Oral Care for a Child with a Cleft Lip and Palate

DISCLOSURE: Noelle Copeland RDH is an Oral Care Specialist and Dental Consultant who provides content for Brilliant Oral Care and Baby Buddy.

I will never forget the time I made a patient cry! This precious patient would always see my colleague for her appointments, since she was a child actually, but my colleague was unexpectedly out that day, so this person, who was now a young adult, was moved into an open slot on my schedule for her appointment time. No biggie, right? Wrong! Apparently, no one informed the patient of this, and she was surprised to see me call her name as I cheerfully went to collect her from the waiting room that day for her cleaning.

She was timid and nervous as I went through introducing myself, not unusual for first visit encounters with clinicians, so I continued as I usually would. I explained that her hygienist was out sick and I would be doing her cleaning and radiographs. I was a bit hurried that day too, talking a bit fast and doing multiple things at once, since I was fitting in appointments into an already overscheduled day. I did my review of her current medical history, secured her vitals, and started to lean back her chair as I washed my hands and was multitasking; talking through what was about to happen.

She suddenly began to cry...I stopped, frozen, quickly realizing she was not ready for me, even though I was completely ready for her.

She didn't know that I had read her entire chart early that morning, and I was up to date on all the treatment notes and her past history. Nor did she know that I knew the details about her cleft palate and lip, the surgeries she'd had, the scar tissue and tightening that limited her ability to open wide and the sensitivity she experienced. She had been through alot and experienced trauma, grief, pain, and suffering over the years and this sudden shift and change to what she was expecting was too much. No matter how much experience I had treating other cleft patients, she needed to spend time getting to know me and wanted me to be more inquisitive about her and her special needs.

I felt like such a booger, she was crying, then I was crying. I was usually waaaay more intune with the body language and non-verbal vibes I sensed from people but this day I was busy and distracted, and totally missed it. I stopped everything, leaned her chair back up, took off all my personal protective equipment (which made me look like a lab scientist) and re-set the room, spending almost thirty minutes just talking to her and apologizing for setting such a bad mood. She was gracious and kind, and really just needed me to go slower, which to her, meant gentle and easy. She was very self conscious about her clefting and needed lots of reassurance and verbal stimulation. I can't express enough, the importance of empathy in special needs oral care. It means everything but means something different to each individual, so it takes purposeful time and effort to do this.

A cleft lip or palate can be mild with slight separation or very severe affecting more than just facial appearance. Profound cases can affect a child’s feeding, speech, hearing, dental development, facial growth, and psychological well-being.

Clefts develop during the first few weeks of pregnancy. The tissues that form the roof of the mouth and the lip grow to connect during this early gestational stage, and if that process is interrupted or genetically modified in any way, the tissue doesn't join correctly.

• A newborn can have a cleft lip, cleft palate, or both.
• Clefting is one of the most commonly seen birth defects in newborns. Approximately 1 in every 2800 births in the United States.
• Male babies are more likely to have a cleft lip without a cleft palate.
• Female babies are more likely to have a cleft palate without a cleft lip.
• Most babies born with a cleft are otherwise healthy.
• The most common early problem associated with clefting is feeding issues.

Cleft Complications

• Challenges feeding: More profound with cleft palate. Latching, suckling, breathing and eating, with the ability to close the lips together all make bottle feeding or nursing very difficult.
• Speech delay: Diction and speech can be very difficult to learn when parts of the palate are missing and when teeth are missing. Speech apprehension is very vulnerable to the tongue touching and adhering to the roof of the mouth and the back of the teeth.
• Ear infections and hearing loss: Ear infections occur more frequently with cleft palates because the tube that connects the middle ear and the throat is vulnerable due to the open space, which allows fluid collection and inflammation to occur in the middle ear more easily. When ear infections happen more regularly, this can lead to hearing loss and further complicate speech delays.
• Dental problems: Clefting affects the upper lip and jaw, causing separation of the bones/tissues with missing teeth and anatomy. Some teeth are shaped differently, out of alignment, or missing entirely. Orthodontic treatment is usually needed.

What Causes a Cleft

There is no one cause, but studies show certain factors increase risk. Genetic components and environment combined make this form of a birth defect multifactorial.

• Multiple genes or mutations inherited from both parents.
• Environmental exposure to toxins.
• Smoking during pregnancy.
• Maternal diabetes.
• Maternal diet.
• Use of certain medicines by the mother.
• Exposure to air pollutants.

Dental care should be coordinated with the other physicians providing treatment early on, this includes surgeons, speech therapists, orthodontists, prosthodontists, and counselors. A pediatric cleft and craniofacial team is a group of experts who work together to care for a child’s cleft care needs. Oral care is very important in this process and is personalized to meet each individual's special needs.

Every child born with any degree of clefting requires preventative care. Some children may additionally require orthodontic or prosthodontic treatment as well, on top of any reconstructive surgeries.

Preventative Dental Care

Preventative dental care encompasses professional dental cleanings and routine oral care visits, in addition to what is done at home during brushing and flossing. Children with clefts tend to have a higher decay rate due to many factors. These factors include excessive oral air exposure that leads to dry mouth and abnormal salivary gland production. These factors adversely affect the amount of saliva that's excreted, allowing bacteria to flourish more easily.

Orthodontic Dental Care

Active alignment or realignment of oral structures to compliment or correct the bite, in addition to eruption or bone patterns in the mouth. Many children born with a cleft lip and palate need several phases of Ortho care with braces and gear.

Prosthodontic Dental Care

Process of making appliances to replace missing anatomy in the mouth. Can be removable or permanent. Examples include crown, bridge, speech bulb, palatal lift, flippers, or insertion retainers.

Oral Care at Home for the Child with a Cleft Lip or Palate

• Start oral care early.
• Use a sterile mouth wipe to cleanse the oral tissues, preferably one with added xylitol for help in controlling bacteria and fungus.
• Utilize soft silicone or latex based teethers and brushes to massage gums.
• As soon as the teeth erupt, use a small, soft toothbrush to clean the teeth.
• Find your pediatric dental team as soon as possible and have your first visit before the first teeth arrive.
• Utilize fluoride and xylitol as soon as possible per the instructions of your dentist. Decay is much more prevalent in children with clefts.

On a final note, I would like to recommend our Brilliant round head toothbrush to anyone with clefting for their preventative homecare. One of the common struggles I heard many of my clefting patients stress was the plastic back of their toothbrush being a source of discomfort. When the lip or palate have deeper grooves and openings between them, these spaces harbor more bacteria, food debris and plaque, so it's imperative they get extra attention when cleaning, otherwise they can get infected. It can be a challenge to reach the deeper crevice in a palatal cleft or around grafting sites or extra bone and tissue. Maneuvering around these areas with a regular one sided toothbrush can be very difficult and painful. The Brilliant toothbrush allows a parent or caregiver to easily and gently invert the brush head vertically to access the roof of the mouth or the back side of the front teeth, without bumping or hitting that sensitive tissue with the end cap of the toothbrush. This increases oral care acceptance and effectiveness, especially after such inclusive events like oral surgery, often experienced with clefting patients.

If you want to try the best toothbrush for kids or one of our specialty toothbrushes look no further than Brilliant Oral Care. https://www.brilliantoralcare.com Be sure to check out our selection of toothbrushes for individuals with special needs. This includes our silicone toothbrushes that make oral care easy to start. Our DINOSAUR, PENGUIN, and DUCK character sonic toothbrushes make oral care fun. And our special soft toothbrush with our most extensive bristle count has the softest texture brush that we offer.

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