Oral health status and dental care for hospitalized patients with facial fractures

Objective: to analyze the oral health profile of inpatients victims of oral and maxillofacial trauma at the Institute Dr. José Frota Hospital, Ceará, Brazil. Methodology: a study carried out in 2020 started with an examination of the oral cavity at the bedside, application of the DMFT and The Bedside Oral Exam indexes, together with the survey of dental needs and application of the Oral Health Impact Profile Scale (OHIP-14), relating the findings, applying average, standard deviation and calculating Cronbach's alpha coefficient and Spearman's correlation for the OHIP-14 finding. Results: We evaluated 78 patients, mostly male (88%), with a mean age of 32.72 ± 11.63 years old, with hypertension being the most prevalent comorbidity. Besides, 60% of the sample had a fracture in the lower third of the face. The average number of decayed teeth per patient was 5.69. About 62.82% had poor oral health, seen from generalized biofilm and swollen gums. LowLevel Laser therapy was indicated for 94.8% of the sample, periodontal treatment in 58.9%, restorative therapy in 69.2%, and surgical in 42.3%. Regarding the OHIP-14 questionnaire, facial trauma negatively impacted the participants' quality of life, especially in dimensions related to pain. Conclusion: there was a significant prevalence of oral diseases, such as gingivitis and dental caries, which justifies the need for dental intervention before the maxillofacial surgical approach.


Introduction
The word trauma comes from the Greek "traûma", which means "wound", characterized by a violent action injury, originating outside the organism, representing a costly injury to the Unified Health System. In the meantime, the World Health Organization (WHO) estimates that the global number of deaths from trauma will reach 2.4 million in 2030 (WHO, 2018).
The oral and maxillofacial traumas are associated with various etiological factors, such as negligence in traffic, drug and alcohol abuse, and interpersonal violence, influenced by the population's lifestyle and psychosocioeconomic status (Abosadegh & Rahman, 2018). An epidemiological study carried out in the United States revealed that most of the admissions to the emergency department were men who were victims of motorcycle accidents, affected by open and closed mandibular fractures (Allareddy et al., 2011).
In a complementary way, in facial traumas, the repercussions and/or sequelae are associated both with the stomatognathic functional condition and with the physical and mental well-being, with repercussions from the hospitalization period until the conditioning after discharge (Conforte et al., 2016;Prashanth et al., 2015;Kaukola et al., 2015).
In the literature, the OHIP-14 questionnaire is used to measure the perception of the influence of oral health on the social sphere and quality of life. In this perspective, Conforte et al. (2016) and Lewandowski et al. (2018) reinforced that the immediate post-traumatic period is associated with the prevalence of pain complaints and difficulty in eating, as well as limitations due to hospitalization. Thus, the hospitalization process may compromise the oral health of patients, as a result of limitations in performing self-care, given the weakness of their condition, impacting well-being and increasing the risk of secondary infections (Fiske et al., 2000;Needleman et al., 2012).
Thus, although oral diseases represent preventable diseases, inequality in access and use of dental services in Brazil contributes to the process of developing caries and periodontal disease in the population, negatively influencing identity and interpersonal relationships. Dental caries represents the most common oral disease among the population, with the most common etiological agents to S. mutans and Lactobacillus, being associated with oral pain and loss of teeth (Needleman et al., 2012; (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i8.16637 BRASIL, 2010;Peres et al., 2019).
In studies carried out in Brazilian public hospitals, we can observe a sample of the population affected by carious lesions and periodontal disease. The panorama is described by Souza et al. (2017), from an integrative review, revealed that most of the hospitalized patients had periodontal problems, reinforcing the need for treatment and implementation of oral hygiene instructions, aiming at the prevention of oral infections that may progress to secondary infections.
Given the high incidence of facial bone trauma, which is dynamic and with a high risk of contamination of the surgical site, the hospital dentist and the maxillofacial surgeon need to know the clinical, dental, and psychological profile of the patient for effective therapy and to avoid secondary infections in the postoperative period for this patient. The literature is scarce when it comes to dental care protocols for hospitalized trauma victims.
We believe that this population has a high rate of caries and gingivitis, causing pain and discomfort, and the need for intervention to adapt the mouth. This study seeks to characterize the incidence of fractures in the face region and the impacts of trauma on the quality of life and oral health conditions of patients admitted to the Hospital Instituto Dr. José Frota.

