Wednesday, March 31, 1999

Cleft lip & palate management
How the face changes
By Dr Yogesh Caplash

IN your lifetime you have seen the faces of thousands of people and each face is recognisable to you as distincitively individual. Consider, relatively how few parts compose a face — a lower jaw and a chin, cheek bones, a mouth and an upper jaw, a nose and two orbits. Add a forehead and supraorbital ridges for the neurocranial parts of the face. Amazing how so few components underlie such a great variation in the facial form! A very slight alteration in the configuration of any part can make a substantial difference in the appearance and character of one’s face as a whole.

“The human face”, a dynamic growing part of the human body, can have growth aberrations because of heredity and environmental reasons. The cleft-lip-and-palate is one such common growth aberration and requires a comprehensive management protocol, based on the individual presentation.

In a team approach towards the management of the cleft-lip-and-palate patients, the team includes.

A plastic surgeon.

A dential specialist (paedodontist, orthodontist, prosthodontist)

Speech pathologist.

They have a true peer relationship with shared interaction aimed at achieving the optimal result for the patient.

The plastic surgeon is usually the first to be seen when a child is born with cleft deformity. He gives information about the morphology, tissue reaction, tolerance and the timing of the elective surgical procedures. He alleviates the parents’ fears about their child, reassuring them that their child would be a normal being, although he may require a number of surgical procedures till he reaches adulthood. The number of survical procedures will vary depending on the child’s presentation. However, these procedures are well tolerated by them without any detrimental effects.

As the team surgeon and head, he follows the patients longitudinally and is involved with the patients from birth to adulthood. His primary functions are lip repair, closure of the defect in the palate, closure of the alveolar cleft (cleft in the gums), secondary palatal and pharyngeal procedures and later surgical improvements in the lip and the nose. Some children may even require movement of the jaws to improve the profile, which is also undertaken by him. All the above procedures are timed to maximise the possibility of attaining adequate structure function and the appearance for normal physiological and psychological development.

The interaction of the plastic surgeon and the dental specialist begins early. A variety of dental problems may be found in the patient with cleft lip and palate. These range from trivial dental rotations to major dentoskeletal dysharmonies. Some of these deformities are due to the cleft malformation whereas others are secondary deformities resulting from specific management options taken in childhood. Working as a team having close interaction, the incidence of secondary deformities is reduced.

After the alignment of the arch of the upper jaw, the alveolar cleft (cut in the gums) is closed allowing the normal teeth to erupt through the repaired cleft area. Such a procedure if not done, leads to improper teeth eruption and the loss of good healthy teeth. Progressive orthodontics allows for the proper alignment of the teeth in the upper jaw, obviating the need for prosthetic teeth replacement later.

It continues throughout the growing period in consideration with occlusal factors, and primary and secondary dentition. In some cases, a combination of orthodontics and orthognathic surgery (jaw surgery) is necessary to correct the deformity, i.e. normalise the dentition, the facial skeleton and the appearance.

In his relationship with the orthodontist, the speech pathologist has specific information to offer. When orthodontic appliances are necessary for management, they must be planned so as not to interfere with the speakers’ articulation.

In consultation with the surgeon, the speech pathologist/therapist should emphasise the complete primary physical management that should be accomplished before the age of three years to enable each child to develop adequate speech and language and to avoid the frequent cleft palate stigmata. His/her primary responsibility to the team lies in the deep assessment of velar adequacy for speech. He/she emphasises on three methods of obtaining information — direct testing, information response and examiner observation. With the information obtained by these tests, the cleft-lip-and-palate child is given specific therapy.

The child may have voice problems along with impaired articulation. There will be excessive nasality, i.e hypernasality and the person may seem to be speaking through his nose. The speech seems to be punctuated by the little “catches of the breath”.

Some may have delayed language development, i.e slow in the development of the vocabulary and the length of utterance. His goal of treating a cleft-lip-and-palate child is to decrease the nasal emission, the hypernasality, the defective articulation, the improvement of adequate oral pressure and the oral airflow, the elimination of abnormal foci of tension, the abnormal nostril contraction, etc.

