orthodontic insight
Explanation for the signs and symptoms of
tooth eruption: mast cells
Solange de Oliveira Braga Franzolin1, Maria Inês Moura Campos Pardini2, Leda A. Francischone3,
Elenice Deffune2, Alberto Consolaro4,5
DOI: https://doi.org/10.1590/2177-6709.24.2.020-031.oin
This study contributes to the understanding of the mechanisms associated with signs and symptoms of tooth eruption, by investigating the presence of mast cells in pericoronal tissues during the intraosseous (Group 1) and submucosal
(Group 2) phases of eruption. We compared findings for these two groups with each other and with those for the oral
mucosa (Group 3). In each group, 14 specimens were analyzed microscopically after hematoxylin and eosin staining and
immunohistochemical analysis of c-Kit and tryptase expression. Results revealed that the number and density of mast cells is
different in follicular tissues according to the eruption phase, which may mean that: 1) masticatory trauma of the oral mucosa
and dental follicles in the submucosa may explain why reduced enamel epithelium exposes enamel to the cells of the connective tissue; 2) exposure of antigenic enamel proteins might correspond to the release of sequestered antigens, which may lead
to the interaction of IgE and a greater number of mast cells in the region; and 3) the consequent degranulation and the local
release of mediators, such as histamine, leukotrienes, prostaglandins, proteases, cytokines and growth factors, contribute to
the understanding of signs and symptoms associated with tooth eruption.
Keywords: Tooth eruption. Dental follicle. Mast cells. Odontogenesis.
Para contribuir com a compreensão dos mecanismos relacionados à sintomatologia e aos sinais associados à erupção dentária, investigou-se a presença de mastócitos nos tecidos pericoronários na fase intraóssea (Grupo 1) e submucosa (Grupo 2),
comparando-os entre si e com a mucosa bucal (Grupo 3). Em cada grupo, 14 espécimes foram analisados microscopicamente
em cortes corados com hematoxilina e eosina, e imunocitoquimicamente marcados com Ckit e Triptase. Pelos resultados
obtidos, concluiu-se que a quantidade/densidade dos mastócitos é diferente nos tecidos foliculares de acordo com a fase
de erupção, o que permite inferir que: 1) O traumatismo decorrente da mastigação sobre o conjunto “mucosa bucal com
o folículo pericoronário na submucosa” pode explicar porque o epitélio reduzido exporia o esmalte às células do tecido
conjuntivo; 2) A exposição das proteínas do esmalte com propriedades antigênicas corresponderia à liberação de antígenos
sequestrados que levariam à interação de IgE e mastócitos em número aumentado na região; e 3) A consequente degranulação e liberação de mediadores no local, como histamina, leucotrienes, prostaglandinas, proteases, citocinas e fatores de
crescimento, contribuem para a compreensão dos sinais e sintomatologia atribuídos à erupção dentária.
Palavras-chave: Erupção dentária. Folículo pericoronário. Mastócitos. Odontogênese.
1
Universidade Nove de Julho, Faculdade de Medicina (Bauru/SP, Brazil).
Universidade Estadual Paulista, Faculdade de Medicina (Botucatu/SP, Brazil).
3
Private Practice (Bauru/SP, Brazil).
4
Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).
5
Universidade de São Paulo, Faculdade de Odontologia de Ribeirão Preto, PósGraduação em Odontopediatria (Ribeirão Preto/SP, Brazil).
How to cite: FFranzolin SOB, Pardini MIMC, Francischone LA, Deffune E, Consolaro A. Explanation for the signs and symptoms of tooth eruption: mast cells. Dental Press J Orthod. 2019 Mar-Apr;24(2):20-31.
DOI: https://doi.org/10.1590/2177-6709.24.2.020-031.oin
» The authors report no commercial, proprietary or financial interest in the products
or companies described in this article.
