ORIGINAL ARTICLE
Cleft Lip and Palate Care in Nigeria: Current Status of Orthodontic Residents’ Training in the Management of Children With Cleft Lip and Palate Tokunbo Abigail Adeyemi, BDS, MSc
anagement of children with cleft lip and palate (CL/P) is multidisciplinary in nature, specialists in several disciplines work together to give holistic care for affected children. In general, cleft care specialists include surgeons, speech therapists, orthodontists, nurses, psychologists, and ENT surgeons. Management of children with CL/P starts from birth and continues to adulthood. Primary surgery is done in the early years, whereas secondary care continues till adolescence and adulthood.
Cleft lip and palate is known to have consequences on the dentition, presenting as missing teeth, supernumeraries, and pegshaped laterals.1 Orthodontic treatment in children affected with CL/P has been known to improve the oral health quality of life.2 Orthodontic treatment for children with CL/P requires acquisition of special skills because of the abnormal growth of the jaw and resultant postsurgical scar tissue.3 In Nigeria, a previous study reported that orthodontic treatment is rarely done for children with CL/P, reasons given were shortage of specialists and equipment.4 However, in the last 5 years, cleft care in Nigeria has experienced some form of improvement with charity organizations sponsoring free treatment for affected children in the country. These charity organizations also aim at training cleft specialists in most developing countries.5 The need to train and improve the skills of cleft care specialists by managing children with CL/P in high volume cleft care centers have been recommended previously as well as the need for postgraduate orthodontic training posts to develop a structured program in CL/P management.6,7 As part of the training to become specialists, orthodontists are expected to acquire skills in the management of children with CL/P in the following areas: counselling, fitting of neonatal appliances, presurgical orthopedics, prebone graft orthodontics, definitive orthodontic treatment, and planning of orthognatic surgery.4 In Nigeria, the last few years has seen an increase in the number of dentists undertaking specialist training in orthodontics.7 Presently, in the country, there are 14 accredited dental internship training centers, 5 of which undertake specialist orthodontic training. The curriculum of orthodontic postgraduate training in Nigeria has been reported previously. To qualify as a specialist, residents are required to treat and manage a specific number of patients, do research, and present their findings at conferences.7 However, it is unclear if there is a structured orthodontic training program in CL/P management. Training of orthodontists to acquire special skills in the management of children with CL/P may provide solution to the problem of orthodontic care in children with CL/P, and it may assist cleft charities to realize their vision for ancillary care in developing countries. Presently, in Nigeria, there is no published literature on training of orthodontic specialists in CL/P management. The purpose of this study is to assess the current training of orthodontic residents in the management of children with CL/P.
From the Department of Child Oral Health University College Hospital, Ibadan, Nigeria. Received April 26, 2014. Accepted for publication January 31, 2015. Address correspondence and reprint requests to Tokunbo Abigail Adeyemi, BDS, MSc, Department of Child Oral Health, University College Hospital, Ibadan, Nigeria; E-mail: [email protected] The author reported no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001670
The study design was a cross-sectional survey, semistructured questionnaires were sent by electronic mail to residents training to become orthodontic specialists in 3 major training centers in Nigeria. The training centers were located in the southwest region of Nigeria; all had been training orthodontic residents for some years now. Center A had been training orthodontic residents for 20 years, whereas centers B and C had a history of training of 10 and 8 years, respectively. The purpose of the questionnaire was to elicit useful
