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Dental health in children born very preterm.

Article  in  Neonatal, Paediatric and Child Health Nursing · January 2004

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Margo Anne Pritchard

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Dental health in children born preterm:
N E O N ATA L , PA E D I AT R I C A N D C H I L D H E A LT H N U R S I N G
Review of screening and prevention
Margo Anne Pritchard
The long-term health and development of children born
Introduction
preterm, especially those born <1500g – very low birth-
weight (VLBW) – remains a central concern for families
and health care clinicians. Dental caries and delayed
dental development are twice as common in children born
preterm compared to the general paediatric population 1-8.
This increased risk is due to local trauma and systematic
factors including neonatal asphyxia, respiratory distress
syndrome, hyperbilirubinemia and neonatal infection.
Premature loss of teeth and malformation of the oral cavity
can lead to speech and appearance problems.
The National Health & Medical Research Council
(NHMRC) recent review of dental health in the general
paediatric population concluded that there is insufficient
evidence to make a recommendation for or against
screening and suggests focusing on preventive strategies in
pre and school age children 9. The aim of this paper is to
review the literature on dental health in children born
preterm and assist neonatal clinicians to offer appropriate
advice to parents on dental health in children born preterm
and with a VLBW. In addition, recommendations are
suggested for early dental screening in children born with
a VLBW based on likely prevention or reduction in dental
caries and other problems.
Controlled cohort, case reports and longitudinal studies
Aetiology of preterm dental problems
show that 40-70% of children born VLBW, compared to
approximately 1-39% of children born at term in Australia,
have generalised enamel hypoplastic lesions (quantitative
loss of enamel giving rise to pits and grooves) and/or enamel
opacity (enamel translucency without a break in enamel
continuity) in primary 10-12 and permanent 13 dentition.
Margo Anne Pritchard
BA
Perinatal Research Centre
Royal Brisbane and Women’s Hospital
The University of Queensland, Qld
24
VOL.7 NO.2 J U LY 2 0 0 4
The pathogenic mechanisms of dental defects in children
born very premature are unclear, but it is likely that both
local and systemic causes are involved. Generalised
defects are usually symmetrically distributed and most
likely associated with low bone mineral stores, often
associated with systemic illness and metabolic
derangements (severe infection-gastroenteritis, pneumonia
and rubella, metabolic disorders-liver and renal disease,
birth asphyxia, anaemia, hyperbilirubinaemia and
respiratory distress) in the neonatal period 1.
Mineral loss can persist beyond the neonatal period and
affect mineralisation of the permanent teeth where enamel
formation continues up until 14 years 3. Although there
appears to be a direct relationship between bone mineral
stores and enamel hypoplasia, current neonatal prophylaxis
through supplementation of calcium, phosphate and
vitamin D against metabolic bone disease does not protect
dentition 3, 14, 15.
Localised defects are commonly associated with trauma
caused by traumatic laryngoscopy causing localised enamel
hypoplasia, crown dilacerations and palatal distortions 4, 5, 7.
Ideally, there should be no traumatic forces applied to the
anterior alveolus during laryngoscopy; however, this is very
difficult to prevent due to the size of the preterm child’s oral
cavity. Force is often, unavoidably, exerted on the left side
as the laryngoscope is pushed to that side to enable
insertion of the orotracheal tube. Tracheal intubation and
prolonged mechanical ventilation have been associated
with increased presence of enamel defects in primary but
not permanent dentition 15. Distortions of the palate have
been observed in children with prolonged endotracheal
intubation but are corrected in early infancy by the natural
growth and remodelling of the palate 5.
The structural defects resulting from insults during enamel
development in the neonatal period are permanent. Dental
tissue does not remodel like bone, so that the imprint of a
metabolic disturbance will remain even though the primary
disturbance is corrected. This places the very preterm
infant at greater risk for dental caries and malformation of
the palate compared to children born at term (Table 1).
Delay in dental growth and development of primary and
Dental growth and development
permanent dentition is more common in infants born
preterm than those born at term. Longitudinal and cross-
sectional studies have shown that infants born preterm do
N E O N ATA L , PA E D I AT R I C A N D C H I L D H E A LT H N U R S I N G
not have a delayed corrected primary teething age 14.
When using chronological age, the primary teeth are
slower to erupt but ‘catch-up’ with children born at term by
18-24 months 6. Primary tooth eruption is likely to be
associated with somatic growth and genetics and not
skeletal maturity.
The effects on the permanent dentition show
developmental dental delay of approximately 3 months in
seven year corrected age children born preterm compared
to children born at term. Catch-up dentition occurs by 9
years of age when children born preterm have the same
dental age as children born at term 1, 13. Children with a
birthweight <1000g and with a gestation <30 weeks have
the greatest lag in dental development (Table 1).
Estimations of dental maturity and eruption should be
made on corrected age 13. The clinical significance is in
relation to orthodontic planning of treatment, where
consideration of growth status plays a significant role 1.
Much of the dental damage occurs as a consequence of
Preventative interventions
prematurity and its life saving management. Overall
improvements in the management of prematurity will
likely reduce the negative impact on dentition, although
the prevalence of enamel hypoplasia has not changed from
those reported over 10 years ago 2, 3, 11, 16. While little can be
done at present in the neonatal period to improve dentition,
early advice to parents on what to expect in relation to their
child’s dentition, various preventative strategies and early