Contact address: Alberto Consolaro
E-mail: consolaro@uol.com.br
2
© 2019 Dental Press Journal of Orthodontics
Submitted: March 01, 2019 - Revised and accepted: March 10, 2019
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Franzolin SOB, Pardini MIMC, Francischone LA, Deffune E, Consolaro A
orthodontic insight
INTRODUCTION
Tooth eruption may be divided into three phases
according to bony crypt movements: 1) pre-eruptive;
2) eruptive, or pre-functional; and 3) post-eruptive, or
functional.1
Fully formed enamel is covered with reduced
enamel epithelium. Together with the capsular connective tissue that nourishes it, it forms the dental follicle, or dental sac, which has a fundamental role in
tooth eruption, confirmed by the fact that its removal
interrupts this process.2
Dental follicles have a high concentration of chemical mediators of osteoclasis,3-6 such as:
a) Prostaglandins;
b) Epidermal growth factor (EGF);
c) Interleukin-1 (IL-1);
d) Bone morphogenetic protein 4 (BMP-4);
e) Colony-stimulating factor 1 (CSF-1);
f) Transforming growth factor (TGF-β).
They act as a cascade of molecular signs, beginning
with EGF or TGF-β1, which increases the genic expression of IL-1α in the stellate reticulum. IL-1α activates CSF-1, which takes part in the influx of monocytes in the pericoronal tissues, which differentiate
into the osteoclasts necessary for tooth eruption.2,7
Deciduous tooth eruption has already been erroneously associated with several health disorders, such as
sleep disruption, ear and cheek itching, primary herpetic gingivostomatitis, cough, croup, bronchitis, diarrhea, fever, convulsions and even death8. McDonald
and Avery9 described tooth eruption as a physiological
process, which does not justify its association with fever and systemic disorders. Fever and respiratory tract
infections in this period of life may happen at the same
time as eruption, but are not associated with it.
Inflammation of gingival tissues before the full
emergence of the crown may cause transient pain for
a few days. Other signs and symptoms believed to be
associated with this phase of eruption are irritability,
sleep disruption, gingival inflammation, salivation, diminished appetite, diarrhea, intraoral ulcers, temperature increase, need to bite objects, itching and earache.8
Pierce et al.10 conducted an experimental study
using a murine model and immunohistochemistry,
and found IgE in the follicular tissues during the
enamel maturation phase, which suggests that it is a
consequence of exposure of enamel matrix proteins
© 2019 Dental Press Journal of Orthodontics
to immunocompetent cells in the extrafollicular
connective tissue.
This local hypersensitivity reaction may explain
the frequent clinical signs found during tooth eruption. The tissues that surround the erupting tooth
accumulate inflammatory cells, especially lymphocytes11 and increased numbers of mast cells,12 evidencing that the enamel matrix proteins are sequestered and antigenic.13-17
Mast cells were first described in 1877 by Ehrlich.
They derive from pluripotential cells of the bone marrow and reside in connective tissue, predominantly
near blood vessels, nerves and subepithelial tissues.
A mature mast cell is relatively large, fusiform, polygonal or oval, measuring 15 to 20 μm, with a cytoplasm
slightly eosinophilic and full of granules loaded with
mediators. The nucleus is basophilic, slightly eccentric
and relatively large, measuring 4 to 7 μm in diameter
and having multiple chromatin agregates.18
The number of mast cells in human skin ranges
from 5,120 to 9,472 per cubic millimeter18, but they
are found in innumerable other sites, such as lungs,
bronchi, nose, adenoid glands, lymph nodes, intestines, liver, iris, heart18,19 and oral tissues.20-22 After activation, they release their granules, rich in chemical
mediators, such as histamine, proteoglycans, proteases,
bFGF, NO, MMPs, acid phosphatase and cytokines,
including interferons (IFN), TNF-α and interleukins (IL), as well as products derived from arachidonic
acid, such as prostaglandins and leukotrienes.
Because of the great variety of active pharmacological mediators in its granules, mast cells have a fundamental role in both hypersensitivity reactions and inflammation. Mast cells significantly affect independent
or IgR-dependent responses, extending its potential as
pro-inflammatory effector cells to the regulating components of the immune system and contributing to the
development and amplification of specific and unspecific inflammatory responses
The study conducted by Pierce et al10 suggests the
question about whether mast cells may be present
in dental follicles, in the intraosseous phase of tooth
eruption, in similar distribution and number to those
of the oral mucosa and of the dental follicles during the
submucosal phase. The answer to this question may
help clarify some anatomic and physiological aspects
of tooth eruption and its clinical signs and symptoms.
