The Oral Health of Children with CleftsA Review

FANNY W. L. WONG, B.D.S., M.D.S.

NIGEL M. KING, B.D.S., M.SC., PH.D., F.H.K.A.M., L.D.S.R.C.S.
A review of the studies of the caries prevalence and periodontal health of
patients with cleft lip and palate (CLP) revealed that only five investigations of
caries prevalence in CLP patients included children. One reported that CLP
children did not have a higher caries prevalence in the permanent dentition,
whereas more recent studies have reported a higher caries prevalence in both
the primary and permanent dentitions of CLP children than in those of noncleft
children. However, there is wide variation in the teeth examined and the method of presenting data on caries prevalence. Six papers have reported on the
periodontal health of adult CLP patients, and only one has done so on that of
children. The adult CLP patients had poorer oral hygiene and more gingivitis,
but there is no conclusive evidence that they have a higher risk of developing
periodontal disease. No data on the oral hygiene of CLP children were available, but it has been emphasized that they have significantly more gingivitis
than noncleft children, especially in the maxillary anterior teeth.
KEY WORDS: caries, cleft, CLP, gingivitis, periodontal disease

People who have a cleft lip and/or palate (CLP) experience

cosmetic, speech, hearing, and dental problems. A multidisciplinary approach to their management has become more prevalent in recent years (Semb et al., 1990) and is now the accepted approach. Although it has been said that the basic cleft
team should include a plastic surgeon, a pediatrician, a pedodontist, an orthodontist, a speech pathologist, a psychologist,
an otolaryngologist, and a social worker (Shah and Wong,
1980), there are many other specialists who can be valuable
members of a team, such as an oral and maxillofacial surgeon,
an allergist, a psychiatrist, an audiologist, a prosthodontist, and
a sociologist.
The high prevalence and severity of malocclusion among
CLP subjects has been well documented (Mazaheri et al.,
1971; Bergland and Shidu, 1974; Ross, 1975; Hall, 1976). The
malocclusion problem in Chinese subjects has been shown to
manifest itself in the primary dentition or early in the transitional dentition (Tang and So, 1992). It has often been speculated that the irregularity of the teeth results in a higher frequency of caries in CLP children than in normal children
(Shah and Wong, 1980). Regular dental care, both preventive
and therapeutic, needs to be implemented during childhood to
minimize morbidity due to the loss of teeth (King et al., 1996).
As a member of a cleft team, the pediatric dentist has the
major responsibility to prevent dental disease and to monitor
eruption of the teeth. The other members of the cleft team must

also be informed about the growth and development of the

dentition so as to facilitate future treatment planning. Therefore, consideration should be given to the question, How
much do we really know about the oral health of children with
CLP? Hence, the objective of this paper is to review the
published data on the oral health of adults and, when available,
children with CLP.
DENTAL CARIES
Although the prevalence of dental caries in different communities around the world is decreasing, it is not yet extinct
(Bowen, 1991), and it has been found to be higher in certain
high-risk groups (Winter 1988; Leverett et al., 1993a; 1993b).
Only a small number of studies have been conducted to determine the prevalence of caries in CLP children.
In a pioneering study that was performed on the permanent
dentition of CLP children, Lausterstein and Mendelsohn
(1964) reported that the caries experience of these children did
not differ markedly from that of normal children. However,
this finding was subsequently contradicted by a study conducted in Japan, where CLP children were found to have a
higher caries prevalence in the permanent dentition than normal children (Ishida et al., 1989). Studies of the caries experience in the primary dentition of CLP children have also revealed that these children had a higher caries prevalence than
did unaffected children (Johnsen and Dixon, 1984; Dahllof et
al., 1989; Ishida et al., 1989).

Dr. Wong is Dental Officer, Department of Health, Hong Kong Government,

Hong Kong. Dr. King is Professor, Faculty of Dentistry, University of Hong
Kong, Hong Kong.
Submitted April 1997; Accepted November 1997.
Reprint requests: Professor Nigel M. King, Faculty of Dentistry, Prince Philip
Dental Hospital, 34 Hospital Road, Hong Kong.

