J Bagh College Dentistry Vol. 29(4), December 2017 Oral Health among Pedodontics, Orthodontics and Preventive Dentistry 96 Oral Health Condition and Nutritional Status among Cleft Lip and Palate in Baghdad-Iraq Mais M. Almaeeni, B.D.S. (1) Abeer M. Hassan, B.D.S., M.Sc. (2) ABSTRACT Background: Orofacial cleft is the most common craniofacial birth defect and the fourth most common congenital malformation in humans that have an effect on oral health in addition to nutrient intake affected in those children. This research aims to investigate gingival condition, dental caries experience and nutritional status among children with orofacial cleft and compare them with normal children. Materials and methods: The study group included 36 children with an age ranged (4-9) years of orofacial cleft. The control group included 37 children matched the control group in age and gender. Gingival condition measured by Gingival Index (Löe and Silness, 1963), while dental caries status was measured by (D1-4MFs/d1-4mfs) index according to the criteria of Manji et al (1989). The nutritional status was assessed using body mass index for age. Data analysis was conducted through the application of the SPSS (version 21). Results: The DMFs, dmfs and Ds mean values were higher in study group than control group with no statistically significant differences, while ds mean values were higher in study group than control group with highly significant difference. GI mean values were higher in study group than control group with statistically highly significant difference. No significant difference in body mass index between study and control groups. Concerning severity, the study group had more gingival inflammation severity than control group, while regarding dental cries severity only grades d1, d3 and d4 were significantly increased in study group than control group. Conclusion: The children with orofacial clefts had increased risk for dental caries and gingival inflammation than normal children. The nutritional status was not different between children with orofacial cleft and healthy children. Key words: Cleft lip and palate, nutrition, dental caries, gingival condition. (J Bagh Coll Dentistry 2017; 29(4): 96-101) INTRODUCTION Orofacial cleft (OFC) is the most common craniofacial birth defect and the fourth most common congenital malformation in humans (1, 2). The craniofacial structures development is a coordinated process involving the growth of multiple independently derived embryologic prominences called primordia. Incomplete fusion of this facial structures during the fourth to eighth week of embryologic life results in a gap leads to cleft lip, cleft of the primary or secondary palate, or a combination of them. Elevated infant mortality and significant lifelong morbidity are associated with OFC such as cosmetic deformities, feeding problems, swallowing difficulties, failure to gain weight, change in nose shape, recurrent ear infections, poor growth of the maxilla, speech difficulties, misaligned teeth and dental abnormalities (2-4). Persons with OFC are at a significant risk for periodontal disease and dental caries (5-8). Body growth is important in OFC children because it reflects the accumulation of metabolism over time (9). Many factors, such as feeding problems, recurrent respiratory infections and reconstructive surgery may affect the growth pattern of OFC children (10-12). The nutrient intake of OFC children was little different from that of normal children (13). (1) Master Student, Department Of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad. (2) Assistant professor, Department Of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad. Another study found that nutritional status had no average differences from norms for children with OFC (9). This study was designed and conducted in order to gain knowledge about nutritional status, dental caries experience and gingival condition among children with orofacial cleft and compares them with normal children. MATERIALS AND METHODS This study was carried out in Baghdad city, Iraq. Informed consent was obtained from each participant enrolled in this study before any data collection and examination of oral health. Two groups were examined with age range (4-9). The study group included thirty-six children, which matched the inclusion criteria and attended Alwasity and Ghazi Alhareery Teaching Hospitals/ maxillofacial departments. The inclusion criteria of the study group were as follow: (1) Non-syndromic