Knowledge, awareness, and attitude on cleft lip and palate management among dental students

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Research Article Knowledge, awareness, and attitude on cleft lip and palate management among dental students S. Sruthi, Arvind Sivakumar, Saravana Pandian K., Navaneethan R.

1 Research Article Knowledge, awareness, and attitude on cleft lip and palate management among dental students S. Sruthi, Arvind Sivakumar, Saravana Pandian K., Navaneethan R. ABSTRACT Purpose: The purpose of the study was to assess the knowledge, awareness, and attitude on cleft lip and palate management among dental students. Materials and Methods: A questionnaire with 10 questions was printed and distributed among dental undergraduate students and knowledge, awareness, and attitude on cleft lip and palate management was assessed. Results: The results were interpreted in pie chart, and the undergraduate dental students were aware of the condition but were not completely aware of the treatment procedure, treatment timing, the sequential timeline followed for each procedure and the role of each specialty in managing the cleft lip and palate. Conclusion: The knowledge, awareness, and attitude on cleft lip and palate management among dental students is necessary for proper timely care and efficient treatment. KEY WORDS: Cleft lip and palate management, Knowledge and awareness, Undergraduate dental students INTRODUCTION Cleft lip and/or palate (CL/P) is the most common congenital craniofacial malformation. Patients with CL/P require appropriate corrective treatment to improve function and esthetics. Treatment of CL/P is not a single stage treatment and requires multiple stages of intervention at different timing of development. Knowledge about the various treatment procedures involved and the timing of the procedures among the dental students is vital for them to refer the patient at the correct stage to the appropriate specialist, who will provide the best of patient care. MATERIALS AND METHODOLOGY A questionnaire consisting of 10 questions was printed and distributed among dental students and knowledge, awareness, and attitude on CL/P were assessed. Questionnaire 1. What are the causes of CL/P? a. Maternal smoking and alcohol. b. Intake of teratogenic drugs. c. Genetic defect. Access this article online Website: jprsolutions.info ISSN: Do you think CL/P management requires multidisciplinary team approach? a. Yes. b. No. c. Not always. d. Rarely. 3. Who are all the participants of CL/P team? a. Feeding specialist, nurse coordinator, plastic/ craniofacial surgeon, and otolaryngologist. b. Pedodontist, orthodontist, and prosthodontist. c. Geneticist, speech therapist, and social worker. 4. Who will you refer a CL/P patient? a. Pedodontist. b. Orthodontist. c. Craniofacial surgeon. d. Speech therapist. 5. Which specialty performs Nasoalveolar Molding (NAM)? a. Prosthodontist. b. Orthodontist. c. Craniofacial surgeon. d. Pedodontist 6. What are the age criteria for performing NAM? a. Immediately after birth till 5 years. b. 2 weeks after birth till 6 months after birth. c. Immediately after birth till 3 months after birth. d. 2 weeks to 9 months after month. Department of Orthodontics and Dentofacial Orthopaedics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India *Corresponding author: S. Sruthi, Department of Orthodontics and Dentofacial Orthopedics, Saveetha Dental College and Hospitals,Saveetha Institute Of Medical And Technical Sciences,Chennai,Tamil Nadu, India. dr.sruthi92@gmail.com. Received on: ; Revised on: ; Accepted on:

7. What are the benefits of performing NAM? a. Eliminates surgical columella reconstruction and the resultant scar tissue in bilateral CL/P. b. Indicates better lip and nasal form, reduced oronasal fistula and labial deformities.

Pedodontist. 9. What is the role of maxillary expansion in CL/P management? a. Eliminates vertical discrepancy in maxilla. b. Eliminates transverse discrepancy in maxilla. c.