Sample Sizes
Although CLP is one of the most common congenital anomalies, its prevalence is reported to range only from 0.91 to 2.69
248

Wong and King, LITERATURE ON THE ORAL HEALTH OF CLP

per 1000 in Caucasians and from 0.85 to 2.68 per 1000 in

Japanese (Vanderas, 1987). Therefore, epidemiological studies
involving CLP subjects rarely have an adequate-sized sample
or a narrow enough age range to produce valid statistics. A
representative sample is especially important if dental caries is
being studied because of the multifactorial nature of the disease; furthermore, it varies with age and there are secular
trends. These limitations have been demonstrated in many published studies. Two studies had rather small samples (Stephen
and MacFadyen, 1977; Johnsen and Dixon, 1984). In two other
studies, although impressive sample sizes were constructed,
they included subjects with a wide age range (Lausterstein and
Mendelsohn, 1964; Ishida et al., 1989). This is inappropriate,
because caries prevalence is known to vary with age. In the
primary dentition, the effects are cumulative until about 7
years of age, after which the effects decline as the primary
teeth begin to exfoliate (Evans and Lo, 1992). Although the
sample size studied by Dahllof et al. (1989) was not impressive, the study was well structured because it included CLP
children who were only 5 to 6 years old. Ishida et al. (1989)
were aware of the importance of not only age but also of the
quality of data gathered. They subdivided their subjects into
2- to 5- and 6- to 14-year-old groups, which provided data for
both the primary dentition and the transitional and permanent
dentitions. They also indicated that the 2- to 5-year-old children were new patients who were examined over a 7-month
period, while the 6- to 14-year-old children were regular attenders, all of whom were examined within one month.
Most studies have attempted to pool all children into one
group, regardless of cleft type (Lausterstein and Mendelsohn,
1964; Stephen and MacFadyen, 1977; Johnsen and Dixon,
1984; Dahllof et al., 1989). One team of investigators even
stated that syndrome cases had been included (Dahllof et al.,
1989). Unfortunately, it was not stated whether this was done
in any of the other studies. It has been, and is still, common
practice to consider that children with different types of clefts,
with or without other malformations, are a homogenous group,
in spite of the fact that clefts are genetically heterogenous and
despite recommendations that data should be presented for specific cleft types whenever possible (Fraser, 1970). Each cleft
type should then be subdivided according to the presence or
absence of associated congenital malformations (Spry and Nugent, 1975). Furthermore, syndrome cases should be separated
from nonsyndrome cases (Bixler, 1981). The statistical lumping of all patients together has been criticized because it raises
suspicions about the results and their interpretation (Bernat,
1989). The problem encountered when subdividing a sample
into specific cleft types is the drastic reduction in the sample
size. In two studies, the investigators failed to mention whether
there was a difference in the caries experience of children with
different cleft types (Lausterstein and Mendelsohn, 1964;
Dahllof et al., 1989). However, their conclusion that cleft type
did not alter the caries experience is not convincing, because
in the study by Lausterstein and Mendelsohn (1964), the CLP
children were divided into five groups according to cleft type,
and the mean ages of these groups varied from 6.8 to 9.0 years

249

old. These groups were then analyzed using a one-way analysis of variance, which revealed no significant difference in
caries experience. Their conclusion is rather surprising, because caries is cumulative with age. Conversely, Ishida et al.
(1989) reported that the caries rate of 5-year-old CLP children
was highest in those with bilateral CLP (77%), followed by
those with unilateral CLP (64%), compared to 37% in the control group. Finally, the study by Dahllof et al. (1989) offered
no elaboration or explanation about the relationship between
caries and cleft type.
Control Groups
The use of an adequate-sized control group enhances the
validity of any conclusions. Patients chosen from pedodontic
practices as the control group can bias the outcome, because
it is probable that the children attended the practice for the
management of dental caries (Lausterstein and Mendelsohn,
1964). It is acceptable to compare the caries experience data
for a group of CLP subjects to values that have been gathered
from noncleft subjects in another study, provided that the data
are recent and the subjects are of similar ages. In Johnsen and
Dixons (1984) study, the data were compared to those for
patients with other craniofacial anomalies. The control group
was therefore even smaller than the CLP group, which itself
was small. Dahllof et al. (1989) raised the quality of the data
of their control group by using similar numbers of age- and
sex-matched children, while one study (Ishida et al., 1989)
tried to overcome the problem by using a larger number of
children of similar ages.
Other Factors Affecting Caries
Fluoride is a well-recognized and effective agent for preventing caries. Therefore, the fluoride history of the subjects
in a sample should be considered. Lausterstein and Mendelsohn (1964) mentioned that less than half of the CLP children
studied lived in a fluoridated region, whereas 80% of the control children had lived all of their lives in a fluoridated region.
They then concluded that the cleft did not influence the caries
experience. The fact that both groups had the same caries experience appears to indicate that the CLP subjects were naturally more resistant to caries than their noncleft counterparts,
the majority of whom had received the benefits of water fluoridation.
Caries is a multifactorial disease. In epidemiological studies
of caries in CLP subjects, it is difficult, if not impossible, to
eliminate other contributing factors and to truly evaluate the
effect of a cleft on the caries rate. It is tempting to use the
data for the mandibular teeth as a control and to compare them
with those for the maxillary teeth of the same subjects, thus
eliminating most of the other co-factors that can influence the
caries attack rate (Lausterstein and Mendelsohn, 1964). However, the caries susceptibility of teeth in normal subjects differs
according to the tooth type and whether they are maxillary or
mandibular teeth (Evans and Lo, 1992; Hicks and Flaitz, 1993;

