|Year : 2010 | Volume
| Issue : 4 | Page : 236-240
Comparison of oral hygiene and periodontal status in patients with clefts of palate and patients with unilateral cleft lip, palate and alveolus
Ramesh Babu Mutthineni, Rajasekhar Nutalapati, Suresh Kumar Kasagani
Department of Periodontics, Mamata Dental College and Hospital, Khammam, Andhra Pradesh, India
|Date of Submission||19-Nov-2009|
|Date of Acceptance||15-Sep-2010|
|Date of Web Publication||19-Feb-2011|
Ramesh Babu Mutthineni
Department of Periodontics, Mamata Dental College, Khammam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: This study was conducted to analyze and compare the oral hygiene and periodontal status in patients with clefts of palate (CP) and patients with unilateral cleft lip, palate and alveolus (UCLPA). Materials and Methods: The study group consisted of 120 cleft patients. Subjects were divided into two groups of 60 each. Group I - patients with UCLPA and Group II - patients with CP. For comparison, all the four quadrants were defined, Q1-right upper quadrant, Q2-left upper quadrant, Q3-left lower quadrant and Q4-right lower quadrant, in both groups and the following parameters were recorded: Plaque Index (PI, Silness and Loe), Sulcus Bleeding Index (SBI, Muhlemann and Son), Probing Pocket Depth (PPD), Clinical Attachment Level (CAL), Mobility Index (Miller) and Radiographic Amount of Bone Loss. Results: The periodontal destruction was seen to be higher in UCLPA patients compared with CP patients. The poor oral hygiene status, as indicated by higher values of PI, and the periodontal status, evaluated by SBI, PPD, CAL, mobility and Radiographic Amount of Bone Loss, were higher in patients with UCLPA than in patients with CP. Conclusion: In this study, patients with cleft lip, palate and alveolus had poor oral hygiene and periodontal status compared with patients with cleft palate.
Keywords: Cleft patients, oral hygiene, periodontal status
|How to cite this article:|
Mutthineni RB, Nutalapati R, Kasagani SK. Comparison of oral hygiene and periodontal status in patients with clefts of palate and patients with unilateral cleft lip, palate and alveolus. J Indian Soc Periodontol 2010;14:236-40
|How to cite this URL:|
Mutthineni RB, Nutalapati R, Kasagani SK. Comparison of oral hygiene and periodontal status in patients with clefts of palate and patients with unilateral cleft lip, palate and alveolus. J Indian Soc Periodontol [serial online] 2010 [cited 2020 Feb 26];14:236-40. Available from: http://www.jisponline.com/text.asp?2010/14/4/236/76928
| Introduction|| |
An orofacial cleft is caused by an incomplete fusion of the maxillary processes from the fourth to the 12th week of fetal life. The most important etiologic factors are of genetic origin, determined by a monogenetic or polygenetic inheritance pattern as well as some exogenous factors, such as smoking, alcohol, X-rays and antimitotics.
There are large variations in shape and extension of the deformation, reaching from a cleft of the lip to a cleft of the lip, alveolar process and palate. Each cleft can be complete or incomplete, unilateral or bilateral. The deformity may be present as a single disorder or in association (10%) with a syndrome such as Pierre-Robin Syndrome, Crouzon Syndrome or Treacher-Collins Syndrome. 
The incidence of this malformation varies considerably among races, and depends on the type of cleft, with an increased incidence in males (ratio 2/1), and 80% of the deformity is unilateral. 
Children and adolescents with a cleft lip and palate (CLP) are at increased risk for the development of periodontitis and carious lesions. The persisting soft tissue folds before closure, which is difficult to reach with conventional cleaning techniques, and may serve as a habitat for putative pathogens, thereby enhancing the intraoral translocation of pathogens and, consequently, the risk for periodontal infection. 
Analyzing the progression rate of periodontitis in adolescents with various forms of cleft lip, palate and alveolus (CLPA), high incidences of plaque and bleeding on probing were reported.  Teeth adjacent to the cleft, often with a long supra-crestal connective tissue attachment, showed a slightly more pronounced cumulative periodontal destruction.
