Dental Care for the Patient with a Cleft Lip and Palate. Part 1: from Birth to the Mixed Dentition Stage

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

C. J. Rivkin,1 O. Keith,2 P. J. M. Crawford,3 and I. S. Hathorn,4

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 Cmonest congenital abnormalities. team whose members are able to provide Around 1 in every 700 live births in the a comprehensive service including: dental UK has a cleft of the lip and/or palate.1,2 care, audiology, specialised counselling The type of cleft can range from a simple and clinical genetics.4 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 While the child with a cleft lip and hard palate, alveolus and lip (Fig. 1). 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 through to adulthood.3 Specialities repre- ment through to the adult years. The bilateral cleft lip and palate 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 The baby with a cleft lip and palate Palate recommends that the care of chil- In brief and the pre-mixed dentition years • The dentist has an essential role in Within the first few days after the birth, 1*Senior Community Dental Officer, Honorary giving early preventive advice for parents of babies born with a cleft lip and Lecturer in Paediatric Dentistry, Specialist in the young child with a cleft lip and palate will receive advice in hospital from Paediatric Dentistry, Community Unit, Division of palate the surgeon and orthodontist on the Child Dental Health, Bristol Dental Hospital, Lower immediate and long-term management Maudlin Street, Bristol BS1 2LY 2Consultant • The parents are helped to focus on Orthodontist, Maxillofacial Unit, Derbyshire Royal the importance of good oral health of their child. This will often be supple- Infirmary, London Road, Derby DE1 2QY for their child mented by written information on the 3Consultant Senior Lecturer in Paediatric Dentistry, condition itself, and related aspects Division of Child Dental Health, Bristol Dental • Advice on weaning practices and dentally-safe foods and drinks is including oral health and dental care. The Hospital, Lower Maudlin Street, Bristol BS1 2LY orthodontist is usually the first dental 4Consultant Orthodontist, Division of Child Dental important specialist whom the family will Health, Bristol Dental Hospital, Lower Maudlin • Particular attention should be given Street, Bristol BS1 2LY encounter. The cleft and cranio-facial *Correspondence to: Dental Department, Newton to toothbrushing in the cleft region unit may have a cleft co-ordinator or Heath Health Centre, 2 Old Church Street, Newton • Reassurance regarding the other named person, such as a clinical Heath, Manchester M40 2JF variability of dental development in REFEREED PAPER nursing specialist, to give support to the Received 17.03.98; accepted 04.06.99 the cleft area is helpful. family and advice on feeding. The health © British Dental Journal 2000; 188: 78–83 visitor and general medical practitioner

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information, preventive advice and acclimatisation are the important aspects of these early visits. Parents can be particularly 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 Fig. 2 High caries are helped to focus instead on this aspect rate in a child with a bilateral cleft lip and of the oral development. Establishing the palate. First dental correct dental habits from an early age visit at the age of will help to ensure the health of the pri- 7 years mary and permanent dentition. 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 the first teeth erupt and this is an ideal Considerations for planning time to discuss preventive care. They dental care 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 In Bristol, the cleft team policy is for a Robin,9 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 Fig. 3 The child in Fig. 1 shown at age 6 months. Bilateral cleft lip and palate involved with cleft care. Reassurance, essential to allow for appropriate dental 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- Fig. 4 An 8-year-old tain age, (sometimes 2–2ﬁ years). By this child with a left unilateral cleft lip time caries may already have developed and palate. Early 6,7 in the primary dentition. In some extraction of the cases there is not a family dentist and the upper right primary child then ‘slips through the net’ for reg- second molar has resulted in space ular dental care (Fig. 2). loss Parents of babies with a cleft appear to

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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 The need for general anaesthesia for surgi- acclimatisation and confidence building. therefore easily become carious.7 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. Diet and dentist providing regular care. Feeding difficulties are a common problem It is important to obtain details con- The dental examination 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 Social history skirchen, Germany; UK distributors: Mead Johnson bottle (Mead Johnson 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- ent as a trusting relationship is built with are easily missed in this region. ing no active suction for operation.12 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 support group formed by parents of children with a cleft and professional staff caring for these patients. Contact with other parents 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 hospital visits and previous hospitalisation Fig. 5 Dental may play a part. Children may also be examination of a young child influenced by their parents’ behaviour,

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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 suitable 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 that fruit drinks and squashes, including unilateral cleft lip baby fruit juices, have an erosive poten- and palate. Shows 13 missing upper left tial. Sugar-containing and acidic drinks primary lateral should be kept to a minimum and given at incisor and mealtimes only, with the introduction of a hypoplastic upper training beaker or cup from the age of left primary central incisor 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 between the frequency of sugar in the diet the cleft region.6 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’ Where the upper lip has been repaired, should be avoided. Enlisting the help of a after a meal. 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. persevere. instructions. These can be referred to at A small baby brush is advised as the first 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

