Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate

Cleft lip and palate affects the child in many ways, particularly appearance, dental arch relationships, growth of the face, and speech development. The key to successful care is management in a multidisciplinary team adhering to a well-designed protocol, and careful audit of results. We present the intermediate outcome audit of 15 patients with complete bilateral and unilateral cleft lip and palate whose condition was managed in a multidisciplinary team according to a strict protocol. We give the results observations of operations of a single surgeon's functional primary surgery over a 6-year period in terms of dental arch relationships, cephalometric analyses, aesthetic assessments, and speech analysis. The results show good early facial growth, with dental arch relationships appropriate for the age and group; we found only minor speech discrepancies, with no patients requiring pharyngoplasty. The results show the importance of multidisciplinary management, the value of keeping to sound surgical protocols, and functional techniques in cleft lip and palate surgery. Our study includes the neglected group of children who have bilateral cleft lip and palate, and it conforms to the style of pan-European projects.     

Genetics of cleft lip and palate revisited

Cleft lip with or without cleft palate (CL/CP) is one of the most common structural birth defects with treatment including multiple surgeries speech therapy, and dental and orthodontic treatments over the first 18 years of life. Providing care for these patients and families includes educating patients and parents about the genetics of CL/CP, as well as meeting the immediate medical needs. Attempts at identifying susceptibility loci via family and case-control studies have proved inconsistent. It is likely that initial predictions of the complex interactions involved in facial development were underestimated. The candidate gene list for CL/P is getting longer and the need for an impartial systematic screening technique, to implicate or refute the inclusion of particular loci, is apparent. So we are faced with the question "Can this complex trait be too complex?" The aim of this review is to make the dentist aware of the differences between syndromic and non-syndromic cleft as well as understanding the etiological variation in cleft lip with and without cleft palate. This will aid the dentist in diagnosis and give proper genetic counseling to parents and patients of cleft lip and palate.     

Outcomes of cleft care in Western Australia: a pilot study

The purpose of this study was to compare outcomes and delivery of cleft care in Western Australia with the average standard of care in the United Kingdom (UK). This was achieved through a cross-sectional study involving children born with unilateral cleft lip and palate between April 1983 and March 1985 (12 year olds) or between April 1990 and March 1992 (5 year olds). A total of 38 children born with unilateral cleft lip and palate were under the care of the cleft team based at Perth's Princess Margaret Hospital. Dental arch relations, facial skeletal pattern, speech, hearing, success of alveolar bone grafting and dental health were measured. It was found that fewer Princess Margaret Hospital children in both age cohorts had revision surgery and speech therapy compared with the UK average. The facial skeletal pattern, speech, hearing and alveolar bone grafting outcomes from Princess Margaret Hospital were similar to the UK at age 12. Seventeen per cent of the Princess Margaret Hospital 12 year olds had a poor dental arch relationship compared with 39 per cent in the UK. In the 5 year olds, most outcomes in Princess Margaret Hospital patients appeared better than the UK with lower residual treatment needs. While it is difficult to draw firm conclusions because of the small numbers involved, this study indicates standards need to be set and determined for Australia.     

Vestibuloplasty in patients with cleft lip and palate

After cleft lip repair the upper lip is sometimes attached at the premaxilla. The scar bands and contractures may occur deleterious effects on: the growth, the facial expression, the speech, problems during orthodontic treatment and in prosthetic dental care, regression of the attached gingiva, resorption of the transplanted bone and the aspect of the upper lip. In nine edentulous patients with cleft lip palate, in six patients with cleft lip palate and with a mutilated dentition and in ten younger patients with cleft lip palate the buccal sulcus was successfully restored. The importance of a free upper lip and adequate sulcus has been under-emphasized in treatment of the patient with cleft lip palate.     

