Evaluation of a modified Huddart/Bodenham scoring system for assessment of maxillary arch constriction in unilateral cleft lip and palate subjects

The aim of this retrospective study was to describe the use and reliability of a numerical scoring system (modified Huddart/Bodenham) for the measurement of maxillary arch constriction in patients born with unilateral cleft lip and palate (UCLP), and to compare and contrast the new scoring system with the current methods of measuring treatment outcome, the Goslon and 5-year-old indices. Dental study models of 50 patients aged 5 years, and 50 patients aged 10 years, were scored using the 5-year-old and Goslon indices, respectively. Four examiners scored each set of models using the modified Huddart and Bodenham system, and repeated the scoring one month later. The intra- and inter-rater reliability of the numerical scoring system was assessed using the Kappa (kappa) statistic. The scores using the new method were correlated with the 5-year-old and Goslon scores using Spearman's (rho) and Kendall's (tau) rank correlation coefficients. There was a high level of intra-rater reliability for both the 5 (0.87: incisors, 0.91: canines, 0.88: molars) and 10 (0.9: incisors, 0.84: canines, 0.78: premolars/molars) year models. The weighted kappa values measuring inter-rater reliability were above 0.85 and 0.74, respectively, for all examiners. There was a statistically significant correlation between the modified Huddart/Bodenham scores and both the 5-year-old and Goslon scores in all cases (P < 0.001). It is concluded that the modified Huddart/Bodenham system provides an objective and reliable assessment of maxillary arch constriction. It has a high degree of correlation with the recommended standards, but is more versatile and sensitive to inter-arch discrepancies.

Smoking and orofacial clefts: a United Kingdom-based case-control study

OBJECTIVE

To investigate the association between smoking and orofacial clefts in the United Kingdom.

DESIGN

Case-control study in which the mother's exposure to tobacco smoke was assessed by a structured interview.

SETTING

Scotland and the Manchester and Merseyside regions of England.

PARTICIPANTS

One hundred ninety children born with oral cleft between September 1, 1997, and January 31, 2000, and 248 population controls, matched with the cases on sex, date of birth, and region.

MAIN OUTCOME MEASURE

Cleft lip with or without cleft palate and cleft palate.

RESULTS

There was a positive association between maternal smoking during the first trimester of pregnancy and both cleft lip with or without cleft palate (odds ratio 1.9, 95% confidence interval 1.1 to 3.1) and cleft palate (odds ratio 2.3, 95% confidence interval 1.3 to 4.1). There was evidence of a dose-response relationship for both types of cleft. An effect of passive smoking could not be excluded in mothers who did not smoke themselves.

CONCLUSION

The small increased risk for cleft lip with or without cleft palate in the offspring of women who smoke during pregnancy observed in this study is in line with previous evidence. In contrast to some previous studies, an increased risk was also apparent for cleft palate. In these U.K. data, there was evidence of a dose-response effect of maternal smoking for both types of cleft. The data were compatible with a modest effect of maternal passive smoking, but the study lacked statistical power to detect or exclude such an effect with confidence. It may be useful to incorporate information on the effects of maternal smoking on oral clefts into public health campaigns on the consequences of maternal smoking.

