Management of cleft lip and palate in primary care

A Longitudinal Investigation of Nasolabial Changes With and Without Revision Surgery in Patients with Non-Syndromic Unilateral Cleft Lip and Palate

OBJECTIVE

To determine a baseline of anticipated change in nasolabial appearance following primary repair of unilateral cleft lip/palate and evaluate the degree to which revision surgery improves nasolabial appearance.

DESIGN

Retrospective chart review.

SETTING

Patients treated at the Lancaster Cleft Palate Clinic interdisciplinary clinic.

PATIENTS

Twenty-three patients with complete unilateral cleft lip and palate who underwent primary surgical repair and 19 additional patients who underwent subsequent revision surgery were included.

INTERVENTIONS

Patients in the non-revision group underwent a Tennison-Randall triangular flap lip repair at 3mo. Patients in the revision group underwent a modification of the Nakajima straight-line repair after primary Tennison-Randall triangular flap lip repair at an average age of 141mo.

MAIN OUTCOME MEASURES

A modification of the Asher-McDade Aesthetic Index was utilized to evaluate Nasolabial Frontal (NLF), Nasolabial Profile (NLP), Vermillion Border (VB), and total change in appearance. Scores for patients in the revision group were evaluated before and after revision while appearance for patients without revision was evaluated at 3 distinct ages. Scores were averaged across time-points and inter-rater reliability was assessed.

RESULTS

Nasolabial appearance in the non-revision sample did not change significantly over time, except for nasal profile. Scores improved after revision surgery - NLP: 3.48 to 2.97, (p = 0.001); NLF: 3.50 to 2.95 (p = 0.001); and Total Nasolabial Score: 3.29 to 3.01 (p = 0.004), with no significant change in VB.

CONCLUSION

Decisions regarding need for nasolabial revision surgery may be made as early as 5yo with successful outcomes following secondary surgery improving appearance except for vermillion border appearance.

Stem Cell-Based Regenerative Approaches for the Treatment of Cleft Lip and Palate: A Comprehensive Review

Cleft lip and/or palate (CLP) is a prevalent congenital craniofacial abnormality that can lead to difficulties in eating, speaking, hearing, and psychological distress. The traditional approach for treating CLP involves bone graft surgery, which has limitations, post-surgical complications, and donor site morbidity. However, regenerative medicine has emerged as a promising alternative, employing a combination of stem cells, growth factors, and scaffolds to promote tissue regeneration. This review aims to provide a comprehensive overview of stem cell-based regenerative approaches in the management of CLP. A thorough search was conducted in the Medline/PubMed and Scopus databases, including cohort studies, randomized controlled trials, case series, case controls, case reports, and animal studies. The identified studies were categorized into two main groups: clinical studies involving human subjects and in vivo studies using animal models. While there are only a limited number of studies investigating the combined use of stem cells and scaffolds for CLP treatment, they have shown promising results. Various types of stem cells have been utilized in conjunction with scaffolds. Importantly, regenerative methods have been successfully applied to patients across a broad range of age groups. The collective findings derived from the reviewed studies consistently support the notion that regenerative medicine holds potential advantages over conventional bone grafting and represents a promising therapeutic option for CLP. However, future well-designed clinical trials, encompassing diverse combinations of stem cells and scaffolds, are warranted to establish the clinical efficacy of these interventions with a larger number of patients.

Evaluation of Anxiety in Turkish Parents of Newborns with Cleft Palate with or Without Cleft Lip

OBJECTIVE

(1) To compare anxiety between parents of newborns with cleft lip and palate (CLP), isolated cleft palate (CP), and healthy newborns and (2) to evaluate anxiety between parental dyads within these groups.

DESIGN

A cross-sectional study.

SETTING

University Hospital.

PARTICIPANTS

Surveys were completed by 20 mothers and 20 fathers of newborns with CLP, 21 mothers and 21 fathers of newborns with CP, and 23 mothers and 23 fathers of healthy newborns (controls).

MAIN OUTCOME MEASURE

The State-Trait Anxiety Inventory (STAI) assessed parental anxiety. Mothers of newborns with a cleft reported on concerns regarding cleft-related issues and facial appearance.

