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There are many oral health implications for people born or living with a cleft of the lip and palate. Dentists have an important role to play in providing long-term care. By Frank Leggett
At the Royal Children’s Hospital in Melbourne, specialist paediatric dentist Associate Professor Nicky Kilpatrick and orthodontist Dr Susan Needham are integral members of the Cleft Service. The service provides comprehensive care—from birth until adulthood—to children who are born with a cleft of the lip and palate. Each child has access to a team of multidisciplinary professionals who are coordinated by a cleft nurse consultant.
“General dentists and oral health therapists have a fundamental role to play in this process,” says A/Prof Kilpatrick, clinical lead of the cleft program. “A general dentist can help a child with a cleft lip and palate establish a local dental home—a place where the child feels confident, comfortable and supported.”
As children born with a cleft lip and palate are more at risk of dental decay, regular dental check-ups are essential. Their teeth can be crooked or there may be extra teeth, particularly around the site of the cleft, that act as a food trap. Lip surgery can cause scarring that makes it difficult to get a toothbrush under a tight lip. When teenagers with cleft palates go through extended orthodontic treatment, they often get fed up with brushing their teeth properly. Without regular visits to the dentist, their oral health can rapidly decline.
Working in collaboration with the cleft team, a general dentist can effectively provide preventive care for these patients through childhood, adolescence and adulthood.
“It’s important that general dentists are aware of the challenges and special social adjustment problems faced by many cleft adolescents in relation to their perceived ‘different’ facial appearance and speech,” says Dr Needham, who has a special interest in nasoalveolar moulding where plates and tapes are used to realign cleft segments of babies prior to the primary repair. She also works in private practice at the Brighton Dental Group. “Developing a positive attitude and relationship with their dentist is invaluable for these children.”
Children with a cleft lip and palate also have an increased incidence of dental anomalies. Teeth may be missing, impacted, ectopic, malformed and there are often supernumerary teeth. The maxilla may be hypoplastic resulting in a malocclusion that requires surgery to correct.
“After surgery on the palate, the scar tissue can limit the growth of the jaws as the child gets older,” says A/Prof Kilpatrick. “Most children born with a cleft of the lip and palate require orthodontic treatment. That treatment is often very prolonged and takes place in two or three phases.”
Dr Needham adds, “Patients with a cleft lip and palate are best treated by a cleft team providing interdisciplinary care that meets the unique needs of each individual, no matter how severe the cleft. It starts at the antenatal diagnosis. The team includes paediatricians, plastic surgeons, geneticists, paediatric dentists, orthodontists, maxillofacial surgeons, ENT surgeons, audiologists, prosthodontists, psychologists, and social workers. As these children are transitioning into adult care, the one person who is consistently there through this long and often difficult journey is the general dental practitioner.”
Patients with clefts are discharged from most cleft services around 21 years of age as most cleft teams operate out of children’s hospitals.
“It’s essential that adults with clefts have an ongoing relationship with a general dentist,” says A/Prof Kilpatrick. “No orthodontic treatment is permanent and the relapse rate is potentially higher in these patients. They need a general dentist to maintain their oral health but to also facilitate referrals to specialists. This really is the only way to keep these patients linked with specialised care providers they may need as they get older.”
Born in England, A/Prof Kilpatrick completed her dentistry degree at Birmingham University in 1985, then trained as a specialist paediatric dentist in the UK. In 1995, she saw an advert for a fellowship position at Royal Children’s Hospital in Melbourne. As she had finished her PhD, and knew that the RCH had a comprehensive cleft service—an area that had always interested her—she applied and was soon on her way to Melbourne.
“In Australia, between 500 and 600 babies are born each year with cleft issues,” says A/Prof Kilpatrick. “About 30 per cent will have complete clefts of the lip and palate. We pick up most of those cases in the routine 18-week ultrasound. Babies with only a cleft palate are generally not identified prenatally because of the way the baby’s positioned during the ultrasound. The majority of babies with cleft lips and a cleft lip and palate will be identified antenatally and their care starts then.”
Cleft teams are based in each state’s capital city in a children’s hospital. A patient visit often requires a long journey after which the child is seen by multiple professionals. Establishing a local dental home where the patient sees the same dentist as their siblings helps to normalise dental care.
“Regular routine dental care and restorations, if needed, can all be done locally,” says A/Prof Kilpatrick. “If there’s any doubt about treatment, the practitioner can contact the patient’s cleft team. It really is just a matter of treating these patients like everyone else, though maybe with a little more patience and understanding.”
The Medicare Cleft Lip and Palate Scheme
A/Prof Kilpatrick points out that many families are unaware that all children born with a cleft are eligible to access the Medicare Cleft Scheme. This provides help covering costs of orthodontic treatment and some dento-alveolar surgical procedures. It does not cover routine dental treatments.
For further information about the Medicare Scheme go to: tinyurl.com/yv3599a2