Oral health in 4-6 years children with cleft lip/palate: a case control study.

BACKGROUND: Oro-facial clefts are a major public health problem. Children with clefts rarely escape dental complications. AIMS: This study was to determine differences in the dental caries experience, gingival health, and prevalence malocclusion, enamel defects and oral mucosal lesions among 4-6 year old children with and without cleft in Panchkula.
MATERIALS AND METHODS: The sampling frame consisted of 4-6 year old children with clefts visiting Swami Devi Dyal Hospital and Dental College, Panchkula, India. As a control group an age (±3 months) and gender-matched sample from the same geographical areas were recruited. Dental caries status, gingival health status, developmental defect of enamel, malocclusion and oral mucosal health were assessed and compared between the two groups.
RESULTS: Significant differences in dental caries and gingival health status were found between children with and without cleft. Anterior open-bite, increased overjet and oral mucosal lesions (P < 0.05) were more prevalent among children with clefts. Children with and without clefts had similar developmental defects of enamel (P > 0.05).
CONCLUSION: Differences of oral health status exist among 4-6 year old children with and without clefts. Children fare worse in terms of dental caries, gingival health, oral mucosal health and malocclusion.

Introduction

Oro-facial clefts are a major public health problem affecting 1 in every 500 to 1000 births worldwide.[12] According to World Health Organization (2001), every 2 minutes a child is born with a cleft and in India alone three infants are born every hour with clefts.[34] Affected children have a range of functional as well as aesthetic problems. These includes difficulties in breast feeding due to improper oral seal, swallowing and nasal regurgitation, other associated problems are hearing difficulties due to abnormalities in the palatal musculature, and speech difficulties due to nasal escape and articulation problems.[45]

Children with clefts rarely escape dental complications. Since these children and their parents give more importance to the surgical correction of their clefts and neglect their dental health they tend to have more decayed and missing teeth, and poor oral health as compared to that of normal children.[67] However, reports on the oral health status of children affected by clefts have for the most part been limited to clinical samples, have lacked control comparison groups and have been very selective in terms of oral health aspects studied.

This initiated our present study to determine differences in the dental caries experience, gingival health, and prevalence malocclusion, enamel defects and oral mucosal lesions among 4-6 year old children with and without cleft in Panchkula.

Materials and Methods

Sample

The sampling frame consisted of 4-6 year old children with clefts visiting Swami Devi Dyal Hospital and Dental College, Panchkula, India, during January-December 2013. In total, 52 children with clefts were identified and their parents/primary care-givers were invited to participate in the study. As a control group age (±3 months) and gender-matched samples from the same geographical areas visiting the OPD of the dental institution and were free from cleft lip and palate or any systemic disease were recruited. Ethical clearance was obtained from the institutional ethical committee. A written consent was taken from the parents/primary care givers and an oral informed consent was obtained from the participants before the complete oral examination was carried. Those who were uncooperative and refused to participate in the study were excluded.

Data collection

All the recruited children received clinical examinations by a single trained and calibrated examiner. The examination procedures and diagnostic criteria were those recommended in the World Health Organization Oral Health Survey Basic Methods and included assessment of dental caries experience (dmft).[8]

Six index teeth: maxillary right second primary molar (55), maxillary right central primary incisor (51), maxillary left first primary molar (64), mandibular left second primary molar (75), mandibular left central primary incisor (71), mandibular right first primary molar (84) were chosen for the assessment of gingival health and developmental defects of enamel. Gingival health was assessed by the Simplified Debris Index and the Gingival Index.[910]

The presence of developmental defects of enamel was also recorded as being present/absent on index teeth based on the Development Defects of Enamel Index criteria.[11] In assessing malocclusion, the presence or the absence of anterior open-bite and over-jet was recorded. The presence or absence of oral mucosal lesions was also recorded.[12]

The examiner was trained and calibrated prior to the commencement of the study by conducting repeat assessments after 1 week on 20 children (5 cases and 15 controls). Agreement of clinical assessments was established to be good (Kappa values = 0.82) which validated the examination procedure. The number of people enrolled as controls were selected to meet statistical power requirements (80% power) for the case control study.

Statistical analysis

Data were analyzed using the statistical package SPSS PC Version 20.0 (Chicago, IL, USA). Differences in mean caries experience, plaque index and gingival index scores between those with and without clefts were compared using the Mann-Whitney U-test. A comparison of developmental defects of enamel, oral mucosal lesions and open-bite and over-jet between those with and without clefts was assessed using chi-square tests.