Abstract: This study aimed to assess and achieve an overview of the current status of training of orthodontic resident doctors working in Nigeria with regards to the management of children affected with cleft lip and palate (CL/P). Semistructured questionnaires containing 10 categories of questions relating to CL/P care were sent to 20 orthodontic resident doctors training to become specialists and working at 3 hospital training centers in Nigeria. Sixteen out of 20 (80%) questionnaires were eventually completed by the doctors and returned. Results were analyzed and reported as follows; 15 (94%) of the resident doctors had no orthodontic clinical experience in the management of children with CL/P and had never fitted a presurgical orthopedic appliance prior to the time the research was conducted. All the 16 resident doctors (100%) claimed to have been informed and taught in CL/P management by attending formal lectures and presenting seminars topics. Majority 15 (94%) of the resident doctors still did not have the required experience and research skills in the field of CL/P, while 14 (87.5%) of them had never attended craniofacial conferences before now. This study has revealed shortcomings in training of orthodontic residents as it concerns the management of children affected with CL/P in Nigeria. Trainers and orthodontic training institutions in Nigeria may need to restructure their training program to allow for more in depth training as it concerns management of children affected with CL/P. Key Words: Cleft lip and palate, Nigeria, orthodontic residents, status, training (J Craniofac Surg 2015;26: 1106–1108)
M
1106
MATERIALS AND METHODS
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Orthodontic Training Program in CL/P
TABLE 1. Shows the Responses of Residents Concerning Their Postgraduate Training in Cleft Lip and Palate Management Variables
Center A
Lectures in CL/P management Yes 7 No — Seminar presentations Yes 7 No — Conference attendance Yes 1 No 7 Research work Yes 1 No 7 Publications Yes — No 7
Center B
Center C
Total
5 —
4 —
16 (100%) 0 (0%)
5 —
4 —
16 (100%) 0 (0%)
— 5
1 2
2 (12.5%) 14 (87.5%)
— 5
— 3
1 (6.2%) 15 (93.8%)
— 5
— 4
0 (0%) 16 (100%)
The residents were from 3 training centers designated as A, B, C, responses were similar across the 3 training centers. CL/P indicates cleft lip and palate.
FIGURE 1. Age distribution of respondents, most of the residents were in their third decade of life.
information on the current status of orthodontic post graduate training and clinical experience in the management of children with CL/P. Respondents were asked to fill in the questionnaires by ticking the most appropriate answer to the questions. Data collected were analyzed manually, frequencies were generated, and descriptive variables are presented in both figure and tabular form.
RESULTS Sixteen out of 20 residents responded (80%). Those who responded were further categorized as either registrars or senior registrars. Registrars were residents who were less than 2 years into the training program and senior registrars were residents who were more than 2 years into the training program. Results are shown in figure and tabular form. Figures 1 and 2 show the descriptive statistics of the residents. Tables 1 and 2 show responses from residents in centers A, B, and C. Responses from the 3 centers are similar.
DISCUSSION The role of the orthodontist in the management of children with CL/P is important because of the aesthetic and functional consequences associated with CL/P.3–8 The orthodontist also advices on surgical
FIGURE 2. Sex and status of residents, same number of male and female residents responded to the questionnaire.
#
2015 Mutaz B. Habal, MD
timing of palatal repair based on his knowledge and experience with growth and development of the jaws. The usual practice is for children affected with CL/P to be seen in the presurgical, postsurgical, and adolescent or adult stages. In the presurgical phase, modification of the maxilla is done using neonatal orthodontic appliances, with the aim of reducing the gap between the cleft so that surgical repair can be made easy. Feeding has also been reported to be easier in children who use neonatal appliances.9 In the postsurgical phase, the orthodontist is concerned with guidance of tooth eruption in the deciduous dentition and the establishment of an overbite using removable appliances to influence growth and preparation of the maxillary arch before secondary alveola bone grafting.10 Whereas in the adolescent or adult stage, treatment is done to establish occlusion and function in the permanent dentition. TABLE 2. Shows the Responses of Residents Concerning Their Clinical Experience in the Management of Children with Cleft Lip and Palate Variables
Center A
Counselling Yes 7 No — Fitting of neonatal appliance Yes — No 7 Presurgical orthopedics Yes — No 7 Prebone graft orthodontics Yes 1 No 7 Definitive orthodontics Yes 1 No 7 Preparation for orthognatic surgery Yes — No 7
Center B
Center C
Total
5 —
4 —
16 (100%) 0
— 5
— 4
0 16 (100%)
1 5
— 4
1 (6.2%) 15 (93.8%)
— 5
— 3
1 (6.2%) 15 (93.8%)
— 5
— 3
1 (6.2%) 15 (93.8%)
— 5
— 4
0 16 (100%)
The residents were from 3 training centers designated as A, B, C, responses were similar across the 3 training centres.
