Natal and neonatal teeth: early diagnosis and management

Abstract

The eruption of teeth in newborns is a rare disorder of the oral cavity and are called ‘natal teeth’ when they are present at birth or ‘neonatal teeth’ when they erupt within the first month of life. In most of these cases, they are prematurely erupted deciduous teeth or supernumerary teeth. Supportive management should be given, to facilitate child’s feeding and to prevent further complications, such as aspiration as the tooth could be mobile. This study describes a series of cases that were reported to our department, involving teeth located in the mandibular anterior region either at birth or within a few days after birth. The choice of treatment for each child was based on individual assessment of the case, considering options such as monitoring and extraction along with their associated complications.

Background

Natal teeth, also known as congenital teeth, dentitio praecox, or neonatal teeth, are teeth that are present at birth. They are most commonly found in the mandibular incisor region (85%) and less common in the maxillary cuspids or molars (1%). These teeth appear as small, discoloured crowns with underdeveloped roots, often accompanied by enamel or dentin hypoplasia. Due to their increased mobility and poor root development, extraction is usually recommended. This not only prevents the risk of aspiration but also ensures that the teeth do not interfere with feeding or cause ulcers on the tongue.¹

Neonatal teeth erupt within the first 30 days of life. The ratio of natal to neonatal teeth varies between 3:1 and 1:1.^2–5 There are several causative factors that contribute to the presence of natal teeth. These include the superficial position of the tooth germ, infection or malnutrition, a febrile state, hormonal imbalance, hereditary transmission of a dominant autosomal gene, osteoblastic activity, and hypovitaminosis.³ These factors can play a role in the early eruption of teeth in newborns. It is important to note that the presence of natal teeth is a rare occurrence and may require specific attention and management by healthcare professionals.

Hebling (1997) has classified natal teeth into four clinical categories such as category 1—shell-shaped crown poorly fixed to the alveolus by gingival tissue and absence of a root; category 2—solid crown poorly fixed to the alveolus by gingival tissue and little or no root; category 3—eruption of the incisal margin of the crown through gingival tissue; category 4—oedema of gingival tissue with an unerupted but palpable tooth.^{4 5}

It is important to document cases of natal and neonatal teeth, including clinical features, treatment approaches and prognosis. This information can contribute to existing knowledge to help healthcare professionals (paediatricians and gynaecologists) and general dental practitioners provide timely, appropriate care or referral in their routine practice. Thus, the purpose of this article is to revisit and describe a series of cases of natal and neonatal teeth in infants, their treatment approaches undertaken and its prognosis.

Case presentation

Here we describe four cases, who reported to the department of paediatric and preventive dentistry over a period of 8 months in a private dental college. Few mothers complained about difficulty in feeding, while others noticed abnormal growth or mobility of teeth in the lower anterior region of their infants. Two children were prematurely born, and no syndromes or anomalies were reported in any of the children in the case series. Table 1 describes the clinical characteristics and treatment approaches for each case in the series. This information will provide quick valuable insights on the management and its prognosis.

Table 1.

Clinical characteristics and treatment approaches undertaken for the cases

Case	Sex	Natal history (Term/ Type of delivery)	Complaint/ Clinical appearance	Treatment done	Follow-up
Case 1	F	Preterm neonatal/C-section Underweight 1.45 kg	Tooth like structure seen 2 weeks after birth, Mandibular incisor region, Difficulty in feeding, Miller’s grade II mobility present	Extraction	4 months
Case 2	F	Preterm neonatal/C-section Weight 2.35 kg	Tooth like structure seen at birth, Mandibular incisor region, difficulty in feeding, Miller’s grade II mobility present	Extraction	1 month
Case 3	M	Neonatal/VD	Tooth and soft tissue like structures seen 3 days after birth, Mandibular incisor region, difficulty in feeding, Miller’s grade III mobility and soft tissue swelling present	Extraction	1 month
Case 4	F	Neonatal/VD	Palpable tooth like structure covered by gingiva resembling eruption bulge seen in lower incisor region, difficulty in latching, no mobility	Monitoring and Counselling	–

Case 1

A mother reported with a chief complaint of the presence of two teeth in the lower jaw of her preterm neonate and had difficulty in feeding. A review of the medical records revealed that she was born prematurely at 33 weeks of gestation through emergency lower (uterine) segment caesarean section and the infant’s birth weight was 1.85 kg. The mother of the infant had no other personal pathological history. The mother took only vitamin supplements during pregnancy and her antenatal history revealed non-consanguineous marriage. Soon after birth, the infant experienced respiratory distress characterised by grunting which led to her hospitalisation into the neonatal intensive care unit (NICU) where nasopharyngeal continuous positive airway pressure therapy was initiated. The baby was discharged 10 days later from the NICU and was alert, active and euthermic, but underweight with a haemoglobin level of 150 g/L and RBC level 4.03 million/mm³.

