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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 152-159

Oral health status among cleft lip and palate patients in South India: A profile

1 Department of Oral Biology and Genomic Studies, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India
2 Nitte Meenakshi Institute of Craniofacial Surgery, Nitte University, Mangalore, Karnataka, India

Date of Web Publication21-Nov-2017

Correspondence Address:
Shahnawaz Khijmatgar
Department of Oral Biology and Genomic Studies, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte, Mangalore - 575 018, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_43_17

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Background: Cleft lip and palate (CLP) is one of the identified anomalies in India. Many of the CLP cases have compromised oral health status which relates to their quality of life (QoL). Therefore, it is a need to assess their oral health status in terms of dental caries, periodontal disease, hypodontia, malocclusions, etc. Hence, the objective of this study is to investigate the oral health status among CLP cases. Material and Methods: A questionnaire survey was designed for a total of 300 CLP cases that came to the Nitte Meenakshi Institute of Craniofacial Surgery of Nitte University, India, were included in the study. A questionnaire was designed and pretested, and informed consent from the cases and carers was taken. Results: The average mean age of the patients with CLP was 17.48 (3–47). There were 47% males (n = 141) and 53% females (n = 159). 63% (n = 170) of them came from low socioeconomic background. Out of 300 cases, 31.0% (n = 90) had cleft lip; 1.0% (n = 3) had cleft palate, and 67.8% (n = 196) of them had both CLP. Most of the cases, i.e., 65.4% (n = 196) were unilateral CLP and 52.7% (n = 158) had right-sided clefts. The literacy status of the parents, their socioeconomic status, and occupation had a significant interrelation for the occurrence of CLP (P < 0.05). Similarly, diminutive or peg-shaped tooth, hypodontia, facial profile, and absence of lateral incisors in the line of cleft showed a significant association of this CLP condition. There was also strong interrelation between the presence of postoperative intraoral scarring in patients affected with the CLP (P < 0.05). The score for decayed missing and filled teeth (DMFT/dmft) was 5.16 for 6–12 years old and >9 in >13 years old, community periodontal index was between 0 and 2, and the simplified oral hygiene index was 0.9–1.41. There were cases of AQ3 hypodontia, hypomineralization, and malocclusion. The statistical test was performed using ANOVA. Conclusion: We conclude that, there was a moderate dental caries risk. The periodontal status was fair. There was association of occurrence of hypodontia and malocclusions in craniofacial anomalies. This affects their QoL.

Keywords: Key words: Cleft lip, cleft palate, oral health status, quality of life

How to cite this article:
Chowdhury CR, Khijmatgar S, Kishore NP, Shetty V. Oral health status among cleft lip and palate patients in South India: A profile. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:152-9

How to cite this URL:
Chowdhury CR, Khijmatgar S, Kishore NP, Shetty V. Oral health status among cleft lip and palate patients in South India: A profile. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2023 Jun 5];4, Suppl S1:152-9. Available from: https://www.jclpca.org/text.asp?2017/4/3/152/218871

  Introduction Top

Orofacial cleft is the most common anomaly occurring in the craniofacial region. The estimated prevalence is 1.7 in 1000 live births in India.[1] The incidence of cleft lip and palate (CLP) in India ranges between 0.25 and 2.29 per 1000 births. Thirty-five thousand new cleft patients are born in India every year and 1 million cases remain untreated.[1] The data from international registries between 1993 and 1998 suggest that a variation in prevalence of cleft lip with or without cleft palate (CL ± P) is 3.4–22.9 per 10,000 births and an even more pronounced variation for isolated cleft palate (CP) with the prevalence of 1.3–25.3 per 10,000 births.[2]