1107
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Adeyemi
The Journal of Craniofacial Surgery
The problem with the treatment of malocclusion in children with CL/P, unlike children without CL/P, lies in the abnormality of the jaws and subsequent growth as a resultant effect of the cleft and early surgery of the maxilla. Hence, special skills are required for the management of affected children. Training to become a specialist in CL/P care orthodontic specialist in Nigeria takes an average of 6 years. Presently, not all dental schools in developing countries are able to offer comprehensive orthodontic training because of the high academic standard and clinical input required. It is therefore important that the few dental schools that are able to offer specialist training should be of high standard and quality. This study surveyed the training of orthodontic residents in Nigeria, the aim was to report the current status of training as it concerns management of children of CL/P. All (100%) residents agreed that they had taught lectures in CL/P and were capable of presenting seminar topics in the field of CL/P, but had no experience in research and had never attended cleft conferences. The need to integrate research into teaching and learning as well as acquisition of skills for specialists in CL/P management has been reported previously.11,12 This is because conducting research in the field of cleft may provide answers to research questions and problems in the field of cleft, which may be useful for health planning and services. There were shortcomings in clinical experience, 94% of the residents had no clinical experience with fitting of neonatal appliances, presurgical orthopedics, prebone graft orthodontics, and preparation for orthognatic surgery, although all respondents had experience with counselling of families of children affected with CL/P. In conclusion, shortcomings in training of orthodontic residents as it concerns management of CL/P have been reported. Trainers and orthodontic training institutions in Nigeria may need to restructure orthodontic training program so that residents can acquire adequate clinical experience and skills in the management of children with CL/P.
1108
Volume 26, Number 4, June 2015
REFERENCES 1. Long RE Jr, Semb G, Shaw WC. Orthodontic treatment of the patient with complete clefts of lip, alveolus and palate: lessons of the past 60 years. Cleft Palate Craniofac J 2000;37:533 2. Jokovic A, Locker D, Guyatt G. Short forms of the child perceptions questionnaire for 11-14-year-old children (CPQ11-14): development and initial evaluation. Health Qual Life Outcomes 2006;4:4 3. Hodgkinson PD, Brown S, Duncan D, et al. Management of children with cleft lip and palate: A review describing the application of multidisciplinary team working in this condition based upon the experiences of a regional cleft lip and palate centre in the United Kingdom. Fet Mat Med Rev 2005;16:1 1 27 4. Olasoji HO, Hassan A, Adeyemo WL. Survey of management of children with cleft lip and palate in teaching and specialist hospitals in Nigeria. Cleft Palate Craniofac J 2011;48:150–155 5. Mossey P, Little J. Addressing the challenges of cleft lip and palate research in India Indian. J Plast Surg 2009;42(Suppl):S9–S18 6. Lee TJ, Kim ST. A survey of cleft lip and palate management taught in training programs in Korea. Cleft Palate Craniofac J 2003;40:80–84 7. Otuyemi OD. Orthodontics in Nigeria, the journey so far. J Orthod 2001;28:81–82 8. Lee TJ, Cho OH. A survey of cleft lip and palate management taught in training programs in Korea. Korean Soc Plast Reconstr J 1995;22:695– 704 9. Aduss H, Figueroa AA. Stages of orthodontic treatment in complete unilateral cleft lip and palate. In: Bardach J, Morris HL, eds. Multidisciplinary Management of Cleft Lip and Palate. Philadelphia: WB Saunders; 1990. 607:615 10. Bergland O. Treatment of the cleft palate malocclusion in the mixed and permanent dentition. Trans Eur Orthod Soc 1973;571:574 11. Osborn JM, Kelleher JC. A survey of cleft lip and palate taught in plastic surgery training programs. Cleft Palate Craniofac J 1983;20:169 12. Shaw WC, Semb G, Nelson P, et al. The Euro cleft project 1996-2000. Overview. J Craniomaxillofac Surg 2001;29:131
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Cleft Lip and Palate Care in Nigeria: Current Status of Orthodontic Residents’ Training in the Management of Children With Cleft Lip and Palate Tokunbo Abigail Adeyemi, BDS, MSc
anagement of children with cleft lip and palate (CL/P) is multidisciplinary in nature, specialists in several disciplines work together to give holistic care for affected children. In general, cleft care specialists include surgeons, speech therapists, orthodontists, nurses, psychologists, and ENT surgeons. Management of children with CL/P starts from birth and continues to adulthood. Primary surgery is done in the early years, whereas secondary care continues till adolescence and adulthood.
