The Role of Dental Hygienist in Orofacial Cleft Prevention

Orofacial cleft is a birth defect that occurs in about 1 out of every 700 newborns worldwide (de la Torre & Thurman, 2008) and about 1 in every 1,000 newborns in the United States (Bartoshesky & Homeier, 2005). It occurs when the tissues of the mouth or lip do not form properly during fetal development - specifically, when the tissues of the lip and/or palate of a growing fetus fail to fuse together between the 8th and 12th week of gestation (de la Torre & Thurman, 2008).

Orofacial clefts come in three types: cleft lip; cleft palate; or combination of the two. A cleft lip appears as a gap in the skin of the upper lip and ranges in severity from a small notch to a complete opening that extends all the way to the base of the nose. In particularly severe cases, the cleft could include the upper gum as well. A cleft palate is an opening between the roof of the mouth and the nasal cavity and ranges in severity between partial clefting and extensive clefting through both the front (hard) and rear (soft) parts of the palate (Bartoshesky & Homeier, 2005).

Because of their very specific appearance, all types of orofacial clefts are easily diagnosed. In fact, they can be diagnosed even before the birth of the child, during ultrasound screening (de la Torre & Thurman, 2008). Nothing can be done in terms of treatment, however, until the child is at least 20 weeks old, at which time a reconstructive surgery to repair a cleft lip is performed. A cleft palate is repaired through a reconstructive surgery between the ages of 12 and 18 months (de la Torre & Thurman, 2008; Bartoshesky & Homeier, 2005; March of Dimes, 2008). As children grow, additional surgical procedures are almost always necessary (March of Dimes, 2008).

Since orofacial clefts carry with them a wide range of co-morbid conditions, such as difficulty feeding, susceptibility to respiratory and ear infections, hearing loss, speech defects, dental problems, physical deformity, and psychological problems often associated with them, the treatment team for this condition consists of a large number of specialists, such as otolaryngologist, oral surgeon, orthodontist, dentist, plastic surgeon, speech pathologist, audiologist, nurse coordinator, and psychologist or social worker (Bartoshesky & Homeier, 2005).

Since genetic factors figure in the cause of the condition, a geneticist may also be part of this team, but the role of this specialist would be mostly to advise parents on the possibility of their future offspring having the same condition rather than the ways to treat the condition in the current child. The geneticist may be, together with the psychologist or social worker, an integral part of the team that would reassure parents that their child's condition is not their fault, particularly if the condition has been the result of strictly the genetics rather than environmental factors under parents' control.

A cleft lip rarely impedes the child's ability to nurse, but a cleft palate almost always does so by allowing milk to seep into the nasal cavity and causing the child to choke. To prevent this, a child may be prescribed an obturator - a prosthetic palate used specifically to allow the child to eat properly (Bartoshesky & Homeier, 2005).

As mentioned earlier, all types of orofacial cleft are fixed with reconstructive surgery no later than 18 months of age. Surgical procedures are performed under general anesthesia and usually require one or two days stay in the hospital following them, particularly in the case of the palate cleft repair. The severity of the cleft determines whether additional surgeries will be needed in the future (Bartoshesky & Homeier, 2005). Once the child's permanent teeth come in, dental or orthodontic treatments may be needed to ensure that the teeth grow even and in correct spaces.

While genetic predisposition plays a role in the risk of the child being born with the orofacial cleft, a number of studies have produced results that show that cigarette smoking is directly related to the increased risk of the formation of orofacial clefts. Carinci et al. (2003) concluded, based on the results of their study, that toxins in the cigarette smoke inhaled by a pregnant mother affect the genetic markers of at least one of the six chromosomes involved in orofacial cleft development. Saito et al. (2005) discovered that tobacco-specific toxins disrupt the process of fusion of the medial edge epithelial cells that lead to the adherence and fusion of the two palatal shelves in human fetuses. Hypothesizing that human embryos lack the enzyme necessary to detoxify the chemicals arriving into the fetal bloodstream from the smoking mother, Lammer et al. (2005) found that women who smoked 20 or more cigarettes a day increased the risk of their child being born with an orofacial cleft seven-fold, while those women who smoked less than 20 cigarettes a day still tripled the risk of the condition compared to women who did not smoke at all.

Being a preventive care specialist, the role of a dental hygienist in reducing the risk of orofacial clefting in babies is mostly that of an educator. It is imperative for women to know the details of how their smoking affects the child developing inside of them. Simply saying that smoking is bad for her child is not effective enough. What is necessary here is detailed information augmented by images, because pictures usually have a much stronger effect than written descriptions.

The first step is to establish the actual connection between smoking and the orofacial cleft formation. The majority of women are not aware of this connection, and letting them know through easily accessible and understandable written materials and educational programs is important. Since much of such information is derived from academic studies, it may be one of the dental hygienist's tasks to interpret those findings in the language that a layperson would not have troubles understanding.

Next step could be the delivery of details about the actual harm of smoking. Individuals hear every day about the potential harm of smoking, but not until women know that they are actually inhaling 55 different kinds of toxins with every drag on a cigarette that they might become concerned about their own health and the health of their unborn child (de la Torre & Thurman, 2008). The shock value of such information is its most important contribution. For the same reason, expectant mothers who smoke must be provided with photos of children suffering from a cleft lip or cleft palate, particularly the newborns. If seeing those images would not lead these women to the decision to quit smoking, it is doubtful that anything else will.

Of course, simply leading women to a decision to quit smoking is not enough. This type of behavior modification is extremely challenging - in effect, a person must go through drug rehabilitation, and doing it while being pregnant (de la Torre & Thurman, 2008). The work of a dental hygienist, therefore, does not stop here. Women who decided to stop smoking must be provided with information and resources on how best to accomplish this, as well as offered constant support in their quest to get rid of this addiction. This means that dental hygienists must maintain good networking and working relationships with physicians, psychologists, and social workers who might assist expectant mothers to stay away from tobacco.

References
Bartoshesky, L. E., & Homeier, B. P. (2005). Cleft lip and palate. KidsHealth. http://www.kidshealth.org/parent/medical/ears/cleft_lip_palate.html
Carinci, F., Pezzetti, F., Scapoli, L., Martinelli, M., Avantaggiato, A., Carinci, P., Padula, E., et al. (2003). Recent developments in orofacial cleft genetics. The Journal of Craniofacial Surgery, 14, 130-143.
de la Torre, M. A., & Thurman, M. A. (2008). Cigarette smoking and orofacial cleft development: Dental hygiene's role in education and prevention. Access (January): 30-33.
Lammer, E. J., Shaw, G. M., Iovannisci, D. M., & Finnell, R. H. (2005). Maternal smoking, genetic variation of glutathione S-transferases, and risk for orofacial clefts. Epidemiology, 16, 698-701.
March of Dimes. (2008). Cleft lip and cleft palate. Pregnancy and Newborn Health Education Center. http://www.marchofdimes.com/pnhec/4439_1210.asp
Saito, T., Xiao-Mei, C., Yamamoto, T., Shiomi, N., Bringas, P., & Shuler, C. F. (2005). Effect of N'-nitrosonornicotine (NNN) on murine palatal fusion in vitro. Toxicology, 207, 475-485.