Review Reports - <i>Dentinogenesis Imperfecta</i> in Primary Dentition: Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting report of a child affected by dentinogenesis imperfecta, a hereditary dentin defect which compromises tooth structure, aesthetics and function.

Line 176, please improve reference.

This report is well written and addresses a highly relevant multidisciplinary topic that extends beyond the purely clinical management of pediatric dental conditions. In particular, the manuscript appropriately highlights not only the therapeutic aspects of pediatric treatment but also the psychological, social, and aesthetic implications associated with dental alterations in young patients. Such a comprehensive perspective is particularly valuable, as oral conditions in the pediatric population can significantly affect self-esteem, social interaction, and overall quality of life.

The clinical case is clearly and thoroughly described, allowing the reader to follow the diagnostic reasoning and therapeutic decision-making process in a structured and coherent manner. I particularly appreciate the authors’ attention to detail in outlining the stepwise therapeutic approach, which initially prioritizes conservative management and subsequently progresses toward interventions aimed at restoring aesthetic harmony. This approach reflects an appropriate and patient-centered clinical strategy, especially in the context of pediatric care, where minimally invasive and function-preserving treatments should be prioritized whenever possible.

Furthermore, the inclusion of a dedicated section discussing the limitations of the study is commendable, as it demonstrates methodological transparency and scientific rigor. By acknowledging the inherent limitations of a single-case report, the authors appropriately contextualize their findings while still contributing valuable clinical insights to the existing literature.

Overall, this manuscript provides a meaningful contribution to the field by emphasizing the importance of an integrated therapeutic approach that considers the clinical, aesthetic, and psychosocial dimensions of pediatric dental care.

Author Response

For research article: Dentinogenesis imperfecta in primary dentition: case report

Response to Reviewer 1 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
2. Questions for General Evaluation	Reviewer’s Evaluation	Response and Revisions
Does the introduction provide sufficient background and include all relevant references?	Yes
Are all the cited references relevant to the research?	Yes
Is the research design appropriate?	Yes
Are the methods adequately described?	Yes
Are the results clearly presented?	Yes
Are the conclusions supported by the results?	Yes
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: Line 176, please improve reference.
Response 1: We thank the reviewer for this comment. The reference has been corrected. Line 179

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, your manuscript covers a rare and clinically important topic in paediatric dentistry. The longitudinal follow-up, emphasis on asymptomatic progression, and inclusion of psychosocial factors are significant strengths. The case is particularly educational, showing how dentinogenesis imperfecta in primary teeth can develop with few clinical symptoms and highlighting the importance of radiographic monitoring. The discussion is well integrated with current literature.

However, the manuscript needs revision to enhance its suitability for publication.

The manuscript indicates that the provisional diagnosis relied on clinical presentation and family history, with possible differential diagnoses including AI, OI, and medication-induced discoloration. However, the final diagnostic reasoning isn't fully explicit. It is important to clarify how the diagnosis of dentinogenesis imperfecta was established clinically, which criteria helped exclude the other main differential diagnoses, and whether any genetic consultation or systemic evaluation was performed or considered. This clarification is crucial, given that the discussion and conclusion imply examining potential syndromic associations, especially osteogenesis imperfecta.

The therapeutic rationale requires a clearer explanation, especially regarding the chosen restorative options. The manuscript describes a conservative approach, including sealant application on second primary molars and subsequent direct composite veneers for the maxillary incisors, mainly for psychosocial reasons. While this is understandable, the choice to avoid full-coverage restorations on posterior teeth needs a more detailed explanation, particularly since later discussion indicates that stainless steel crowns are often recommended in DI to protect dental structures and maintain occlusion stability. The manuscript should better align the management approach in this case with the existing literature and guidelines.

One strength of the paper is its recognition of uncertainty and its avoidance of making strong causal claims about the later pathology observed in teeth 64 and 84. Nevertheless, this caution should be applied consistently throughout the case presentation and discussion. In several instances, the wording could be more precise to prevent implying that one management option would necessarily have prevented the observed outcomes. The current version is close, but some sentences would benefit from more careful phrasing regarding prognosis, restoration performance, and the protective role of veneers.

The discussion is broad and generally helpful, but some sections feel more descriptive than analytical. The comparison with previous case reports is a valuable addition, but the manuscript would be improved if the authors integrated the clinical implications more directly: for example, clarifying what this case specifically adds beyond illustrating longitudinal asymptomatic pathology, and how it influences the timing of radiographic review, restorative decisions, and communication with caregivers.

The care timeline could be more straightforward. As the case covers multiple years, adding a concise summary table or a simplified chronological outline of visits, radiographic findings, interventions, and outcomes would enhance clarity. This would help readers better grasp the long-term aspects of the report. While a chronology is present, it feels scattered across various sections.

Overall, this case report offers valuable clinical insights, useful follow-up, and educational content. However, it would benefit from minor revisions to better explain the diagnosis, clarify the treatment rationale, enhance the discussion, and address some presentation issues before publication.