Cleft-affected children in Mayo: 1999-2007

The aims of this study were to investigate the medical and dental care of children born in Mayo with cleft lip and/or palate in the period 1999-2007. Thirteen subjects were identified--nine males and four females. Galway was the main locus for cleft surgical referral and care, with 10 subjects receiving treatment by the same surgeon. A total of 54% of subjects required ENT care, with 62% receiving speech and language therapy. DMFT and dmft were zero and 0.037, respectively. Mean age at first dental visit (to a private or community dental clinic, specialist paediatric dental practice or Western Health Board orthodontic service) was 21 months. This represents progress in the objective of early access and provision of dental care for this special care dentistry needs group.     

Dental and prosthodontic care for patients with cleft or craniofacial conditions.

Prosthodontic treatment has a long and rich history in the care of patients with cleft lip and palate. Because of increased knowledge of craniofacial growth and development and improved surgical and orthodontic treatment, today's cleft patients receive better care and in less time. This requires less prosthetic intervention. Still, prosthetics retains an important, if somewhat diminished, place in cleft care, and the prosthodontist remains an integral member of the cleft/craniofacial habilitation team. This review presents the current state of the art in dental/prosthodontic care for patients with cleft palate and related craniofacial anomalies.     

Potential for clinical cooperation between dentistry and speech pathology.

Clinical management of articulation dysfunctions is one area in which the joint efforts of dentistry and speech pathology are particularly beneficial. Those articulation deviations discussed result from: (1) deformities in the upper lip, teeth, mandible and the hard and soft palates; (2) introduction of dentures; (3) difficulties in adjusting to esophageal speech; and (4) special problems associated with cleft palate/cleft prepalate. Team management of the individual with cleft palate and/or cleft prepalate was also reviewed. While orthodontists and prosthodontists provide the technology for correct speech production, speech pathologists furnish therapy for cultivating speech or modifying defective articulation patterns. Speech pathologists also serve as liaisons with respect to patients and other professionals. The authors believe that, ideally, clinicians from all disciplines should assume a holistic attitude in treating organic and functional human pathologies. Such interdisciplinary clinical cooperation is especially effective between dentistry and speech pathology. The concept of team management of cleft palate/cleft prepalate is an excellent example of how concomitant treatment effects total patient care. However, joint research and educational ventures also contribute to this objective and should continue to be encouraged.     

Cleft lip and palate: thoughts about associated anomalies

During two years all new patients referred to the cleft palate team in Nijmegen, were examined by a clinical dentist, to evaluate the occurrence of associated anomalies or syndromes. In 33% of the patients with all types of clefts associated anomalies were found. A percentage of 56% was found for cleft palate only, and of 14% for cleft lip (palate). It is important to make a classifying diagnosis of these associated anomalies because they may have important implications for recurrence risks and prognosis. The percentage of associated anomalies is the highest in the group of patients with cleft palate only or submucous clefts. Therefore, the dentists have to be aware of the presence of submucous clefts and their consequences.     

George Franklin Grant,DMD: renaissance man

While George Franklin Grant may be known as the second African American dental graduate and the inventor of the golf tee, it is not generally known that he was one of the pioneers in cleft palate and speech therapy, a longtime faculty member of Harvard University's dental school, and the founder of the Harvard Odontological Society.     

Speech outcome following treatment in cross-linguistic cleft palate studies: methodological implications.

OBJECTIVE: In cross-linguistic studies of cleft palate speech outcome following treatment, treatment is the independent variable, speech outcome is the dependent variable, and the speakers' language background is a background variable, like sex, age, and cleft type, which must be eliminated. This article focuses on language as a background variable and how it should be treated. The methodological problems are illustrated through a presentation of two cross-linguistic speech outcome studies. CONCLUSION: When speakers of different language background are included in cleft palate studies of speech outcome following treatment, speech outcome data should be based on speech units that are phonetically identical across languages. This affects the make-up of the speech material used in the study. In practice, the requirement of phonetically identical speech units may not be totally met, and detailed information regarding the interaction between the cleft condition and speech sound production is still required to fully understand how the validity of data is affected if this requirement is not met.     

