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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 11  |  Page : 1489-1494

A comprehensive survey of natal and neonatal teeth in newborns


1 Department of Paediatric Dentistry, Izmir Training Dental Hospital, Konak-Izmir, Turkey
2 Department of Orthodontics, Faculty of Dentistry, Ege University, Bornova-Izmir, Turkey
3 Department of Pathology, Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, University of Health Sciences, Konak-Izmir, Turkey

Date of Submission16-Mar-2019
Date of Acceptance25-May-2019
Date of Web Publication13-Nov-2019

Correspondence Address:
Dr. G Bulut
Department of Paediatric Dentistry, Izmir Training Dental Hospital, Konak-Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_152_19

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   Abstract 


Objective: To evaluate clinical and histological characteristics and determine the incidence of natal/neonatal teeth in a large Turkish population. Subjects and Methods: Among 17,829 newborns, who were hospitalized at the Neonatal Clinic of a governmental Children's Hospital between 2005 and 2011, 27 neonates were diagnosed with erupted teeth, which were examined in terms of location, clinical appearance and mobility. Besides histological evaluation, a positive family history was also recorded. The variables were analyzed using Chi-square test. Results: Thirty-two natal/neonatal teeth were observed in 27 infants. The incidence of both natal and neonatal teeth was found to be 1:660, while the incidences were separately recorded as 1:1,048 and 1:1,782, respectively. The histological examination revealed a thin hypoplastic enamel layer and a normal dentin layer. There was no difference between the two genders in terms of natal/neonatal tooth type, positive family history and tooth morphology (p > 0.05); or between normal and conical shapes with regard to natal/neonatal tooth type, positive family history and tooth color (p > 0.05). Conclusions: This study exhibited a higher incidence in natal teeth than neonatal teeth. Macroscopic features were not found to be positively related to gender and tooth type.

Keywords: Incidence, histology, natal teeth, neonatal teeth, supernumerary teeth


How to cite this article:
Bulut G, Bulut H, Ortac R. A comprehensive survey of natal and neonatal teeth in newborns. Niger J Clin Pract 2019;22:1489-94

How to cite this URL:
Bulut G, Bulut H, Ortac R. A comprehensive survey of natal and neonatal teeth in newborns. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 15];22:1489-94. Available from: http://www.njcponline.com/text.asp?2019/22/11/1489/270850




   Introduction Top


The first tooth of a baby occurs in the oral cavity by eruption of the mandibular incisors at about six months of age normally. Prematurely erupted teeth have been called as congenital teeth, fetal teeth, predecidous teeth and dentitia praecox. Massler and Savara have described these teeth as “natal” or “neonatal” teeth which currently are the most commonly used forms. Teeth that are present at birth are called as natal teeth and those erupting within 30 days after birth are called neonatal teeth.[1] The incidence of these teeth varies from 1:2,000 to 1:3,500 births.[2] Natal teeth are more common compared to neonatal teeth [1],[2] and both teeth seem to be observed more frequent in females.[3] The rates of the erupted natal/neonatal teeth in descending order are as follows: Mandibular incisors (85%), maxillary incisors (11%), mandibular canines and molars (3%), and maxillary canines and molars (1%); 90% of these teeth are primary and 10% are supernumerary.[1]

In spite of the fact that the precise etiology is still not known, conceivable etiologies have been reported within the writing such as febrile episodes, hormonal stimulation, hereditary transmission of a dominant autosomal gene, endocrinal disturbances, environmental toxicants, osteoblastic activity within the area of the tooth germ related to bone remodeling phenomena or fever of the mother during pregnancy. The most common accepted etiology is the superficial position of the tooth germ above the alveolar bone, possibly related to hereditary factors.[4],[5],[6]

Natal teeth have also been associated with special conditions such as cleft palate, genetic syndromes, Pfeiffer syndrome, Hallerman-Streiff syndrome, Wiedemann-Rauten Strauch syndrome or congenital hypothyroidism.[7],[8],[9],[10],[11]

Parents, dentists and pediatricians take an evidence interest in natal and neonatal teeth and it is important to accomplish extensive research in this field. Çetinkaya et al., in their comprehensive survey of oral abnormalities in a Turkish newborn population, found the percentage of only natal teeth as 0.4%.[12] There are also some reports from Turkey which evaluate different characteristics of those teeth.[7],[13],[14] Despite the studies undertaken, there is still no widespread investigation regarding the incidence of both natal and neonatal teeth in Turkey. Thus, the aim of this study was to present the incidence and also clinical and histological aspects of natal and neonatal teeth and treatment needs in a large population of Turkish newborns.