Parental craniofacial morphology in orofacial clefting

The parental craniofacial morphology in orofacial clefting (OFC) has been shown to differ from that of the non-cleft population when evaluated using conventional cephalometric analyses comprising a variety of linear, angular, and area measurements. In spite of this, the shape of the parental craniofacial complex is of greater importance in the search for the morphogenes involved in OFC. This retrospective case-control study employed three morphometric techniques [discriminant analysis of the principal components of shape (PCS), Euclidean distance matrix analysis (EDMA), and thin-plate spline analysis (TPS)] to localize the craniofacial skeletal shape differences between (a) the parents of children with OFC and a comparison group, (b) the parents of children with cleft lip and palate [CL(P)] and cleft palate (CP), and (c) the male and female parents of children with OFC. The postero-anterior (PA) cephalograms of 92 parents of children with non-syndromic OFC and 43 comparison group volunteers were scanned and digitized. The configurations of 24 reproducible landmarks were optimally superimposed using Procrustes algorithms to allow shape data to be derived using PCS, EDMA, and TPS. The parental craniofacial shape statistically significantly differed from that of the comparison group using PCS (P < 0.001) and EDMA (P = 0.001). However PCS, EDMA, and TPS differed in their localization of the shape differences, explainable by the different mathematical methods used by the individual techniques. Interestingly, the parental craniofacial shapes in CL(P) and CP were morphologically similar when tested using PCS (P = 0.03) and EDMA (P = 0.027). However, there was no shape-related sexual dimorphism in parental craniofacial morphology in OFC when tested using PCS (P = 0.35) and EDMA (P = 0.525). Thus, the parental craniofacial shape in OFC differs from the non-cleft population, the parental craniofacial shape does not differ between CL(P) and CP and there is no sexual dimorphism in the parental craniofacial morphology in OFC, as viewed on PA cephalograms.

Socioeconomic status and orofacial clefts in Scotland, 1989 to 1998

OBJECTIVE

The purpose of this study was to investigate the association between socioeconomic status and orofacial clefts (OFC) in Scotland.

DESIGN

Study of prevalence at birth over a 10-year period using an area-based measure of material deprivation.

SETTING

Population-based study throughout Scotland.

PARTICIPANTS

Eight hundred thirty-four live births with OFC born between January 1, 1989, and December 31, 1998, ascertained from the nationwide register of the Cleft Service in Scotland, compared with the total 603,825 live births in Scotland in this period.

RESULTS

There was a strong positive relationship whereby the prevalence of OFC at birth increased with increasing deprivation. This trend was statistically significant for cleft lip and/or palate (CL[P]: p =.016) but not for cleft palate (CP; p =.078). For each type of cleft, the relative risk among those resident in the most deprived areas, compared with those resident in the least deprived areas, was 2.33.

CONCLUSIONS

The association between OFC and socioeconomic status is consistent with a report for an earlier period in a smaller part of Scotland. Unlike the earlier study, this pattern appears to be stronger for CL(P) than for CP. These observations do not appear to be an artifact of recording. It is possible that they reflect the association between deprivation and risk factors for OFC, most likely tobacco smoking during pregnancy. Because the relationship between OFC and socioeconomic status appears to have been virtually unstudied in other populations, it would be valuable to investigate this relationship elsewhere and determine whether known risk factors account for the relationship.

Fluoride supplements and changes in tooth decay on the Island of Tristan da Cunha: 1966-1996

BACKGROUND

The island of Tristan Da Cunha is one of the few examples in the world of a remote enclosed community. The inhabitants of the island were transported to England in 1961 as a result of a volcanic eruption and during their time in England they received a detailed dental health examination. They were later examined back on the island in 1966 by Dr John Fisher and in 1982 a school fluoride supplementation programme was introduced.

AIM

The present paper reports the results of the first dental health survey to be carried out on the island since the introduction of a regular school fluoride supplementation programme in 1982.

SUBJECTS AND METHODS

A cohort of 6-19-year-old subjects on the island were examined in 1996 using a similar protocol to that which was used by Fisher in the 1966 examination.

RESULTS

Comparing the 6-12-year-olds who were caries free in 1966 with those caries free in 1996 using the Chi-squared statistic reveals a statistically significant greater number caries free in the more recent cohort (X2 - 6.0, P- 0.014). For the older age group (13-19 years), a similar comparison reveals a highly statistically significant difference(Z2 - 12.26, P 0.005).

CONCLUSIONS

A significant increase in the number of caries free 6-19-year-old children in Tristan Da Cunha between 1966 and 1996 was noted: 1) This is a significant finding in the light of the school fluoride supplementation programme that was introduced on the island in 1982; and 2) Appropriate fluoride supplementation regimes may have conferred a protective effect in a group of children with a cariogenic diet. The paper discusses the significance of this study in the support of fluoridation as a method of reducing the prevalence of dental caries a nd also discusses possibilities for future research on the island of Tristan Da Cunha.