RESULTS

State and trait anxiety were generally in the moderate range for parents of newborns with a cleft, while control parents had low state anxiety and moderate trait anxiety. Mothers of newborns with CP and CLP had significantly higher state and trait anxiety levels than control mothers (p < .05). Fathers of newborns with CLP had a higher state anxiety level than control fathers. When maternal and paternal anxiety was compared within the groups, only trait anxiety scores were significantly higher in mothers of newborns with CLP than that of fathers (p < .05). More than half of mothers of newborns with a cleft were concerned about their newborn's feeding, speech, and palate.

CONCLUSIONS

Parents of children with a cleft may need psychological support in the early postnatal period. It is important for neonatal cleft team providers to help reduce parental anxiety and educate families about cleft care, with a focus on feeding.

The influence of music lessons on the socio-emotional wellbeing of children with cleft lip and/or palate

Introduction There is a dearth of psychological interventions for patients with cleft lip and/or palate (CL/P).Objective To evaluate the influence of music lessons on the socio-emotional wellbeing of children with CL/P.Setting This study was conducted at Asociación San Lucas (Moyobamba, Peru), which has a multidisciplinary programme for children with CL/P. Recorder lessons are offered to all patients aged 6-8 years. From age eight, the children can switch to flute, clarinet, violin, viola or cello.Materials and methods The Glasgow Benefit Inventory (GBI), a post-intervention questionnaire, was administered to all 26 children participating in the music programme.Results Mean GBI scores per question ranged from 59.62 (SD: 31.68) to 92.31 (SD: 23.21), showing an overall positive effect of the music lessons on the patients' socio-emotional wellbeing. Playing a musical instrument gave the children satisfaction and self-confidence. The children lost much of their shame, became less shy, and participated more in social activities. In a non-significant numerical trend, boys, flute/clarinet players and orchestra players had higher mean GBI scores than, respectively, girls, string players and children who did not play in the orchestra.Conclusions Quantitative and qualitative analysis indicated a positive influence of music lessons on the patients' socio-emotional wellbeing.

Peer attitudes towards adolescents with speech disorders due to cleft lip and palate

BACKGROUND AND AIMS

Individuals with speech disorders are often judged more negatively than peers without speech disorders. A limited number of studies examined the attitudes of adolescents toward peers with speech disorders due to a cleft lip with or without a cleft of the palate (CL ± P). Therefore, the aim of the present study was to investigate the attitudes of peers toward the speech of adolescents with CL ± P.

METHOD

Seventy-eight typically developing adolescents (15-18 years, 26 boys, 52 girls) judged audio and audiovisual samples of two adolescents with CL ± P based on three attitude components, i.e., cognitive, affective, and behavioral. The degree of speech intelligibility was also scored by their peers. The study investigated whether the three attitudes were determined by speech intelligibility or appearance of an individual with CL ± P. Furthermore, the influence of knowing someone with a cleft, the age, and gender of the listeners on their attitudes were explored.

RESULTS

A significantly positive correlation was found between the speech intelligibility percentage and the three different attitude components: more positive attitudes were observed when the speech intelligibility of the speaker was higher. A different appearance due to a cleft lip does not lead to more negative attitudes. Furthermore, boys seem to have more negative attitudes toward individuals with CL ± P compared to girls.

CONCLUSION

This study provided additional evidence that peers show more negative attitudes toward adolescents with less intelligible speech due to CL ± P. Intervention should focus on changing the cognitive, affective, and behavioral attitudes of peers in a more positive direction and remove the stigma of patients with a cleft. Further research is needed to verify these results.

First-Trimester Influenza Infection Increases the Odds of Non-Chromosomal Birth Defects: A Systematic Review and Meta-Analysis

Viral infections during pregnancy raise several clinical challenges, including birth defects in the offspring. Thus, this systematic review and meta-analysis aims to prove and highlight the risk of birth defects after first-trimester maternal influenza infection. Our systematic search was performed on 21 November 2022. Studies that reported maternal influenza infection in the first trimester and non-chromosomal congenital abnormalities were considered eligible. We used odds ratios (OR) with 95% confidence intervals (CIs) to measure the effect size. Pooled ORs were calculated with a random effects model. Heterogeneity was measured with I² and Cochran's Q tests. We found that first-trimester maternal influenza was associated with increased odds of developing any type of birth defects (OR: 1.5, CI: 1.30-1.70). Moreover, newborns were more than twice as likely to be diagnosed with neural tube defects (OR: 2.48, CI: 1.95-3.14) or cleft lip and palate (OR: 2.48, CI: 1.87-3.28). We also found increased odds of developing congenital heart defects (OR: 1.63, CI: 1.27-2.09). In conclusion, influenza increases the odds of non-chromosomal birth defects in the first trimester. The aim of the present study was to estimate the risk of CAs in the offspring of mothers affected by first-trimester influenza infection.