   Subjects and Methods Top


This retrospective, 6-year-spanned study was conducted at the department of neonatology in Dr. Behcet Uz Children's Hospital, Izmir/Turkey, between 2005 and 2011. Among 17,829 hospitalized newborns, suffering from any disease, 27 neonates were diagnosed by pediatricians with erupted teeth. Babies were born in either a special or a governmental maternity hospital. Infants with tooth/teeth were referred to the dental clinic for consultation and further examination. This study was undertaken in compliance with the guidelines of the Declaration of Helsinki. An informed consent was taken from the parents of each infant prior to the investigation.

Twenty-seven infants were examined and registered by the pedodontist. Detailed clinical data have been received from the medical chart, including the presence of any systemic diseases of the babies. A family history, photographs and radiographs were taken. As well, intraorally location of the teeth, clinical appearance with regard to tooth morphology and color, degree of mobility of the natal/neonatal teeth have been evaluated. All teeth were extracted for treatment needs and sent for histopathological investigation. The variables were analyzed for gender, type of tooth, positive family history and different clinical characteristics using Chi-square test for assessing possible relationships. P = 0.05 was considered as level of significance.


   Results Top


Incidence survey

A total of 17,829 infants underwent clinical examination and 27 of them were observed to have natal or neonatal teeth. The incidence of natal and neonatal teeth was found to be 1:660. Of the 27 infants, 17 newborns had natal teeth and the incidence of only natal teeth was 1:1,048; 10 infants had neonatal teeth. The incidence of only neonatal teeth was 1:1,782. One infant had both natal and neonatal teeth; this infant was assigned to the natal tooth incidence. From the 27 infants, one twin was observed and both of the twins had neonatal teeth. Also, among the individuals, one was a premature infant who had one natal tooth.

Clinical findings

Totally 32 natal and neonatal teeth (20 natal: 62%, 12 neonatal: 38%) were observed in 27 infants. The examination exhibited no evidence of systemic diseases, congenital abnormalities or any syndromes. In all, 16 of the infants were boys (60%) and 11 of them were girls (40%). The infants with tooth were 2-30 days old. When assessing the location of the erupted teeth, all teeth were observed to be in the mandibular anterior region (100%). Although the difference did not reach the level of significance, the number of incisors were higher on the left side than on the right side [Table 1]. There was no difference between the genders in terms of type of tooth, positive family history and tooth morphology [Table 2]. Concerning the tooth morphology, the statistical difference between normal and conical shapes was not significant with regard to the type of tooth, positive family history and tooth color [Table 3].
Table 1: Clinical characteristics of natal and neonatal teeth

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Table 2: Gender differences in tooth morphology, positive family history and tooth type

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Table 3: Comparisons between tooth morphology and relevant variables

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Of the 27 infants, four were identified with two erupted teeth at the same time, three of these four infants were observed to have the erupted teeth at birth. In one infant with natal tooth, another tooth was diagnosed erupting adjacent to the earlier erupted natal tooth at following couple of days. Remainders had a single tooth. Periapical radiographs showed that all these teeth were of normal complement of primary incisors. None of the patients exhibited sublingual ulceration. In all, except two infants, the teeth showed severe mobility and were categorized as grade II. However, the mothers of these two infants mostly complained about the difficulty of breastfeeding. Since hypermobility entails a high risk for aspiration and as well of feeding problems, extraction of the teeth had to be carried out in all cases under topical local anesthesia. Patients' postoperative courses were considerably uncomplicated. A 2-day-old natal tooth cracked during extraction, since it was not matured enough.

Macroscopic examination

The crowns of 32 teeth were normal in shape and small to normal in size. The enamel layer was hypoplastic and whitish in color. There were rudimentary roots in 22 teeth and no root formation in 10 teeth. In some samples, the pulpal tissue was exposed through the openness in the cervical region [Figure 1] and [Figure 2]. When the broken tooth of the 2-day-old infant was examined macroscopically, it could be seen that the enamel was very immature.
Figure 1: A newborn with a primary lower central incisor. The tooth was mobile and covered with gingival tissue

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Figure 2: Natal tooth after extraction