Posteroanterior cephalometric analysis of the parental craniofacial morphology in orofacial clefting

OBJECTIVE

To evaluate the parental craniofacial morphology in orofacial clefting (OFC).

DESIGN

Case-control posteroanterior cephalometric study.

SETTING

The Department of Orthodontics, University of Dundee Dental School, Scotland, United Kingdom.

PARTICIPANTS

Ninety-two parents from a completely ascertained sample of 286 Scottish babies with nonsyndromic OFC and 43 comparison group volunteers from the University of Dundee Dental School.

MAIN OUTCOMES AND MEASURES

A conventional cephalometric analysis was used to measure linear distances and their ratios, angles, and areas. Two-sample Student's t tests and a discriminant analysis were applied to the data, and the clinically important statistically significant variables were identified using an accepted protocol.

RESULTS

Sixty-four linear distances, 10 ratios, 52 angles, and 7 areas statistically significantly differed between the parental and comparison groups (p <.01). Of these, 62 linear distances (22%), 9 ratios (45%), 41 angles (41%), and 6 areas (24%) were clinically important. Asymmetry was a feature of the results. Canonical variates analysis correctly classified 91.3% of the parental group and 90.6% of the comparison group using a series of 36 variables.

CONCLUSIONS

The parental craniofacial morphology in OFC differs significantly from the noncleft population. A larger superolateral face and smaller central midface and, in particular, a clinically significantly smaller maxillary width, in conjunction with skeletal asymmetry, characterize the parents of Scottish children with OFC. These features may be of morphogenetic importance in the etiopathogenesis of OFC in this ethnic group.

Preliminary investigation of a modified Huddart/Bodenham scoring system for assessment of maxillary arch constriction in unilateral cleft lip and palate subjects

The objective of this study was to describe a numerical scoring system for the measurement of maxillary arch constriction in patients born with unilateral cleft lip and palate (UCLP). A modification of the Huddart/Bodenham scoring system was compared and contrasted with the current methods of measuring treatment outcome, the GOSLON and 5-year indices. The GOSLON and 5-year indices are represented by 10 sets of study models grouped into five categories representing the range of possible outcomes in terms of dental arch relationship, with two sets of models in each of the five categories, whilst the modified Huddart/Bodenham method uses the frequency and severity of crossbite of the dental occlusion to evaluate maxillary arch constriction. The latter system was found to be more objective and reliable, and to correlate well with current recommended standards. It was also more versatile and more sensitive to interarch discrepancies. However, further work is required to refine it to reflect the potential for orthodontic treatment to mask interarch discrepancy following surgery.

Asymmetry of the parental craniofacial skeleton in orofacial clefting

OBJECTIVE

To evaluate size-related and shape-related craniofacial skeletal asymmetries in the parents of children with orofacial clefting (OFC).

DESIGN

Retrospective PA cephalometric study.

SETTING

Glasgow/Dundee, Scotland.

SUBJECTS

Ninety-two parental volunteers from a completely ascertained sample of 286 children born with OFC between 1980-1984 in the West of Scotland.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

A conventional cephalometric asymmetry analysis (CCAA) evaluated size-related right:left asymmetry comprising eight linear distance, nine angular, and three mid-facial area measurements. The right and left landmark configurations were uniformly scaled using Procrustes superimposition and Euclidean Distance Matrix Analysis (EDMA) evaluated shape-related right-left asymmetry.

RESULTS

The three linear distances, nine angles and two areas differed between the right and left sides of the craniofacial complex (P <0.05) indicate size asymmetry characterized by a wider left side of the face and a shorter vertical dimension on the right side (directional asymmetry). EDMA detected shape asymmetry [T statistic = 2.671 (P = 0.10)]. Forty per cent of the EDMA ratios were clinically importantly larger or smaller on the left and right sides respectively, involving landmarks anatomically and morphogenetically important in OFC.

CONCLUSION

Size and shape directional asymmetries characterize the parental craniofacial skeleton in OFC. This heritable directional craniofacial skeletal asymmetry could be of relevance in the left-sided predilection of OFC.

