Role of Pedodontist in management of CLAP

Author : Dr.Faizal C P ,Royal Dental College, Chalissery,Palakkad distict Kerala State, India


Abstract

Cleft lip and palate team consists of persons who are assosiated with patients general development, dental development, speech, esthetics, and psychological well being. Pedodontist is an important member of the team who helps in providing feeding plate, presurgical orthopedics, obturators and also helps in maintaince of growth and oral health . This review discusses the role of pedodontist in the management of cleft lip and palate.

Introduction

Clefts of the lip and palate (CLAP)are the most common congenital deformities involving the orofacial region. It is estimated that the overall global prevalence of orofacial clefts is one in every 800 new born babies ¹. Cleft palate may be inherited as an autosomal dominant condition. Family history in a first degree consanguinity increases the risk by a factor of 20 percent ^2,3 . Environmental factors include maternal epilepsy, alchoholism, certain drugs like steroids, diazepam, phenytoin ,accutane and folic acid deficiency,. Cleft lip and palate also occur as a part of many syndromes, including Down’s syndrome and Treacher Collin’s syndrome. ³

For a child is born with CLP , the services of a team of specialists are needed to care and treat them till adolescence. Careful planning by team members is essential that any proposed procedure keeping with the development of the child ⁴. In the early stages to neonatal period the intervention of pedodontist is of great importance . He is a key member of cleft palate team who can provide feeding plate and pre surgical orthopedic treatment for the baby, monitor the growth and development, perfect oral health and guide the occlusion and facial growth ⁵.

Management

Parents face the unexpected birth of a baby with a CL/P, and usually experience shock, denial, sadness, anger, and great anxiety before being able to bond with their baby. In the management of cleft lip and palate a diversity of treatments and a team of experts has to work hand in hand. The team includes a plastic surgeon, an oral and maxillofacial surgeon, an orthodontist, a speech pathologist, a pediatric dentist, an oral surgeon, an otorlaryngologist, a psychologist and a social worker. The team works in a concerted manner to achieve better understanding and alleviation of the problem in affected children and their families.
In the early stages ie from birth to 18 months the pedodontist can provide feeding plate and pre surgical orthopedic treatment for the baby, monitor the growth and development, perfect oral health. In the primary dentition stage the treatment carried out are mainly adjustments in obturators, restoration of carious teeth, maintenance of oral hygiene and evaluating of erupting dentition and facial growth. Orthodontic treatment is not normally recommended for the primary dentition, lest it damages the underlying permanent dentition follicles. However, in patients with a moderately underdeveloped maxilla and no Class III hereditary defect, reverse headgear treatment may be advocated at the age of 4 to 7 years. The reverse headgear is an orthopedic device, specifically designed to stimulate forward maxillary skeletal development, and produces clinically encouraging results in the short term ⁶

In the mixed dentition period many problems are encountered due to ectopic eruption of teeth and malalignments . during the mixed dentition period treatment is concentrated on correction of traumatic occlusion and teeth allignment and are mainly centered about correction of crossbites , and expansion of maxillary arches by routine palatal expanders ⁶.

Feeding plate

Feeding is the most immediate problem encountered in the daily care of an infant with a cleft lip and/or cleft palate .It is because of leakage of air from the mouth through the nose causing regurgitation of fluids, difficulty in swallowing and breathing ^2,3. These problems can be alleviated by mechanical assistance, such as the use of a feeding plate, and squeeze bottle ,Haberman feeder, NUK nipple, Mead Johnson Nurser ⁵ .The feeding plate obturates the cleft and restores the separation between oral and nasal cavities. It creates a rigid platform towards which the baby can press the nipple and extract the milk( figure 1)

figure 1: Child bottle fed with feeding plate in position

It facilitates feeding, reduces nasal regurgitation, reduces the incidence of choking and shortens the length of time required for feeding. The feeding plate also prevents the tongue from entering the defect and interfering with the spontaneous growth of palatal shelves towards the midline. It also helps to position the tongue in correct position to perform its functional role in the development of jaws, and contributes to speech development. The feeding plate reduces the passage of food into the naso-pharynx thus reducing the incidence of otitis media and naso-pharynhgeal infections. Feeding plate restores the basic functions of mastication, deglutition and speech production until the cleft lip and/or palate can be surgically corrected. mechanical feeding is more suitable if breastfeeding is difficult ^3,5,7. While feeding mother should carry the baby in her arm in a semi sitting posture with the infants body upright and tilted slightly backward. feeding plate is placed only during feeding .However Masarei et al ⁸ and Bessell ⁹ showed no evidence to support the use of maxillary plates in babies with clefts.

Presurgical infant maxillary orthopedics

Naso alveolar molding may prove to be beneficial to the surgeon if a better alignment and closer approximation of the cleft segments is achieved before the actual surgical repair. Naso alveolar molding reduces size of cleft, gives proper form to lips, avoids alveolar grafting, opened up nostrils and airways and also reduces tension after large cleft lip surgery. Some studies view that when used as an adjunctive procedure to definitive lip repair, infant maxillary orthopedics provides presurgical benefits, ¹⁰ . Many different appliances exist for use in the cleft infant for maxillary orthopedics and may be broadly grouped under active, semi- active or passive categories . In addition, are the presurgical nasoalveolar molding (PNAM) plates ^10,11 . Active orthopedic force is given in three pieces of tape joined by two elastic bands(figure 2). The central portion of the tape tends to cup the premaxilla in bilateral cleft cases, thus stabilizing the segment. strapping should be applied immediately after birth and continue until the time of surgery ¹¹.

Figure 2: Presurgical infant maxillary orthopedics

Prevention and treatment of dental diseases

Treatment in primary dentition phase is initially focussed on keeping good oral health ⁴. Oral hygiene protocol should be emphasised to the patient and the parent for optimal oral health . Delay in eruption of teeth is common in cleft patients ⁵ . Parents may be nervous to brush in the region of the cleft following the primary lip and palate surgery. They often think that bleeding from gingival inflammation is caused by damage from toothbrushing. Parents need to be educated about the value of brushing. They should be shown in detail how to brush the teeth and gums properly.

Where the upper lip has been repaired, parents should be shown how to lift it, stretching the lip carefully by sliding an index finger along the labial gingival, without doing any damage to the scar ¹⁰. Topical fluoride gel application, fluoride varnish application twice-yearly is very useful preventive measure for teeth that are at high risk from caries. Three months periodic examination of cleft children can be useful

Summary

The successful treatment of cleft lip and palate needs a good multi disciplinary team of specialists and gas to work with a definite protocol for management . the role of the pedodontist starts from the birth and extends upto adulthood.

References

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