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Year : 2021  |  Volume : 39  |  Issue : 1  |  Page : 101-103

Ultrasonography as a diagnostic aid for a neonate with gingival swelling in a COVID-19 neonatal intensive care unit

1 Department of Pediatric and Preventive Dentistry, Nair Hospital Dental College, Mumbai, Maharashtra, India
2 Department of Pediatrics and Neonatology, BYL Nair Hospital, Mumbai, Maharashtra, India
3 Department of Radiology, BYL Nair Hospital, Mumbai, Maharashtra, India

Date of Submission22-Dec-2020
Date of Decision25-Feb-2021
Date of Acceptance03-Mar-2021
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. Adesh Kakade
Professor and Head, Department of Pediatric and Preventive Dentistry, Nair Hospital Dental College, Dr. A. L. Nair Road, Mumbai Central - Pin Code 400 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_532_20

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COVID-19 pandemic has impacted all the aspects of life and has emerged as the biggest challenge to the health-care sector. Dental fraternity has also taken its significant impact since the transmission of disease is primarily through aerosol droplets. Management of infants with orofacial anomalies such as natal and neonatal teeth born to COVID-19-positive mothers is another challenge due to unavailability of dental facilities in the isolation wards. In such unforeseen circumstances, out-of-routine approaches such as extraoral mandibular ultrasonography were performed for the management of a congenital intraoral swelling in an infant and are being described in this case report.

Keywords: COVID-19 neonate, extraoral ultrasonography, gingival swelling, neonatal teeth

How to cite this article:
Kakade A, Deshmukh B, Agarwal A, Malik S, Shetty DS, Wade PA, Shetty A. Ultrasonography as a diagnostic aid for a neonate with gingival swelling in a COVID-19 neonatal intensive care unit. J Indian Soc Pedod Prev Dent 2021;39:101-3

How to cite this URL:
Kakade A, Deshmukh B, Agarwal A, Malik S, Shetty DS, Wade PA, Shetty A. Ultrasonography as a diagnostic aid for a neonate with gingival swelling in a COVID-19 neonatal intensive care unit. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Dec 2];39:101-3. Available from: http://www.jisppd.com/text.asp?2021/39/1/101/314370

   Introduction Top

Growth and development of a child from conception to the 1st year of life occurs by diverse milestones. Eruption of teeth is one of the developmental milestones that occur by 6 months of age in an infant's life. When this chronology of eruption of teeth is deranged, a tooth can be seen in the oral cavity at birth or during the first 30 days of life which can be denoted as natal teeth or neonatal teeth, respectively; such teeth can become a matter of concern for the clinicians as well as parents. As reported by Spouge and Feasby, the prevalence of such teeth varies from 1:2000 to 1:3500 with certain studies reporting a prevalence rate as high as 1:716.[1],[2] One of the significant concerns pertaining to natal and neonatal teeth is mobility which increases the possibility of them being swallowed or aspirated shortly after eruption in the oral cavity.

COVID-19 pandemic has emerged as one of the biggest challenges to dentists for its severity and clinical variability. Dentists being in the close proximity of the oral cavity are at a great risk for contraction and transmission of the virus. Modification of the existing protocols to minimize aerosol generation and disease transmission is the need of the hour. Intraoral radiography can elicit a strong gag reflex, coughing, and saliva secretion increasing the risk of coronavirus transmission by aerosol generation and therefore shifts the focus toward other forms of diagnostic imaging such as extraoral radiography, ultrasonography, and cone-beam computed tomography.[3]

Ultrasonographic images are produced by sending pulses of ultrasonic waves into the tissues. Keeping in mind the radiation exposure and availability of the imaging modality in a COVID care hospital, USG seems like a promising option to confirm the presence of a prematurely erupting tooth and differentiate between predeciduous and deciduous dentition. In view of concerns pertaining to the COVID-19 pandemic, out-of-the-ordinary planning to confirm the diagnosis and treat this condition was followed and is being described in this case report.

   Case Report Top

Neonates with dental problems are routinely referred to the pediatric dental outpatient department for oral examination and treatment, but since the mother was COVID-19 positive, examination of the 3-day-old infant was done in the neonatal intensive care unit of a designated COVID hospital taking all the necessary precautions and following guidelines issued by the Indian Council of Medical Research and Dental Council of India. An intraoral swelling measuring 4 mm in diameter was noted in the mandibular anterior region close to midline which upon palpation suggested the presence of a hard tissue-like structure [Figure 1]. Since the armamentarium for intraoral radiography was not available in the medical ward, an extraoral mandibular ultrasonography (LOGIQ P9 ultrasound system) was performed on the 10th day to confirm the presence and number of predeciduous and deciduous teeth [Figure 2].
Figure 1: Preoperative photo of the infant with congenital gingival swelling (frontal view)

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Figure 2: Extraoral mandibular ultrasonography performed for diagnosis

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Ultrasonogram of the mandibular symphysis region confirmed the presence of four deciduous tooth buds and one tooth-like structure measuring approximately 8 mm with a supra-alveolar location.

