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G106(P) Premature exfoliation of primary teeth – a manifestation of systemic disease?

Background Loss of the primary dentition is a physiological process. However, changes in pattern of tooth loss may herald systemic disease. Dental trauma and non-accidental injury should also be considered. A number of cases of premature exfoliation with subsequent investigation and diagnosis are presented. Case presentations A four year old girl presented with painful, bleeding gingivae and oral ulceration. Haematological investigations revealed a raised B12 and neutrophil count of 0.16 and a diagnosis of cyclic neutropenia was confirmed. A complicating factor was dental caries which required dental extractions under general anaesthesia. Although this case didn’t present with premature exfoliation there was significant recession and mobility of the primary teeth which if left untreated could lead to exfoliation. A 2 year old female patient presented with a history of pyrexial illness, swollen gingivae and difficulty eating. On examination severely hyperplastic, atrophic erythematous gingivitis affecting the upper and lower anterior gingiva was noted. The severity of the presentation prompted a review of her recent hospitalisation investigations. A discharge summary obtained from her GP showed a neutrophil count of 0.07 × 109/L. An urgent referral to Paediatric Haematology was required for same day hospital admission. A bone marrow aspirate showed the presence of antigranulocyte antibodies in her serum leading to a diagnosis of primary autoimmune neutropenia. Siblings presented with premature exfoliation of anterior primary teeth with generalised bone loss and mobility in the remaining dentition. Blood tests revealed low vitamin D levels which were remedied with vitamin supplementation. They also showed decreased alkaline phosphatase levels and increased CRP levels. Both were diagnosed with odonto-hypophosphatasia. A 3 year old presented with premature loss of upper left central primary incisor. History revealed the child was upset, with oral bleeding and the tooth was found on a coffee table. The contralateral incisor showed signs of trauma. Clinical diagnosis is trauma however the tooth was sent to histopathology to rule out any other cause. Conclusion Premature loss of primary teeth should alert clinicians to the possibility of dental trauma, safeguarding issues or systemic involvement. Therefore, prompt referral to a Consultant in Paediatric Dentistry is indicated.