Author Response

For research article: Dentinogenesis imperfecta in primary dentition: case report

Response to Reviewer 2 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
2. Questions for General Evaluation	Reviewer’s Evaluation	Response and Revisions
Does the introduction provide sufficient background and include all relevant references?	Can be improved
Are all the cited references relevant to the research?	Yes
Is the research design appropriate?	Yes
Are the methods adequately described?	Can be improved
Are the results clearly presented?	Yes
Are the conclusions supported by the results?	Yes
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: It is important to clarify how the diagnosis of dentinogenesis imperfecta was established clinically, which criteria helped exclude the other main differential diagnoses, and whether any genetic consultation or systemic evaluation was performed or considered. This clarification is crucial, given that the discussion and conclusion imply examining potential syndromic associations, especially osteogenesis imperfecta.
Response 1: Thank you for pointing this out. We agree with this comment. Therefore, we have included more detailed explanation: “Differential diagnoses included amelogenesis imperfecta (AI), osteogenesis imperfecta (OI), and medication-induced tooth discoloration. AI was considered less likely due to the absence of primary enamel defects, such as hypoplasia or hypomineralization, and the presence of dentin-related discoloration rather than isolated enamel involvement. OI was not clinically supported at the time of examination, as no history or signs of bone fragility, recurrent fractures, blue sclerae, or growth abnormalities were reported. Medication-induced discoloration was excluded based on the absence of relevant medical history or exposure.” Line 95
Comments 2: The therapeutic rationale requires a clearer explanation, especially regarding the chosen restorative options. The manuscript describes a conservative approach, including sealant application on second primary molars and subsequent direct composite veneers for the maxillary incisors, mainly for psychosocial reasons. While this is understandable, the choice to avoid full-coverage restorations on posterior teeth needs a more detailed explanation, particularly since later discussion indicates that stainless steel crowns are often recommended in DI to protect dental structures and maintain occlusion stability. The manuscript should better align the management approach in this case with the existing literature and guidelines.
Response 2: We certainly agree with your comment. Therefore, we included more detailed explanation to the treatment strategy. Please refer to Line 166: “Although stainless steel crowns are commonly recommended for posterior teeth in dentinogenesis imperfecta, they were not placed in this case due to the patient’s limited cooperation. It was anticipated that such treatment would likely require general anesthesia, which was not considered necessary at that stage of management. During this period, the parents reported significant psychoemotional stress experienced by the child in kindergarten due to peer reactions to tooth color. Following a shared decision-making process, direct composite veneers were planned for the four maxillary primary incisors to address esthetic concerns and support psychosocial well-being. This decision was made with the understanding that such restorations primarily address surface appearance and do not modify the underlying dentin defect. Direct composite veneers were selected as a minimally invasive option that preserves tooth structure while providing acceptable short-term esthetic improvement. However, it was recognized that bonding to DI-affected dentin may be less predictable and that these restorations are not expected to prevent pulpal or periapical pathology. [19] Direct composite veneers were selected as a minimally invasive option to improve esthetics and address psychosocial concerns. Alternative restorative approaches, such as strip crowns or full-coverage restorations, were considered; however, their use was limited in this case due to material availability at the time of treatment and the patient’s young age and cooperation level. In addition, a conservative approach was preferred to preserve as much remaining tooth structure as possible, given the underlying dentin defect associated with dentinogenesis imperfecta. It was recognized that bonding to affected dentin may be less predictable, and therefore the chosen approach was aimed primarily at short-term esthetic improvement rather than long-term structural reinforcement.” Comments 3: In several instances, the wording could be more precise to prevent implying that one management option would necessarily have prevented the observed outcomes. The current version is close, but some sentences would benefit from more careful phrasing regarding prognosis, restoration performance, and the protective role of veneers.
Response 3: We thank the reviewer for this comment. The manuscript has been revised to ensure more precise and cautious wording throughout, avoiding any implication that specific management choices would necessarily have prevented the observed outcomes. Statements that could be interpreted as causal have been reformulated to reflect clinical uncertainty. For instance, the text now states that “it cannot be determined whether earlier restorative intervention would have altered the clinical course,” (Line 215) rather than implying a preventive effect. The role of composite veneers has also been clarified, emphasizing that they primarily address esthetic and psychosocial concerns and are not expected to prevent pulpal or periapical pathology. Similarly, references to full-coverage restorations have been adjusted to acknowledge that, although commonly recommended, there is limited evidence regarding their optimal timing or their ability to prevent disease progression. Overall, prognostic statements have been refined to reflect variability in outcomes and the limited strength of available evidence, ensuring a consistent and evidence-based tone throughout the manuscript. Comment 4: The discussion is broad and generally helpful, but some sections feel more descriptive than analytical. The comparison with previous case reports is a valuable addition, but the manuscript would be improved if the authors integrated the clinical implications more directly: for example, clarifying what this case specifically adds beyond illustrating longitudinal asymptomatic pathology, and how it influences the timing of radiographic review, restorative decisions, and communication with caregivers. Response 4: We thank the reviewer for this valuable comment. The Discussion has been revised to improve its analytical focus and to more directly link the literature with clinical decision-making in the present case. Epidemiological content has been condensed and its limited relevance to isolated DI clarified (e.g., “such epidemiological comparisons have limited direct relevance to isolated DI…” – Line 256) . The diagnosis is now specified as most consistent with dentinogenesis imperfecta type II, with no clinical evidence of osteogenesis imperfecta. We have strengthened justification of treatment decisions, including the conservative approach and the absence of stainless steel crowns, please refer to Line 277. The key finding—radiographic pathology in the absence of symptoms—is now emphasized as a central clinical implication (e.g., “radiographic review should be performed at regular intervals regardless of symptom presentation” – Line 294). Finally, the manuscript more clearly highlights the contribution of this case, particularly its longitudinal follow-up and the discrepancy between clinical and radiographic findings (e.g., “this case provides clinically relevant insight into the discrepancy between symptoms and disease activity…” – Line 236). Comment 5: The care timeline could be more straightforward. As the case covers multiple years, adding a concise summary table or a simplified chronological outline of visits, radiographic findings, interventions, and outcomes would enhance clarity. This would help readers better grasp the long-term aspects of the report. While a chronology is present, it feels scattered across various sections. Response 5: We certainly agree with your comment. We have included a summary of the visits. Please refer to Table 1.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

