ZUBA HEMORRHAGE CONTROL , INFECTION PREVENTION AND APPLICATION ON ANESTHETICS IN EXODONTIA OF NATAL TEETH

Uvod: Zubi koji se pojavljuju u trenutku rođenja zovu se natalni zubi. Najčešći natalni zubi su donji mlečni sekutići.Tačan uzrok nastanka natalnih zuba nije poznat, ali se kao mogući faktori pominju infekcije, trauma, hormonska stimulacije itd.Imajući u vidu da postoji mogućnost aspiracije kao i otežana ishrana bebe, najčešće su indikovani za ekstrakciiju. Prikaz slučaja: Novorođenče staro jedan dan sa zubima u donjoj vilici poslato je na Odeljenje za dečiju stomatologiju u Thumbay u Dubaiju., u Ujedinjenim Arapskim Emiratima. Konstrukcija krunice bila je pričvršćena za desni sa mobilnošću II stepena (Millerova klasifikacija) Školjkasta gleđna struktura natalnih zuba je uklonjena parodontalnom kiretom, obazrivo, da se ne povredi zametak mlečnog sekutića. Vitamin K u dozi od 1 mg dat je IM u anterolateralni predeo butine novorođenčeta dva sata pre hirurškog tretmana.Postoperativni tok protekao je uredno Zaključak: Natalni zubi su retka pojava, međutim, nisu nepoznati kod novorođenčadi,Ekstrakcija je prva opcija tretmana, što je pre moguće, uzimajući u obzir sve komplikacije, uz obaveznu administraciju vitamina K .


Introduction
Human teeth development is a complex process resulting from sequential and reciprocal interaction between oral ectodermal and the underlying mesenchymal tissues.This interaction results in different pathways in which so many signaling mediators are used 1 .These signaling mediators have been shown to be secreted first by the oral epithelium, diffuse into the underlying ectomesenchyme and then induce expression of the transcription factors.This cross talk between the epithelium and connective tissue regulates and controls the tooth development and subsequent tooth eruption time 2 .However, the teeth sometimes, due to unknown reasons, appear early in the oral cavity.The teeth that appear at the time of birth are called Natal teeth, while the teeth erupting within first 30 days after birth are called Neonatal teeth.In addition to that, teeth erupting beyond the natal period of 30 days are usually referred to as early infancy teeth 3 .Natal teeth are most common than neonatal teeth 4 .Natal teeth have other different synonyms such as Dentitia praecox, dens connatalis, congenital teeth, fetal teeth, infancy teeth, predeciduous teeth, and precocious dentition 5,6 .Prevalence of natal teeth ranges from 1:11 to 1:30000 depending on the type of the stud and the most common natal teeth are lower primary central incisors 5,7 .Several reasons have been attributed as the cause for this condition including certain types of infection, febrile status, trauma, malnutrition, tooth germ superficial position, hormonal stimulation and family background, however the exact cause is unknown 6,8 .
It must be considered that natal and neonatal teeth are conditions of fundamental importance since their presence may lead to numerous complications.These complications can be minor complications as painful bite or bleeding nipples in case of breast feeding.However, serious complications can happen due to natal/neonatal teeth such as inhalation of the natal tooth, dehydration, malnutrition leading to low weight, small size that may lead to failure to thrive.So, early detection and treatment of these teeth are highly recommended 5,6,8 .
The crown structure was attached to the gums with grade 2 mobility (Miller's classification).As the crown structure was well attached to the gums, the possibility of aspiration was considered minimal.The same was explained to the baby's parents.They were informed that the natal teeth had to be removed if the mother felt pain or discomfort while feeding or if there was a self-inflicted injury to tongue or lips.
Two days after discharge, the parents returned back to hospital because of the mother's inability to breastfeed due to pain.After discussion with parents, it was decided Analiza krvi , uključujući kompletnu krvnu grupu, PT, INR i aPTT, je urađena i svi parametri su bili u granicama normale.Vitamin K u dozi od 1 mg dat je IM u anterolateralni predeo butine novorođenčeta dva sata pre hirurškog tretmana.
to remove the natal teeth.Blood investigation including complete blood count, PT, INR and aPTT was done and was within normal limits.Vitamin K injection 1mg IM was given in the anterolateral thigh 2hours before the procedure.
The extraction of natal teeth was performed under lidocaine infiltration anesthesia.Care was taken not to injure the underlying tooth bud and the shell like crown was removed with a periodontal curette (Figure 1).Post extraction healing was uneventful.Plain paracetamol syrup was prescribed for possible subjective symptom of pain.Patient was recalled after 2 days for review and followed up for a month.Postoperative hemostasis was achieved and the patient was dismissed after giving the postoperative instructions immediately after the achievement of hemostasis.The patient was recalled after two days for a follow up.(Figure 2).