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orthodontic insight
Explanation for the signs and symptoms of tooth eruption: mast cells
MATERIAL AND METHODS
Sample
The tissue specimens examined in this study
were collected from 42 healthy patients and divided
into three groups:
» Group 1 – dental follicles in the intraosseous
phase of eruption: 14 surgical specimens of patients
(3 men, 11 women; ages: 15 to 21 years) with an
indication for extraction of unerupted intraosseous
tooth. After osteotomy, the dental follicle was carefully removed before extraction (Figs 1 to 3).
» Group 2 – dental follicles in the submucosal
phase of eruption: 14 surgical specimens of patients
(8 men, 6 women; ages: 6 to 19 years) with an indication for gingivectomy. The gingiva and part of the
dental follicle were removed (Figs 4 to 8).
» Group 3 – oral mucosa: 14 surgical specimens
of patients (6 men, 8 women; age: 14 to 82 years)
with an indication for removal of inflammatory fibrous hyperplasia. The oral mucosa of the specimen
margins was free of any pathological changes (Fig 9).
All the specimens were fixed in 10% formalin,
embedded in paraffin and sequentially sectioned at a
thickness of 4 μm. Tissue sections were mounted on
slides to be stained and immunolabeled.
RE
B
M
F
Figure 1 - Dental follicle in intraosseous
phase of eruption (Group 1) shows minimal number of mast cells (M – brownish
circles). In oral mucosa, mast cells are
sparse, diffusely and homogeneously
distributed (RE = reduced enamel epithelium). F = fibroblasts; B = bone; EM = epithelium of the oral mucosa (HE; 40X).
EM
© 2019 Dental Press Journal of Orthodontics
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Franzolin SOB, Pardini MIMC, Francischone LA, Deffune E, Consolaro A
orthodontic insight
Microscopic analysis
The slides were stained with hematoxylin and eosin
(HE) and photographed using light microscopy (Olympus
CH2). The criteria for analyses included the morphological
aspects of the lining epithelium of the connective tissue and
of the odontogenic epithelium of the dental follicle.
class III receptor of tyrosine-kinase family. The natural
ligand for CD117 has been called mast cell growth factor. CD117 is found in progenitor and precursor cells of
all hematopoietic lineage, but not in mature hematopoietic cells, except for mast cells.
» Tryptase (polyclonal; Chemicon International,
Inc., Billerica, MA): family of trypsin-type neutral
serum proteases, predominantly found in mast cells.
As active enzymes, tryptases in mast cells are noncovalent tetramers with 132 kDa. The determination of
mast cells using tryptases has been useful in the identification of focal or diffuse infiltrates rich in mast cells,
Immunohistochemical analysis
Tissue sections underwent two types of immunolabeling:
» CD117 or c-Kit (polyclonal; Dako Inc., Carpinteria, CA): transmembrane protein that belongs to the
RE
Figure 2 - Immunolabeling with c-Kit (CD117)
in dental follicle of tooth in intraosseous
phase of eruption (Group 1), which had a minimal number of mast cells (arrows) (RE = reduced enamel epithelium) (A = 25X, B = 40X).
B
A
RE
RE
A
© 2019 Dental Press Journal of Orthodontics
Figure 3 - Antitryptase immunolabeling of dental
follicle of tooth in intraosseous phase of eruption (Group 1), which had a minimal number of
mast cells (arrows) (RE = reduced enamel epithelium) (A = 25X, B = 40X).
B
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orthodontic insight
Explanation for the signs and symptoms of tooth eruption: mast cells
as well as of atypical mast cells with little granulation or
non-metachromatic.
Four-μm sections were mounted on slides and fixed at
o
70 C for 12 hours. Samples were deparaffinized in four
5-min xylene baths, the sections were hydrated in PBS for
five minutes, and endogenous peroxidase was blocked using 3% H2O2 (hydrogen peroxide) for five minutes. Antigen retrieval was performed in a steamer, in a pre-heated
solution of 2.1% citric acid, pH 6, for 40 min at a temperature of up to 100o C. The Dako K4001 Envision System
HRP labeled polymer antimouse was used for detection.
The slides were incubated in a refrigerator at 4o C
overnight. When removed from the refrigerator,
they were rinsed in PBS, and a 0.1% diaminobenzidine (DAB) chromogen was used for five minutes.
The sections were washed in distilled water and
counterstained with Mayer’s hematoxylin.
The number of mast cells was determined as
the mean number of cells detected in ten different microscopic fields for each specimen, using a
40X objective lens, at 140 fields for each group and
for each immunolabel 23. Therefore, 280 fields were
used for each group.