General Comments:

Thank you for the opportunity to review this interesting case report describing the diagnosis and management of dentinogenesis imperfecta in the primary dentition
The manuscript presents a clinically relevant case with longitudinal follow-up, which provides useful insight into the progression of asymptomatic pathology and the challenges associated with managing dentinogenesis imperfecta in young children
The clinical photographs and radiographs effectively illustrate the presentation and progression of the condition, and the psychosocial considerations discussed in the manuscript are a valuable addition to the clinical narrative
Several areas of the manuscript would benefit from clarification and condensation, particularly the Introduction and Discussion, to maintain focus on the clinical aspects of the case
Additional clarification regarding diagnostic considerations, behaviour management during treatment, and restorative decision-making would further strengthen the manuscript
With these revisions, the manuscript has the potential to make a useful contribution to the literature on the management of dentinogenesis imperfecta in the primary dentition

Specific Comments:

Abstract

The abstract provides a clear overview of the case and its clinical relevance
The statement that there is a “gap in the scientific literature regarding the management of dentinogenesis imperfecta in the primary dentition and long-term outcomes” may be somewhat overstated, as several case reports and reviews on management strategies exist. The wording could be moderated for accuracy
The diagnosis of dentinogenesis imperfecta is presented confidently in the abstract, however, it may be helpful to briefly indicate how the diagnosis was established (e.g. clinical and radiographic features with family history)
The abstract refers to diagnostic challenges and asymptomatic pathology, which are important observations. This aspect could be framed more clearly as a key clinical learning point from the case
Minor language editing could further improve clarity and conciseness, particularly in the description of clinical findings and management.

Introduction and Clinical Significance

The introduction is somewhat lengthy for a case report and could be condensed, particularly the detailed descriptions of genetics, histology, and differential diagnoses – advise reducing by at least half
Several sections read more like a textbook overview of dentinogenesis imperfecta rather than a focused introduction to a single case. Consider shortening these sections to improve flow
The Shields classification is appropriately introduced, but the descriptions of each type could be summarised more succinctly – this and the differential diagnoses could be placed in Tables, such as those in Ref 15 - de La Dure-Molla, M.; Philippe Fournier, B.; Berdal, A. Isolated dentinogenesis imperfecta and dentin dysplasia: revision of the 410 classification. Eur J Hum Genet 2015, 23, 445-451, doi:10.1038/ejhg.2014.159
The statement suggesting a higher incidence among Caucasian populations should either be supported by a clear reference or reconsidered
The claim that there are no previous reports of dentinogenesis imperfecta from the Baltic countries should be phrased more cautiously (e.g. “to the best of the authors’ knowledge”)
A slightly clearer link between the background and the rationale for presenting this specific case would strengthen the end of the introduction.

Case Presentation

The clinical timeline is clearly presented and the longitudinal follow-up (2020–2025) is a strength of the case
The description of diagnosis could briefly clarify how dentinogenesis imperfecta was established (clinical features, radiographic findings, and family history), and whether evaluation for osteogenesis imperfecta or genetic testing was considered
As the case suggests a hereditary dental condition with affected relatives, inclusion of a simple family pedigree diagram may help illustrate the suspected autosomal dominant inheritance pattern
Tooth numbering appears to follow the FDI notation system, but this is not explicitly stated. For clarity to an international readership, the notation system used should be specified at first mention
Although the case is presented chronologically using calendar dates, it may improve readability to state the child’s age at key stages of treatment and follow-up, as this is often more clinically meaningful in paediatric dentistry
As treatment was undertaken under local anaesthesia in a young child, additional information regarding cooperation, behaviour management, and whether inhalation sedation or general anaesthesia were considered would strengthen the case description
As dentinogenesis imperfecta is a hereditary condition that may affect both dentitions, the authors may wish to comment on whether panoramic radiography was considered to assess the developing permanent dentition, or whether imaging was limited to periapical radiographs due to the patient’s age and cooperation
The description of imaging equipment (camera model, radiographic sensor, and software) appears unnecessarily detailed for a case report and could be simplified
When describing the placement of direct composite veneers, the authors may wish to briefly justify the choice of veneers rather than alternative restorative options (e.g. strip crowns or full-coverage restorations), particularly given the challenges of bonding to dentin affected by dentinogenesis imperfecta
In the paragraph describing the placement of composite veneers, the citation “(McGarty)” appears without a corresponding numbered reference. This should be clarified and formatted consistently with the journal’s referencing style.
The manuscript states that the labial surfaces of the incisors were minimally prepared prior to placement of composite veneers. It would be helpful to clarify the rationale for performing tooth preparation in this case and to briefly define what was meant by “minimal preparation” (e.g. enamel roughening vs. measurable reduction), particularly given the importance of preserving tooth structure in dentinogenesis imperfecta

