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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 360-363
Folic acid in cleft lip, alveolus and palate prevention: Awareness among dental professionals

Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram, Chennai - 600 087, India

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Date of Submission10-Sep-2009
Date of Decision23-Oct-2009
Date of Acceptance21-May-2010
Date of Web Publication29-Sep-2010


Objectives : To determine the awareness amongst dental students, practitioners and maxillofacial surgeons the role of folic acid in the prevention of CLAP and its clinical use.
Materials and Methods : Questionnaire based study involving a sample base of 1100, comprising of dental students, practitioners and specialist maxillofacial surgeons.
Results : hundred percent of the sample population were aware of CLAP disorders, of which 9.5 % believed that CLAP could be prevented. 3.8 % of the population were able to correlate folic acid to CLAP while a negligible 0.03 % could provide the dosage.
Conclusion : Educating healthcare providers and, in turn, the prospective parents on benefits folic acid would not only help in reducing the incidence of CLAP but also significantly influence the economics of the patients afflicted with CLAP disorders.

Keywords: Cleft prevention, folic acid, folic acid awareness

How to cite this article:
Elavenil P, Murugavel C, Kannadasan K, Krishnakumar Raja V B, Gnanam A, Kanimozhi G, Davis D. Folic acid in cleft lip, alveolus and palate prevention: Awareness among dental professionals. Indian J Dent Res 2010;21:360-3

How to cite this URL:
Elavenil P, Murugavel C, Kannadasan K, Krishnakumar Raja V B, Gnanam A, Kanimozhi G, Davis D. Folic acid in cleft lip, alveolus and palate prevention: Awareness among dental professionals. Indian J Dent Res [serial online] 2010 [cited 2021 Nov 29];21:360-3. Available from:
Cleft lip, alveolus and palate (CLAP) is one of the most commonly seen congenital anomaly after congenital cardiac anomalies. [1] Because of the lack of an established registry for craniofacial deformities in India, the exact incidence is not available. The last dedicated multicenter study involving three cities in India and 94,906 births was conducted between 1994 and 1996. [2] The present incidence of cleft deformities however is around 1 in 800 live births in India, [3] which translates to around 30,000 new patients every year. This is a large number and when added to the number of individuals who have not been treated, gives us a huge figure as backlog. Various studies have been conducted and several factors have been attributed to the pathogenesis of CLAP, the commonly proposed etiological factors being genetics, drug abuse during pregnancy, stress and nutritional deficiencies during the gestational phase, consanguineous marriages, etc. [4],[5],[6],[7] CLAP deformities are completely correctable and provide the patient a chance to get back into normalcy with predictable quality of life. But, prevention of a condition when options are available is a much better option than the correction of the problem. The role of folic acid in the prevention of clefts has been proven beyond doubt by various studies. [8],[9],[10],[11],[12],[13] The use of folic acid as a prophylactic therapy to any woman of child-bearing age has been proven to decrease the incidence of orofacial cleft by as much as 85%, besides the other proven benefits of folic acid as a nutritional supplement. [9],[12],[13],[14] In financial terms, the staged management of a cleft child through his/her growing phase till adulthood may require a minimum of four surgeries and numerous speech therapy sessions, amounting to a minimum expenditure of approximately $92,000 while the use of folic acid as a prophylactic means may workout to be much cheaper, at approximately $750 for the entire period of the pre-pregnancy and perinatal phases. [1],[15] Although the discovery of the role of folic acid as the single most important prophylactic supplement was around two decades back, the benefits of the discovery are yet to be realized. The incidence of CLAP has remained the same and the associated benefits too have not been utilized solely due to the lack of awareness among the health care providers themselves. This study is an endeavor to assess the awareness of the benefits of folic acid among the dental professionals who play an important role in the diagnosis and management of cleft patients. It is the interest of the authors to pursue this study on a bigger scale and to enable education of health care providers on the preventive qualities of folic acid on congenital anomalies that may prove to be an important agenda on the national health care scheme in the years to come.


  • To assess the awareness among prospective dental professionals (dental students), practicing dentists and selected specialists (oral and maxillofacial surgeons) regarding prevention of CLAP.
  • To evaluate the existing knowledge among the sample group on the influence of folic acid in the prevention of CLAP.
  • To assess the working knowledge about folic acid and its clinical usage and implications.
  • To educate dental professionals on the methods of using folic acid in the prevention of CLAP.

   Materials and Methods Top

The study was designed as a questionnaire-based study involving a sample base of 1,100 individuals divided into three groups.

