Dental manifestations of patient with Vitamin D-resistant\nrickets
A 5 year-old boy was referred to the Pediatric Dentistry Clinic with the complaint of "a\nsmall ball that appeared in the mouth". During the anamnesis, the patient was diagnosed\nas having hypophosphatemic vitamin D-resistant rickets. The child was the third twin;\nhowever, the parents as well as the siblings, did not have the metabolic disorder. The\nmedicines taken by the patient were calcitriol and phosphate supplements. He presented\nshort stature and several skeletal abnormalities.\nClinical examinations revealed fistula at the periapical region of primary maxillary\nleft lateral incisor without caries or trauma (). The patient presented complete primary dentition and none of the teeth\nexamined showed evidence of caries ().\nRadiographic examinations included periapical, panoramic and occlusal views showing pulp\nchambers enlarged, with pulp horns extending to the dentino-enamel junction, poorly\ndefined lamina dura and hypoplastic alveolar ridge (). The patient presented a large physiologic wear of the incisors,\ngeographic tongue and primary mandibular right lateral incisor (#82) and canine (#83)\nwith crown alteration (). There were\nareas of rarefaction around the apices of the primary maxillary right and left central\nincisor (#51,61), primary maxillary right and left lateral incisor (#52,62), primary\nmaxillary right and left canine (#53,63) and primary maxillary right and left first\nmolar (#54,64), primary mandibular right and left central incisor (#81,71) ( and ).\nInitially, two sections of management were performed. The treatment was divided into two\nphases: at first, the extraction of the teeth was performed: #51, 61, 81 and 71. At the\nsecond phase, endodontic treatment of the teeth: #52, 62, 53 and 63. These procedures\nwere executed with local anesthesia and rubber dam isolation. The root canals were\nsubmitted to preparation with Kerr files and dressing with paramonoclorofenol\n(Biodinâmica LTDA, Brazil) for 48 hours. Canals were filled with zinc oxid-eugenol and\niodoform paste and restored with resin glass ionomer cement (Vitremer, 3M/ESPE,\nUSA).\nDuring the aforementioned treatment, primary mandibular right first molar (#84), primary\nmaxillary right and left first molar (#54,64) and primary mandibular left second molar\n(#75) showed periapical fistula without evidence of caries or trauma in a short-term.\nThese teeth were extracted. However, the child was constantly sick and did not attend\nthe consultations. In the other teeth, the primary mandibular right second molar (#85),\nlateral incisor and canine (#82,83), primary maxillary right and left second molars\n(#55,65), primary mandibular left first molar and lateral incisor and canine\n(#74,73,72), the choice of treatment was to open the pulp chambers and make a dressing\nwith formocresol (Biodinâmica LTDA, Brazil). After a 7-day period, the dressing with\nformocresol was removed and the root instrumentation was performed and filled with zinc\noxid-eugenol and iodoform paste, afterwards the teeth were restored with resin glass\nionomer cement (Vitremer, 3M/ESPE, USA) ().\nIn order to maintain the space of primary maxillary right and left second molars and\nprimary mandibular right second molar, a fixed space-maintainer was made and cemented\nwith resin modified glass ionomer cement (Rely X, 3M/ESPE, USA) (). The postoperative clinic course was uneventful and\nafter six months of follow-up, the child did not show clinical abscesses.