The Cleft-screen-questionnaire (CSQ) - A validated screening instrument for health-related quality of life in cleft patients

BACKGROUND

The objective of this study is to develop and validate a specific screening instrument for assessing the quality of life (QoL) of patients with orofacial clefts. The Cleft-Screen-Questionnaire (CSQ) aims at identifying the main problematic areas and is intended for the routine use in everyday clinical practice to constantly evaluate the conditions' and treatments' effects on patients' well-being.

METHODS

First, a pool of 58 questions is created by collecting items from validated questionnaires previously used for assessing the QoL in cleft populations. After the removal of duplicate questions, the questionnaires are answered by 152 patients from a tertiary care center. A factor analysis followed by the calculation of Cronbach's alpha as a reliability measurement led to the final CSQ presented here.

RESULTS

The applied factor analysis resulted in five factors. Items showing low factor loadings (seen as <0.5) were excluded initially. Accordingly, factor analysis led to a preliminary number of 43 items. A reliability analysis using Cronbach's alpha and corrected alpha if item deleted showed an overall moderate to high reliability (seen as: 0.6-0.9). After excluding questions with increasing alphas if item deleted, analyses yielded in a final number of 38 questions.

CONCLUSION

The final 38-item CSQ is a reliable instrument for evaluating the health-related QoL of cleft patients.

The Impact of Social Determinants of Health in Facial and Craniomaxillofacial Reconstruction: Can We Do Better?

Social determinants of health (SDOH) are integral to consider when delivering craniomaxillofacial and facial reconstructive care for patients. The American Cleft Palate-Craniofacial Association (ACPA) has instituted a formalized multidisciplinary care team model that recognizes such determinants and has aggregated patient-led organizations to strengthen patients' education and support system. This review discusses the need for all surgeons engaged in facial and craniomaxillofacial reconstruction to consider SDOH in their practice. Additionally, we explore how factors such as race, insurance status, education level, cost, and access to follow-up care, impact surgical care for craniosynostosis, facial trauma, orthognathic surgery, head and neck cancer, and facial paralysis. We propose that the ACPA team model be applied to other societies that care for the broader scope of patients in need of facial and craniomaxillofacial reconstruction to strengthen the communication, collaboration, and standardization of care delivery that is personalized to the needs of each patient.

Expression Analysis of FGF/FGFR and FOX Family Proteins in Mucosal Tissue Obtained from Orofacial Cleft-Affected Children

Orofacial clefts affect hundreds of thousands of children worldwide annually and are usually corrected by a series of surgeries extending to childhood. The underlying mechanisms that lead to clefts are still unknown, mainly because of the multifactorial etiology and the myriad of interactions between genes and environmental factors. In the present study, we investigated the role and expression of candidate genes belonging to the FGF/FGFR signaling pathway and FOX family in tissue material obtained from 12 pediatric patients undergoing cleft correction surgery. The expression was investigated using immunohistochemistry (IHC) and chromogenic in-situ hybridization (CISH) in three cell/tissue types-epithelial cells, connective tissue, and endothelial cells. We found elevated expression of FGFR1 in epithelial cells while no expression was observed in endothelial cells. Further, our results elucidate the potential pathogenetic role of FGFR1 in cellular proliferation, local site inflammation, and fibrosis in cleft patients. Along with bFGF (also called FGF2), FGFR1 could play a pro-inflammatory role in clefts. Over-amplification of FGFR2 in some patients, along with bFGF, could potentially suggest roles for these genes in angiogenesis. Additionally, increased expression of FOXE1 (also called TTF2) contributes to local site inflammation. Finally, zero to low amplification of FOXO1 could suggest its potential role in inducing oxidative stress in the endothelium along with reduced epithelial apoptosis.

