Orofacial rehabilitation after severe orofacial and neck burn: Experience in a Brazilian burn reference centre
Introduction
Severe burns to the orofacial region undergoing reconstructive surgery may result in complications that extend beyond aesthetic sequelae [1]. These complications usually derive from orofacial contractures and microstomia [2,3]. According to the literature, patients with partial and/or full thickness burns to the head and neck, besides presenting distorted facial expression, can also present functional limitations, especially restrictions in oral opening and closure (i.e. impact on oral intake and speech articulation, chronic drooling, poor dental hygiene, poor oral access for intubation) [[4], [5], [6], [7], [8]]. Moreover, limitations of the oral movements can also have a direct negative impact on the efficiency of swallowing (i.e. dysphagia) [9,10]. Studies have described oral-phase (i.e. one of the swallowing phases — food is chewed and mixed with saliva to form a soft consistency called a bolus. The tongue then moves the bolus toward the back of the mouth) difficulties, causing poor range of motion of the lips, cheek and jaw [9,10]. When daily activities cannot be performed optimally, physical health can be affected as well as the individual’s quality of life [11,12].
Typically, wound healing is a dynamic process, consisting of four integrated, precise and overlapping phases: hemostasis, inflammation, proliferation and tissue remodeling [13]. Adequate remodeling should result in a minimally visible scar tissue [[14], [15], [16]]. Although scar formation is an expected result of wound healing, in burn victims the wound healing process may result in keloids and fibrotic hypertrophic scars [[14], [15], [16]]. According to the literature, 30–90 percent of patients following burns will present hypertrophic scars [17,18]. Prolonged inflammation at the wound site, with the wound healing process lasting longer than 21 days, is the most important risk factor [17,19]. Other risk factors for hypertrophic scarring include infection, deep full-thickness burns, darker color of skin and location of burns (e.g. neck and cheeks) [17]. While hypertrophic scars develop within one to three months after injury, keloid scars may appear up to 12 months after injury [20]. Keloidal scarring, although less frequent in patients with orofacial burns, is one of the most frustrating problems in wound healing and usually results in greater disfigurement. Clinically, keloids are defined as scars that spread beyond the margins of the original wound, invading healthy tissue [21]. They are elevated in appearance (i.e. elevation levels can reach more than 0.5 cm above skin level), can become pruritic and/or painful and rarely regress over time [22].
Considering rehabilitation of patients with burn injuries, the literature accepts that full thickness injury of the orofacial region is a complex area to treat, since it is prone to persistent scarring and contractures, especially when considering the oral region [5]. There is a general understanding that the management of orofacial contracture benefits from a collaborative teamwork to achieve the best outcome possible for every patient [23]. Over the last decade, different health professionals (i.e. medical doctors, physiotherapists, speech-language pathologists and nurses) have been involved in a handful of studies describing the outcomes of treatments for orofacial contractures. Despite the several treatment techniques that have been described to manage patients with facial contractions and to prevent hypertrophic scar formation, there is still limited evidence to support the efficacy of treatments that target the functional rehabilitation of adult patients with orofacial and neck burns [24]. In general, the described techniques involve exercise, massage, pressure, splinting, skin grafting, debridement, drugs and silicone [1,4,5,23,[25], [26], [27], [28], [29], [30]]. Although this existing literature supports the benefits of orofacial contracture rehabilitation, specifically related to vertical and horizontal gains in mouth opening, several limiting factors, such as sample size (i.e. several studies are case reports), retrospective nature of the data, poor description of quantitative and control measurements, compromise the quality of the studies [4].
In Brazil, until the year 2000, the treatment of patients with burn injuries did not present any kind of standardization. It was only after this year that the National Health System established the parameters for the organization and implementation of Burn Reference Centers in the country [31]. Currently, Brazil has 64 registered Burn Reference Centers. Although the European Practice Guidelines for Burn Care recommends the presence of speech-language pathologists (SLPs) as part of the professionals working in burn units [32], SLPs are not yet included as a mandatory part of the burn team within public policies related to burn patients [33]. This issue might be explained by the lack of definition of the SLP scope of practice in burn care and by the lack of evidence that highlight the importance of this professional in addressing the clinical conditions presented by burn-injured patients [34]. According to a study developed in 2016, orofacial contractures are usually managed by a multidisciplinary team, involving medical doctors, nurses, occupational therapists, and physiotherapists. However, SLP involvement in this area of practice was reportedly minimal [34].
The current study aimed to quantify the benefits of a functional oral rehabilitation program for impairment caused by full thickness orofacial and neck burns, comparing the effects of early and late intervention.
Section snippets
Ethics
The study design was approved by the Ethics Committee for the Analysis of Research Projects of the Institution (Protocol no. 1.455.644). Prior to their enrollment, all participants were informed of the purpose and procedures, after which all gave written informed consent.
Participants
An observational cohort study was conducted over a 2-year period (April 2017 to April 2019). Participants of this research were individuals with orofacial and neck burns who were referred to the Division of Oral Myology,
Results
Results of the oral motor clinical assessment for both groups are reported in Table 1. Between pre and post oral rehabilitation program, there was a significant positive improvement noted in all of the assessed aspects for both groups. Considering that the maximum number of points on the OMES-E is 230, both groups of patients presented an overall improvement rate of approximately 15%.
The results of the outcomes regarding the mandibular range of movement for both groups of patients are reported
Discussion
The results of the current study confirm what has already been described in the literature, indicating that patients with full thickness burns to the orofacial region and neck present oral motor functional deficits and limited mandibular range of movements [[1], [2], [3],5,6,43,44]. When looking at the maximum possible scores on the oral motor clinical assessment, patients (i.e. G1 and G2) presented, at the beginning of treatment, a deficit of approximately 30% in each one of the tested
Conclusion
This is one of the few studies with the largest cohort of full thickness burn patients to examine non-invasive orofacial contracture management outcomes. The results of this study indicate that non-invasive orofacial contracture management is effective for patients with orofacial and neck burns, including for patients who receive delayed orofacial functional rehabilitation. Future studies should include a randomized controlled trial comparing different treatment protocols and measurements of
Authors’ contributions
All authors have made substantial intellectual contributions to the conception and design of the study and the analysis and interpretation of the data. All authors have been involved in drafting the manuscript and revising it critically for important intellectual content.
Conflict of interest statement
This paper was unfunded. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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