CASE REPORT ARTICLE

 

Outpatient dental treatment under general anesthesia in children with cleft lip palate: case report

 

 

Ana Clara Suplicy Diogo Santos^I; Kimberlly Tennylle Vonsovicz^I; Sheila de Carvalho Stroppa^I; Juliana Yassue Barbosa da Silva^I

 

^I Department of Dentistry, Positivo University – Curitiba – PR – Brazil

 

Correspondence

 

 

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ABSTRACT

Introduction: This study aimed to report the case of an eight-year-old patient with cleft lip and palate associated with undiagnosed syndrome presenting high level of carious lesions, difficulty on oral hygiene, no collaborative behavior and cariogenic diet. Case report: The patient underwent outpatient treatment for dental extraction and Atraumatic Restorative Treatment. Later at the following-up appointment, the child presented new active white spots and fractured restorations. Then, dental treatment under general anesthesia for amalgam restorations was indicated. Conclusion: We conclude that dental care under general anesthesia was an alternative treatment for the reported child in this clinical case that had a high prevalence of caries, cariogenic diet, loss of lip elasticity due to corrective surgeries, difficult access for oral hygiene and caregiver's fear to toothbrush near to the cleft.

Keywords: Dentistry; children; general anesthesia.

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Introduction

Cleft lip and palate (CLP)'s etiology occurs in intrauterine life. Many of cleft cases are related to multifactorial inheritance ^12,15,25. CLP can be caused by environmental factors such as use of alcohol, drugs, malnutrition, and ionizing radiation during pregnancy; a minor part is linked to a gene and/or altered chromosome ¹⁵. CLP causes various functional difficulties and can affect speech, hearing, nutrition, and aesthetic and psychological problems, such as social integration. According to the severity of the cleft, is must have a multidisciplinary approach with speech therapy, psychology, dentistry, and different surgical interventions ¹³.

The clefts are divided into two groups according to their etiology: cleft lip or cleft lip and palate. As for cleft lip, at the seventh week of intrauterine life no fusion occurs between the frontal prominence and nasal processes with the maxillary process. Cleft palate occurs when there is no fusion of the bilateral processes in the midline, around the 12th week of embryonic development ²⁹.

According to Spina et al. ³⁰, clefts are classified according to their relationship with the incisive foramen, as follows: complete or incomplete pre-foramen incisive - when it is located before the foramen, but without going over it; transforamen incisive – the cleft surpasses the incisive foramen, affecting lip, alveolar ridge and palate complete or incomplete; post foramen incisive is located posterior to the incisive foramen. Both pre-foramen incisive and the transforamen incisive clefts can still be classified as unilateral, bilateral, and median. Furthermore, there are also rare facial clefts. Studies show the prevalence of cleft lip or cleft lip and palate in males, while cleft palate occurs more frequently in females ⁸.

Regarding the oral health of the individual with CLP, regardless of the type of cleft, there is greater risk of dental caries, periodontal disease, and malocclusion ^3,19,35. According to Dahllof et al. ¹⁴ and Hewson et al. ¹⁶, children with oral clefts have 3.5 times more surfaces of decayed teeth than children without clefts, more likely evident in primary teeth.

This fact is related to the presence of mutans microorganisms transmitted vertically from mother to child ^7,9,20,23, because of the close contact with the child's food and affection demonstrations, like kiss on the lips ³³. Furthermore, Wan et al. ³³ attribute the increased risk to oral disease among individuals with cleft lip and palate to the anatomy of the region, time and frequency of carbohydrate intake in combination with the lack of education of parents in diet and oral hygiene habits ^2,31. There are also factors such as lack of information about the correct way of brushing in infants and children with clefts, trauma to administer the region affected by the cleft, difficult access around this area, decreased lip elasticity of the surgically repaired region, anatomy changed, and fear of intervention in the fissured region ¹⁴.

Children with clefts have difficulty of gaining weight, so parents are encouraged to offer food more often, thus leading to an accumulation of food debris in the mouth ¹⁰. Some parents tend to make up for the up children's health by providing a diet that most pleases them ¹⁸. In addition, some caregivers fail to understand the importance of oral care to avoid caries disease because they believe that surgical treatment is the most important, which ends up compromising the success of the treatment as a whole ¹⁰. They end up leaving the oral health at the lower end on the scale of priorities and do not give due attention ¹¹. Bokhout et al. ⁶ reported that the highest rate of poor oral hygiene came from lower socioeconomic families as the highest socioeconomic class families followed the best recommendations on hygiene and more restricted sucrose consumption. There are several factors after reconstructive surgery that may act as obstacles to effective oral hygiene, making the children most likely to decay, such as remaining tissue, scar retraction, dental anomalies and persistent fistulas ^11,20.

