Dental Outcomes of Preterm Infants

Diane L. Eastman, MA, RN, CPNP

Disclosures

NAINR. 2003;3(3) 

In This Article

Oral Defects Associated with Intubation

Premature infants frequently require assisted ventilation because of respiratory insufficiency, apnea, asphyxia, and sepsis. Prolonged endotracheal intubation is often necessary for the ELBW infants. Orotracheal tubes are the preferred method of intubation for most premature infants. Orotracheal tubes are used to avoid the septal and respiratory impairments associated with nasotracheal tubes.[16] Orotracheal tubes have been associated with development of acquired cleft palate, palatal grooving, alveolar grooving, primary tooth dilaceration, palatal depth and width asymmetry, crossbites, and poor speech intelligibility and nasality.

Erenberg and Nowak[17] reported the association between long-term use of orotracheal tubes and a higher incidence of palatal groove formation in a group of infants requiring intubation from 1 to 62 days. Alveolar grooves have been reported by a number of others.[18,19] The use of "soft" ET tubes has not resulted in a reduction in palatal grooves.[20,21]

Multiple factors influence abnormal palate formation. The narrow elongated "preemie head" may cause a narrow high vaulted palate, made worse by head posture contributing to collapse of the palate. The ET tube may press on the midline palate and alveolar ridge, disturbing its growth. The pressure applied to the ET tube to keep it properly positioned may further affect the developing palate. Babies sucking on their ET tubes may also result in some molding of the tissues.[25]

Prevention of palatal groove formation has been attempted with the introduction of various appliances designed to protect the palate from increased pressure from ET and orogastric tubes. Several similar appliances have been reported in the literature.[21,22] Design differences were primarily for stabilizing only the endotracheal tube or both the ET and feeding tubes. Fadavi et al[23] in a randomized prospective study of 26 infants with birthweights of 540 to 1,740 grams and orally intubated from 7 to 109 days found no evidence of palatal grooving in the group who were fitted for the palatal device. Palatal grooves of 2 to 5 mm in depth developed in the control group without the palatal plate. Ginoza et al[24] found the palate plate significantly diminished the degree of groove formation in a randomized trial of VLBW infants intubated for at least 5 days. Ash et al[25] compared preterm infants with and without palate plates to measure changes in the palate other than groove formation. In this study of babies less than 32 weeks' gestation, 15 nonintubated babies were used as a control group and 30 babies intubated for more than 10 days were randomly assigned to the palate plate and no palate plate groups. The palates of babies without plates were smaller, narrower, and deeper than nonintubated babies. There was a reduction in the narrowing and depth of the palate of those with the plate. Narrowing of the palate was not limited to intubated babies but was more extensive and persisted longer in that group. Palate plates did not restrict the lateral growth of the infant palate. The palate plate also allowed for early resolution of gum pad depression compared with the nonpalate plate group.

Kopra and Davis[26] found a higher incidence of oral abnormalities in two groups of LBW children ages 3 to 5 and 7 to 10 years old who had been intubated than in same age children of average birth weight who had not been intubated. In both age groups, intubated subjects had a greater incidence of high vaulted palate, palatal grooving, and posterior crossbite compared with the control group. Their speech was also judged to be less intelligible. This study is one of the few that demonstrates these defects persist into middle childhood. They concluded that a high vaulted or grooved palate may result in the tongue not meeting the palate correctly. This may adversely affect the production of normal speech sounds and contribute to hypernasality and poorer speech intelligibility. From their analysis, they also concluded that length of intubation did not influence oral defects and speech characteristics.

In a more recent study by Macey-Dare et al[27] of former premature and LBW infants, palatal widths, arch widths, and palatal depths were measured. The children were 8 to 11 years old at the time. The 43 premature infants had birthweights of 957 to 2,040 grams and gestational ages of 20 to 37 weeks. Intubation ranged from 1 to 58 days. The study group was compared with a control group of 50 term, normal birth weight children. Intubated children were divided into two groups: those intubated less than or equal to 15 days and those intubated for more than 15 days. There were no statistical differences between the two intubated groups at any level of measurement in this study. There were significant differences when the intubated and nonintubated groups were compared. The children who had been intubated had significantly narrower palate widths posteriorly, and palatal vaults were steeper anteriorly. The intubated group also had palatal width asymmetry with the left side consistently wider than the right.

In contrast to these findings, Seow et al[28] compared palate and dental arch symmetry between intubated and nonintubated groups of children. They found no significant differences in the two groups, but none of the children in the intubated group had been intubated for more than 20 days.

Continued research regarding the long-term effects of intubation appears warranted from these results. In particular, persistence of effects into adolescence is important as many orthodontic interventions occur in this age group.

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