Dental caries is found to be most prevalent oral ailments among CLP cases; gingivitis, periodontal disease, hypodontia, hypoplasia, and maintenance of poor oral hygiene are also prevalent among CLP cases.[3],[4],[5],[6],[7] The prevalence of associated systemic diseases and those are detected postnatally is 25% among CLP and CL ± P.[8] Several studies have found that the CP also associated with another anomaly (45.9%; range 22.2%–78.3%);[8] such associated anomalies are common among cases of bilateral CLP.[9] The ailments such as hypodontia, hypomineralization, missing teeth in the line of clefts, and impaired growth of maxillary/mandibular jaw bones occur in CLP cases, and some of them suffer from severe malocclusion.[10],[11],[12],[13]

It has been reported that the patients affected with orofacial clefts have poor oral health and they lead a poor quality of life (QoL).[3] The number of factors such as literacy level of their parents, socioeconomic status, and occupation of the parents also contributes to the poor QoL of CLP cases.[14],[15]

Management of these problems in orofacial cleft cases requires an extensive multidisciplinary team and a good coordination between these teams that will highly influence the results of the other. Hence, the objective of this study is to assess the oral health status of CLP cases to improve their QoL by improving oral health status.

  Materials and Methods Top

Survey location

The study was carried out at Department of Oral Biology and Genomic Studies at A. B. Shetty Memorial Institute of Dental Sciences and Nitte Meenakshi Institute of Craniofacial Surgery, Nitte University, Mangalore, India.

Ethical approval

The ethical approval was taken from the Ethics Committee of Indian Academy of Oral Biology.

Sampling criteria

The purpose of the study was explained to the patients and parents of the children below 18 years old. A total of 300 patients who were affected with cleft lip (CL), CP, and CLP and came to the Department of Craniofacial Surgery were included in the study.

Variables recorded

A pretested questionnaire and format was used to record the demographic information, type of cleft, hypodontia, hypomineralisation, decayed missing and filled teeth (DMFT), community periodontal index of treatment need (CPITN), oral hygiene index-simplified (OHI-S), salivary pH, any associated anomalies, intraoral scarring, missing teeth in the line of cleft, skeletal pattern, and profile of the face including another defeats of the CLP cases. The data were collected by examiners who were trained and calibrated for the study, and interexaminers' validity was examined using Kappa test.

The socioeconomic status was categorized as low, average, and high as per criteria set by the Government of India, i.e., below poverty line (BPL). The patients' parents who were farmers, beedi workers and rollers, construction workers, factory laborers, small shopkeepers, drivers, etc., were categorized into low category. The parents who were on service, government, and private company jobs were categorized into the average category and the individuals who are coming from established businesses, jobs in IT, health care, etc., were categorised into high socioeconomic status. To mention about the DMFT: DMFT score 1–4 = low caries status; DMFT score 5–9 = medium caries status, and DMFT score >9 = high caries status. The indices for OHI-S scoring scale: good – 0.0–1.2, fair – 1.3–3.0, and poor when the OHI-S is scored 3.1–6.0.

  Results Top

Demographic variables

A total number of 300 patients affected with CLP were included in the study. The average mean age of the patients with CLP was 17.48 (ranged between 3 and 47 years old). There were 47% males (n = 141) and 53% females (n = 159). About 27% (n = 82) of the patients completed their high school and 63% (n = 170) came from low socioeconomic background. Nearly 40.7% (n = 122) of the patient's parents were working as laborers [Table 1]. Out of the total 300 cases, 67.8% (n = 196) cases affected with CLP, i.e., 31.0% (n = 90) were CL cases and 1.0% (n = 3) were CP cases. Most of them were unilateral cases, 65.4% (n = 196), out of them 52.7% (n = 158) had prominence in their right side of the face. In 23.2% of the cases, the father had tobacco habits (smoking or/and chewing), tobacco before the time of gestation of the mother of cleft cases. Mothers of 10.2% cases were on medication during the period of gestation. Four percent (4.0%) of the cases were associated with the syndrome. Among 9.7% of the cases, it was recorded that the first-grade relatives (blood-related) have got a history of CLP [Table 2]. Almost 43.3% of the cases have diminutive/peg-shaped tooth, 76.3% have hypodontia, 6.4% have systemic disease, 26.4% have retrognathic maxilla, 26.8% have Class III molar relationship, 8.0% have supernumerary teeth, 92.6% have intraoral scarring, 7.0% have hearing difficulties, and 1.3% is suffering from cardiac problems [Table 1].
Table 1: Demographics profile of cleft lip and palate cases

