1 Volume 24 2025 e255018 Original Research Braz J Oral Sci. 2025;24:e255018http://dx.doi.org/10.20396/bjos.v24i00.8675018 1 Postgraduate Program in Primary Health Care, State University of Montes Claros, Unimontes, Montes Claros, Minas Gerais, Brazil. 2 Postgraduate Program in Health Sciences, State University of Montes Claros, Unimontes, Montes Claros, Minas Gerais, Brazil. 3 Center for Rehabilitation of Craniofacial Anomalies, Dental School, University of José Rosário Vellano, Unifenas, Alfenas, Minas Gerais, Brazil. 4 Dental School, University Center of Lavras, UniLavras, Lavras, Minas Gerais, Brazil. 5 Department of Oral Diagnosis, Dental School, State University of Montes Claros, Unimontes, Monte Claros, Minas Gerais, Brazil. Corresponding author: Samuel Trezena Costa State University of Montes Claros, Prof. Darcy Ribeiro University Campus. Rui Braga Avenue, Vila Mauricéia, Montes Claros - MG, Postal Code: 39401-089, Brazil. Phone: +55 (38) 99174-9401. E-mail: samueltrezena@gmail.com Editor: Dr. Altair A. Del Bel Cury Received: November 15, 2023 Accepted: April 19, 2024 Anxiety, depression, stress, and fear of COVID-19 in parents and caregivers of children with non-syndromic oral clefts: case-control study Samuel Trezena1* , Fabrício Emanuel Soares de Oliveira1,2 , Cintia Eliza Marques3 , Nádia Carolina Teixeira Marques4 , Verônica Oliveira Dias1,5 , Daniella Reis Barbosa Martelli1,2,5 , Hercílio Martelli Júnior1,2,3,5 Aim: to assess the levels of anxiety, depression, stress, and fear of COVID-19 among parents and caregivers of children with nonsyndromic cleft lip and/or palate (NSCL/P). Methods: cross-sectional, case-control study at a Craniofacial Anomalies Rehabilitation Center, Brazil. Non-probabilistic convenience sampling was used and data were collected between October 2021 and November 2022. Variables were assessed by Depression, Anxiety and Stress Scale (DASS-21) and Fear of COVID-19 Scale (FC-19S). Pearson’s chi-square test and multivariate binary logistic regression model have been performed. Results: data were obtained of 80 NSCL/P parents group and 130 by control group. Severe symptoms were higher in NSCL/P parents indicated by rates (8.8% vs 6.9% to anxiety; 12.5% vs 8.5% to depression and 17.5% vs 10.0% to stress). As for the predilection in case group there was an association (p<0.05) for manifestation of mild stress (OR: 4.09; 95%CI 1.28-13.06). Levels of fear of COVID-19 were higher in control group (43.8% vs 28.7% p<0.05). Conclusions:.a higher prevalence of anxiety, depression and stress extremely severe was observed in parents of children with NSCL/P. Control group was associated with higher fear of COVID-19. Keywords: Cleft lip. Cleft palate. Anxiety. Depression. COVID-19. https://orcid.org/0000-0002-4217-1276 https://orcid.org/0000-0003-0164-1179 https://orcid.org/0009-0008-6651-1678 https://orcid.org/0000-0001-5046-2906 https://orcid.org/0000-0003-1989-7797 https://orcid.org/0000-0002-7497-6052 https://orcid.org/0000-0001-9691-2802 2 Costa et al. Braz J Oral Sci. 2025;24:e255018 Introduction Cleft lip and/or palate (CL/P) is the most prevalent congenital craniofacial anomaly worldwide. In 70% of the cases, CL/P is nonsyndromic (NSCL/P)1. From birth, children with CL/P should be followed-up by a multi-professional team. General health, aes- thetics, nutrition, speech, audition, oral health problems, and psychosocial impacts are reasons for health monitoring2. The birth of children with CL/P impacts their family. Parents’ expectations are shat- tered and a specific routine for CL/P childcare begins3. Qualitative research has shown that parents of children with CL/P experience feelings of distress, fear, mourning, and guilt after birth. These emotions are harmful to their mental health and can persist throughout early childhood and adulthood4. In the literature, there are few quantitative results that have evaluated