Study population
This is a cross-sectional, descriptive, and analytical study, with a quantitative approach. The inclusion criteria were patients

Oral Condition Assessment
We evaluated the patients on the hospitalization bed in the emergency room of the hospital and invited them to participate in the research. When they agreed, they signed the Informed Consent Form (ICF). A single researcher performed the data collection through a clinical-dental examination, carried out at the bedside, with the aid of artificial light (headlamp), wooden spatula, blunttip probe, and sterile gauze, to dry surface, respecting biosafety criteria. The Bedside Oral Exam (BOE) index (Prendergast et al., 2012) assessed the mucosal integrity. In its original proposal, it is used as an oral health measure in patients admitted to Intensive Care Units, enabling the evaluation of eight subtitles: swallow, lips, tongue, saliva, mucous membranes, gingiva, teeth or dentures, and odor. A change was made to the "tongue" category, and the presence of a lingual coating was added for this research. Total scores range from 8 (excellent oral health) to 24 (poor oral health). For the caries diagnosis, we used the DMFT index (WHO, 1998) that expresses the sum of decayed, missing, and filled teeth. High values of this index reflect poor oral health conditions. After the oral examination, the dental needs of the participants were raised: restorative, endodontic, surgical, periodontal therapy, semi-rigid containment, and use of low-power laser.

Quality of Life Assessment
To assess the participants' quality of life, we applied the OHIP-14 questionnaire (Conforte et al., 2016), adapting the end of each sentence, replacing the phrase "because of problems with your teeth, mouth or denture" with "after suffering facial trauma".

Data Analysis and Statistics
We tabulated the data in Microsoft Excel 2010 (MICROSOFT CORPORATION, 2010) and expressed it in the form of absolute frequency, percentage, average, and standard deviation. Data from the OHIP-14 questionnaire were exported to SPSS version 20.0 (Windows), adopting 95% confidence in the analyzes. The averages, standard deviations, and frequencies of each item and each domain were calculated and submitted to internal consistency analysis by calculating the total Cronbach's alpha coefficient and if the item/domain was deleted. Spearman's correlation was performed to correlate each item/domain with the overall OHIP-14 score. The OHIP-14 scores and BOE categories were categorized based on the median (29) at low (<29) and high (30+) dissatisfaction with the quality of life-related to oral health and two categories were created (very satisfactory vs. not very satisfactory) which were associated with other variables using Fisher's exact test or Pearson's chi-square test.

Oral Health Condition
When performing the BOE exam most patients had Moderately Impaired Oral Health (Table 2). When we crossed the DMFT data with the age group, the highest average of this index was found in the fifth decade of life, with a value of 9.9 due to the  Figure 1).   Source: SPSS v20.0.

Quality of life assessment
Severe pains in the mouth were experienced "frequently" and "always" by a total of 48 people (61.54%), while discomfort during feeding by 46 (58.97%). Speech limitations occurred "always" in 24 (30.77%) of the patients and "never" in 13 (16.67%) of them. Another finding of the study was that patients who presented fractures of the maxilla and/or mandible had a greater negative impact on the dimensions of "social disability", "physical pain" and "physical disability", with percentages of 97.66%, 86.72 %, and 74.22%, respectively, as shown in the table below. There was an impact on the questionnaire, with worsening quality of life, for patients with moderate lip assessment and unpleasant odor (Table 4 and 5).

