Dental caries prevalence in children with cleft lip/palate aged between 6 months and 6 years in the West of Scotland.
Abstract: AIM: To compare the prevalence of dental caries in children with cleft lip/palate with national data at the same age. METHOD: Ethical approval was granted from the West of Scotland Ethics Committee. Children attending the Oral Orthopaedic Clinic were examined for caries according to the criteria of the British Association for the Study of Community Dentistry (BASCD) by two trained and calibrated examiners (KB, RW). Subjects were divided into five age groups: 0.5-1.49; 1.5-2.49; 2.5-3.49; 3.5-4.49 and 4.5-6.0 years. Mean dmft scores were compared with available national data (National Dental Inspection Program of Scotland) for nursery [NDIP 3-year-old survey 2008, unpublished] and 5-year-old children in Scotland [NDIP, 2008]. RESULTS: 209 subjects were examined (participation rate of 87.4%); 45.9% were female, 54.1% male; 21 children (10%) had a recognised syndrome and were reported separately. Cleft Palate (CP) was the most commonly occurring cleft in both syndromic and non-syndromic groups, followed in decreasing numbers by Unilateral Cleft Lip and Palate (UCLP), Bilateral Cleft Lip and Palate (BCLP), Unilateral Cleft Lip (UCL) and Bilateral Cleft Lip (BCL). The only age group with a significantly higher level of dental caries compared with national data was the 4.5-6.0 year-olds where only 37.2% of the children with clefts were caries free compared with the national figure of 57.7% (p=0.004). This same age group had a mean dmft for the cleft group of 3.24 compared with 1.86 nationally. The other age groups had similar dmft and percentages of subjects caries free compared with the national data. The differences did not reach significance. Caries was more common in the anterior teeth of the youngest two age groups, but in the posterior teeth of the two oldest age groups. CONCLUSION: By the age of 4.5 years, children with cleft lip/palate in the West of Scotland have significantly more caries than their non-cleft peers.

Key words: cleft lip/palate, caries, children
Article Type: Report
Subject: Cleft lip (Risk factors)
Cleft lip (Diagnosis)
Cleft lip (Care and treatment)
Dental caries (Risk factors)
Dental caries (Care and treatment)
Prevalence studies (Epidemiology) (Usage)
Children (Health aspects)
Authors: Britton, K.F.M.
Welbury, R.R.
Pub Date: 10/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Oct, 2010 Source Volume: 11 Source Issue: 5
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 276898054
Full Text: Introduction

Orofacial clefts are the most commonly occurring craniofacial defect with an average prevalence of 1.2/1000 live births [Mossey et al., 2007]. Children born with an orofacial cleft (CLP) have a high burden of care throughout their childhood. Most can expect: at least one general anaesthetic for surgery; speech therapy assessments and treatment; dental and orthodontic treatment; and possible psychological problems associated with the appearance of their cleft.

Papers investigating the prevalence of caries in cleft children and adults have variously reported a higher prevalence of caries in children with CLP [Dahllof et al., 1989; Bokhout et al., 1997; Paul and Brandt, 1998; Chapple and Nunn, 2001; Hewson et al., 2001; Ahluwalia et al., 2004; Kirchberg et al., 2004; Al-Wahadni et al., 2005; Stec-Slonicz et al., 2007; Mutarai et al., 2008], a lower prevalence [Gregg et al., 1999] or have concluded that there is no evidence to suggest a difference [Lausterstein and Mendelsohn 1964; Parapanisiou et al., 2009]. No studies investigating the prevalence of caries in CLP children have been carried out in Scotland to date.

Two papers, Wong and King [1998] and Hasslof and Twetman [2007], conducted systematic reviews of the literature. Hasslof and Twetman found potential problems with the control children used, caries diagnosis methods and a lack of data on 'social class indicators'. Wong and King concluded that small sample sizes, varying methods of presenting caries results, a lack of suitable control groups and a wide age range constitute some of the methodological difficulties in carrying out research in this field. They recommended that caries data should be presented by region and that this 'would give a comprehensive picture of caries experience that is suitable for future comparisons'.