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Table 2: Parental, medication, family pedigree influence in occurrence of cleft lip and palate

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The overall average mean DMFT value is 3.61 [Table 4] [Table 5]. The mean value of OHI-S is 1.31. The CPITN scores are given in [Table 3].
Table 3: Oral health status in cleft lip and palate patients

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Table 4: Analysis of variance test

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Table 5: Post hoc test

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The literacy of parents, socioeconomic status, occupation of the parents, diminutive/peg-shaped tooth, hypodontia, facial profile, absence of laterals in the line of cleft, and intraoral scarring showed a significant association in CLP patients (P < 0.05).

  Discussion Top

Demographic information

Literacy status of the parents

Children's oral health status is often related to social dimensions, such as parental income and education.[15] This is also true in the occurrence of CLP. The parents who are less educated and the parents worked as daily wagers (laborer) in India. Since these jobs are quite stressful, the parents develop recreational habits of tobacco and alcohol drinking which seems to reduce their stress. The results of the study revealed that 23.3% of the (n = 60) parents had a habit of either smoking or tobacco chewing before the period of gestation of a cleft child. Nearly 27.9% (n = 82) of parents completed high school education, 23.8% (n = 70) preuniversity education, and 16.6% (n = 48) university education.

Occupation of a parent

It is reported through many studies that there is an association between the occupation of a parent and risk of developing a congenital defect in newborn infants. Maternal exposure to chemicals such as organic solvents, glycol ethers, pesticides, xylene, toluene, and acetone has also reported to increase the rate of occurrence of CLP cases;[16] however, other studies failed to find a link between pesticides and CLP risk.[1],[17],[18],[19],[20],[21],[22],[23] The reason for this may be due to the number of cases in the study was small, and the measure of exposures was based on census records.[24] In our study, 7.0% (n = 20) of the mothers were involved in labor work and 91.9% (n = 274) were homemakers at the time of gestation. The number of CLP defects was more in homemakers compared to mothers who were involved in labor work. Most of the mothers who were involved in labor work were beedi rollers. Beedi rolling was found to be relatively safe during pregnancy, but it could produce adverse effects if it was continued into the third trimester and for longer durations. This might be due to that fact that other environmental factors were involved.[25]

The father's occupation is also an important factor that needs to be considered as a risk to develop cleft defects. In our study, 40.7% (n = 122) participants were from labor work, 23.3% (n = 70) were from agriculture, and 20.7% (n = 62) were doing business before and at the time of gestation. The number of cleft defects occurring in our study was more in the parent who was associated with labor work followed by the parents who were farmers. The association is quite significant in labors and farmers because they practice unhealthy lifestyles, for example, tobacco smoking, chewing and alcohol consumption, etc. The pesticides used by the farmers for agricultural purposes might also be a contributing factor, but there is still lack of evidence for this to prove.[20]

Socioeconomic status

The association between CLP and socioeconomic status is poorly reported. It was not possible to establish an association due to differential participation in case–control studies and variations in inclusion criteria for cases. In our study, we found that nearly 170 (63.0%) belonged to low socioeconomic group (BPL) and showed a significant risk between the occurrence of CLP. Similar results are confirmed by other studies.[4]

A study by Aggarwal et al. (2014) tried to determine the association between CLP and socioeconomic status by comparing the occurrence of cleft in rural and urban populations. The author found that out of 250 cases, 106 (61.99%) cases were from rural population. The author suggested for further population-based studies that are previously done in US and China.[26],[22]

