Siham Said Abdullah Al Shereiqi1, Triveni Mohan Nalawade2* and Rachappa MM2
Received:January 21, 2019 Published: January 30, 2019
*Corresponding author: Triveni Mohan Nalawade, Senior Lecturer, Oman Dental College, Muscat, Oman
The aim of this article is to highlight an uncommon eruption sequence of deciduous maxillary central incisors, create awareness and its early management if indicated. There might be underlying systemic cause and a prompt visit to a dentist might help in arriving on a proper diagnosis, and thus improve prognosis.
One of the most eagerly awaited moment by parents in their child’s life is the eruption of the first deciduous tooth. Teething is one of the major and important milestones a baby has to attain. That is a reason why parents get anxious if there is a delayed or even a slight difference in the sequence of eruption. General sequence of eruption of deciduous teeth is central incisors, lateral incisors, first molars, canines and lastly second molars. Usually mandibular teeth erupt before maxillary teeth. Eruption of deciduous teeth begins at around 6 months and is completed by 30 months most of the times . Variations in the sequence of eruption can be seen in some cases but eruption of maxillary laterals prior to maxillary centrals is quite uncommon. It is important for the parents to know that there is a variation in the sequence of erupting and when is it essential to contact a specialist.
An eleven-month-old girl who is also my niece had a very uncommon appearance when her first deciduous teeth erupted. She actually looked like a Vampire with only maxillary deciduous canines having erupted before maxillary deciduous central and lateral incisors. I felt it was uncommon and at the same time was worried what was the reason for this occurrence. Were the maxillary deciduous central and lateral incisors congenitally missing or just delayed in eruption? Next day at our work place, a teaching institute, with the photographs of my niece, I consulted two of pediatric dentists for opinion. To my surprise, even they had not seen such a case in their 13 years of exclusive pediatric dentistry practice. On having a closer look at the pictures, both Pediatric dentists noticed that her maxillary deciduous lateral incisors had erupted before the central incisors and not maxillary canines as I had thought before. She had maxillary lateral incisors in 11 month and two weeks. Note the presence of eruption bulges in the maxillary central incisor area ruling out the possibility of my niece having congenitally missing teeth (Figure 1). After two weeks her mandibular deciduous central incisors erupted (Figure 2). At least my worst fears were proven wrong, but I was curious whether this eruption sequence is common? On a detailed literature we found no published article related to this unusual eruption sequence. As we did not come across any published article from our literature search; we did a brief review from online sources (a mother’s online group in UK Baby Centre birth club groups). This article reports a case and an online review of a few unusual eruption sequence cases which have not been published in literature before. These cases were collected in the period of 2009 to 2015. We came across a total of 33 cases of which 15 were girls and 18 were boys.
Figure 1: Intra-oral photograph showing deciduous maxillary lateral incisors erupted at 11 month and two weeks. .
Figure 2: Intra-oral photograph showing deciduous mandibular central incisors erupted after two weeks.
Table 1: Showing the respective calendar year of such cases being reported by mothers in the online forum and the gender of the children who have had this unusual eruption pattern.
Table 1 showing the respective year of such cases being reported by mothers in the online forum and the gender of the children who have had this occurrence. It was observed that males had a slight predilection in this unusual eruption order of Deciduous Maxillary laterals erupting before centrals. This unusual sequence of eruption was observed in the maxillary arch only. A few interesting correlations were found. One mother reported that the father of the baby girl also had similar Vampire teeth. Another pair of siblings both being sisters too had similar Vampire teeth! Also, few of the mothers immediately posted the eruption of maxillary centrals in a short span of time. So, we can conclude that there was no case with congenitally missing deciduous maxillary centrals reported (Table 1).
Most of children have a normal pattern of eruption sequence with a slight delay of 6 months being considered normal. Deciduous first molars erupt prior to deciduous canines in both maxillary and mandibular arches and is considered the common eruption sequence . But in some cases, there is a notable variation in erupting sequence as in above cases which might cause parental anxiety. All teeth observed to have delayed eruption were deciduous maxillary central incisors. This might have been due to heavily keratinized mucosa covering the deciduous maxillary centrals and the presence of a deeply attached labial frenum. This might delay the deciduous maxillary centrals cutting through the thick mucosa and thus erupt after the deciduous lateral incisors . Due to two cases reported by mothers in family members i.e. father-daughter and another instance of sisters there seems to be genetic predisposition . As it was seen, only 33 cases were found in online mother’s group in a period of six years. The lower number of such reported cases in the literature might be due to subsequent eruption of centrals as in the reported case of my niece. Even elders in the family must be giving timely advice that this being normal occurrence and nothing to worry about. So most of parents are not visiting a pediatric specialist and hence no reported case in available published literature! Some of deciduous teeth eruption does not follow a correct chronological sequence, due to multiple reasons such as trauma, genetic traits, thickness of mucosa over central incisor region as it requires more time to cut and erupt thorough. All these factors contribute to alterations in the normal eruption sequence of the teeth . In other cases, a delay in eruption of teeth can be a symptom of underlying health issues. Prematurely born and low birth weight babies can get their teeth late and may also have enamel defects. Some genetic conditions, such as amelogenesis imperfecta and regional odontodysplasia, can cause delay in tooth eruption and be poorly formed. Delayed tooth eruption can also be a symptom of malnutrition and a deficiency in vitamins or minerals, especially calcium and vitamin D. It could also be associated with Down’s syndrome or a hypothyroidism. Other symptoms of hypothyroidism, such as weakness, fatigue, headaches, and joint stiffness may cause baby to experience delays in walking, talking and may be overweight . So, an accurate analysis of local causes like eruption cysts , supernumerary teeth etc and systemic factors causing delay in eruption should be done by a dentist.
This case report will also bring to the notice of novice dentists that this is a normal variation in most of the cases and not something to advice unnecessary investigations and add to the parent’s anxiety rather than relieve it. If otherwise, a prompt visit to a dentist might help in arriving on a proper early diagnosis, and thus improve prognosis of any associated systemic health condition as goes the English proverb goes, “A stitch in time saves nine”!
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