Full text of DOI:10.1038/sj.bdj.4800393a

PRACTICE
cleft lip and palate
Dental care for the patient with a cleft lip
and palate. Part 1: From birth to the
mixed dentition stage
1
2
3
4
C. J. Rivkin, O. Keith, P. J. M. Crawford, and I. S. Hathorn,
This is the first of two articles looking at dental care for the
patient with a cleft lip and palate. Part 1 looks at the needs of
the child with a cleft lip and palate from birth through to the
mixed dentition stage.
left lip and palate is one of the com- dren with clefts should be carried out by a
C
monest congenital abnormalities. team whose members are able to provide
Around 1 in every 700 live births in the a comprehensive service including: dental
1,2
UK has a cleft of the lip and/or palate.
care, audiology, specialised counselling
4
The type of cleft can range from a simple and clinical genetics. The Clinical Stan-
incomplete cleft of the soft palate, which dards Advisory Group Report on Cleft
is not clinically obvious and may be undi- Lip and/or Palate stresses the importance
agnosed in the early days, to a bilateral of team work between all the specialities.5
complete cleft involving both the soft and
hard palate, alveolus and lip (Fig. 1).
While the child with a cleft lip and
palate should be treated as a ‘normal’
Management of the patient with a cleft patient whenever possible for regular
is best carried out by a multi-disciplinary dental care, there are specific needs with
team of healthcare professionals who regard to oral health which can be identi-
undertake the cleft care from birth fied at different stages of dental develop-
Fig. 1 A 2-month-old child with a complete
bilateral cleft lip and palate
3
through to adulthood. Specialities repre- ment through to the adult years. The
sented on the cleft team in the UK vary dentist providing regular dental care
from region to region but the core mem- might be a general dental practitioner, role of the dentist in the dental manage-
bers of the team are the surgeon, ortho- community dentist or hospital dentist. ment of the patient with a cleft lip and
dontist, speech and language therapist, The aim of this article is to discuss the palate.
and ENT specialist. The Royal College of
Surgeons Steering Group on Cleft Lip and
Palate recommends that the care of chil-
The baby with a cleft lip and palate
and the pre-mixed dentition years
Within the first few days after the birth,
parents of babies born with a cleft lip and
palate will receive advice in hospital from
the surgeon and orthodontist on the
immediate and long-term management
of their child. This will often be supple-
mented by written information on the
condition itself, and related aspects
including oral health and dental care. The
orthodontist is usually the first dental
specialist whom the family will
encounter. The cleft and cranio-facial
unit may have a cleft co-ordinator or
other named person, such as a clinical
nursing specialist, to give support to the
family and advice on feeding. The health
visitor and general medical practitioner
In brief
The dentist has an essential role in
giving early preventive advice for
the young child with a cleft lip and
palate
• The parents are helped to focus on
the importance of good oral health
for their child
•
1*Senior Community Dental Officer, Honorary
Lecturer in Paediatric Dentistry, Specialist in
Paediatric Dentistry, Community Unit, Division of
Child Dental Health, Bristol Dental Hospital, Lower
2
Maudlin Street, Bristol BS1 2LY Consultant
Orthodontist, Maxillofacial Unit, Derbyshire Royal
Infirmary, London Road, Derby DE1 2QY
3
Consultant Senior Lecturer in Paediatric Dentistry,
•
Advice on weaning practices and
dentally-safe foods and drinks is
important
Division of Child Dental Health, Bristol Dental
Hospital, Lower Maudlin Street, Bristol BS1 2LY
4
Consultant Orthodontist, Division of Child Dental
Health, Bristol Dental Hospital, Lower Maudlin
Street, Bristol BS1 2LY
•
Particular attention should be given
to toothbrushing in the cleft region
*Correspondence to: Dental Department, Newton
Heath Health Centre, 2 Old Church Street, Newton
Heath, Manchester M40 2JF
• Reassurance regarding the
variability of dental development in
the cleft area is helpful.
