Hospital del Niño DIF, Pachuca de Soto, Hidalgo, México.
During the first three months of pregnancy, the parts of the palate and upper lip normally meet. When this union does not occur, the baby will present cleft lip and / or cleft palate. This type of malformation occurs in 1 in every 700 births. The presence of a cleft lip and cleft palate can cause various dental problems such as changes in shape, number, size, dental malposition, as well as developmental defects of enamel. Poor oral hygiene of children with cleft lip and cleft palate may contribute to the high prevalence of dental caries in these patients. We performed comprehensive dental rehabilitation of a female patient of 5 years 4 months old, diagnosed with cleft lip and cleft palate, which initially presented dental malposition, poor hygiene, and irregular shape of the arches and involvement of adjacent teeth to the slit. Strategies have been developed to prevent early childhood tooth decay, which should be considered for inclusion in the protocol of patients with cleft lip and cleft palate. We conclude that an early dental management of such patients, a periodic monitoring of bacterial plaque and instructing parents to good oral hygiene of the patients, reduce caries risk factors in this type of patients, thus favoring treatment operative success.
Keywords: Treatment Dental; Caries; Cleft Lip and Palate
The mouth of the fetus is formed during the first three months of pregnancy. During that time, parts of the upper palate and the upper lip normally bind. When this union does not occur, the baby will then present cleft lip and / or cleft palate (CLCP). Studies report the presence of this malformation in 1 of every 700 births. A CLCP, can cause various dental problems, including changes in shape, number, size, bad dental position and developmental defects of enamel, which increase in prevalence with age.1 The enamel hypoplasia is evident in the incisors adjacent to the slit and first molares.2 Reports have shown that in these patients, unlike children without CLCP, periodontal disease and gingivitis are most often.3 The care of the oral cavity of a patient with CLCP is a complex and extensive treatment, which requires a maxillofacial surgeon who will perform the necessary surgeries (palatine surgery, for example), as well as an orthodontic specialist person, who prepares the patient for surgery and controls the proper growth of the jaws. To minimize the risk of loss of dental organs, the care of oral cavity should be implemented in childhood. The dentist has the function of preventing dental disease, regularly reviewing the patient and carrying out preventive and operative therapy necessary for the proper development of organs dentales.4
A study in Japan showed that children with CLCP present greater incidence of caries in both temporary and permanent teeth, unlike patients without this malformación.5 The streptococcus mutans and lactobacillus are important pathogenic species for the formation of dental caries. The S. mutans cannot usually be detected before the eruption of temporal teeth.6 However, the presence of this organism before 2 years of age is a risk factor for caries. A study of patients under 2 years with CLCP detected the presence of S. mutans in 45% of pacientes.6 However, other studies have found no difference in prevalence of S. mutans between patients with CLCP and patients controles.2, 7 The first treatment for a patient with CLCP is the placement of attachments for orthodontic treatment, and this type of palate facilitates early colonization of lactobacillus and S. mutans.2, 7
Poor oral hygiene of patients with CLCP could contribute to an increased presence of dental caries. It has been reported in some studies that patients with oral clefts, have poor oral hygiene, when compared with patients without problems of clefts. One study found that patients who had cleft palate alone had the cleanest teeth in comparison with CLCP patients; the last ones presented the incisors with more bacterial plaque.8 This fact suggests that there are difficulties in achieving optimal oral health by lack of access to brush all of the teeth, due to loss of elasticity of the surgically repaired lip, also because of the anatomy of the fissure and a little scare to make a good brushing around the area fisura.8, 9 The presence of a palatal fistula causes two problems in patients with CLCP, on one hand, there is a drainage of the fluid nasal to the oral cavity and, on the other hand, food can escape through the nose and returned to the mouth.8-11 This could increase the risk of caries, because sugars and cariogenic bacteria are present in the mouth for a longer period of time.
Some children with cleft palate can use intraoral devices very soon after birth. These devices are made of acrylic and can be used up to 18 months. The benefits of the devices include food assistance and guidance for the growth and development of the palate. However, the apparatus of acrylic can facilitate early colonization of S. mutans.6 This early colonization predisposes patients to an early onset of caries in the primary dentition. There is a greater risk of caries in patients with pre-surgical orthopedics.4 It has been shown that children with oral clefts treated with oral appliances are more likely to get caries at the age of two years that children with oral fissures but without intra-orals appliances.12 Patients with CLCP often have numerous dental skeletal anomalies such as hypodontia, supernumerary teeth, changes in tooth size and shape, and misalignment of the tooth.3 Several studies have shown that patients undergoing fixtures for orthodontic treatment have a higher risk of dental caries.12 The consistency of a soft diet indicated for orthodontic treatment increases its retention and alter the swallowing of saliva, allowing substrates to remain in the mouth for a longer period, favoring cariogenic bacteria. This can cause an increase in acid production and promotes the risk of destruction by caries.2 Most patients undergoing treatment with fixed orthodontics appliances are at an age where their teeth are not completely mineralized upon the eruption, which makes them vulnerable to the caries. This period usually continues during the first years after the eruption of teeth. This could explain the increased prevalence of caries in patients with fixed orthodontic appliances.6
Prolonged orthodontic therapy and the use of prostheses to prevent collapse of the dental arches causing in most cases, inflammation of the papillae. Some authors suggest implementing prophylactic therapy for patients with CLCP.8 Alveolar bone grafting has had good results, showing that normalizes the periodontal condition in the region of the cleft.9 To get a good result in the integral treatment of patients with CLCP, it is important to maintain healthy periodontal tissues. The teeth adjacent to the closure of the cleft have increased risk of periodontal disease unlike to the unaffected zone.1 Patients receiving timely periodontal treatment, resulting with better health tissue periodontales.3
Recently the Department of Dental Health in Children's Hospital "Royal Children's" in Brisbane, Australia, made some recommendations to prevent tooth caries in early childhood. This hospital recommends advising parents, especially the eating habits of mothers before child birth, strengthening dental education in parents, using chemical-therapeutic agents for cleaning the orthodontic appliances, avoiding cross contamination by not having direct contact (not kiss on the lips of the baby), educating in cleaning teeth after surgery, and teaching brushing technique especially around the area of the cleft and go to the dentist for reviews periodics.8
Female patient, 5 years 4 months old, who goes to Craniofacial Center at Hospital del Niño DIF Hidalgo, diagnosed with CLCP. Upon entering the program, parents relate two previous surgeries performed in another institution: Cheiloplasty at 2 months old and Palatoplasty at the first year of age. During the interrogation to parents, they mentioned that the patient had not received orthodontic treatment. On examination of the oral cavity, we observed dentition, regular hygiene and anterior crossbite (Figure 1).