Closure of the defects was carried out at different times in life in order to interfere as little as possible with palato-facial growth and speech development. The lip was closed at the age of 3 months, the soft palate at 18 months and the hard palate at 4-6 years. Mostly, bone graft was placed at the age of 9-10 years to restore the alveolar ridge, to support the soft tissues and to allow the eruption of the canine. 
In the case of multiple tooth malpositions, transversal space deficit and a primary cross-bite situation, periodontal trauma increases and is detrimental to periodontal health. Orthodontic treatment adds to this trauma.  Reitan  had described the correlation of pressure exertion and damage to the periodontium caused by orthodontic appliances. The greatest damage to the periodontium was caused by dental tilting movements and intrusions. The length and duration of pressure were responsible for the extent of periodontal damage.
In osseous clefts, the osseous structures are absent or poorly developed in the region of periodontal supportive tissue. The osseous structures are additionally traumatized in the course of long-term orthodontic therapy. A considerable improvement in periodontal health can be achieved by secondary osteoplastic surgery. 
The question concerning cleft-specific damage of the periodontium can be answered only when comparing the periodontal situation of patients with different types of clefts and similar states of oral hygiene.
Periodontal health in cleft patients
The cleft deformity and surgical scars can make it difficult to control plaque. Prolonged orthodontic therapy and the wearing of a prosthesis to prevent collapse of the dental arch commonly result in inflammatory papillary hyperplasia. Intensive prophylactic programs for CLP patients should be implanted as early as possible and a coordinated team approach for the treatment of all aspects of care should include close supervision of oral hygiene measures and regular professional maintenance through a regular recall system for the entire lifetime of the patient. 
Bone grafting of the cleft has become an accepted means of improving the morphology of the alveolar ridge, supplementing the amount of bone to facilitate tooth eruption. Alveolar bone grafting has come to produce such good results that it has been stated that the periodontal condition is normalized following bone grafting and that gingivitis is seldom seen in the cleft region. Clinically, it might be assumed that  the ultimate success of a bone graft is dependent on the total elimination, or at least the controlling, of the level of gingivitis prior to the placement of a bone graft. Preoperative gingival health has been considered to be a more important factor in determining the success of the operation than the anatomical source of the bone graft.
The need for subsequent surgery in the orofacial region further substantiates the need for good oral hygiene and oral health. Hence, it is important to have healthy periodontal tissues not only to optimize the treatment results but also because each step in the treatment process can jeopardize periodontal health.
Alveolar bone condition in cleft patients
Comparing sites from teeth adjacent to an alveolar cleft with control sites that were unaffected by a cleft, it was found that  the radiographic alveolar bone level was significantly more apical at the cleft sites whereas the probing attachment level was similar at the cleft and the control sites. These findings indicated that a long connective tissue attachment might be present at the cleft sites.
Teeth with a long supra-crestal connective tissue fiber attachment, as observed at sites adjacent to the alveolar cleft defects, appear to be equally resistant to periodontal disease as any other tooth in the dentition.
| Materials and Methods|| |
The present study was conducted in 120 patients with age ranging from 12 to 18 years, who reported to the Mamatha Dental College and Hospital, Khammam, during July 2008 to July 2009. Ethical committee clearance was obtained and consent was taken from all the subjects.
They were divided into two groups: Group I consisted of 60 patients, 20 females and 40 males with unilateral cleft lip, palate and alveolus (UCLPA) and Group II consisted of 60 patients, 19 females and 41 males with clefts of palate (CP).
For comparison, all the four quadrants were defined, Q1-right upper quadrant, Q2-left upper quadrant, Q3-left lower quadrant and Q4-right lower quadrant, in both CP and UCLPA patients.
- Patients with cleft palate (unilateral/bilateral/anterior/posterior/ both)  who had not been operated [Figure 1].
- Patients with UCLPA who had not been operated. [Figure 2]
|Figure 2: Cleft lip, palate and alveolus - maxillary and mandibular view|
Click here to view
- Systemically healthy subjects.
- Patients with age ranging from 12 to 18 years.
- Only the permanent teeth were considered for periodontal examination.
The patients selected for this study were clinically examined 1-2 days after admission to the Mamatha General Hospital. The examination was carried out during the hospital stay.
