Premature exfoliation of primary teeth in a 4-year-old child, a diagnostic dilemma

Abstract

Premature exfoliation of primary teeth is an important diagnostic event warranting urgent investigation. The majority of conditions presenting with early loss of teeth are serious and in some cases fatal. This is a case of premature exfoliation of primary teeth in a 4-yr-old female. On presentation her teeth were mobile and there was a history of gingival bleeding when biting into food. Hair loss and fatigue were also reported. Her medical history revealed she had dry skin but was otherwise fit and healthy. Extra-oral examination was unremarkable. Dental examination revealed she had a full complement of primary teeth with unusual spacing, generalised tooth mobility, halitosis and an orange extrinsic dicolouration. Her gingivae were inflamed in the 84 region. Radiographic examination revealed severe generalised bone loss. She received periodontal care including regular scaling, a short course of metronidazole, preventative advice and continued monitoring. She was also sequentially referred to the departments of Dermatology, Paediatric Haematology, Immunology, Oral Microbiology and Oral Pathology for further investigation. Underlying disorders known to cause premature tooth loss were ruled out. Two years on, there has been early exfoliation of her 54, 51, 61, 62, 64, 71, 84 and 81 with no new progressive mobility of her remaining primary teeth. The commonest causes of premature tooth loss have been eliminated including Papillion-Lefevre syndrome, Chediak-Higashi syndrome, hypophosphatasia, Langerhans' cell histiocytosis, neutropenia and leukemia. Therefore, this fit and healthy 4-yr-old has an aggressive early onset periodontal condition with associated fatigue and hair loss. Diagnosis of associated systemic conditions is not straightforward in these cases and requires multi-disciplinary input.