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Cleft PalateCraniofacial Journal, May 1998, Vol. 35 No. 3

TABLE 1 Studies of the Caries Experience of Children with Cleft Lip and Palate (CLP)
Study Group
Author

Location

Source

Control Group
Age (years)

Source

Number

Age (years)

285

8.5 6 2.1
(mean)
1.54.0
(range)
5.08 6 1.56
(mean)

Pedodontic clinc
patients
Other craniofacial
defect patients
Hospital cleft patient (retrospective data)
Age- and sexmatched children
School children

300

962
(mean)
1.54.0
(range)
4.7 6 0.11
(mean)

Permanent

49

5.5
(mean)

Primary

642

214
(range)

Primary and
permanent

Lausterstein and
Mendelsohn (1964)
Johnsen and Dixon
(1984)
Stephen and MacFadyen (1977)*

U.S.A.

CLP group

U.S.A.

Hospital CLP
patients
Hospital CLP
patients

41

Dahllof et al. (1989)

Sweden

CLP children

49

5.5
(mean)

Ishida et al. (1989)

Japan

Bilateral and unilateral CLP

119

214
(range)

England

Dentition
Examined

Number

57

23
34

Primary incisors
Primary excluding
incisors

* Study of the effectiveness of a dental preventive program.

Published in Japanese.

Margolis et al., 1994). Thus, it is inappropriate to use the mandibular teeth of a CLP subject as a control for the maxillary
teeth.
In one study of bilateral and unilateral cleft subjects, the
data were compared by tooth type between the cleft and noncleft sides in CLP children, as well as with data for normal
children (Ishida et al., 1989). The caries attack rate on the cleft
side was greater than that on the noncleft side for the CLP
subjects, which in turn was greater than that for the noncleft
subjects. The pooling of data for the cleft side from bilateral
and unilateral cleft types relies on the assumption that clefts
involving the alveolus are homogenous in nature and that the
effect of the anatomical differences can be ignored. Also, the
volume of data available for the noncleft side in CLP children
is drastically reduced if this approach is adopted.
Measures of Caries Experience
Two studies used the dmft (deft) and dmfs (defs) indices to
measure the caries experience of the whole mouth (Lausterstein and Mendelsohn, 1964; Dahllof et al., 1989); another
study used the same index but excluded the incisor teeth (Stephen and MacFadyen, 1977). In contrast, Johnsen and Dixon
(1984) reported only the percentage of children with caries
affecting the primary incisors. This may have been done because some of the CLP children were too young to have a full
primary dentition. The most comprehensive study expressed
the caries experience as the percentage of carious teeth and
carious tooth surfaces in cleft and noncleft children and the
percentage of carious teeth by tooth type on the cleft side and
the noncleft side in cleft children and normal children (Ishida
et al., 1989). This study revealed that the maxillary anterior
teeth had the highest caries rate, which the investigators attributed to the presence of the cleft (Ishida et al., 1989). Unfortunately, Ishida et al. (1989) did not indicate whether any
statistical analyses had been performed to test for differences
in caries experience; hence, the validity of their conclusion can
be questioned.
From the available data, it can be argued that presenting the
caries experience for the entire mouth by region and by tooth

