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Number and Types of Teeth Abnormalities

• Complete True Anodontia: All teeth are missing, rare, and associated with hereditary ectodermal dysplasia.
• Partial Anodontia (Congenital Missing Teeth) involves the congenital absence of one or more teeth.
• Third molars, maxillary lateral incisors, and second premolars are commonly affected by partial anodontia.
• Congenitally missing teeth are uncommon in the primary dentition.
• Affected teeth usually involve the maxillary lateral incisors.
• Oligodontia: Absence of six or more teeth.
• Hypodontia: Absence of fewer than six teeth.
• Hyperdontia: Development of an increased amount of teeth, the additional teeth are called supernumerary teeth.

Supernumerary Teeth

• They are teeth in excess of the normal number.
• Maxilla (90%) is more likely affected than the mandible (10%).
• A supernumerary tooth in the maxillary anterior incisor region is termed a mesiodens whereas an accessory fourth molar is called a distomolar or distodens.
• A posterior supernumerary tooth situated lingually or buccally to a molar tooth is termed a paramolar.
• Supplemental type supernumerary teeth have normal size and shape.
• Rudimentary supernumerary teeth have abnormal shape and smaller size.

Mesiodens

• Mesiodens are the most common supernumerary teeth.
• Found in the palatal midline between the two maxillary central incisors, almost always posterior to the normal centrals allowing them to erupt normally.
• Mesiodens are morphologically smaller with a cone-shaped crown and a short root.
• Mesiodens may be erupted, impacted, or inverted.
• The best time to remove mesiodens in the primary dentition is just before the permanent maxillary central incisors erupt.

Natal and Neonatal Teeth

• Natal teeth are present in newborns.
• Neonatal teeth arise within the first 30 days of life.
• Most (around 90%) natal and neonatal teeth are prematurely erupted deciduous teeth; around 10% are supernumerary teeth.
• Prematurely erupted primary teeth should be preserved if possible.
• Removal is indicated if the teeth are mobile and at risk for aspiration.

Macrodontia vs. Microdontia

• Macrodontia involves the presence of an unusually large tooth.
• It affects isolated teeth in the jaw, associated with hyperdontia.
• Macrodontia may be due to a systemic disease, such as pituitary gigantism.
• Microdontia involves an unusually small tooth, associated with hypodontia.
• Lateral incisors are most frequently affected (peg-shaped).
• Microdontia may be due to a systemic disease, such as pituitary dwarfism.