Figures and Images

The clinical photographs and radiographs are relevant and helpful, illustrating both the presentation and progression of pathology
Figure legends could be expanded slightly to clarify patient age therein, alongside key findings, such as pulp obliteration, periapical radiolucencies, and root resorption
It may improve clarity to highlight the relevant teeth on the radiographs (e.g. arrows or markers)
Ensure that each figure is clearly referenced in the text at the appropriate point in the case description

Discussion

The discussion provides a broad overview of dentinogenesis imperfecta; however, some sections could be condensed to maintain focus on the presented case, particularly the extended epidemiological comparisons across different countries
Several paragraphs summarise prevalence of dentinogenesis imperfecta in osteogenesis imperfecta populations, which is only indirectly related to the current case and could be shortened
The discussion would benefit from stronger linkage between the literature and the clinical decisions made in the present case, particularly regarding restorative choices and monitoring strategy
The manuscript discusses the use of stainless steel crowns as a common management approach, but these were not used in the present case. The authors may wish to briefly comment on the rationale for this difference in treatment approach
The observation that radiographic pathology developed despite minimal clinical symptoms is an important finding illustrated by this case and could be emphasised more clearly as one of the key clinical learning points
Some statements regarding the lack of evidence-based guidelines for management of dentinogenesis imperfecta are repeated in several sections and could be streamlined
When discussing previously published case reports, it may be helpful to more clearly highlight how the present case contributes additional insight, particularly the longitudinal follow-up and the discrepancy between radiographic findings and clinical symptoms
While dentinogenesis imperfecta is discussed extensively in the introduction, the manuscript does not clearly state which type of dentinogenesis imperfecta is suspected in this patient. Clarifying whether the findings are most consistent with Type II or another variant, and whether osteogenesis imperfecta was excluded clinically, would strengthen the diagnostic interpretation
At lines 258-259, the authors cite Areej Alqadi and Anne C. O’Connell using full names. If author names are used in the narrative, it is conventional to cite surnames only (e.g. Alqadi and O’Connell), or alternatively use the numbered reference format to maintain consistency with the Vancouver-style referencing used elsewhere in the manuscript

Conclusions

The conclusions appropriately emphasise the importance of ongoing monitoring and early identification of pathology in children with dentinogenesis imperfecta
Some statements regarding the lack of evidence-based guidelines for management repeat points already discussed earlier in the manuscript and could be slightly condensed
As this is a single case report, the conclusions should remain closely aligned with the observations from the presented case and avoid broader generalisations where possible

Comments on the Quality of English Language

Overall, the manuscript is generally clear and understandable, but minor grammatical and stylistic revisions would improve readability
Some sentences are overly long and complex, particularly in the Introduction and Discussion, and could be simplified to improve flow
There are occasional inconsistencies in citation style, for example the use of author names in the text while the manuscript otherwise follows numbered referencing
One citation appears incomplete (“McGarty”) and should be corrected to match the journal’s referencing format
Minor language edits may be beneficial to improve clarity and conciseness, particularly where technical descriptions are repeated

Author Response

For research article: Dentinogenesis imperfecta in primary dentition: case report