type should give a comprehensive picture of the caries experience that is suitable for future comparisons. However, none
of the published studies have presented caries experience data
in these formats.
The Effectiveness of Caries Preventive Programs on CLP
Children
Stephen and MacFadyen (1977) examined the effects, after
3 years, of a preventive program that included dietary advice,
fluoride therapy, and fissure sealants in 3- to 5-year-old CLP
children by comparing the findings with retrospective data for
CLP children of a similar age range. However, there were
some major flaws in the study design. The analysis of retrospective data relies heavily on the validity of the original data.
In their study, the authors did not mention the period over
which the retrospective data extended. Consideration was apparently not given to the decline in dental caries that would
be expected to be superimposed on the effect of any preventive
program. The mean age of the CLP group which benefited
from the preventive programs was stated to be 5.08 6 1.56
years, meaning that the age range was 2 to 7 years, not 3 to
5 years as stated by the investigators. The mean age of the
control group (retrospective data) was 4.7 6 0.11 years, which
falls within the narrow range of 4.5 to 5 years. The number
of subjects in both groups was small, with 34 in the control
group and 57 in the CLP group. It was also disappointing that
the primary incisors were not included in the study, because
the proximity of the incisors to the cleft has been stated to be
detrimental to the health of the maxillary anterior teeth (Johnsen and Dixon, 1984; Ishida et al., 1989).
The findings from the various studies that provide data on
the caries experience of CLP children that have been reviewed
are summarized in Table 1.
PERIODONTAL IMPLICATIONS FOR

THE

CLP PATIENT

Surgical, orthodontic, and prosthodontic intervention play

major roles in the rehabilitation of the CLP patient. The cleft
deformity and surgical scars can make it difficult to control

Wong and King, LITERATURE ON THE ORAL HEALTH OF CLP

plaque. Prolonged orthodontic therapy and the wearing of a

prosthesis to prevent collapse of the dental arch commonly
result in inflammatory papillary hyperplasia (Tan and Henry,
1985). It has been suggested that intensive prophylactic programs for CLP patients should be implemented as early as
possible and that a coordinated team approach for the treatment of all aspects of care should include close supervision of
oral hygiene measures and regular professional maintenance
through a regular recall system for the entire life of the patient
(Bragger et al., 1985, 1992).
Bone grafting of the cleft has become an accepted means
of improving the morphology of the alveolar ridge (Turvey et
al., 1984), supplementing the amount of bone to facilitate tooth
eruption (Boyne and Sands, 1972; Johanson et al., 1974; El
Deeb et al., 1982; Turvey et al., 1984; Bergland et al., 1986),
and providing stability of the maxillary segments (Turvey et
al., 1984; Bergland et al., 1986). Alveolar bone grafting has
come to produce such good results that it has been stated that
the periodontal condition is normalized following bone grafting and that gingivitis is seldom seen in the cleft region (Johanson et al., 1974). Clinically, it might be assumed that the
ultimate success of a bone graft is dependent on the total elimination, or at least the controlling, of the level of gingivitis
prior to the placement of a bone graft. However, there is a lack
of adequately large long-term clinical series from which to
draw any conclusions that are less than speculative. Nevertheless, gingivitis has been cited as a factor in the failure of alveolar bone grafts. For example, in one case series, 20% of
the failures were attributed to infection of the graft as a result
of gingivitis, and it was concluded that it is inappropriate to
operate before the gingivae have been rendered healthy (Bergland et al., 1986). Preoperative gingival health has been considered to be a more important factor in determining the success of the operation than the anatomical source of the bone
graft (Samman et al., 1993, 1994).
Patients with severe maxillary growth disturbances due to
clefting benefit from an osteotomy after cessation of growth
(Tideman et al., 1980; Cheung et al., 1994; Samman et al.,
1994). The need for subsequent surgery in the orofacial region
further substantiates the need for good oral hygiene and oral
health. Hence, it is important to have healthy periodontal tissues not only to optimize the treatment results, but because
each step in the treatment process can jeopardize periodontal
health.
Periodontal Condition of CLP Patients
Only a few studies pertaining to the periodontal health of
CLP patients have been published. It has been said that gingivitis is seldom seen in the cleft region after grafting because
the procedure normalizes the condition of the periodontium
(Johanson et al., 1974). However, other published data indicate
that these patients have less than satisfactory oral hygiene and
periodontal health (Bragger et al., 1985; Dahllof et al., 1989).
Young adults who had been supervised for at least 18 years
by a coordinated team were found to have poor oral hygiene,