OFC, (2) Surgically repaired, (3) Cleft with bone involvement. The control group, which included thirty-seven healthy children, those children attended pedodontics department at Baghdad Dentistry College. Control group matched study group in age and gender. Dental caries and its severity were assessed according to decayed, missed and filled surfaces (D1-4 MF/ d1-4 mfs) index (14). The gingival health condition was assessed by Gingival Index (15). Height was measured using an ordinary measuring tape fixed at true vertical, flat surface, J Bagh College Dentistry Vol. 29(4), December 2017 Oral Health among Pedodontics, Orthodontics and Preventive Dentistry 97 while body weight measurements were taken on digital scale (16). The percentile growth chart defined by The CDCP (Center for Disease Control and Prevention) was used to indicate the BMI according to age and gender (17). Data analysis was conducted through the application of the SPSS (version 21) and Microsoft Office Excel (2007). Statistical analysis can be classified into two categories: (1) Descriptive Analysis which include percentage for nominal variables while mean, standard deviation (SD) and standard error SE for numeric variables and graphs, (2) Inferential analysis which include Levene test and two independent samples T-test. The confidence limit was accepted at 95% (P <0.05). RESULTS Results showed that there is no significant statistically differences between boys, girls and age groups; for that reason the whole sample were considered as one group without subgrouping according to gender and age. Table 1 and 2 showed caries experience and caries severity differences between study and control groups for permanent and primary dentition respectively. The DMFs and Ds means were higher in study group than control group with no statistically significant difference (P>0.05), while the dmfs and ds means were higher in study group than control group with no statistically significant difference (P>0.05) for dmfs and highly significant difference (P<0.01) for ds component. The Gingival index means among the study and control groups are illustrated in Table 3. The table shows that GI means were higher in study group than control group with statistically highly significant difference (P<0.01). The gingival inflammation severity illustrated in Figure 1. The figure shows that healthy gingiva was absent in study group, while the percentage of it within control group was 10.80%. The percentage of mild type of the gingival inflammation within study group was 72.20%, while its percentage within control group was 86.50%. The percentage of moderate type of the gingival inflammation within study group was 27.80%, while its percentage within control group was 2.70%. The sever type of the gingival inflammation was absent in both study and control groups. Table 4 illustrates the mean values and standard deviations of the BMI among study and control groups. This table shows that no significant difference in BMI between study and control groups (P>0.05). The numbers and percentages of underweight, healthy, at risk of overweight and obese children in study and control groups represented in Table 5. The percentage of underweight children within study group was 2.8%, while its percentage within control group was 5.4%. The percentage of healthy children within study group was 91.7%, while its percentage within control group was 73%. The percentages of both at risk of overweight and obese children within study group were 2.8%, while their percentages within control group were 10.8%. Table 1: Caries experience and caries severity differences between study and control groups for permanent dentition. Variables Groups Independent sample Test Study Control T# df Sig. N Mean ±SD SE N Mean ±SD SE D1 23 1.00 1.38 0.29 33 0.91 1.26 0.22 0.255 54 0.799 D2 23 2.26 2.20 0.46 33 1.73 1.99 0.35 0.946 54 0.348 D3 23 0.04 0.21 0.04 33 0.30 1.02 0.18 -1.426 35.80 0.162 D4 23 0.70 2.22 0.46 33 0.03 0.17 0.03 1.431 22.19 0.166 Ds 23 4.00 3.55 0.74 33 2.97 3.09 0.54 1.154 54 0.253 Ms 23 0.22 1.04 0.22 33 0.00 0.00 0.00 1.000 22 0.328 Fs 23 0.17 0.65 0.14 33 0.18 0.53 0.09 -0.050 54 0.960 DMFs 23 4.39 4.15 0.87 33 3.15 3.19 0.56 1.263 54 0.212 #=Not significant at P>0.05. J Bagh College Dentistry Vol. 29(4), December 2017 Oral Health among Pedodontics, Orthodontics and Preventive Dentistry 98 Table 2: Caries experience and caries severity differences between study and control groups for primary dentition. Variables Groups