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oped, it is essential that they are restored as soon as possible with the most suitable material. Radiographic assessment is necessary 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 Principles of child management, pre- unilateral cleft lip vention of dental disease and restorative and palate. Parent care for children have been well-docu- using interspace mented in the dental literature and the brush for teeth in the palatal cleft region reader is advised to consult such texts for the current definitive guidelines on these topics.21–24 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.16,17 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 Fluoride supplements. The use of fluoride be ongoing throughout the whole of the supplements needs to be considered and Use of personal child health record cleft management period. Two-way com- 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.17,18 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. to deal with any worries as soon as they the dietary control of sugar, thorough arise. Parents should feel able to ask ques- toothbrushing with a fluoride toothpaste Restorative care 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

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advice given and any problems encoun- 5 Clinical Standards Advisory Group Report on 16 Rock W P. Young children and fluoride tered which can be referred to at subse- Cleft Lip and/or Palate. London: The Stationery toothpaste. Br Dent J 1994; 177: 17-20. Office, 1998. 17 British Society of Paediatric Dentistry. A policy quent visits. Seeing the parent and child 6 Bokhout B, Hofman F X W M, van Limbeek J, document on fluoride dietary supplements and on a regular basis encourages a good rela- Kramer G J C, Prahl-Andersen B. Incidence of fluoride toothpastes for children. Int J Paediatr tionship. Time invested at this early stage dental caries in the primary dentition in Dent 1996; 6: 139-142. is invaluable and check-up visits at four, children with a cleft lip and/or palate. Caries 18 A statement by the British Dental Association, or six-monthly intervals, or more fre- Res 1997; 31: 8-12. the British Society of Paediatric Dentistry and 7 Johnsen D C, Dixon M. Dental caries of the British Association for the Study of quently if necessary, are advisable for primary incisors in children with cleft lip and Community Dentistry. Fluoride supplement careful monitoring of the child’s oral palate. Cleft Palate J 1984; 21: 104-109. dosage. Br Dent J 1997; 182: 6-7. health.25 8 Roberts-Harry D, Sandy J R. Repair of cleft lip 19 Clark D C. A review on fluoride varnishes: an Part 2, the second and final article, will and palate: 1. Surgical techniques. alternative topical fluoride treatment. Dent Update 1992; 19: 418-423. Community Dent Oral Epidemiol 1982; 10: deal with dental care for the patient with a 9 Sommerlad B C. Management of cleft lip 117-123. cleft lip and palate from the mixed denti- and palate. Curr Paediatr 1994; 4: 20 Goodman J R. News and views: Personal child tion stage through to adolescence and young 189-195. health records. Int J Paediatr Dent 1995; 5: adulthood. 10 Roberts I F, Roberts G J. Relation between 278-279. medicines sweetened with sucrose and dental 21 Andlaw R J, Rock W P. A Manual of Paediatric disease. Br Med J 1979; 2: 14-16. Dentistry. 4th ed. Edinburgh: Churchill 1 Coupland M A, Coupland A I. Seasonality, 11 Trenouth M J, Campbell A N. Questionnaire Livingstone, 1996. incidence, and sex distribution of cleft lip and evaluation of feeding methods for cleft lip and 22 Curzon M E J, Roberts J F, Kennedy D B. palate births in Trent region, 1973-1982. Cleft palate neonates. Int J Paediatr Dent 1996; 6: Kennedy’s Paediatric Operative Dentistry. 4th Palate J 1988; 25: 33-37. 241-244. ed. Oxford: Butterworth Heinemann, 1996. 2 Gregg T, Boyd D, Richardson A. The incidence 12 Thom A R. Modern management of the cleft 23 Welbury R. Paediatric Dentistry. 1st ed. Oxford: of cleft lip and palate in Northern Ireland from lip and palate patient. Dent Update 1990; 17: Oxford Univ Press, 1997. 1980-1990. Br J Orthod 1994; 21: 387-392. 402-408. 24 Setting Standards in Dental Care for Children. 3 Albery E H, Hathorn I S, Pigott R W. Cleft lip 13 Smith A J, Shaw L. Baby fruit juices and tooth Dental Profile special ed. Dental Practice and palate: a team approach. Bristol: Wright, erosion. Br Dent J 1987; 162: 65-67. Board, 1997. 1986. 14 Holt R D, Moynihan P J. The weaning diet and 25 National Clinical Guidelines: Paediatric 4 Shaw W C, Williams A C, Sandy J R, Devlin H dental health. Br Dent J 1996; 181: 254-258. Dentistry. Continuing Oral Care — Review B. Minimum standards for the management of 15 Health Education Authority. The scientific basis and Recall: The Faculty of Dental Surgery of cleft lip and palate: efforts to close the audit of dental health education. 4th ed. London: the Royal College of Surgeons of England, loop. Ann R Coll Surg Engl 1996; 78: 110-114. HEA, 1996. 1997.

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.

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