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Dental issues in Children with Cleft Lip and Palate

About one in 700 babies born in the Republic of Ireland are born with a cleft palate, a cleft lip, or both. These defects are correctable. Cleft palate means there is a split in the roof of the mouth. Cleft lip refers to a split in the upper lip. Some syndromes are associated with clefts. The condition isn’t harmful, but it can be alarming for new mums and dads. It is the most common birth defect of the head and neck area. It occurs during the early weeks of pregnancy when the face is forming. Neglected teeth make the management of clefts much more difficult so it is especially important for these children to receive high quality, expert dental care.

Cleft lips and palates can be the result of a number of factors, including genetic and environmental. Certain drugs such as anticonvulsants taken during pregnancy can increase the risk. The risk of having a baby with a cleft is higher if here is already a family member with the condition. The condition itself means that during development, the tissues in the lip or mouth don’t join up. In the case of a cleft lip, the gap will be between the upper lip and the nose. In the case of a cleft palate, the gap is in the roof of the mouth. Cleft lip can make breast feeding problematic and later on, have an impact on speech, hearing, social and dental development. The paediatric dentist is a central member of the cleft team and is the health care professional who, the child is likely to see most often and for the longest time throughout their care.

Children with clefts require multidisciplinary care from a range of specialities including plastic surgery, oral surgery, paediatric dentistry, orthodontics, psychology, ear nose and throat surgery, genetics and speech and language therapists amongst others. Dentally these children face serious challenges around the cleft area. There may be missing teeth, extra teeth, poorly formed or shapen teeth. Due to the amount of medical intervention these children receive, they may have more anxiety than usual in relation to dental treatment. Feeding problems and failure to thrive can lead to the need to feed the children with high calorific formula which damages the teeth.

Preventive dental care is a high priority for a child with a cleft. Cleaning around the cleft site can be very difficult. Teeth in the area can be poor quality and this often makes these children more prone to decay. Management of missing teeth is made very difficult if children are exposed to decay and consequently loose more teeth. Preventive care means parents receive guidance, support and professional help with cleaning, nutrition and the use of fluoride products. Due to the serious implications of dental disease for these children, it is highly desirable that they have a dental home with a paediatric dentist who has experience and training in the management of children with cleft lip and palate and can provide the advanced preventive care and advice required or at the very least coordinate the plan of care.

The initial management of children with clefts often starts before birth. If a cleft shows up on a scan parents are offered counselling. The next hurdle is feeding; Specialist nurses help parents with feeding which can be made difficult if there is insufficient lip seal or if the milk escapes through a hole in the roof of the mouth. In the United States and Australia paediatric dentists may use appliances to help mould together the lips, the nose and the sides of the cleft before surgery. Research in this area is showing very promising results and greatly assists the job of the surgeon at the next step. At about 3 months of age the plastic surgeon performs an operation to join the sides of the cleft together. Between the ages of 2 and 3 years, the child’s speech sounds are assessed and if it is felt that air is escaping through the mouth into the nose affecting speech sounds, this is corrected by either an ear nose and throat specialist or the plastic surgeon.

When the child is 8 or so they normally are normally referred to the orthodontist who may start some treatment to grow the palate. The next phase of treatment is usually with the oral surgeon who takes bone from another part of the body to fill in the cleft site. This normally happens around age 11 when the permanent eye tooth is starting to come into place. After all the permanent teeth come into place, a full course of orthodontics is often required to align the teeth. When growth is complete in the early twenties, implants and crown and bridge work can be considered to deal with missing teeth. The treatment needs of children born with cleft lip and or palate are complex and require the expertise of a paediatric dentist with the appropriate training and experience.

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