Independent sample Test Study Control T df Sig. N Mean ±SD SE N Mean ±SD SE d1 36 1.75 1.63 0.27 37 0.86 1.21 0.20 2.63 * 64.47 0.011 d2 36 4.58 5.17 0.86 37 5.11 3.57 0.59 -0.51 71 0.614 d3 36 4.28 5.44 0.91 37 1.54 2.28 0.37 2.79 ** 46.65 0.008 d4 36 5.83 7.94 1.32 37 2.57 4.39 0.72 2.17 * 54.23 0.035 ds 36 16.44 11.23 1.87 37 10.08 6.17 1.01 2.99** 54.03 0.004 ms 36 1.89 4.15 0.69 37 3.76 5.38 0.88 -1.66 71 0.102 fs 36 0.53 1.73 0.29 37 0.95 2.54 0.42 -0.82 71 0.415 dmfs 36 18.86 12.04 2.01 37 14.78 8.72 1.43 1.66 71 0.101 *=Significant at P<0.05, **=Highly significant at P<0.01. Table 3: The Gingival index difference among the study and control groups. Variable Groups Independent sample Test Study Control T df Sig. Mean ±SD SE Mean ±SD SE GI 0.90 0.31 0.05 0.37 0.26 0.04 7.989** 71 0.000 **=Highly significant at P<0.01. Table 4: The BMI difference among the study and control groups. Variable Groups Independent sample Test Study Control T# df Sig. Mean ±SD SE Mean ±SD SE BMI 15.69 1.13 0.19 16.59 2.82 0.46 -1.79 47.54 0.081 #=Not significant at P>0.05. Table 5: The distribution of the study and control group according to nutritional status. Nutrition Groups Study Control N % N % Underweight 1 2.8 2 5.4 Healthy 33 91.7 27 73.0 At risk overweight 1 2.8 4 10.8 Obese 1 2.8 4 10.8 J Bagh College Dentistry Vol. 29(4), December 2017 Oral Health among Pedodontics, Orthodontics and Preventive Dentistry 99 Figure 1: The gingival inflammation severity among study and control groups. DISCUSSION The present study data showed that there was no significant difference for DMFs between study and control groups, this result agreed with some previous studies conducted by Lucas et al and Cheng et al (18-19), while it was controversial with the findings of others (3, 4, 7). This may due to that caries is a chronic infectious disease and the DMF/dmf index is a lifetime cumulative index of dental disease and treatment and may have little bearing on caries activity at a specific point in time; also the age range for the present study is short for permanent dentition observation (20). Concerning dmfs and ds component were higher in study group than control group. These results agreed with Ja’afar and Dahllöf et al (3,5) and disagreed with other study conducted in Jordan (7). Increased caries experience in children with OFC could be relate to dental abnormalities and the restricted access to proper oral hygiene and natural cleansing of the teeth because of the loss of elasticity and the anatomy of surgically repaired lip leads to fear of brushing around this area (5, 21), also tenacious nature of nasal fluid that drain from the palatal fistula enhances dental plaque stickiness (22), on the other hand parents are usually unaware of their children’s increased susceptibility to dental caries and insufficient education about tooth brushing techniques and the important of oral hygiene and dietary practices, also they are more concerned with other aspects of care (surgery and speech development) so that the oral health at the lower end of the priority scale unless the child has discomfort (18, 19). The results of current study showed that the mean value of gingival index for the study group was higher than that for the control group with statistically highly significant difference between two groups. This result was also reported by studies conducted previously (5, 7) and disagreed with others (8, 18). As mentioned previously, the maintenance of oral hygiene influenced by the cleft deformity and the surgical scars, also the children’s families preoccupied with other aspects of care (5). Prolonged orthodontic therapy and wearing of prosthesis to prevent collapse of the dental arch commonly result in gingival inflammations (23). Tissue discontinuation of alveolar and palatal area allows pathological bacterial colonies migration between the oral and the nasal cavities (8). No significant difference was found in present study regarding BMI between study and control groups. This agreed with findings of Bowers et al and Gopinath (9, 13). The percentage of underweight children within study group was lower than that within control group. The percentage of healthy children within study group was higher than that within control group, but the control group experienced increased percentages of both at risk of overweight and obese than study group. This could be relate to adequate nutritional intake in hospitals before and after surgical intervention to facilitate healing and growth and may relate to parental education and motivation concerning the importance of good nutrition (13). This study made novel observations in Iraq that will provide a platform for further research that must collect additional and more detailed dietary analysis on a larger group of patients and longer duration in order to make entirely conclusive quantitatively results. REFERENCES 1. Jugessur A, Farlie PG, Kilpatrick N. The genetics of isolated orofacial clefts: from genotypes to subphenotypes. Oral Disease 2009; 15: 427–435. 