REFEREED PAPER
Received 17.03.98; accepted 04.06.99
©
British Dental Journal 2000; 188: 78–83
78
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PRACTICE
cleft lip and palate
information, preventive advice and accli-
matisation are the important aspects of
these early visits. Parents can be particu-
larly anxious about teething and what the
teeth might look like when they eventu-
ally erupt. Understandably, they often
focus on the anticipated future appear-
ance of their child’s teeth. It is important
that the parents understand the value of
good dental health from the outset and
are helped to focus instead on this aspect
of the oral development. Establishing the
correct dental habits from an early age
will help to ensure the health of the pri-
mary and permanent dentition.
Fig. 2 High caries
rate in a child with a
bilateral cleft lip and
palate. First dental
visit at the age of
7
years
Pain, sepsis, or the need for dental
extractions as a result of caries are unac-
welcome opportunities for discussion ceptable for all children. However, early
and support regarding their child’s dental removal of primary teeth in children with
development. They do not seem to find a cleft is particularly contraindicated
this intrusive, even though they are busy because of possible space loss, especially
adjusting to the needs and demands of the in the upper arch, making orthodontic
new baby, with possible feeding prob- treatment more difficult (Fig. 4). An
lems. They are also mentally preparing for intact dentition will allow for the best
the necessary lip surgery at about 3 possible results from later orthodontic
months after birth (Fig. 3), and palate intervention if required.
repair later in the first year.8 Parents
appear to value dental advice even before
Considerations for planning
the first teeth erupt and this is an ideal
dental care
time to discuss preventive care. They
appreciate the opportunity to ask ques- Medical history
tions and to have time to discuss any con- The child with a cleft may have an associ-
cerns about their child’s teeth.
ated syndrome or sequence, such as Pierre
9
In Bristol, the cleft team policy is for a Robin, or have additional medical prob-
senior community dentist to see all babies lems. They may be under the care of a
born with a cleft by the age of six months. paediatrician or other specialist. An
This is arranged by the orthodontic team understanding of the medical condition is
involved with cleft care. Reassurance, essential to allow for appropriate dental
Fig. 3 The child in Fig. 1 shown at age 6
months. Bilateral cleft lip and palate
following lip repair
also have their traditional roles to play in
post-natal support and ongoing care.
There may be a hiatus with regard to
dental care between this early stage and
the first dental check-up, especially if
the family general dental practitioner
does not register children below a cer-
tain age, (sometimes 2–2fi years). By this
Fig. 4 An 8-year-old
child with a left
unilateral cleft lip
and palate. Early
time caries may already have developed
in the primary dentition.6 In some extraction of the
,7
cases there is not a family dentist and the upper right primary
second molar has
child then ‘slips through the net’ for reg-
ular dental care (Fig. 2).
Parents of babies with a cleft appear to
resulted in space
loss
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 2, JANUARY 22 2000
79

PRACTICE
cleft lip and palate
management and treatment planning. In which is sometimes anxious and over- to the parent and points out all the teeth
particular, the implications of any med- protective. The dentist needs patience to present. Simple explanations of the vari-
ical conditions in relation to dental care establish good communication, especially ability in dental development at the site of
or dental disease, for example, a congeni- in the early years. Speech and hearing dif- the cleft may help to alleviate parental
tal cardiac anomaly, should be fully dis- ficulties are a common occurrence in concerns. The number of teeth, and their
cussed with the relevant specialist.
patients with a cleft palate. Speech devel- eruption pattern, morphology and posi-
Young patients with a cleft lip and palate opment is monitored from an early age by tion can be worrying for parents. There
often have associated middle ear problems a speech and language therapist. Prob- may be missing teeth, commonly the
and consequent hearing difficulties. These lems with speech and hearing may pre- upper primary lateral incisor (Fig. 6), or
children may have a history of frequent sent a possible barrier to satisfactory there may be supernumerary teeth pre-
courses of antibiotics for repeated ear communication with the child.
sent in the cleft area. Teeth in the cleft
infections. They may be under the care of It is important to get to know the region are often crowded and rotated.
an ENT surgeon and require the placement patient as an individual and to allow time They may be of poor quality with
of grommets under general anaesthesia. for the necessary behaviour management, hypoplastic enamel (Fig. 6) and can
7
The need for general anaesthesia for surgi- acclimatisation and confidence building. therefore easily become carious.
cal procedures might present an opportu- However, it is equally important to get to
nity for necessary dental treatment to be know the parents, as gaining their trust
carried out simultaneously. This requires and confidence will facilitate the provi-
Preventive management
good communication between the hospital sion of regular dental care.
and dentist providing regular care.