2 7. What are the benefits of performing NAM? a. Eliminates surgical columella reconstruction and the resultant scar tissue in bilateral CL/P. b. Indicates better lip and nasal form, reduced oronasal fistula and labial deformities. c. 60% reduction in the need for secondary alveolar bone grafting. 8. Which specialty is involved in fabrication of the NAM appliance? a. Prosthodontist. b. Orthodontist. c. Craniofacial surgeon. d. Pedodontist. 9. What is the role of maxillary expansion in CL/P management? a. Eliminates vertical discrepancy in maxilla. b. Eliminates transverse discrepancy in maxilla. c. Eliminates sagittal discrepancy in maxilla. d. Eliminates maxillary discrepancy in all planes. 10. What are the sequelae of CL/P management? a. CL/P repair, NAM, rhinoplasty, ear surgery, orthodontic treatment, and orthognathic surgery. b. NAM, CL/P repair, ear surgery, rhinoplasty, orthodontic treatment, and orthognathic surgery. c. CL/P repair, rhinopla and sty, ear surgery, NAM, orthognathic surgery, orthodontic treatment. Chart 1: Causes of Cleft lip and palate RESULTS A questionnaire consisting of 10 questions was distributed among dental students and knowledge, awareness, and attitude on CL/P management were assessed. The responses deduced were, a question on causes of CL/P were raised 27% responded telling that maternal smoking and alcohol as main cause, 23% said intake of teratogenic drugs were the main cause, 31% claimed that it was a genetic defect, and 19% said all of the above [Chart 1]. The necessity of multidisciplinary team approach in CL/P management was reviewed of which 41% said yes, 30% said no, 20% said not always, and 9% said rarely it requires a multidisciplinary team approach [Chart 2]. The participants of CL/P team were investigated in which 27% said feeding specialist, nurse coordinator, plastic/craniofacial surgeon, and otolaryngologist are involved, 23% said pedodontist, orthodontist, and prosthodontist are involved. 22% said geneticist, speech therapist, and social worker are in the team. 27% said all of the above specialties are involved [Chart 3]. A question on who will they refer a CL/P patient once they encounter them for the 1 st time was asked, for which 32% responded as pedodontist, 23% as orthodontist, 18% as craniofacial surgeon, and 27% as speech therapist as their first line of referral [Chart 4]. Specialty involved in performing NAM Chart 2: Need for multidisciplinary team approach Chart 3: Participants of Cleft lip and palate team 2609

3 (NAM, 27% responded as prosthodontist, 23% felt it is orthodontist, 19% as craniofacial surgeon, and 31% as pedodontist [Chart 5]. Age criteria to perform NAM were assessed, 27% said immediately after birth, 32% said 2 weeks after birth till 6 months after birth, 23% said immediately after birth till 3 months after birth, and 18% said 2 weeks to 9 months after month [Chart 6]. Benefits of NAM were questioned the responses were 35% said it eliminates surgical columella reconstruction and the resultant scar tissue in bilateral CL/P, 15% said it indicates better lip and nasal form, reduced oronasal fistula and labial deformities, 18% said it causes 60% reduction in the need for secondary alveolar bone grafting, and 32% said all of the above statements are true [Chart 7]. Specialty involved in the fabrication of NAM appliance was investigated, they responded as 27% as prosthodontist, 23% as orthodontist, 19% as craniofacial surgeon, and 31% as pedodontist [Chart 8]. Role of maxillary expansion in CL/P management was asked, 15% said it eliminates vertical discrepancy in maxilla, 35% said it eliminates transverse discrepancy in maxilla, 18% said it eliminates sagittal discrepancy in maxilla, and 32% it eliminates maxillary discrepancy in all planes [Chart 9]. Sequelae involved in CL/P management were asked, 16% responded as CL/P repair, NAM, rhinoplasty, ear surgery, orthodontic treatment, and orthognathic surgery; 34% as NAM, CL/P repair, ear surgery, rhinoplasty, orthodontic treatment, and orthognathic surgery; 42% as CL/P repair, rhinoplasty, ear surgery, NAM, orthognathic surgery, and orthodontic treatment; and 8% as all the above [Chart 10]. DISCUSSION The CL/P is a congenital defect which can be cured and requires multidisciplinary team effort and good patient and doctor rapport and parental cooperation. The cleft and craniofacial team involves nurses, general dentists, orthodontists, oral surgeons, otolaryngologists, geneticists, prosthodontists, speech therapists, radiologists, psychologists, feeding specialists, and plastic surgeons. The cleft children needs are multifactorial, [1] the need for gingivoperiosteoplasty in cleft management is explained in few articles, [2] it is often simple to appreciate when one starts to list out the functional and anatomic areas affected by the dentofacial deformity. The craniofacial team is composed of nursing and physician specialists with specific interest and special training in the care of children with cleft and craniofaciail deformities. A study suggests that the prepubertal midface growth in sagittal vertical and transverse planes (9 13 years) remained unaffected by presurgical NAM and gingivoperiosteoplasty, [3,4] the need for early nose and lip correction is emphasized for better molding of soft tissues and increase self- Chart 4: Primary referral of Cleft lip and palate patient Chart 6: Age criteria for performing NAM Chart 5: Dental specialty performing Nasoalveolar Molding (NAM) Chart 7: Benefits of performing NAM 2610