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Histological findings

The majority of the incisor teeth presented a thin layer of hypoplastic enamel [Figure 3]a and [Figure 3]b. Dentinal tubules were regular in the incisal area [Figure 4]a. In the cervical area, osteodentin and large interglobular areas were present in dentin and the dentinal tubules were irregularly arranged [Figure 4]b. The dentin layer seemed to be comparatively normal. Irregularities in odontoblast layer were detected in the predentin. The number of dilated blood vessels was slightly higher in pulpal tissues [Figure 5]. Histological examination revealed no extraordinary findings.
Figure 3: (a) Light microscopic photograph showing view of the longitudinal section of the whole natal tooth in the labiolingual direction (Hematoxylin and eosin stain; ×4). (b) Light microscopic photograph showing view of the longitudinal section of the whole natal tooth in the mesiodistal direction (Hematoxylin and eosin stain; ×4)

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Figure 4: (a) Light microscopic photograph showing thin layer of hypoplastic enamel and regular dentinal tubules in the incisal area (Hematoxylin and eosin stain; ×40). (b) Light microscopic photograph showing large interglobular areas in the cervical region. (Hematoxylin and eosin stain; ×20)

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Figure 5: Light microscopic photograph showing blood vessels of various sizes (Hematoxylin and eosin stain; ×10)

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   Discussion Top


To date, the incidences of natal and neonatal teeth have been documented in the literature by several authors. In a review article, Zhu and King presented the incidence of both natal and neonatal teeth as ranging from 1:716 to 1:30,000 resulted from 10 studies from 1876 to 1991.[15] In another review article, Chow reported the incidence of natal and neonatal teeth as ranging from 1:2,000 to 1:3,500, according to the data obtained from the studies conducted between 1966 and 1980.[2] Kates et al. reported the highest incidence for natal teeth as 1,716 which was followed as 1:800 indicated by Anderson for natal and neonatal teeth, disregarding greater rates in infants with cleft lip and palate.[7],[16],[17],[18] In this study, the incidence was found to be 1:660 for natal and neonatal teeth and this finding is the highest rate documented in the literature until today. The incidences of only natal teeth and only neonatal teeth were evaluated as 1:1,048 and 1:1,782, respectively. Most of the incidence studies reported in the literature are mutual incidences of natal and neonatal teeth. This is probably the only research study that presents the incidences separately.

In previous studies, the ratio of natal to neonatal teeth was reported as 3:1 or 2.58:1, which was found to be as 1.66:1 in our survey.[4],[19] In the present study, the finding that all teeth occurred in the mandibular central incisor region is similar to former reports in which 85% of the teeth were noticed in this area.[1],[4],[16],[19],[20] Further, locational distribution was stated as the area of maxillary incisors (11%), mandibular canines and molars (3%), and maxillary canines and molars (1%).[1],[4] Since the teeth that first erupt in the mouth are the lower incisors, the expectancy is very strong that natal teeth are usually lower incisors.[20],[21] Only a few authors presented their cases suffering from natal/neonatal molar teeth.[8],[22],[23],[24] In this study, the finding that all teeth were normal complement of primary dentition meets with previous results that give 90% for it.[1],[6],[16],[19] In contrast to the majority of the literature, Basavanthappa et al. identified all teeth as supernumerary with radiographic examination in their study.[20] They also found the teeth in pairs in only a small number of patients as we have seen in our study in 18.5% of the infants, which remains at a low rate comparing with the earlier reports identified between 38% and 76%.[1],[16],[19] As a very rare condition, multiple natal and neonatal teeth eruption were observed, although they usually erupt in pairs or single. The most unusual case report is presented by Portela et al., describing a newborn with eleven natal teeth that belong to the normal primary dentition.[25]

Although several previous studies reported that natal and neonatal teeth were more common in females than males, the gender gap in incidence is still polemic.[1],[2],[3],[10],[16],[19] Our study showed no sexual tendency as in line with some reports.[7],[12],[20],[26] Furthermore, regarding gender correlation with the studied variables, no significant differences were also found in tooth morphology and positive family history.

Uzamıs et al., in their study evaluating the surface topography of mandibular natal and neonatal incisors by using scanning electron microscopy, stated that the enamel exhibited hypoplastic, depressed areas and that the incisal of examined natal teeth had an incompletely developed enamel. In addition, the root formations were seen not to be completed, which correlated with the finding that those teeth may erupt without root formation.[14] While, for normal primary teeth, the enamel layer reaches 1,000-1,200 μm,[5] enamel thickness in natal/neonatal teeth was determined as 130 μm.[14] Histological studies have also affirmed that enamel in these teeth is an average for newborn, however, since mineralization is incomplete, the uncalcified enamel matrix abrades in premature erupted teeth.[27] Bigeard et al. presented a study in which the characteristic ultrastructure was examined by using transmission electron microscopy and reported no significant disturbances in size, number, and distribution of the dentinal tubules.[5] In the present study, the histological examination showed an immature tooth with a thin layer of hypoplastic enamel covering the crown, but a relatively normal dentin. Dentinal features did not reveal significant disturbances compared to normal primary teeth as had been observed by other authors.[5],[15],[16],[24] The histological aspects of natal/neonatal teeth in the present study seem to be comparable with the findings reported by Massler et al.,[1] Rusmah,[6] Zhu et al.[15] and the review by Leung et al.[21]

