|Year : 2020 | Volume
| Issue : 1 | Page : 13-18
Prolonged neonatal intubation: Prosthodontics beyond dentistry
Sagar Sachdeva, Haitham Hesham Kamel, Sunitha Shamnur, Poonam Khinnavar, DB Nandeeshwa
Department of Prosthodontics and Crown and Bridge, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Submission||31-May-2019|
|Date of Acceptance||11-Nov-2019|
|Date of Web Publication||16-Jul-2020|
Dr. Sunitha Shamnur
Department of Prosthodontics and Crown and Bridge, Bapuji Dental College and Hospital, Davangere, Karnataka
Source of Support: None, Conflict of Interest: None
Neonates with respiratory distress, inadequate gag reflex, poor sucking, and swallowing commonly require intubation as a routine treatment modality in the neonatal intensive care unit. It can be done by the nasal or oral route. Although nasotracheal intubation reduces the movement of the tube, it has some serious repercussions such as airway obstruction and possible hypoxia, leading to labored breathing, occlusion of the nasal aperture during a crucial period of development, nasal infections, and hypertrophy of the nasal lining. Hence, oral route is preferred over the nasal route as the oral mucosa is less susceptible to infection. However, an infant with an orotracheal tube is at risk for complications such as accidental extubation, damage to the maxillary alveolar ridge, development of a cleft palate, defective dentition, tracheal mucosal damage, subglottic stenosis, and laryngeal damage. Therefore, in an effort to reduce these complications, an appropriate recognition and dental intervention is required by the prosthodontist who by conferring with the prescribing physician could device a customized intraoral appliance for the neonate on prolonged intubation. Various intraoral appliances are being used to stabilize the tubes for infants who require prolonged intubation. For the present review, the database from various digital platforms was searched for studies published on prolonged neonatal intubation. The palatal appliances effectively stabilize the orotracheal and orogastric intubation tubes and prevent the associated complications. Thus, this early prosthodontic treatment for neonates requiring prolonged intubation further expands the scope of prosthetic dentistry to newer horizons in patient care and management.
Keywords: Endotracheal intubation, mouth protectors, neonate, prolonged intubation
|How to cite this article:|
Sachdeva S, Kamel HH, Shamnur S, Khinnavar P, Nandeeshwa D B. Prolonged neonatal intubation: Prosthodontics beyond dentistry. Int J Oral Health Sci 2020;10:13-8
|How to cite this URL:|
Sachdeva S, Kamel HH, Shamnur S, Khinnavar P, Nandeeshwa D B. Prolonged neonatal intubation: Prosthodontics beyond dentistry. Int J Oral Health Sci [serial online] 2020 [cited 2020 Aug 4];10:13-8. Available from: http://www.ijohsjournal.org/text.asp?2020/10/1/13/289874
| Introduction|| |
The neonatal airway has become a specific area of concern in recent years as modern advances in neonatology have improved the survival rates of preterm and other critically ill newborns. Intubation is the method of choice as the incidence of mortality and morbidity for tracheostomy in the neonate is much higher than that of endotracheal intubation. The oral mucosa is less susceptible to damage than nasal mucosa. Orotracheal route is the preferred method of intubation in premature infants as they are obligate nasal breathers. Ineffective stabilization of the tubes is a frequent problem often resulting in accidental extubation and displacement of orotracheal and orogastric tubes. Complications of prolonged endotracheal intubation include palatal groove formation by pressure against the hard palate, infection, accidental extubation, malposition, laryngeal or tracheal edema and ulceration, tracheal stenosis, and vocal cord injury. Various oral appliances to stabilize the tubes are being used for infants who require prolonged intubation.
| Search Methodology|| |
The database from various digital platforms such as PubMed, Medline, and Google Scholar was searched for the studies published on prolonged neonatal intubation using the keywords “prolonged intubation” and “mouth protectors.” Studies elaborating on prolonged neonatal intubation and oral appliances were included.
| Appliance Designs|| |
Sullivan et al. (1981)
A palatal appliance was fabricated with anterior and posterior grooves and modified for the snap fit of the intubation tubes with small stainless steel tag [Figure 1]. The appliance was constructed in heat-curing methyl-methacrylate resin on the master mold by a dental technique used in the manufacture of denture base plates. The grooves were cut in the glossal surface of the appliance to accept the appropriate feeding tubes. The grooves were open to the surface and were modified with cold-cured methyl-methacrylate resin to provide a “snap” fit for the feeding tubes. A small stainless steel tag was incorporated in the plate to provide attachment for a length of dental floss. The floss was taped to the infant's cheek to prevent the plate falling to the back of the mouth in the unlikely event of its becoming dislodged. The fitted appliance has proved capable of resisting a displacing force of 150–200 g, and this retention effect was more than adequate to support two feeding tubes in position.
(1) Tubes can be inserted into the appliance after they are placed at its location; (2) snap fit allows for easy placement and retrieval; (3) appliance need not be removed for replacing either tube.