Tooth Shape Abnormalities

• Gemination: A partial division of a single tooth bud forms a bifid crown with one common root.
  • Gemination is commonly found in the incisor region of primary dentition.
• Fusion: A fusion of two separate tooth buds may involve the entire tooth (enamel, dentin, and cementum) or just the roots (dentin and cementum).
  • Fusion is common in the incisor region of primary dentition.
• Gemination and fusion can look similar clinically.
• The larger tooth should be counted as a single tooth.
• In gemination, the patient has a larger tooth but a normal number of teeth overall, whereas in fusion, the patient has a larger tooth, but one less tooth overall.
• Twinning is a complete division of a single tooth bud into two completely separate teeth.
• Concrescence is the union of the roots of two or more teeth caused by confluence of their cementum surfaces, believed to be related to overcrowding or trauma.
  • Concrescence is most commonly seen in maxillary second and third molars.
• Dens-in-dente (Dens invaginatus) technically means "tooth within a tooth".
• Dens-in-dente results from invagination of the inner enamel epithelium during development, most frequently involving the maxillary lateral incisors.
• In mild cases, there's an invaginated lingual pit extending into the tooth. In extreme forms, the deep invagination results in a bulbous expansion of the affected root
• The base of the pit or deep invagination is very susceptible to carious destruction, leading to pulpitis, pulpal necrosis, and inflammatory periapical disease.
• Radiographically, dens-in-dente presents as an inverted teardrop radiolucency with opaque borders.
• Dens evaginatus (central tubercle, tuberculated cusp, accessory tubercle) results from evagination of the inner enamel epithelium.
• Premolar teeth are more commonly affected specifically in the mandible.
• The accessory cusp consists of enamel and dentin, with pulp present about half of the cases.
• Clinically looks like an extra cusp in the case of posterior teeth, also known called "cusp of Carabelli."
• It’s seen as a "talon" cusp on anterior teeth (maxillary lateral and central incisors).
• Dens evaginatus is associated with another coronal anatomy variation called shovel-shaped incisors..
• Ankylosis refers to the fusion of cementum to the surrounding alveolar bone and sometimes the dentine.
• It is associated with hypodontia and may be secondary to trauma, injury, chemical or thermal irritation, or genetics.
• The mandibular primary first molar is the most commonly ankylosed tooth.
• The ankylosed tooth found in infraocclusion as the patient grows.
• Percussion produces a sharp, solid, metallic sound of the involved tooth
• Hypercementosis (Cemental Hyperplasia) refers to the accumulation of secondary cementum, usually confined to the apical half of the root.
  • It's asymptomatic and typically affects vital mandibular molars and premolars.
  • Radiographically, presents as a bulbous enlargement with a distinct, unbroken periodontal membrane space and a normal lamina dura.
• Factors that can cause hypercementosis include Paget's disease, hyperthyroidism, pituitary gigantism, supra-eruption, periodontal infection, and occlusal trauma.
• Dilaceration is an abnormal bend or curve of the root during its development, thought to result from a traumatic episode, usually to the primary dentition.
• Consistent in children with congenital ichthyosis.
• Grossly deformed teeth often require surgical removal, but extraction can result in root fracture.
• Taurodontism (Bull-like tooth) is characterized by a large, long pulp chamber with short roots, increased apico-occlusal height, bifurcation close to the apex, and lack of constriction at the cemento-enamel junction.
  • It affects permanent teeth more frequently than deciduous teeth.
• There is an increased frequency of taurodontism reported in patients with hypodontia, cleft lip, and cleft palate.
• Its unusual root shape probably results from late invagination of Hertwig's root sheath.
• No treatment is required; however, can be a complicating factor during root canal treatment procedures..
• Ectopic enamel refers to droplets of enamel or enamel pearls (enameloma) found on the roots of teeth.
• It forms when cells of Hertwig's epithelial root sheath fail to migrate away from the dentin and differentiate.
• BIfurcation or trifurcation of teeth is commonly affected.
• Radiographically, they appear as well-defined, radiopaque nodules along the root's surface.
• Cervical enamel extensions (projections) occur along the surface of dental roots.
  • Connective tissue cannot attach to enamel, these extensions have been correlated positively with localized loss of periodontal attachment with furcation involvement.
• Abrasion: Loss of tooth structure due to non-masticatory friction, such as tooth brushing, that causes a "V" shaped notch on the cervical margin and the canine/premolar area.
• Atrasive foods cause abrasion.
• Attrition: Wearing of tooth structure due to normal or excessive masticatory functions (bruxism), which leaves polished "Facets" on incisal and occlusal surfaces.
• Erosion is the loss of tooth structure due to non-mechanical means, such as in bulimic individuals who expose enamel to stomach acids.
• Abfraction occurs when a piece of enamel near the cemento-enamel junction fractures off due to flexure of the tooth during mastication.