Response to Reviewer 3 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
2. Questions for General Evaluation	Reviewer’s Evaluation	Response and Revisions
Does the introduction provide sufficient background and include all relevant references?	Must be improved
Are all the cited references relevant to the research?	Not applicable
Is the research design appropriate?	Can be improved
Are the methods adequately described?	Can be improved
Are the results clearly presented?	Can be improved
Are the conclusions supported by the results?	Can be improved
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: The statement that there is a “gap in the scientific literature regarding the management of dentinogenesis imperfecta in the primary dentition and long-term outcomes” may be somewhat overstated, as several case reports and reviews on management strategies exist. The wording could be moderated for accuracy.
Response 1: Thank you for pointing this out. We agree with this comment. Therefore, we adjusted the text accordingly. Please refer to Line 74: “To the best of the authors’ knowledge, there are no published reports specifically describing dentinogenesis imperfecta in patients from the Baltic region.”
Comments 2: The diagnosis of dentinogenesis imperfecta is presented confidently in the abstract, however, it may be helpful to briefly indicate how the diagnosis was established (e.g. clinical and radiographic features with family history)
Response 2: Agree. We have, accordingly, modified the abstract section: “The diagnosis of dentinogenesis imperfecta was established based on characteristic clinical features, radiographic findings, and a positive family history.” (Line 12) Comments 3: The abstract refers to diagnostic challenges and asymptomatic pathology, which are important observations. This aspect could be framed more clearly as a key clinical learning point from the case Responses 3: We thank the reviewer for this helpful comment. The Abstract has been revised to more clearly present the occurrence of asymptomatic radiographic pathology as a key clinical learning point. This aspect is now explicitly emphasized as a central finding of the case, highlighting the limitation of symptom-based assessment and the importance of routine radiographic monitoring. Comments 4: Minor language editing could further improve clarity and conciseness, particularly in the description of clinical findings and management. Responses 4: We thank the reviewer for this suggestion. The manuscript has undergone careful language editing to improve clarity, conciseness, and overall readability, particularly in the sections describing clinical findings and management. Comments 5: The introduction is somewhat lengthy for a case report and could be condensed, particularly the detailed descriptions of genetics, histology, and differential diagnoses – advise reducing by at least half. Responses 5: We thank the reviewer for this comment. The Introduction has been substantially condensed, with detailed genetic, histological, and differential diagnostic descriptions reduced to improve focus and readability in line with case report requirements. Comments 6: Several sections read more like a textbook overview of dentinogenesis imperfecta rather than a focused introduction to a single case. Consider shortening these sections to improve flow. Responses 6: We agree with this observation. The Introduction has been revised to reduce textbook-style content and to better focus on clinically relevant information that supports the context of the presented case. Comments 7: The Shields classification is appropriately introduced, but the descriptions of each type could be summarised more succinctly – this and the differential diagnoses could be placed in Tables, such as those in Ref 15. Responses 7: We thank the reviewer for this suggestion. The descriptions of the Shields classification have been simplified and made more concise. While a table format was considered, the content was instead streamlined within the text to maintain coherence and avoid unnecessary expansion of the manuscript. Comments 8: The statement suggesting a higher incidence among Caucasian populations should either be supported by a clear reference or reconsidered. Responses 8: We agree with this comment. The statement regarding higher incidence among Caucasian populations has been removed to avoid unsupported generalization. Comments 9: The claim that there are no previous reports of dentinogenesis imperfecta from the Baltic countries should be phrased more cautiously (e.g. “to the best of the authors’ knowledge”). Responses 9: We thank the reviewer for this remark. The statement has been revised to a more cautious wording (“to the best of the authors’ knowledge”) to reflect the limitations of available data. Please refer to Line 74. Comments 10: A slightly clearer link between the background and the rationale for presenting this specific case would strengthen the end of the introduction. Responses 10: We agree and have revised the final paragraph of the Introduction to more clearly connect the background information with the rationale for presenting this case, emphasizing its longitudinal follow-up and the clinical relevance of asymptomatic disease progression. Comments 11: The description of diagnosis could briefly clarify how dentinogenesis imperfecta was established (clinical features, radiographic findings, and family history), and whether evaluation for osteogenesis imperfecta or genetic testing was considered. Responses 11: We thank the reviewer for this comment. The diagnostic section has been revised to explicitly describe the clinical, radiographic, and familial features supporting the diagnosis of dentinogenesis imperfecta. Clarification has also been added regarding the exclusion of osteogenesis imperfecta based on clinical findings and that genetic consultation was recommended but not pursued by the family. Please refer to Line 95 and Line 103. Comments 12: As the case suggests a hereditary dental condition with affected relatives, inclusion of a simple family pedigree diagram may help illustrate the suspected autosomal dominant inheritance pattern. Responses 12: We agree this would be informative. A statement on Line 106 has been added clarifying that a detailed family pedigree was not obtained, as family history was based on parental reporting. This limitation is now acknowledged in the manuscript. Comments 13: Tooth numbering appears to follow the FDI notation system, but this is not explicitly stated. For clarity to an international readership, the notation system used should be specified at first mention. Responses 13: We thank the reviewer for this observation. The manuscript has been revised to explicitly state that the Fédération Dentaire Internationale (FDI) two-digit notation system is used on Line 127. Comments 14: Although the case is presented chronologically using calendar dates, it may improve readability to state the child’s age at key stages of treatment and follow-up, as this is often more clinically meaningful in paediatric dentistry. Responses 14: We appreciate this suggestion. The manuscript has been revised to include the patient’s age at key clinical stages to improve clarity and clinical relevance. Comments 15: As treatment was undertaken under local anaesthesia in a young child, additional information regarding cooperation, behaviour management, and whether inhalation sedation or general anaesthesia were considered would strengthen the case description. Responses 15: We thank the reviewer for this comment. Additional information on Line 158 has been included regarding the patient’s level of cooperation, the use of non-pharmacological behavior management techniques, and consideration of sedation and general anesthesia, which were ultimately not required. Comments 16: As dentinogenesis imperfecta is a hereditary condition that may affect both dentitions, the authors may wish to comment on whether panoramic radiography was considered to assess the developing permanent dentition, or whether imaging was limited to periapical