anxiety, depression, and/or stress symptoms in parents of children with NSCL/P. Therefore, there are publications5-9 with divergent results that may be caused by inconsisten- cies in the methods used and multiple non-standard instruments used to assess these symptoms6. Furthermore, most of the studies2,3,6,10 that evaluated CL/P chil- dren’s parents’ psychosocial impacts were not directed at anxiety, depression, and stress symptoms but focused on variables such as social support, quality of life, presurgical parental stress, or resilience in children with CL/P. The coronavirus disease (COVID-19) pandemic has delayed the care of patients with NSCL/P, mainly because of the cancellation of elective surgeries. Studies showed that there were significant changes in the protocols used, delays in surgical repairs, increased time for care, maintenance of aesthetic and functional problems, and a reduction in the number of rehabilitation procedures11,12. Changes in the care of chil- dren with CL/P during the pandemic have caused signs and symptoms in their par- ents’ mental health12. Moreover, fear provoked by COVID can be a potential trigger of harm to the psychological health of the population as well as a predictor of the adop- tion of preventive methods of contagion13. Thus, the association between COVID-19 fear and the psychological impacts of chil- dren with NSCL/P children on parents and caregivers are still not well understood. No studies were identified in Brazil or Latin America that evaluated the presence of anxiety, depression, and stress symptoms in parents of children with NSCL/P. To date, no study has applied the Fear of COVID-19 Scale (FC-19S)13 to parents and caregivers of children with NSCL/P. Therefore, this study aimed to assess the levels of anxiety, depression, stress, and fear of COVID-19 among parents and caregivers of children with NSCL/P. Material and methods Study design and context This was a quantitative, cross-sectional, case-control study. Non probabilistic conve- nience sampling was chosen because of the transpandemic period. Paired control 3 Costa et al. Braz J Oral Sci. 2025;24:e255018 group was adopted in order to compare whether the outcome variables of the study group are different compared to the general population. Study participants The case group comprised parents and/or caregivers of children with NSCL/P. The children were treated at the Craniofacial Anomalies Rehabilitation Center, Dental School, Edson Antônio Vellano University (Minas Gerais, Brazil). The eligibility cri- teria were as follows: being a responsible caregiver for children with NSCL/P. The control group consisted of parents and/or caregivers of children without CL/P, sys- temic, or syndromic alterations. The control group was recruited from the Pedi- atric Dentistry Clinic of the same institution. Caregivers from both groups aged less than 18 years and older than 60 years were excluded. The instruments used were validated for adult population so the exclusion of participants from another age group. Data collection The studied variables were measured using three questionnaires: sociodemographic profile, Depression, Anxiety and Stress Scale (DASS-21)14, and Fear of COVID-19 Scale (FC-19S)13,15. Trained researchers collected data between October 2021 and Novem- ber 2022. Before data collection, the researchers conducted a pilot with 10% of the possible sample (which were not included in the final study results) for training. Socio- demographic variables included sex, age, child’s age, marital status, kinship with child, monthly income, and education level. The DASS-2114 was used to measure and classify the anxiety, depression, and stress symptoms. The instrument consisted of 21 questions. Responses were rated on a Likert scale with the scores 0 to three (totally disagree to totally agree). Of the 21 questions, questions 2, 4, 7, 9, 15, 19, and 20 were related to anxiety. The