Stamfelj I, Jan J, Cvetko E, Gašperšic D Size, ultrastructure, and microhardness of natal teeth with agenesis of permanent successors. Ann Anat. 2010; 19:220-226 https://doi.org/10.1016/j.aanat.2010.05.003
Zhu J, King D Natal and neonatal teeth. ASDC J Dent Child. 1995; 62:123-128
Cunha RF, Boer FAC, Torriani DD Natal and neonatal teeth: review of the literature. Pediatr Dent. 2001; 23:158-162
Gladen BC, Taylor JS, Wu YC Dermatological findings in children exposed transplacentally to heat-degraded polychlorinated biphenyls in Taiwan. Br J Dermatol. 1990; 122:799-808 https://doi.org/10.1111/j.1365-2133.1990.tb06269.x
Samuel SS, Ross BJ, Rebekah G, Koshy S Natal and neonatal teeth: a tertiary care experience. Contemp Clin Dent. 2018; 9:218-222 https://doi.org/10.4103/ccd.ccd_814_17
Ooshima T, Mihara J, Saito T, Sobue S Eruption of tooth-like structure following the exfoliation of natal tooth: report of case. ASDC J Dent Child. 1986; 53:275-278
Chowdhary S, Bukoye B, Bhansali AM Risk of topical anesthetic-induced methemoglobinemia: a 10-year retrospective case-control study. JAMA Intern Med. 2013; 173:771-776 https://doi.org/10.1001/jamainternmed.2013.75
Barash M, Reich KA, Rademaker D Lidocaineinduced methemoglobinemia: a clinical reminder. J Am Osteopath Assoc. 2015; 115:94-98 https://doi.org/10.7556/jaoa.2015.020
Rusmah M Natal and neonatal teeth: a clinical and histological study. J Clin Pediatr Dent. 1991; 15:251-253
Nedley MP, Stanley RT, Cohen DM Extraction of natal and neonatal teeth can leave odontogenic remnants. Pediatr Dent. 1995; 17
Natal and neonatal teeth: A case series and management flow chart Ka Hey Christy Chan Isabelle Holroyd Alexandra Lyne Dental Update 2025 52:5, 326-330.
Authors
Ka Hey ChristyChan
BDS, MFDS, Dental Core Trainee, Paediatric Dentistry Department, Royal National ENT and Eastman Dental Hospitals, London; Oral and Maxillofacial Surgery Department, King's College Hospital, London.
Natal and neonatal teeth newborns have a prevalence range of 1:2000–3500 live births. Depending on the extent of consequent mobility, natal and neonatal teeth can pose a risk of aspiration, or cause trauma to the mother during nursing or intra-oral ulceration in the infant. A retrospective audit of paediatric dentistry clinics was conducted covering December 2019 to March 2023, identifying infants who were referred shortly after birth (up to 3 months of age). Thirty infants were identified with a range of oral diagnoses. A majority had natal or neonatal teeth (n=19), followed by soft tissue anomalies such as eruption cyst, Bohn's nodules, Epstein's pearls, and an alveolar notch. Natal and neonatal teeth are rare, but can be distressing for parents. Cases were managed with reassurance and monitoring, or extraction of natal/neonatal teeth in certain circumstances. A management flow chart is presented to help neonatal teams and general dental practitioners to determine the most appropriate course of action.
CPD/Clinical Relevance:
Depending on the extent of mobility, natal and neonatal teeth can pose a risk of aspiration or result in trauma to the mother during nursing.
Article
Natal teeth are teeth present at birth, while neonatal teeth are those that erupt within the first month of life.1 Natal and neonatal teeth are uncommon findings, with a prevalence range of 1:2000–3500 live births.2 Their prevalence has been reported to be higher in certain populations, particularly among Chinese infants (to 1991).3 Natal teeth are three times more common than neonatal teeth, and are slightly more prevalent in girls.2,4
Over 90% of natal and neonatal teeth are premature eruption of deciduous teeth, with less than 10% supernumerary.2 According to Bodenhoff and Gorlin's findings, 85% of natal teeth are lower incisors, 11% are maxillary incisors, with canines and molars accounting for the remaining 4%.5
The exact aetiology of natal teeth and neonatal teeth is unknown.2 It has been suggested that the existence of natal teeth could be related to superficial positioning of the tooth germs, an accelerated pattern of dental development or increased resorption of overlying bone.6,7 It may also be a normal variation in dental development.
