Integrating dental care as a protocol in the management of children with cleft lip and palate

Gayatri Moghe; Sukhvinder Bindra

doi:10.4103/jclpca.jclpca_34_21

REVIEW ARTICLE

Year : 2022 | Volume : 9 | Issue : 1 | Page : 60-68

Integrating dental care as a protocol in the management of children with cleft lip and palate

Gayatri Moghe¹, Sukhvinder Bindra²
¹ Department of Pediatric Dentistry, Toothbuddies(Comprehensive Cleft Care Centre), Hyderabad, Telangana, India
² Department of Dentistry, Shenoy Hospitals, Secunderabad, Telangana, India

Date of Submission	19-Sep-2021
Date of Acceptance	15-Nov-2021
Date of Web Publication	01-Jan-2022

Correspondence Address:
Dr. Gayatri Moghe
Tooth Buddies (Comprehensive Cleft Care Centre), Hyderabad, Telangana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jclpca.jclpca_34_21

Abstract

Children born with cleft lip/palate need regular dental care from birth till adulthood. Special feeding requirements, maintenance of oral hygiene, prevention and treatment of dental disease are essential components of oral healthcare provided by dental health care personnel. Malaligned teeth and dental anomalies should be addressed by orthodontics, guided by the developmental stage of the child. For the unmet need of dental care to be mitigated, it is essential that the core and coordinating teams be aware of the need for regular dental care visits. Each team needs to formulate sustainable oral health policies in their management protocol.

Keywords: Feeding in cleft child, pit and fissure sealants, preventive dental care, restorative pediatric dentistry

How to cite this article:
Moghe G, Bindra S. Integrating dental care as a protocol in the management of children with cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2022;9:60-8

How to cite this URL:
Moghe G, Bindra S. Integrating dental care as a protocol in the management of children with cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2023 Mar 31];9:60-8. Available from: https://www.jclpca.org/text.asp?2022/9/1/60/333648

Introduction

Oral health is a fundamental component of general health; however, it does not merit as much attention in a cleft/craniofacial team setting where it is considered a secondary specialty and ranks at the lower end of the scale. The COVID-19 pandemic situation has resulted in a heavy backlog of essential cleft care and routine follow-ups have become challenging.

In the last two decades, the surgical facilities helmed by cleft charities have vastly improved access to surgical care. However, in most low- and middle-income countries, there are enormous regional gaps in the quality, availability, and accessibility of dental care. In these regions, oral health-care and ancillary services are available mostly at urban centers. Access to care and type of treatment received depend on parental ability to afford costs of treatment. In addition, there is poor understanding of the typical pathway of cleft intervention, superstitions among patients, little education, and motivation toward regular oral hygiene routines in daily family life. A combination of gene-environment factors increases the oral health complications and impact the quality of life.

The long-term surgical outcome and overall health of a child cleft lip palate (CLP) will depend on the foundation of good oral health. It is important to realize that just like surgical care, dental care for the child with CLP is rarely one procedure at 1 time but rather a culmination of several interventions precisely timed in the growing phase of the child from infancy to adulthood.

Well-crafted guidelines for oral health care promote quality by reducing variations, improving diagnostic accuracy, promoting effective therapy, and discouraging ineffective – or potentially harmful – interventions. However, there is a dearth of integrated high-quality clinical practice guidelines that can be used as universal guidelines by health professionals in a range of disciplines for improving oral health in children and adolescents with cleft problems.^[1]

The objective of this paper is an attempt by the authors to create a “what-when-how- to” manual with oral health-specific preventive, interceptive, therapeutic measures and anticipatory guidance such that can be readily implemented into the management protocol of patients with CLP.

Oral and Dental Health Challenges

The presence of a CLP compromises the precise synchronization in sequence of sucking, swallowing, and breathing 1:1:1 necessary for feeding.^[2],[3],[4] One of the first difficulties faced is nursing. Bottle feeding and use of infant formula thus become a necessary evil, considering that some mothers may be unable to express breast milk due to low milk supply or lack of means. Inherent problems with bottle feeding include the risk of stagnation and pooling of the contents of the bottle. An open communication between oral and nasal cavities places milk and oral secretions in close proximity to the Eustachian tube ^{More Details}, leading to a high risk of middle ear infection.^[5]

Congenital Dental Anomalies

Children born with CLP are at increased risk for congenital dental anomalies, such as malformed/hypoplastic teeth, supernumerary teeth and/or missing teeth, natal teeth and ectopically erupting teeth.^[6],[7],[8] Odontogenesis begins between weeks 5 and 8 of intrauterine life and orofacial clefting that occurs during the same window plays a crucial role in disturbed odontogenesis. The teeth present in the cleft site are thus vulnerable to maldevelopment and injury.