As described by Basavanthappa et al. and Leung et al., the natal/neonatal teeth are often smaller and more conical than normal deciduous teeth. Additionally, they might reflect yellowish or whitish color and they might represent hypoplastic enamel and dentin with poor or absent root development.[20],[21] In the present study, the majority of the tooth crowns were of normal shape and size (69%). Kates et al. observed 31% of the teeth in their study confirming that immature enamel is not able to complete its maturation as soon as the gingival coating disappears and subsequently the immature enamel breaks down.[16] Bjuggren has stated that after the enamel becomes unprotected, it usually turns into a yellow brown color and continues to deteriorate as long as it is unprotected.[26] In the present study, the probable reason why most of the teeth were whitish is that these teeth have not been in the mouth for too long after eruption.

A positive relationship between natal/neonatal teeth and positive family history was suggested by previous studies. While some of these studies reported a strong association with incidence rates ranging from 8% to 46%, in this study we stayed at a very low level (15%).[1],[3],[4],[26]

In the literature, different explanations have been suggested for the early eruption of teeth. Although malnutrition,[10] hormonal stimulation,[11] febrile status and familial pattern [1],[6],[14] are reported for the etiology of natal/neonatal teeth, the exact cause is still unknown. As well as not being proved definitely, some researchers indicate that natal and neonatal teeth may be associated with some syndromes and developmental disturbances.[8],[9],[10] For example, while Koklu and Kurtoglu expressed natal teeth in a case of neonatal transient pseudohypoparathyroidism,[13] Mandal et al. found those teeth in an infant suffering from congenital hydrocephalus and congenital glaucoma.[28] It is known that there is a familial inclination and supporting evidence of autosomal dominant features,[29] but still premature eruption is seen commonly to be correlated to superior position of the tooth germs,[20] which is what we also think of as the probable etiology of many teeth in our study. Within the knowledge of these given data, there is a general agreement in the literature that the etiology of natal teeth needs further study.[19]

Natal teeth can lead to some adverse conditions. The major complications of natal/neonatal teeth are traumatic ulceration to the tongue (known as  Riga-Fede disease More Details), feeding problems and aspiration because of the hypermobility as reported by several authors.[21],[30] In our study, Riga-Fede disease was not observed in any of the infants. Without exception, all the natal/neonatal teeth were extracted for the reason of excessive mobility or the risk of spontaneous exfoliation and aspiration. Almost in all studies appearing in the literature, extraction is a preferred procedure as treatment, because of the aforementioned potential complications.[6],[8],[20] When evaluated immunologically and hematologically, the best time for extraction was deliberated to be at 7-25 days of birth.[31] In addition, vitamin K administration is recommended for prophylactic purposes due to the risk of hemorrhage, since coagulation may not be achieved properly until the child is 10 days old.[6]


   Conclusion Top


Incidences of the diagnosed natal and neonatal teeth were determined separately. It was seen that the natal teeth exhibited a higher incidence than the neonatal teeth. All teeth were the normal completeness of the primary incisors and were observed in the mandibular anterior region. Males were affected for the most part. There were no differences between genders in terms of tooth type, tooth morphology and positive family history. Moreover, there were no significant differences between normal and conical shapes with regard to tooth type, tooth color and positive family history. Most of the tooth crowns were normal in shape and small to normal in size. A thin hypoplastic enamel cover and a comparatively normal dentin layer was detected in the majority of teeth. Still there is further need for more comprehensive research, particularly on the etiology in the field of natal and neonatal teeth.

Ethics

This study followed the principles of the Declaration of Helsinki. The participants signed an explicative authorization document of their own free will before enrollment in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Berman DS, Silverstone LM. Natal and neonatal teeth. A clinical and histological study. Br Dent J 1975;139:361-4.  Back to cited text no. 27
    
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Mandal AK, Hornby SJ, Jones RB. Congenital hydrocephalus associated with congenital glaucoma and natal teeth. Indian J Ophtalmol 2002;50:322-3.  Back to cited text no. 28
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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