Discussion
Most babies get their first tooth between 4 and 7 months of age.The first teeth that poke through the gums are the central incisors, which are located on the bottom front.While most infants get their first teeth months after birth, some babies are born with one or more teeth.These are called natal teeth.Natal teeth are relatively rare, occurring in about 1 out of every 2000 births 3 .
The incidence of natal and neonatal teeth has been reported in a number of studies, ranging from 1 in 50 (2%) in a series of over 2000 babies examined within 20 hours of birth in Mexico to 1 in 30000, in a summary of studies published between 1876 and 1991.Most studies however give an incidence between 1 in 2000 to 1 in 3500 live births 3,6 .The incidence probably varies between different racial groups, with some American Indian tribes reported to commonly present with natal teeth.
Natal teeth are said to be three times more common than neonatal teeth.The male to female ratio varies in different studies with some reporting a male predominance and others no difference or a female predominance.Natal and neonatal teeth are rarely seen in very premature babies 9 .
There appears to be an inherited tendency to developing natal teeth with up to 60% of cases reporting a positive family history with an autosomal dominant pattern (meaning about half the children of an affected individual are affected) 10 .
Natal teeth are associated with cleft lip/palate: 10% of children with bilateral cleft lip/palate have natal teeth and 25% of children with unilateral cleft lip/palate have natal teeth 11 .Cleft lip/palate can be a feature of a number of syndromes in which natal teeth have also been reported such as Meckel-Gruber syndrome (MIM249000) and Pierre Robin sequence (MIM261800).Furthermore, there are some syndromes in which natal teeth are a recognized feature: Ellis-van Creveld syndrome (chondroectodermal dysplasia, MIM225500), Jackson-Lawler (pachyonychia congenita 2, MIM167210), Steatocystoma multiplex with natal teeth (MIM184510) and Hallerman-Streiff (oculo-mandibulofacial syndrome with hypo-trichosis, MIM234100 ) 5 .
As treatmentis considered if teeth are luxale or because of the interference with the nasoalveolar molding appliance.Extraction (or spontaneous loss) can be complicated by the development of 'residual neonatal teeth', said to occur in approximately 9% and necessitating a second surgical procedure 12 .
Vitamin K in an important coagulation factor that is found to be deficient in newborns/neonates 13,14 .This deficiency state arises due to endogenous factors like insufficient bacterial colonization and exogenous factors such as low concentration of vitamin K in breast milk and poor placental transport 13 .Low levels of Vitamin K in neonates is known to cause vitamin K deficiency bleeding (VKDB), therefore 0.5 mg (birthweight 1500 g or less) or 1 mg (birthweight greater than 1500 g) of vitamin K is the recommended dosage administered intramuscularly to all newborns within the first 6 hours after birth for initial stabilization as approved by the Canadian pediatric Society 15 .
On evaluating the patient's laboratory report, it was observed that the aPTT was higher (44.7) when compared to the normal reference range (26.0 -40.0).A higher aPTT refers to lack of or low level of blood clotting factors.Therefore, in the present case the patient was administered an additional dose of 1mg of vitamin K IM, 2 hours prior to the extraction procedure 14 .
No antibiotic coverage was suggested prior to the extraction as the child was on breast milk.Human breast milk is a reservoir of nutrients and biologically active compounds.The most recognized immune protective components in human breast milk are immunoglobulins, IgA being present in large quantities followed by IgM and IgG.IgA provides protection against infection by blocking the contact of the pathogen with the intestinal epithelial layers and entrapping the pathogen within the mucin layers.Immune cells in the breast milk produce cytokines such as transforming growth factor beta (TGFβ), interleukin 1 (IL1) and interleukin 13 (IL13) which help in suppressing inflammation 16 .
For newborns, the amount of L.A to be administered is calculated based on the child's body weight, medical history, duration of the dental procedure, need for hemorrhage control, it should comply with the American Academy of Pediatric Dentistry (AAPD) recommendations and never exceed the maximum total dosage 17 .
The recommended dosage is 7 mg/Kg body weight for pediatric patients, in the present case the child weighed 2.5 kg, therefore, a total of 1.5 ml of L.A (2% lidocaine with adrenaline 1:100,000) was administered as infiltration.
Literature studies state that a mandibular buccal infiltration is as effective as an inferior alveolar nerve block 17 .

Conclusion
This study is about surgical treatment of natal teeth from the standpoint of hemorrhage control, infection prevention and application on anesthetics that highlights: 1.The occurrence of natal teeth is a rare case however it is not uncommon in the newborns, 2. Extraction as the first treatment choice should be performed as soon as possible considering all possible complications, 3. Vitamin K administration is a mandatory step in the treatment, 4. Proper calculation of the amount of the local anesthesia given during the treatment should be carefully determined according to the body weight of the newborn, 5. Administration of the antibiotic is not necessary in such case.

Figure 1 .
Figure 1.Clinical pictures and surgical extraction procedure of the natal teeth: A) center and lateral incisors are present from day one in the oral cavity (white arrows), B) another clinical picture showing that natal teeth are causing trauma to the upper jaw (white arrows), C) the needle and the anesthesia used in the surgical procedure, D) using periodontal curette to remove the Natal teeth.

Slika 2 .Figure 2 .
Figure 2. Follow up after surgical procedure.In this figure: I) Immediate clinical picture after the surgical procedure, II) Follow up after 2 days from the surgical procedure, III) Follow up after 4 weeks and IV) radiographic image showing tooth germ of the deciduous incisors (black asterisk).