Global oral health inequalities: challenges in the prevention and management of orofacial clefts and potential solutions

Abstract

The birth prevalence of orofacial clefts, one of the most common congenital anomalies, is approximately one in 700 live births, but varies with geography, ethnicity, and socio-economic status. There is a variation in infant mortality and access to care both between and within countries, so some clefts remain unrepaired into adulthood. Quality of care also varies, and even among repaired clefts there is residual deformity and morbidity that significantly affects some children. The two major issues in attempts to address these inequalities are (a) etiology/possibilities for prevention and (b) management and quality of care. For prevention, collaborative research efforts are required in developing countries, in line with the WHO approach to implement the recommendations of the 2008 Millennium Development Goals (www.un.org/millenniumgoals). This includes the "common risk factor" approach, which analyzes biological and social determinants of health alongside other chronic health problems such as diabetes and obesity, as outlined in the Marmot Health inequalities review (2008) (www.ucl.ac.uk/gheg/marmotreview). Simultaneously, orofacial cleft research should involve clinical researchers to identify inequalities in access to treatment and identify the best interventions for minimizing mortality and residual deformity. The future research agenda also requires engagement with implementation science to get research findings into practice.

Fig. 1.

Results of fixed-effects meta-analysis of the relative risk of cleft lip, with or without cleft palate, in the offspring of mothers who smoked during pregnancy compared with the offspring of mothers who did not smoke. Note: This Forrest plot is for demonstration purposes and the articles referred to in this meta analysis do not appear in the references.

Fig. 2.

Manhattan plots of −log₁₀ (p-values) from conventional transmission disequilibrium tests (TDT) for a genome-wide panel of autosomal SNPs on CL/P case-parent trios. Chromosomes are denoted by alternating blue and green colors. SNPs flagged for any QC metric are omitted. Results based on 1908 CL/P trios. Reproduced with permission from Beaty et al., 2010.

Fig. 3.

Flow chart with features of current NIH-funded trial of the timing of surgery for CP.

Fig. 4.

Access to care as indicated by age at primary surgery. Reproduced with permission from B. Modell of the London School of Hygiene and Tropical Medicine, London, UK.