251

generalized plaque accumulation, gingival inflammation, and

the initial signs of periodontal disease, which was documented
clinically as a loss of attachment and radiographically as loss
of alveolar bone height. Compared to available data for noncleft individuals in a similar age range, the amount of periodontal tissue destruction was more pronounced in the CLP
patients at the initial examination (Bragger et al., 1985). Bragger et al. (1985) also examined the progression rate of periodontal disease in CLP patients with fixed prostheses who had
received limited supportive therapy in the form of traditional
dental care by general practitioners. Over an 8-year period,
these patients were found to have inadequate oral hygiene and
generalized gingival inflammation that persisted, and further
loss of clinical attachment and alveolar bone was observed.
However, the periodontal disease was less severe than that reported for noncleft individuals who had not been recipients of
frequent supportive therapy (Bragger et al., 1992).
Periodontal Condition with Different CLP Types
No statistically significant differences have been demonstrated for plaque control, calculus deposits, gingivitis, loss of
attachment, or furcation involvement between different cleft
types. However, the mean probing depth has been found to be
shallower in subjects with clefts who have not received any
orthodontic treatment (Bragger et al., 1985). The differences
were attributed to long-term orthodontic therapy with fixed
appliances in all except the isolated cleft lip group.
Periodontal Condition on the Cleft Side and on the
Noncleft Side
When probing depth and loss of clinical attachment at the
sites adjacent to the cleft were compared with those at two
control sites, no statistically significant differences were found,
whereas radiographically, there was a statistically significant
lower bone height in the cleft region. This indicates the presence of long connective tissue attachment with reduced bone
support in the region of the cleft (Bragger et al., 1985). A
follow-up study (Bragger et al., 1992) revealed that attachment
loss over the 8 years of the study was no more pronounced at
cleft sites than at the two control sites. However, the cumulative effects of developmental disturbances, therapeutic intervention, and the inflammatory process up to the age of 28
years led to a periodontal condition which was less favorable
in the cleft region, with 0.5 mm deeper probing pocket depths
and 0.6 mm more loss of clinical attachment. Because the periodontal destruction was found to be no more severe at cleft
sites with a long connective tissue attachment than at control
sites not affected by cleft defects, it was concluded that sites
with long supracrestal connective tissue attachments do not
seem to be more prone to periodontal attachment loss than do
sites with normal-length supraalveolar fibrous attachments
(Bragger et al., 1990).
Ramstad (1989) compared the abutment and nonabutment
teeth in CLP patients after the insertion of a fixed prosthesis

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Cleft PalateCraniofacial Journal, May 1998, Vol. 35 No. 3

TABLE 2 Studies of the Periodontal Health of Adults and Children with Cleft Lip and Palate
Sample
Author
Bragger et al. (1985)
Ramstad (1989)
Dahllof et al. (1989)
Bragger et al. (1990)
Teja et al. (1992)
Mombelli et al. (1992)

Cleft Type

Number

Age (years)

All
Uni- or bilateral
All
Uni- or bilateral
Unilateral
(ungrafted)
Uni- or bilateral
(residual cleft)

80
50
69
25
18

1820
17.823.8
56
2628
1945

10

2730

Parameters Evaluated
Plaque, calculus, gingivitis, probing depth, furcation involvement
Plaque, gingivitis, probing depth
Gingivitis
Plaque, gingivitis, probing depth, attachment level, bone level
Plaque, gingivitis, probing depth, tooth mobility, bone level
Plaque, calculus, gingivitis, probing depth, attachment level, microbiological sample

* Different aspects of one longitudinal study.

Sample also included 10 patients who did not receive regular therapy as a control group.

in the cleft area. The maxillary teeth were examined for the
presence or absence of plaque and gingivitis. It was found that
the periodontal condition was poorer on the abutment teeth
than on the nonabutment teeth, which is consistent with observations for the general population. Thus, it was concluded
that the adverse effects of prosthodontic treatment, rather than
the anatomic variation created by repairing the cleft, were the
cause of the poor periodontal health in the teeth adjacent to
the cleft.
The teeth adjacent to a residual cleft appear to be at higher
risk of gingivitis, but not of periodontal disease, than comparable teeth in noncleft sites (Teja et al., 1992). However, the
authors proposed that a long-term follow-up study of the same
subjects should be conducted to determine the risk of these
subjects eventually developing periodontal disease.

Epidemiological Studies of the Periodontal Condition of

CLP Children
There are no published data on the oral cleanliness of CLP
children compared with that of normal children. One study,
however, did consider gingival inflammation in a group of 5to 6-year-old CLP children using the gingival bleeding index,
and a comparison was made with an age- and sex-matched
control group (Dahllof et al., 1989). In this study, the CLP
children were found to have a significantly greater number of
tooth units with gingivitis, and the difference between the two
groups was even more marked when only units in the maxillary anterior region were considered.
The findings from the various studies on periodontal health
of CLP subjects that have been reviewed are summarized in
Table 2.