depression construct was measured using questions 3, 5, 10, 13, 16, 17, and 21. Stress was assessed using questions 1, 6, 8, 11, 12, 14, and 18. The total score is calculated based on the score sum of the seven items of each subscale, which is later multi- plied by two. The sum was interpreted as follows: 1) normal: 0-7, 0-9 and 0-14, for anxiety, depres- sion, and stress, respectively; 2) mild: 8-9, 10-13 and 15-18, for anxiety, depression, and stress, respectively; 3) moderate: 10-14, 14-20 and 19-25, for anxiety, depression, and stress, respectively; 4) severe: 15-19, 21-27 and 26-33, for anxiety, depression, and stress, respectively; and 5) extremely severe: scores above 20, 28 and 34, for anxiety, depression, and stress, respectively. The FC-19S is a validated instrument with psychometric properties that are robust and reliable for general population applications13,15. The questionnaire consisted of seven Likert-type answers (1 = strongly disagree to 5 = strongly agree). The compos- ite score ranged from 7 to 35, with a higher score indicating greater fear of COVID‐19. The levels were classified as mild (7–19 points), moderate (20–26 points), or severe (> 27 points).The questionnaires were in the native Portuguese language as validation studies of the use in Brazilian territory. 4 Costa et al. Braz J Oral Sci. 2025;24:e255018 Data analysis The obtained data were entered into Microsoft Excel 2013 software and exported to the IBM Statistical Package for the Social Sciences (SPSS), version 22.0 for statisti- cal analysis. Descriptive analyses of absolute (n) and relative (%) frequencies were performed for the categorical variables. Mean and standard deviation (SD) were cal- culated for continuous numeric variables. Bivariate analysis was performed using Pearson’s chi-square test at two different time points with different dependent vari- ables. Odds Ratio (OR) and Confidence Interval (CI95%) also were calculed Pearson’s chi-square test. First, the group (case/control) was selected as the dependent variable. Sociode- mographic variables were selected as independent variables. A multivariate binary logistic regression model using the forced-entry method was used to test the prediction of symptoms between groups. In the forced-entry method, all predic- tor variables are included in the same block with no hierarchy between them. The Hosmer–Lemeshow test was used to test the goodness of fit and accuracy of the model (indicated by p > 0.05). Anxiety, depression, and stress were dichotomized (00: normal, mild and moderate symptoms; 01: severe and extremely severe symp- toms) for bivariate analyses using sociodemographic variables. For all analyses, the significance level was set at 5% (p < 0.05). Results The final sample consisted of 210 parents and caregivers: 80 (38.1%) from the case group and 130 (61.9%) from the control group. The participants were predominantly female (90.0%), lived with a partner (65.2%), and had studied at least high school (35.2%). Their monthly income was 371.27 US$ (SD: 290.92 US$). Most caregivers were mothers (80.5%), fathers (8.6%), or other relatives (grandparents, uncles, stepfa- thers, or stepmothers, 11.0%). The associations of sociodemographic characteristics among the study groups are shown in Table 1. Anxiety, depression, stress, and fear of COVID-19 are presented in Table 2. It is seen that even though there are no associations with anxiety, depression and stress levels, between the groups, case group had higher OR for severe form these symptoms. Being a caregiver of a child without NSCL/P was likely to lead to a greater fear of COVID-19. Table 1. Bivariate analysis between groups (case/control) witch sample sociodemographic characteristics (n=210), 2021-2022. Variable Control Case OR (95%CI) p-value* n (%) n (%) Sex Male 9 (6.9) 12 (15.0) 1 0.058 Female 121 (93.1) 68 (85.0) 0.42 (0.16–1.05) Age*** 35.6 (9.5) 35.4 (8.7) - 