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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 170-177

Oral mucosal lesions in newborns: Relationship with prematurity, low birth weight, and associated factors


1 Department of Pediatric Dentistry, Dental School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
2 Department of Pediatrics, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Date of Submission22-Dec-2020
Date of Acceptance22-Apr-2021
Date of Web Publication28-Jul-2021

Correspondence Address:
Poliana Valdelice Cruz
Department of Pediatric Dentistry, Faculty of Dentistry, Federal University of Minas Gerais Av. Antonio Carlos 6627, Belo Horizonte, MG, 31270-901
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_209_20

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  Abstract 


Background: An increase in prematurity and low birth weight (LBW) has been observed worldwide, to which several factors may be associated. This cross-sectional study aimed to evaluate the relationship between gestational age and LBW with oral mucosal lesions in newborns, maternal health conditions, newborn health conditions, and socioeconomic levels. Materials and Methods: The sample was comprised of 431 pairs of mothers-newborns born from a high and medium complexity hospital (CAAE nº: 57295316.3.0000.5149). Maternal health conditions and childbirth information were collected through the medical records and mothers answered a questionnaire on socioeconomic indicators. Oral mucosal lesions were evaluated by oral clinical examination. Gestational age and birth weight were analyzed, together with oral mucosal lesions and related factors, through bivariate and multivariate logistic regression models (α = 5%). Results: Prematurity and LBW were associated with Epstein pearls (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.03–3.0; OR: 1.8; 95% CI: 1.1–3.2, respectively) and mucocele (OR: 4.6; 95% CI: 1.3–16.1; OR: 3.7; 95% CI: 1.1–13.1, respectively), but not ankyloglossia (OR: 1.0; 95% CI: 0.5–2.1; OR: 0.7; 95% CI: 0.3–1.6, respectively) or breastfeeding (OR: 0.5; 95% CI: 0.1-2.1; OR: 1.9; 95% IC: 0.2–15.6, respectively). Conclusion: Preterm and LBW newborns were more likely to have Epstein pearls and mucocele than full terms. Breastfeeding and ankyloglossia were not associated with prematurity and LBW.

Keywords: Low birth weight, newborn, oral mucosal lesion, oral pathology, preterm birth


How to cite this article:
Cruz PV, Bendo CB, Bouzada MC, Machado MG, Martins CC. Oral mucosal lesions in newborns: Relationship with prematurity, low birth weight, and associated factors. J Clin Neonatol 2021;10:170-7

How to cite this URL:
Cruz PV, Bendo CB, Bouzada MC, Machado MG, Martins CC. Oral mucosal lesions in newborns: Relationship with prematurity, low birth weight, and associated factors. J Clin Neonatol [serial online] 2021 [cited 2021 Sep 17];10:170-7. Available from: https://www.jcnonweb.com/text.asp?2021/10/3/170/322531




  Introduction Top


Premature infants are those born with a gestational age of 36 weeks and 6 days or less. Low birth weight (LBW) is defined as a newborn with <2500 g.[1],[2] These conditions may have short and long-term consequences on neonatal health.[3],[4] The care offered throughout the gestational and postnatal period, for both mother and newborn, must consist of early identification of possible health risk factors.[5] Preterm birth can affect craniofacial complex structures,[6],[7] since the shorter the gestational age at birth, the greater the risk of congenital changes.[8] Thus, oral clinical alterations in newborns are very common, such as inclusion cysts, mucocele, and ankyloglossia.[6],[7],[8],[9]

The inclusion cysts are classified according to their location: (1) Epstein pearls occur in the region of the mean palatine raphe, (2) Bohn's nodules occur on the buccal or lingual surfaces of the alveolar ridge, and (3) dental lamina cysts occur bilaterally on the maxillary or mandibular alveolar ridge.[10] Most of these alterations are rarely observed after the first month of life due to their inoculum and/or transitory character.[11] However, there are cases in which these cysts occur more severely, leading to the occurrence of secondary lesions in the oral mucosa, causing pain and difficulties during breastfeeding,[12] and consequently to early weaning.

