Text I. A little patient with a cleft lip and palate

The palatine shelves emerge from the maxillary prominences during the sixth week of embryonic development and grow obliquely downward on each side of the tongue. Between 8 and 12 weeks, the palatine shelves become horizontal (in a matter of hours) and begin fusing with each other and the nasal septum to form the secondary palate. Cleft palate results from a disturbance in the elevation, fusion, or mesenchymal penetration of the palatine shelves. A cleft in the fetal lip may be visualized with the use of transvaginal ultrasonography as early as 11 weeks of gestation and may be detected by means of transabdominal ultrasonography at 16 weeks. If a cleft lip is detected, the fetus has an increased likelihood of having another malformation, a chromosomal aberration, or both.

From birth to the mixed dentition stage

Cleft lip and palate is one of the commonest congenital abnormalities. Around 1 in every 700 live births in the UK has a cleft of the lip and/or palate. The type of cleft can range from a simple incomplete cleft of the soft palate, which is not clinically obvious and may be undiagnosed in the early days, to a bilateral complete cleft involving both the soft and hard palate, alveolus and lip. Management of the patient with a cleft is best carried out by a multi-disciplinary team of healthcare professionals who undertake the cleft care from birth through to adulthood. Specialties represented on the cleft team in the UK vary from region to region but the core members of the team are the surgeon, orthodontist, speech and language therapist, and ENT specialist. The Royal College of Surgeons Steering Group on Cleft Lip and Palate recommends that the care of children with clefts should be carried out by a team whose members are able to provide dental care, audiology, specialised counselling and clinical genetics.

The pre-mixed dentition years. Within the first few days after the birth, parents of babies born with a cleft lip and palate will receive advice in hospital from the surgeon and orthodontist on the immediate and long-term management of their child. This will often be supplemented by written information on the condition itself, and related aspects including oral health and dental care. The orthodontist is usually the first dental specialist whom the family will encounter. The health visitor and general medical practitioner will give post-natal support to the family and advice on feeding.

Parents of babies with a cleft appear to welcome opportunities for discussion and support regarding their child's dental development. They are also mentally preparing for the necessary lip surgery at about 3 months after birth, and palate repair later in the first year. Parents appreciate the opportunity to ask questions and to have time to discuss any concerns about their child's teeth. Parents can be particularly anxious about teething and what the teeth might look like when they eventually erupt. They often focus on the anticipated future appearance of their child's teeth. Establishing the correct dental habits from an early age will help to ensure the health of the primary and permanent dentition.

Medical history

The child with a cleft may have associated anomalies. An understanding of the medical condition is essential to allow for appropriate dental management and treatment planning. This requires good communication between the hospital and dentist providing regular care. It is important to obtain details concerning the child's prescribed medication. The regular administration of sucrose-containing medicines will give rise to dental caries. It is essential to explore the possibility of a sugar-free alternative in these cases.

Social history

Each patient and their family have their own particular needs. Some parents feel isolated with their problem, while others cope very well. The Cleft Lip and Palate Association is a support group formed by parents of children with a cleft and professional staff caring for these patients. Contact with other parents and children in a similar situation is helpful for some families.

Behavior management

In some cases the young patient with a repaired cleft may be shy, nervous, or have a behavioral problem. The reasons are usually multi-factorial but frequent hospital visits and previous hospitalization may play a part. Children may also be influenced by their parents' behavior, which is sometimes anxious and over-protective. The dentist needs patience to establish good communication, especially in the early years. Speech and hearing difficulties are a common occurrence in patients with a cleft palate. Speech development is monitored from an early age by a speech and language therapist. Problems with speech and hearing may present a possible barrier to satisfactory communication with the child.

Preventive management. Diet

Feeding difficulties are a common problem for babies with a cleft palate and few mothers are successful with breastfeeding. Specialized feeding bottles have helped to overcome some of the feeding problems.

Parents should be recommended milk and cooled, boiled water as the only suitable dentally safe drinks for use in a feeding bottle. They must be aware that fruit drinks and squashes, including baby fruit juices, have an erosive potential. Sugar-containing and acidic drinks have to be kept to a minimum and given at mealtimes only, with the introduction of a training beaker or cup from the age of 6 months. Weaning foods and drinks should be free from non-milk extrinsic sugars, as far as possible, to encourage good dietary habits for a healthy dentition. Parents need to appreciate the importance of good dental health before the teeth erupt. They should be given the correct advice regarding dietary control of sugar-containing food and drinks, and know how to implement it. They need to understand fully the relationship between the frequency of sugar in the diet and tooth decay, in simple terms.