Psychosocial and socioeconomically aspects of mothers having a child with cleft lip and/or palate (CL/P): a pilot-study during the first year of life

Background

The emotional impact on parents at the birth of their new-born with cleft lip and/or palate (CL/P) can be traumatic for parents, especially mothers, and affect the sensitive early parent-child relationship. Unlike many other congenital malformations facial deformities are visible to all. The uncommon facial appearance creates feelings and reactions in the mother, families and other people. Only few studies deal with this psychosocial burden of these mothers.

Material and Methods

This pilot-study deals with mothers’ early experiences (n=84) having a child with CL/P. Mothers were asked to complete a questionnaire at diagnosis, birth and after lip surgery. The questions were focused on the social background of the mother (educational degree, marital status, lifestyle and prenatal care), the medical information at diagnosis and the following reaction. The surveys were administrated from 01/2014 – 12/2016.

Results

84 mothers of affected children (CL/P) replied the completed questionnaire (84/103, 81.5%). At diagnosis 65 mothers (77%) lived in a solid partnership and 44% worked full-time (40h). The diagnosis caused fear among the mothers (60.7%, p≤0.01), despair (27.4%, p≤0.01), grief (17.9%, p≤0.01) and guilt (16.7%, p≤0.01). Despite the emotional stress after the diagnosis only 5 mothers asked for psychological support (6.0%). The medical information by the gynecologist (41.6%) or maxillofacial surgeon (32.2%) was rated as “good” (n=26) or “very good” (n=26) in 60.2%. A lack of medical information and care was rated with “insufficient” (11.9%) or “poor” (14.3%).

Conclusions

There are only few studies about mothers’ early feelings and emotions having a child with a CL/P. We found high parental stress, physical and emotional strain among the mothers after diagnosis, mostly caused due to insufficient information’s. This stress was not correlated with the educational level and CLP appearance showed no relation about the socioeconomic status.

Key words:Cleft lip/palate, mother’s emotional experience, psychosocial aspects

A Qualitative Analysis of Factors Impacting Comprehensive Cleft Lip and Palate Care in Ghana

OBJECTIVE

The objective of this study was to examine practices regarding cleft lip and palate (CLP) among medical professionals and caregivers of children with CLP and to identify barriers and facilitators to comprehensive CLP care at a hospital in West Africa.

DESIGN

Qualitative methods used consisted of individual semistructured interviews with caregivers of children with CLP and one focus group with CLP team members.

SETTING

A majority of the interviews took place in the hospital, with some occurring during home visits. The focus group was conducted in the same hospital.

PARTICIPANTS

Forty-five caregivers of children with CLP and 1 adult with CLP completed an interview. Additionally, 2 of the caregivers had CLP and completed an interview from their perspective. The focus group consisted of 13 CLP team members from a comprehensive CLP team in Ghana.

INTERVENTIONS

Interviews consisted of semistructured, open-ended questions, and the focus group relied on a discussion guide. Line-by-line coding was used to identify common themes regarding barriers and facilitators to CLP care.

RESULTS

Barriers to CLP care that were consistent across caregiver interviews and the focus group were lack of knowledge regarding CLP, stigma and cultural beliefs surrounding CLP, transportation, financial, and feeding/nutrition issues. Barriers to care identified in the interviews and focus group were similar; however, facilitators to care varied greatly between the 2.

CONCLUSIONS

Two different qualitative methods provided unique perspectives on barriers and facilitators to CLP care. However, patients and caregivers continue to face substantial barriers to obtaining care.

Cleft of lip and palate: A review

Cleft of lip and palate are most common serial congenital anomalies to affect the orofacial region . It can occur isolated or together in various combination and/or along with other congenital deformities particularly congenital heart diseases. .Patient with oro-facial cleft deformity needs to be treated at right time and at right age to achieve functional and esthetic well being. Successful management of the child born with a cleft lip and palate requires coordinated care provided by a number of different specialties including oral/maxillofacial surgery, otolaryngology, genetics/dysmorphology, speech/language pathology, orthodontics, prosthodontics, and other. This article aims to the review the point primary care physicians in literature knowledge about cleft lip and palate. A review of literature have made to discuss introduction, epidemiology, clinical feature, etiology factor and management of cleft lip and palate.

Comparison of Microbial Activity Among Infants With or Without Using Presurgical Nasoalveolar Molding Appliance

PURPOSE

The aim of the current study is as follows: (1) to study whether wearing the presurgical nasoalveolar molding appliance (PNAM) had facilitated the establishment of Streptococcus mutans and Lactobacillus (LB) and to determine other factors including pH and caries susceptibility associated with wearing the PNAM.