Dental treatment need and dental general anesthetics among preschool‐age children with cleft lip and palate in northern Finland

Cleft lip and palate incidence is high in northern Finland. This study aimed to investigate the proportion of children in need of restorative dental treatment among cleft lip and palate patients in northern Finland, as well as their need for dental treatment under general anesthesia. The records of 183 cleft lip and palate patients, treated in Oulu University Hospital from 1997 to 2013, were reviewed. Data on dental caries were analyzed in association with cleft type, considering also the presence of syndromes. The frequency of dental general anesthetic (DGA) use, and of treatments, were also analyzed. Dental treatment need was most frequently observed, in this rather limited study population, in patients with the most severe deformities, namely bilateral cleft lip and palate, of whom 60% had caries. Among the study population, 11.5% (n = 21) had a syndrome. Of those, 57.1% had dental caries at the age of 3 or 6 yr, and only four could be treated without a DGA. Dental treatment under general anesthesia was performed in 14.8% of cleft patients without a syndrome, but in 38.1% of those with a syndrome. General anaesthesia is required for the provision of dental care more often in cleft (17.5%) than in non‐cleft (0.2%) patients, and especially for those with a syndrome.     

Patient-dentist-technician communication within the dental team: Using a colored treatment plan wax-up

Communication among the restorative dental team must include the patient. The patient wants to know the details of the anticipated restorations; but because a patient is not aware of many dental innovations, care must be taken to provide them with a clear explanation of all anticipated treatment parameters. Many patients have little understanding of today's advancements in restorative procedures, and they may or may not understand all of the possibilities. Through effective communication, the patient gains confidence in the dental team and better understands the proposed restorative treatment. Patient satisfaction is significantly enhanced through effective communication. CLINICAL SIGNIFICANCE: This article describes the use of a diagnostic wax-up to facilitate optimal communication between the dental team and the patient.     

Medical and psychosocial risk factors in the dental treatment of the elderly

There is evidence to show that a 'new' type of elderly consumer of dental services is evolving with characteristics and expectations different from those of the 'old' elderly that dentists have had experience in treating. In providing care for the 'new' elderly the dentist must consider the many modifying factors which influence the type of treatment that an individual patient needs. These are the patient's lifespan, medical history, drug history, mental status, mobility, neuromuscular coordination, dental status, previous dental experience, the patient's or family's dental expectations as well as the economic status of the patient and the family. Before commencing treatment the dentist must also assess his/her own skills, the facilities in which he/she is working and the availability of equipment to carry out the dental procedures that may be required. Only when all of these considerations have been taken into account can rational dental care for an individual elderly person be planned and completed. The variation in what is rational is large. For one patient it may be no treatment at all and for another the most technologically sophisticated care dentistry can provide.     

Possibilities and Limitations of Comprehensive Treatment of Mentally Retarded Patients with Cleft Lip, Alveolus and Palate

The comprehensive, successful treatment of patients with cleft lip, alveolus and palate requires numerous surgical interventions and very close cooperation between various medical and dental specialists. The willingness and ability of the patient to undergo treatment are undoubtedly important factors in achieving optimal treatment outcomes. The presented case report shows that limited compliance makes it much more difficult for speech pathologists and orthodontists to treat mentally retarded patients. Only with combined orthodontic therapy and orthognathic surgery could the dental and skeletal abnormalities be corrected in adulthood.     

Cleft lift and palate surgery from the viewpoint of orthodontics, maxillo-facial and reconstructive surgery--state of the art in Hungary

The author reviews the literature of cleft lip--and palate concerning on the incidence and treatment of these disorders. Describes the most often used surgical treatments, emphasises the importance of team work, details the surgical and orthodontic roles. The author reviews the treatment plan of cleft lip and palate applied at the Oral--and Maxillofacial Clinic of the Semmelweis University and suggests to introduce it as a general procedure. The author nominates to create a Hungarian Cleft Centre based on the declaration of EuroCleft project.     

Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.     

