Dysphagia Research Articles

Parents’ views and experiences of raising babies born with cleft lip and palate: a qualitative study

BackgroundParents of children born with cleft lip/palate encounter numerous challenges. This study aims to provide a deeper understanding for authorities to better support these parents by exploring the views and experiences of Iranian parents raising babies with cleft lip/palate through qualitative research.MethodsThis qualitative study collected data through face-to-face, in-depth, semi-structured interviews. Using purposive sampling, parents of children with cleft lip/palate who visited the Department of Oral and Maxillofacial Surgery at the Children’s Medical Center in Tehran, Iran, were selected. Thematic content analysis was employed to interpret the data and identify themes and subthemes.ResultsFrom 20 interviews, six themes were identified. The diagnosis theme was associated with timing. Key concerns within the psychosocial experiences theme included initial reactions, pressure from society, the child’s future in the community, hiding from family, feeling guilty about the anomaly, and couples’ relationships. The challenges in childcare theme included feeding difficulties, financial challenges, and cleft treatments. The information acquisition theme included primary awareness and the importance of knowing how to care for the child. The coping theme included gaining awareness, accepting the problem as God’s will and destiny, minimizing the significance of the child’s cleft, and support. Parents had concerns about informing the child of his/her condition.ConclusionsParents of infants with cleft lip/palate feel unsupported by medical staff in feeding practices and seek improved training for staff. They propose a program to empower staff and advocate for psychological support for parents. Access to specialized baby bottles and financial support is crucial, along with establishing a parent-led community for sharing experiences.

Gastrostomy tube feeding in children: a single-center experience

BackgroundDespite the widespread use of percutaneous endoscopic gastrostomy (PEG) in pediatric populations, there is a paucity of data on the indications and outcomes of this procedure in Switzerland. This manuscript presents our experience with PEG indication, outcomes, and related complications in children.MethodsThis single-center retrospective study included patients < 18 years old who underwent PEG placement between 2007 and 2016. We retrieved demographics, PEG indications, associated comorbidities, pre-placement workup, growth parameters up to 12 months, and associated complications.ResultsEighty-one patients were included, with a median age of 7 years. Common indications included inadequate caloric intake (85%), failure to thrive, and feeding difficulties. Neurological conditions (46%) were the most commonly associated comorbidity. Thirty-six patients (44%) underwent a pH study before PEG placement. There were significant increases in z-scores for weight (p < 0.002) and body mass index (p < 0.001) 12 months after PEG placement. Minor complications were relatively frequent (n = 55, 68%), mainly granulation tissue or local erythema. Two patients had major complications.ConclusionPEG is a safe technique for providing long-term enteral nutrition in children, with neurological disease being the most common clinical indication. Our experience demonstrated significant weight gain in children after one year of PEG, with frequent but well-controlled complications.

Assessing neonatal nurses: transitioning preterm infants to oral feeding - a multicenter cross-sectional study

BackgroundIn Egypt, approximately 10% of preterm deliveries occur between 32 and fewer than 37 weeks, leading to high neonatal intensive care unit (NICU) admissions. Preterm infants often face oral feeding difficulties due to immature development, which can lead to extended hospital stays and increased health risks.AimTo assess neonatal nurses’ performance in terms of the transition to oral feeding in preterm infants, focusing on knowledge, practices, and attitudes.MethodsA descriptive, quantitative, multicenter, cross-sectional study was conducted across 16 hospitals in five governorates in Egypt from November 2023 to March 2024 involving 553 neonatal nurses. The data were collected through a self-administered questionnaire assessing knowledge and attitudes and through an observed checklist for nurses’ practices. The study used statistical methods, including binary logistic regression, to analyze the data.ResultsThe findings revealed significant knowledge gaps among nurses, particularly in terms of oro-motor function, suck-swallow-breathe patterns, and nonnutritive sucking. A total of 64.6% of the nurses had unsatisfactory knowledge, 58.6% had unsatisfactory practices, and 45% had a negative attitude toward the oral feeding transition. Key predictors of satisfactory practices included higher education levels, full-time employment, and positive attitudes.ConclusionThis study highlights critical gaps in neonatal nurses’ knowledge and practices regarding the transition to oral feeding in preterm infants. Addressing these gaps through targeted educational interventions and ongoing support is essential for improving care quality and outcomes for infants. The findings revealed that a substantial proportion of nurses lacked adequate knowledge of critical areas, such as oro-motor function, the suck-swallow-breathe pattern, and nonnutritive sucking. These knowledge deficits could hinder the ability of nurses to provide optimal care during this crucial transition.

