The impact of nonsyndromic cleft lip with or without cleft palate on oral health-related quality of life

Abstract Nonsyndromic cleft lip with or without cleft palate (NSCL±P) compromises oral health, leading to missing or malformed teeth, and hampering oral hygiene. Apart from anatomic damages, NSCL±P also culminates in an impact on the routine quality of life with social privation and psychological embarrassment. Objective To evaluate the impact of NSCL±P on oral health-related quality of life. Material and Methods The study was classified as exploratory and descriptive, with quantitative approach. Patients with NSCL±P treated between August 2013 and September 2014 at the Cleft Lip and Palate Integral Care Center (CAIF), Curitiba, Brazil, were invited to participate. Age and sex-related data were collected, as well as level of education, financial income, type of orofacial cleft, use of orthodontic and prosthetic appliances, and number of previous orofacial surgeries. Selected patients were asked to answer the Oral Impact on Daily Performance (OIDP) questionnaire designed to measure the impact of oral health on daily performances. Results The sample was composed of 103 (44.59%) women and 128 (55.41%) men, with mean age of 19.74 ± 10.20 (7–65) years. The OIDP values ranged from 1 to 175 in 114 (49.35%) patients (mean: 22.38), whereas 117 patients (50.65%) presented total OIDP value equal to zero. High negative impact of NSCL±P on daily performances was detected when associated with the female sex (p=0.037). Daily performances related to phonetics (OIDP2; 2.63) and aesthetics (OIDP5; 2.48) presented the highest average values when compared to other daily performances, except OIDP6. The main symptoms and reported oral problems comprised the aesthetic dissatisfaction. Conclusions Almost half of the patients evaluated in this study showed negative impact of NSCL±P in the performance of daily activities.


Introduction
Cleft lip with or without cleft palate is a common congenital disorder 18 resulting from the lack of merging between the embryonary structures that precede the formation of lip and palate 6 . About 70% of oral clefts occur as a nonsyndromic form, and the remaining 30% are associated with Mendelian disorders or chromosomal, teratogenic and sporadic conditions 12 . The prevalence of nonsyndromic cleft lip with or without cleft palate (NSCL±P) varies according to ethnicity and geographic position; in Brazil, it is estimated at 0.99 (95% confidence interval, 9.6-10.2) per 1,000 live births 13,17 . NSCL±P etiology is related to a complex interplay between environmental exposures, genetic, and epigenetic factors 9,14 .
Clinically, NSCL±P compromises oral health, leading to missing or malformed teeth, and hampering oral hygiene. Moreover, the relation between dental loss and oral cleft is still being discussed, indicating that Some of these tools were adapted for dental investigations, allowing to detect dentomaxillofacial alterations that possibly interfere within the daily routine of patients 2,8,15,16 . In this context, the Index of Oral Impacts on Daily Performances (OIDP), based on the international classification of the WHO for disabilities and deficiencies 23 , was developed by Adulyanon and Sheiham 2 (1997), and validated for application in Portuguese language by Abegg, et al. 1 (2015

Discussion
The impact of OHQoL has been extensively explored in the medical literature 2,4,5,7,8,15,16,19  In this study, the female sex was associated to the high negative impact of NSCL±P on daily activities. The fact that women are more concerned with oral health than men may explain this result because they have a different perception of oral health compared to men 5 .
In this study, the OIDPs 2 and 5 showed the highest mean values when compared to other daily performances. Moreover, a larger number of patients showed negative impact on OIDPs 2 and 5 compared to the other OIDPs. These data confirm the impressions during data collections: the patients showed a direct relationship between these two performances, reporting that they did not smile and did not speak because of dissatisfaction with appearance or deformity of his/her mouth or face. The deformity of the mouth or face was a major dental problem mentioned by patients in both performances. In addition, out of 44 patients with negative impact on OIDP5, 10 (27.78%) indicated that the main reason for this difficulty was missing tooth. Mendonça, et al. 11 (2010) reported that 41.3% of patients with missing teeth had difficulty in smiling.
In this study, although only 15 (6.49%) patients reported problems to hygienize the teeth (OIDP3), 50% of them reported feeling pain when performing this function. This result agrees with Gomes and Abbeg 5 (2007), who reported that the pain was significant and impacted the quality of life of patients, although they did not evaluate patients with NSCL±P.
According to Suliman,et al. 19 (2012) dissatisfaction, such as orofacial malformation, was the main associated complication.
OIDP is a social/dental tool used to quantify the oral health condition in relation to the associated impact on daily performances 2 . The quantified outcomes enable the identification of the main symptoms and complications related to the daily performances, reflecting physical, psychological, and social conditions 2,5,15 at wide age ranges, making the screening of proper treatment planning also solid.
Based on that, the OIDP was applied in this study.
The delay in the questionnaire application due to the length of questions and number of evaluated performances, as well as some difficulties of children and adolescents in understanding questions, are some limitations of this study.
Rehabilitation of NSCL±P patients is beyond the physical intervention, extending to the psychological and social environments from birth to adult ages.

Conclusion
Almost half of the patients evaluated in this study showed negative impact of NSCL±P on the performance of daily activities. The high negative impact of NSCL±P on daily activities was associated with women. Physical and psychological damages figured as the most prevalent affected performances.