Cleft lip and palate is known to have consequences on the dentition, presenting as missing teeth, supernumeraries, and pegshaped laterals.1 Orthodontic treatment in children affected with CL/P has been known to improve the oral health quality of life.2 Orthodontic treatment for children with CL/P requires acquisition of special skills because of the abnormal growth of the jaw and resultant postsurgical scar tissue.3 In Nigeria, a previous study reported that orthodontic treatment is rarely done for children with CL/P, reasons given were shortage of specialists and equipment.4 However, in the last 5 years, cleft care in Nigeria has experienced some form of improvement with charity organizations sponsoring free treatment for affected children in the country. These charity organizations also aim at training cleft specialists in most developing countries.5 The need to train and improve the skills of cleft care specialists by managing children with CL/P in high volume cleft care centers have been recommended previously as well as the need for postgraduate orthodontic training posts to develop a structured program in CL/P management.6,7 As part of the training to become specialists, orthodontists are expected to acquire skills in the management of children with CL/P in the following areas: counselling, fitting of neonatal appliances, presurgical orthopedics, prebone graft orthodontics, definitive orthodontic treatment, and planning of orthognatic surgery.4 In Nigeria, the last few years has seen an increase in the number of dentists undertaking specialist training in orthodontics.7 Presently, in the country, there are 14 accredited dental internship training centers, 5 of which undertake specialist orthodontic training. The curriculum of orthodontic postgraduate training in Nigeria has been reported previously. To qualify as a specialist, residents are required to treat and manage a specific number of patients, do research, and present their findings at conferences.7 However, it is unclear if there is a structured orthodontic training program in CL/P management. Training of orthodontists to acquire special skills in the management of children with CL/P may provide solution to the problem of orthodontic care in children with CL/P, and it may assist cleft charities to realize their vision for ancillary care in developing countries. Presently, in Nigeria, there is no published literature on training of orthodontic specialists in CL/P management. The purpose of this study is to assess the current training of orthodontic residents in the management of children with CL/P.
From the Department of Child Oral Health University College Hospital, Ibadan, Nigeria. Received April 26, 2014. Accepted for publication January 31, 2015. Address correspondence and reprint requests to Tokunbo Abigail Adeyemi, BDS, MSc, Department of Child Oral Health, University College Hospital, Ibadan, Nigeria; E-mail: [email protected] The author reported no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001670
The study design was a cross-sectional survey, semistructured questionnaires were sent by electronic mail to residents training to become orthodontic specialists in 3 major training centers in Nigeria. The training centers were located in the southwest region of Nigeria; all had been training orthodontic residents for some years now. Center A had been training orthodontic residents for 20 years, whereas centers B and C had a history of training of 10 and 8 years, respectively. The purpose of the questionnaire was to elicit useful
Abstract: This study aimed to assess and achieve an overview of the current status of training of orthodontic resident doctors working in Nigeria with regards to the management of children affected with cleft lip and palate (CL/P). Semistructured questionnaires containing 10 categories of questions relating to CL/P care were sent to 20 orthodontic resident doctors training to become specialists and working at 3 hospital training centers in Nigeria. Sixteen out of 20 (80%) questionnaires were eventually completed by the doctors and returned. Results were analyzed and reported as follows; 15 (94%) of the resident doctors had no orthodontic clinical experience in the management of children with CL/P and had never fitted a presurgical orthopedic appliance prior to the time the research was conducted. All the 16 resident doctors (100%) claimed to have been informed