Group 1 consisted of 600 undergraduate students doing their bachelors in dental surgery.

Group 2 consisted of 400 dentists in private practice.

Group 3 consisted of 110 post-graduate trainees and trained specialists in the specialty of oral and maxillofacial surgery as they were actively involved in the management of CLAP.

Two questionnaires were formatted for this study. Questionnaire 1 was designed to assess the basic knowledge of the person regarding cleft lip and palate and its preventive methods. It contained questions on the clinical exposure of the person to clefts, prevalence in their families and their awareness about methods of prevention of CLAP.

Questionnaire 2 was focused on the awareness about folic acid in particular and its clinical use and prescription. It also contained a suggestion column on the person's ideas to improve awareness and methods of implementation of awareness programmes.

   Results Top

The following observations were made after assessment of the filled questionnaires [Figure 1]. According to the assessment, 100% of the samples in all the three categories were aware of CLAP disorders and their occurrence.
Figure 1 :Demonstrating the awareness status of the dental population on CLP, role of folic acid in CLP, folic acid therapy and dosage

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The number of samples interviewed who believed that CLAP could be prevented was as follows. Fifteen of the undergraduate population, 38 of the practicing dentists and 52 from the oral and maxillofacial trainees and specialists thought CLAP disorders could be prevented by various methods. The preventive methods that they suggested were documented as follows: (1) avoiding consanguineous marriages, (2) avoiding drug and substance abuse during pregnancy and (3) genetic counseling and screening tests.

A very small number from the population was able to correlate the influence of folic acid in the prevention of CLAP. Eighteen of the undergraduates, 16 of the practitioners and 18 of the specialist group were in this league. A negligible four persons in the whole sample population were able to answer questions related to the time of onset of folic acid therapy and frequency of the drug intake. But, no one was able to give the appropriate dosage regimens [Figure 1].

Statistical analysis

The statistical analysis for the study was performed by Chi-square test under four groups.

  • Awareness on whether CLAP can be prevented or not
  • Awareness on influence of folic acid on CLAP
  • Awareness regarding commencement of prophylactic therapy
  • Awareness on the dosage and frequency of prescription
The standard deviation values were 217.57, 37.84, 93.343 and 101.038, respectively, and all data were highly significant, with P-values <0.001 at 99.9%.

   Discussion Top

The use of folic acid has been shown to decrease the incidence of neural tube defects by almost 70%, and may be higher than the influence of consanguineous marriages as a single entity. [11] It was noted that in women who took 400 μg of folic acid in the time between their pre-marital examination and their first trimester, there was a decreased incidence of neural tube defects by more than 85% in a region with a high risk and by 40% in regions with low risk. [9] In prevention of CLAP disorders, prophylactic therapy with folic acid may reduce the incidence by almost 30%. [13] It is also of significance that women produce autoantibodies against the folate receptors, preventing the binding and transport of folic acid to cellular components during critical periods of embryonic development. Supplemental folic acid competes with the autoantibodies and restores cellular folate. [16] Although the importance of folic acid in the prevention of CLAP was recognized and accepted worldwide, [8],[9],[10],[11],[12],[13],[17] its practical implementation has eluded reality. The main reason for this is the extremely low degree or, in certain cases, lack of awareness among the medical population and health care providers who actually interact with people affected by CLAP. [18],[19],[20] It has been found that proper counseling of prospective mothers and their education is the best means of achieving the goal of prevention. [9],[11],[18],[19],[20],[21] For this to occur, health care providers need to be aware and have to be educated with the benefits as well as clinical usage of folic acid.

The aim of this study was to evaluate awareness among the dental professionals who form a part of the global community of health care providers. This included students, practicing dentists and specialists - in this case, oral and maxillofacial surgeons (post-graduate trainees and qualified consultants) - as they were clinically associated more with the management of patients with CLAP. The objective of this study was to determine the reality situation among this population in relation to the knowledge about folic acid and its role in the prevention of CLAP. This would form a stable platform based on which awareness programmes can be planned and initiated. The effect of folic acid in the prevention of other neural tube defects and its value as an important micronutrient in a balanced diet also needs to be highlighted. This study would also form a basis to increase the impact of health promotion campaigns for the prevention and management of CLAP disorders.

This article also aims at educating the health care professionals on the basics of folic acid, its benefits and the mechanism of action of folic acid in the prevention of CLAP.