Statistical analysis
Results are reported as mean number of immunolabeled cells in the microscopic fields. The Student t
test was used to compare the two immunolabeling
methods (c-Kit and tryptase) in the same group; and
ANOVA was used for the comparisons between the
three groups. The level of significance was set at 5%
for all the analyses.
RESULTS
Microscopic analysis
Group 1 – dental follicles in the intraosseous
phase of eruption
Dental follicles had reduced enamel epithelium
with four to five layers and projections that invaded
the connective tissue (Fig 3A). On the surface, there
was a continuous cuboidal cell layer composed of reduced ameloblasts (Fig 3B). These superficial cells
had eosinophilic cytoplasm with distinct borders,
whereas their nuclei had moderately condensed chromatin. In the underlying layers, cells were spherical, and their nuclei were strongly stained. Reduced
enamel epithelium was not continuous along the sur-
Figure 4 - Harvesting of specimen for Group 2, composed of dental follicle of teeth in submucosal phase of eruption. Elliptical fragment (circle)
and surgical bed during gingivectomy.
© 2019 Dental Press Journal of Orthodontics
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orthodontic insight
face of the follicular connective tissue and had areas
where structure and organization were intact (Fig. 1).
The follicle in eleven specimens had reduced epithelium of the enamel organ. The other three specimens
had a stratified squamous epithelium with three to five
cell layers. Follicular connective tissue was loose in
some cases, mainly in the subepithelial and perivascular
spaces; in other cases, it was fibrous. Interspersed islands
and cords of odontogenic epithelium, remnants of the
dental lamina, were regularly observed. No areas of inflammatory infiltrate or exudate were found in teeth in
the intraosseous phase of eruption.
nective tissue with fragments of reduced enamel epithelium. In the oral mucosa, stratified squamous epithelium had an average of 15 to 30 cell layers, with discreet
to moderate hyperplasia. In the lamina propria and submucosa, there were sporadic polymorphonuclear and
mononuclear leukocytes. There were rare and scattered
islands of odontogenic epithelium. The number and aspect of blood vessels were normal (Figs 5 and 6).
On the internal surface of the tissue fragment of
dental follicle, the reduced enamel epithelium was
not continuous. In four specimens, the internal lining
was composed of reduced enamel epithelium; in ten,
of stratified squamous epithelium. The fibrous connective tissue of the oral mucosa was continuous with
the follicular connective tissue, with no signs of clear
borders between them. The connective tissue near the
follicular epithelium was looser and less collagenous.
» Group 2 - dental follicles in the submucosal
phase of eruption
Dental follicles had an overlying oral mucosa, lamina
propria and submucosa that contained follicular con-
RE
B
RE
M
F
EM
EM
Figure 5 - Dental follicle of teeth in submucosal phase of eruption (Group 2), which had a larger number of mast cells (M, brownish circles) (RE = reduced enamel epithelium); F = fibroblasts; B = bone; EM = epithelium of the oral mucosa (HE; 10X).
© 2019 Dental Press Journal of Orthodontics
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Explanation for the signs and symptoms of tooth eruption: mast cells
RE
RE
B
A
Figure 6 - Dental follicle of teeth in submucosal phase of eruption (Group 2), which had ulcers and enamel exposure and was disorganized (RE = reduced enamel epithelium) (HE; A = 25X, B = 40X).
vealed a marked presence of mast cells in the submucosal
connective tissue and in the dental follicle. Mean number of
mast cells in the microscopic fields was 10.96, with a standard deviation of 2.67 cells (Figs 7 and 8).
» Group 3 – In the oral mucosa, mast cells immunolabeled using c-Kit and tryptase were scattered. Mean number of mast cells per microscopic field was 4.4, with a standard deviation of 1.63 (Fig 9).
The number of mast cells (mean and standard deviation) in the three groups is shown in Table 1. There were
no significant statistic differences between immunolabeling
methods (p > 0.05). The evaluation of the same immunolabeling in the different groups, considering Group 1 and
Group 2, Group 1 and Group 3, and Group 2 and Group 3,
revealed a statistically significant difference (p < 0.05) in all
comparisons (Tab. 2).