The aim of this study was therefore to compare the prevalence of caries in cleft children in the West of Scotland with national data from non-cleft children of the same age taking into consideration the recommendations of the review papers quoted above. It is hoped that this data will improve the evidence base in the West of Scotland and provide a database for comparison in any future studies.

Materials and Methods

Study Subject. All children with CLP, between the ages of 6 months and 6 years, in the West of Scotland were invited to attend the Oral Orthopaedic Prevention Clinic at Glasgow Dental Hospital and School. The children receive a dental examination and preventive dental advice was given to parents regarding toothbrushing and diet. All these children were eligible to take part in this study.

Demographic Data. The demographic data collected from the subject's clinical notes comprised: name; gender; date of birth; age; full postcode; side and type of cleft. After data collection, study subjects were allocated a study number to ensure anonymity when entered into the password-protected database on an encrypted computer. Study subjects were divided into the following age groups for analysis: 0.5-1.49 years; 1.5-2.49 years; 2.5-3.49 years; 3.5-4.49 years; and 4.5-6.0 years.

The postcode of the parents/carers home was used to allow the degree of deprivation to be analysed using the Scottish Index of Multiple Deprivation (SIMD) system. A UK postcode represents a street, a part of a street or a small village. Each postcode encompasses a maximum of 80 properties. SIMD uses the full postcode and converts this into a measure of deprivation. SIMD 2006, the version available during the study timeframe, combines information regarding current income, employment, health, education, skills and training, housing, geographic access and crime. These seven domain scores are weighted to provide an overall score for each data zone. The Scottish Government website (www.scotland.gov.uk/topics/statistics/SIMD) provides a 'lookup' file which enables a postcode to be entered and converted into its SIMD score. There are five categories or quintiles ranging from 1 (least deprived) to 5 (most deprived). The SIMD data was analysed to determine whether deprivation was associated with the presence of a cleft and to see whether this study replicated the link between increasing deprivation and increasing prevalence of caries found in previous studies.

CLP annotation. The CLP types were recorded as unilateral cleft lip only (UCL), bilateral cleft lip only (BCL); unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (CP). The percentage occurrence of each cleft type was calculated.

Dental caries registration. Caries was recorded as both dmfs and dmft according to BASCD criteria [Mitropoulos et al., 1992; Pitts et al., 1997] to the D2 level i.e. caries extending into dentine. Clinical examinations form an integral and routine part of the Oral Orthopaedic Prevention Clinic at Glasgow Dental Hospital and School and the study subjects were examined using a dental light, mirror and CPITN probe when reclined in the dental chair.

The study clinicians were trained and calibrated to BASCD standards prior to the start of the study. The training component involved an illustrated lecture and discussion session on how to record the caries present in accordance with criteria set down by BASCD. Thereafter a day of clinical training and calibration was held to determine whether either dentist's lay records within the acceptable range of agreement. The Kappa scores were 1.0 for both KB and RW.

Dental caries as dmft and dmfs scores were calculated for each study subject. Within each age group the following were calculated in addition:

* mean dt, mt, ft and dmft,

* mean dmfs; percentage of subjects with no obvious caries (dmft = 0),

* mean dmft where >0,

* the distribution of caries between anterior and posterior teeth,

* Dental Care Index.

The Dental Care Index is a measure of how much of any existing caries has been restored expressed as a percentage. It takes no account of any extracted teeth and is calculated by ft/dmft x 100. The mean dmft was calculated for each different cleft type.

Dental caries comparisons. The comparisons for this study population were the 2008 National Dental Inspection Program of Scotland (NDIP) figures for the appropriate age matched groups. NDIP is a yearly epidemiological monitoring programme of the dental health of Scottish school children in mainstream school. Each year all children in Nursery School (mean age 3 years) and either Primary One (mean age 5 years) or Primary Seven (mean age 12 years) are inspected according to BSASCD criteria. In 2008 the 5-year-old children and Nursery children were inspected. The results of these dental inspections are available on-line at www.scottishdental.org/index.aspx?o=2153.