 

Case report

An 8-year-old boy, GAD, was referred to Center for Cleft Lip and Palate (CAIF/AFISSUR) at two months of age without previous treatment. The boy had unilateral complete preforamen incisive cleft, congenital cardiomyopathy with small ventricular septal defect, mild pulmonary valve stenosis with a syndrome without defined diagnosis. He was unable to perform breastfeeding, so bottle feeding with artificial milk was prescribed. The boy was submitted to the corrective lip surgery at 1 year and 4 months-old, when he started to attend the Pediatric Dentistry Sector. At that moment, the mother was instructed regarding diet and oral hygiene. The boy already had a cariogenic diet rich in carbohydrates and used baby bottle with powdered milk (Ninho and Farinha Láctea, Nestlè) and milk flour before sleeping. The mother reported difficult in performing oral hygiene with toothbrush and she used gauze. The mother studied up to 8th grade of elementary school and the father up to 7th grade of elementary school, the family income was from 2 to three minimum wages.

The boy frequently attended the Pediatric Dentistry Sector receiving instruction on preventive oral care. Notwithstanding, the boy showed carious lesions that were properly restored. At 5 years-old, he still used baby bottle and the mother still reported difficult in oral hygiene due to the boy's lack of compliance. Accordingly, the boy was submitted to restorative and preventive dental treatment under general anesthesia. Then, the boy continued undergoing preventive following-up treatment.

At the beginning of 2015, the boy returned to the institution for following-up appointment and the difficult to perform oral hygiene was still present associated with the cariogenic diet and poor compliance. At clinical examination, new carious lesions were diagnosed and a new treatment was started.

After the reading and signing of the Free and Clarified Consent Form, the child was submitted to physical restraint aiming at his safe, and at assuring the treatment quality, due to his noncooperative behavior (figure 1).

 

 

 

The tooth #64 showed endodontic fistula and deep large dentin carious lesion (figure 2), and thus extraction was indicated because of the impossibility of performing the radiographic examination due to noncompliance and impossibility to restore the tooth.

 

 

 

We performed the Atraumatic Restorative Treatment (ART) on teeth: #55 (occlusal surface), #54 (distal-occlusal surface); #61 (labial-mesialpalatal surface); #65 (occlusal surface), through removing the infected dentin and keeping the affected dentin followed by the restoration with conventional glass ionomer cement (GIC) (Fuji®). The child was submitted to dental prophylaxis with Robinson brush and sealant with glass ionomer cement (Fuji®) on teeth #16 and #26 (occlusal surfaces).

Also, we instructed the parents regarding oral hygiene (figure 3) with the aid of plaque disclosing solution (Replak®), followed by tooth brushing (figure 4), and application of fluoride varnish (Fluorniz®) on all teeth (figure 5).

 

 

 

 

 

 

 

After 3 months, the patient was reassessed to control oral health. The mother could not perform oral hygiene and cariogenic diet continued. At clinical examination, some GIC restorations fractured and the child had active white spots on other teeth (figures 6, 7, and 8). Furthermore, the mother reported that the boy should undergo a diet due to overweight.

Considering that, the treatment planning comprised dental treatment under general anesthesia at a hospital setting through nasal intubation (figure 9) to provide adequate space for dental treatment.

 

 

 

 

 

 

 

 

 

To prevent bacterial endocarditis, we prescribed antibiotic prophylaxis. Firstly, dental prophylaxis with Robinson brush and saline solution was executed to remove the plaque. Then, local anesthesia with mepivacaine + adrenalin 1:100.000 was applied aiming to obtain the vasoconstriction of the tissue surrounding tooth #74 prior to the extraction because of the carious lesion on occlusal, distal, lingual surfaces.

Amalgam restorations (Permite SDI®) were carried out on teeth: #55 (mesial-occlusal-distalpalatal), #54 (occlusal-distal, with GIC liner), #65 (occlusal-palatal), #75 (occlusal-buccal), because the GIC restorations had fractured and/or showed marginal leakage. Resin composite restoration (Charisma®) shade A1 was performed on tooth #52 (mesial-labial-palatal).

Tooth #46 received GIC sealant, and teeth #62 (labial), #61 (labial-mesial-palatal), and 85 (lingual) received GIC restorations. Because active white spots were present on teeth #73, #83, and #46, we applied f luoride varnish under dental anesthesia and the subsequent applications would be executed in dental chair. The other teeth also received f luoride varnish (figure 10). The finishing and polishing procedures were executed at outpatient setting.

