Oral pathology Lecture#4 Other disorders of teeth We will start talking about eruption and .

shedding of the teeth .SLIDE#2 We talked about developmental changes in teeth; one of these is premature or delayed :eruption of teeth Premature eruption: natal and neonatal teeth, now natal teeth eruption happens at birth, while neonatal teeth eruption happens within .1 month after birth Now natal and neonatal are deciduous dentition ,they have enamel and dentine but the tooth germ is superficially located, the location of tooth structure is superficial, so they are very close for eruption , as a consequence they erupt prematurely .so the cause of premature eruption is the superficial location of the tooth germ. In these teeth the enamel and dentine of the crown are normal, but there is an absence of root formation, may be because of premature eruption ,and the superficial location of the tooth ,but either or the root formation is absent ,or .there is minimal root formation Prognosis: the future of those teeth either shedding by themselves, or they should be .extracted if there are any complications

The pictu re abov e: individual with a single tooth which is either natal or neonatal, its deciduous teeth that is prematurely erupted, because of superficial .location of tooth germ Now in pathology you need to understand the pathogenesis of the condition ,in oral medicine you can know that this tooth is either natal or neonatal ,and in the case of oral surgery you can determine if this tooth need to be extracted or it will be lost continuously by itself ,but in pathology you need to know the causes of natal or neonatal ,and also the general treatment out lines ,but most important the pathogenesis .So the pathogenesis here is .superficial location of tooth germ ..SLIDE#4 Now delayed eruption or retarded ..eruption From the previous lectures we could say that sometimes when you look at the patient mouth you will see that there are no teeth but when you take a radiograph you will see a lot of unerupted teeth .Now delayed :eruption is caused by

One of the students said the fibrosis of .1 (gingival and that is possible (DR.said .Crowdning of teeth so there is no space .2 In general delayed eruption may be associated :with Endocrinopathies which is the decreasing in .3 the growth hormones, in pituitary gland hormones and that may delay the teeth eruption in general, either its primary or .permanent .Nutritional deficiencies .4 Down syndrome (in which there is mental .5 .retardation and retardation in teeth eruption trumatic displacement of tooth germ, as we .6 said in premature eruption there is superficial location of tooth germ, while in delayed eruption there is dislocation in tooth .germs That means sometimes the tooth germ before it forms it may be displaced for areason or another, and this displacement means that it goes far away from eruption ,that could give us delayed eruption ,otherwise when its superficial displacement it will give premature eruption, sometimes the crown may be too big due to gemination or fusion so the space will be not enough for the tooth to erupt ,in case of cleidocranial dysplasia we said that retarded eruption is due to multiple supernumerary impacted teeth ,crowding ,loss of space ,all of these will delay the .eruption of permanent teeth ..Slide#5

.Premature loss of teeth We said that hypophosphatasia is one of the causes of premature loss, where there is decrease in the enzyme hypophosphatase and what is going on here in this case is that cementum formation is almost absent, their is no encouragement in the socket for tooth to erupt, because we all know that the PDL in normal teeth make there insertion in cementum,so in the case where there is no cementum to make insertion in there will be early loosening of teeth. what else causes ?premature loss of teeth Dentine dysplasia type1 .1 periodantal diseases and inflammation where.2 there will be pocketing and spacing around the tooth and causes loosening of the tooth like people who have PDL disease they have mobile teeth, and there will be drifting to one .side because of this mobility Dental caries will eat the tooth and there will be loss of the tooth (crown) from the oral cavity and then caries will go down to the .root and finally the tooth will be gone SLIDE#6 .Persistence of deciduous teeth Now why sometimes there will be persistence of deciduous teeth? Sometimes the child doesn't change the teeth .the permanent does not appear on 6 or even 7 years of age, ?why is that May be there is no permanent teeth at all, because we all know that shedding of