The 3-year-old NDIP subjects had an age range of 2.5 years to 4.5 years and were used as the non-cleft comparison for the 2.5-3.49 and 3.5-4.49 years study groups. The 5-year-old NDIP subjects had an age range of 4.5 to almost 6 years and were used as the non-cleft comparison for the 4.5-6.0 years study group. The study clinicians were trained and calibrated to the same BASCD standards to ensure that valid comparisons could be made between NDIP and study data.

Statistical Analysis. This was a mainly descriptive study using means and proportions with standard deviation and confidence intervals where appropriate. The results were analysed using Minitab 15 English and SPSS 15.0 for Windows. Differences between study and comparator data were analysed using Fisher's exact test and statistical significance was reported at a 5% level (p [less than or equal to] 0.05).

Results

Study Subjects. 209 subjects were examined of whom 21 (10%) had been diagnosed with a syndrome or an inherited chromosomal abnormality and were excluded from the study. Of the 188 study subjects 45.9% were female and 54.1% were male. Isolated cleft palate (CP) accounted for the majority of the clefts present (45%), followed in decreasing numbers by Unilateral Cleft Lip and Palate (UCLP) 26%, Bilateral Cleft Lip and Palate (BCLP) 11%, Unilateral Cleft Lip (UCL) 7 % and Bilateral Cleft Lip (BCL) 1%.

The Scottish Index of Multiple Deprivation (SIMD) divides the population into five equal 'quintiles', and as such, one would expect 20% of the population to be represented in each quintile. In this study there was a linear trend of increasing proportions of subjects within each category from the least deprived (13.9%) to the most deprived quintile (31.1%) and less than an expected 20% within SIMD category 1 (least deprived) whilst there were more than the expected 20% in SIMD category 5 (most deprived). When comparing this with data for 5-year-olds in Greater Glasgow the figures showed a broadly similar distribution. Approximately 60% of both the study and general population of 5-year-olds were present in the two most deprived SIMD quintiles.

Dental caries data. The mean dt, mt, ft and dmft scores with standard deviations (SD) for each age group were 1.5-2.49 years, 0.49 (2.08); 2.5-3.49 years, 1.03 (2.70); 3.5-4.49 years, 0.94 (1.98); 4.5-6.0 years, 3.24 (4.43). The dt, mt, ft and dmft scores with 95% CI for each study age group are shown in Table 1. The mean dmft (SD) for those subjects who had a dmft score of greater than zero in the study age groups was: 1.5-2.49 years, 5.5 (5.19); 2.5-3.49 years, 4.0 (4.21); 3.5 - 4.49 years, 2.9 (2.6); 4.5 - 6.0 years, 5.16 (4.63). The percentage of each age group who were caries free is shown in Table 2. The proportion of caries in anterior and posterior teeth by tooth and surface detail is shown in Figure 1 and 2.

Dental caries by cleft type. The mean dmft scores for each cleft type varied by type. Subjects with BCLP had the highest mean dmft figure of 2.77 (5.98). This was followed by CP 1.16 (2.32), UCLP 0.81 (1.84) and UCL 0.57 (1.28). Numbers in each cleft type group were too small to allow valid statistical comparison.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Dental Care Index. The Dental Care Index was not applicable in the 0.5-1.49, 1.5-2.49 and 2.5-3.49 year study groups as no restorations had been carried out at all. The Dental Care Index for the 3.5 - 4.49 years group was 10.5 and for the 4.49-6.9 years group was 10.9.

Comparator Data. The available comparator figures for the percentage of subjects caries free were those for 3-year-olds [NDIP, 2008] and 5-year-olds [NDIP, 2008]. These national figures are shown in Table 1. In the present study the 4.5-6.0 year-old age group had significantly fewer subjects who were caries free compared with their non-cleft peers (p=0.004). The comparison of study mean dmft with the 2008 NDIP results for the same age groups, where available, is shown in Table 3.

Unfortunately the standard deviations of the mean dmft figures were not available for the national data. This prevented assessment of significance between study and national groups. The Dental Care Index (ft/dmft x100) for the 4.5-6.0 year age group was 10.9.