Structural Anomalies

• Amelogenesis Imperfecta: An inherited ectodermal disorder that represents a defect in enamel formation (pulp, dentin and cementum are normal). Normal enamel formation progresses through 3 stages:
  • Enamel matrix formation
  • Mineralization of the enamel matrix (primary mineralization)
• Enamel maturation (secondary mineralization)
• Most cases of amelogenesis imperfecta are hypoplastic, hypocalcification or hypomaturation.
• Differences in inheritance patterns, clinical appearances, and radiographic features allows for the recognition of numerous subtypes of Amelogenesis Imperfecta.
• Mutations in several genes involved in enamel formation (amelogenin, enamelin, kallikrein 4, MMP20, and others) are found in multiple variations.
• Amelogenesis Imperfecta has three main types:
• Hypoplastic (Type 1): Loss of quantity of enamel but it is well mineralized and does not chip.
• Deficiency in enamel matrix can be traced to lack of differentiation of the cells of the inner enamel epithelium to ameloblasts.
• Enamel thickness is thinner than normal in focal or generalized areas.
• Crown size varies from small to normal and the teeth may lack interproximal contacts.
• Enamel thickness and color varies (from normal to opaque white-yellow-brown).
• Enamel looks normal radiographically because its radiopacity is greater than the adjacent dentin.
• Hypomaturation (Type II): Normal enamel thickness however the matrix is immature (containing residual enamel protein), so the enamel chips and abrades easily.
• Teeth vary from creamy opaque colors to yellow/brown (dentin underneath the enamel) in addition to rough surfaces.
• Teeth exhibit dental sensitivity.
• Enamel has similar radiopacity as dentin when seen radiographically. Hypocalcified (Type III):Normal quantity of enamel, but the matrix is poorly calcified (lack of enamel proteins) which causes enamel to chip and abrade easily.
• Hypocalcified enamel shows that similar clinical characteristics as the hypomature type of Amelogenesis Imperfecta.
• The enamel is less radiopaque than dentin.
• Defects in mineralization in both the hypomaturation and hypocalcifications variants.
• Distinction is hazy with a spectrum of enamel quality, and many investigators use the term hypomineralization for both variants.
• Treatment focuses on esthetics and protection of tooth tissue, using restorative procedures.
• Enamel Hypoplasia has the same characteristics as the hypoplastic type of amelogenesis imperfecta, but it is more localized.
• It is environmental, not genetic, in that it is only involves one or a few teeth.
• Defects may be affect entire tooth or shown as small pits.
• Both deciduous and permanent teeth are affected, and signs include:
  • Lack of contacts
  • Rapid breakdown of the occlusal surfaces
• Yellowish-brown stain where the tooth is worn down to dentin.
• Turner's hypoplasia affects the individual's permanent teeth, caused by a local infection or trauma to the primary precursor.
• Enamel defects vary from focal areas of white, yellow, or brown discoloration to extensive hypoplasia, involving the entire crown.
• Most common in the permanent premolars because of their relationship to the overlying deciduous molars.
• Dental Fluorosis results from the ingestion of excess fluoride, which leads to the formation of hypomineralized enamel that affects the way light is reflected causing white, chalky areas.
• Mild to moderate dental fluorosis includes white enamel spots developing to mottled (brown-and-white) discolorations, with severe cases appearing as discolored and pitted enamel.
• The severity is dose-dependent, where greater fluoride ingestion during critical periods leads to severe cases.
• In warm regions with higher water consumption, the recommenced fluoridation concentration is 0.7 ppm, whereas in temperate regions it is 1 ppm.
• Crowns of the maxillary central incisors are very important as they compete development by age 3, so fluoride intake should be very close monitored during the first 3 years of life.
• Syphilitic Hypoplasia results from congenital syphilis resulting in damaged enamel.
• Anterior teeth altered by syphilis are termed Hutchinson incisors and exhibit crowns that are shaped like straight-edge screwdrivers, whereas altered posterior teeth are termed mulberry molars.
• Dentinogenesis Imperfecta (hereditary opalescent dentin) is an autosomal dominant condition where abnormal dentin development occurs in both dentitions. There is fragile dentin and normal enamel, there will be fractures, root fractures, and translucent or opalescent teeth with colors varying from yellow/brown to grey.
• Microscopically, dentin contains fewer, but larger and irregular, dentinal tubules.
• Crowns have an excessive restriction at the CEJ resulting in the crowns having a bell or tulip shape.
• Type 1 involves a osteogenesis imperfecta, patient will have bone fractures and blue sclera.
  • Teeth show obliterated pulp chambers in primary teeth are affected more.
• Type 2 is the most common, similar to type 1 but there is no link to osteogenesis imperfecta, and the dentition is affected equally.
• Type 3 exhibits multiple pulp exposures, periapical radiolucencies, and shell like appearance. -Dentin appears thin, and the root and pulp canal appear enlarge.
• Dentin Dysplasia is an autosomal dominant disease of the dentin that is unrelated to dentinogenesis imperfecta and affects both dentitions.
• Type 1/Radicular Dysplasia: Most common, both dentitions affected with normal appearing crowns despite having increased mobility due to extremely short roots, obliterated pulp chambers (containing chevrons), and periapical radiolucencies.
• Type 2/Coronal Dysplasia: Primary teeth are opalescent and have similar features to type 1 dentinogenesis imperfecta.
• Permanent teeth can be identified due to the presence of thistle tube.
• Pulps are filled with abnormal dentin (pulp stones), but no periapical radiolucencies.
• Regional Odontodysplasia is non-hereditary/localized abnormality where all structures enamel, dentin, and pulp are affected.
• Known best due to “ghost teeth”, where radio geographically the teeth have reduced mineral and thin layers of enamel and dentin.
• Also exhibit short roots along with open apices.