primary teeth depends on the growth of permanent dentition or the force of the permanent dentition, as one factor of shedding of deciduous teeth not the whole process caused by permanent, but the failure of eruption of permanent teeth causes the delayed in the process of shedding ,why we have failure in eruption of permanent teeth, they may be originally missing or displaced. The DR said that there is a patient came to the oral diagnosis clinic and he still having deciduous canine. The is still there but where is the (3)? It will be either horizontally impacted or displaced, it's not giving the forces of eruption so that the deciduous will not be shaded so failure of eruption. Tooth that may be displaced like max.canine, or missing like the (5).sometimes the second premolar is congenitally missing, so the (e) may still there for along time .now when all the deciduous dentition stay for a longtime than it should be? Answer: in a case like cleidocranial dysplasis .when there are a lot of mechanical causes to impact the permanent ,like ;no spaces ,supernumerary teeth etc ,as a consequence so a lot of permanent teeth will not erupt and a lot of deciduous teeth will stay there. One of the students asked could we find deciduous and .permanent tooth at the same time Answer: may be, when the tooth germ is misplaced. The lateral incisor may erupt palatally and the (b) labially, but eventually

the pressure of the permanent with the motion of the tongue will cause the deciduous to be missed because the permanent tooth tends to return to its .original area ..SLIDE#7 .Impaction of teeth ?What's the meaning of impaction Delayed eruption beyond the normal time. why ?the tooth may be impacted Gingival fibrosis .1 Loss of the space .2 Big crown .3 Abnormal angulations of the tooth may be .4 inclined mesially or distally Complications .Odontogenic tumour , odontogenic cyst Now the radiograph is your way to figure out impacted teeth, crowding, odontogenic cyst .or tumor If the problem retains deciduous teeth and we took a radiograph and all the permanent teeth are there ,no obvious problem ,no impaction no supernumerary, no mechanical problems ,then we would think about hormonal changes ,may be there is reduced level of a certain hormone that does give the drive for permanent teeth to erupt. May be, its the growth hormone that is affected, so every thing will be retarded. The teeth that are most commonly impacted; canine, third molar, premolars which are most likely to be .delayed in eruption

If I have a mandibular third molar which is impacted , I will not leave it there ,because I dont want to expose my self to odontogenic cysts ,or odontogenic tumors ,and I dont want the impacted 8 to cause pressure on my 7 the second molar, so the complication is causing pressure on the surrounding teeth, after the pressure on the surrounding teeth, and the pressure on the adjacent teeth there will be absorption of the root and later on the 7 may be extracted so we dont want to loose .adjacent teeth .SLIDE#8 .Reimpaction of teeth Now the tooth may starts eruption but stops at a certain level, and then the adjacent teeth may incline over it, this is called submerged tooth. The submerged tooth is usually the (e) which is primary second molar .what happens is that the tooth starts to erupt, and .ankylosis occurs ?What is ankylosis Answer: fusion between cementum and the bone, and you know that the PDL is normally located around the cementum. In ankylosis cementum and bone fuse without the PDL in between, so the tooth does not erupt further and as a consequence the alveolar process is not fully developed. Look at the picture :below

Submerged tooth, Submerging mandibular

This tooth is below the level of occlusion it started to erupt but at a certain level it stopped, may be due to ankylosis, the surrounding bone is not reaching the normal level, as consequence the erupting teeth tend and try to close the space. We will face this case in the clinic, usually we dont find the (5).The teeth that are mostly congenitally missing are 5, 8, and sometimes lateral incisor, when the 5 is missing it may associated with infra occlusion or retention of the deciduous tooth, so what's the ?disadvantages First it will affect the occlusion, and the food will accumulate in the spaces, periodontal diseases, caries .so submerged is a synonyms .to infra occlusion So ,my colleagues all what we have talked about is a revision for the last three lectures ,beside this is not what pathology is ,this is like apiece of cake the real pathology is later (on (wa ma 5afia kan a3tham ..SLIDE#9 ..Non-bacterial loss of tooth structure ?Now what does caries mean Its the loss of the tooth structure due to acids and these acids come from bacteria working on food particles. We have loss of tooth structure due to non-carious causes, which

include attrition, abrasion, erosion, .resorption Attrition It is the loss of tooth structure due to tooth to tooth contact. It may be physiologic, which include age. There is always tooth to tooth contact and age is one of the physiologic causes. Attrition is located on the incisal edges, occlusal surfaces of molars, and for the upper teeth palatal cusps and for .mandibular it's on the buccal cusps We talked a little pit about occlusion in dental anatomy last year and we recognized the way of occlusion, which I could describe it as the following, the buccal cusps of the upper molars located buccally and the palatal cusps of the upper molars located in the central fossa of the mandibular teeth .actually the parts that are responsible for mastication and function of the tooth are palatal cusps of upper molars with buccal cusps of lower molars, and in these places the attrition occurs, because there is a heavy load on them. What we will find on these parts are wearing facets (cup shaped,surrounded by ?enamel. Why its cup shaped not flat Answer: because the dentine is softer than enamel, so the dentine in the middle will be wearing faster than enamel and we will have a cup shape appearance of the tooth due to physiologic action of the attrition one of the factor that increases attrition is the hard

food . Look at the picture below and notice :the cup shaped appearance of the teeth

