Developmental Defects
CC: "I thought baby teeth weren't supposed to fall out until they were 6, why did his tooth come out?" 3 year old female, mom holding tooth #O in a Ziploc bag. Root is fully intact.
What do you suspect is the cause? If you had a PCP run labs, what would you expect to see?
Hypophosphatasia, lack of serum alkaline phosphatase
A parent comes in and tells you that fluoride made their older son autistic but they're open to using it for their younger kid, only if you can tell them the three mechanisms of action of fluoride.
1) Inhibits demineralization and promotes remineralization of the tooth
2) Antibacterial- Disrupts enzyme systems (ATPases)
3) Systemic- Improves enamel crystallinity, reduces acid solubility and improves tooth morphology
A 13 year old with autism comes to BCH with no history of caries. They tell you that they only drink water, don't snack, and use fluoridatede toothpaste twice daily. Upon exam and BWs, they have no plaque and no incipient lesions. What is their caries risk and when would you repeat BWs?
I think moderate? Repeat BWs in 18-36 months for low risk. 6-12 months for anything higher?
Your patient comes in and complains of puffy gums. Medical history includes seizures, high blood pressure and rheumatoid arthritis, all of which they take medications for. Which 3 medications would you expect are contributing to the gingival hyperplasia?
1. Phenytoin/dilantin (antiepileptic)
2. Cylosporin (immunosuppressant)
3. Calcium channel blockers (antihypertensive)
18 year old frat bro presents to clinic with white plaques on the side of their tongue. They told you they recently had infection mononucleosis. What is at the top of your differential diagnosis for the lesion?
Oral hairy leukoplakia (often caused by latent EBV)
You take a panoramic and notice a child is missing their mandibular second molars. The child asks, "Doctor, can you name congenitally missing teeth from most to least common? At what stage of tooth development would this happen?"
Third molars> mandibular 2nd premolars > maxillary lateral incisors > maxillary 2nd premolars
Initiation
Medical advice page comes in that a 5 year has ingested a quarter of a tube of Crest Kids toothpaste. You do the calculations and figure out that its likely less than 8 mg/kg fluoride. What treatment do you recommend?
Slow absorption with milk, calcium carbonate, and aluminum-magnesium based antacids and observe for at least 6 hours. If symptomatic, go to ED.
If > 8 mg/kg go to ED.
Your patient's mother is pregnant and tells you that she had a dental infection last week that her dentist prescribed an antibiotic for. Which antibiotics should that dentist avoid prescribing?
Erythromycin (maternal hepatotoxicity), fluoroquinones, tetracycline (staining as early as 5th month, bone growth)
Patient with ALL presents to your clinic for a pre-SCT evaluation. He reports nocturnal pain on the lower left side. Upon radiograph you see #19 has caries into the pulp with PARL. You recommend RCT. When should the treatment be completed? Would this recommendation change if the patient was asymptomatic?
At least one week prior to immunosuppression, asymptomatic teeth can be delayed until patient is immunocompetent
Patient presents to the ED with a large swelling on the hard palate. You rule out caries as the source. The ED suspects it may have something to do with the salivary gland, but they forgot which one. What is the most common benign salivary gland tumor? The most common malignant? What salivary gland is it associated with?
Benign: Pleiomorphic adenoma
Malignant: Mucoepidermoid carcinoma
A mom points at her 8 year old's front teeth, which have white/tan creamy well demarcated lesions, and asks what are five possible causes of this?
1) Febrile illness
2) Antibiotics
3) Nutritional deficiencies
4) Preterm birth
5) Dioxin compounds in breast milk
A parent calls you and says that their child ate a tube of toothpaste. What is the toxic dose and lethal dose of fluoride, respectively?
Toxic: 5 mg/kg
Lethal: 16-32 mg/kg
You get a page from Barack Krauss in the ED for a primary tooth trauma. What is the peak age for primary tooth trauma and why is this?
Age 2-3, gross motor development stage
A 5 year old female presents to your clinic for a pre-chemo dental evaluation. When you call the oncologist, he tells you that the child has the most common primary malignant bone tumor. What type of cancer does this child have?
