A Non-Invasive Approach for Management of Riga Fede Disease by LaserPhoto-Biomodulation Therapy: A Case Report

Introduction

Neonatal teeth, a rare developmental anomaly, present unique challenges in clinical management due to their premature eruption within the first month of life.¹ While relatively uncommon, neonatal teeth occur with an incidence ranging from 1 in 2000 to 1 in 3500 births. Natal teeth, present at birth, are three times more common than neonatal teeth, which emerge during the neonatal period.^2,3

Various clinical features characterize neonatal teeth, including the potential risk of aspiration if dislodged, ulceration of the ventral surface of the tongue, feeding difficulties or refusal, weight loss, and maternal discomfort during breastfeeding due to nipple ulceration. Radiographically, neonatal teeth usually have a hollow calcified cap of enamel and dentin, which helps them distinguish from normal dentition or supernumerary teeth.⁴ Histologically, neonatal teeth may demonstrate alterations in enamel formation and pulp morphology, with varying degrees of mineralization and structural abnormalities.⁵

Etiologically, neonatal teeth may arise from genetic predispositions, endocrine disturbances, infections, nutritional deficiencies, febrile conditions during pregnancy, osteoblastic activity within the tooth germ, and superficial positioning of the tooth germ. They may be associated with syndromes, such as Ellis-van Creveld, pachyonychia congenital, and Hallerman-Streiff.⁶

Diagnosing neonatal teeth involves a comprehensive assessment, including a complete patient history, physical examination, and radiographic findings to differentiate them from normal dentition or super-numerary teeth. Treatment options vary based on factors such as tooth mobility and classification, ranging from extraction to composite restoration and prophylactic measures such as vitamin K administration to prevent hemorrhage.

To reduce the risk of hemorrhage, particularly in infants with underdeveloped commensal intestinal flora, prophylactic vitamin K administration (0.5-1.0 mg, i.m.) is recommended. This measure supports adequate proth-rombin production in the liver, minimizing potential complications during neonatal tooth extraction.^7,8

By elucidating the clinical features, diagnostic considerations, aetiology and treatment options of neonatal teeth, this case report aims to contribute to the understanding and effective management of this rare dental anomaly, ultimately improving patient outcomes and quality of care.

Case Presentation

A 22-day-old male newborn weighing 4 kg exhibited reduced eating frequency and concomitant screaming during feeding. Clinical examination identified a newborn tooth in the mandibular front area with grade 1 mobility. The presence of an ulcer 10 millimeters in width, covered with a grey-white fibrinous membrane, situated on the ventral portion of the tongue, is a specific symptom of fever disease (Figure 1).

Radiographic evaluation showed partially calcified crowns in teeth 81, 82, 71, and 72, characterized by shell-like appearances. It was confirmed that the neonatal tooth was part of normal dentition (Figure 2).

Treatment

The patient was informed about the various treatment options. Informed consent was obtained from the infant’s parents, and all ethical considerations were adhered to throughout the management.

1. Incisal Edge Smoothening: This initial step aimed to reduce discomfort and prevent further ulceration by smoothening the sharp edges of the neonatal teeth using a polishing bur was carried out.

2. Photo-Biomodulation Therapy:

• A diode laser with a wavelength of 640 nm was used at 50 mv for 60 seconds for three cycles for the ulcer on the ventral aspect of the tongue (Figure 3).
• This procedure was repeated every alternative day for a week.
• The therapy aimed to enhance tissue repair, reduce inflammation, and alleviate pain, thus promoting rapid ulcer healing and improving feeding comfort. 

Follow-Up Assessments: A follow-up assessment conducted 10 days after the initial assessment revealed a reduction in the size of the ulcers, with no reported complications and improved feeding behavior. Regular follow-up assessments were conducted to evaluate the efficacy of the treatment and monitor patient progress. Follow-up was conducted for almost 71 months until the eruption (Figure 4).