radiographs due to the patient’s age and cooperation. Responses 16: We agree and have clarified that imaging was limited to periapical radiographs due to the patient’s young age, cooperation level, and the intention to minimize radiation exposure. The absence of panoramic imaging and its rationale are now stated on Line 133. Comments 17: The description of imaging equipment (camera model, radiographic sensor, and software) appears unnecessarily detailed for a case report and could be simplified. Responses 17: We thank the reviewer for this suggestion. The description of imaging equipment has been simplified to improve readability and align with case report conventions on Line 84. Comments 18: When describing the placement of direct composite veneers, the authors may wish to briefly justify the choice of veneers rather than alternative restorative options (e.g. strip crowns or full-coverage restorations), particularly given the challenges of bonding to dentin affected by dentinogenesis imperfecta. Responses 18: We agree with this comment. The manuscript has been revised to provide a clearer justification for the use of direct composite veneers, including considerations related to minimally invasive treatment, patient cooperation, material availability, and psychosocial needs on Line 181. Comments 19: In the paragraph describing the placement of composite veneers, the citation “(McGarty)” appears without a corresponding numbered reference. This should be clarified and formatted consistently with the journal’s referencing style. Response 19: We thank the reviewer for identifying this issue. The reference has been corrected and reformatted according to the journal’s referencing style. Please refer to Line 179. Comments 20: The manuscript states that the labial surfaces of the incisors were minimally prepared prior to placement of composite veneers. It would be helpful to clarify the rationale for performing tooth preparation in this case and to briefly define what was meant by “minimal preparation” (e.g. enamel roughening vs. measurable reduction), particularly given the importance of preserving tooth structure in dentinogenesis imperfecta. Responses 20: We appreciate this comment. The manuscript has been revised to clarify that minimal preparation consisted of superficial enamel roughening, performed to enhance adhesion while preserving tooth structure and avoiding unnecessary dentin exposure. Please refer to Line 190. Comments 21: Figure legends could be expanded slightly to clarify patient age therein, alongside key findings, such as pulp obliteration, periapical radiolucencies, and root resorption. Responses 21: We agree and have revised the figure legends to include the patient’s age at the time of imaging, as well as key radiographic findings, including pulp chamber obliteration, periapical radiolucencies, and root resorption. Comments 22: It may improve clarity to highlight the relevant teeth on the radiographs (e.g. arrows or markers). Responses 22: We thank the reviewer for this suggestion. Where possible, the radiographs have been updated to include visual markers highlighting the relevant teeth and pathological findings to improve clarity. Comments 23: The discussion provides a broad overview of dentinogenesis imperfecta; however, some sections could be condensed to maintain focus on the presented case, particularly the extended epidemiological comparisons across different countries. Responses 23: We thank the reviewer for this comment. The Discussion has been condensed, and epidemiological sections have been shortened to maintain focus on the presented case. Comments 24: Several paragraphs summarise prevalence of dentinogenesis imperfecta in osteogenesis imperfecta populations, which is only indirectly related to the current case and could be shortened. Responses 24: We agree and have reduced these sections, clarifying their limited relevance to isolated dentinogenesis imperfecta. Comments 25: The discussion would benefit from stronger linkage between the literature and the clinical decisions made in the present case, particularly regarding restorative choices and monitoring strategy. Responses 25: We thank the reviewer for this suggestion. The Discussion has been revised to more clearly link the literature with clinical decision-making, particularly regarding the choice of conservative management, restorative approach, and the use of structured radiographic monitoring. Comments 26: The manuscript discusses the use of stainless steel crowns as a common management approach, but these were not used in the present case. The authors may wish to briefly comment on the rationale for this difference in treatment approach. Responses 26: We agree and have added clarification explaining that stainless steel crowns were not used due to the patient’s young age, limited cooperation, and the aim to avoid general anesthesia, favoring a minimally invasive approach. Please refer to Line 277. Comments 27: The observation that radiographic pathology developed despite minimal clinical symptoms is an important finding illustrated by this case and could be emphasised more clearly as one of the key clinical learning points. Responses 27: We thank the reviewer for highlighting this point. This finding has now been explicitly emphasized as a key clinical learning point in both the Discussion and Conclusions. Comments 28: Some statements regarding the lack of evidence-based guidelines for management of dentinogenesis imperfecta are repeated in several sections and could be streamlined. Responses 28: We agree and have streamlined these statements to avoid repetition and improve clarity. Comments 29: When discussing previously published case reports, it may be helpful to more clearly highlight how the present case contributes additional insight, particularly the longitudinal follow-up and the discrepancy between radiographic findings and clinical symptoms. Responses 29: We thank the reviewer for this suggestion. The manuscript has been revised to more clearly highlight the contribution of this case, particularly its longitudinal follow-up and the observed discrepancy between radiographic findings and clinical symptoms. Comments 30: While dentinogenesis imperfecta is discussed extensively in the introduction, the manuscript does not clearly state which type of dentinogenesis imperfecta is suspected in this patient. Clarifying whether the findings are most consistent with Type II or another variant, and whether osteogenesis imperfecta was excluded clinically, would strengthen the diagnostic interpretation. Responses 30: We agree and have clarified in the Discussion that the findings are most consistent with dentinogenesis imperfecta type II and that osteogenesis imperfecta was not supported clinically based on the absence of systemic features. Please refer to Line 261. Comments 31: At lines 258–259, the authors cite Areej Alqadi and Anne C. O’Connell using full names. If author names are used in the narrative, it is conventional to cite surnames only (e.g. Alqadi and O’Connell), or alternatively use the numbered reference format to maintain consistency with the Vancouver-style referencing used elsewhere in the manuscript. Responses 31: We thank the reviewer for noting this inconsistency. The citation has been corrected to follow the journal’s referencing format. Please refer to Line 271. Comments 32: Some statements regarding the lack of evidence-based guidelines for management repeat points already discussed earlier in the manuscript and could be slightly condensed. Responses 32: We agree and have revised the Conclusions to reduce repetition and improve conciseness. Comments 33: As this is a single case report, the conclusions should remain closely aligned with the observations from the presented case and avoid broader generalisations where possible. Responses 33: We thank the reviewer for this important remark. The Conclusions have been refined to more closely reflect the findings of the present case and to avoid overgeneralization, emphasizing observations directly supported by the reported clinical course.