Surgical repair of the cleft may lead to a mesioangular collapse of the lesser segment(s) of the cleft, and potentially, a deficiency in the development of the maxilla, leading to malocclusion. Besides an unfavorable appearance, patients with CLP suffer from malocclusion, periodontal damage, insufficient alveolar bone growth, reduced chewing ability, inarticulate pronunciation, and other problems.

Contributory Factors to Poor Oral Health

Early bacterial colonization of tooth surfaces due to use of intraoral removable appliances for presurgical nasoalveolar molding ^{[9],[10],[11]}
Limited parental understanding, poor motivation, and substandard oral hygiene routines since infancy^[12],[13]
Decreased flexibility of the surgically repaired lip, palate and nose, caregiver's fear of hurting the area, anatomy of the cleft^[12],[14]
An undiagnosed tongue tie results in reduced range of motion and function of the tongue and makes it difficult to clean the surfaces of the teeth^[15]
Consumption of a pureed diet low in dietary fiber and rich in sugars^[14]
Poor dental alignment and poor oral clearance of consumed diet^[16],[17]
Presence of abnormal frenal attachments near the surgical site and/or fistula (e)^[17]
Medical conditions that require regular administration of sweetened medication^[18],[19]
Retentive niches on the teeth due to malformation or hypoplasia^{[16],[20],[21]}

Considerations For Planning Dental Care

It is generally assumed that all children are under the care of a pediatrician for routine vaccinations and childhood issues, close to the area of residence. It is very rare in low- and middle-income countries for patients to have access to regular dental care unless it is provided as a part of the comprehensive care. Hence, the onus lies on the treating team to initiate a referral to a child dental specialist. A cleft team becomes an affected child's medical home, similarly, a dental home should be established as early as possible. Considering the global burden of dental disease, particularly untreated dental caries, the WHO Collaborating Centre situated at University of Nijmegen in The Netherlands has worked within primary oral health-care principles to create an affordable and sustainable community service called the basic package of oral care (BPOC). The concept of BPOC places great emphasis on approaches which are acceptable, feasible, and affordable and can be adapted to the existing cleft team settings. The following have been included in the WHO List of Essential Medicines for Adults and Children (2021).^[22]

Fluoride toothpaste
Glass Ionomer Cement (GIC)
Silver Diamine Fluoride (SDF).

Fluoride toothpastes

The efficacy of fluoride toothpastes as a preventive strategy for tooth decay has been well-documented.^[23] “Fluoride-free” training toothpaste is not recommended even during infancy.^[24],[25]

Postbrushing rinsing with water causes a “wash-out” and reduces the clinical efficacy of fluoride toothpaste. Three documented methods of increasing postbrushing fluoride retention – (a) “spit don't rinse,”^[26] (b) rinsing with a slurry of fluoride toothpaste and saliva, and (c) rinsing with a mouth rinse containing fluoride – could be beneficial for control of tooth decay at the individual level.

The fluoride-releasing properties of GIC, its ability to bond to enamel and dentine, its pulpal biocompatibility, and its ease of manipulation make it a suitable material for restoring decayed teeth. In addition, GIC acts as a reservoir for fluoride, as it takes up fluoride ions from topical fluoride.^[27] The Atraumatic Restorative Technique procedure^[22] does not require the use of local anesthetic, as it does not produce pain. Chemomechanical removal of caries is well accepted by children. The unaffected fissures should also be sealed by GIC as a measure of prevention.^[22]

SDF: The Game Changer in Cleft Team Settings

SDF is a clear liquid that combines the antibacterial effects of silver and the remineralizing effects of fluoride. One drop (0.05 ml) of SDF solution at 38% concentration (2.24 F-ion mg/dose) can be applied with a microbrush to all asymptomatic decayed teeth and all pits and fissures deciduous molars. This can easily and safely be applied by both oral health professionals and nonoral-health professionals in a variety of settings. Allergic reactions to the materials may be the only risk.^[28],[29] An unsightly dark discoloration of the demineralized areas of decayed teeth is observed after the application of SDF. Both fluoride and silver ions contained in SDF appear to have the ability to inhibit the formation of cariogenic biofilms of Mutans Streptococci, Actinomyces, and Lactobacilli.