METHODS

Saliva samples of 61 infants (4.5 ± 2.06 months old) were collected from the following 3 groups: PNAM (n = 23), healthy (n = 30), and cleft lip and palate (CLP) without any treatment (n = 8). Saliva samples were assessed using selective agar to enumerate total LB and S mutans and subjected to adenosine triphosphate (ATP)-driven bioluminescence determinations using a luciferin-based assay system, and pH level was evaluated. One-way analysis of variance with least significant difference post hoc test (P < .05) and Pearson correlation were used to evaluate S mutans, LB, pH, and ATP levels.

RESULTS

A total of 63 patients (30 healthy patients, 23 patients with cleft lip/palate who had PNAM appliance and 8 patients with cleft lip/palate who did not use the appliance) were seen in this study. There is a significant difference in pH (P = .012), LB Caries Risk Test (P < .001), LB colony count (P < .001), S mutans Caries Risk Test (P < .001), and S mutans colony count (P < .001) among the 3 groups (PNAM > CLP > healthy). The ATP level was not significantly different among the 3 groups.

CONCLUSION

Higher bacterial count and lower pH were found in the PNAM group. Cleft lip and/or palate patients wearing the PNAM appliance are at higher risk for dental caries.

A qualitative study of children's quality of life in the context of living with cleft lip and palate

Background and objective

Quality-of-life measures have been expanded to help in assessing the physical and psychosocial effects of oral health. Although, in the case of children undergoing oral surgery, the oro-facial status is generally measured by studies, it is essential to carry out investigations into the level of quality of life (QoL) after surgery to assess the actual effect of these surgeries on children’s lives. Hence, our study is aimed at evaluating the QoL in these children.

Methods

The study was performed using qualitative content analysis method. Eighteen caregivers of 4–6 year old children with a history of unilateral cleft lip and palate participated in in-depth interviews about the children’s experiences with different problems affecting their daily lives. The results were divided into codes, sub-categories and categories through an inductive process in which the researchers moved from the specific to the general.

Result

A number of problems were identified, particularly insufficient functional and socio-emotional well-being including, difficulty in eating and speaking, dento-facial problems, shame, anxiety, insufficient peer interaction and dissatisfaction with their own appearance.

Conclusion

The most critical problems derived from the participants’ experiences were insufficient functional and socio-emotional well-being that contributed to the reduced QoL among these children. Long term multidisciplinary interventional strategies such as psycho-social supportive programs are required to improve the QoL of these children. These interventions should be considered from the early stages of treatment, or even early stages of diagnosis.

Predisposing Factors to Dental Caries in Children with Cleft Lip and Palate: A Review and Strategies for Early Prevention

Objective:

To review predisposing factors contributing to dental caries in patients with cleft lip, cleft palate, or both (CL/P).

Design:

Patients with CL/P have a higher susceptibility to caries compared with the population group without clefts. A review of the literature was undertaken to determine factors that could account for the compromised oral hygiene and the high caries prevalence in patients with CL/P.

Results:

After a literature review, modern strategies for the prevention of early childhood caries were developed and should be considered for integration into the overall management protocol of patients with CL/P.

Conclusions:

Preventive dental care is ever more so important in patients with CL/P compared with patients without clefts.

Presurgical cleft lip and palate orthopedics: an overview

Patients with cleft lip and/or palate go through a lifelong journey of multidisciplinary care, starting from before birth and extending until adulthood. Presurgical orthopedic (PSO) treatment is one of the earliest stages of this care plan. In this paper we provide a review of the PSO treatment. This review should help general and specialist dentists to better understand the cleft patient care path and to be able to answer patient queries more efficiently. The objectives of this paper were to review the basic principles of PSO treatment, the various types of techniques used in this therapy, and the protocol followed, and to critically evaluate the advantages and disadvantages of some of these techniques. In conclusion, we believe that PSO treatment, specifically nasoalveolar molding, does help to approximate the segments of the cleft maxilla and does reduce the intersegment space in readiness for the surgical closure of cleft sites. However, what we remain unable to prove equivocally at this point is whether the reduction in the dimensions of the cleft presurgically and the manipulation of the nasal complex benefit our patients in the long term.