Paracetamol overdose as a result of dental pain requiring medical treatment - two case reports

Two cases of unintentional paracetamol overdose are presented. Over a one month period these patients presented to an Accident and Emergency (A&E) department with symptoms of paracetamol toxicity, following the ingestion of large quantities of analgesia for the self treatment of dental pain. In one case the patient had no access to a dentist. Both patients required admission under the care of the medical on-call team and required anti-toxicity treatment to prevent permanent liver injury. Subsequent referrals were made to the oral and maxillofacial surgery team who provided emergency dental treatment and advice on further dental care. This paper highlights the significant signs and symptoms of paracetamol overdose about which dental practitioners should be aware. It also describes the management principles required to prevent potentially life threatening liver damage. Discussion is also made of the potential impact on patients struggling to cope with pulpal pain without access to a general dental practitioner.     

维吾尔语腭裂术后语音清晰度词表的初步构建

目的:创建符合维吾尔语语音特点的语音清晰度词表,在此表基础上为维吾尔族腭裂术后语音障碍患者语音治疗奠定基础。方法:按照正常维吾尔语声学特征以及构词特征构建正常维吾尔语语音清晰度词表,由31名维吾尔语腭裂术后患者和正常人分别朗读或跟读正常语音清晰度词表,并同时录音,将内容录入电脑后,让2名审听者评分,计算清晰度;最终腭裂语音特征以及维吾尔语的特征相结合构建腭裂语音清晰度词表。结果:总结维吾尔语腭裂术后患者语音特征,首创维吾尔语腭裂语音清晰度测试词表。结论:维吾尔语腭裂语音清晰度测试词表为维吾尔语腭裂术后患者语音治疗奠定了理论基础,为语音病理学研究提供了必要的参考,开启了维吾尔语语音病理学的研究。     

Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients: Supraperiosteal flap technique versus mucoperiosteal flap technique.

BACKGROUND: The aim of this study was to evaluate and compare the maxillary dental arch shape and speech of cleft palate patients following pushback palatoplasty using either the supraperiosteal flap technique or the mucoperiosteal flap technique. PATIENTS: Sixty-two patients (29, cleft palate only; 33, unilateral cleft lip, alveolus and palate) operated on by the supraperiosteal technique and 47 patients (23, cleft palate only; 24 unilateral cleft lip, alveolus and palate) by the mucoperiosteal technique were reviewed in this study. Study design: Dental arch shape and speech proficiency at preschool and school age were evaluated in all patients. RESULTS: Dental arch shapes were classified as U type (good dental arch shape) and V type (narrow dental arch shape). In cleft palate only patients, U type was observed in 90% of the supraperiosteal group and 83% of the mucoperiosteal group. In unilateral cleft lip, alveolus and palate patients, U type was observed in 85% of the supraperiosteal group, while only in 33% of the mucoperiosteal group. In cleft palate only patients, normal speech at school age was observed 100% of the supraperiosteal group and 83% of the mucoperiosteal group. In unilateral cleft lip, alveolus and palate patients, normal speech at school age was observed in 97% of the supraperiosteal group and 75% of the mucoperiosteal group. Misarticulation was frequently found in patients with the V type of dental arch shape. CONCLUSION: It is suggested that pushback palatoplasty using the supraperiosteal technique is more advantageous for speech development compared with the mucoperiosteal technique.     

A questionnaire survey of attitudes and concerns of three professional groups involved in the cleft palate team.

This study investigated the opinions of three of the professional groups who treat cleft lip and palate patients in the United Kingdom. Plastic surgeons, orthodontists, and speech therapists were asked to give their opinions regarding adolescents with a unilateral cleft of the lip and palate. A mail questionnaire investigating four main areas: treatment, facial appearance and speech, social and emotional aspects, and the perceived success of the specialists was sent to each subject. Nearly all the subjects reported that they worked as part of a cleft palate team and there was good agreement among the three groups. Although the professionals felt that they have been successful, they were not satisfied with the results of their treatment nor with the patients' overall facial appearance or speech. They also felt that the patients are emotionally and socially affected by their cleft and are teased. The subjects noted that they think patients feel similarly to themselves on all aspects. The significance of the results is discussed.