The craniofacial morphology of the parents of children with orofacial clefting: a systematic review of cephalometric studies

OBJECTIVE

To systematically review the cephalometric studies investigating the craniofacial morphology of the parents of children with orofacial clefting (OFC).

SEARCH STRATEGY

The search strategy was based on the keywords 'parent', cephalometry', and 'cleft', identifying 17 studies, of which 15 'case/control' studies met the inclusion criteria Statistically significant clinically relevant cephalometric variables from univariate statistical tests and multivariate results were collated and presented unweighted.

RESULTS/CONCLUSIONS

The parental craniofacial complex in OFC is distinctive in comparison to the non-cleft population. However, there is insufficient consistency in study designs and results to accurately characterize the parents of children with OFC. Although the craniofacial morphology of the parents of children with CL(P) differs to the parents of children with CP, there is insufficient information to accurately localize these differences.

The Structured Clinical Operative Test (SCOT) in dental competency assessment

INTRODUCTION

This paper describes a method of assessment of invasive clinical procedures which are currently being devised, and which are perceived to be a method that may be used to complement OSCEs in overall clinical skills assessment.

OBJECTIVE

The objective of the Structured Clinical Operative Tests (SCOT) is to introduce a greater level of objectivity to the assessment of operative clinical skills. Invasive or irreversible clinical operative procedures from a large part of dental undergraduate training and are by their very nature precluded from OSCE scenarios. It is also important to test intraoperative skills, communication skills and contingency management, and performance of these with awareness of the psychosocial context and ethical framework. The paper describes the use of checklists in the monitoring of clinical operative skills in a more authentic clinical situation using the SCOT. FORMATIVE ASSESSMENT: Continuous assessment should a) record achievement of competency in as objective a manner as possible and b) should encourage continuous self-evaluation. In the SCOT the students reflect on their clinical performance and in consultation with their supervisors record their plans to improve their competence in that skill or procedure in the future. This is done immediately on completion of a clinical task while the experience is still fresh in the mind. This encourages deep reflective learning as opposed to superficial factual learning which is characteristic of the more traditional curriculum, and is described as supervisor validated self-assessment.

DISCUSSION

The discussion outlines how SCOTs can be practically implemented and integrated into the undergraduate curriculum and an example of a SCOT is appended to the paper. The scope for using SCOTs in postgraduate assessment such as in VT/GPT is also described.

Scope of the OSCE in the assessment of clinical skills in dentistry

INTRODUCTION

The objective structured clinical examination (OSCE) is now an accepted tool in the assessment of clinical skills in dentistry. There are however no strict or limiting guidelines on the types of scenario that are used in the OSCE examinations and experience and experimentation will inevitably result in the refinement of the OSCE as a tool for assessment.

AIM

The aim of this study was to compare and contrast different types of clinical operative skills scenarios in multi-station OSCE examinations.

METHODOLOGY

Student feedback was obtained immediately after the sitting of an OSCE examination on two different occasions (and two different cohorts of students). The same questionnaire was used to elicit the responses.

RESULTS

The questionnaire feedback was analysed qualitatively with particular regard to student perception of the usefulness and validity of the two different kinds of OSCE scenarios.

CONCLUSIONS

OSCE scenarios which involve phantom heads are perceived to lack clinical authenticity, and are inappropriate for the assessment of certain clinical operative skills. While the OSCE is useful in the examination of diagnostic, interpretation and treatment planning skills, it has apparent limitations in the examination of invasive operative procedures.

An investigation into the use of a structured clinical operative test for the assessment of a clinical skill

AIM

This study was designed to investigate the level of agreement between a group of assessors observing students undertaking a structured clinical operative test.

METHOD

3 assessors agreed a series of criteria to assess the performance of undergraduate students in the recording of a dental impression. Guidelines for assessing whether the students adequately performed in relation to each criteria were also agreed. Following preliminary validation between the assessors, 2 assessors independently scored the performance of each student by reference to the agreed criteria, and the levels of agreement between assessors were compared. The 3 assessors worked in pairs with each other on three groups of students who were in the early stages of their clinical course.