Dental caries

Our study results found that the prevalence of dental caries among CLP patients from the South Indian subcontinent is 5.16, which indicates moderate caries risk [Table 6]. There are studies which have found similar to our results, i.e., moderate caries to high caries risk in patients with CLP cases.[4],[27],[28],[29],[30],[31],[32] A study by Hewson et al. has found a significant difference in caries experience in permanent teeth of CLP patients.[33] However, some studies have found low caries risk in CLP patients.[6],[8],[11],[26],[34],[35] The differences in these findings might be due to different methodology, factors responsible for dental caries, oral hygiene practices, education awareness, and cultural practices.[3] One of the possible explanations to low caries risk findings is that the patients were intervened at an early age for correction of CLP defects, which might have influenced parents and patients to keep the oral cavity hygienic. A recent meta-analysis has confirmed that the prevalence of dental caries is more in CLP patients compared to noncleft population.[21] The age-specific DMFT is given in [Table 6].
Table 6: Age-specific oral health status

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Saliva pH

Salivary buffering capacity has an important role in individuals' caries risk. The ability of saliva to buffer acids is essential for maintaining pH values in the oral environment above the critical pH (pH-5.5) that protects teeth against demineralization. The normal pH range is between 6 and 7.[36] Our study found that the average mean saliva pH is 6.6 in CLP cases. A study by Cunha-Cruz (1939) tried to find the relationship between salivary pH and dental caries. The study results found that salivary characteristics were associated inconsistently across the different age groups, i.e., low buffering capacity associated with increased rate of dental caries in older individuals (≥60 age) and decreased rate of dental caries in children and adolescents. Cunha-Cruz et al.'s study results show that a low resting salivary pH was not associated with higher caries experience in different age groups. However, resting salivary pH was significant overall. Resting saliva bathes the oral cavity 90 percent of the time, and its pH usually is lower than the pH of stimulated saliva.[29] Studies rarely indicate resting pH as a risk factor for dental caries, but our findings may warrant further investigation.[37]

The difference in salivary profile in CLP cases and normal cases can be explained based on the study conducted by Cheng LL et al. This study found that the CLP cases undergoing orthodontic treatment presented with microbiological and salivary profiles were less favorable for caries development. This is due to regular oral hygiene reinforcement, and dental health education had a positive effect on oral health.[38]

Oral hygiene index-simplified

OHI-S is used most commonly to assess the level of debris and calculus covering the tooth surface. It is seen that the patients with CLP have difficulty in maintaining oral hygiene due to the defect or due to the ongoing orthodontic treatment. Most of our study cases were cleft operated cases with ongoing orthodontic treatment. It has been reported previously, oral hygiene improves more in older CLP cases following reconstruction of palatal vault, premaxilla, and anterior lip seal by secondary bone grafting method when compared with oral hygiene indices results in primary periosteoplasty cases.[39] In our study, we found that the average mean value for OHI-S was found to be 0.90 ± 0.7 in 6–12 years' old patients and 1.41 ± 1.05 in patients >13 years, which lies in fair zone of OHI-S (1.3–3.0). Most of our study participants were above 6–7 years of age (overall mean age = 17.48 years). The age-specific OHI-S is provided in [Table 6].

Community periodontal index of treatment need

CPITN is commonly used for measuring the severity of periodontal disease due to plaque and calculus. According to previous studies, a poor periodontal situation was found in patients with unilateral CLP and alveolus. Our study results of CPITN scores were between 0 and 2 [Table 3]. The most common periodontal problem was bleeding on probing, supra- and sub-gingival calculus, plaque retention factors, and periodontal pockets not >3.5. Since these patients were operated cases and were undergoing orthodontic treatment, some were wearing appliances that might also be a possible reason for periodontal problems.[9],[40],[41] The CPITN scores were similar, i.e., 0–2 in different age groups.

