ORIGINAL ARTICLE
The Influence of Orotracheal Intubation on the Oral Tissue Development in Preterm Infants Patricia Valeria Milanezi Alvesa/Ronir Raggio Luizb Purpose: Preterm children may not be prepared for extra-uterine life and thus need neonatal intensive care, such as artificial ventilation through orotracheal intubation. Oral tissue development changes as a result of the use of an orotracheal tube and its mechanical influence in preterm neonates has not been intensively studied. The purpose of the present study was to determine the association of orotracheal intubation with incidence of oral alterations in preterm infants. Materials and Methods: A retrospective cohort of 117 subjects who were born during the period 2002–2003 in Brazil were evaluated and the data were analysed using the Fisher and Mann-Whitney exact tests. A 95% confidence interval was calculated for observed oral conditions. Results: The cohort revealed that the most frequent oral conditions included anterior crossbite, superior alveolar contour and palatal deformation. Conclusions: The association between the intubated-infant group and the non-intubated–infant group suggested that mechanical trauma had an influence on the oral structure development. Key words: malocclusion, oral development, orotracheal intubation, preterm infants Oral Health Prev Dent 2012; 10: 141-147.
A
ccording to the literature, preterm birth has an incidence of 5% to 10% in Europe, North America, and parts of South America, whereas most African and Southeast Asian countries have higher incidences, 10% to 30%. In Brazil, preterm infants represent approximately 10% of all births (Michelazzo et al, 2004). Preterm is defined by the World Health Organization (WHO) as birth occurring prior to the 37th week of gestation or birthweight less than 2,500 grams. Its aetiology is multifactorial and may be related to diseases involving either the foetus or mother. However, in most cases the aetiological factors are unknown (WHO, 1980; Usher, 1981; Avery and First, 1988;). Regarding oral investigations, epidemiological, microbiological and immunological studies
a
Dentist, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
b
Associate Professor, Institute of Public Health Studies, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
Correspondence: Ronir Raggio Luiz, Institute of Public Health Studies, Federal Univeristy of Rio de Janeiro, Praça Jorge Machado Moreira 100, Cidade Universitária 21941-598, Rio de Janeiro/RJ, Brazil. Tel/Fax: +55-21-2598-9278. Email:
[email protected]
Vol 10, No 2, 2012
Submitted for publication: 26.07.10; accepted for publication: 15.11.10
suggest that maternal periodontal disease may be an independent risk factor of preterm and low birthweight (LBW) (Berkowitz and Papiernik, 1993; Marlow et al, 1993; Stjernqvist and Svenningsen, 1995; Wolke, 1998; Hediger et al, 2002; Lopez et al, 2002; McGaw, 2002). Preterm delivery exposes the children when they cannot be prepared for extra-uterine life; as a result, they may need neonatal intensive care in order to prevent possible complications of susceptible organs, such as the brain, lungs and eyes (Usher, 1981). Because of the respiratory problems resulting from the underdeveloped lung tissues, such children may also need artificial ventilation through an orotracheal tube (Roberton, 1993; Lissauer and Claydon, 1997; Cooper et al, 1998). Like other tissues and organs of the body, orofacial tissues can be affected by preterm birth. Many studies have shown that preterm birth can affect the dental enamel by mineral loss (hypoplasia) or qualitative alteration in translucency (opacity) (Seow, 1997). On the other hand, the influence caused by the local trauma of the oral tube, which exerts pressure on the antero-superior alveolar contour, is highlighted (Seow, 1986).
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Alves and Luiz
Altered alveolar contour Presence of crossbite Altered palate from Changed eruption sequence Altered shape of the crown Altered mineralisation of the crown 0
3
6
9
12 15 18 21 24 27 30 33 % (95% CI)
Fig 1 Oral alterations observed in preterm infants, incidence (%) and 95% confidence interval.
In spite of the medical and dental literature addressing the association between orotracheal intubation and developmental changes, it is difficult to elucidate whether the effects on the orofacial tissues could be related to the preterm birth only or to the influences from extrinsic factors like the use of the orotracheal tube. Therefore, the purpose of this study was to evaluate the incidence of changes in the maxillary anterior teeth, alveolar contour and palate in preterm infants. The possible association between these changes and time of intubation in comparison with cases who had not been submitted to artificial ventilation was also verified.
MATERIALS AND METHODS All preterm children who were born in a public hospital in São Paulo, Brazil, during the period 2002– 2003 and who had been in the neonatal intensive care units constituted the sample. This hospital represents an important health unit in a populous area due to the complexity of the attention and neonatal intensive care required. The rate of preterm births for the period of study was 7% of the total number of term births. A total of 170 children born preterm and their parents were invited to participate in this study; of these, 117 preterm children aged 2 and 3 years old were located and evaluated. The sample was divided into two groups: group 1 with 66 infants who had been intubated immediately following their birth, and group 2 with 51 infants who
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needed no orotracheal intubation. In order to assure data reliability, some criteria were adopted for including an infant in the study: 1) absence of genetic or congenital syndromes, 2) absence of developmental changes at birth, 3) absence of neurological changes by hypoxia or other neonatal complications, 4) up-to-date vaccination, favourable health and oral history as well as normal development and 5) absence of deleterious oral habits, such as dummy (pacifier) or finger sucking and tongue thrust, due to possible mechanical interference in the oral tissue development. This information was searched in the medical and background data and parents’ accounts. Therefore, the sample was determined by the number of located children who had been registered in the obstetrics/paediatrics services and who had not presented any criteria of exclusion. The method adopted for gathering the children’s data involved oral clinical examinations carried out in the paediatric outpatient units at the hospital referred to above. The same examiner performed the clinical examinations by using a dental exam set under sufficient illumination. Information concerning the time of orotracheal intubation, characteristics of the erupted anterosuperior teeth crowns, dental eruption sequence, anterior crossbite, superior alveolar contour and palatal form was gathered. The oral conditions were clinically evaluated according to the following aspects: 1) whether or not the shape and colour of the dental crown showed dilacerations and spots,
Oral Health & Preventive Dentistry
Alves and Luiz Table 1 Oral conditions analysed, frequency of cases with/without alterations in the intubated and non-intubated groups and statistical significance following intergroup correlation Oral conditions
Intubation Total
Yes - G1 (n = 66)
No - G2 (n = 51)
n
%
n
%
n
%
Altered
27
23.1
24
36.4
3
5.9
Normal
90
76.9
42
63.6
48
94.1
Present
15
12.8
13
19.7
2
3.9
Absent
102
87.2
53
80.3
49
96.1
Altered
14
12.0
11
16.7
3
5.9
Normal
103
88.0
55
83.3
48
94.1
Changed
7
6.0
7
10.6
0
0.0
Normal
110
94.0
59
89.4
51
100.0
Altered
7
6.0
5
7.6
2
3.9
Normal
110
94.0
61
92.4
49
96.1
Altered
4
3.4
3
4.5
1
2.0
Normal
113
96.6
63
95.5
50
98.0
P value of Fisher’s exact test
Alveolar contour