Tooth wear with a large element of (attrition (cup shape

Now the pathologic actions which increase the :attrition The habits of bruxism (clenching); putting .1 .the teeth in occlusion for along time Abnormal acclusion there will be no balance .2 .between loads on the parts of the tooth Abnormal tooth structure; abnormal enamel .3 or abnormal dentine like amelogenesis .imperfecta In amelogenesis imperfecta the tooth loss will be highly accelerated, this is pathologic not physiologic, the physiologic is only due to normal mastication. In pathologic causes there are other factors like misalignment of teeth, habits of bruxism, and the abnormal tooth structure. The response of our teeth to attrition is the formation of secondary dentine to protect the pulp, by surrounding the pulp champers with dentine. Because

when dentine is lost substances will go .directly to the pulp and cause pulpitis Now the exposed dentine will be discolored because you know that dentine relatively has higher organic material than enamel, so it will stain easily and there will be hypersensitivity due to the movement of the fluid in dentinal tubules which will cause pain. Because the tooth forms secondary dentine in the case of attrition around the pulp many people have attrition without any kind of sensitivity. Another reaction caused by attrition is the closure of dentinal tubules .to protect the pulp ..SLIDE#13 ..Abrasion Its the loss of the tooth structure due to friction of other bodies, like tooth brush, pencils, hair grips holding, pipe smoking, so its pathologic wearing of tooth due to friction .of other particles What increases the abrasion by tooth brush is the tooth paste it self if it has hard particles it will accelerate the abrasion, which type of brushing will increase the abrasion? its the .horizontal way in tooth brushing :Clinically The abrasion is wedge shaped it has sharp edges like inverted pyramid, and the dentin it self is polished and shiny from tooth .brushing The areas that carry a heavy force are the canine and premolars areas ,because of that

canine is a very important tooth ,when there is abrasion ,heavy occlusal load may induce further fraction of the enamel, this is called abfraction, so abfraction is the fracture of enamel due to flection (not sure) its type of force applied to hard structure like enamel ,enamel does not tend its brittle ,and this breakdown of enamel on heavy load areas is called flection. These pictures show abrasion ..due to wrong teeth brushing

Note that the abrasion is on the cervical third of the teeth, because of the wrong method in tooth brushing, heavy occlusal load on canine and premolar may induce fracture cervically. It's already weakened by abrasion but the .occlusal surface may be fracture Now let's talk about habitual abrasion other than tooth brushing, the pip smoker. The place where the pipe is put is loosed and it :stains in dark. Look at the picture

Look at the staining of dentine, because dentine absorbs pigment easily so .discoloration of dentine occurs Sometimes its occupational abrasion like hair grip holding or any other foreign material inserted in the mouth, all of these induce .abrasion ..SLIDE#16 .Erosion Erosion is loss of tooth structure due to chemical process other than bacterial action, the acid here is not produced by bacteria ,the acid comes from our food like Pepsi which will be in contact with labial surfaces of tooth, so we will see shallow and broad loss of tooth structure due to acidic drink .Remember its shallow and broad not sharp wedge shape with sharp angles found on the labial surfaces of max.teeth and palatal surfaces of the posterior teeth because after we drink acidic material it will go down through the whole mouth not only the anterior regions. Look at this picture the DR said it's difficult to tell if its erosion or attrition or even abrasion because we have porcelain bridges where there is no tooth to .tooth contact, so forget about this picture

Now look at the picture below here at the labial or buccal surfaces there is shallow broad loss of tooth structure
Shallow broad loss of tooth structure