Site-specific expression of gelatinolytic activity during morphogenesis of the secondary palate in the mouse embryo

Morphogenesis of the secondary palate in mammalian embryos involves two major events: first, reorientation of the two vertically oriented palatal shelves into a horizontal position above the tongue, and second, fusion of the two shelves at the midline. Genetic evidence in humans and mice indicates the involvement of matrix metalloproteinases (MMPs). As MMP expression patterns might differ from sites of activity, we used a recently developed highly sensitive in situ zymography technique to map gelatinolytic MMP activity in the developing mouse palate. At embryonic day 14.5 (E14.5), we detected strong gelatinolytic activity around the lateral epithelial folds of the nasopharyngeal cavity, which is generated as a consequence of palatal shelf elevation. Activity was concentrated in the basement membrane of the epithelial fold but extended into the adjacent mesenchyme, and increased in intensity with lateral outgrowth of the cavity at E15.5. Gelatinolytic activity at this site was not the consequence of epithelial fold formation, as it was also observed in Bmp7-deficient embryos where shelf elevation is delayed. In this case, gelatinolytic activity appeared in vertical shelves at the exact position where the epithelial fold will form during elevation. Mmp2 and Mmp14 (MT1-MMP), but not Mmp9 and Mmp13, mRNAs were expressed in the mesenchyme around the epithelial folds of the elevated palatal shelves; this was confirmed by immunostaining for MMP-2 and MT1-MMP. Weak gelatinolytic activity was also found at the midline of E14.5 palatal shelves, which increased during fusion at E15.5. Whereas MMPs have been implicated in palatal fusion before, this is the first report showing that gelatinases might contribute to tissue remodeling during early stages of palatal shelf elevation and formation of the nasopharynx.

Dental and oral hygiene status in Jordanian children with cleft lip and palate: a comparison between unilateral and bilateral clefts

OBJECTIVES

The purpose of this study was to assess and compare the dental health and oral hygiene status of subjects with unilateral and bilateral cleft lip and palate (BCLP).

METHODS

Oral and dental examinations were carried out in 98 children with cleft lip and palate and 98 unaffected subjects matching in gender and age, using the standard dental indices dmft and DMFT. Plaque and gingival indices were scored using the plaque and gingival indices of Silness and Löe.

RESULTS

The prevalence of dental caries was significantly higher in children with cleft lip and palate than their control in both permanent and deciduous teeth. Patients with BCLP experienced more dental caries than unilateral cleft lip and palate (UCLP) patients in both dentitions. Similarly, plaque accumulation and gingivitis were significantly higher in the cleft lip and palate patients compared with their controls. Only plaque accumulation was significantly higher in the BCLP patients than in the UCLP patients.

CONCLUSION

Bilateral cleft lip and palate patients appear to be at a higher risk of caries experience and poorer in oral hygiene than those with UCLP patients. These findings not only provide a baseline for oral health parameters in patients with cleft lip and palate but also emphasize the need for intensive preventive measures of oral disease to optimize clinical outcome.

Primary care physician experience with children with oral clefts in three states

BACKGROUND

The experience of primary care physicians in Arkansas, Iowa, and New York treating children with oral clefts (OCs) was investigated, along with their knowledge and comfort caring for or referring these children.

METHODS

A mail survey was conducted with all primary care physicians in Iowa and Arkansas, and a random sample of 4000 physicians in New York, selected from the American Medical Association (AMA) Master File. The final dataset consisted of 1435 usable surveys. Outcome measures were experience and comfort providing care to or referring children with OC. Differences between states were tested using Pearson or Kruskal-Wallis chi-square tests, or F-tests for differences in means.

RESULTS

Two-thirds of respondents had provided care to a child with an OC since completing residency. Physicians were most comfortable providing routine care and much less comfortable providing counseling on cleft-related issues. Eighty percent had an organized cleft team to which they could refer. About two-thirds were very comfortable with the expertise available for surgical care, speech, and hearing; half were for dental care; only 40% were for behavioral or emotional counseling. Two-thirds were interested in continuing medical education (CME) on cleft care.

CONCLUSIONS

Primary care physicians in all three states had little experience with children with OCs. This limited experience poses significant barriers to care. Increased experience during training and CME opportunities could improve knowledge and comfort with providing OC-related care. Increasing knowledge of referral options for team care and other cleft-related services could also help physicians when caring for children with OCs.