Osteosarcoma
- malignancy of mesenchymal cells that produce bone and osteoid
On a panoramic image for your 10 year old patient, you see multiple unilocular, well demarcated radiolucencies in the posterior mandible. When you look at the neurology note, you also see this child has a calcified falx cerebri and spina bifida. His dermatology note mentions a history of skin cancer. What is the lesion you saw on your panoramic and what medical diagnosis do you suspect for this child?
Gorlin Goltz Syndrome/Nevoid basal cell carcinoma syndrome
1) Enlarged occipitofrontal circumference
2) Mild ocular hypertelorism
3) Multiple basal cell carcinomas
4) Multiple odontogenic keratocysts of the jaws
5) Epidermoid cysts of the skin
6) Calcified falx cerebri
7) Spina bifida
8) Rib anomalities
A child presents to BCH with mottled yellow and brown enamel with pitting. Upon taking BWs, you also note taurodontism on the molars. You speak to your attending Dr. Sulyanto, who asks what developmental defect this child may have? She also asks during which of tooth development the defect occurred? She says "A++ if you can tell me how many weeks of gestation this happened in"
Amelogenesis Imperfecta Type IV (Hypoplastic/hypomaturation)
- Taurodontism with mottled yellow and brown pits
- Occurs during histodifferentiation stage (~ 11 weeks)
A parent brings their 3 year old with ECC to the clinic. They do not want to have any teeth treated. You offer SDF as an option. What are the three mechanisms of action of SDF that you can tell the parent?
1) Inhibits biofilm formation
2) Has anti-bacterial action
3) Penetrates deep into the tooth enamel and reduces its solubility
__ is more effective than ___ for maintaining long term pulp vitality for indirect pulp caps and direct pulp caps but have the same success rates for partial and complete pulpotomy
MTA, CaOH
CC: "His teeth look weird." Mom discloses that the patient has some disease where his bones break frequently, she doesn't remember the name. You look in the medical chart and see that he has Osteogenesis imperfecta. Which dental condition is associated with this and how does it present?
Dentinogenesis imperfecta type 1
- Opalescent teeth, affects primary more than permanent, type 1 collagen defect
A child presents to your clinic with a mucous filled bubble around the oral cavity. You diagnose this as a mucocele. Where would you expect to see this?
Lateral to midline on the lower lip is most common site
A patient with a history of unilateral cleft lip and palate presents to your clinic and has an extra tooth in the cleft site. What other four syndromes may present with hyperdontia?
1. Crouzon syndrome
2. Apert syndrome
3. Down syndrome
4. Gardner's syndrome
A parent calls and is concerned because their kid starts having symptoms from eating half a bottle of Prevident. What symptoms would you expect from fluoride toxicity?
-Diarrhea
-Drooling
-Eye irritation (if it gets in the eyes)
-Headache
-Abnormal levels of calcium and potassium in the blood
-Irregular or slow heartbeat
-Nausea and vomiting
-Shallow breathing
-Tremors (rhythmic movements)
-Weakness
You start working for a private practice that uses LSTR for necrotic pulp therapy. What are the three antibiotics in the 3-mix solution used?
You are paged to the ED for a patient with mouth pain. You don't see any dental caries but notice vesicles on the childs hands and feet. What is the virus causing this and where would you expect to see oral manifestation? What is the treatment recommended?
Coxsackie (enterovirus); buccal mucosa, labial mucosa and tongue lesions, palliative treatment until resolves in 7-10 days
A 8 month old African American baby presents to your clinic. Parent are worried because there is a blue swelling on his gums on the maxillary ridge that has grown in size over the past week. When you take a PA, you can see that #O and P are displaced as a result of this lesion. What is on your differential diagnosis?
Melanotic neuroectodermal tumor of infancy
(DDX might be eruption hematoma/cyst but this wouldn't displace teeth or rapidly grow)
- tumor of neural crest origin
They are frequently pigmented blue or black and are on the anterior maxilla
These lesions also rapidly expand and may displace teeth