Chart 8: Dental Specialty involved in fabrication of the NAM appliance One of the first consultations starts with the feeding specialist, who assists families with managing the special feeding needs

A specialty nurse coordinator acts as a communicator between the patient and family and the craniofacial team.

They found no evidence regarding the effect of wartime conditions in Norway impaired perinatal survival, affecting either directly or through an effect on women born during the war.

4 Chart 8: Dental Specialty involved in fabrication of the NAM appliance One of the first consultations starts with the feeding specialist, who assists families with managing the special feeding needs of cleft newborns. The geneticist plays a role in diagnosing associated syndromes and counsel parents regarding genetic risks and future possibilities of inheriting it. A specialty nurse coordinator acts as a communicator between the patient and family and the craniofacial team. There may be some variability in the specific roles of the surgeons on the team, but these usually consist of a plastic surgeon, otolaryngologist, and oral surgeon. They found no evidence regarding the effect of wartime conditions in Norway impaired perinatal survival, affecting either directly or through an effect on women born during the war. [17] Parents of newborns with clept lip and palate should be informed about basic information in the immediate newborn period, especially feeding instructions and identifying illness. [18] In this study, a series of alveolar cleft sites treated with pre-surgical orthopedics and gingivoperiosteoplasty, showed that 60% did not require a secondary alveolar bone graft in the mixed dentition. [19] Chart 9: Role of maxillary expansion in Cleft lip and palate management Chart 10: Sequelae of Cleft lip and palate management esteem of the patient, [5] the periosteoplasty, and lip adhesion approach achieves the main goal of moving the palate into a preferred position and stabilizing the arch with an osseous bridge that attracts teeth. It prevents the emergence of anterior fistulae and presents a symmetrical platform on which the lip and nose correction can be brought out. [6] The use of NAM and gingivoperiosteoplasty is more preferred than SABG since it is cost-effective in the management of unilateral cleft management. [7-9] In the management of bilateral CL/P repair, the need for presurgical orthodontic intervention is overemphasized, [10,11] the impaired weight and height gain because of feeding difficulties soon after birth is magnified. [12-16] An arch alignment appliance is illustrated in this article which is capable of both maxillary expansion and premaxillary retraction, works based on a pinned screw mechanism and capable of extraoral activation which is useful in treating patients with cleft lip and palate. [20] Grayson and Maull reveals the primary objective of presurgical nasoalveolar molding (NAM) is to decrease the severity of the initial cleft deformity. [21] In this article the author emphasise on the use of Bone morphogenetic protein 2 for tissue-engineered bone construct that is compatible with the growing craniofacial skeleton, even though regarding the safety and efficacy of this compound in pediatric craniofacial surgery remains a question. [22] The review discuss the effects of certain orthodontic/ orthopedic treatment approaches as well as the role of dental implants in treatment of cleft lip and palate patients. [23] The role of an orthodontist in cleft lip and palate management is emphasised in this article along with the critical decision-making and sequelae of treatment performed by the orthodontist during the adult dentition stage. The need for multidisciplinary team to execute proper care is addressed. [24] The most frequently used surgical cleft repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. [25] 2611