Intra oral examination revealed two teeth-like structures in the anterior mandibular, central incisor region (figure 1). The remaining gum pads, tongue and intraoral mucosa appeared normal. As per Miller’s classification of mobility, the clinical condition was natal teeth with grade II mobility and the clinical appearance corresponding to Hebling’s classification category 1. Considering the risk of aspiration due to excessive mobility and feeding difficulties, a decision was made to extract the natal teeth.

Figure 1.

Preoperative image showing natal teeth (A) and following extraction in case 1 (B).

Subsequently, the treatment plan was comprehensively explained to the parents and written consent was obtained for extraction. Both the natal teeth were extracted using extraction forceps under topical anaesthesia. The size, shape and colour of the two teeth were similar to normal. No curettage of the extraction site was performed.

Postoperatively, there were no complications such as bleeding or infection and the mother was allowed to resume breast feeding. Eventually, after a week, the mother noted a small mass that appeared around the extraction site. On intraoral examination, a small, mobile soft tissue structure resembling a tooth-like structure was observed in the lower anterior region with respect to 81 (figure 2). There was no difficulty in breast feeding. The infant was kept under observation and the decision was made to wait and watch for the prognosis. After 2 weeks of follow-up, no reduction in the size of the mass was observed hence the child was kept under observation with frequent follow-ups. Complete resolution of mass was observed after 4 months (figure 3).

Figure 2.

Post-operative complication after 1 week in case 1.

Figure 3.

Follow-up after 4 months showed complete resolution of mass without any intervention in case 1.

Case 2

A preterm neonate’s mother reported with a chief complaint of two teeth in the lower jaw since birth and had problems in breast feeding with continuous crying during feeding. On intraoral examination, the presence of natal teeth in relation to 71 with grade II mobility was seen in an otherwise healthy newborn. It was decided to extract the teeth and consent was obtained from the parent and paediatrician. Extraction was performed under local anaesthesia and the healing was noted to be satisfactory.

Case 3

A neonate’s mother reported with a chief complaint of two mobile teeth in the lower jaw since birth and problems in breast feeding. Intraoral examination revealed the presence of natal teeth in relation to 71 and 81 with grade III mobility associated with soft tissue swelling. Extraction was planned after obtaining consent from the paediatrician and parent and the healing was satisfactory.

Case 4

A neonate’s mother complained of difficulty in latching and the presence of swelling in her child’s mouth. On intraoral examination, an eruption bulge of the natal tooth was observed and on palpation, a hard calcified structure which is not mobile with clinical criteria similar to Hebling type 4 was observed (figure 4). The parents were apprehensive and unwilling to the extraction procedure and hence were advised to report if their child experienced any symptoms with the loose tooth. They were also counselled on the potential risks of aspiration if the tooth became very mobile.

Figure 4.

Eruption bulge of natal teeth in lower incisor region observed in case 4.

Investigations

Due to the age and limited ability of infants to cooperate during radiographic investigations, it was determined that it would be best to avoid exposing them to unnecessary radiation. In these cases, the treatment plan involved a straightforward extraction procedure for the natal and neonatal teeth; there was no immediate need for radiographic investigations. If further concerns arise or if the child’s oral health requires additional diagnostic measures, radiographic investigations may be considered in the future, with careful consideration of the risks and benefits.

Differential diagnosis

It was observed that the growth in case 1 was asymptomatic, soft and spongy. It did not have a pedunculated appearance and did not easily bleed. Therefore, it was determined that the condition was not consistent with pyogenic granuloma.

Treatment

Considering the feeding difficulties and risk of aspiration due to excessive mobility, a decision was made to extract the natal/neonatal teeth. Subsequently, the treatment plan was comprehensively explained to the parents, and written consent was obtained for extraction. Extraction of natal and neonatal teeth was carried out in three cases using extraction forceps under topical anaesthesia (2% lignocaine gel) which was well tolerated by the children (figure 1). All four cases had taken vitamin K prophylaxis immediately after birth. No curettage of the extraction site was performed in any case. Postoperatively, there were no complications such as bleeding or infection. Oral hygiene Instructions were given to the mother and was instructed to resume breast feeding.

In case 4, the parents expressed concerns about the extraction procedure and hence were advised to report back once they faced any difficulties with feeding or if they were willing to proceed with further management. They were also counselled on the potential risks of leaving the teeth untreated, including the possibility of aspiration and other adverse effects.

Outcome and follow-up

In case 1, the mother noticed a small mass around the extraction site 1 week after the procedure (figure 2). On intraoral examination, a small, mobile soft tissue mass resembling a tooth-like structure was observed with respect to the lower anterior region. Feeding history revealed no difficulty in breast feeding. So a decision was made to wait and watch for the prognosis and the infant was kept under observation. After 2 weeks of follow-up with no reduction in the size of the mass, an opinion was sought with the faculty of the department of oral medicine, radiology and diagnosis. After a thorough examination, the mass was provisionally diagnosed to be pyogenic granuloma or inflammatory reaction following extraction. No intervention was done and regular follow-up was suggested to the parent. It was decided to surgical excise the mass if it did not resolve within a month. Follow-up after 1 month revealed a gradual reduction in the size of the mass which was soft and non-tender posing no difficulty in feeding. With 2 months follow-up, a noticeable decrease in the size of the mass was observed. Follow-up after 3 and 4 months revealed complete resolution of mass with a significant increase in body weight up to 4.41 kg (figure 3). The patient will be recalled and reviewed every 3 months until the eruption of primary dentition. As for cases two and three, healing was satisfactory and uneventful with no difficulty in feeding. Unfortunately, case 4 was lost to follow-up (figure 4).

