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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 78 BRITISH DENTAL JOURNAL, VOLUME 188, NO. 2, JANUARY 22 2000 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 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 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 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.

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