RESULTS

A total of 39 clinical dental students were assessed in the recording of a dental impression. The 3 pairs of assessors had satisfactory levels of agreement in the study with similar judgements being made on 90% or more of the 12 criteria assessed. Some differences existed between the pairs of assessors. Certain criteria were more easily judged than others and this was reflected in the level of agreement seen. For over 90% of the criteria, positive assessments were made by each of the 3 assessors, and although there were minor variations between the pairs of assessors, this may have reflected the ability of the groups of students studied.

CONCLUSION

The study showed that different assessors were generally able to make agreed judgements on performance criteria in a structured clinical operative test. In setting up performance assessment it is necessary to have close collaboration between assessors to make clearly defined criteria so that judgements are not too subjective. Furthermore, for the assessment of more complex clinical skills, great care is needed in assembling criteria that can be used reproducibly, and sufficient preparation time for the assessors is critical.

Oral clefts and vitamin supplementation

OBJECTIVES

The evidence linking low levels of folic acid and orofacial clefting (OFC) is presently equivocal. There is stronger evidence for the role of folic acid supplementation in protection against the occurrence and recurrence of neural tube defects. The present investigation tested the hypotheses that cleft lip, cleft palate, or both are inversely associated with maternal intake of dietary and supplemental vitamins during the periconceptional period and first 4 months of pregnancy in a Brazilian population.

DESIGN

A population-based, case-control study of cleft lip with or without cleft palate (CL(P)) and isolated cleft palate (CP) in a Brazilian population. In structured interviews, case histories were taken from the mothers of a consecutive sample of 450 infants born with nonsyndromic OFC.

RESULTS

Mothers who had children with CL(P) were less likely to have been supplemented during the periconceptional period. The statistical significance of the difference in prevalence of the use of supplements between mothers of patients and of controls was greater for the CL(P) group: p < .05 for CP and p < .001 for CL(P). Multivariate analysis confirmed this finding of a protective effect for both types of orofacial cleft.

CONCLUSIONS

The use of vitamin supplements in the first 4 months of pregnancy was suggestive of a protective effect against the occurrence of CP and CL(P) in this population. The significance of an association between multivitamin supplementation and OFC and the possible role of gene/environment interaction are discussed.

The heritability of malocclusion: part 2. The influence of genetics in malocclusion

The relative influence of genetics and environmental factors in the aetiology of malocclusion has been a matter for discussion, debate and controversy in the orthodontic literature. This paper reviews the literature and summarises the evidence for the influence of genetics in dental anomalies and malocclusion. Among the conclusions are that, while phenotype is inevitably the result of both genetic and environmental factors, there is irrefutable evidence for a significant genetic influence in many dental and occlusal variables. The influence of genetics however varies according to the trait under consideration and in general remains poorly understood. More precise research tools and methods are required to improve knowledge and understanding, which in turn is a prerequisite to the appreciation of the potential for genetic and/or environmental manipulation in orthodontic therapy.

The heritability of malocclusion: Part 1--Genetics, principles and terminology

The relative contribution of genes and the environment to the aetiology of malocclusion has been a matter of controversy throughout the twentieth century. Genetic mechanisms are clearly predominant during embryonic craniofacial morphogenesis, but environment is also thought to influence dentofacial morphology postnatally, particularly during facial growth. Orthodontic and orthopaedic techniques are used in the treatment of malocclusion and other dentofacial deformities, but with limited effectiveness. The key to the determination of the aetiology of malocclusion, and its treatability lies in the ability to differentiate the effect of genes and environment on the craniofacial skeleton in a particular individual. Our ability to do this is limited by our lack of knowledge on the genetic mechanisms that control facial growth and lack of scientific evidence for the influence of environmental factors on human craniofacial morphogenesis.

Teaching dental undergraduates behaviour change skills

This paper describes an active learning-based education tool which enables dental students to learn preventive techniques relevant to patient dental health behaviour. 2 studies were conducted involving 33, 2nd year (study 1) and 9, 3rd year (study 2) undergraduate dental students. In study 1, snacking behaviour and its antecedents were analysed from detailed 3-day diet diaries completed by the students. Study 2 entailed the students changing one aspect of their sugar/diet behaviour using self-management techniques. It is concluded that dental students can successfully (a) identify antecedents to sugar snacking behaviours on several levels, i.e., cognitive, emotional and situational, (b) set goals and use behaviour change techniques to modify these behaviours, and (c) appreciate that this experience is relevant to similar preventive techniques that they will use in clinical practice. Training in the application of these skills to their own maladaptive behaviours provides a strong educational tool based on psycho-educational theories.

