Minimizing Otitis Media by Manipulating the Primary Dental Occlusion: Case Report
The Journal of Clinical Pediatric Dentistry, Volume 22, Number 3/1998 by Stephen R. Branam / Arthur P. Mourino

INTRODUCTION:
Otitis media is a very common infection in children under three years of age. The infection is a frequent cause for medical treatment to prevent pain and potential hearing loss associated with this infection. Medical management consists of antibiotic treatment and/or myringotomies.

Children with otitis media can have varied skeletal patterns and occlusions with constricted or non-constricted dental arches and open bites or deep dental overbites. The exact role of dental occlusion and mandibular posturing in otitis media occurrence has not been determined scientifically.

This proposed dental procedure is a safe, easy, and a cost effective alternative to long term antibiotic therapy and myringotomies.

See also:
Pacifier Use and Otitis Media

farid@drfarid.com

 613-216-2016

Different components of dental occlusion have been studied, but no study has been performed regarding the disclussion of the primary dentition and the resultant effects on otitis media and symptoms. The patient presented in this article had a malocclusion that would cause posterior positioning or posturing of the mandible. In other words, the mandible could not assume a forward position.

MINIMIZING OTITIS MEDIA

OCCLUSION vs OTITIS MEDIA
Mew and Meredith acknowledge the relationship between ENT problems and posturing of the tongue against the palate with regard to lip seal with the teeth in or near contact. As otolaryngologists they acknowledged that orthodontic palatal expansion allows or enables the mandible to be positioned or postured forward, which increases oral muscle tone. This together with firmer contractions of the tongue and facial muscles when swallowing may provide ENT advantages. They also examined correct oral posturing vs. incorrect oral posturing and the effect on equilibration of the middle ear pressure as the patient swallowed and positioned the tongue against the palate. The exact relationship of the dental occlusion on the middle ear and the Eustachian tube function has not been documented.

Mew showed that rapid and semi-rapid palatal expansion enables the mandible to be brought forward a substantial distance, thus changing the mandibular posture or position. He also acknowledges that the success is sometimes not predictable if functional appliances are used, because some patients do not always adhere to the prescribed wearing instruction or schedule.

Prolonged pacifier use, digital habits, and baby bottle feeding can cause constriction of the maxilla.

The anatomy of the Eustachian tube is closely situated to the nasopharynx. Normally, the Eustachian tube is closed. The tube opens during actions such as swallowing, yawning, or sneezing. This active and passive opening protects the middle ear cavity from reflux of secretions from the nasopharynx. Bluestone reports active opening of the Eustachian tube is caused by tensing of the tensor veli palatini muscle.

The Eustachian tube in an infant is horizontal, and if you bottle feed a child lying down, there is a greater chance of secretions getting into the Eustachian tube. The Eustachian tube becomes more vertical with growth into adulthood. Therefore, the question remains, how does a pacifier, digit habits, and bottle feeding influence this pathogenesis of Eustachian tube malfunction? The teat of a normal pacifier or bottle will reach to the junction of the hard and soft palate in an infant. The sucking action, in turn, will lift the soft palate. The rising of the soft palate will contract the tensor veli palatini muscle. As a result, the Eustachian tube becomes actively patent allowing secretions to enter and eventually otitis media ensues. The maxillary constriction could cause dental malformation also.

CASE REPORT
The patient was a four-year, six-month old female, who presented to the office for a "regular dental exam." Her past medical history revealed that she was a healthy normally developing child with a history of severe ear infections. She had bilateral myringotomies performed at age eleven months and continued to have otitis media infections six to seven times per year to the point that her eardrum had ruptured. The parent was a nurse and preferred not to have myringotomies performed again. She also had a history of using a pacifier on a regular basis until age sixteen months. The dental examination revealed that she was caries free with a Class I skeletal and dental pattern with minimal inter dental spacing and a clinical overbite of 80% and an overjet of 1.0 millimeter. There was some slight constriction of the maxilla and she had no dental crossbite or mandibular functional shifts. She had no caries and very good oral hygiene.

TREATMENT
The mandibular right primary second molar was isolated with cotton rolls and the occlusal surface of the tooth was roughened with a high speed #330 bur and the grooves were accentuated prior to being cleaned with a pointed bristle brush prophy angle and pumice. The occlusal surface was dried with air and etched with 37% phosphoric acid gel for 30 seconds. The acid etch gel was rinsed off the tooth, which was allowed to remain damp, and adhesive was brushed onto the occlussal surface and the excess was blown off with a short blast of air. The adhesive was .... At six months following the resin buildups of the primary molars, the patient has had no ear infections. This same procedure has been done on other similar patients with very comparable results and the patient and parents have been extremely pleased. All patients treated have been ages two years, six months to six years, four months.

DISCUSSION
Otitis media in infants and children is a very common infection, which is of great concern to parents and physicians. The tow most popular methods of treatment to date are placing the patient on a regimen of antibiotic therapy for a long or short term or performing myringotomies. Both methods of treatment have a good success rate, but are not one hundred percent effective. Physicians are quite concerned because some patient populations are becoming resistant to current antibiotic regimens. Therefore, new and stronger antibiotics are needed to treat these patients who experience chronic otitis media episodes. Some parents as well as physicians are reluctant to have myringotomies performed because of the need for general anesthetic for the procedure to be completed. This proposed method of treatment could avoid long term antibiotic therapy and a need for a general anesthetic and surgery. This dental procedure does require a certain degree of cooperation from the patient, who must sit still for at least five to height minutes. The cooperation level is easily increased by administering nitrous oxide and/or giving the patient a very safe level or oral sedation. The most positive aspect of this procedure is that it is painless and does not require local anesthetic, which is also a postoperative concern in these very young children.

CONCLUSION
Posterior acrylic resin bounded to the occlusal surfaces of mandibular second primary molars was found to be an effective method to disclude the primary dentition and reduce or eliminate otitis media in young children between the ages of two to six years of age. The exact relationship between dental occlusion and otitis media has not yet been established and further research is needed in this area. This proposed dental procedure is a safe, easy, and a cost effective alternative to long term antibiotic therapy and myringotomies.