Tooth Color Abnormalities

• Abnormal colorations may be extrinsic or intrinsic.
• Extrinsic stains occur with surface accumulation of an exogenous pigment that is removed with surface treatment.
• Intrinsic stains come arise from an endogenous material that is incorporated into the enamel or dentin that is no removed by prophylaxis with toothpaste or pumice.
• Extrinsic include bacterial stains, iron, tobacco, food, gingival hemorrhage, restorative materials, and medications.
• Intrinsic include: amelogenesis/dentinogenesis imperfecta, dental fluorosis, erythropoietic porphyria, hyperbilirubinemia, ochronosis, medications, trauma, localized red blood cell breakdown
• Extrinsic can be seen with chromogenic bacteria (green or black/orange), mostly seen on the labial surfaces of maxillary or lingual incisors
• Tobacco, tea, and coffee: brown discoloration of surface enamels, most often mandibular incisors.
• Medications such as fluoride and chlorhexidine causes staining.
  • Fluoride staining from the combination of stanous with bacterial causing black stains.
  • Chlorhexidine staining presents itself as interproximal stains that is yellowish brown close to the gingiva.
• Intrinsic staining includes hyperbilirubinemia causing yellow green discolorations that are normally associated with deciduous teeth but may occasionally affect 1st morlar casps.
• This includes erythroblatosis fetalis, incompatibility, and hemorrhaging.
• Trauma can also discolor the teeth (coronal discoloration) and calcífic metamorphosis often presents a yellow pulp.
• Medications such as tetracycline, can also discolor, cross the placenta/should not be used at 8 or during pregnancy.

Diagnostic and Descriptive Terminology

• Macule: Non-raised and altered in color, less than 1 cm.
• Patch: Pigmented area larger than a macule.
• Erosion: Denudation above the basal cell epithelial layer.
• Ulcer: Below the Basal layer.
• Fissure: Linear in the Epidermis (Candidiasis).
• Papule:Elevated with solid less than 1 cm
• Plaque: Elevated/flat greater 1 cm in diameter.
• Nodule: Deep with wide 1cm/
• Vesicle: Fluid filled elevation small.
• Pustule: Has pus vesicles.
• Bulla: Large with a diameter greater than one cms.
• Cyst - is when the cavity is epithelial lined, and often present.