Effects of Regular Periodontal Therapy

CONCLUSIONS
CLP patients who receive regular periodontal maintenance
therapy have been found to have better gingival health than
do patients who do not receive therapy, although the differences in terms of probing pocket depth and attachment levels
are not statistically significant (Mombelli et al., 1992).
Microflora in the Cleft Region
The presence of specific pathogenic microorganisms in
plaque can be related to progressive periodontal disease (Bragd
et al., 1987; Dzink et al., 1988; Slots and Listgarten, 1988).
Therefore, the cleft region, which may not be easily cleaned
by conventional oral hygiene techniques, may favor the growth
of these specific microorganisms. Nevertheless, the microflora
of the cleft are less complex irrespective of whether there has
been any maintenance therapy (Mombelli et al., 1992). However, in patients who have not received regular maintenance
therapy, anaerobic gram-negative organisms can be found, and
marked differences can be illustrated when samples from specific teeth are compared. Thus, it is probable that the composition of the subgingival microflora is of greater importance
for the health and stability of the periodontium than are the
anatomical features of this structure.

Epidemiological data on oral health for CLP subjects generally suffer from methodological deficiencies (Hook, 1988;
Sayetta et al., 1989), and this is especially true for studies of
caries in CLP children. Inadequate sample size is the major
problem. The presentation of data for different cleft types further diminishes the effective sample size, which makes statistical analysis weak or invalid. Choosing an appropriate control
group seems to be equally difficult, especially considering that
caries is a multifactorial disease that has declined in prevalence
in the last decade (Anderson et al., 1982; Brown, 1982; Brunelle and Carlos, 1982; Koch, 1982). Several of the more recent investigators have improved on this aspect of their studies
(Dahllof et al., 1989; Ishida et al., 1989). This review of the
literature has shown that there is some evidence that CLP children may have a higher caries prevalence than normal children, especially in the primary dentition, with the difference
being most marked in the maxillary anterior teeth. Additional
studies with carefully constructed samples and control groups
and detailed examination of the caries attack rate in different
regions of the mouth, and on different tooth types would provide researchers with a better understanding of the subject.
How effective preventive programs can be in the prevention

Wong and King, LITERATURE ON THE ORAL HEALTH OF CLP

of caries in these subjects has yet to be evaluated, especially

now that the use of fluoride products is almost routine.
Young adult CLP patients have been said to have poorer
oral hygiene and manifest the initial signs of periodontal disease to a slightly greater extent than normal individuals of a
similar age (Bragger et al., 1992). However, due to the absence
of a well-matched control group, Bragger et al.s (1992) study
cannot be considered to conclusively demonstrate that CLP
patients really have a higher risk of developing periodontal
disease than do normal subjects.
Nevertheless, comparison of data for the cleft and noncleft
sites of CLP patients with unilateral and bilateral CLP suggests
that the anatomical variation due to the presence of a cleft is
not the decisive factor in the development of periodontal problems; rather, periodontal disease occurs because of prosthodontic treatment (Ramstad, 1989; Bragger et al., 1990; Mombelli et al., 1992). Although the study by Mombelli et al.
(1992) was based on an extremely small sample, it did indicate
that the periodontal health of CLP patients does benefit from
regular periodontal maintenance therapy.
Therefore, the available literature does not conclusively
demonstrate that cleft patients have a higher chance of developing periodontal disease than do normal patients, although
they may have more gingivitis. However, implementation of
regular maintenance therapy can be expected to be beneficial
for the preservation of the dentition, especially after the provision of complex dental treatment.
Alveolar bone grafting has been comprehensively demonstrated to provide good treatment results (Johanson et al.,
1974; El Deeb et al., 1982; Turvey et al., 1984; Bergland et
al., 1986). Further, it has been stated that the operation should
not be performed until the gingivae have been rendered
healthy (Bergland et al., 1986), because preoperative gingival
health can determine the success of operations in CLP patients
(Samman et al., 1993, 1994).
Unfortunately, there are almost no data available on the oral
hygiene of CLP children. Therefore, more studies on the periodontal condition of CLP children are essential to facilitate the
integration of oral hygiene and dental preventive regimens into
the treatment protocol for these children in order to establish
desirable habits and oral health prior to the provision of reparative surgery and complex dental treatment.
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