Each participant was subjected to clinical assessment using a dental mirror, explorer and a William's periodontal probe, under an artificial light.
In all four quadrants, for both the groups, the following parameters were recorded:
Radiographic bone loss was measured on periapical radiographs with a digital caliper from the C.E.J. to the alveolar crest. A long-cone paralleling technique was used to take these radiographs [Figure 3]. 
- Plaque Index (PI, Silness and Loe 1964)
- Sulcus Bleeding Index (SBI, Muhlemann H.R. and Son S. 1971)
- Probing Pocket Depth (PPD)
- Clinical Attachment Level (CAL)
- Mobility Index (Miller)
- Radiographic Amount of Bone Loss
Mean and standard deviation were estimated from the sample for each study group. Mean values were compared between groups by using either Student's independent t-test or Mann-Whitney U-test appropriately.
Proportions of different mobility scores were estimated and compared using Pearson's Chi-square test.
| Discussion|| |
CLP has been recognized as a major source of disability, preventing people from realizing their potential and contributing fully to society. In the developed world, many of these challenges have been redressed through the institution of a multidisciplinary approach to the child identified with an orofacial cleft. Rigorous attempts to minimize impaired speech, hearing, dental, nutritional and intellectual functions have revolutionized contemporary cleft lip and cleft palate patient care. Surgical techniques have been refined such that a high level of esthetic restoration is the rule rather than the exception. Unfortunately, in developing countries, access to rehabilitative and supportive treatment programs is limited or nonexistent. 
According to Ramjford,  Lindhe et al.  and Silness,  healthy periodontium is a prerequisite for the long-term health of the stomatognathic system. Adequate plaque control may be regarded as the most important single factor in the maintenance of periodontal health in cleft patients.
In adult patients with a congenital complete unilateral CLP, anatomic deviation and therapeutic intervention may create conditions that hamper proper plaque control in relation to maxillary teeth. The degree of anatomic deviation depends on the characteristics of the original malformation and the type of treatment to which the patient has been subjected.  Prevalence and extent of gingival lesions and periodontal destruction in patients with CLPA and CP are significant functional criteria in the assessment of an interdisciplinary treatment outcome.
In the present study, average PI scores in Group I patients was higher than that in the Group II patients [Table 1]. This in accordance with the results of studies by Bragger et al.,  Costa et al.,  Ahluwalia et al.  and Pandey et al.  . The obvious reason for this is the difficulty in achieving optimal tooth cleaning because of the anatomy of the cleft area in Group I (patients with cleft involving the alveolus). Incompetent lip closure was found in many of the cleft patients, which hampered access for adequate oral hygiene in the maxillary quadrants. Also, the mucosal tissue is much more sensitive than attached tissue at the cleft side, because of which individuals brush much less thoroughly where the teeth have reduced amounts of attached tissue.
|Table 1: Comparison of mean plaque index scores between group I and group II |
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Average SBI scores in Group I patients was higher than that in Group II patients [Table 2]. In Group II patients, the patients were able to efficiently clean the buccal surface of the maxillary quadrants compared with Group I patients, who were not able to maintain their oral hygiene in both the buccal and the palatal surfaces of the maxillary quadrants. This may be the reason for the low SBI score in Group II patients. These results were in accordance to the study performed by Alexander et al.,  and Schultes et al.  The presence of cleft, which hampered brushing efficiency, especially in both quadrants of the maxillary arch, resulted in more accumulation of plaque. The constant presence of irritants surrounding the gingival margin lead to inflammatory reaction and increased bleeding index scores in Group I patients.
|Table 2: Comparison of mean sulcus bleeding index scores between group I and group II |
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The average PPD score for Group I patients was higher than that of Group II patients [Table 3]. The reason for this was the presence of cleft involving alveolus in Group I. This was similar to the results of a study carried out by Bragger et al.,  Bragger et al.  and Teja et al. 
|Table 3: Comparison of mean probing pocket depth (in mm) between group I and group II |
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The average CAL scores for Group I patients was higher than that for Group II patients [Table 4]. This was in accordance to the study results of Bragger et al.  and Alexander et al.  Also, Novak et al.  described no clinically or histologically detectable loss of attachment despite a substantial lack of supporting bone.