Results

It was possible to conduct oral examinations for 92.3% (48/52) of the children with clefts (four care givers declined to participate in the study). The mean age of the children was 57 ± 8 months (Cases = 56 ± 8, Controls = 58 ± 9), of whom 59% were males. The characteristics of the 74 children with cleft evaluated in this study are shown in Table 1. An age (±3 months) and gender match sample of 48 children attending the dental institution acted as the control group for the study. No significant difference was observed in the dental caries experience, gingival health, and prevalence malocclusion, enamel defects and oral mucosal lesions among children with different types of cleft. Henceforth results for children with different types of cleft were combined and not depicted separately.

Table 1

The characteristics of the 48 children with cleft

Among the children with cleft the prevalence of dental caries was found to be 71.9% and mean dmft score was found to be 3.8. A significant difference was observed in caries experience between cleft and non-cleft children (P < 0.05) (Table 2).

Table 2

A comparison of the dental caries experience and periodontal condition of children with and without cleft

In terms of gingival health of children with cleft, the mean plaque index score was 0.92 and the mean gingival index score was 0.83 for the index teeth. Children with clefts had higher plaque index scores (P = 0.005) and higher gingival index scores (P = 0.002) than the children without clefts.

Table 3 shows the comparison of developmental defects of enamel, malocclusion and oral mucosal health among children with and without cleft. The presence of an anterior open-bite and over-jet was more common among children with clefts, when compared to those without clefts, 26.0% versus 2.7%, respectively (P < 0.001). In addition, children with cleft more frequently had an oral mucosal lesion present (ulcers, coated tongue, candidiasis) than children without cleft, 20.6% versus 8.2%, respectively (P = 0.03). There was no significant difference (P > 0.05) in the prevalence of development defects involving enamel among children with and without cleft.

Table 3

A comparison of developmental defects of enamel, malocclusion and oral mucosal health among children with and without cleft

Discussion

This was a comparative cross-sectional study of children with and without clefts matched for sex and age. Although this was time consuming it enabled a reasonably large and representative sample to be obtained.

In assessing the oral health, a large number of oral health factors were considered, including dental caries experience, gingival health, developmental defects of enamel and oral mucosal condition, so as to provide a comprehensive view of the oral health status of children with clefts. Considering limited level of cooperation in 4-6 year children and for having comprehensive assessment, index teeth were used for a number of assessments (i.e., partial sampling). This type of approach is commonly adapted by clinicians who frequently examine and treat young children and special needs patients.[13]

The caries experiences were significantly greater in cleft subjects than those in the non-cleft control group. The results are in concordance to study done by Britton et al. (2010) and Aldrees (2009).[1415] Although the underlying mechanism remains unclear, this can be attributed to dry mouth caused by mouth-breathing habits, less natural cleaning of the teeth because of the morphology, different diet or feeding habits,[16] irregularity of the teeth,[17] increased oral clearance time for foods, and more carious bacteria in the oral cavity of cleft children.[18] Further research is necessary to elucidate the cause. No significant difference was observed in caries prevalence between cleft and non-cleft children. This can be due to caries is a chronic infectious disease; the observation period is too short for 4- to 6-year-old children, limiting us from demonstrating the effect of cleft on the development of caries. More research is needed to clarify this point. The results for caries prevalence reported in the study were similar to results reported among pre-school children in India i.e. 40-70%.[19202122]

Poor oral hygiene was observed in children with clefts as compared to controls. Possible reasons for the poorer oral hygiene in children with cleft can be: (a) the presence of residual scar tissue as a result of the multiple surgical procedures carried out at the cleft region which in turn impairs tooth cleaning; (b) the lack of interest for oral hygiene due to many other health problems such as otitis media, difficulty in speech and the fear that children often have when they brush their teeth at the cleft area.[23] All the above factors make the importance of the administration of individualized preventive oral health programs in cleft patients, indispensible.

In assessing malocclusion two attributes were considered. The presence or absence of an anterior open-bite and increased over-jet were found more common among children with clefts. This could possibly be related to aberrant tongue movement or positioning, a poor swallow reflex and frequent mouth breathing. Furthermore, the prevalence of developmental defect of enamel was higher in children with cleft than those without, but the difference was not statistically significant. These findings are in agreement with the literature.[2425]

Patients and their families are usually concerned with other aspects of their health care, such as surgery, nutrition, mental health, and speech development, that they pay little/no attention to basic preventive dental care.[26] These assessments not only provide a baseline for oral health parameters in young patients with clefts, but also underline the need for a more vigorous approach to the prevention of oral disease to improve on clinical outcome.

Conclusion

In this case control study, conducted in SDDHDC, Panchkula differences of oral health status exist among 4-6 year old children with and without cleft. Children with cleft tend to fare worse in terms of dental caries, gingival health, malocclusion and oral mucosal health than normal 4-6 year old children. These findings have implication in advocation for oral health care for children with clefts.