and taught in CL/P management by attending formal lectures and presenting seminars topics. Majority 15 (94%) of the resident doctors still did not have the required experience and research skills in the field of CL/P, while 14 (87.5%) of them had never attended craniofacial conferences before now. This study has revealed shortcomings in training of orthodontic residents as it concerns the management of children affected with CL/P in Nigeria. Trainers and orthodontic training institutions in Nigeria may need to restructure their training program to allow for more in depth training as it concerns management of children affected with CL/P. Key Words: Cleft lip and palate, Nigeria, orthodontic residents, status, training (J Craniofac Surg 2015;26: 1106–1108)
M
1106
MATERIALS AND METHODS
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Orthodontic Training Program in CL/P
TABLE 1. Shows the Responses of Residents Concerning Their Postgraduate Training in Cleft Lip and Palate Management Variables
Center A
Lectures in CL/P management Yes 7 No — Seminar presentations Yes 7 No — Conference attendance Yes 1 No 7 Research work Yes 1 No 7 Publications Yes — No 7
Center B
Center C
Total
5 —
4 —
16 (100%) 0 (0%)
5 —
4 —
16 (100%) 0 (0%)
— 5
1 2
2 (12.5%) 14 (87.5%)
— 5
— 3
1 (6.2%) 15 (93.8%)
— 5
— 4
0 (0%) 16 (100%)
The residents were from 3 training centers designated as A, B, C, responses were similar across the 3 training centers. CL/P indicates cleft lip and palate.
FIGURE 1. Age distribution of respondents, most of the residents were in their third decade of life.
information on the current status of orthodontic post graduate training and clinical experience in the management of children with CL/P. Respondents were asked to fill in the questionnaires by ticking the most appropriate answer to the questions. Data collected were analyzed manually, frequencies were generated, and descriptive variables are presented in both figure and tabular form.
RESULTS Sixteen out of 20 residents responded (80%). Those who responded were further categorized as either registrars or senior registrars. Registrars were residents who were less than 2 years into the training program and senior registrars were residents who were more than 2 years into the training program. Results are shown in figure and tabular form. Figures 1 and 2 show the descriptive statistics of the residents. Tables 1 and 2 show responses from residents in centers A, B, and C. Responses from the 3 centers are similar.
DISCUSSION The role of the orthodontist in the management of children with CL/P is important because of the aesthetic and functional consequences associated with CL/P.3–8 The orthodontist also advices on surgical
FIGURE 2. Sex and status of residents, same number of male and female residents responded to the questionnaire.
#
2015 Mutaz B. Habal, MD
timing of palatal repair based on his knowledge and experience with growth and development of the jaws. The usual practice is for children affected with CL/P to be seen in the presurgical, postsurgical, and adolescent or adult stages. In the presurgical phase, modification of the maxilla is done using neonatal orthodontic appliances, with the aim of reducing the gap between the cleft so that surgical repair can be made easy. Feeding has also been reported to be easier in children who use neonatal appliances.9 In the postsurgical phase, the orthodontist is concerned with guidance of tooth eruption in the deciduous dentition and the establishment of an overbite using removable appliances to influence growth and preparation of the maxillary arch before secondary alveola bone grafting.10 Whereas in the adolescent or adult stage, treatment is done to establish occlusion and function in the permanent dentition. TABLE 2. Shows the Responses of Residents Concerning Their Clinical Experience in the Management of Children with Cleft Lip and Palate Variables
Center A
Counselling Yes 7 No — Fitting of neonatal appliance Yes — No 7 Presurgical orthopedics Yes — No 7 Prebone graft orthodontics Yes 1 No 7 Definitive orthodontics Yes 1 No 7 Preparation for orthognatic surgery Yes — No 7
Center B
Center C
Total
5 —
4 —
16 (100%) 0
— 5
— 4
0 16 (100%)
1 5
— 4
1 (6.2%) 15 (93.8%)
— 5
— 3
1 (6.2%) 15 (93.8%)
— 5
— 3
1 (6.2%) 15 (93.8%)
— 5
— 4
0 16 (100%)
The residents were from 3 training centers designated as A, B, C, responses were similar across the 3 training centres.