Also, irregularity of shape and size of upper arch, bad dental position and anomaly in the guide of eruption were found. Caries grade I in bodies 55-65; grade II in 51-52, root piece in 64 and maladjusted amalgam with recurrent caries in 54 (Figure 2).
In the lower arch, amalgams mismatched in first molars and caries grade II in second molars were found (Figure 3). The shaped of the arch was oval and the floor of the mouth was vascularized, hydrated, without pathological lesions.
Figure 1. Front view when entering to the Pediatric Dentistry service at the hospital.
Figure 2. Upper Occlusal before the treatment.
Figure 3. Lower Occlusal before the treatment.
The dental restoration was carried out in 8 sessions, working for hemi-arcades. Medical history was realized in the 1st appointment and family history of CLCP was the major concern. Brushing technique is taught and the first control bacterial plaque (BP) is recorded. In the 2nd session the caries of the dental body 54 is eliminated, making pulpotomy, sealing with zinc oxide eugenol. In the 3rd appointment, there is an improvement in oral hygiene and in the use of brushing technique; caries of the molars second are removed, sealing with photocurable resins. The removal of remaining dental root body 64 is performed at the 4th session (Figure 4).
Figure 4. Upper Occlusal after the treatment.
For the 5th visit to service, it is decided to prepare, adjust and cement the crown of the upper right central dental body. At the 6th session of operative treatment, the lower right hemi-arcade is worked, removing amalgam maladjusted of the first molar and eliminating caries of the second molar, placing in both photocurable resin. In the seventh appointment, unadjusted amalgam is removed from the dental organ 74 and carious tissue from the 75, sealing with photocurable resin (Figure 5). In the last session, chrome crown was prepared for the first upper right molar, it is adjusted and sealed with glass ionomer, after removing caries grade II, photocurable resin is placed in dental organ 62.
Prophylaxis and topical application of fluoride as a preventive measure (Figure 6) is performed. Recurring control appointments are given for preventive management every four months and patient is sent to the orthodontic area for treatment.
Figure 5. Lower Occlusal after the treatment
Figure 6. Front view at the end of the treatment
This article aims to explain the relationship among the presence of CLCP, dental organs and disruption of periodontal tissues. Demineralization occurs when environmental conditions favor the growth of cariogenic bacteria (ie, low pH and high availability of the fermentation of carbohydrates). Rather, the buffering capacity of saliva and saliva ions, proteins and enzymes can raise the pH of the environment and promote re-mineralization of tooth enamel. However, the ability to do this varies individually. Therefore, some people are at higher risk of caries than others.12 According to some authors, it is clear that patients with CLCP have a higher incidence of dental caries than patients without oral clefts. The existence of dental abnormalities, such as enamel hypoplasia and deficient oral hygiene due to the hard tissues of the surgically repaired lip predispose to accumulation of bacterial plaque.3 In addition, a nasal fistula increases the consistency of the plaque, which helps the adhesion of bacteria and more colonización.2
Parents of these children also tend to feed their children too much, providing a high cariogenic diet, because food can stick between the dental organs in a bad position, and even in cleft palate and fístula.13 Consequently, sufficient fermentable substrates are exposed to the oral environment for a longer period, which could create an acidic environment that favors desmineralización.14
There are a number of factors contributing to the early establishment of cariogenic bacteria. Patients with CLCP are undergoing orthodontic treatment with several episodes of stationary and removable appliances.15 Orthodontic treatments can start from birth with pre-surgical operative oral appliances where the cleft is sealed in order to help feed and mold the rim alveolar.2 Other devices are made to prevent the collapse of the upper arch. These devices can promote early establishment of cariogenic bacteria in the oral cavity. As can be seen in the clinical case, most often affected dental organs are adjacent to the slit. Studies show that patients with cleft lip and / or cleft palate have poor dental hygiene, so it is important to maintain good hygiene of the oral cavity. Periodic monitoring of bacterial plaque, teach good brushing technique and advice parents on their eating habits, that helps get favorable results after the treatment surgical.16
The presence of CLCP is a predisposing factor for developing dental caries and periodontal disease. A good brushing technique must be implemented and instruct parents for good hygiene and nutrition from birth, that will result in a successful dental treatment. It is important to keep consults with specialists in charge of the integrated management of these patients in order to restore chewing function, improving aesthetics and as a result, to provide better quality of life.
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Author for corresponding:
Hospital del Niño DIF, Pachuca, Hidalgo, Méxic