0.838 Continue 5 Costa et al. Braz J Oral Sci. 2025;24:e255018 Continuation Marital status No partner 52 (40.0) 21 (26.2) 1 0.042* With partner 78 (60.0) 59 (73.8) 1.87 (1.01–3.44) Years of study Up to 8 68 (52.3) 41 (51.2) 1 0.882 More than 8 62 (47.7) 39 (48.8) 1.04 (0.59–1.82) Monthly income (minimum salary) Up to minimum 64 (50.8) 25 (32.9) 1 0.045* One to two 34 (27.0) 27 (35.5) 1.57 (1.01–2.43) More than two 28 (22.2) 24 (31.6) 1.64 (1.05–2.56) Kinship with the child Other caregivers 20 (15.4) 3 (3.8) 1 0.009* Father/Mother 110 (84.6) 77 (96.2) 4.66 (1.34–16.25) Child’ age*** 7.5 (2.2) 5.4 (5.7) - <0.001** *Pearson’s chi-square test significant statistical association (p≤0.05). **Student t test significant statistical association. ***In these variables, values were described witch mean and standard deviation values. Table 2. Bivariate analysis by binary logistic regression between groups witch psychological characteristics (n=210), 2021-2022. Variable Control Case OR (95%CI) p-value* n (%) n (%) Anxiety levels Normal 65 (50.0) 44 (55.0) 1 Mild 2 (1.5) 3 (3.8) 2.21 (0.35 – 13.80) 0.394 Moderate 23 (17.7) 14 (17.5) 0.89 (0.41 – 1.93) 0.785 Severe 9 (6.9) 7 (8.8) 1.14 (0.39 – 3.31) 0.797 Extremely severe 31 (23.8) 12 (15.0) 0.57 (0.26 – 1.23) 0.154 Depression levels Normal 62 (47.7) 40 (50.0) 1 Mild 14 (10.8) 6 (7.5) 0.66 (0.23 – 1.87) 0.438 Moderate 14 (10.8) 7 (8.8) 0.77 (0.28 – 2.08) 0.614 Severe 11 (8.5) 10 (12.5) 1.40 (0.54 – 3.62) 0.476 Extremely severe 29 (22.3) 17 (21.2) 0.90 (0.44 – 1.86) 0.793 Stress levels Normal 61 (46.9) 33 (41.2) 1 Mild 8 (6.2) 11 (13.8) 2.54 (0.93 – 6.93) 0.068 Moderate 19 (14.6) 4 (5.0) 0.38 (0.11 – 1.23) 0.110 Continue 6 Costa et al. Braz J Oral Sci. 2025;24:e255018 Continuation Severe 13 (10.0) 14 (17.5) 1.99 (0.83 – 4.73) 0.119 Extremely severe 29 (22.3) 18 (22.5) 1.14 (0.55 – 2.36) 0.710 Fear of COVID-19 Mild 73 (56.2) 57 (71.2) 1 Moderate to severe 57 (43.8) 23 (28.7) 0.51 (0.28 – 0.93) 0.029* *Significant statistical association through binary logistic regression (p≤0.05). Table 3 shows the prediction results of the binary logistic regression of the symptoms evaluated in parents of children with NSCL/P. The Hosmer-Lemeshow test results showed a well-fitted model (p=0.662). A negative correlation was observed between the development of extremely severe anxiety and moderate fear of COVID-19. A pos- itive correlation was observed between the development of mild and severe stress. Table 3. Predictive factors, through binary logistic regression, of psychological symptoms in parents of children with non-syndromic oral clefts (n=210), 2021-2022. Variables β OR 95%CI p-value Extremely severe anxiety -1.602 0.20 0.20 – 0.49 0.027* Mild stress 1.410 4.09 1.28 – 13.06 0.017* Moderate fear of COVID-19 -1.047 0.35 0.14 – 0.83 0.018* Only variables that presents statistical significance (≤0.05) were included. *Statistical significance (p≤0.05). Among the population studied, associations were observed between being female and severe anxiety and depression symptoms, being a parent/caregiver of children average aged seven years and depression symptoms, and being very fearful of COVID-19 and all symptoms DASS-21 measured (Table 4). Table 4. Association between severe and extremely severe psychological symptoms and characteristics of sample (n=210), 2021-2022. Variables Anxiety OR (95%CI) P-value* Depression OR (95%CI) P-value* Stress OR (95%CI) p-value* Group Control 40 (67.8) 1 40 (59.7) 1 42 (56.8) 1 Case 19 (32.2) 0.70 (0.37–1.32) 0.272 27 (40.3) 1.14 (0.63–2.07) 0.653 32 (43.2) 1.39 (0.78–2.49) 0.257 Sex Male 01 (1.7) 1 02 (3.0) 1 04 (5.4) 1 Female 58 (98.3) 8.85 (1.16–6.75) 0.012* 65 (97.0) 4.98 (1.12–2.20) 0.020* 70 (94.6) 2.50 (0.80–7.27) 0.102 Continue 7 Costa et al. Braz J Oral Sci. 2025;24:e255018 Continuation Age*** 35.3 (8.6) (-2.46–3.14)a 0.811 36,2 (9.9) (-1.73–3.66)a 0.482 34,8 (8.6) (-1.57–3.69)a 0.427 Marital