Mucocele is a benign oral lesion commonly found in newborns and may be caused by mechanical trauma, resulting in the rupture of the secretory ducts of the salivary glands, which leads to the formation of a cystic cavity filled with mucus. Mucoceles can be found on the lips and cheeks, as well as on the floor of the mouth.[13]

Ankyloglossia is characterized when there is a shortening or thickening of the lingual frenulum. These characteristics can lead to a decrease in the free lingual portion, which in turn causes functional restriction, which may interfere with speech, in the position of the dental arches and teeth, although it does not seem to affect breastfeeding.[14],[15],[16]

Although oral mucosal lesions have been discussed previously, most studies are only descriptive.[10],[11],[12] Two studies evaluated the relationship between inclusion cysts and prematurity and LBW.[9],[17] However, other types of oral mucosal lesions other than inclusion cysts were not analyzed. It is important that health professionals closely monitor pregnant women and the fetus during pregnancy, at all levels of complexity, to maintain the health of the newborn. Therefore, it is necessary to identify possible oral changes that may be associated with the general health condition of newborns and that may influence early weaning. Thus, our study aimed to evaluate the relationship between gestational age and LBW with oral mucosal lesions in newborns and associated factors.


  Materials and Methods Top


This cross-sectional study was conducted at a University Hospital, a reference center in care for pregnant women under gestational risk, located in Belo Horizonte, Brazil. Data were collected from August 2016 to April 2017, and the study was approved by the Human Research Ethics Committee of the Federal University of Minas Gerais (CAAE # 57295316.3.00005149). The inclusion criteria were: all mothers who were hospitalized at the time of data collection and their newborns of both sexes. The exclusion criteria were newborns with neurological disabilities, craniofacial anomalies, and heart disease at birth reported on the medical records. Those mothers who agreed to participate signed an informed consent form.

The sample size was calculated using a prevalence of 56.4% of oral mucosal lesions,[18] with a margin of error of 5% and a 95% confidence interval (CI). A minimum sample of 378 newborns was determined, and 20% were added to compensate for possible losses, generating an estimated final sample of 453 newborns.

A theoretical training exercise was performed through pictures of oral mucosal lesions, followed by an oral clinical examination in newborns who did not participate in the main study. Calibration was conducted by a gold standard, expert in pediatric dentistry. The kappa value was 0.90 for inter-examiner agreement between the examiner and the gold standard.

A pilot study was conducted with 10 pairs of mothers/newborns before the main study. Participants were selected at the same hospital where the main study was conducted. As there were no intercurrences at this stage and no changes were necessary, all participants were included in the main study. The questionnaire and clinical examinationss were adequate.

Oral mucosal lesions were clinically diagnosed by the calibrated examiner. The newborns were lying down in their hospital crib and the examiner used a sterile clinical mirror, cotton swab, and artificial headlight. A research assistant took notes during oral examinations. The research team used appropriate personal protective equipment. The evaluated oral mucosal lesions included: Epstein Pearls, dental lamina cysts, Bohn's nodules, ankyloglossia, and mucocele, as described elsewhere.[9]

Through newborn's medical records, we collected the following data: newborn's sex, gestational age, birth weight, presence of infections (parasitic and viral infectious diseases, such as candidiasis, syphilis, human immunodeficiency virus [HIV] and infections caused by maternal urinary tract infection), need to be in the incubator, and admission to a neonatal intensive care unit (NICU) before being examined at the rooming-in.

The mothers were approached by the researchers in their hospital beds in the Rooming-in and filled a structured questionnaire with information on gestational habits, use of medications during pregnancy, history of previous diseases, and socioeconomic level (defined according to the monthly family income and the Brazilian minimum wage[9]).

Data were also collected related to mothers through medical records: sexually transmitted infections (HIV, Syphilis), previous health changes (parasitic and viral infectious diseases, cancers, Diabetes Mellitus), type of childbirth (vaginal childbirth, cesarean birth), and high-risk pregnancy. High-risk pregnancy was collected through the medical records, defined by complications developed during pregnancy or pre-existing comorbidities during pregnancy.[4] The following conditions were considered high-risk pregnancy: diabetes mellitus, infectious diseases (HIV, Syphilis), anemia, hypertensive disorders (chronic hypertension, eclampsia, pre-eclampsia), cardiovascular disease, respiratory diseases, and changes in amniotic fluid volume (polyhydramnios/oligohydramnios).

The main variables were categorized as: birth weight (≥2500g; <2500g) and gestational age (full-term: ≥37 weeks; preterm: <37 weeks).

The other variables were categorized as type of childbirth (vaginal childbirth/cesarean section), newborn sex (female/male), mother's age (up to 19 years; 20 to 35 years; 36 years and over), and socioeconomic level. The socioeconomic level was categorized as “high” and “low” according to the questionnaire of the standard criterion of economic classification of the Brazilian Association of Research Companies, as described elsewhere.[19] The other variables were dichotomized into “yes” for the presence of the condition and “no” for the absence of the condition.