A positive family history has been reported in 8–62% of cases, with inheritance of an autosomal dominant gene.8,9 Suggested causative factors include endocrine disturbances, malnutrition, congenital syphilis, febrile episodes and exposure to environmental toxins during pregnancy.10,11 Natal teeth have also been reported in association with various syndromes such as cleft lip and palate, ectodermal dysplasia, craniofacial dysostosis and Pierre Robin syndrome.4
Natal and neonatal teeth generally have limited periodontal attachment owing to a lack of root formation or bony support and, depending on the extent of consequent mobility, partially erupted teeth can pose a risk of aspiration.1
Natal or neonatal teeth with sharp edges can result in trauma to the mother during nursing or intra-oral ulceration in the infant, typically to the ventral surface of the tongue, known as Riga–Fede.12
Teeth with severe mobility and a risk of aspiration will require extraction.13. Any sharp edge resulting in difficulty in nursing, soft tissue trauma or Riga–Fede may require smoothing or extraction.14 Decisions regarding the management of prematurely erupted deciduous teeth should be made on an individual basis.1
This article presents a case series of infants referred for abnormal oral or dental findings shortly after birth, and summarizes the presentation and management of various oral findings in the newborn.
Material and methods
A retrospective audit of paediatric dentistry clinics from December 2019 to March 2023 was conducted at the Royal National ENT and Eastman Dental Hospital in London. Clinical notes of all infants (aged up to 12 months) referred to the Paediatric Dentistry Department during this period were reviewed.
The data collected included sex, patient age at referral and at the first paediatric dentistry consultation, referral source, significant pregnancy, birth, medical history, oral features, diagnosis, clinical features, management and issues noted during follow-up.
Results
A total of 30 infants were referred and assessed between December 2019 and March 2023. The most common diagnosis was natal teeth (n=12), neonatal teeth (n=7), eruption cysts (n=5), Bohn's nodules (n=3), Epstein's pearls (n=2) and alveolar notching (n=1).
The characteristics of the 19 patients with natal and neonatal teeth are presented in Table 1.
Demographics/feature
Findings
Number of patients
Average age at time of referral (range) in days
8 days (range 0–54 days)
Gestational age
>40 weeks
5
>39 weeks (+0–6 days)
2
>38 weeks (+0–6 days)
3
>37 weeks (+0–6 days)
2
>36 weeks
1
=28 weeks + 4 days
2 (twins)
Not reported
4
Birth gender
Males
10
Females
9
Number of teeth
Single tooth
12
Multiple teeth
7
Position (and laterality) of teeth
26 in lower central incisor position (14 right side, 11 left side, 1 not reported)
Two in upper incisor position (1 left, 1 right)
Management
16 teeth extracted
12 teeth monitored/no treatment
Out of the 19 babies, 18 were referred to the dental service by their maternity or neonatal team from five hospitals in central and north London. One patient referral was made at 8 weeks of age by a local dentist.
Reported issues in the medical, pregnancy or birth history included preterm birth (n=3), suspected sepsis (n=3), jaundice (n=2), fetal bradycardia (n=2), low birthweight (n=1), respiratory distress (n=1), pulmonary haemorrhage (n=1), anaemia (n=1), cyanosis (n=1) and polycythaemia (n=1).
A family history of natal or neonatal teeth was reported in five cases; 57% (n=16) of teeth were extracted, all with fingers and gauze and either no local anaesthetic (LA) or topical LA only (lidocaine 5% gingival gel).
The indications for extraction of natal and neonatal teeth included: perceived airway risk owing to mobility (example shown in Figure 1); maternal discomfort or trauma to the nipple on breastfeeding; and oral ulceration caused to the tooth by conditions such as Riga-Fede (example shown in Figure 2).
Figure 1. Natal teeth, assumed to be the lower central incisors, which were excessively mobile on clinical examination and felt to be an aspiration risk. The constant mobility of these teeth during feeding was felt to be the cause of the white-yellow inflammatory change in the labial gingivae.Figure 2. Riga-Fede on the ventral surface of the tongue in a 31-day old patient, with a natal tooth in the lower right central incisor position.
Of 28 natal and neonatal teeth, 10 were extracted at the first visit and 18 left to be monitored. Of the teeth that were monitored, six went on to cause mobility or concerns later, and were extracted at a follow-up appointment.
Figure 3 shows a 13-day-old patient with two natal teeth, assumed to be the lower central incisors, that were initially partially erupted, firm and not causing the baby or mother any discomfort. The mother contacted the department and was seen again a week later, as the tooth in the lower right central incisor position had erupted further and was now mobile (Figure 4). The tooth was extracted at this follow-up visit as it posed an airway risk. The natal tooth in the lower left incisor region remained partially erupted and was monitored.
Figure 3. Partially erupted natal teeth of a 13-day-old patient. Two teeth are visible.Figure 4. The same patient 7 days later, showing further eruption of the lower right incisor.
Of the 16 extracted teeth, one post-operative complication was reported. Figure 5 shows a case where a white plaque developed in the area of the extracted teeth. The neonatal intensive care unit re-referred the patient 10 days after the extractions, thinking that these plaques might be new teeth forming. The patient was reviewed on the ward and the family reassured that this is a variation of normal soft tissue healing. They were reviewed 3 months later, and the area had healed to normal pink gingivae, causing no further concern (Figure 6).
Figure 5. Photograph showing the extraction site of two neonatal teeth 2 weeks after the procedure.Figure 6. Photographs showing the extraction site of two neonatal teeth 3 months after the procedure.
