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A Wide and Healthy Smile
   By Iris H. Sageser RDH MS

Most parents are concerned about their children having a healthy mouth that is free of cavities and gum disease. For parents of cleft lip/palate children, this dental concern is shared but perhaps to a greater extent. These children have undergone lip and/or palatal surgeries that are usually followed later with extensive dental and orthodontic treatment. The child's oral hygiene becomes an important health factor in the overall treatment of cleft lip and palate.

How do the oral hygiene needs of children with cleft lip/palate differ from other children? This question was presented to Dr. Delmar Halak, pediatric dentist in Cincinnati, Ohio, who has treated craniofacial children for over 30 years. Dr. Halak is also a member of the Craniofacial Anomaly Team at Children's Hospital Medical Center.

Dr. Halak says, "Many parents are overwhelmed by the lip and palatal surgeries required in the baby's early life. As the baby begins to erupt teeth, the parents may need encouragement to keep those teeth clean. Sometimes parents overlook the teeth because they are a minor concern compared to the major surgical procedures done."

Dr. Halak explains that tooth-brushing may seem insignificant in comparison to other treatments a child is receiving, but actually it's very important. For the child with cleft lip/palate, good maintenance of teeth is essential not only for dental development, but also for speech.

Dr. Halak offers parents of an infant or toddler the option of using a toothette rather than a toothbrush for cleaning a few teeth. A toothette is a soft sponge containing mouthwash that is on a lollipop-type handle. Parents can use the toothette to swab plaque off the child's teeth. (Inquire about toothettes from your dentist or a store that sells home nursing products.) Dr. Halak also recommends a small soft child's toothbrush.

"Most parents think that their children can brush for themselves after three years of age." cautions Dr. Halak. "However, young children don't have the manual dexterity yet to brush well. Often they will brush the front teeth  only." Dr. Halak suggests letting the child brush himself first to get into a daily habit, but a parent should supervise their child's tooth brushing until at least age 6.

"Parents often tell me that it is difficult to brush their child's teeth well" comments Dr. Halak. "The child is moving around and the parent cannot maneuver the brush easily." Dr. Halak recommends that parents sit in a chair and position the child standing between the legs with his back to the parent. This way the child's body can rest against the parent that the parent can brush the teeth in a position they are used to brushing. It is much more difficult for parents to brush while facing the child, especially if he is active.

Dr. Halak continues, "I also tell parents that the brushing of teeth to remove plaque and food is a more important action than using toothpaste. Kids often don't like toothpaste much. It is better to use only a small amount of paste or brush only with water."

Flossing the teeth is a routine that Dr. Halak suggests parents begin when the six year molars have erupted.  Parents need to floss the child's teeth and demonstrate flossing techniques to the older child.

Most children with clefts experience orthodontic appliances and braces for several years. During these treatment phases the child will encounter more oral hygiene problems. Crowded and malaligned teeth are areas that are more difficult to brush. An appliance or braces traps food and plaque around the teeth. Dr. Halak offers two tips for his patients.

"I suggest to parents that they invest in an oral water irrigator such as Waterpik. The irrigator does a good job cleaning around appliances and braces by flushing food out. I stress, however, that the irrigator is NOT a substitute for tooth brushing." warns Dr. Halak.

He continues, "For children in braces, I recommend an orthodontic toothbrush that has grooved bristles. These bristles allow contact with the teeth above and below the braces. Using a regular toothbrush works well also, but the kids need to give special brushing attention to the gums and brackets. Directing the bristles in different angles is necessary to thoroughly clean the gums and braces."

Dr. Halak points out that for many children with a cleft there is a psychological component in their oral hygiene care. Some children don't feel personally good about their mouths. Others don't like things done to their mouths, especially after all the treatment they've experienced.

"I try to encourage these kids that good dental hygiene will benefit them. They will look better with clean teeth, which in turn means a healthy mouth," says Dr. Halak. "Adolescents are particularly difficult to motivate. Their hygiene deteriorates because they are too busy to brush and floss. At the same time, they are conscious about looking clean and attractive to the opposite sex. I stress that teeth that are well cared for do much to improve appearance."

Dr. Halak feels that the oral hygiene for most children with a cleft could be improved. Both parents and the dentist or orthodontist need to encourage better hygiene habits. Dr. Halak admits, "Perhaps the dentist doesn't stress enough the importance of good hygiene because he is focused more on the actual dental problems and treatment needed. I find myself more concerned about a patient's rotated tooth or crossbite and how I am going to treat it." That is why Dr. Halak implores parents to help their children maintain a healthy mouth. A healthy mouth contributes to a healthier and happier child!

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