Data were entered into the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA: IBM Corp.).

Data analysis included descriptive statistics (frequency distribution, mean, and standard deviation). Bivariate and multivariate logistic regression analyses were conducted to verify the association between preterm birth or birth weight and other variables. The quality of models was tested by the Hosmer–Lemeshow test. Model #1 (bivariate analysis), which included all variables, was not adjusted. Model #2 included all the independent variables with P < 0.20. For Model #3, we looked for a better fit model than Model #2, when appropriate.


  Results Top


The final sample was comprised of 431 pairs of mothers/newborns. The response rate was 95% and only 5.0% of the sample was excluded from the study due to incorrect completion of the questionnaire. Seventy-three newborns (16.9%) were preterms and 69 (16%) were LBW. The mean maternal age was 27.3 years ± 7.12 (minimum = 15; maximum = 59 years). Of the total of newborns, 54.1% were males, with an average of 3.0 ± 3.4 days of life.

The minimum weight at birth was 1.690 kg and the maximum weight was 4.700 kg (mean = 3.056 kg ± 531.26 g). The minimum preterm birth was 33 weeks and the maximum full-term birth was 42 weeks (mean = 38.2 weeks ± 1.83).

[Table 1] shows bivariate (Model #1) and multivariate (Models #2 and #3) analyses for comparison between preterm and full-term birth. Data for gestational age were missing on 13 of the medical records, and 418 newborns were included in this analysis. Model #1 showed that babies who were not breastfed (odds ratio [OR]: 0.5; 95% CI: 0.1–2.1) and who presented ankyloglossia (OR: 1.0; 95% CI: 0.5–2.1) were not associated with prematurity. NICU and incubator were collinear variables (P < 0.001), and NICU was removed from the final adjusted multivariate model (Model #3). The type of birth and previous health change was also removed for a better adjustment of the model (Hosmer and Lemeshow test- P = 0.708). Model #3 showed that newborns that had Epstein pearls had a 1.7-fold greater chance (OR: 1.7; 95% CI: 1.03–-3.0) of belonging to the preterm group than did those without Epstein pearls. Newborns who presented mucocele had a 4.6-fold greater chance (OR: 4.6; 95% CI: 1.3–16.1) of belonging to the preterm group than those without mucocele. Also associated with high-risk pregnancy were prematurity (OR: 2.3; 95% CI: 1.3–3.9), being in the incubator (OR: 3.2; 95% CI: 1.7–5.9), and low socioeconomic status (OR: 2.4; 95% CI: 1.1–5.2).
Table 1: Bivariate and multivariate association between gestational age and other variables

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[Table 2] shows bivariate (Model #1) and multivariate (Models #2) analyses for birth weight. There were six missing pieces of data for birth weight on the medical records, and 425 newborns were included in this analysis. Breastfeeding (OR: 1.9; 95% CI: 0.2–15.6) and ankyloglossia (OR: 0.7; 95% CI: 0.3–1.6) were also not associated with LBW (Model 1). Model #2 included all variables with P < 0.20 in the bivariate analyzes (Model #1), and the Hosmer and Lemeshow test showed a good adjustment (P = 0.969). Thus, Model #2 showed that newborns with mucocele presented a 3.7-fold greater chance (OR: 3.7; 95% CI: 1.1–13.1) of belonging to the LBW group. Likewise, newborns with Epstein pearls presented a 1.8-fold greater chance (OR: 1.8; 95% CI: 1.1–3.2) of belonging to the LBW group, when compared to those newborns without these oral mucosal lesions.
Table 2: Bivariate and multivariate association between birth weight and other variables

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  Discussion Top


This study demonstrated that Epstein pearls and mucocele were more frequent oral mucosal lesions in preterm birth and LBW newborns.