5 The secondary rhinoplasty has to be performed at 5 years of age. [26] The dentist is responsible for dental restorations and encouraging good dental hygiene. The orthodontist manages malocclusion, internal derangement, and palatal expansion, often in planning for orthognathic procedures. They are involved in the presurgical molding of the cleft lip before surgical repair. The speech pathologist assesses language skills and reviews diagnostic assessment of velopharyngeal function. A local children s hospital is critical as a source of surgical inpatient facilities and staffing and as a resource for community education and awareness. If possible, a dedicated clinic space with examination rooms, dental examination and treatment areas, dental laboratory, radiology facilities, photographic room, adequate waiting area for children, staff offices, and electronic record maintenance unit are preferred. Although not a significant part of the craniofacial team, the patient s local pediatrician and community dentist also play a critical role in coordination and dispersal of primary care needs. If the craniofacial center is located far away from a patient, local physician care is even more important. A patient s visit to the craniofacial clinic is attended by all members of the craniofacial team. This provides for multi-specialist exposure in a single visit. In addition, seeking multidisciplinary attention at the same time and place, communication, and consultation between the specialists are vastly facilitated and sometimes take place during a scheduled craniofacial conference that follows the clinic. [1,27] Orthodontic treatment is essential for all CLP cases, and the decision to proceed in a surgical or nonsurgical manner is critical to the overall successful outcome for the patient. Since the main objective of pre-surgical orthodontics is to decompensate the existing malocclusion, therefore a detailed and timed sequelae of treatment plan should be developed before execution of actual treatment. To be developed before any actual treatment is provided. Moreover, and given the long-term need for orthodontic intervention in CLP, proper treatment planning must be staged for each procedure such as a timeline and work within the time frame. [28] Orthognathic surgery that involves maxillary advancement, mandibular setback, maxillary distraction osteogenesis, a combination of both mandibular setback, maxillary advancement and, occasionally, and isolated mandibular setback. The selection of the optimal treatment protocol for a specific patient depends on physiological and functional parameters including the rate of advancement needed, amount of the maxillomandibular discrepancy, velopharyngeal insufficiency, retention/relapse/stability relationships, esthetic outcome, and the consideration of the possible complications. At present, innovations in distraction osteogenesis have decreased the need for conventional osteotomies as the important treatment for correction of maxillary and mandibular discrepancies. Regardless, conventional osteotomies still play an key role in the management of the very complex and multiphasic CLP patients. [29] Long-term follow-up is much in need to achieve the maximum outcome of secondary alveolar grafting, the age of the patient should be within the mixed dentition period, there is no sex predilection, varied socioeconomic status. It can be either unilateral or bilateral. [30] The knowledge, awareness, and attitude of dental students in CL/P management were considerably low, and the undergraduates were aware of the CL/P and the treatment procedures but were not well aware of treatment time, patient management and the role of each specialty. Awareness of the scope of CL/P management should lead to improved access and efficient delivery of quality service. Our medical and dental colleagues need to have the necessary knowledge to make informed decisions about their patient s management. Equally, the public would benefit from knowing what the dental team offers them so that they can request an appropriate referral. CONCLUSION The CL/P management requires a multidisciplinary team approach and special care, and attention should be given. In this study, we have assessed