Discussion

Although the number of study subjects (209) was relatively low this represented the majority of the available CLP population of the appropriate age range in the West of Scotland. Of the 289 subjects who would qualify for the study from birth data, nine died in infancy, 40 lived at a some distance from Glasgow and receive their preventive and continuing care nearer to home and one had moved away from the area leaving 239 potential subjects. Therefore the study participation rate was 87.4%. Of the 30 potential subjects who did not participate, 13 failed to attend at least one appointment during the period of the study. The remaining 17 were born in 2008 and were barely six months old so that their initial appointment would have been just after the end of the study period.

In order to give a more accurate picture of the prevalence of dental caries, and to try to alleviate the potential problem of a wide age range [Wong and King, 1998], subjects were divided into yearly age bands from 6 months of age up to 6 years of age.

The gender ratio found in this study was almost identical to those reported by two previous Scottish studies. Clark et al. [2003] reported 45% female and 55% male, and Womersley and Stone [1987] reported 45.3% female and 54.6% male. The proportion of CLP types in this study was similar to those of Chapple and Nunn [2001] in their North of England study who also found that the majority presented with CP, followed in turn by UCLP and BCLP combined and UCL. Conversely, Ahluwalia et al. [2004] in the South of England reported that UCLP presented most commonly, followed in turn by BCLP, CP and UCL. The number of subjects in this study with a syndrome (10%) lies between the 6.1% reported by Dahllof et al. [1989] and 15.5% by Hasslof and Twetman [2007].

Dental Caries Data. Unfortunately the only two Scottish studies involving the CLP population examined the distribution of the different types of cleft and did not investigate dental caries. Regarding the percentage of subjects with no caries Chapple and Nunn [2001] reported that 63% of their 4-year-old cleft subjects in the Newcastle area of England were caries free, a figure that is slightly lower than the 4-year-olds in this study. Bokhout et al. [1996] reported that 74% of the 2.5-year-old Dutch study subjects were caries free, again a similar figure to that found in this study. Hewson et al. [2001] reported that 22% of their Irish cleft subjects were caries free. However this was a figure for the whole study population that ranged in age from 18 months to almost 17 years. Paul and Brandt [1998] also reported data for a wider age range in their study conducted in Billericay, England. 78% of the 41 subjects in their 3-5 year age group were caries free.

The only study reporting a significantly higher percentage of CLP children caries free was that of Gregg et al. [1999]. Those authors reported that 50% of their 5-year-old subjects were caries free. This figure was achieved following specialist paediatric dental intervention for the CLP children, including preventive advice and restorative care.

In our study the 0.5-1.49, 1.5-2.49, 2.5-3.49 and the 3.5-4.49 year age groups had similar percentages of subject who were caries free compared with the National data from NDIP, [2008]. The differences did not reach significance. However, the 4.5-6.0 year age group had 20% fewer caries free cleft children when compared with their Scottish non-cleft peers (p = 0.004). When considering the 2008 NDIP figures for the Greater Glasgow and Clyde (GGC) health board area alone, then 27% fewer cleft children were caries free (p = 0.01).

Mean dt, mt, ft and dmft scores. Studies investigating caries in cleft children have been undertaken in many varied geographical locations over a long period of time. These, together with the fact that many differing thresholds for the diagnosis of caries have been employed, makes valid statistical comparisons with many study results impossible. In most studies considering dental caries in CLP children, the levels of caries were found to be higher in children with a cleft compared with the unaffected population [Dahllof et al., 1989; Bokhout et al., 1997; Paul and Brandt, 1998; Chapple and Nunn, 2001; Hewson et al., 2001; Ahluwalia et al., 2004; Kirchberg et al., 2004; Al-Wahadni et al., 2005; Stec-Slonicz et al., 2007; Mutarai et al., 2008].

Age group comparisons. For the age group 0.5-1.49 years no other studies found have reported dmft for this age group of cleft children. In the age group 1.5-2.49 years the mean dmft for this study group was 0.49. Although Ankola et al. [2005], reported a much higher D3 dmft of 6.57 for the 2-year-old cleft children in India, this must be viewed in relation to the generally higher prevalence of caries in India.