Author Response File: Author Response.docx

Reviewer 4 Report

Comments and Suggestions for Authors

The case is well documented and provides a clear longitudinal follow-up; however, in my opinion, it does not offer a significant scientific contribution to the topic. The restorative management of the aesthetic area is only superficially described, and relevant clinical images documenting the treatment procedures are lacking, which limits the educational value of the report.
Furthermore, current restorative approaches, such as the injection technique, could have been considered and discussed, as they represent a minimally invasive and increasingly adopted option in similar clinical scenarios.
Overall, while the case is interesting from a clinical perspective, it would benefit from a more comprehensive description of the therapeutic approach and a stronger discussion of contemporary treatment alternatives.

Author Response

For research article: Dentinogenesis imperfecta in primary dentition: case report

Response to Reviewer 4 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
2. Questions for General Evaluation	Reviewer’s Evaluation	Response and Revisions
Does the introduction provide sufficient background and include all relevant references?	Must be improved
Are all the cited references relevant to the research?	Must be improved
Is the research design appropriate?	Must be improved
Are the methods adequately described?	Must be improved
Are the results clearly presented?	Must be improved
Are the conclusions supported by the results?	Must be improved
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: The case is well documented and provides a clear longitudinal follow-up; however, in my opinion, it does not offer a significant scientific contribution to the topic. The restorative management of the aesthetic area is only superficially described, and relevant clinical images documenting the treatment procedures are lacking, which limits the educational value of the report.
Response 1: We thank the reviewer for this comment. The manuscript has been revised to better highlight the clinical contribution of this case, particularly the longitudinal follow-up and the key finding of radiographic pathology developing in the absence of clinical symptoms, now emphasized as a central learning point. The therapeutic rationale has been expanded, including clearer justification of restorative choices and the decision to avoid full-coverage restorations based on patient age, cooperation, and the aim to avoid general anesthesia. We acknowledge the limitation regarding the absence of procedural images; however, we have improved the description of the restorative procedures to enhance clarity and educational value. We believe these revisions strengthen the clinical relevance of the report
Comments 2: Furthermore, current restorative approaches, such as the injection technique, could have been considered and discussed, as they represent a minimally invasive and increasingly adopted option in similar clinical scenarios.
Response 2: We thank the reviewer for this valuable suggestion. We agree that minimally invasive techniques, such as the injection molding technique, represent an emerging approach in restorative dentistry. A brief comment has been added to the Discussion to acknowledge this option. However, this technique was not considered in the present case due to material availability and clinical setting at the time of treatment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I thank the authors for their time in improving the manuscript. All suggestions have been upgraded in the text and they added scientific robustness.

Author Response

We sincerely thank the reviewer for taking the time to carefully evaluate our manuscript and for providing thoughtful and constructive feedback. Your comments have been highly valuable in improving the clarity, structure, and overall quality of the paper.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, I commend your work. Your revised manuscript details a longitudinal pediatric case report of dentinogenesis imperfecta affecting the primary teeth, tracking a child's condition from 2020 to 2025. It outlines the diagnostic process, serial clinical and radiographic observations, preventive and aesthetic treatments, and the eventual disease progression that led to the removal of some primary teeth. Its main contribution is highlighting that significant pulp and periapical issues can develop without noticeable symptoms, emphasising the importance of regular radiographic check-ups and tailored, risk-based treatment plans for children with dentinogenesis imperfecta.

This revised version is considerably clearer overall. The diagnostic framework is simplified, the therapeutic reasoning is more convincingly explained, and the distinction between observation and inference is more explicit, enhancing clarity. The addition of a summary table also improves readability during longitudinal follow-up. Notably, the manuscript now more clearly explains why the diagnosis remained clinical, why genetic consultation was not completed, why extensive imaging was limited, and why the treatment approach stayed conservative in early care stages. These adjustments strengthen the report's clinical transparency and scientific credibility.