1107
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Adeyemi
The Journal of Craniofacial Surgery
The problem with the treatment of malocclusion in children with CL/P, unlike children without CL/P, lies in the abnormality of the jaws and subsequent growth as a resultant effect of the cleft and early surgery of the maxilla. Hence, special skills are required for the management of affected children. Training to become a specialist in CL/P care orthodontic specialist in Nigeria takes an average of 6 years. Presently, not all dental schools in developing countries are able to offer comprehensive orthodontic training because of the high academic standard and clinical input required. It is therefore important that the few dental schools that are able to offer specialist training should be of high standard and quality. This study surveyed the training of orthodontic residents in Nigeria, the aim was to report the current status of training as it concerns management of children of CL/P. All (100%) residents agreed that they had taught lectures in CL/P and were capable of presenting seminar topics in the field of CL/P, but had no experience in research and had never attended cleft conferences. The need to integrate research into teaching and learning as well as acquisition of skills for specialists in CL/P management has been reported previously.11,12 This is because conducting research in the field of cleft may provide answers to research questions and problems in the field of cleft, which may be useful for health planning and services. There were shortcomings in clinical experience, 94% of the residents had no clinical experience with fitting of neonatal appliances, presurgical orthopedics, prebone graft orthodontics, and preparation for orthognatic surgery, although all respondents had experience with counselling of families of children affected with CL/P. In conclusion, shortcomings in training of orthodontic residents as it concerns management of CL/P have been reported. Trainers and orthodontic training institutions in Nigeria may need to restructure orthodontic training program so that residents can acquire adequate clinical experience and skills in the management of children with CL/P.
1108
Volume 26, Number 4, June 2015
REFERENCES 1. Long RE Jr, Semb G, Shaw WC. Orthodontic treatment of the patient with complete clefts of lip, alveolus and palate: lessons of the past 60 years. Cleft Palate Craniofac J 2000;37:533 2. Jokovic A, Locker D, Guyatt G. Short forms of the child perceptions questionnaire for 11-14-year-old children (CPQ11-14): development and initial evaluation. Health Qual Life Outcomes 2006;4:4 3. Hodgkinson PD, Brown S, Duncan D, et al. Management of children with cleft lip and palate: A review describing the application of multidisciplinary team working in this condition based upon the experiences of a regional cleft lip and palate centre in the United Kingdom. Fet Mat Med Rev 2005;16:1 1 27 4. Olasoji HO, Hassan A, Adeyemo WL. Survey of management of children with cleft lip and palate in teaching and specialist hospitals in Nigeria. Cleft Palate Craniofac J 2011;48:150–155 5. Mossey P, Little J. Addressing the challenges of cleft lip and palate research in India Indian. J Plast Surg 2009;42(Suppl):S9–S18 6. Lee TJ, Kim ST. A survey of cleft lip and palate management taught in training programs in Korea. Cleft Palate Craniofac J 2003;40:80–84 7. Otuyemi OD. Orthodontics in Nigeria, the journey so far. J Orthod 2001;28:81–82 8. Lee TJ, Cho OH. A survey of cleft lip and palate management taught in training programs in Korea. Korean Soc Plast Reconstr J 1995;22:695– 704 9. Aduss H, Figueroa AA. Stages of orthodontic treatment in complete unilateral cleft lip and palate. In: Bardach J, Morris HL, eds. Multidisciplinary Management of Cleft Lip and Palate. Philadelphia: WB Saunders; 1990. 607:615 10. Bergland O. Treatment of the cleft palate malocclusion in the mixed and permanent dentition. Trans Eur Orthod Soc 1973;571:574 11. Osborn JM, Kelleher JC. A survey of cleft lip and palate taught in plastic surgery training programs. Cleft Palate Craniofac J 1983;20:169 12. Shaw WC, Semb G, Nelson P, et al. The Euro cleft project 1996-2000. Overview. J Craniomaxillofac Surg 2001;29:131
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