It is important to obtain details con- The dental examination
Diet
Feeding difficulties are a common problem
for babies with a cleft palate11 and few
cerning the child’s prescribed medication. The easiest way to examine a baby is with mothers are successful with breast feeding.
The regular administration of sucrose- its head gently lowered onto the dentist’s The use of feeding plates and pre-surgical
containing medicines will give rise to den- lap and the parent sitting facing the den- orthopaedic correction plates is controver-
tal caries.10 It is essential to explore the tist, supporting and controlling the child’s sial and varies regionally between cleft
possibility of a sugar-free alternative in arms and legs (Fig. 5). The use of a small teams. Specialised feeding bottles such as
these cases.
dental mirror (eg Busch no. 2, 18 mm the Haberman feeder (Athrodax Surgical
diameter mirror [Busch & Co, Engel- Ltd, Ross-on-Wye, Herefordshire) and
skirchen, Germany; UK distributors: Mead Johnson bottle (Mead Johnson
Social history
An appreciation of the family situation is Glover Dental Supplies Ltd, Lancaster Nutritionals, Hounslow, Middlesex) have
important to allow for the optimum Road, Shrewsbury]) is helpful in tiny helped to overcome some of the feeding
delivery of dental care. Each patient and mouths, especially in the patient with a problems. The Haberman system consists
their family have their own particular cleft. Particular care is needed when of a standard bottle with a soft variable-
needs and these gradually become appar- examining the palatal cleft area as teeth flow teat and a pump action valve, requir-
12
ent as a trusting relationship is built with are easily missed in this region.
ing no active suction for operation. The
the dentist. For the young child with a cleft lip and Mead Johnson is a very soft bottle which
Some parents feel isolated with their palate, it helps if the dentist shows the area can be squeezed to help the flow of milk
problem, while others cope very well. The of the cleft on the alveolus and hard palate and any standard teat can be fitted. Various
Cleft Lip and Palate Association (CLAPA
—
CLAPA Head Office, 134 Buckingham
Palace Road, London SW1 9SA) is a sup-
port group formed by parents of children
with a cleft and professional staff caring
for these patients. Contact with other par-
ents and children in a similar situation is
helpful for some families.
Behaviour management
In some cases the young patient with a
repaired cleft may be shy, nervous, or have
a behavioural problem. The reasons are
usually multi-factorial but frequent hos-
pital visits and previous hospitalisation
may play a part. Children may also be
influenced by their parents’ behaviour,
Fig. 5 Dental
examination of a
young child
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PRACTICE
cleft lip and palate
other bottles and teats are recommended
by the Cleft Lip and Palate Association
with the main aim of encouraging normal
feeding methods whenever possible.
Parents should be recommended milk
and cooled, boiled water as the only suit-
able dentally-safe drinks for use in a feed- Fig. 6 A 4-year-old
ing bottle. They should be made aware child with a left
unilateral cleft lip
and palate. Shows
baby fruit juices, have an erosive poten-
missing upper left
that fruit drinks and squashes, including
13
tial. Sugar-containing and acidic drinks
primary lateral
should be kept to a minimum and given at incisor and
hypoplastic upper
left primary central
incisor
mealtimes only, with the introduction of a
training beaker or cup from the age of
6
months. The dentist is in a position to
help with advice on weaning practices.