Discussion
According to the survey data, the incidence of maxillofacial trauma was higher among males (88%), with the third decade of life being the age group with the greatest involvement, representing 33.33% of cases. These findings are similar to other studies (Abosadegh & Rahman, 2018;Allareddy et al., 2011;Gupta et al., 2009;Einy et al., 2016) when they highlighted the male gender as the majority and being victims of urban violence and traffic accidents and average young age.
In the research, the main associated etiological factors were motorcycle accidents and accidents related to aggression, associated or not with drug use. The panorama seen can be attributed to the fact that this age group is often involved in the inadequate and careless driving of motorcycles, coupled with the increase in the number of vehicles, non-use of helmets, and the growing urban violence according to literature data (Abosadegh & Rahman, 2018;Einy et al., 2016).
Due to the discomfort from pathological changes after the hospitalization period, and changes in routine and habits (Sousa et al., 2014) many hospitalized patients neglect oral and body hygiene care, reducing the frequency of tooth brushing, which favors the creation of a favorable environment for the development and maturation of dental biofilm (Carrilho et al., 2011;Amaral et al., 2018).
The results obtained, using the BOE index, reinforced the deficiency in the oral health of the sample (62.82%), seen from inflammation and gingival edema (56.41%), combined with the presence of generalized biofilm in teeth. Among the participants with the worst score on the BOE index, there was worse control of dental plaque and the presence of a thick tongue coating. This shows that these patients already arrived at the hospital with an acute oral health condition, with the need to intervene previously to avoid worsening the systemic and local condition.
According to data from the last epidemiological survey on oral health in Brazil, SB Brasil (2010), the average DMFT for the 35-44 age group was 16.75, while the Northeast region had an average of 1.99 decayed teeth and 8.92 missing teeth. However, the survey reflects a lower average value when compared with the last national and regional census average, however alarming, considering that 80% of the patients had dental caries.
Also, the average of 15.2 teeth lost in the age group from 51 to 60 years stands out, revealing that, over the years, the degree of edentulism increases, similar to the one in the literature, which suggests the worsening in oral health with advancing age (Carrilho et al., 2011). Consequently, Amaral et al. (2018) in their clinical study, obtained an average DMFT of 17.9, with 1.95 decayed teeth, while 68.9% needed for restorative treatment, emphasizing the demand for oral health and the presence of the dental surgeon in the multi-professional teams to establish an oral care routine.
The bidirectional relationship of oral and systemic diseases is already well documented in the literature, together with the high risk of worsening (Lewandowski et al., 2018;Peres et al., 2019). Among the study participants, 76 patients (97.44%) needed preoperative clinical and dental follow-up, where 12.82% had a chronic pathology common to the Brazilian population, such as systemic arterial hypertension. Indication of extractions, given the presence of root remains or teeth with extensive coronary destruction, restorative treatment, and periodontal therapy were corresponding to procedures, mostly of moderate complexity, routine to the dentist's clinic. Also, 23 participants (29.49%) reported some major dental complaints related to dental-alveolar trauma or dental pain. Thus, based on studies, there is a significant number of patients who need treatment in the hospital for dental pains (Carrilho et al., 2011;Amaral et al. (2018).
For patients diagnosed with paresthesia and/or facial paralysis, post-trauma, and neural injury, we indicated a low-level laser treatment (94.87%), also titled Laser therapy, and more recently, Photobiomodulation (PBM). Infrared light therapy is noninvasive, effective, which is based on a photochemical effect and has positive effects on axonal growth and regeneration of neural injuries in vivo (Merigo et al., 2019;Qi et al., 2020).
In the OHIP-14 questionnaire, we found that the trauma interfered with the participants' quality of life, especially in the Research, Society and Development, v. 10, n. 8, e15810816637, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i8.16637 social, pain, and physical disability dimensions. Since 51% of the patients had more than one bone in the fractured face, increasing the complexity of treatment, the main complaints reported during the clinical and dental examination were: "pain in the teeth when I speak", "bad to brush my teeth", "teeth don't fit, it's bad to eat", "pain in the broken tooth" and "pain in that root tooth". Conforte et al. (2016) talk about a similar pattern of facial fractures and their impact on patients' quality of life, especially in the areas of functional disability and physical pain, immediately after the trauma. Nevertheless, outcomes related to psychological and social disability are seen less frequently. However, despite the lower number of patients reporting impacts related to shame, they reported concern about their physical appearance due to fracture features, bruises on the face, or facial paralysis.
Many patients were hopeful in improving physical comfort after definitive surgical treatment, since oral-maxillofacial trauma affected the physical pain dimension, especially during feeding, similar to the findings of Magalhães et al. (2018) after analyzing events of condyle fracture, suggesting that, for the success of surgical treatment, in addition to the patient's clinical conditions, the psychological sphere should be considered.
The mobility of fractured mandibular stumps causes discomfort due to friction in the periosteum region (Lewandowski et al., 2018). For this reason, patients who had a mandible fracture exhibited greater complaints about the food, even with a mild or liquid diet, and in the pronunciation of words. In this sense, studies (Lewandowski et al., 2018;Omeje et al., 2015) emphasize the need for special management for these patients, due to the presence of multiple fractures and exacerbation of painful symptoms during manipulation. For the treatment of oral adequacy of these patients, the use of a good local anesthetic technique and immobilization of the segments fractured is recommended for greater patient comfort.
The limitations of the research correspond to the limited sample size, a panorama that, in part, is due to the pandemic of COVID-19. We could not assess the effects of dental procedures performed before definitive surgical treatment and their impact on the patient's well-being. Given the results, we need to elaborate an intervention plan for the adequacy of the oral health of these patients before the definitive surgical approach, seeking to reduce the risks of postoperative infections, especially patients with different foci of infection and multiple fractures of the face, given limitation and difficulty of oral hygiene caused by the accident.

Conclusion
Most patients needed dental intervention in a hospital environment, evidenced by the presence of periodontal disease and dental caries. Facial trauma inferred repercussions on the quality of life, affecting aspects of speech, food, and general well-being.
Also, multiple fractures in the face reflected the participants' neglect of oral care. We conclude that patients indicate oral adequacy before the treatment of definitive fractures.