Some people work at area with acidic atmosphere so the upper and lower teeth will .be eroded Pathologic causes of erosion like, continuous vomiting and you know that it's full of acids since it comes from the stomach, and it will affect the palatal aspect of the teeth, .especially the upper anterior teeth .Conditions with frequence vomiting Pregnancy* Alcohol drinking* Anorexia nervosa and bulimia nervosa* Bulimia nervosa: people eat a lot, but after they finish eating they realize that they ate a lot then they starts inducing vomiting this is not a normal case because they can't control .their apatite Anorexia nervosa: people who think they are fat but they are not they look at the mirror they see themselves very fat so they start induce vomiting, again this is not normal .the

net result is palatal erosion of the teeth because of recurrent vomiting ,and secondary dentin will form to protect the .pulp and dentinal tubules may be closed SLIDE#19 .Resorption Let's talk about root loss: the root has dentin and cementum, in resorption we have we have something related to physiologic and .pathologic Physiologic root resorption: you can't see it radio graphically, it's a continuous process .sometimes the resorption happened on the osteoclast and the then deposition, but you dont see it radio graphically .ones you see resorption radio graphically its pathologic Now the resorption may be) (.external or internal ?Why there is external root resorption Answer: most likely due to inflammation, when there is bacteria reaching the pulp the bacterial toxins and products, mediator of inflammation like chemokine and cytokine will induce osteoclast resorption,mechanical pressure, like crowding, cysts and tumor, orthodontic treatment all these may induce resorption. Sometimes heavy occlusal load on certain tooth may induce resorption or hypercementosis. Sometimes resorption is .idiopathic you can't find the causes Now you should know the location of each type of resorption,the inflammation occasionally . on the periapical regions

Other causes of resorption is due to luxation and reimplantation, sometimes the tooth goes out of its socket due to trauma, so we immediately brush it and return it to its location and this is called reimplantation, it could cause progressive resorption of the root and replace it by bone .when we reimplant the tooth acute inflammation . happens, then resorption, and deposition One of the students asked "what about the nerve and blood vessels what will happen to "them Answer: the DR said the tooth will be non vital because we do RCT at least 4 weeks after trauma to avoid necrotic products of the pulp .to go out and induce chronic inflammation The Dr was not sure if implantation causes ankylosis or not so she asked one of the students to search about this and here are some information about it I hope it is helpfulof course this will not be enough we still need our colleague research because .this is one of the trails

A study was designed to determine if avulsed permanent incisors which have been kept dry for a period and then immersed in an isotonic solution prior to implantation have an increased healing rate(perform less ankylosis) . After extraction of the teeth, the teeth of a treatment class were stored either dry, wet, Or first dry and then wet One week after reimplantation, the percentage of sites with ankylosis increased with increased dry time. Subsequent wet storage in Hanks solution (isotonic solution mimics the oral environment) decreased the frequency of ankylosis. Storage in just a wet environment For up to 60 minutes resulted in a negligible Percentage of ankylosis. It was concluded that avulsed Teeth which have been kept dry for 15 minutes or longer should be conditioned in an isotonic solution for about 30 minutes prior to reimplantation. When the dry time exceeds 30 minutes, there is a greatly increased risk of ankylosis after reimplantation. * So we conclude that ankylosis occurs but in different percentage depending on the drying time of the tooth after extraction. Reference (PEDIATRIDCE NTISTRY/ The American academy Pedodontics/ Vol 4. , No. 4/ Ankylosis of experimentally reimplanted teeth

Related to extra-alveolar period and storage environment

Lars Matsson, DDS, Odont Dr Jens Andreasen, DDS Miomir Cvek, DDS, Odont Dr Lars Granath, DDS, Odont Dr)

Now we talked about orthotreatment as mechanical cause of pressure on the teeth ,sometimes there is excessive force on the tooth so its location of resorption is apically when the cause is gone its reversible, hypercementosis occurs and the tooth become normal , so any cause of pressure may induce resorption. Look at this tooth and predict the cause?

Answer: it may be trauma which cut the blood supply and then there will be necrosis of the pulp which will induce inflammation even if there is no bacteria, so it may be trauma, orthotreatment, may be idiopathic, one of the students said that it could be dentine dysplasia and the DR answered that, if the pulp is obliterated we could think about it but in this case its not. Now for idiopathic

causes the best location is the cervical region, now ankylosis may result. SLIDE#25. Internal root resorption The pathologic resorption may start from pulpal surfaces, there is necrotic pulp, and then the pulpal inflammation starts resorping the inside of the pulp chamber and the inside of the canal, so the internal resorption starts from the inside , idiopathic type may also occurs. Look at the tooth below the pink appearance of this tooth, because there is a decrease in thickness of dentine due to internal resorption.