Weaning foods and drinks should be free
from non-milk extrinsic sugars, as far as primary lip and palate surgery. They often additional aid where there is overlap and
possible, to encourage good dietary habits think that bleeding from gingival inflam- crowding of teeth, or in the case of the
for a healthy dentition.14
mation is caused by damage from tooth- bilateral cleft where the upper anteriors
Parents need to appreciate the impor- brushing or the breakdown of the surgical can be very retroclined. It is especially
tance of good dental health before the repair. Parents need to understand the helpful for teeth in the cleft region of the
teeth erupt. They should be given the cor- value of toothbrushing. They should be hard palate (Fig. 7).
rect advice regarding dietary control of shown in detail how to brush the teeth
For the toddler, parents are advised to
sugar-containing food and drinks, and and gums properly. It is important to stand or kneel behind the child when
know how to implement it.15 They need point out the potential problem areas of brushing, with the chin supported and
to understand fully the relationship plaque accumulation around the teeth in head resting against the parents’ chest. It
6
between the frequency of sugar in the diet the cleft region. The use of the dental may help if the child is in their baby seat
and tooth decay, in simple terms. Snacks mirror with the child supine will aid or pushchair, or even lying on the carpet.
should be free from sugars, and foods demonstration of difficult access regions Children may resist toothbrushing and
containing non-milk extrinsic sugars to the parent by indirect vision.
confrontation situations in the bathroom
should be kept as an occasional ‘pudding’
after a meal.
Where the upper lip has been repaired, should be avoided. Enlisting the help of a
parents should be shown how to lift it, second person is useful on these occa-
Babies with a cleft are usually able to stretching the lip carefully by sliding an sions. With the child supine, one person
cope with a dummy, although its use is index finger along the labial gingivae, can concentrate on the brushing with the
best deferred until after the palate repair is without doing any damage to the scar. child’s head in their lap while the other
fully healed. The exception to this is the This helps to give them a clear view of the person can control the legs and arms
baby with the Pierre Robin sequence, cleft region with good access to the while distracting the child. Varying the
where the use of a dummy can help to crowns of the anterior teeth and the gingi- time and place of toothbrushing for a
encourage the sucking reflex. As for all val margins for plaque removal. Parents brief period is another good ploy to bring
babies, parents are advised that the should be given the opportunity to prac- in a surprise element to cope with the
dummy should not be dipped in any food tice the toothbrushing technique in the unco-operative child. Many parents who
or drink and comforters containing dental surgery. Once they understand are keen to do their best become anxious
sweetened drinks should also be avoided, what they need to do and feel reassured if they have problems. Parents of chil-
especially at bedtime. While verbal that they are not causing harm to the cleft dren with a cleft lip and palate need extra
dietary advice should always be given to region, they can then carry out regular support, encouragement and praise to
parents, it is useful to give them written toothbrushing with confidence.
instructions. These can be referred to at A small baby brush is advised as the first
persevere.
A low fluoride children’s toothpaste
home and shown to resistant or well- toothbrush. For many children with containing no more than 600 ppm fluo-
meaning family members, friends, child- clefts, this size of brush can be used up ride is recommended for children under
minders and other providers of child care. until the eruption of the first permanent 6 years of age in order to reduce the likeli-
molars and beyond. A small-sized head is hood of enamel opacities in the perma-
Toothbrushing
ideal where there is a lack of sulcus depth, nent teeth.16 Children with a high risk of
Parents may be nervous to brush in the or awkward tooth positions in the cleft developing caries should use a standard
region of the cleft, especially following the region. An interspace brush is a useful toothpaste (1,000 ppm fluoride). Parents
BRITISH DENTAL JOURNAL, VOLUME 188, NO. 2, JANUARY 22 2000
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PRACTICE
cleft lip and palate
oped, it is essential that they are restored
as soon as possible with the most suitable
material. Radiographic assessment is nec-
essary for thorough treatment planning
with regard to caries activity and progres-
sion. Bitewing radiographs should be
considered once the child is able to co-
operate satisfactorily (See ‘Radiographic
management’ in Part 2).