The mean dmft in the age group 2.5-3.49 years was 1.03. Bokhout et al. [1996] have reported a lower dft of 0.59. Ankola et al. [2005], reported a higher mean dmft of 3.95 for the 3-year-old children in their study. When compared with the NDIP results for the 2008 inspections of nursery-aged children, the mean dmft figures are very similar (NDIP 0.97, our study 1.03).

In the age group 3.5-4.49 years Chapple and Nunn found a mean dmft of 1.3 for the 37% of the 4-year-old cleft children with dental caries in their 2001 study. Both these figures are slightly higher than our mean of 0.94 for our 3.5-4.49 age group. This study took place in Newcastle, England, and although it used the D3 threshold of diagnosis, it was carried out in 2001, since when there have been significant reductions in the incidence of caries in both England and Scotland. In addition a large proportion of the children in the Newcastle study will have been receiving fluoridated water.

When compared with the NDIP results for the 2008 inspections of nursery-aged children, the mean dmft figures are virtually identical (NDIP 0.97, our study 0.94) showing that there is little difference between children with a cleft and their non-cleft peers in the 3.5-4.49 age group.

Considering the age group 4.5-6.0 years the mean dmft for this group was 3.24. This was a large increase in the prevalence of caries from a mean of 0.93 in the 3.5-4.49 year age group. When compared with the NDIP results, the mean dmft in our study of 3.24 was greater than that of the general population at 1.86 [NDIP, 2008]. CLP children in this age group have an average of 1.38 more carious teeth than their non-cleft peers of the same age. This is certainly a clinically significant difference even although we have been unable to analyse the significance statistically. When compared with the NDIP, [2008] data for the Greater Glasgow and Clyde area, whose mean dmft for 5-year-olds was 2.07, the CLP study children had 1.17 more carious teeth.

Mean dmft scores for each CLP type. When looking at caries and CLP type, the sample sizes within each cleft type were too small to allow valid statistical analysis of the mean dmft figures. But generally the results showed that subjects with more severe cleft types had a greater prevalence of caries.

Mean dmft where dmft > 0. In the 4.5-6.0 year age group the mean dmft for those subjects who did have caries (dmft >0) was 5.16, higher than the NDIP [2008] figure of 4.39. Although 0.77 more teeth with caries was a clinically significant difference it was not possible to test statistical significance, as the NDIP standard deviation figures were again unavailable.

Distribution of dental caries between anterior and posterior teeth. It was thought interesting to see whether the caries in the study subjects was mainly on the anterior teeth around the cleft site [Bokhout et al., 1996; Bokhout et al., 1997] or whether it was distributed evenly between the anterior and posterior teeth. With regard to both tooth and surface detail, the 1.5-2.48 and 2.5-3.49 age groups both presented with more caries in the anterior teeth. In the 3.5-4.5 age group the caries was distributed evenly between anterior and posterior teeth. The 4.5-6.0 age group had more caries in the posterior teeth. An explanation for this could be the eruption pattern of the primary teeth. It may be that the anterior teeth are more carious in the younger age groups because they have been erupted for a longer time and that by the 3.5-4.49 age group the posterior teeth have been exposed to the oral environment for long enough for caries to develop.

Dental Care Index. The Dental Care Index of 10.9 found in the 4.5-6.0 year age group compared favourably with the National Care Index of 9.68 [NDIP, 2008]. No other national Dental Care Index figures were available for comparison. Analysis of the Dental Care Index (ft / dmft x 100) showed that cleft subjects with high dmfs/t scores were more likely to have a high ms/mt score--i.e. it was more likely that caries would be treated by extraction rather than restoration.