So you can see the shadow of the pulp through the reduced dentine thickness. SLIDE#26. External resorption of the crown.. External resorption of the crown it self is rare, if the tooth is impacted and there is a pressure in the surrounding teeth there may be resorption and even ankylosis may occur even its on the crown itself may be attached to the bone. Discoloration of the teeth SLIDE#2

The changes in the color of the tooth may be from outside or due to the structure it self like in dentinogenesis imperfecta and amelogenesis imperfecta. Lets talk about extrinsic staining in general where there is adsorption of the pigment on the surface of the tooth, like coffee, tea food pigments, the other type is chromogenic bacteria, which is a kind of bacteria which produces black pigment seen commonly in children teeth on cervical margin , another thing is the diffusion of pigment inside dentin either after tooth formation or during tooth formation. We talked about amelogenisis and dentenogenisis in details in the previous lectures; we talked about opalescent appearance of teeth due to abnormality in dentine. SLIDE#6 Diffusion of pigment after tooth formation. Suppose we have exposed dentine, look at this picture..

Notice the color of dentine, because we have exposed dentine then the pigment diffuse inside dentine, and this is called diffusion of

pigment after tooth formation. For the person in the picture does the he have formed or forming dentine? It's formed and the tooth has yellow appearance due to diffusion of pigment after tooth formation. Another reason for diffusion of pigment after root formation is pulp necrosis; its something coming from the inside, the result pulp necrosis will diffuse through dentine .and this will changes the color of the tooth, and this is a common case in the clinic, the tooth is brown in color we take a radiograph, and we will find a periapical region and we will find that the pulp is necrotic and this is the pigment that diffuse in the coronal dentine, another case is patient with amalgam filling ,so people prefer to put composite rather than amalgam fillings. all of these are discoloration after tooth formation.

(Discoloration of tooth due to amalgam filling) One of the student asked why people with RCT will have blue color around the tooth. Answer: the reason is that the pulp chamber is no totally removed during RCT, Ideally you should remove all the pulp chamber, if the dentist only opened the axis of the root canal and didnt remove the pulp chamber he would leave mesial ,distal pulp this pulp

which is left on either side of the axis will degrade and degenerate and the pigment will diffuse in dentine. Look at this picture.

The color may be due to diffusion of pigment through dentine but mostly it's due to internal root resorption. SLIDE#8 Incorporation of pigment into dental hard tissues during their formation.. Now if something happened during development of teeth, pigment may diffuse through dentine, due to disease like congenital porphyria where there is error in porphyrin metabolism which gives us red color that deposits on any tissue in the body, like bone, tooth structure and even in the urine. So this deposition will change the color of the teeth. Another thing is neonatal jaundice, some times neonates have jaundice (hyperbilirubinamia) this will deposits bilirubin every where in the body including the brain, another type jaundice is due to hemolytic anemia if this happened during tooth development the pigment will deposit inside dentine. Deposition of pigment may be in enamel or dentine but it's much more in dentine because it contains more protein and more organic substances than enamel. Look at this picture you can notice that hemolytic anemia affects the entire tooth which means

it took place for along period of time during development of all these teeth.

SLIDE#10 Congenital porphyria Congenital porphyria again there is an error in porphyrin metabolism, so there is red pigment, even in the body, urine. so the teeth will appear red to brown, darkly stained. Now why neonate jaundice is not good, because of the deposition of bilirubin in the brain in high amount which may inhibits the mental function of the individual, so they replace the whole blood. SLIDE#13.. Tetracycline pigmentation.. Its an anti biotic given for several reasons, incorporates within dentine so we should take care when we give it to our children .children below 9 should not be given this drug, because it will diffuse in dentine, appearing in horizontal bands or lines of yellow to brown which will darken with time and also pregnant ladies should not take it ,because it will cross the placenta and goes

to deciduous dentition of the neonate, the bands will fluoresce yellow under UV. The staining depends on the dose as we increase the dose the stain will become more intense. And it also depends on age according to the level at which the tooth is being formed. Look at the bands in the picture below

Fluorescent bands of tetracycline along incremental lines of coronal

Thats it Sorry for any mistake .. ** ** Done by: Bayan mrayan