» Group 3 – oral mucosa
Specimens in this group had stratified epithelium with
15 to 30 layers, and lamina propria was free of inflammation. Epithelium was parakeratinized and, in some areas,
moderately hyperplastic. In the oral submucosa, fibrous
connective tissue had sporadic leukocytes, but their morphology did not indicate inflammation (Fig. 9).
Immunohistochemical analysis
» Group 1 – Immunolabeling of follicular tissues in
the intraosseous phase using both c-Kit (Fig. 2) and tryptase
(Fig. 3) revealed a small number of mast cells, with some
specimens with no mast cells at all. In this group, mean
number was 0.5 cells, with a standard deviation of 0.63.
» Group 2 – Immunolabeling of dental follicles in the
submucosal phase of eruption using c-Kit and tryptase re-
© 2019 Dental Press Journal of Orthodontics
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Franzolin SOB, Pardini MIMC, Francischone LA, Deffune E, Consolaro A
orthodontic insight
EM
B
A
Figure 7 - c-Kit (CD117) immunolabeling of dental follicle of tooth in submucosal phase of eruption (Group 2), which had a large number of mast cells
(arrows) (EM = epithelium of the oral mucosa) (A = 25X, B = 40X).
EM
B
A
Figure 8 - Antitryptase immunolabeling of dental follicle of tooth in submucosal phase of eruption (Group 2), which had a few mast cells (arrows)
(EM = epithelium of the oral mucosa) (A = 25X, B = 40X).
© 2019 Dental Press Journal of Orthodontics
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Explanation for the signs and symptoms of tooth eruption: mast cells
EM
EM
A
B
C
Figure 9 - Oral mucosa (Group 3) with well distributed mast cells (arrows) in submucosa, but in smaller number than in Group 2, which was composed of follicles
of teeth under eruption in submucosal phase (EM = oral mucosa epithelium) (A = HE; 25X; B = c-Kit (CD117), 40X; C = antitryptase, 100X).
Signs and Symptoms
in
Tooth Eruption
**
**
**
discontinuity of reduced
enamel epithelium
e.g.: masticatory trauma
itching
redness/local erythema
inflammation
sialorrhea
discomfort
need to bite
enamel exposure
with antigenic proteins
IgE + mast cells
degranulation
release of
mediators
**
**
**
*
histamine
leukotrienes
prostaglandins
proteases
cytokines
growth factors
other
Figure 10 - Schematic representation of mechanism suggested to explain signs and symptoms associated with tooth eruption.
© 2019 Dental Press Journal of Orthodontics
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orthodontic insight
Table 1 - Evaluation and comparison of mean number of mast cells in the connective tissue of dental follicles (G1 and G2) and oral submucosa (G3), according to
the techniques used (c-Kit and tryptase) for each group.
immunolabeling technique
c-Kit
Tryptase
/ Groups
Mean ± SD
Mean ± SD
G1
0.51 ± 0.62
0.84 ± 0.97
0.28**
G2
10.96 ± 2.67
11.50 ± 2.43
0.59**
G3
4.40 ± 1.63
4.91 ± 1.23
0.36**
P-value*
* Student t test; values below 0.05 indicate statistically significant differences. ** no statistically significant differences.
Table 2 - Evaluation and comparison of groups G1, G2 and G3 to each other, according to the immunolabeling used (c-Kit and tryptase).
immunolabeling
Groups
P-value*
G1
G2
G3
c-Kit
0.51
10.96
4.40
< 0.0001**
Tryptase
0.84
11.50
4.91
< 0.0001**
* ANOVA; values below 0.05 indicate statistically significant differences.. ** no statistically significant differences.
DISCUSSION
The presence of IgE in dental follicles in the phase
after enamel is secreted may confirm that there is a
hypersensitivity reaction during tooth eruption, as
reported by Pierce et al.10 The detection of IgE indicates the presence of mast cells, which adapt to
specific sites and functions.18,19 They respond to immunological and inflammatory stimuli, but were
not found in the tissues of the dental follicles in the
intraosseous phase (x = 0.51 per microscopic field)
(Table 1). The epithelium of the dental follicle,
when intact and intraosseous, seems to protect the
enamel by sequestering it from the action of these
cells or of IgE.
Group 2 represented the moment of tooth eruption, the submucosal phase, during which the epithelium of the dental follicle was no longer continuous, with areas where the enamel was exposed to the
extrafollicular connective tissue. Immunolabeling of
these follicles using c-Kit and tryptase revealed a
large number of mast cells.