Interdisciplinary craniofacial teams compared with individual providers: is orofacial cleft care more comprehensive and do parents perceive better outcomes?

OBJECTIVE

The primary objective was to examine whether children with orofacial clefts received more comprehensive care and whether their parents perceived better outcomes if the care was delivered by interdisciplinary teams compared with individual providers.

DESIGN

Data about services received and outcomes were collected from mothers of children with orofacial clefts.

PARTICIPANTS

Mothers of children born between 1998 and 2003 with orofacial clefts from Arkansas, Iowa, and New York who participated in the National Birth Defects Prevention Study were eligible.

MAIN OUTCOME MEASURE(S)

Services and treatments received and maternal perception of cleft care, health status, aesthetics, and speech were evaluated by team care status.

RESULTS

Of 253 children, 24% were not receiving team care. Of those with cleft lip and palate, 86% were enrolled in team care. Compared with children with team care, those without had fewer surgeries and were less likely to have seen a dentist, received a hearing test, or had a genetic consultation. Mothers of children lacking team care were twice as likely to give lower ratings for overall cleft care; maternal perceptions of global health, facial appearance, and speech did not differ by team care status.

CONCLUSIONS

Recommended care tended to be received more often among those with team care. A larger, longitudinal study might answer questions about whether team care provides the best care and the role that type and severity of the condition and racial/ethnic differences play in the services received and outcomes experienced.

Salivary analysis and antioxidants in cleft lip and palate children

OBJECTIVE

To investigate the sialometry, sialochemistry and antioxidants in cleft patients prior to alveolar closure procedures.

DESIGN

Saliva was collected from 21 children with unilateral and bilateral cleft lip and palate (UCLP and BCLP) with overt oronasal alveolar communication and with recurrent licking of fluids and soft diet complaints (the study group) and in 22 normal individuals (the control group). Salivary flow rate was measured, and calcium (Ca), phosphate (P), magnesium (Mg), total protein, albumin, amylase, lactate dehydrogenase (LDH), and secretory IgA were analysed. Salivary total antioxidant status (TAS), peroxidase activity, superoxide dismutase (SOD) activity, uric acid (UA), was also determined.

RESULTS

The sialometry and sialochemistry analyses did not reveal significant difference between the two groups. Salivary median uric acid concentration was 6-fold lower in the cleft group (p<0.05). The median total antioxidant status (TAS) of the cleft group however, was significantly higher by 58% (p<0.005) than that of the control group. Median SOD activity was also higher in the cleft group, by 42%, though these differences did not reach statistical significance.

CONCLUSIONS

Our findings suggest that the oral biology system of cleft patients in their prealveolar closure stage does not differ significantly from normal controls. Low UA found in the saliva of cleft patients may suggest that some genetic alteration of the UA transport occurs simultaneously when cleft lip and palate occur. TAS reduction may also reveal an increased oxidative stress burden in the oral cavities of cleft children which has never been shown before.

A mutation in RYK is a genetic factor for nonsyndromic cleft lip and palate

OBJECTIVE

The RYK, EPHB2, and EPHB3 genes are attractive candidates for cleft lip and/or palate and cleft palate only pathogenesis. Both the Ryk-deficient mouse and Ephb2/Ephb3 (genes for interaction molecules with RYK) double-mutant mouse show cleft palate.

SETTING

Mutation searches for RYK, EPHB2, and EPHB3 were carried out in a large number of Japanese and Vietnamese patients with cleft lip and/or palate and cleft palate only. Case-control study and transmission disequilibrium tests were performed also, using three single nucleotide polymorphisms within a linkage disequilibrium block in RYK. Seven haplotypes were constructed from the single nucleotide polymorphisms.

RESULTS

A missense mutation, 1355G>A (Y452C), in RYK was identified in one Vietnamese patient with cleft lip and/or palate. This mutation was not found among 1646 Vietnamese, Japanese, and Caucasians, including 354 cleft lip and/ or palate and cleft palate only patients. Colony formation assay using NIH3T3 cells transfected with mutant cDNA revealed that mutant RYK had significantly reduced protein activity, compared with those with wild-type RYK, implying that the transformation ability of RYK is depleted by this mutation. Although a case-control study and transmission disequilibrium tests on three individual single nucleotide polymorphisms provided no evidence for association with oral clefts, a case-control study on one rare haplotype suggested a positive association in Japanese patients with cleft lip and/or palate and cleft palate only. No mutations in EPHB2 and EPHB3 were found in any patients examined.