Additionally, the revised manuscript features a more balanced Discussion. The authors now better acknowledge the limitations of a single-case report, avoid overstating treatment effects, and correctly state that causality cannot be confirmed regarding whether earlier intervention would have altered the clinical course. This improvement aligns the interpretation more closely with the evidence level inherent to a case-report design.

That said, a few points could still be refined prior to publication.

The manuscript now provides a clearer diagnostic picture, but caution should still be used when discussing DI type II. The Discussion describes the findings as “most consistent with dentinogenesis imperfecta type II,” which is appropriate within the context. However, since there was no genetic confirmation and the family history was based on parental report rather than pedigree analysis, the wording should consistently reflect a clinically supported subtype impression rather than a definitive diagnosis. The current wording is already close to this, but maintaining consistent phrasing throughout the manuscript would strengthen it further.

The radiographic monitoring schedule could be clarified more explicitly. While the manuscript convincingly argues that symptom-based follow-up alone is insufficient, adding one or two sentences to explain how the authors decided on the timing for radiographic reassessment would be helpful. Even if they did not adhere to a strict interval protocol, noting whether imaging was influenced by factors such as patient age, cooperation, previous findings, or risk level would increase its practical value for readers.

The psychosocial outcome is more explicitly incorporated, though its source could be defined more accurately. The revised version effectively highlights peer-related distress and mentions an enhancement in psychosocial well-being after veneer placement. To strengthen the manuscript, the authors should clearly specify whether this improvement is reported by parents, observed clinically in the child's behaviour, or noted during informal follow-up discussions.

Finally, this revised manuscript is significantly improved, offering a more convincing, clinically valuable, and appropriately cautious case report. The inclusion of longitudinal follow-up, clear documentation of asymptomatic pathology, and enhanced treatment rationale adds educational value for pediatric dentists and clinicians dealing with hereditary dentin disorders. I believe it is now ready for publication with only minor editorial revisions.

Author Response

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

General Comments:

Thank you for the opportunity to review the revised version of this case report
The manuscript has improved following revision, with clearer description of diagnostic reasoning, management decisions, and the longitudinal clinical course
The addition of further detail regarding behaviour management, imaging rationale, and restorative decision-making has strengthened the clinical relevance of the report
The emphasis on asymptomatic radiographic pathology as a key clinical learning point is now more clearly articulated and represents an important contribution to the manuscript
The inclusion of a structured summary of clinical visits is also a valuable addition, improving clarity of the longitudinal timeline
A small number of areas would still benefit from further refinement, particularly with regard to concision in the introduction and discussion, minor repetition within the case presentation, and final language and formatting edits

Specific Comments:

Abstract

The abstract provides a clear and accurate summary of the case and its clinical relevance
The description of how the diagnosis was established has been appropriately clarified
The key clinical learning point regarding asymptomatic radiographic pathology is now more clearly emphasised, with clear relevance to clinical decision-making and follow-up strategies

Introduction and Clinical Significance

The introduction has improved and is more focused than in the original submission
The rationale for presenting the case is now clearer and more appropriately framed
However, the section remains somewhat lengthy for a case report and the descriptions of genetics, histology, classification, and differential diagnoses could be further condensed to maintain focus on the clinical aspects of the case
Some sections still read as a general overview rather than being tightly linked to the presented case

Case Presentation

The clinical timeline is clearly presented and the longitudinal follow-up remains a key strength of the manuscript
Clarification of diagnostic reasoning, including clinical, radiographic, and familial features, has strengthened this section
Additional detail regarding behaviour management and treatment under local anaesthesia is appropriate and improves clinical context
The rationale for limiting imaging and not undertaking panoramic radiography is clearly explained
The justification for the use of direct composite veneers has been improved and is now more clearly linked to psychosocial considerations and minimally invasive management
There is some minor repetition in the description of the veneer approach, particularly regarding bonding limitations and treatment objectives, which could be streamlined
The description of imaging equipment remains slightly detailed for a case report and could be simplified further

Figures and Images

The clinical photographs and radiographs are appropriate and effectively illustrate the presentation and progression of the condition
Figure legends have been improved with inclusion of patient age and key findings
Minor grammatical inconsistencies remain within figure legends and should be corrected
Ensure consistency in wording, tense, and formatting across all figure descriptions

Discussion

The discussion is more focused and demonstrates improved linkage between the literature and clinical decision-making
The emphasis on asymptomatic disease progression and the limitations of symptom-based assessment is appropriate and well presented
Some sections, particularly those relating to epidemiology and osteogenesis imperfecta populations, remain slightly broader than necessary and could be further condensed
Repetition of statements regarding the lack of evidence-based guidelines could be reduced to improve clarity

Conclusions

The conclusions are appropriately aligned with the findings of the case
The importance of ongoing monitoring and recognition of asymptomatic pathology is clearly emphasised
Minor repetition of earlier points could be reduced

Comments on the Quality of English Language

Minor grammatical and stylistic issues remain, particularly within figure legends and some longer sentences

Author Response

Author Response File: Author Response.docx

Reviewer 4 Report

Comments and Suggestions for Authors

The paper has been improved and that the suggested recommendations have been followed.

Author Response