Other benefits of folic acid

  1. Preventive role in neural tube defects apart from CLAP
  2. Helps in prevention of cardiovascular diseases, especially fetal coronary heart diseases
  3. Helps in prevention of age-related hearing loss
  4. Helps combat adverse effects of methotrexate in anti-cancer therapy
  5. Important role in the prevention of psychological depression
  6. Has been proven to have a role in the prevention of psoriasis [22],[23],[24]

Chemistry and pharmacotherapy

Folic acid is pteroyl mono glutamic acid. It is a synthetic compound used in dietary supplements and fortified food. The term folate includes all components that have the vitamin properties of folic acid, including folic acid and its naturally occurring compounds in food, which are leafy green vegetables, fruits, dried beans and peas.

Mechanism of action

Folic acid is an essential component in the development and maintenance of cells and tissues. It is necessary for homocysteine metabolism. Folic acid also plays a vital role in the synthesis of DNA and RNA, which are the building blocks of cells. They are essential for the synthesis of puridine, thymidylate and methionine.

Effective forms of administration

Blood folate concentrations are increased much more by folic acid supplementation than by naturally occurring folate in the diet. Recommended dietary allowance for folates [25] can be prescribed for

  1. Adults
  2. Women of child-bearing age [Table 1]
Table 1 :Folic acid dosage regimens for women of child-bearing age

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Normal adults are prescribed a daily intake of 400 μg of folate. Administration of folic acid in excess of 1,000 μgm may mimic symptoms of Vitamin B12 deficiency, especially the changes in the nervous system in elderly people.

Women of child-bearing age

  1. Protocol
  2. Time of administration

All persons interviewed had a basic knowledge about CLAP and were aware of the defect and its occurrence. But, the percentages varied widely when they were questioned on the preventive aspects of CLAP. The undergraduates showed minimal awareness and the specialists showed the maximum awareness due to the extent of inclusion of CLAP and related disorders in their core curriculum. Oral and maxillofacial surgeons are the most actively involved specialty in the management of CLAP, and it forms an integral part of their curriculum and training. Hence, they were the group that had the highest percentage in terms of awareness and prevention concepts. But, the awareness about the role of folic acid and its influence on neural tube defects and CLAP was very poor in all the groups, with the specialists having a marginal edge. This may be attributed to the omission of clinical information about folic acid in their standard reference and study materials. A negligible number of four individuals were able to answer questions on the commencement and ideal timing of therapy, while none were aware of the exact dosage and frequency. Of the four individuals, three were specialists who had attended a lecture on the role of folic acid in CLAP during their post-graduate training period, while one was an intern who was pregnant at the time of the interview and was educated about the benefits of folic acid during her perinatal counseling by her obstetrician.

Hundred percent of the population voiced the opinion that awareness about the benefits of folic acid was very poor. The omission of these details in text books was quoted as one main reason for even specialist trainees not being aware of the benefits of folic acid. Use of media publicity, government policy for cleft prevention and use of celebrities as ambassadors to endorse awareness programmes were the modes suggested as a means for increasing awareness for the public.

This study is a practical eye-opener of the current status of a segment of health care providers to awareness of folic acid therapy and its benefit. A proper implementation of educating the healthcare providers and, in turn, the prospective parents would not only help in reducing the incidence of CLAP but also significantly influence the economics of the patients afflicted with CLAP disorders, their parents and the society as studies have shown that the preventive costs for a disorder are negligible compared to the large expenses borne for their treatment. [1],[26],[27]