Hypodontia/missing laterals in the line of cleft

There is a varied prevalence of hypodontia across the globe. Hypodontia results due to genetic causes and is transmitted by autosomal dominant inheritance, within complete penetrance and variable expression. Environmental factors, however, may also play a role in the etiology of this condition. The 8% incidence of hypodontia, excluding third molars, reported in normal Finnish children and 31.5% was increased in those affected with an isolated CP.[12] Shapira et al. found an incidence of 74% for missing maxillary lateral incisors and 18% for missing second premolars in children with CL, CP, or both.[42] Hypodontia outside the cleft region was much higher in cleft-affected children than in others. The frequency of missing teeth outside the cleft site for children's affected with CLP, in descending order of magnitude, was 7.5%–32.3% for the maxillary second premolars, 3.1%–10.4% for the maxillary lateral incisors, and 0.4%–10.8% for the mandibular second premolars.[4] Hypodontia was found more frequently in the clefted maxilla than in the mandible, and in unilateral clefts, hypodontia was more often on the same side as the cleft.

The prevalence of hypodontia in the isolated cleft was reported to be 4 times more than that of the noncleft group and higher in the maxilla (six-fold) than in the mandible (three-fold). The increased incidence of hypodontia in children with clefts might be a result of not only the genetic factors directly affecting hypodontia but also of the factors causing the cleft itself. This suggests that the same etiologic factors may be responsible for both the formation of the clefts and the hypodontia in affected children. In our study results, we found that 228 (76.3%) cases had hypodontia and absence of laterals in the line of cleft.

Diminutive or peg-shaped tooth

The congenital absence of the maxillary lateral incisors is associated with other dental changes, both in the size and number of teeth. When not absent, the maxillary lateral incisor on the cleft site is nearly always abnormal in size and shape, and the second premolars show delay in development and eruption. There was a deviation from the normal size and shape of the lateral incisor (small or peg-shaped) on the contralateral side, and the delayed eruption of the second premolars observed in majority of the reports suggestive of mild expression of hypodontia. In all cleft groups, hypodontia was more frequent in girls than in boys, but the differences were not statistically significant.


Enamel hypomineralization is basically a defect without visible loss of enamel, but changes in color and translucency occur. In our study, the enamel hypomineralization was found in 37.0% cases. Previous studies have found enamel hypomineralization in 27% of their study cases.[5]

Facial profile

Patients with unoperated CP demonstrate reduced maxillary length and retruded premaxillary position relative to the cranial base.[18] In our study, 26.4% had retrognathic maxilla and 60.8% had straight profile. Previous cephalometric studies have found that maxillary retrusion was more marked in complete than in incomplete unilateral clefts while mandibular retrusion and maxillary dentoalveolar retroinclination were more marked in bilateral than in unilateral clefts.[19] Our study found similar results, i.e., 41% of CL cases had hypoplastic maxilla alone compared to 30% in both CLP cases.

A study by Bishara et al. tried to look at the dental relationships of individuals with unoperated clefts of the lip and/or palate. The study used 20 un-operated cases from the southern part of India (Kerala). Out of 20 cases, 11 cases were unilateral CLP cases and 9 (83%) out of them had Class I, 2 (17%) Class II, and none had Class III.[43] Our study includes (n = 272) operated cases. We found 62.4% (n = 181) Class I, 2.1% (n = 6) Class II, and 26.8% (n = 80) Class III cases. Our results were similar to study done by Handelman and Pruzansky. The total sample size was n = 26, out of them 69.2% (n = 18) had Class I, 15.4% (n = 4) Class II, and 3.8% (n = 1) Class III malocclusion.[44]

  Conclusion Top

Our study results found that there is a significant association between literacy, occupation, socioeconomic status, periodontal problems, diminutive/peg-shaped tooth, hypodontia, and missing teeth in the line of cleft and hypoplastic maxilla in the occurrence of CLP. A further population-based study and educational intervention is required so that the policy can be introduced to improve the oral health status of the potential risk population and social life of affected patients and support for their parents.


We would like to thank Nitte University for supporting the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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