The Implications of Cleft Palate and Lip on the Oral Cavity

The Implications of Cleft Palate and Lip on the Oral Cavity

Addie Bardon

Kirkwood Community College

DHYG IV

Lisa Hebl

December 1st, 2022

The Implications of Cleft Palate and Lip on the Oral Cavity

According to the CDC about 1:1700 babies born in the United States have cleft palate,

and about 1:2800 babies are born with cleft lip (Centers for Disease Control and Prevention

[CDC], 2020). What does that mean for us as hygienists? It means that education and

understanding are very important when it comes to dealing with patients who have cleft

lip/palate or patients who have children with the disability as well.

The first part to understanding a disability is first recognizing where it came from. Our

first documentation we have of cleft lip/ palate is steeped in superstitions and religious beliefs,

particularly of the Spartans and the Romans. It is said that both the Spartans and Romans would

often kill these children because it was believed that they harbored evil spirits (Bhattacharya et

al. 2009). The first documented cleft lip surgery performed was in China, year 390 BC. An 18-

year-old solider by the name of Wey Young-Chi was the patient, his surgeon was Albucasis of

Arabia, the surgery was considered a success! According to Bhattacharya et al, (2009) during the

16th century, one of the greatest surgeons of that time period, Ambroise Pare, was credited as the

first physician to do an in-depth study on the anatomy of the cleft lip and palate; he was also the

first to refine the suturing techniques involved in repairing the clefts.

Now that we understand that the first documentations of this disability go all the way

back to the Romans and Spartans, what exactly is this disability? Cleft lip and palate are

essentially gaps or openings that have occurred in a child’s lip or palate at birth due to the

incorrect formation of the tissues and structures that make up one’s lip and palate. Cleft lip and

palate are congenital abnormalities. It is thought to be a genetic factor, believed to be caused by

an abnormality in the chromosomes of the child. However, research shows that exposure to

alcohol, cigarette smoke, steroids, rubella, anticonvulsants, retinoids, and hypoxia have all been

associated with cleft lip and palate (Kosowski et al., 2012). They are even beginning to link
The Implications of Cleft Palate and Lip on the Oral Cavity

advanced paternal age as a risk factor of cleft lip and palate. Now, what’s the epidemiology of

the disability? Who does it effect? Kosowski et al. (2012) article found the following:

Cleft palates affect 1:2,000 live births worldwide regardless of race. This is in contrast to

cleft lips, which show racial variability with the highest incidence in Asian and Native

Americans (1:450 live births) and the lowest incidence in African Americans (1: 2,000

live births). Isolated cleft palate occurs more in females (57%) than in males (43%).

Gender differences may be related to differences in timing of embryologic development.

Now that it’s clear who can be affected, when is the population affected? This is an easy question

to answer. The population is affected during a mother’s gestational period. Specifically, cleft lip

forms between the 4th and 7th week in utero, and cleft palate forms between the 6th and 9th week in

utero. Why those specific dates? According to the CDC (2020) the lip and palate should be

completely formed during the 4th though 9th week of pregnancy, after that it could then be

possible for the disability to be detected through an ultrasound; or of course after the baby is

born.

Understanding of the origin, the epidemiology, and the predisposing factors of the disease

have all been discussed; now an understanding of how this disability affects the body is required.

According to Kosowski et al. (2012) “cleft lip results from a failure to maintain an epithelial

bridge due to lack of mesodermal delivery and proliferation from the maxillary and nasal

processes.” To make that explanation simpler the authors are really just saying that the lip hasn’t

fully formed because the maxillary and nasal process never meet, making a gap or an opening.

Clefting of the lip can occur bilaterally, on both sides of the lip, or on just one side of the lip. It

can also appear directly in the middle of the lip; this usually creates a larger gap.
The Implications of Cleft Palate and Lip on the Oral Cavity

Like a cleft lip, a cleft palate occurs because the tissues that make up the roof of the

mouth don’t fuse together during the gestational period, again leaving an opening or a gap.

Sometimes both the anterior and the posterior portion of the palate have an opening, this is called

a complete cleft palate. An incomplete cleft palate is described as only one portion of the hard

palate having an opening, this can occur in the posterior or anterior portion of the palate. The

physical effects that these opening have on the body can cause a baby to be more prone to having

problems with speaking, feeding, hearing, and problems with their dentition (CDC, 2020).

Cleft lip and palate is not a disability that comes with any known intellectual concerns.

However, it is important to note that many children will suffer from mental health issues, such as

anxiety and depression, due to issues with their self- esteem associated with their cleft or the

scarring from the cleft reconstruction surgery (CDC, 2020). This is especially so for children

with clef lip due to their disability affecting a part of their face that is easily visible.