2. Szabo GT, Tihanyi R, Csulak F, Jambor E, Bona A, Mark L. Comparative Salivary Proteomics of Cleft Palate Patients. Cleft Palate–Craniofacial Journal J Bagh College Dentistry Vol. 29(4), December 2017 Oral Health among Pedodontics, Orthodontics and Preventive Dentistry 100 2012; 49(5): 519-23. 3. Ja’afar ZJ. Oral health status and treatment needs among (3-12) years old children with cleft and/or palate in Iraq. Master thesis, Pedodontic department, University of Baghdad, 2006. 4. Zhu WC, Xiao J, Liu Y, Wu J, Li J. Caries experience in individuals with cleft lip and/or palate in China. Cleft Palate–Craniofacial Journal 2010; 47(1): 43-7. 5. Dahllöf G, Ussisoo-Joandi R, Ideberg M, Modeer T. Caries, gingivitis and dental abnormalities in preschool children with cleft lip and/or palate. Cleft Palate Journal 1989; 26(3): 233-8. 6. Paul T, Brandt RS. Oral and dental health status of children with cleft lip and/ or palate. Cleft Palate J 1998; 35(4): 329–32. 7. Al-Wahadni A, Abu Alhaija E, Al-Omari MA. Oral disease status of a sample of jordanian people ages 10 to 28 with cleft lip and palate. Cleft Palate– Craniofacial Journal 2005; 42(3): 304-8. 8. Antoszewska J, Matthews-Brzozowska T, Kawala B. Streptococcus mutans and lactobacillus levels in oral cleft patients. Journal Of Preventive Medicine 2006; 14(1-2): 87-95. 9. Bowers EJ, Mayroa RF, Whitakera LA, Pasquarielloa P, Larossaa D, Randalla P. General body growth in children with clefts of the lip, palate, and craniofacial structure. Scandinavian Journal of Plastic and Reconstructive Surgery 1987; 21(1): 7-14. 10. Becker M, M.D. Henry Svensson M, Kallen B. Birth weight, body length, and cranial circumference in newborns with cleft lip or palate. Cleft Palate– Craniofacial Journal 1998; 35(3): 255-61. 11. Masarei AG, Sell D, Habel A, Mars M, Sommerlad B, Wade A. The nature of feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infants. 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J Bagh College Dentistry Vol. 29(4), December 2017 Oral Health among Pedodontics, Orthodontics and Preventive Dentistry 101 بين شق الحنك والشفة الوالدي في بغداد ـ التغذویة الحالة حالة الفم الصحية و العراق الخالصة عند ثرتتأ قد التغذوية الحالة. البشر كثر شیوعا فيألاويعتبر ھو رابع تشوه خلقي والديقحفي عیب ھو الحنكو الشفة شق :خلفية التغذوية الحالة دراسة إلى البحث ھذا يھدف. واألسنان الفم صحة سالمة على تؤثر اللثة لتھابوإ األسنان تسوس. طفالاأل ھؤالء .السلیمین األطفال مع ومقارنتھا والشفة الحنك شق من يعانون الذين األطفال بین اللثة حالة و األسنان وتسوس عمارھمأ احوتتر )المجموعة تحت الدراسة( اب بشق الحنك والشفة الوالديصم طفال ٦٣ الدراسة ھذه تضمنت :والطرق المواد قیاس تموقد تم مراعاة تطابق العمر والجنس بین المجموعتین. )المجموعة الضابطة( طفل سلیم ٦٣ ع( سنوات تمت مقارنتھم م٩ـ٤) مراض اللثة فقد تم أما أ ، et al(Manji 1989)(وفقا لمعايیر )mfs)4-1dMFs/4-1D ستخدام دالة التسوسسريريا من خالل إ األسنان تسوس أجري تحلیل البیانات .للعمر بالنسبة الجسم كتلة مؤشر ستخدامبأ تغذويةال الحالة تقییم تم. (Löe and Silness, 1963 ) ايیرقیاسھا وفقا لمع (.12اإلصدار SSSSمن خالل تطبیق برنامج ) في المجموعة تحت الدراسة من المجموعة أعلى قیم لمتوسط الرتبكانت sDو sFMD،sfmD ان وجد في ھذه الدراسة :النتائج تحت مجموعة ال في أعلى كانت (sDاللبنیة )سنان فیما يخص السطوح المسوسة لأل حصائیة.ابطة مع عدم وجود فارق ذو داللة إالض مجموعة في أعلى كانت (IGقیم متوسطات التھاب اللثة ) ا انالدراسة مع فارق ذو داللة احصائیة عالیة. ھذه الدراسة اظھرت ايض كثر شدة في المجموعة تحت الدراسة من إلتھاب اللثة كان أ .عالیة إحصائیة داللة ذو فارق مع الضابطة المجموعة من الدراسة إزدادت بشكل ملحوظ في المجموعة تحت الدراسة من 1d ,3dوd 4 بما يتعلق بشدة التسوس، فقط الدرجات عة الضابطة.المجمو .الضابطةو الدراسة ن تحتمجموعتیال بین الجسم كتلة مؤشر في كبیر فرق يوجد الالمجموعة الضابطة. ، السلیمین األطفال من اللثة لتھابوإ األسنان لتسوس كثر عرضةأالشفة والحنك الوالدي شق من يعانون الذين األطفال إن :ستنتاجاإل الشفة والحنك الوالدي. شق من يعانون الذين ألطفالل التغذوية الحالة على تأثیر شق الشفه والحنكل لیس كذلك .اللثة حالة األسنان، تسوس التغذية،والحنك، الشفة شق :الرئيسية الكلمات