"Spontaneous" degeneration of the dental pulp associated with phosphate diabetes

Prosthetic rehabilitation of a patient with X-linked hypophosphatemia using dental implants: a case report and review of the literature

BACKGROUND

X-linked hypophosphatemia is associated with a range of dental problems, many of which may result in early loss of the dentition. Most patients, but especially young adults, are likely to desire fixed prosthodontic replacements, and dental implants may be the preferred solution in many cases. The use of dental implants to rehabilitate this patient group has not been widely studied with the literature limited to a small number of case reports with limited follow-up.

CASE PRESENTATION

This case report describes the dental journey of a young adult with X-linked hypophosphatemia, his eventual tooth loss and rehabilitation with multiple dental implants. Over 10 years' follow-up of three of the fixtures is presented.

CONCLUSIONS

This case report shows a common presentation and progression of a patient with X-linked hypophosphatemia and will hopefully provide further positive evidence for the clinician to rely on when considering dental implant based treatments for such patients.

Review of the dental implications of X-linked hypophosphataemic rickets (XLHR)

OBJECTIVES

The aim of this article was to review the dental implications of X-linked hypophosphataemic rickets (XLHR) and to provide suggestions regarding the dental treatment of these patients.

MATERIALS AND METHODS

The following search items "x-linked hypophosphataemia, hypophosphataemic rickets, vitamin D-resistant rickets" were used for literature search. Only full-text articles were analysed and summarized to get an overview of the different treatments and outcomes of hypophosphataemic patients.

RESULTS

Radiographically, very large pulp chambers with an abnormally high pulp volume/tooth volume ratio, suggesting taurodontism, are often evident. The affected teeth are characterised by a thin enamel layer and dentinal defects. The gender distribution of hypophosphataemic patients is almost equal, but postpubertary males seem to show a trend to develop more severe dental symptoms of the disease. Abscesses without any signs of dental caries or trauma are frequent findings. The most often affected teeth are incisors followed by molars and premolars.

CONCLUSIONS

Treatment options include frequent dental examination, application of topical fluoride varnish and sealing of pits and fissures to prevent microbial invasion that may result in pulpitis and further endodontic complications.

CLINICAL RELEVANCE

X-linked hypophosphataemic rickets is associated with marked structural alterations of dental hard tissues and the development of multiple abscesses and sinus tracts of dental origin. Therefore, profound knowledge of the various dental implications of XLHR is required to provide these patients with the best possible treatment options.

Familial hypophosphatemic vitamin D-resistant rickets: dental findings and histologic study of teeth

A case of familial hypophosphatemic vitamin D-resistant rickets or X-linked hypophosphatemia (XLH) accompanied by specific systemic and dental findings is reported. A 15-year-old boy with XLH visited our facility complaining of a toothache in the left lower canine region. Two other family members of the patient, his younger sister and their mother, also had XLH, whereas the other 2 members, his younger brother and father, are healthy. Those with XLH show systemic signs of the disease, such as growth retardation, limb deformity, and spinal curvature disorders; however, these symptoms are more severe in the patient than in the others. The patient had multiple periodontal abscesses, but no evidence of dental caries, trauma, or periodontal disease on the corresponding teeth at the time of his oral examination. A radiographic examination showed root dysplasia and enlarged pulp chambers.A histologic examination of an extracted third molar showed marked globular dentin and an increased predentin width. The abscess was thought to be caused by pulpal infection, which came from bacterial invasion through enamel cracks and dentinal microcleavage of the teeth. The treatments provided in this case are discussed.

An unusual giant cell lesion in a child with vitamin D-resistant rickets

This paper reports the presence of a focus of giant cells in a sinus tract associated with an abscessed primary tooth in a patient with vitamin D-resistant rickets. The relevance of this giant cell lesion to the systemic disorder is discussed.

Structural deformities of deciduous teeth in patients with hypophosphatemic vitamin D-resistant rickets

Structural deformities of deciduous teeth from patients with hypophosphatemic vitamin D-resistant rickets (HVDRR) (1 male and 2 female patients) were examined by means of transmitted light microscopy, contact microradiography, and x-ray microanalysis. Freshly extracted teeth were fixed in formalin and subsequently hemisected longitudinally through the midline. One half was prepared for ground sections and the other half for decalcified sections. Neither gross nor microscopic abnormalities were present in enamel of patients with HVDRR. The concentration of calcium and phosphorus and the calcium/phosphorus ratio of the enamel of patients with HVDRR were nearly equal to those of normal teeth, although the degree of radiopacity was less in HVDRR. On the other hand, numerous microscopic abnormalities in the dentin of patients with HVDRR were found, such as interglobular dentin, wide predentin zones, and tubular defects. The concentration of phosphorus in the dentin of a patient with familial HVDRR was extremely low. Furthermore, formation of reparative dentin was observed at the pulp horn of teeth in patients with HVDRR that had been subjected to definite attrition at the corresponding dentin site.

Management of the primary dentition in vitamin D-resistant rickets

Vitamin D-resistant rickets (familial hypophosphatemia) is a systemic disease secondary to defective renal-tubular reabsorption of phosphate. The major oral manifestations are spontaneous abscesses in a caries-free dentition. Pulpotomies or extractions were frequently described in the dental literature as the therapies of choice. This article presents a new prophylactic approach utilizing zinc oxide--eugenol pulpectomies and full crown coverage in an attempt to retain the primary dentition and prevent abscess formation.

Origin, diagnosis, and treatment of the dental manifestations of vitamin D-resistant rickets: review of the literature and report of case

Previous discussions center on early diagnosis, initial treatment, and follow-up therapy for the patient with vitamin D-resistant rickets. Both the medical and dental aspects of treatment for these patients has a long-range effect on the normal developmental patterns. Although treatment is begun at an early age, some rachitic skeletal effects such as minor bowing of the legs and bossing of the skull will invariably be noticed. In patients with controlled rickets the alveolar processes undergo normal development, with apparent normal dental eruption. The poor development and calcification of the alveolus seen in the untreated patient leads to loss of the lamina dura and periodontal ligament of the teeth. Patients with resistant rickets possess a functional dentition, although not without inherent defects. Various degrees of fracture and attrition of enamel can be seen, and hypoplasia of dentin is nearly a universal result. Defects extending to the dentinoenamel junction have been shown in repeated cases. Cementum, because of its close relationship with dentin calcification, also appears abnormal. Pulp tissue may undergo abberations of physiology in resistant rickets, although further work in this respect is needed. With respect to the possible dental pathoses seen in this disease, the dental history of the patient with resistant rickets discussed in this report showed that several of the deciduous teeth, possibly the mandibular left second premolar and right first molar, and definitely the maxillary right second premolar and canine and the mandibular left canine had all undergone pulpal degeneration of apparently unknown causation. In the maxillary right second premolar and the mandibular left canine, enamel fractures were clinically and radiographically apparent. However, the maxillary right canine originally had an acute abscess with no defects other than normal, minimal wear facets. No causative factor for its necrosis could be found. Overt enamel fractures in the maxillary right second premolar and the mandibular left canine may have led to microexposures of the pulp with subsequent bacterial pulpal contamination. Suppuration present in several of the pulps when first entered during endodontic treatment, as well as chronic fistulas in several areas, support the conclusion that contamination by some means does indeed occur.