Fig. 7 A 5-year-old
child with a left
unilateral cleft lip
and palate. Parent
using interspace
brush for teeth in the
palatal cleft region
Principles of child management, pre-
vention of dental disease and restorative
care for children have been well-docu-
mented in the dental literature and the
reader is advised to consult such texts for
the current definitive guidelines on these
topics.2
1–24
are advised to use just a trace on the brush fluoride varnish is a very useful preventive Communication with the cleft team
initially, and to brush with water rather measure for teeth that are at risk from For the parents of babies with a cleft, the
than not brushing at all if the child cannot caries.19 These include hypoplastic or stages of cleft surgery are major ‘land-
tolerate the taste. The eventual goal is crowded teeth in the cleft region, and any marks’ or ‘milestones ’. The dentist needs
to establish a twice-daily toothbrushing teeth which already show early signs of to have an understanding of the surgical
regime with the recommendation of no decalcification. Fluoride varnish should procedures and their timing so that den-
more than a small pea-sized amount of always be applied carefully, bearing in tal care can be integrated sensitively
toothpaste on the brush. Parental help mind the high fluoride concentration of within the overall treatment plan.
and supervision continues to be impor- the varnish (5% sodium fluoride). With a
Good communication between the
tant at least until 7 or 8 years of age.1
6,17
co-operative child the best method of dentist and the cleft team is essential for
application is to apply the varnish with a accurate exchange of information. It is
brush to dried tooth surfaces. The applied important for the dentist to liaise with the
Use of fluoride
varnish sets in contact with saliva.
cleft team (and vice versa) and this should
be ongoing throughout the whole of the
cleft management period. Two-way com-
Fluoride supplements. The use of fluoride
supplements needs to be considered and Use of personal child health record
discussed with the parents as a caries-free This is currently issued to the parents of munication helps to achieve the most
dentition is a high priority for this group all new-born babies in the United King- effective treatment plan for the individual.
of patients. Current recommendations dom.20 It contains information on the For example, the dentist needs to inform
and dosages for fluoride dietary child’s health, growth and development the orthodontist about any relevant dental
supplements have been published.1
7,18
from birth and provides a helpful record management problems, such as a high
Decisions regarding fluoride supplements book for parents and other health profes- caries rate or behavioural difficulties.
will depend on various factors such as the sionals. There is a section on dental care Teeth with a poor long-term prognosis
fluoride content of the local water supply, by the British Society of Paediatric Den- should be discussed in order to aid future
the likelihood of compliance, the caries tistry and the British Association for the orthodontic treatment planning. Any
experience of the patient and other family Study of Community Dentistry, with extractions as a result of caries should be
members, and other factors related to the space for the dentist to write details of jointly planned, especially if teeth are to be
family’s social circumstances.
dental visits. Use of this book by the removed under general anaesthesia. A
child’s dentist could help to reinforce the short letter or telephone call is often all
Fluoride varnish. Regular dental check-ups important aspects of dental care which that is required.
should help to detect early enamel are highlighted in the book, and improve
demineralisation which can be arrested by communication between some of the Summary
the implementation of a good preventive health professionals providing care for the An important aim of these early visits is
regime. The main preventive measures are child with a cleft.
the dietary control of sugar, thorough
toothbrushing with a fluoride toothpaste Restorative care
to deal with any worries as soon as they
arise. Parents should feel able to ask ques-
tions at any time, either face-to-face or by
and the use of fluoride supplements where As for all children, the aim for the child telephone, and be made to feel that noth-
indicated. In addition, the twice-yearly with a cleft lip and palate is a caries-free ing is too trivial. Detailed note-taking
professional application of topical dentition. If carious lesions have devel- helps to keep a record of the preventive
82
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PRACTICE
cleft lip and palate
advice given and any problems encoun-
tered which can be referred to at subse-
quent visits. Seeing the parent and child
on a regular basis encourages a good rela-
tionship. Time invested at this early stage
is invaluable and check-up visits at four,
or six-monthly intervals, or more fre-
quently if necessary, are advisable for
careful monitoring of the child’s oral
health.25
Part 2, the second and final article, will
deal with dental care for the patient with a
cleft lip and palate from the mixed denti-
tion stage through to adolescence and young
adulthood.