examination (screening) by a dentist can be discussed as
part of the family’s discharge strategy.
Table 1: Prevalence of dental problems in very preterm and term
controls.
Condition
Enamel defects primary teeth
• Hypoplastic
• Opacity
Enamel defects permanent teeth
• Hypoplastic
• Opacity
Distortions of the palate-cross bite
Dilaceration of dental crowns
Dental growth and development
• Primary dentition
• Permanent dentition
Defects in intubated/
not intubated VP
VOL.7 NO.2 J U LY 2 0 0 4
There are various preventative strategies, which have been
reported to optimise oral health in children born preterm
and at term; these are presented in summary form below.
Neonatal care
Laryngoscopic procedures
A cushioning sponge or device has been used to reduce the
force on the dental ridge; however, there is no supportive
published data [correspondence, K Seow 2003]. Clinicians
should be made aware of the potential for damage and
minimisation of pressure on the laryngoscope while
inserting orotracheal tube 4-7. A palate stabilising device to
hold orotracheal and orogastric tubes has been seen to
relieve pressure and reduce palatal grooves. These are not
widely used and their use is questionable as it is unclear if
palatal grooves cause permanent damage 17.
Improvement in mineral retention
Breastmilk supplementation of calcium, phosphorus or
vitamin D has not been shown to reduce the prevalence of
enamel defects in primary and permanent dentition or
affect dental maturation in children born preterm 14, 15.
Long term care
Fluoride
Fluoridated water supplies, tablets 18, professional
application of topical fluoride varnishes, gels 19, 20 and
toothpaste 21 have been shown to be effective in the
reduction of dental caries. Fluoride acts at the tooth/plaque
interface, through promotion of remineralisation of early
caries and by reducing tooth enamel solubility in primary
and permanent dentition. However, compliance with
tablets has been seen to be difficult. Children should be
supervised to avoid ingestion of toothpaste or topical
fluoride. Side effects from fluoride (tooth staining,
fluorosis, or oral allergic reactions) have been reported but
not well studied. There is no evidence to support a specific
combined regime and dental advice within the context of
ongoing management should be sought.
Preterm Term
Feeding behaviours
43-96% 1-39%
Going to sleep with a bottle or prolonged sucking from a
66-52% 2-6%
bottle during the day can result in pooling of liquid around
10-13% 6-19%
the maxillary incisors, causing destruction and premature
loss of primary teeth; this in turn may lead to malalignment
38% 11%
of permanent teeth. It is recommended that children are
47% 25%
neither put to bed with a bottle nor allowed to sip from a
bottle during the day, nor have sweetened liquids in the
15% 15%
bottle 18, 22.
rare rare
Primary caries
Dental cares remains one of the most common infectious
No delay using
diseases known to humans. Primary teeth have important
corrected age;
functions of mastication and guide the eruption of the
18-24 months’ delay
permanent dentition. They also contribute to the
using chronological age
development of speech and facial appearance. Decay in
Catch up development
by 9 years
the primary dentition should be treated. Untreated decay
can lead to pain and abscess formation 1.
85%/22% N/A
25
N E O N ATA L , PA E D I AT R I C A N D C H I L D H E A LT H N U R S I N G
Health promotion
The use of fluoride and chair-side oral health promotion by
the dentist has been shown to be an effective method of
health promotion 23. There is little evidence to support the
effectiveness of tooth brushing per se in the prevention of
caries; however, tooth brushing with fluoridated toothpaste
under supervision in high-caries-risk school age children
has proven benefit in caries reduction 24. Powered
toothbrushes with a rotation oscillation action achieve a
modest reduction in plaque and gingivitis compared to
manual toothbrushing in the general population 25. However,
children cannot effectively clean their teeth until they can
write, therefore parental supervision is recommended.
Consultation with a dentist is also recommended before
commencing powered toothbrushes 26.
Diet manipulation
Reduced refined carbohydrate intake is associated with
fewer dental caries and is recommended. Sugar substitutes
have been seen to reduce caries but are not recommended
due to evidence of a carcinogenic effect in mice 19.
There are no published reports on dental screening
Screening recommendations
programmes in children born preterm. Observational
studies suggest that a preventative clinical examination by
a dentist has potential benefits for optimal oral health.
Although the current NHMRC recommendations suggest
that there is insufficient evidence for or against screening
in the general paediatric population, consideration should
be given to a screening programme for children born
preterm based on their high prevalence of dental problems.
A dental examination by a dentist when the first teeth have
started to erupt would ensure early identification and
management of problems and enable early dental health
promotion and monitoring.
Funded by a Royal Brisbane and Women’s Hospital
Acknowledgement
Research Scholarship.
This review has aimed to provide concise information for
Conclusions
clinicians to use as a fundamental basis to inform health
care practice and advice for parents of children born
preterm. As with all recommendations, they provide a
framework to work within when considering management
and advice for the individual family.
References
1. Seow WK (1997). Effects of preterm birth on oral growth and
development. Australian Dental Journal 42:2, 85-91.
2. Seow WK, Brown JP, Tudehope DI & O’Callaghan MJ (1984). Defects
in the primary dentition of children born prematurely with very low
birthweight and neonatal rickets. Pediatric Dentistry 6, 88-92.
3. Seow WK, Masel JP, Tudehope DI & Weir C (1989). Mineral
deficiency in the pathogenesis of enamel hypoplasia in prematurally
born, very low birth weight children. Pediatric Dentistry 11, 297-302.
4. Seow WK, Brown JP, Tudehope DI & O’Callaghan MJ (1984).
26
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VOL.7 NO.2 J U LY 2 0 0 4
Developmental defects in the primary dentition of very low birth
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