Dental caries and deprivation (SIMD). The relationship between caries and deprivation levels was confirmed in this study where increasing deprivation was associated with increasing levels of caries. When comparing the proportion of study 5-year-olds in each SIMD quintile to the proportion of 5-year-olds in the Greater Glasgow and Clyde area in each SIMD quintile, there was a similar trend towards increased numbers in the two most deprived quintiles. Unfortunately the numbers were too small to make statistical analysis reliable. Nevertheless, descriptively it seems that there was not a higher level of deprivation within the CLP study group. It is tempting to conclude that the increased prevalence of caries in the CLP study children in the 4.5-6.0 age group was due to the presence of a cleft. However without statistical evidence no firm conclusions can be drawn as to whether the presence of a cleft is a significant causal factor in the development of caries.

The results of this study indicate that relying on General Dental Practitioners for targeted dental caries prevention, as has been the case to date, appears to be insufficient to maintain the child CLP group at national parity and that this population would benefit from specialist treatment and being seen more frequently in a specialist centre.

Conclusion

By the age of 4.5 years, CLP children in the West of Scotland have significantly more caries than their non-cleft peers. This study shows that the current regime of follow up at intervals of more than 6 months is insufficient and the CLP children should be seen more frequently and given treatment within a specialist centre. The aim is now for 4 monthly recalls with a zero tolerance policy for the treatment of early dental caries that will be undertaken by specialist paediatric dentists. With these new provisions we hope to reduce the burden of dental caries in the child cleft population in the West of Scotland.

Acknowledgements

This paper is based on a presentation that was a poster prize winner of EAPD/BSPD Young Researcher at the Congress of the EAPD held in Harrogate, England, June 2010. Ethical approval was granted by the West of Scotland Ethics committee. The support of the members of the West of Scotland Cleft team is gratefully appreciated.

References

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K.F.M. Britton, R.R. Welbury, Dept. Paediatric Dentistry, Glasgow Dental Hospital and School, Glasgow, Scotland.

Postal address: Prof. R. R. Welbury. Dept. of Paediatric Dentistry, Dental Hospital and School, 378 Sauchiehall Street, Glasgow, Scotland, G2 3JZ.

Email: Richard.Welbury@glasgow.ac.uk
Table 1. Mean dt, mt, ft and dmft for a group of West
of Scotland cleft lip and palate children by age group.

             Means with 95% CI
Age Group
in Years             dt                   mt

0.5 - 1.49           0                    0
1.5 - 2.49   0.49 (-0.14, 1.11)           0
2.5 - 3.49    1.0 (0.09, 1.90)            0
3.5 - 4.49   0.77 (0.06, 1.48)    0.06 (-0.07, 0.19)
4.5 - 6.0    1.57 (1.02, 2.12)    1.25 (0.32, 2.19)

Age Group
in Years             ft                  dmft

0.5 - 1.49           0                    0
1.5 - 2.49           0            0.49 (-0.13, 1.11)
2.5 - 3.49           0            1.03 (0.10, 1.95)
3.5 - 4.49   0.09 (-0.05, 0.24)   0.93 (0.21, 1.66)
4.5 - 6.0    0.35 (0.09, 0.61)    3.24 (0.21, 1.66)

Table 2. Percentage of West of Scotland cleft lip and palate
children with no dental caries compared with to the National
Dental Inspection Program of Scotland (NDIP) comparators.

Age Group    This       NDIP            NDIP
in Years     Study   3-year-olds    5-year-olds
                       (2008)          (2008)

0.5 - 1.49    100        --              --
1.5 - 2.49   91.1        --              --
2.5 - 3.49   74.3     75.6 (ns)          --
3.5 - 4.49   67.7     75.6 (ns)          --
4.5 - 6.0    37.2        --        57.7 (p=0.004)

Table 3. Mean dmft for West of Scotland cleft lip and palate
children by age group compared with the National Dental
Inspection Program of Scotland (NDIP) comparators.

Age Group    This    NDIP 3-year-olds   NDIP 5-year-olds
in Years     Study        (2008)             (2008)

0.5 - 1.49     0            --                 --
1.5 - 2.49   0.49           --                 --
2.5 - 3.49   1.03          0.97                --
3.5 - 4.49   0.94          0.97                --
4.5 - 6.0    3.24           --                1.86
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