|Table 4: Comparison of mean clinical attachment level (in mm) between group I and group II |
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The average grade I mobility in Group I was higher than the average grade I mobility in Group II [Table 5]. The average grade II mobility in Group I was higher than the average grade II mobility in Group II. The reason for this is that individuals with alveolar cleft deformity have thinner alveolar housing in the site of the defect; increased mobility on the cleft side could have been caused by the reduced amount of supporting bone and, also, higher higher scores in PI, SBI, PPD and CAL were found in Group I than Group II. Grade III mobility was not detected in any of the four quadrants in both Group I and Group II. The results obtained in this study were lower than those obtained by Schultes et al.  and Alexander et al.,  which could be due to the differences in the study population.
|Table 5: Percentage of grades of tooth mobility in group I and group II |
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The average radiographic amount of bone lossscores in Group I patients was higher than that in Group II patients [Table 6]. This was in accordance with the study by Bragger et al.  and Bragger et al.,  which showed radiographically significant lower bone height in UCLPA, indicating the presence of long connective tissue attachment with reduced bone support.
|Table 6: Comparison of mean radiographic amount of bone loss (in mm) between group I and group II |
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In general, the values of all the parameters were higher in Group I than in Group II in the present study, indicating a poor oral hygiene and periodontal condition in the UCLPA patients. This was in accordance with the study carried out by Johnson et al.,  Bragger et al.  and Schultes et al.,  who examined various forms of cleft patients for periodontal status.
Studies performed by Lucas et al.  and Bastos et al.  failed to show a poor periodontal status in cleft patients. These variations in the results may be due to the difference in the study population in terms of their socioeconomic status, educational level, oral hygiene awareness, etc.
The limitation of this study was that it did not include the socioeconomic status and there was no comparison between the presurgical and the postsurgical cases, nor was there any comparison with the periodontal status in the general population. Hence, in the future, a longitudinal study of longer duration and large sample size is necessary to evaluate the relationship between periodontal status and cleft patients.
Thus, it may be inferred from this study that subjects with CLPA are more prone for periodontal lesions. In case of neglected oral hygiene, these subjects are predisposed to periodontal disease in the direct vicinity of clefts, leading to premature pathological loosening of teeth. Thus, intensive oral hygiene measures taken by these subjects along with early interdisciplinary treatment are an effective way to prevent extensive periodontal disease.
| Conclusion|| |
A healthy periodontium is an important prerequisite for unhindered dentition and long-term oral health. In cleft patients, the oral hygiene maintenance is a difficult task because of the patient's oronasal communication. The crowding of teeth in cleft patients is a common finding, especially in CLPA.
From this study, it can be concluded that patients with UCLPA had a poor oral hygiene and periodontal status when compared with cleft palate patients.
Further studies of longer duration and large sample size are necessary to evaluate the oral hygiene and periodontal status in cleft patients. The intensive oral hygiene measures advocated to the cleft patients along with early multidisciplinary treatment are an effective way to prevent extensive periodontal destruction.