Discussion

The recurrent ulcerations of the oral mucosa are the defining characteristic of Riga-Fede disease, which is classified as a reactive traumatic mucosal illness. During continuous protrusive and retrusive motions, the mandibular incisor teeth cause the tongue to sustain repeated damage, which leads to developing this condition when it occurs.⁹ Newborns are the most likely to be affected by this disorder, and the onset of the lesions typically corresponds with the emergence of the primary teeth. It has been stated that there are several management solutions. Either by itself or in combination, they can be utilized.¹⁰

In neonatal teeth treatment, photo-biomodulation therapy is a valuable adjunct to traditional interventions such as incisal edge smoothening. The initial step of smoothening the sharp edges of the neonatal tooth helps in reducing discomfort during feeding. Following this, photo-biomodulation therapy can further enhance the healing process. By stimulating cellular activity and promoting tissue regeneration, the therapy accelerates the resolution of ulcers and promotes soft tissue healing around the affected area. Obradovic et al., demonstrated that the application of low-level laser therapy with a wavelength of 670 nm resulted in enhanced healing and collagen formation.¹¹

Photo-biomodulation therapy, also known as low-level laser therapy (LLLT), represents a novel and promising approach to the management of neonatal teeth, particularly in pediatric dentistry. This non-invasive technique involves the application of low-level laser light to biological tissues, aiming to promote tissue repair, reduce inflammation, and alleviate pain. When applied to neonatal teeth, photo-biomodulation therapy can play a significant role in facilitating the early healing of ulcers and improving feeding comfort for the infant.^12-14

One of the primary advantages of photo-biomodulation therapy in neonatal teeth treatment is its non-invasive nature, which minimizes trauma for both the infant and the parents. Unlike extraction procedures, which may be distressing for parents and carry inherent risks, photo biomodulation therapy offers a gentle and well-tolerated alternative. Kohale et al., assessed the effects of low-level laser therapy using a diode laser (InGaAsP) on patient response and wound healing, with results indicating that LLLT has the potential to expedite the process of wound healing.¹⁵

This aspect is crucial for newborns, where minimizing invasive interventions is paramount. Furthermore, radiophoto biomodulation therapy contributes to improved feeding comfort for the infant by facilitating early healing of ulcers and promoting a smoother tooth surface. Infants with neonatal teeth often experience feeding difficulties and discomfort due to sharp tooth edges and associated ulcers. Photo-biomodulation therapy helps alleviate these symptoms, enabling smoother feeding experiences for both the infant and the mother.

During the follow-up, the maternal cousin of the current case, a 3-month-old male infant, was presented with mucosal swelling in the left lower quadrant characterized by palpable unerupted tooth. In a detailed case history evaluation, it was noted that the mothers of both patients were sisters. Radiographic examination indicated teething earlier than the typical eruption time. Photo-biomodulation therapy was administered using a laser with a wavelength of 680 nm for 60 seconds per session, three times.

The hereditary nature of neonatal teeth is supported by numerous studies, indicating a substantial genetic predisposition. The familial case presented here, with a history of neonatal teeth in both kids, reinforces the autosomal dominant inheritance pattern hypothesis. Genetic counselling was provided to the family, discussing the likelihood of recurrence in future offspring. The successful management of neonatal teeth complications using PBM therapy, in this case, highlights its potential as a non-invasive treatment option.

Both cases demonstrated significant improvement in symptoms and overall patient comfort following photo-biomodulation therapy. The combined treatment of incisal edge smoothening in the first case proved to be a better treatment option than invasive treatment. These case reports contribute to the growing evidence supporting the efficacy of photo-biomodulation therapy in neonatal teeth management. Future research, including long-term studies, is necessary to establish standardized treatment protocols further and validate the benefits observed in these cases.

By documenting these cases and outlining the methodology employed, we aim to enhance the understanding and management of neonatal teeth, ultimately improving patient outcomes and quality of care. While photo-biomodulation therapy in neonatal teeth treatment represents a promising approach, further research is warranted to fully elucidate its efficacy and optimal protocols. Long-term studies evaluating the outcomes of this intervention, including its impact on tooth development and patient comfort, are necessary to establish its place in clinical practice. Nevertheless, as a non-invasive and potentially beneficial adjunct therapy, photo-biomodulation holds promise in improving the management of neonatal teeth and enhancing the overall experience for both infants and parents.

Conclusion

Managing neonatal teeth requires a thorough approach to diagnosis and treatment to address potential complications effectively. Our cases demonstrate successful outcomes with interventions like incisal edge smoothening and photo-biomodulation therapy, resolving symptoms and promoting healing. Early detection and tailored management are essential for optimal outcomes. Further research is needed to understand the long-term implications of neonatal teeth better. This report contributes valuable insights to improve clinical care for affected infants and their families.

Conflict of Interest

Nil