Discussion

Massler and Savara (1950) used the terms ‘natal’ or ‘neonatal teeth’ for the first time. They defined natal teeth as those teeth that are present at birth. The incidence of natal teeth is slightly higher in females compared with males with a frequency of 3:1.⁶ Natal teeth are more prevalent in underweight and preterm infants. Few cases of natal teeth in underweight infants were reported by Khandelwal et al (1.5 kg), Garg et al (1.7 kg) and Parvathy et al (1.15 kg).^7–9 Even though literature states that delay in tooth eruption is more prevalent in preterm infants, there are high chances that natal teeth occur in premature and preterm infants with low birth weight <1.5 kg making gestational age as one of the factors in determining the prevalence of natal and neonatal teeth. Among the four cases, two of our cases were preterm infants among which one infant was underweight <1.5 kg. Contrarily, Shiv et al stated that there is no correlation between the birth weight of infants and the development of natal teeth.^{2 10}

According to Singh et al, if the degree of mobility of natal teeth exceeds 2 mm, they need to be extracted to avoid the risk of aspiration and the same was performed in three of our cases.¹¹ It has been suggested to avoid extraction up to the 10th day of life to prevent haemorrhage. Few considerations which has to be done before extraction are to assess the need to administer vitamin K before extraction, the general health condition of the baby, avoiding unnecessary injury to the gingiva, and being alert to the risk of aspiration during removal.^{5 12} Three cases included in this report had excessive tooth mobility with an associated risk of aspiration leaving extraction as the only treatment option, whereas one case was lost to follow-up with no treatment due to non-compliance by the parents. Before extraction, we were assured that Vitamin K was administered at birth and the same was confirmed from the children’s medical report.

Berendsen and Wakkerman (1988) reported a case of eruption of tooth-like structures following extraction of two neonatal teeth in the lower incisor region, which persisted in the oral cavity up to the age of 5 years when they naturally exfoliated. The decision to retain these teeth is based on the basic necessity of survival of living beings.¹³

Following extraction of the natal tooth, curettage of the socket is recommended to prevent the continued development of dental papilla cells. Ooshima et al and Tsubone et al reported that it would continue to grow, resulting in the eruption of tooth-like structures several months later and termed it ‘residual natal tooth’.¹⁴ Curettage of socket was not done in case 1 and the changes observed during follow-up was a soft-tissue mass which resolved on its own. Hence, the suspicion of residual natal tooth is not applicable in this case.

Gingival mass in infants includes reactive lesions like irritation fibroma, pyogenic granuloma, peripheral giant cell granuloma and peripheral ossifying fibroma which could be accompanied by natal teeth, although these are unusual. These lesions might represent reactive gingival proliferation caused by mobility or irritation of the natal teeth or procedural error during extraction.^{1 2}

Pyogenic granuloma is an inflammatory hyperplasia that appears clinically as an asymptomatic, dark red, soft and spongy tissue that bleeds easily. It is generally a pedunculated, elevated or sessile mass with a lobulated, smooth surface. It might become ulcerated and can be enveloped by yellow-tan fibrinous exudates.¹⁵ In case 1, the growth observed was asymptomatic, soft and spongy. It was neither pedunculated nor bled easily. No ulceration or fibrinous exudate was evident hence the condition was not considered as pyogenic granuloma.

Complications following the extraction of natal teeth are rare findings. Histological examination was not done in any of the cases as the parents wanted to take the extracted teeth with them. Hence, in case 1 it could be suspected that the presence of low-grade irritation might have led to postoperative complications.

Thus, early diagnosis, prompt treatment and gentle handling of the tissues should be of primary concern in the management of natal teeth. Periodic follow-up with a paediatric dentist is essential to monitor the child’s oral health and ensure proper growth and development. Regular re-evaluation will help identify any potential issues early on and allow for immediate intervention if necessary.

Patient’s perspective.

The problem faced during difficulty in feeding was our major concern because of which our child was not fed sufficiently. I understood the treatment procedures explained by the dentists and gave consent for extraction. I was convinced that the treatment and feeding issues were resolved in our child.

Learning points.

• This case series provides succinct knowledge about every aspect of premature teeth and appropriate treatment modalities.

• Possible complications following extraction of natal teeth and the measures taken to manage it are explained in detail.

• Reassurance and appropriate counselling by paediatricians to parents are vital. Referring children to paediatric dentists in complex cases requiring extraction ensures that specialised care is provided.

• General dental practitioners can provide primary care to infants with premature teeth by proper initial management. In more complex cases, secondary care services from specialised paediatric dentists must be sought.

Ethics statements

Patient consent for publication

Consent obtained from parent(s)/guardian(s)