There are a few non-negotiable self-care routines that health professionals on the cleft team need to reinforce for every patient during postsurgical and routine follow-up visits.

Use of fluoridated toothpastes for toothbrushing, twice daily. The use of nongel, herbal toothpastes, and abrasive tooth powders is to be discouraged.
Avoiding between-meal sugary snacks and processed food.
Resume gentle tooth brushing, tongue cleaning, and oral hygiene routines 24 h postsurgery. The importance of a clean oral environment in wound healing needs to be emphasized.

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] discuss the specific oral health management protocols across different age ranges. These have been modified and adapted from the FDI-Smile Train guidelines (2020).^[30] These are general recommendations; however, all necessary preventive and restorative treatment decisions need to be customized as per the individual dentition status, risk factors, and treatment needs [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16].

Table 1: Age group 0-2 years

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Table 2: Age group 2-6 years

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Table 3: Age group 6-12 years

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Table 4: Age group 12-18 years

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Table 5: Age-group 18 years and above

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Figure 1: White/brown spots on the teeth indicating initial caries

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Figure 2: (a) Poorly accessible area causing difficulty in brushing. (b) Interdental aids for difficult-to-reach areas

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Figure 3: Ulceration due to trauma from the feeding bottle

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Figure 4: Unsupported neonatal teeth may need extraction

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Figure 5: (a) Brown spots indicating tooth decay and (b) Red areas on the gums indicating lower abscessed teeth with draining sinuses

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Figure 6: Scar management leading to a nearly invisible scar

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Figure 7: Panoramic radiograph showing ectopic eruption of the maxillary first permanent molars, alveolar cleft, positions of tooth buds, and root development of permanent teeth

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Figure 8: (a and b): Thick maxillary labial frenum needing soft tissue revision

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Figure 9: Buccal myomucosal flaps may cause mechanical interference with eruption of maxillary first permanent molars

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Figure 10: (a-c) Molar incisor hypoplasia treated conservatively

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Figure 11: (a-c) Tooth in cleft site to be extracted before bone grafting, no derotations in areas of bone deficiency

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Figure 12: Canine-premolar transposition on the left side of the maxillary arch

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Figure 13: (a-c) Restoration/extraction decisions taken bearing future orthodontics in mind. Second left permanent molars migrated in place of extracted first molars

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Figure 14: Meticulous oral hygiene maintenance is required during orthodontics

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Figure 15: Arch preparation for future jaw surgery with temporary replacement of missing teeth

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Figure 16: (a)Poor esthetics due to dental fluorosis, (b) Suboptimal dental care and poor esthetics

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These recommendations are meant to assist clinicians by providing an evidence-based framework for decision-making strategies. These are not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and will need further adaptations and changes as medical knowledge expands and technology advances. Patient-centered outcomes should be at the forefront, therefore, addressing dental needs is one of the important services. In a team lacking general dentists and oral health-care specialists, treatment outcomes may not be optimal.

Conclusion

Oral health education alone is simply insufficient to change oral conditions. As an adjunct to receiving oral health education and improving oral hygiene practices, individuals with CLP need basic oral treatment. Oral health promotion must go hand-in-hand with oral health service provision, within the settings of a cleft team. Neglect of preventive oral health makes dental care expensive, hence it is important to use limited resources effectively. Rather than emphasize the need for a particular type of treatment, inexpensive low-technology alternatives in line with sound clinical practice can be adapted for various clinical situations. Understanding the protocols in cleft centers where dental care has improved surgical results, and simple treatment with better outcomes [Figure 17] would motivate more centers to adopt the services of dentists. Development of accurate prognostic indicators for dental health in a patient with CLP would go a long way in treatment planning and success of long-term comprehensive care outcomes.

Figure 17: (a and b) Esthetically and functionally pleasing result at the completion of comprehensive care

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Take home messages

In cleft care, a sound dentition is essential for orthodontics, which in turn improves surgical outcomes.
Integrate oral health check-ups into primary cleft care, early detection of tooth decay and immediate intervention to prevent associated problems.
Sustained anticipatory guidance on toothbrushing routines, use of fluoridated toothpaste, limited dietary consumption of free sugars as a part of a preventive oral health-care regimen must be provided by all cleft care professionals.
Provision of basic dental services within a cleft team greatly improves patient-centered outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

[40]

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