal line% that"s !robably about 12 #icrons% you can actually #easure this. )o$% $hat $ould ha!!en if you $ould have a neonatal line thatAs about 25 #icrons+ *nd $hat ha!!ens if $hen you $ere born you $erenAt delivered for about 25 hours% and you"re not getting enough oxygen% you"re neonatal line is gonna be that big. *nd so children $ho have different ty!es of birthing !roble#s% !re#aturity for exa#!le% their neonatal line is distorted. *nd so it"s very co##on for children to have ena#el defects $hen they"re !re#ature. It"s also very co##on to have ena#el defects if you have a !rolonged% difficult birth. ;others that are obese often have children $ith ena#el defects% because a #other $ho"s obese% itAs very difficult to deliver a baby fro# an obese #other. Slide 2F3 S8;s So #y friends in Ger#any% and this is 1an Kuhnisch% and he did S8;% but loo& at that neonatal line% and so#e of it is in Ger#an% you see the disru!tions+ These are so#e of the !ris#s being for#ed% and this is different neonatal line% loo&ing at it $ith S8; he acid etched% loo& at this beautiful $or&% loo& ho$ disjunctive that is% so there is so#ething very disturbing about this a#eloblasts that caused it to for# this huge ga!. )o$ $hat $ould be the sheer !ressure reEuired to brea& that ga! if you !ut !ressure on that tooth% $ould it tend to fracture+ Bell% if all the a#eloblasts along the neonatal line $ere si#ilarly affected% you $ould have a structural defect% and that defect $ould be susce!tible to brea&age. *nd I &no$ I have to Euite% but let #e just !lant t$o otherD Slide 213 8vents

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So things that $ill cause the neonatal line to be% it"s dia#eter and its Euality has to do $ith hy!oxia at birth% difficult birthing% !re#aturity is nu#ber one. --section% if youAre delivered by - section youAre gliding right out% hardly any neonatal line at all. So if you give #e a tooth of a child and I section it I can tell you if they"re a --section% because they"re just sliding out. )o$% I"# tal&ing about a !lanned --section% o&+ So it"s not as trau#atic co#ing through the birth canal% hy!oxia% stuff going on% obesity and all that. Slide 223 Tooth e#ergence )o$ there"s a $hole host of events that can cause this% again% I"# running out of ti#e% but if during those 1FFF days% and teeth are develo!ing% de!ending% you can"t see anything on this. De!ending on those teeth% and $hat stage of develo!#ent they"re in% that $ill dictate ho$ you $ill see the defect. Slide 273 (y!o!lasia So I just $ant to sho$ you an enlarge#ent of a very #ild for# of% you see the hy!o!lasia% the $hite% a very% very #ild% al#ost can"t see it% no$ if you follo$ that line across you get $hat $e call a fro$n. )o$ these are exactly related bac& to $hen those teeth $ere% no$ these are !ri#ary teeth% these are baby teeth. If you loo& at that !attern% ti!s of the cu!s% this goes exactly bac& in utero% to develo!#ent of teeth in that ti#e. so so#ething ha!!ened to that child very #ild% at a s!ecific ti#e% that caused that hy!o!lasia. Let #e sho$ you a #ore extre#e case very Euic&ly and then $e"ll dis!erse. Slide 253 Linear 8(9 ou see the defect goes in this 0 sha!e+ It"s not !erfect. In this case% this childAs #other had extre#e infection% #alnutrition that caused that defect. *nd if you loo& at the surface of the child"s teeth% again this is not so#ething you could loo& at #acrosco!ically $ith your eyes% if you loo& at it $ith S8; these teeth are !oc&ed% and if you"re tal&ing about caries and bacteria coloni'ing teeth% causing caries% that"s a !erfect environ#ent. I"# gonna sto! no$% and I a!ologi'e that I"# a bit slo$ and I ca#e late% but $e"ll !ic& this u! next year in cariology.

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