The treatment basically depends upon the individual’s problem and varies from person to person. With the help of breath direction exercises, muscle training exercises, blowing exercises and articulation therapy the child can get rid of his problem as early as possible.

In conclusion, as evident from the above discussion, the cleft-lip-and-palate child requires comprehensive treatment as he or she grows into adulthood. This is best achieved through a team approach, having a close and positive interraction between the team members, striving to give their best to this unfortunate group.

— Dr Y. Caplash has produced this piece with contributions from Dr G. Munjal and Ms Dimple Jain.

Pain: alternative therapies
By Dr K.C. Kanwar

PAIN in any form and of any type is never welcome. Even though it is biologically protective, it portends injury somewhere in the body and alerts and even forces the sufferer to undertake remedial measures. Dr Mitchell Max of the Pain Research Facility of the NIH Laboratories at Bethesda (USA) terms pain as “a burglar’s alarm nobody can shut off.”

Pain is not merely an inseparable affliction but also a drain on economy. Several working days are lost specifically to pain-related problems, thus causing collossal losses to economy — globally.

Medical science, over the years, has geared up to fight the pain menace but perhaps not very successfully. Complete and safe relief is still elusive for many suffering from chronic pains — may be of back (spine) or of joints or even those afflicted with recurrent headaches!

Such sufferers because of ineffective medication, get frustrated and depressed which aggravate further the original pain. Despite the inadequancy of the medical profession in managing pain, relief does not figure prominently in medical curricula.

Pain research over the years undoubtedly has achieved a lot but perhaps a lot more remains to be done, lament experts. “We have very poor understanding of who gets back pain and why, and our management of it leaves much to be desired”, says Dr Loeser, Director of Clinical Pain Service, University of Washington, Seattle (USA). The same despondency is witnessed with respect to joint pains. Arthritis, experts say, “has not always been easy to diagnose, much less to cure, on a permanent basis”. Therapies so far available to manage osteoarthritis or rheumatoid arthritis — may be physical exercise, heat fomentation or even the administration of gold salts — do not cure these aliments but simply help patients feel better and that too temporarily.

Similarly, cancer pain — the pain at its cruellest — is dreaded even by doctors who simply quieten down these by administering opiates or even heroin which are highly addictive and hesitantly prescribed for continuous use in only terminal cases. Even at present about 25 per cent of all cancer patients die in severe pain.

Society by and large has a strong anti-drug attitude, perhaps rightly so, as none of the pain-killers is considered safe for heavy and prolonged use. At the same time, if one is plagued by constant nagging pains and medically advised not to increase the prescribed doses of the pain-killers, few would blame them for “looking past the edge of estbalished medicine for comfort”. In fact, pain specialists are increasingly finding that some of the alternative unconventional approaches comprising hypnosis, acupuncture, meditation or massage can be useful as part of a comprehensive treatment programme. Doctors welcome these approaches of pain management since these do not involve the use of drugs and are, therefore, free of side-effects.

(To be concluded)

Depression: national disease?

HAMBURG: Depression is the world’s second most common illness, according to the World Health Organisation (WHO), trailing heart and circulatory disease in the number one spot.

In its current issue’s lead story, “Psychologie Heute” (psychology today), a German specialist magazine, calls depression a “national disease.” Depressions vary wildly in intensity and character, and an estimated 40 per cent of the depression cases in Germany go unrecognised and untreated.

Women, at least in the industrialised West, are about twice as likely to suffer from depression as men, says the WHO, and depression sufferers are getting younger and younger all the time.

Psychiatrists cite a mix of social and psychological factors and a chemical imbalance in the brain as the usual causes of depression, which is itself a blend of melancholy and unhappy feelings, dejection and hopelessness, but the whole depressive symptom complex has been a bit of a riddle for specialists.

Now, research results are beginning to point to another possible cause of depression — stress.