Richards S D (1981)
A double-stick disc for stethoscope and electrode attachment was placed over the endotracheal tube and attached to the bottom side of the endotracheal tube connector [Figure 2]. The tube can be no larger than center hole in the disc, limiting its size to five points 5 mm tube or less. The endotracheal tube was placed in a routine manner into the patient. The disc was then removed from the connector and slid down the tube to the level of the tube insertion at the vermilion border. The disc was folded and molded onto the endotracheal tube, and the paper portion of the disc was removed [Figure 3]. This left the double-adhesive plastic attached to the endotracheal tube. It provided an extremely adhesive surface to which the tape may be attached. The tape was torn and folded along the dotted line so that the nonadhesive side was folded on itself [Figure 4]. The short ends of the tape were wrapped around the disc and pressed together again.
|Figure 2: Double-stick disc is placed over endotracheal tube and attached to the bottom side of connector|
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|Figure 3: Disc is removed from the connector and slid down to the level of tube insertion (left). The disc is folded and molded onto tube (center), and double adhesive plastic is attached to tube (right)|
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Because of the interface of two adhesive surfaces, i.e., the adhesive portion of the tape to the adhesive portion of the disc, a strong bond is formed. This provides a high degree of security for the endotracheal tube as well as immobility. This appliance is particularly useful for the prone patient who may salivate onto the tube.
Once placed, it is difficult to remove the tape and needed to be pulled back and repositioned which even resulted in rashes on the skin.
Erenberg A and Nowak A (1984)
A palatal appliance was fabricated with continuous antero-posterior groove and further modified for the snap fit of the tubes along with a stainless steel tag in the anterior portion of the plate [Figure 5]. In the fabrication of this appliance, dental wax rods slightly smaller than the orogastric feeding or orotracheal tubes used in the infant and are softened and placed along the length of the palate, parallel to the palatal suture. Cold cure methyl methacrylate is “dusted” to the master cast and up to approximately two-thirds of the wax rods and placed in a 43°C water bath at 15 lb. of pressure for 10 min for final curing. After the acrylic appliance is lifted off the cast, the wax rods are removed with hot water, leaving one or two grooves. The remaining acrylic is finished with conventional finishing burs and polished to a high luster. The appliance is moistened, and a nontoxic denture adhesive powder is applied to the upper surface and then pressed lightly against the palate. The orotracheal and/or orogastric feeding tube is snapped into the appropriate groove by finger pressure.
|Figure 5: Intraoral appliance with a 2.5-mm orotracheal tube (top) and 5-Fr orogastric feeding tube (bottom) in place|
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It protects the upper surface of the oral cavity and decreases the trauma to the airway mucosa and vocal cords and avoids accidental intubation of the right or left mainstream bronchus.
It covers more area as it covers the tubes anteroposteriorly.
Mc Court JW (1992)
The appliance consists of light-cured pink denture base resin, one 0.032″ stainless steel ball-clasp wire, a closed-link synthetic elastic latex polymer chain, and a 10 cm piece of dental floss [Figure 6] and [Figure 7]. After blending the two components of vinyl impression putty for 20 s, the putty is introduced to the palate with a suitable tray and held for 30 s to produce an accurate impression. A model is made and is marked in the following areas: along the midsagittal suture to the labial sulcus; at both lateral sulci, 1 mm labial to the crest of the posterior alveolar ridge, on the anterior alveolar crest between the lateral sulcus, and at the hard palate junction with the soft palate [Figure 8]. A small sheet of 2-mm thick urethane is placed upon the model and trimmed with a no. 15 scalpel blade to the established lines drawn on the model's alveolar ridge and posterior palate.
|Figure 6:A neonatal palatal appliance holding an orogastric tube and orotracheal tube|
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|Figure 8: Impression and model withdrawn guidelines for the appliance construction|
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The ball-clasp wire is bent at a distance of 4 mm from its ball end to 30° [bend #1, [Figure 9]. A 90° bend (bend #2) is made 6 mm from the first. Another 90° bend (bend #3) is made 1 cm from the first. The wire between these 90° bends will be retained in the urethane. At 4 mm from the last bend, the wire is looped upon itself (bend #4), and the excess is cut. A closed-four-link latex chain is secured to this loop of wire, and a colored piece of dental floss is attached to the wire and latex chain link. The floss is knotted every 2 cm along its length, and then the third link of the latex chain is placed on the ball clasp with very slight tension. The loop or ball-clasp end of the wire is adjusted to create the desired tension on the latex chain. The fourth link remains free for easy access to the chain. This assembly of wire, latex chain, and dental floss is pressed into the urethane sheet material on the palate, according to the lines drawn on the model. Urethane covers the wire. The ball on the wire must clear the urethane by at least 3 mm for easy placement of the latex chain. The urethane material should be about 2 mm thick throughout the appliance base plate. The appliance is light cured two times. The initial cure is with the appliance on the model, and the second cure is with the appliance off the model, tissue side up. The latex chain is disengaged from the ball wire, and the appliance is scrubbed with a bactericidal soap, rinsed, and gas sterilized. All surfaces then are smoothed with a suitable acrylic bur.