5
6
Clinical Standards Advisory Group Report on
Cleft Lip and/or Palate. London: The Stationery
Office, 1998.
Bokhout B, Hofman F X W M, van Limbeek J,
Kramer G J C, Prahl-Andersen B. Incidence of
dental caries in the primary dentition in
children with a cleft lip and/or palate. Caries
Res 1997; 31: 8-12.
Johnsen D C, Dixon M. Dental caries of
primary incisors in children with cleft lip and
palate. Cleft Palate J 1984; 21: 104-109.
Roberts-Harry D, Sandy J R. Repair of cleft lip
and palate: 1. Surgical techniques.
Dent Update 1992; 19: 418-423.
Sommerlad B C. Management of cleft lip
and palate. Curr Paediatr 1994; 4:
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Roberts I F, Roberts G J. Relation between
medicines sweetened with sucrose and dental
disease. Br Med J 1979; 2: 14-16.
16 Rock W P. Young children and fluoride
toothpaste. Br Dent J 1994; 177: 17-20.
17 British Society of Paediatric Dentistry. A policy
document on fluoride dietary supplements and
fluoride toothpastes for children. Int J Paediatr
Dent 1996; 6: 139-142.
18 A statement by the British Dental Association,
the British Society of Paediatric Dentistry and
the British Association for the Study of
Community Dentistry. Fluoride supplement
dosage. Br Dent J 1997; 182: 6-7.
19 Clark D C. A review on fluoride varnishes: an
alternative topical fluoride treatment.
Community Dent Oral Epidemiol 1982; 10:
117-123.
20 Goodman J R. News and views: Personal child
health records. Int J Paediatr Dent 1995; 5:
278-279.
21 Andlaw R J, Rock W P. A Manual of Paediatric
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Livingstone, 1996.
22 Curzon M E J, Roberts J F, Kennedy D B.
Kennedy’s Paediatric Operative Dentistry. 4th
ed. Oxford: Butterworth Heinemann, 1996.
23 Welbury R. Paediatric Dentistry. 1st ed. Oxford:
Oxford Univ Press, 1997.
24 Setting Standards in Dental Care for Children.
Dental Profile special ed. Dental Practice
Board, 1997.
25 National Clinical Guidelines: Paediatric
Dentistry. Continuing Oral Care — Review
and Recall: The Faculty of Dental Surgery of
the Royal College of Surgeons of England,
1997.
7
8
9
1
0
1
Coupland M A, Coupland A I. Seasonality,
incidence, and sex distribution of cleft lip and
palate births in Trent region, 1973-1982. Cleft
Palate J 1988; 25: 33-37.
11 Trenouth M J, Campbell A N. Questionnaire
evaluation of feeding methods for cleft lip and
palate neonates. Int J Paediatr Dent 1996; 6:
241-244.
12 Thom A R. Modern management of the cleft
lip and palate patient. Dent Update 1990; 17:
402-408.
13 Smith A J, Shaw L. Baby fruit juices and tooth
erosion. Br Dent J 1987; 162: 65-67.
14 Holt R D, Moynihan P J. The weaning diet and
dental health. Br Dent J 1996; 181: 254-258.
15 Health Education Authority. The scientific basis
of dental health education. 4th ed. London:
HEA, 1996.
2
3
4
Gregg T, Boyd D, Richardson A. The incidence
of cleft lip and palate in Northern Ireland from
1980-1990. Br J Orthod 1994; 21: 387-392.
Albery E H, Hathorn I S, Pigott R W. Cleft lip
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Shaw W C, Williams A C, Sandy J R, Devlin H
B. Minimum standards for the management of
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loop. Ann R Coll Surg Engl 1996; 78: 110-114.
Continuing Professional Development
The response to the first unit of CPD, Endodontics has been far greater than
anticipated and unfortunately this has resulted in delays in the marking process.
We hope to inform participants of their results in early January. The BDJ aplo-
gises for any delay and would like to thank those that sent in their answers for
taking part and for their patience.
Any other developments will also be announced via the website:
www.bdj.co.uk/cpd
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