Preterm and LBW have a high collinearity[9] and present similar associated factors. As expected, the main problems arising from high-risk pregnancy are preterm birth and LBW. These factors are unfavorable for postnatal newborn survival.[20] High-risk pregnancy comprises a wide range of clinical and obstetric conditions and may compromise the healthy course of pregnancy.[4],[20],[21] When there are one or more risk factors related to maternal and/or fetal factors, an interaction can be observed between systemic components leading to adverse pregnancy outcomes.[4],[20],[21] About 15% of pregnant women develop some type of complication during pregnancy. These pregnant women need specific care, as their health status directly influences the fetal health status.[20]

Some studies did not find a significant association between birth weight, gestational age, and oral inclusion cysts.[17],[22],[23],[24] Another study of 60 preterm and 60 term newborns found that oral inclusion cysts were not associated with prematurity and LBW, but were positively associated with increased gestational age and weight gain.[11] Studies have shown that premature birth can affect craniofacial complex morphology,[6],[7] and the shorter the gestational period presented at birth, the greater the risk of congenital changes.[17] Epstein pearls tend to disappear spontaneously soon after birth.[18] A possible hypothesis that justifies the association found in this study is that newborns did not complete adequate gestational weeks for full development and there was not enough time for the remission of these lesions, that is, the more premature the newborn, the greater the chance of Epstein pearls to be present.[9]

Mucocele was associated with prematurity and LBW in the present study. The etiology of mucocele is mainly due to trauma and subsequent obstruction of the salivary glands.[13] Many preterm and LBW infants may be hospitalized in neonatal units and use neonatal intubation. Prolonged or incorrectly placed neonatal intubation can cause palatal groove formation by pressure against the hard palate, infection, laryngeal or tracheal edema, tracheal stenosis, and vocal cord injuries. However, injuries to the oral mucosa are less frequent than injuries to the nasal mucosa.[25] However, our newborns did not undergo neonatal intubation through the oral cavity, but rather through the nose. Other possible causes of mucocele are problems due to breastfeeding,[13] in utero thumb sucking, damages in oral mucosa during the passage in the birth canal, and the use of forceps.[26] Moreover, newborns hospitalized at the NICU or at the incubator may be more manipulated than newborns that are discharged from the hospital right after birth. However, one case report showed that mucocele is not frequent in newborns,[27] although the data are not from an epidemiological study. Moreover, the present found a low frequency of mucocele (n = 14 cases, 3.4%).

In fact, preterm and LBW newborns were more hospitalized at the NICU and the incubator. When the health status of the newborn is affected as a result of complications related to maternal and/or fetal health, the newborn may need specific care at the NICU and/or incubator,[18] be it for weight gain, thermal regulation, or cardiorespiratory stability.[28],[29]

Ankyloglossia proved not to be associated with prematurity and LBW. In our study, the diagnostic criterion used was that proposed by Martinelli et al.[30]

Language development occurs between the 8th and 11th week of gestational period. At this stage, the cells of the frenulum undergo apoptosis and migrate to the median portion of the lingual dorsum. When there is interference in this process, the condition of ankyloglossia is installed.[31] Its relation to breastfeeding is controversial. Some studies relate the occurrence of ankyloglossia to functional problems linked to milk sucking, swallowing, and weight gain.[32],[33] Other studies do not support this association between ankyloglossia and breastfeeding.[16],[34],[35]

The difference in the distribution of preterm newborns and LBW in relation to full-term and NBW newborns can be considered a limiting factor in this study. Future studies should follow-up on newborns to consolidate the results found in this study.


  Conclusion Top


Epstein pearls and mucocele more commonly occurred in preterm and LBW newborns. These lesions can be transient and do not present risks. However, it is necessary to know the clinical characteristics of these lesions so that appropriate management would be performed if clinical interventions are needed. In many cases, the health professional may not identify the presence of oral lesions in newborns or can misdiagnose them with other oral alterations. There may be situations where parents or caregivers may notice the presence of some oral mucosal lesions, resulting in their search for oral health care.[36]

The results found in this study emphasize the relevance of knowing adverse health problems in specific populations. There are situations where oral mucosal lesions can compromise the newborn's performance during breastfeeding. This dysfunction can lead to early weaning.[37] Thus, future studies should investigate oral mucosal lesions as possible risk factors for early weaning.

Acknowledgements

The authors thank all the medical and nursing staff at the University Hospital of the Universidade Federal de Minas Gerais, for all information and authorization.

Financial support and sponsorship

This study was supported by the National Council for Scientific and Technological Development (CNPq), the Coordination for the Improvement of Higher Education Personnel (CAPES) – Finance code 001, the Minas Gerais State Research Foundation (FAPEMIG, process #APQ-00323-17) and Pró-Reitoria de Pesquisa da Universidade Federal de Minas Gerais (PRPq-UFMG).

Conflicts of interest

There are no conflicts of interest.



 
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