Cephalometric features in the parents of children with orofacial clefting

This nonrandomised retrospective case-comparison survey was based on the hypothesis that craniofacial morphometric features can be used to identify individuals at greater risk for having children with a cleft. The theory of aetiological heterogeneity suggests there may be differences according to gender and cleft type. From a completely ascertained sample of 286 children with cleft lip and/or palate born in the West of Scotland between 1 January 1980 and 31 December 1984, a sample of 83 parents of the children with non-syndromic clefts volunteered for lateral cephalometric examination. A comparison group was derived from the archives of Glasgow Dental Hospital. Multivariate statistical analyses were applied to identify which parental craniofacial parameters, if any, determine predisposition to orofacial clefting. Compared to the male comparison group, the fathers of children with CL(P) were shown to have reduced mandibular and symphyseal areas (P < 0.001), reduced maxillary area (P < 0.01) and a shorter palatal length (P < 0.01). The cranial base angle was more acute (P < 0.01) and the cross-sectional area of the cranium on lateral skull radiographs was significantly smaller (P < 0.001). However, the occipital subtenuce was larger in the fathers (P < 0.05). The craniofacial morphology in the mothers of children with CL(P) was characterized by a longer mandible (P = 0.011), an increase in the anterior facial height (P < 0.05) and greater facial length (P < 0.01). Anterior cranial base and the clivus length were also larger in the mothers (P < 0.05). The cranial parameters showed a similar trend to the paternal group with a reduced cranial area (P < 0.01) and an increase in the occipital subtenuce length (P < 0.001). Different cephalometric parameters distinguish fathers from a male comparison group and mothers from their female counterparts. An awareness of these parameters might be of value in the prediction of liability to clefting and may prove to be important in the quest for clues to the pathogenesis of both CP and CL(P).

Prediction of liability to orofacial clefting using genetic and craniofacial data from parents

BACKGROUND

Cleft lip with or without cleft palate (CL(P)) and isolated cleft palate (CP) are separate clinical entities and for both polygenic multifactorial aetiology has been proposed. Parents of children with orofacial clefting have been shown to have distinctive differences in their facial shape when compared to matched controls.

OBJECTIVE

To test the hypothesis that genetic and morphometric factors predispose to orofacial clefting and that these markers differ for CL(P) and CP. Methods-Polymorphisms at the transforming growth factor alpha (TGFalpha) locus in 83 parents of children with nonsyndromic orofacial clefts were analysed, and their craniofacial morphology was assessed using lateral cephalometry.

RESULTS

Parents of children with CL(P) and CP showed an increased frequency of the TGFalpha/TaqI C2 allele (RR=4.10, p=0.009) relative to the comparison group. Also the TGFalpha/BamHI A1 allele was more prevalent in the CP parents. MULTIVARIATE STATISTICAL ANALYSIS: Using stepwise logistic regression analysis the TGFalpha/TaqI C2 polymorphism provides the best model for liability to orofacial clefting. To determine the type of clefting a model involving interaction between the parental TGFalpha/BamHI and TGFalpha/RsaI genotypes showed the best fit. Using genotype only to predict the clefting defect in the children according to parental genotype, 68.3% could be correctly classified. By adding information on craniofacial measurements in the parents, 76% of CP and 94% of CL(P) parents could be correctly classified.

CONCLUSIONS

This study provides a model for prediction of liability to orofacial clefting. These findings suggest that different molecular aberrations at the TGFalpha locus may modify the risk for CP and CL(P).

Defining, conferring and assessing the skills of the dentist

The task facing educators in dentistry is never an easy one. It is an area where as many questions as answers arise. This paper looks at how the skills that a dentist needs can be defined and the best way to confer them.