Cleft lip and/ or palate is a lifelong condition, but it can be fixed with surgery, and after

successful treatment most children do very well and lead normal and happy lives. Treatment can

be quite extensive though, depending on the severity of the cleft. Treatment for cleft lip and

palate requires a large team of professionals. These professionals are usually referred to as the

craniofacial team, this team will have nurses, plastic surgeons, speech pathologists,

otolaryngologists, audiologists, orthodontists, oral surgeons, and pediatric dental professionals

(Geneser, 2017). There are many professionals that will work on a child’s care plan due to the

fact the child can and most likely will have many different roadblocks to maintaining their

health. A few of these roadblocks are chronic ear infections hearing loss, and arguably the most

important issue that begins at the start of the child’s life, which is the issues with feeding that a

cleft palate can cause. A child’s first surgical intervention will normally happen around the first 3
The Implications of Cleft Palate and Lip on the Oral Cavity

to 6 months of the baby’s life (Geneser, 2017). Sometimes a child will require more surgeries to

fix the cleft depending on the severity, but other times only one surgery is needed. No

medication is used to treat cleft lip or palate, however since the child will be more prone to ear

infections during their treatment process, an antibiotic will be a drug that the child’s physician

might frequently prescribe to them. An antibiotic won’t adversely affect the body or the oral

cavity, unless of course the child has an allergy to that specific antibiotic. That’s why it is

important for the child’s physician to determine which antibiotic is best for the child to avoid any

allergic reactions.

So why as hygienists is learning about cleft lip and/ or palate a big issue? It’s because it

affects the oral cavity, the place where we do our job! So how does the disability affect the oral

cavity? Physically, this disability’s point of origin is the oral cavity itself, so you will see a gap in

the lip and the palate of the child. It can be an incomplete cleft palate (one portion of the palate

didn’t close) or it can be a complete cleft palate (both portions of the palate aren’t closed). As for

a cleft lip it can be bilateral, unilateral, or right in the middle.

How does this disability affect the incidence of decay, periodontal disease, alignment,

etc.? A study done by Grewcock et al. (2022) conculuded that:

The overall findings of the meta-analyses align with previous global literature, showing

higher caries experience in children with cleft lip/ palate compared to those without, for

children’s primary and mixed dentition caries experience.

Another main concern with children that have cleft lip and/ or palate is the need for orthodontic

care. Many children could have malposed or missing teeth. It’s possible that these children will

also have constricted arches due to their reconstructive surgeries. The children with clefts will
The Implications of Cleft Palate and Lip on the Oral Cavity

almost definitely need to have orthodontic appliances. Or even possibly have surgeries based on

the severity of each case ( Geneser, 2017).

What should a treatment for a patient with cleft lip and palate look like? A caretaker is

going to be needed for treatment because clefting occurs in babies, so a parent or guardian will

be the natural caretaker involved. The parent is responsible for brushing their child’s teeth,

making their dental appointments, and getting them to those appointments. The parent will also

play a key role in helping to teach and motivate their child to continue their oral health care as

they grow older. Someone who has had cleft palate when they were younger but has since grown

up will not need a caretaker. What toothbrush should be used? A regular toothbrush for the

appropriate age group can be used. As the child gets older an electric toothbrush can be used as

well, assuming the child has the cleft fixed, with no restrictions. If proper care is taught both by

parent and hygienist, no toothbrush modifications are necessary. In terms of dental aides,

children with clefts will undoubtedly have malposed and maligned teeth, so flossing aides such

as a water flosser might really benefit the child after their teeth have come in and especially

during their orthodontic treatment. Since this disability affects young children, the patient will

most likely need to be in the knees and lap position for the dental operator during the first few

years of their life. Also, as the patient gets older extensive oral health instructions should be

taught by the hygienist since the incidence of caries is higher in children who have cleft lip and/

or palate.

When you think of the craniofacial team that is involved in helping a child with cleft lip

and palate, a hygienist might not be the first person to come to mind, but we play an important

role of educating parents and the child as they grow up how to properly take care of their teeth

and mouth throughout their lives. We will see them every 6 months hopefully for the rest of their
The Implications of Cleft Palate and Lip on the Oral Cavity

lives, we will become a trusted caretaker for them and their parents as they navigate this

challenging journey. For us to be knowledgeable about our patients’ disabilities is not only

important when creating a treatment plan but important to help relate and create relationships

with your patients. And this is true of every patient with a disability that comes into your chair,

not just a child with cleft lip and palate. Being a hygienist means being a person that cares about

your patients as more than just a patient.

The Implications of Cleft Palate and Lip on the Oral Cavity

References

Bhattacharya, S., Khanna, V., & Kohli, R. (2009). Cleft lip: the historical perspective. Indian

Journal of Plastic Surgery, 42(S 01), 8.

Centers for Disease Control and Prevention. (2020, December 28). Facts about cleft lip and cleft

palate. https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Geneser, M. K. (2017). The treatment of cleft lip and/ or palate. Dimensions of Dental Hygiene,

15(11), 33-36.

Grewcock, R. E., Innes, N. P. T., Mossey, P. A., & Robertson, M. D. (2022). Caries in children

with and without orofacial clefting: a systematic review and meta-analysis. Wiley

Periodicals LLC, 28(5), 1400-1411.

Kosowski, T. R., Weathers, W. M., Wolfswinkel, E. M., & Ridgway, E. B. (2012). Cleft

palate. Seminars in Plastic Surgery, 26(04), 164–169.