status No partner 23 (39.0) 1.29 (0.69–2.40) 0.422 29 (43.3) 1.71 (0.94–3.12) 0.076 25 (33.8) 1 With partner 36 (61.0) 1 38 (56.7) 1 49 (66.2) 1.06 (0.58–1.94) 0.826 Years of study Up to 8 36 (61.0) 1.67 (0.90–3.08) 0.099 38 (56.7) 1.32 (0.74–2.38) 0.339 41 (55.4) 1.24 (0.70–2.19) 0.454 More than 8 23 (39.0) 1 29 (43.3) 1 33 (44.6) 1 Monthly income (minimum salary) Up to minimum 25 (44.6) 1.30 (0.58–2.87) 0.514 29 (44.6) 1.19 (0.56–2.51) 0.644 32 (43.8) 1.06 (0.51–2.17) 0.872 One to two 19 (33.9) 1.50 (0.64–3.50) 0.339 21 (32.3) 1.29 (0.58–2.88) 0.526 23 (31.5) 1.14 (0.52–2.47) 0.733 More than two 12 (21.4) 1 15 (23.1) 1 18 (24.7) 1 Kinship with the child Other caregivers 05 (8.5) 1 07 (10.4) 1 05 (6.8) 1 Father/ Mother 54 (91.5) 1.46 (0.51–4.13) 0.472 60 (89.6) 1.08 (0.42-2.76) 0.873 69 (93.2) 2.10 (0.74–5.92) 0.151 Child’ age*** 7.38 (3.97) (-2.10–0.36)a 0.166 7.58 (4.16) (0.03–2.40)a 0.044** 6.83 (3.92) (-1.29–1.04)a 0.835 Fear of COVID-19 Mild 27 (45.8) 1 35 (52.2) 1 41 (55.4) 1.34 (0.61–2.91) 0.461 Moderate 10 (16.9) 1.15 (0.50–2.63) 0.730 10 (14.9) 0.82 (0.36–1.84) 0.635 11 (14.9) 1 Severe 22 (37.3) 5.59 (2.56–12.22) 0.00**** 22 (32.8) 3.98 (1.85–8.53) 0.00**** 22 (29.7) 4.26 (1.65–11.01) 0.002* *Pearson’s chi-square test significant statistical association (p≤0.05). **Student t test significant statistical association. ***In these variables, values were described which mean and standard deviation values. ****Pearson’s chi-square test significant statistical association (p<0.001). aDifference between means confidence interval. Discussion In the present study, no statistical differences were identified in anxiety, depres- sion, or stress levels between the parents and caregivers of children with NSCL/P and healthy children. However, the discussion of the results with these literature findings must be interpreted with caution. Even without the presence of statistical associations in the inferential tests, descriptive results showed a higher prevalence of extremely severe symptoms in the case group. In addition, the regression model showed predictions of some of these symptoms to the group of caregivers of children with NSCL/P. 8 Costa et al. Braz J Oral Sci. 2025;24:e255018 Three studies7-9 used the DASS-21 to measure the psychological symptoms in par- ents of children with NSCL/P. An Indian study7 conducted with 50 parents of children with NSCL/P observed a positive association between parents’ stress and depressive symptoms and the child’s behavioral problems. A second study was conducted in Belgium with 90 NSCL/P children’s parents8, which, in addition to measuring psychological symptoms, also applied instruments to com- pare self-esteem and concerns about their social behavior. Anxiety, depression, and stress scores were normal, with no differences from the other studies analyzed in the discussion. Moreover, higher anxiety scores were significantly associated with an older parental age. Older parental age was associated with depression and a postna- tal cleft diagnosis. In Kumar et al.9 (2020) study, there was a similarity to the methodology applied in our study, mainly because of the presence of comparative groups. Parents of CL/P adoles- cents (10–17 years) showed a statistically significant association with higher levels of symptoms in the three dimensions measured by the DASS-21 (p<0.001). Furthermore, the prevalence of severe and extremely severe depressive symptoms was 22.9% and 20%, respectively, in the group of children with CL/P, where as, in the group of healthy children, the prevalence was 1% and 2% for the same symptom ratings. Regarding anxiety in parents of children with CL/P, the prevalence of extremely severe classifi- cation was 50%, where as in the control group, the prevalence was 6.1%. Regarding stress, severe symptoms were 21.4% in case group, and 1% of patients in the case and control groups, respectively. Similar to the