| References|| |
|1.||Quirynen M, Dewinter G, Heidbuchel K, Verdonck A, Carels C. A split-mouth study on periodontal and microbial parameters in children with complete unilateral cleft lip and palate. J Clin Periodontol 2003;30:49-56. |
|2.||Derijcke A, Eerens A, Carels C. The incidence of oral clefts - a review. Br J Oral Maxillofac Surg 1996;34:488-94. |
|3.||Quirynen M, Soete DM, Steenberghe DV. The intra-oral translocation of periodontopathogens jeopardises the outcome of periodontal therapy. J Clin Periodontol 2001;28:499-507. |
|4.||Bragger U, Schurch E, Salvi G, Wyttenbach TV, Lang NP. Periodontal conditions in adult patients with cleft lip, alveolus and palate. Cleft Palate Craniofac J 1992;29:179-85. |
|5.||Andlin SA, Eliasson LA, PaulinG. Periodontal evaluation of teeth in bone grafted regions in patients with unilateral cleft lip and cleft palate. Am J Orthod Dentofacial Orthop 1995;107:144-52. |
|6.||Schultes G, Gaggl A, Karcher H. Comparison of periodontal disease in patients with clefts of palate and patients with unilateral clefts of lip, palate, and alveolus. Cleft palate craniofac J 1999;36:322-7. |
|7.||Reitan K. Factors determining the evaluation of forces in orthodontics. Am J Orthod 1988;43:32-6. |
|8.||Alexander G, Gunter S, Hans K, Rudolf M. Periodontal disease in patients with cleft palate and patients with unilateral clefts of lip, palate and alveolus. J Periodontol 1999;70:171-8. |
|9.||Fanny WL, Wong FW, Nigel M. The oral health of children with clefts - A review. Cleft Palate Craniofac J 1998;35:248-54. |
|10.||Eldeeb ME, Hinrichs JE, Bandt CL. Repair of alveolar cleft defects with autogenous bone grafting-Periodontal evaluation. Cleft Palate J 1986;23:126-36. |
|11.||Bragger U, Nyman S, Lang NP, Wyttenbach TV, Salvi G, Schurch E. The significance of alveolar bone in periodontal disease. A long-term observation in patients with cleft lip, alveolus and palate. J Clin Periodontol 1990;17:379-84. |
|12.||Malik NM, Cleft Lip and Cleft Palate Management. Malik NM. Text book of oral and maxillofacial surgery, First edition. New Delhi, Jaypee Brothers, 2002; 507-25. |
|13.||Dewinter G, Quirynen M, Heidbuchel K, Verdonck A, Willems G, Carels C. Dental abnormalities, bone graft quality, and periodontal conditions in patients with unilateral cleft lip and palate at different phases of orthodontic treatment. Cleft palate craniofac J 2003;40:343-50. |
|14.||Mehboob EM, Jackson IT, Omar E, Khan AH, Tariq GB, Amit M. Epidemiology of cleft lip and cleft palate in Pakistan. J plas reconst surg 2004;113:1548-55. |
|15.||Ramfjord SP. Indices of prevalence and incidence of periodontal disease. J periodontol1959;30:51-9. |
|16.||Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health - A longitudinal study. J clin periodontol 1975;2:67-79. |
|17.||Silness J. Periodontal conditions in patients treated with dental bridges. J Periodontal Res1979;5:60-8. |
|18.||Ramstad T. Periodontal condition in adult patients with unilateral complete cleft lip and palate. Cleft pal J 1989;26:14-20. |
|19.||Bragger U, Schurch E, Salvi G, Gusberti FA, Lang NP. Periodontal conditions in adolescents with cleft lip, alveolus and palate following treatment in a co-ordinated team approach. J clin periodontol 1985;12:494-502. |
|20.||Costa B, Lima JE, Gomide MR, Pereira OP. Clinical and microbiological evaluation of the periodontal status of children with unilateral complete cleft lip and palate. Cleft palate cran J 2003;40:585-9. |
|21.||Ahluwalia S, Brailsford R, Tarelli E. Dental caries, Oral hygiene and Oral clearance in children with craniofacial disorders. J Dent Res 2004;83:175-9. |
|22.||Pandey SC, Pandey RK. The status of oral hygiene in cleft lip, palate patients after surgical correction. J Indian soc pedod preven dent 2005;23:183-5. |
|23.||Teja Z, Persson R, Omnell ML. Periodontal status of teeth adjacent to nongrafted unilateral alveolar clefts. Cleft palate cran J 1992;29:357-62. |
|24.||Novak M, Polson J, Freeman J. Periodontal attachment mechanism without alveolar bone-Case report. J Periodontol1983;54:112-8. |
|25.||Johnson DC, Dixon M. Dental caries in primary incisors of children with cleft lip and palate. Cleft palate J 1984;21:104-9. |
|26.||Lucas VS, Gupta R, Ololade O, Gelbier M, Roberts GJ. Dental health indices and caries associated microflora in children with unilateral cleft lip and palate. Cleft palate cran J 2000;37:447-52. |
|27.||Bastos EM, Marcos B, Pordeus IA. Oral health of individuals with cleft lip, cleft palate, or both. Cleft palate cran J 2004;41:59-63. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]