Pierce et al10 found IgE on the surface of ameloblasts in the post-secretory phase, suggesting that
it is a result of the exposure of enamel matrix proteins to immunocompetent cells of the extrafollicular connective tissue, which confirms the present
findings. Their study was conducted with a murine
© 2019 Dental Press Journal of Orthodontics
model, and the phases might be coincident, as they
reported that IgE was clearly observed at 15 days of
life, but was scarce at 5 days. Findings were associated
with the immunoresponse and signs and symptoms
during the emergence of teeth in the oral cavity.10-13
The analysis of mast cells revealed that the three
groups had distinct results, with differences that were not
markedly significant. Group 1 had few mast cells in only
a few specimens. These results could not be compared
with others in the literature, because the present search
did not retrieve any studies with similar methods to detect mast cells in pericoronal tissues in this phase. The intact epithelium of the dental follicle probably protects the
enamel from the action of the cells in the connective tissue, associated with immunopathological reactions.
In contrast, Group 2 had a larger number of immunolabeled mast cells. The ruptured epithelium of
the dental follicle and the exposure of enamel to the
connective tissue may attract more mast cells to the
region, because enamel has proteins that may act as
sequestered antigens.10,13
In normal oral submucosa (Group 3), the number
of mast cells was much smaller than in the connective
tissue of the dental follicles during the submucosal
phase. Masticatory trauma of oral mucosa and dental
follicles in the submucosa may explain why reduced
enamel epithelium exposes enamel to the cells of the
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Dental Press J Orthod. 2019 Mar-Apr;24(2):20-31
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Explanation for the signs and symptoms of tooth eruption: mast cells
presence of mast cells in follicular connective tissues.
3. In the submucosal phase, the number of mast cells
is significantly higher than in the intraosseous phase of
tooth eruption, and in the submucosa of the normal oral
mucosa not associated with teeth.
These results suggest that:
1. Trauma due to mastication on the set of oral mucosa and dental follicles in the submucosa may explain
why reduced enamel epithelium exposes enamel to the
cells of the connective tissue.
2. Exposure of antigenic enamel proteins might correspond to the release of sequestered antigens that would
lead to the interaction of IgE and the greater number of
mast cells in the region.
3. The consequent degranulation and the local release of mediators, such as histamine, leukotrienes,
prostaglandins, proteases, cytokines and growth factors, contribute to the understanding of signs and
symptoms assigned to tooth eruption, such as itching,
inflammation, local redness and sialorrhea.
connective tissue. These traumas may promote the
discontinuity of the reduced enamel epithelium, frequently seen in Group 2.
Exposure of antigenic enamel proteins might correspond to the release of sequestered antigens.13 Such exposure
may hypothetically lead to the interaction between IgE and
mast cells at a larger number in the region, and to the consequent degranulation and local release of mediators, such as
histamine, leukotrienes, prostaglandins, proteases, cytokines
and growth factors. This process helps the understanding, at
least partially, of the occurrence of signs and symptoms associated with tooth eruption, such as itching, inflammation,
local redness and increased salivation.
Conclusions
The results of this study suggest that:
1. The amount/density of mast cell is different in follicular tissues according the eruption phase.
2. During the intraosseous phase of eruption, immunohistochemical analyses do not reveal any marked
Author’s contribution (ORCID )
Solange O. B. Frazolin (SOBF): 0000-0002-6396-2886
Maria Inês M. C. P. (MIMCP): 0000-0001-6470-0944
Leda A. Francischone (LAF): 0000-0001-6470-0944
Elenice Deffune (ED): 0000-0002-0533-3248
Alberto Consolaro (AC): 0000-0002-5902-5646
Conception or design of the study: SOBF, AC. Data
acquisition, analysis or interpretation: SOBF, MIMCP,
LAF, ED, AC. Writing the article: SOBG, MIMCP, AC.
Critical revision of the article: SOBF, MIMCP, LAF, ED,
AC. Final approval of the article: SOBF, MIMCP, LAF,
ED, AC. Obtained funding: SOBF, MIMCP, ED, AC.
Overall responsibility: SOBF, MIMCP, LAF, ED, AC.
© 2019 Dental Press Journal of Orthodontics
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Franzolin SOB, Pardini MIMC, Francischone LA, Deffune E, Consolaro A
orthodontic insight
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