After obtaining consent from the parent, extraction was planned on the 13th day. Vitamin K (0.5 mg) status was confirmed from the neonatologist before extraction in order to prevent potential hemorrhage. Local anesthesia 2% lignocaine with 1:200,000 adrenaline (Lox 2% adrenaline) was administered. An incision was made on the swelling; tissue was retracted to visualize the tooth. Extraction was performed, and gentle curettage of the socket was done [Figure 3]. The procedure was well tolerated by the infant [Figure 4]. The extracted tooth had a crown with incomplete root development. The patient was discharged after 7 days when the mother tested negative for COVID-19.
Figure 3: Extracted tooth specimen with incomplete root development measuring approximately 6.5–7 mm

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Figure 4: Postoperative photo of the infant showing the extraction site

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   Discussion Top

Management of natal and neonatal teeth is a challenging task for most of the clinicians. One to ten percent of such teeth are supernumerary in origin while the remaining 90% are prematurely erupted deciduous teeth.[4],[5] The decision to maintain these teeth in the oral cavity or to extract depends on several factors. Treatment ranges from simply keeping the patient under observation to extraction in cases of advanced mobility and discomfort during lactation.

The parents were informed about all the possible complications and risks such as aspiration of tooth, difficulty in feeding, and mucosal ulceration. Keeping the patient under observation until the eruption of the tooth was taken into consideration but due to the COVID-19 pandemic, difficulty in commuting due to the countrywide lockdown, and potential risk of exposure of the newborn during follow-up visits, immediate extraction was preferred. Nevertheless, the teeth of supernumerary origin most definitely require extraction.[6] The final diagnosis in this case was that of an immature supernumerary tooth, thereby implying a poor prognosis (1966).[1]

Natal and neonatal teeth, as described by Massler and Savara,[7] are the teeth that erupt at birth or shortly thereafter. The tooth in this particular case although extra-alveolar in location since birth, had not erupted in the mouth clinically and thus cannot be called a natal or a neonatal tooth.

The peculiarity of this case report was the use of extraoral mandibular ultrasonography to confirm the diagnosis and differentiate between the predeciduous and deciduous dentition. The anechoic shadow seen on the ultrasonogram confirmed the presence of a supernumerary tooth. Ultrasonography is an alternative diagnostic imaging technique, and several studies have shown that it can be successfully used for the diagnosis of periapical lesions.[8] Thus, ultrasonography can be routinely used in dental radiology when all its advantages are taken into consideration. Ultrasonography was used as the preferred imaging modality in this case and hence can be called a working diagnostic aid.

COVID-19 pandemic has vociferated for modifications in the existing diagnostic and treatment approaches, and this case report takes an out-of-the-box approach in conforming the diagnosis as well as management of a neonate with a congenital intraoral swelling.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Spouge JD, Feasby WH. Erupted teeth in the newborn, Oral Surgery, Oral Medicine, Oral Pathology, 1966;22:198-208. doi.10.1016/0030-4220(66)90281-7.  Back to cited text no. 1
Kates GA, Needleman HL, Holmes LB. Natal and neonatal teeth: A clinical study. J Am Dent Assoc 1984;109:441-3.  Back to cited text no. 2
Ilhan B, Bayrakdar İS, Orhan K. Dental radiographic procedures during COVID-19 outbreak and normalization period: Recommendations on infection control. Oral Radiol 2020;36:395-9.  Back to cited text no. 3
de Almeida CM, Gomide MR. Prevalence of natal/neonatal teeth in cleft lip and palate infants. Cleft Palate Craniofac J 1996;33:297-9.  Back to cited text no. 4
Cunha RF, Boer FA, Torriani DD, Frossard WT. Natal and neonatal teeth: Review of the literature. Pediatr Dent 2001;23:158-62.  Back to cited text no. 5
Mhaske S, Yuwanati MB, Mhaske A, Ragavendra R, Kamath K, Saawarn S. Natal and neonatal teeth: An overview of the literature. ISRN Pediatr 2013;2013:956269.  Back to cited text no. 6
Massler M, Savara BS. Natal and neonatal teeth; a review of 24 cases reported in the literature. J Pediatr 1950;36:349-59.  Back to cited text no. 7
Arslan ZB, Demir H, Berker Yıldız D, Yaşar F. Diagnostic accuracy of panoramic radiography and ultrasonography in detecting periapical lesions using periapical radiography as a gold standard. Dentomaxillofac Radiol 2020;49:20190290.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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