   References Top

1.Wyszynski DF. Cleft lip and palate - from origin to treatment. Vol. 35. Oxford: Oxford University Press; 2002. p. 458-67.  Back to cited text no. 1      
2.World Health Organisation. Global registry and database on craniofacial anomalies: Report of a WHO registry meeting of craniofacial anomalies. WHO library cataloguing-in-publication data, 2001.  Back to cited text no. 2      
3.Raju S. In search of a smile-study of children born with cleft lip and palate in India. Tata Institute of Social Sciences: Mumbai; 2000. Available from: [last cited on 2009 Aug 15].  Back to cited text no. 3      
4.Beaty TH, Maestri NE, Hetmanski JB, Wyszynski DF, Vanderkolk CA, Simpson JC, et al. Testing for interaction between maternal smoking and TGFA genotype among oral cleft cases born in Maryland 1992-1996. Cleft Palate Craniofac J 1997;34:447-54.  Back to cited text no. 4  [PUBMED]    
5.Kondo A, Kamihira O, Ozawa H. Neural tube defects; prevalence, etiology and prevention. Int J Urol 2009;16:49-57.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Murray JC. Gene/Environmental causes of cleft lip and/or palate. Clin Genet 2002;61:248-56.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Zeiger JS, Beaty TH, Liang KY. Oral clefts, maternal smoking and TGFA: A meta-analysis of gene-environment interaction. Cleft Palate Craniofac J 2005;42:58-63.  Back to cited text no. 7  [PUBMED]    
8.Folic acid for the prevention of neural tube defects. American Academy of Pediatrics. Committee on Genetics. Pediatrics 1999;104:325-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, et al. Prevention of neural tube defects with folic acid in China. N Engl J Med 1999;341:1485-90.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Czeizel E, Timar L, Sarkozi A. Dose dependent effect of folic acid on the prevention of orofacial clefts. Pediatrics 1999;104:e66.  Back to cited text no. 10      
11.Jaber L, Karim IA, Jawdat AM, Fausi M, Merlob P. Awareness of folic acid for prevention of neural tube defects in a community with high prevalence of consanguineous marriages. Ann Genet 2004;47:69-75.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Loffredo LC, Souza JM, Freitas JA, Mossey PA. Oral clefts and vitamin supplementation. Cleft Palate Craniofac J 2001;38:76-83.  Back to cited text no. 12  [PUBMED]    
13.O′Neill J. Do folic acid supplements reduce facial clefts? Evid Based Dent 2008;9:82-3.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Ray JG, Meier C, Vermeulen MJ, Wyatt PR, Cole DE. Association between folic acid fortification and congenital orofacial clefts. J Pediatr 2003;143:805-7.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Waitzman NJ, Romano PS, Scheffler RM. Estimates of the economic costs of birth defects. Inquiry 1994;31:188-205.  Back to cited text no. 15  [PUBMED]    
16.Rothenberg SP, da Costa MP, Sequeira JM, Cracco J, Roberts JL, Weedon J, et al. Autoantibodies against folate receptors in women with a pregnancy complicated by a neural-tube defect. N Engl J Med 2004;350:134-42.  Back to cited text no. 16      
17.Tolarova M. Periconceptional supplementation with vitamins and folic acid to prevent recurraence of cleft lip. Lancet 1982;2:217.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Bener A, Al Maadid MG, Al-Bast DA, Al-Marri S. Maternal knowledge, attitude and practice on folic acid intake among Arabic Qatari women. Reprod Toxicol 2006;21:21-5.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Ren A, Zhang L, Li Z, Hao L, Tian Y, Li Z. Awareness and use of folic acid, and blood folate concentrations among pregnant women in northern China: An area with a high prevalence of neural tube defects. Reprod Toxicol 2006;22:431-6.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Nawapun K, Phupong V. Awareness of the benefits of folic acid and prevalence of the use of folic acid supplements to prevent neural tube defects among Thai women. Arch Gynecol Obstet 2007;276:53-7.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Shaw GM, Nelson V, Carmichael SL, Lammer EJ, Finnell RH, Rosenquist TH. Maternal preconceptional vitamins: Interactions with selected factors and congenital anomalies? Epidemiology 2002;13:625-30.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Braun RD. Serum folate and risk of fatal coronary heart disease. JAMA 1996;275:1893-6.  Back to cited text no. 22      
23.Fry L, Macdonald A, Almeyda J, Griffin CJ, Hoffbrand AV. The mechanism of folate deficiency in psoriasis. Br J Dermatol 1971;84:539-44.   Back to cited text no. 23  [PUBMED]    
24.Houston DK, Johnson MA, Nozza RJ, Gunter EW, Shea KJ, Cutler GM, et al. Age-related hearing loss, vitamin B-12 and folate in elderly women. Am J Clin Nutr 1999;69:564-71.   Back to cited text no. 24  [PUBMED]  [FULLTEXT]  
25.Food and Nutrition Board, Institute of Medicine, National Academies. Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Vitamins, 2004.  Back to cited text no. 25      
26.Sayed AR, Bourne D, Pattinson R, Nixon J, Henderson B. Decline in the prevalence of neural tube defects following folic acid fortification and its cost benefit in South Africa. Birth Defects Res A Clin Mol Teratol 2008;82:211-6.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]  
27.Bower C, Stanley FJ. Case for mandatory fortification of food with folate in Australia, for the prevention of nueral tube defects. Birth Defects Res A Clin Mol Teratol 2004;70:842-3.  Back to cited text no. 27  [PUBMED]  [FULLTEXT]  

Correspondence Address:
P Elavenil
Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram, Chennai - 600 087
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.70802

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