Superior strength, complete polymerization, and low bacterial adherence.
Urethane is more brittle than acrylic resins, cumbersome to fabricate.
Shimoyama T et al. (2002)
A palatal appliance was fabricated with an outer guide antero-posteriorly through which the tube could be passed [Figure 10]. The oropharyngeal tube inside it was waxed up on the wax base plate. While the impression of the maxilla was being made, using a custom tray with silicone impression material, the patient was placed in a supine position that brought his head down slightly without sedation and oxygen was delivered over the nose. The diameter of the outer guide tube was made approximately 1 mm larger than the oropharyngeal tube, and the oropharyngeal tube was able to be fixed with a frictional force inside the outer guide tube. A curved contour was added to the outer guide tube in accordance with the shape of the soft palate, and the pharynx also referring to a lateral neck radiograph. An extra outer guide tube, which was used to insert the suction catheter, was added beside the main outer guide tube. The diameter of the extra outer guide tube was made large enough to pass through the suctioning tube loosely. The wax pattern of the base plate with the outer guide tube, about one point 5 mm thick, was cured in one piece by a heat-curing resin. A clear colored resin was used for the material of the appliance to watch the changes of the surface of the mucosa easily [Figure 11]. After the placement of the appliance, the oropharyngeal tube was inserted through the outer guide tube, and the tube was secured without anchoring adhesive tape, as the frictional force was strong enough.
|Figure 10: Occlusal (a) and lateral (b) views of the study cast and the palatal appliance|
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|Figure 11: Lateral (a) and lower (b) views of the palatal appliance with oropharyngeal tube and suction catheter|
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The outer guide tube caught hold of the oropharyngeal tube sufficiently and the respiratory tube could be held without adhesive tape. The extra outer guide tube was useful to suck the secretion easily.
It would not hold the tube tight enough as the diameter of the outer tube is greater than the tube, and the tube needs to be placed through the outer guide after insertion of the appliance.
Role of a prosthodontist
- The prosthodontist plays a pivotal role in the early recognition and appropriate dental intervention to prevent the development of palatal deformities caused by prolonged pressure exertion on the hard palate by intubation tubes
- The prosthodontist should confer with the prescribing physician concerning specific requirements for the tube diameter and desired location before initiation of the palatal appliance
- The dentist should be aware of various designs and necessary techniques for the adequate positioning and stabilization of an endotracheal tube in a palatal device to facilitate intubation while reducing morbidity associated with prolonged use of oral intubation in infants
- The prosthodontist should assume the responsibility for periodically monitoring the need for the replacement of the soft lining material to ensure the stability of the prosthesis. When the infant is growing, a new appliance may be needed approximately every 4 weeks.
| Conclusion|| |
The intraoral appliances being used for intubated infants not only stabilize these tubes but also protect the palate from pressure exerted by orotracheal tubes. The nursing staff at the neonatal intensive care unit and the caregivers need to be instructed regarding the ongoing use of the appliance, which includes providing adequate oral hygiene, assessing the fit of the appliance, and monitoring the response of the infant to the procedures. Information is given to parents explaining the reasons for using the appliance and the associated care given to the infant. Hence, the use of these palatal appliances is justified as they have proved to be beneficial in the stabilization of orotracheal and orogastric intubation and prevented the complications resulting from prolonged neonatal intubation. Thus, an early prosthodontic care is essential by successfully advocating these techniques in neonates requiring prolonged intubation.
Financial support and sponsorship
This study was financially supported by PubMed, Medline, and Google Scholar.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shimoyama T, Kato T, Horie N, Nasu D, Kaneko T. Oropharyngeal airway appliance for infant with upper airway obstruction: Report of a case. J Clin Pediatr Dent 2002;27:25-8.
Sullivan PG, Haringman H. An intra-oral appliance to stabilise orogastric tube in premature infants. Lancet 1981;1:416-7.
Kamble VB, Shah SK, Rathod VB, Ambadkar PS, Patil CN. Prosthodontic approach in management of prolonged neonatal intubation. J Clin Diagn Res 2016;10:ZD19-20.
Richards SD. A method for securing pediatric endotracheal tubes. Anesth Analg 1981;60:224-5.
Erenberg A, Nowak A. Appliance for stabilizing orogastric and orotracheal tubes in infants. Crit Care Med 1984;12:669-71.
McCourt JW. Neonatal palatal appliance: Light cured resin material and flexible design. Pediatr Dent 1992;14:256-9.
Gonten AS, Meyer JB, Kim AK. Dental management of neonates requiring prolonged oral intubation. J Prosthodont 1995;4:222-5.
Boutain DM, Foreman SW, Hitti JE. Interconception challenges of women who had prior preterm births. J Obstet Gynecol Neonatal Nurs 2017;46:209-19.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]