All the parents or patients with natal and neonatal teeth were advised that these teeth were presumed to be incisors in the normal primary dentition series.
Discussion
Oral abnormalities including natal and neonatal teeth are rare but can be a source of distress for the neonatal team and family.
The characteristics of the patients in this study are consistent with those in previous studies. For example, the almost equal split of male and female babies was also found by Samuel et al in 2018 (male:female ratio of 5:6).15 They also found a positive family history in 24% of cases (n=8/33); which is similar to the 26% (n=5/19) in our study.
Samuel et al reported an association between natal teeth and several medical conditions, including Down syndrome, Carpenter syndrome, Aicardi-Goutières syndrome and hypothyroidism.15 Notably, both Down syndrome and hypothyroidism are typically linked to delayed tooth eruption rather than early eruption.
The sample of patients in this study had no diagnosed syndromes and this may be owing to the small sample size, as well as the consideration that children in the UK with severe craniofacial syndromes are more likely to have their care transferred to a specialist craniofacial service, which would involve an in-house dental team.
Similarly, natal and neonatal teeth have also been associated in children with cleft lip and palate (CLP).16 In this case series, there were no children with CLP; this is because specialist medical and dental care is provided for babies born with CLP in the UK at designated hub-and-spoke centres.17
In this case series, 57% of teeth were extracted, which is similar to Samuel et al's findings at 65%.15
Both studies recorded common indications for extractions, including instances of traumatic injury to the baby's tongue or maternal breast leading to feeding difficulties, as well as cases involving mobility with a perceived risk of aspiration.6
However, there is no literature documenting infants aspirating or choking on a natal or neonatal tooth. Cases of spontaneous tooth exfoliation have been documented, so aspiration remains a theoretical but serious potential risk.18 In this study, there was a single case where the patient's mother reported a spontaneous exfoliation of a neonatal tooth before the patient was assessed.
In routine dental extractions, local anaesthetic infiltrations around the tooth are required before the procedure. However, in newborn babies, attempting routine local anaesthetic injections is not advisable for the safety of the child and operator. In addition, natal and neonatal teeth are generally mobile, with no root in alveolar bone so local anaesthetic does not provide additional clinical benefit.
The use of topical local anaesthetic can be controversial. Methaemoglobinaemia, defined as an increase in oxidized haemoglobin resulting in a reduction of oxygen-carrying capacity, is a rare but serious known complication of topical anaesthetic use.19
It has been suggested that neonates, often having underdeveloped hepatic and renal function, are at increased risk of methaemoglobinaemia.20 Therefore, despite the overall low prevalence of methemoglobinemia, given its potential severity, the risks and benefits of the use of topical anaesthetics should be carefully considered.19
Dental forceps that are used in routine extractions are bulky in a newborn's mouth, and often eschewed in favour of extraction with fingers only. A thin layer of gauze held in the fingers can be used to protect the airway during extraction, as well as provide some grip on the tooth with the fingers.
If dental forceps are selected as the extraction instrument, using gauze can be beneficial. The gauze not only helps protect the airway but also improves the grip of the forceps, facilitating a safer and more controlled extraction process.
Previous literature has suggested that any extractions should be delayed until the baby is 10 days old to avoid the risk of bleeding in a newborn.21 This was suggested because of the time needed for the newborn to start producing vitamin K.
However, vitamin K injections are usually given to newborns in the UK soon after birth. Therefore, confirming that the child has received this injection before performing any extractions is advisable. In this case series, two babies had extractions before 10 days of age, with no reported bleeding issues postoperatively.
In cases of nipple or tongue trauma from the sharp incisal edge of the tooth, an alternative to extraction is to smooth this sharp edge. This was not offered to any patients in this series, owing to the risk of iatrogenic damage to the baby by using a large dental handpiece in their mouth. One mother elected to use nipple guards to prevent nipple trauma during breastfeeding as an alternative to tooth extraction.
All the babies in this case series were offered follow-up, either by booking a routine 3- or 6-month outpatient appointment or being placed on open access, which allows the parents to contact the dental service if they feel follow-up is needed.
In the long term, these children will need routine dental care with their dentist, and it is expected that the natal or neonatal teeth are normal teeth in the primary dentition.2
Patients were warned about the possibility of a tooth root continuing to grow in the area of the extracted natal or neonatal tooth, as root stem cells may be left behind in the gingivae after extraction.22
A management flowchart for natal and neonatal teeth is shown in Figure 7. The flowchart should be used separately for each tooth.
Figure 7. Management flow chart for babies with natal and neonatal teeth.
Key points
Natal and neonatal teeth are rare, but can cause distress for new parents;
Natal and neonatal teeth are thought to be the premature eruption of the normal deciduous teeth, most commonly the lower central incisors;
Natal and neonatal teeth can be monitored or extracted if they are felt to be excessively mobile or causing trauma to the infant's tongue or mother's nipple on breastfeeding.