Incisional versus Excisional Biopsy

• Incisional
• Performed for large lesions with hazardous locations.
• Is performed to identify the differential characteristics.
  • Is surgical where it is just a sample or specimen instead of being completely excavated
  • In non-healing, where malignancy can be suspected.
• Excisional:
  • Removal of the entire lesion - also includes normal tissue.
• Excisional is normally indicated where the lesion is thought to be benign, is small (less than 1 cm), and vascular.
  • The main indication for incisionals is when it is suspected that the lesion is considered to be a carcinoma, which needs more analysis.
  • Excisional are contraindicated. Can be used when there is a case of a pigmented case, where you suspect the lesions to a malignant melanoma, is small (less than 1 cm), and has blood near it.

Pigmented (Brown) Lesions

• Pigementated lesions occur if there is in increased production and over excessive proliferation
• Pigmentia occurs commonly in dark skinned people and is normally symmetrical (melanoplakia).
• Smoker's lesions is due high stimulus (benzpyrene), but does not have overgrowth of melanocytes or cause melanomas.

Melanotic Macule versus Nevus

• Melanotic macules: Most common melanotic lesions, with the most common side for them be lower lip due to a focal increase in melanosis.
• *The color from that is shown from them varies highly depending on the source .
• The overall diameter is normally around 7ml, with no sun exposure.
• Histoligucially, there are more basal melanins. But does to have malignant capacity when the transformation is new.
• Nevus: There is growth in moles on the skin due to melanocytes or nevus overgrowth.
• Normally less than 1cm and found on a hard palate or lingual mucosa
• High chance of them becoming malignant.
• Acquired moles begin to show later in life, with a dark slightly raised papule.
• Intradermal are the most common. J-unctional nevus: Rare and found within the epdermias and lamina.
• Note the pigmentation increase, change size/color

Peutz Jeghers/McCune Albright

• Peutz: Auto dominants with mucosla freckles and polyps, in jejum and ileum.
• McCune: Genetics causing café oil spots (unilateral over trunk and thighs).
• Drug induced pigmentation:
• Bismuth-heavy metal.
  • Amiodarone-blue/grey usually stimulate.
  • The first stages of treating is discontinue treatment with medication, followed by an biopsy where needed.
• B-K dysplatic Nevus Syndrome-characterized by numerous large pigmented atypical nevi where the chances of melanoma is great, with the treatment option being, for example the skin lesions.

Red Lesions

• Red Lesions consist of acute Atropic Cadisis which presents long term broad antioboics, and is presented pain.
• Cytological, smears can help identify lesions. Includes removing the medication and antifungal
• Chronic/Denture somatitis: Presents a symptmatic, it could be ill fitting, cadida.
• Angular chelitis: Multi inflamation due to iron deficiency anemia.
• It depends on the course of treatment but can be caused due to mechanical trama, vitamin B deficiency and with patients feeling burining sensations.
• And also happening after wearing face masks.
• Burning mouth syndrome: Is a common condition patients can usually get, after menopause. The overall causes an exclusion with clinical appearance being normal.
• Erytrokplakia versus Erythrolekplakia: With a persistent patch malignancy.
• Normally are symptomatic where 90 persent shows it, with severe squamous Dysplasia.
• It is best to excise them with full follow ups.
• Hereditary Syndrome where it is spider-like and usually 1-3mm.
• Earlier on, with nosebleeds(epistaxis) caused in the fragileness, the main treatment is to treat the issues along side (iron, GI bleeds).
• Hemangiomas vs vessel are different, and it occurs during the 8 weeks(1/2months) of life, and common inside. Where the vessel is in bone.
  • With 1-10 common with high tumors that is common with females-with a rare case of not seeing the presence of any tumors (hard).
  • Hemangiomas are commonly found in areas on the tongue.
  • It is recommended to differiate/distinguish hematomas, it will not blanch if an pressing tool is applied.
  • Varicose areas is where you have high acutting vasion that occurs usually by older adults/common in elder, with the best route to fix it being sclerotherapy of the site.