In the past several decades, the stress level in western societies like Germany’s has increased dramatically. American stress researcher Richard Rahe says the stress level has shot up 44 per cent since 1960, based on his own research, into subjects’ positive and negative life experiences.

The increased stress level seems to be the result of the growing confusion and complexity in day-to-day life and the need for people to become ever more flexible in adapting to rapidly changing circumstances and conditions. The skyrocketing insecurity in the working world also plays a role in the increasing stress level, as does the proliferation of information the average person thinks he has to assimiliate daily.

That unusually high stress can trigger a gamut of complaints — not just depression — has been known for a long time. A study of 6,000 senior German managers, conducted by the institute for work and social hygiene in Karlsruhe, revealed that 85 per cent of them reported suffering from non-specific discomforts that could not be traced back to any organic cause.

The Karlsruhe researchers suggested new candidate as the possible cause of the problems: above-average stress levels. If they’re right, the damage stress-related illnesses do the German economy annually is staggering — about $ 56 billion.

The reasons for the relatively high number of depressed women are relatively complicated. New studies suggest serious psychological trauma in childhood — traumas such as physical or sexual abuse — can cause later depression. Hormonally caused stress — such as stress related to menstruation, pregnancy, childbirth or the menopause — can also make women vulnerable to depressive episodes.

One other stress factor is more characteristic of women than of men — women tend to define themselves through their relations with other people. So they tend to react far more strongly to unsatisfactory relationships or the end of a relationship — even if the relationship involved is a platonic relationship rather than a love relationship.

Men, on the other hand, seem to suffer far more stress from problems or anxieties about personal status or work.

Psychological, social or physical factors can trigger a depressive episode individually or in combination. During a depression, says the American neurobiologist Antonio Damasio of the University of Iowa, the “soul is breathing through the body.” So to understand depression, says Damasio, you have to disentangle the tightly woven interaction of body and psyche. — DPA

Medicines cut AIDS risk in mothers

CHICAGO: Researchers trying to reduce the cost of preventing AIDS among the world’s poor have found that giving mothers standard medicines for just a week cuts the risk they will pass on the virus during childbirth by more than one-third.

Doctors have known for about five years that the drug AZT during pregnancy blocks HIV-infected mothers from giving the virus to their babies. However, such information is of little use in places such as Africa and India, where most mother-to-child transmission of AIDS occurs.

In wealthy countries, infected mothers typically receive five months of AZT, a treatment that can cost more than $ 1,000. Such therapy is impossible in places where even aspirin is unaffordable and prenatal care is unheard of.

Doctors reported yesterday that a far less intensive kind of treatment works reasonably well, even though not as effectively as the standard US approach.

Even if we start treating very late in pregnancy, we can make a difference,’’ said one of the researchers, Dr Joseph Saba of the United Nations AIDS Programme. He presented the results at the sixth conference on retroviruses and opportunistic infections.

If this or some similar approach is tried, it could have a major impact on the spread of AIDS during childbirth, which now accounts for nearly 600,000 HIV infections around the world each year.

The doctors experimented with three different regimens of two standard drugs — AZT and 3TC. A comparison group received dummy placeboes.

The study shows that to work at all, the medicine must be given when labour starts, and it must be given to both mother and child for a week following birth. This is to protect the child from exposure to AIDS-contaminated blood and secretions, as well as from virus in breast milk, which causes about one-third of all AIDS infections in the young.

The study found that when women got dummy pills, 17 per cent of their babies were infected. By comparison:

The infection rate was the same if the mother got AZT during labour but it was not given to both mother and child for the week following.

The infection rate fell to 11 per cent if the two drugs were given when labour started and continued for a week after birth.

It was 9 per cent if treatment began 26 weeks before delivery and continued for a week afterward. Those results were similar to a study last year from Thailand, which gave AZT for 26 weeks.

It’s a step toward producing something less complex, less costly and that has a better chance of working in the less developed world,’’ said Dr Constance Benson of the University of Colorado. — (AP)