present study, other study11 have not shown an association between anxiety and depression in the investigated groups. However, findings on this subject are diverse. There are publications in which parents of healthy children scored more than NSCL/P caregivers16,17, as well as contrary results5,6,9. However, in most studies, symptom levels were measured using different instruments. Self-perceived parental stress is a consistently evaluated variable in studies on par- ents and caregivers of children with NSCL/P3,6-16. Jeong et al.16 (2013) showed that par- ents had lower scores on Beck’s Anxiety and Depression Inventory had more stress. Furthermore, a reduction in stress levels was noted in parents of children with NSCL/P during childhood3. In addition, there was a correlation between these symptoms and children’s behavior3,16. Only two studies that measured the psychological impact on parents of children with NSCL/P in Brazil were identified18,19. The first was a cohort study18 that aimed to analyze parental stress in parents of children with NSCL/P before and after surgical procedures. This study found that the stress levels progressively decreased after the intervention. Carvalho et al.19 (2021) evaluated the emotions of parents and caregiv- ers using an elaborate questionnaire. This patient did not show anxiety, depression, and/or stress symptoms, but feelings of fear, despair, sadness, and shock were more prevalent after cleft diagnosis. Our study is the first to apply the FC-19S to parents of children with NSCL/P. Being a parent or caregiver was found to be a protective factor in relation to the parents or caregivers of healthy children. However, this remains unclear. However, it should be 9 Costa et al. Braz J Oral Sci. 2025;24:e255018 noted that some patients with CL/P during the pandemic were assisted by teleori- entation. This could have contributed to the fact that the caregivers of children with NSCL/P did not feel the impact of the pandemic more intensely and thus demon- strated less fear than the control group. Studies20,21 have also evaluated the fear of COVID-19 among parents of healthy children. However, they did not use FC-19S20, and another aimed fear and breastfeeding effectiveness were associated21. This high- lights the importance of verifying fear of COVID-19 as an aggravating factor in family cycle mental health20,21. Regarding group feature differences, parents of children with NSCL/P had a higher OR for having a partner and had a higher monthly income than the control group. However, no results in the literature explain this finding. It is necessary to point out that in Brazil, the treatment of CL/P is paid by the Unified Health Public System (SUS in Portuguese)22. Therefore, regardless of the family members’ socioeconomic status, all patients with CL/P were treated in the same specialized center. Similar to other studies, being female showed an association between anxiety and depressive symptoms23,24. Publications suggesting that women have a higher OR for anxiety and depression symptom development are based on many factors, mainly physiological issues and social demands23,24. In addition, women have histor- ically sought health services where surveys are conducted. Furthermore, during the COVID-19 pandemic23, there has been an increase in the number of domestic violence cases, which has contributed to the risk of developing mental disorders. Children’s age (mean, 7.5 years) was associated with their parents’ depression symp- toms. This result differs from that of an Indian study in which parents of NSCL/P children over ten years old had greater scores in DASS-21 all dimension compared to parents of clinically healthy children and younger CL/P children. However, in a study25 of caregivers of children, it was found that mothers of younger children, regardless of the presence of disabilities or anomalies in their children, commonly