the knowledge, attitude, and awareness of CL/P management among dental students, in which they were aware of CL/P and various procedures involved but was not aware of the timing of different procedures, the multidisciplinary team involved and role of each speciality at different phases of treatment. REFERENCES 1. Nahai FR, Williams JK, Burstein FD, Martin J, Thomas J. The management of cleft lip and palate: Pathways for treatment and longitudinal assessment. Semin Plast Surg 2005;19: Berkowitz S. The use of gingivoperiosteoplasty in CUCLP. Cleft Palate Craniofac J 1997;34: Lee CT, Grayson BH, Cutting CB, Brecht LE, Lin WY. Prepubertal midface growth in unilateral cleft lip and palate following alveolar molding and gingivoperiosteoplasty. Cleft Palate Craniofac J 2004;41: Wood RJ, Grayson BH, Cutting CB. Gingivoperiosteoplasty and midfacial growth. Cleft Palate Craniofac J 1997;34: Millard DR Jr., Morovic CG. 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6 outcome analysis of costs in the treatment of unilateral cleft alveolus. Cleft Palate Craniofac J 2002;39: Sachs SA. Nasoalveolar molding and gingivoperiosteoplasty verses alveolar bone graft: An outcome analysis of costs in the treatment of unilateral cleft alveolus. Cleft Palate Craniofac J 2002;39: Losken A, Williams JK, Burstein FD, Malick D, Riski JE. An outcome evaluation of sphincter pharyngoplasty for the management of velopharyngeal insufficiency. Plast Reconstr Surg 2003;112: Rutrick R, Black PW, Jurkiewicz MJ. Bilateral cleft lip and palate: Presurgical treatment. Ann Plast Surg 1984;12: Black PW, Scheflan M. Bilateral cleft lip repair: Putting it all together. Ann Plast Surg 1984;12: Pandya AN, Boorman JG. Failure to thrive in babies with cleft lip and palate. Br J Plast Surg 2001;54: Avedian LV, Ruberg RL. Impaired weight gain in cleft palate infants. Cleft Palate J 1980;17: Jones WB. Weight gain and feeding in the neonate with cleft: A three-center study. Cleft Palate J 1988;25: Richard ME. Weight comparisons of infants with complete cleft lip and palate. Pediatr Nurs 1994;20: Lee J, Nunn J, Wright C. Height and weight achievement in cleft lip and palate. Arch Dis Child 1997;76: Wilcox AJ, Skjaerven R, Irgens LM. Harsh social conditions and perinatal survival: An age-period-cohort analysis of the World War 2 occupation of Norway. Am J Public Health 1994;84: Young JL, O Riordan M, Goldstein JA, Robin NH. What information do parents of newborns with cleft lip, palate, or both want to know? Cleft Palate Craniofac J 2001;38: Santiago PE, Grayson BH, Cutting CB, Gianoutsos MP, Brecht LE, Kwon SM, et al. Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty. Cleft Palate Craniofac J 1998;35: Georgiade NG, Latham RA. Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance. Plast Reconstr Surg 1975;56: Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus, and palate. Clin Plast Surg 2004;31:149-58, Smith DM, Cooper GM, Mooney MP, Marra KG, Losee JE. Bone morphogenetic protein 2 therapy for craniofacial surgery. J Craniofac Surg 2008;19: Friede H, Katsaros C. Current knowledge in cleft lip and palate treatment from an orthodontist s point of view. J Orofac Orthop 1998;59: Vlachos CC. Orthodontic treatment for the cleft palate patient. Semin Orthod 1996;2: Katzel EB, Basile P, Koltz PF, Marcus JR, Girotto JA. Current surgical practices in cleft care: Cleft palate repair techniques and postoperative care. Plast Reconstr Surg 2009;124: Salyer KE. Excellence in cleft lip and palate treatment. J Craniofac Surg 2001;12: Nowak AJ, Casamassimo PS. The dental home: A primary care oral health concept. J Am Dent Assoc 2002;133: Shetye PR. Presurgical infant orthopedics. J Craniofac Surg 2012;23: Levy-Bercowski D, DeLeon E Jr., Stockstill JW, Yu JC. Orthognathic cleft-surgical/orthodontic treatment. Semin Orthod 2011:17: Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 1972;30: Source of support: Nil; Conflict of interest: None Declared 2613

Figure 1. Basic anatomy of the palate

Figure 1. Basic anatomy of the palate CHAPTER 10 CLEFT LIP AND PALATE Chen Yan, MD and Sanjay Naran, MD I. ANATOMY AND DEFINITIONS A. Cleft Lip (CL) alone, Cleft Lip with Cleft Palate (CLP), and Cleft Palate (CP) alone 1. CL alone and CLP