CONCLUSION

The findings suggested that a missense mutation, 1355G>A, and one rare single nucleotide polymorphisms haplotype may play a role in the development of cleft lip and/or palate in the Vietnamese, and cleft lip and/ or palate and cleft palate only in the Japanese.

Transforming growth factor-beta3 promotes mesenchymal cell proliferation and angiogenesis mediated by the enhancement of cyclin D1, Flk-1, and CD31 gene expression during CL/Fr mouse lip fusion

BACKGROUND

Cleft lip with or without cleft palate is the most common congenital anomaly in the craniofacial region. Knowledge of the molecular mechanisms behind normal lip fusion can contribute to better intervention and improved functional clinical outcome. Transforming growth factor-beta3 (TGF-beta3) has been implicated in lip morphogenesis. Therefore, we hypothesized that TGF-beta3 functions during lip fusion through regulation of angiogenesis and mesenchymal cell cycle progression during early developmental stages.

METHODS

To test this hypothesis we used the CL/Fraser mouse model, which has a high incidence of cleft lip. Lips isolated from embryonic day (ED) 11.5 mouse embryos were allowed to develop in serum-free organ cultures in the presence or absence of TGF-beta3. The lips that developed in these cultures fused in 2 days.

RESULTS

During normal development, we detected positive immunoreactions for TGF-beta3 at the site of fusion. We also detected mesenchymal cells that were immunopositive for Flk-1 and CD31, which are markers for endothelial cell precursors. Exogenous TGF-beta3 accelerated lip fusion in culture. This enhancement was associated with an increase in the number of capillary blood vessels in the lips cultured in the presence of TGF-beta3, in comparison with controls. In tandem, TGF-beta3 increased the level of expression of both Flk-1 and CD31. Our data suggest that an elevated level of TGF-beta3 may promote angiogenesis in developing lips that is mediated by increased Flk-1 and CD31 expression. We also detected increased cyclin D1 expression (a marker for cell proliferation) in the presence of TGF-beta3, which suggests that TGF-beta3 promoted cell proliferation.

CONCLUSIONS

TGF-beta3 promoted cell proliferation and angiogenesis in lip mesenchymal tissues. These events led to enhanced lip fusion in the presence of TGF-beta3.

Chondroitin sulfate in palatal wound healing

Chondroitin sulfate is up-regulated in granulation tissue during wound healing. To investigate the role of chondroitin sulfate in the wound-healing process after surgical repair of cleft palate, we isolated and cultured rabbit palatal fibroblasts. Treatment with chondroitin-6-sulfate resulted in a dose-dependent increase in cell adhesion and cell proliferation, whereas the reverse effects were seen after chondroitinase degradation of chondroitin sulfate. The biological actions of chondroitin sulfate appeared to be dependent on the presence and position of sulfate groups. Inhibition of glycosaminoglycan sulfation by chlorate treatment led to reduced cell adhesion and cell proliferation and a slower rate of wound closure in vitro. Furthermore, exposure to chondroitin-4-sulfate resulted in a dose-dependent reduction in cell adhesion. Together, these results show that chondroitin sulfate is involved in palatal wound healing.

TGF-beta-3 promotes scarless repair of cleft lip in mouse fetuses

TGF-beta3 mediates epithelial-mesenchymal transformation during normal fusion of lip and palate, but how TGF-beta3 functions during cleft lip repair remains unexplored. We hypothesize that TGF-beta3 promotes fetal cleft lip repair and fusion by increasing the availability of mesenchymal cells. In this investigation, we demonstrated that cleft lips in mouse fetuses were repaired by fetal surgery, producing scarless fusion. At the site of the operation, we first observed an infusion of platelets expressing TGF-beta3, followed by increased expression of cyclin D1 and tenascin-C, and coupled with increased mesenchymal cell proliferation. In an ex vivo serumless culture system, cleft lip explants fused in the presence of exogenous TGF-beta3. Cultured lips also showed up-regulation in cyclin D1 and tenascin-C expression. These findings suggest that microsurgical repair of cleft lip in the fetus that produced scarless fusion is mediated by TGF-beta3 regulation of mesenchymal cell proliferation and migration at the site of repair.