 

 

 

Discussion

In this case report, the child had cleft lip and palate and high caries activity at mixed dentition, agreeing with the studies of Dahllof et al. ¹⁴ and Hewson et al. ¹⁶, who reported a higher caries incidence in children with cleft lip and palate with deciduous teeth. On the other hand, the studies on permanent dentition evaluate and compare the caries prevalence in individuals with and without CLP. Lauterstein and Mendelsohn ²², Lucas et al. ²⁴, and Hewson et al. ¹⁶ did not observed significant difference in the caries prevalence of these two groups. But, other studies ^1,4,6,14,18 found greater risk for individuals with CLP.

Cheng et al.¹¹ noted that there are many factors that can contribute to the emergence of caries in primary teeth of children with CLP, such as difficulty of oral hygiene done by their caregivers, fear of hurting the area of the cleft, difficult access to the toothbrush near the cleft, because it is a sensitive area or even because some children have associated syndromes as in this case report, the patient is not collaborative, and the mother has difficulty in performing oral hygiene. According to Johnsen and Dixon ¹⁸ and Bokhout et al. ⁵, there is a higher percentage of dental caries in children with bilateral cleft lip and palate than in those with unilateral clefts. Moreover, the authors also observed a greater prevalence in the teeth adjacent to the cleft and the first permanent molar because of hypoplastic enamel defects, resulting in a rough surface facilitating the adhesion and colonization of cariogenic bacteria. The anterior teeth may have greater accumulation of plaque in individuals with cleft lip and palate, as they have lower lip elasticity due to the surgical repair, in addition to brushing fear in the cleft region ¹⁴. Concerning to oral hygiene, may studies ^1,25,30,32 reported worst results in individuals with cleft lip and palate.

In this present clinical case, the child had cariogenic diet, with daily and frequent ingestion of carbohydrates, sucrose, bottle feeding until 5 years of age. According to Ahluwalia et al. ¹, sugars are fermented from starch intake and cause the appearance of tooth decay. The presence of cleft palate promotes food impaction, causing the food cake escapes to the nose and is regurgitated to the mouth, increasing the risk of caries because food is available for a longer time in the oral cavity for bacteria ¹¹.

The family of this case report had low socioeconomic status, agreeing with the study of Bokhout et al. ⁶, who reported that children with clefts, with poor oral hygiene, and cariogenic diet were from families with monthly low income. The authors believe that families with higher incomes followed better the recommendations and restricted the consumption of cariogenic foods high in sucrose.

Johnsen ¹⁷ found that parents of children with clefts tend to abuse cariogenic diets to promote a form of satisfaction, because of the child's medical condition. Johnsen and Dixon ¹⁸ reported that the pattern of caries in children with clefts was similar to early childhood caries.

The study conducted by Saldunaite . et al. ²⁸, in Lithuania, concluded that the socioeconomic level and parental education has an influence on the prevalence of dental caries in children and had direct relation to the degree of concern that parents had in relation to oral hygiene of children. Accordingly, in the case reported herein, the mother studied up to 8th grade of elementary school, the father until the 7th grade and the family income was two to three minimum wages.

According to Roberts et al. ²⁷, the initial attempts to manage the behavior of children involve some basic techniques as communicative orientat ion, say-show-and-do, voice control, nonverbal communication, positive reinforcement, distraction, the presence or absence of parents and administration of nitrous/oxygen oxide. When these approaches are not capable of providing adequate treatment, advanced techniques can be applied, involving physical restraint, sedation, and general anesthesia ²⁷.

As the child of this report presents intellectual disability and no collaborative behavior, we opted for the hospital dental treatment. According to Bengtson et al. ⁴, the general anesthesia, when properly used by professionals, reduces the risk of procedures and promotes the well-being of the patient and the work team.

For dental treatment under general anesthesia in children, both the hospital and the presence of an anesthesiologist during the procedure are required to check whether the patient is still unconscious and in the absence of anxiety, thus allowing dental treatment ⁴.

 

Conclusion

The case reported herein showed the failure of the outpatient treatment because of the great difficulty of the mother to perform oral hygiene, the lack of cooperation of the child, and the cariogenic diet. Thus, the treatment option with the best prognosis was planned for the hospital setting under general anesthesia, in which it can perform all the necessary procedures in the most effective way for the rehabilitation treatment of the child.

 

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Corresponding author:
Juliana Yassue Barbosa da Silva
Rua Professor Pedro Viriato Parigot de Souza, 5.300
Campo Comprido
CEP 81280-330
Curitiba – PR – Brasil
E-mail: juyassue@hotmail.com

 

 

Received for publication: February 12, 2016
Accepted for publication: March 23, 2016