presented some anxiety, depression, and stress levels. Symptoms of anxiety, depression, and stress were strongly associated with severe fear of COVID-19. Thus, it can be inferred that individuals with more mental health problems were more afraid of COVID-19. Although a relatively new scale, some studies26-28 have used the FC-19S in conjunction with the DASS-21. Additionally, associations were found between fear of COVID-19 and higher scores for these symptoms26. Furthermore, there was a strong correlation between instruments27. However, it should be noted that such association measures may change over time. Some studies emphasize that data collection was conducted during the initial pan- demic period or at the peak of the viral infection wave26,28. These factors may inter- fere with the fear of COVID-19 scores, which have a predilection for psychological symptoms. A difference from our study is that the data collection was carried out over a year; thus, the participants experienced different pandemic phases, reducing possible bias regarding the high levels of fear of COVID-19. This study has some limitations. As this was a convenience sampling study, the find- ings may be underreported because the COVID-19 pandemic has led to changes in the health habits of individuals with greater mental health problems. Another limita- 10 Costa et al. Braz J Oral Sci. 2025;24:e255018 tion was the cross-sectional design of the study, which could not measure the causal- ity of parenting with measured symptom development. In conclusion, no differences were observed between anxiety, depression, and stress levels in the control group or in the parents and caregivers of children with NSCL/P. However, a predilection for severe symptoms was found in parents of chil- dren with oral clefts. Additionally, parents and caregivers of children with NSCL/P had less fear of COVID-19. Anxiety, depression, and stress symptoms were associ- ated with female sex, responsible of seven year-old aged children and severe fear of COVID-19. Acknowledgment The authors would like to thank The Minas Gerais State Research Foundation – FAPEMIG, Brazil, National Council for Scientific and Technological Development – CNPq, Brazil and the Coordination for the Improvement of Higher Education Person- nel, CAPES, Brazil. Conflict of Interest The authors have no conflict of interest to disclose. Data availability Datasets related to this article will be available upon request to the corresponding author. Author Contribuition Samuel Trezena Costa: Conceptualization, methodology, data curation, writing – original draft preparation, review and editing. Fabrício Emanuel Soares de Oliveira: Conceptualization, methodology, data curation, writing – original draft preparation, review and editing. Cintia Eliza Marques: Investigation and data curation. Nádia Carolina Teixeira Marques: Conceptualization, methodology and data curation. Verônica Oliveira Dias: Conceptualization, writing –review and editing. Daniella Reis Barbosa Martelli: Conceptualization, methodology, investigation, writing – original draft preparation, review and editing. Hercílio Martelli Júnior: Conceptualization, methodology, investigation, writing – original draft preparation, review and editing. All authors actively participated in the discussion of the manuscript’s findings, revised, and approved the final version of the manuscript. References 1. Voigt A, Radlanski RJ, Sarioglu N, Schmidt G. [Cleft lip and palate]. Pathologe. 2017 Jul;38(4):241-7. German. doi: 10.1007/s00292-017-0313-x. 2. De Cuyper E, Dochy F, De Leenheer E, Van Hoecke H. The impact of cleft lip and/or palate on parental quality of life: a pilot study. Int J Pediatr Otorhinolaryngol. 2019 Nov;126:109598. doi: 10.1016/j.ijporl.2019.109598. 11 Costa et al. Braz J Oral Sci. 2025;24:e255018 3. Baker SR, Owens J, Stern M, Willmot D. 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