Complementarity of biomarker screening and genetic analyses based on the case of an attenuated multiple sulfatase deficiency.

Multiple sulfatase deficiency (MSD) is an ultra-rare lysosomal disease caused by defective activation of cellular sulfatases comprising clinical features of mucopolysaccharidoses, sphingolipidoses, and other sulfatase deficiencies. We present a case of an infant with feeding difficulties related to autism spectrum disorder (ASD) who was diagnosed at 10months of age with MSD by next-generation sequencing (NGS). Biochemical results obtained in dried blood spot (DBS) samples were inconsistent and not suggesting MSD in the light of identified pathogenic SUMF1 variants. However, follow-up analyses at 20months of age revealed an increased concentration of sulfatides in DBS. It should be noted that biochemical tests, routinely used as screening methods, have a risk of false negative results, especially regarding mild/attenuated phenotypes, as presented in our report.

Lived experiences of dysphagia-related quality of life among esophageal cancer patients: a qualitative study

IntroductionEsophageal cancer impairs basic functions such as eating and drinking frequently resulting in difficulty swallowing (dysphagia) and other problems such as weight loss, pain, fatigue, and taste alterations. There is still a research gap in understanding the impact of dysphagia on quality of life, as patients continue to bear significant physical and psychological burdens despite advances in treatment. This study attempted to address this gap by examining the lived experiences of dysphagia-related quality of life among esophageal cancer patients.MethodsA phenomenological study was employed to analyze the data provided by 14 patients with esophageal cancer at the Oncology Center of the University of Gondar Comprehensive Specialized Hospital from March to April 2023. An interview guide was employed to carry out in-depth interviews with purposively selected patients. The interviews were audio-taped, translated, transcribed, and analysed using thematic analysis.ResultsThree main themes emerged from the analysis of the participant interviews: physical challenges related to difficulty swallowing, altered dietary habits, and struggle to maintain weight; psychosocial strain, including emotional distress and social isolation; and reliance on assistance, encompassing both dependency and financial burden.Conclusion and recommendationsThis study underscores the significant physical, emotional, and social challenges experienced by esophageal cancer patients with dysphagia. To enhance support, healthcare providers should develop personalized care plans that address both the physical and emotional aspects of dysphagia, with sensitivity to cultural practices. Efforts should also be made to alleviate feelings of dependency and promote public awareness to reduce stigma and build a more supportive community.

Histoire naturelle des allergies alimentaires non IgE-médiées

Non-IgE-mediated food allergies are adverse immune reactions to certain food allergens that are specific for a given individual, but do not involve specific serum IgE antibodies. They mainly affect infants and young children. They include allergic proctocolitis, food protein-induced enterocolis syndrome (FPIES), allergic enteropathy, aspecific digestive dysmotility (e.g., severe reflux, constipation) and certain eosinophilic oesophagitis (EoE) responding to the avoidance diet. The most common allergen involved is cow's milk, but other foods may be responsible, particularly in breast-fed infants, although this is rare. The main symptoms are haematochezia in allergic proctocolitis, acute vomiting with pallor and hypotonia in FPIES, stunted growth and chronic diarrhoea in allergic enteropathy, and reflux with feeding difficulties in infantile EoE. Eviction-reintroduction of the suspected allergen is used as a diagnostic test in allergic proctocolitis and enteropathy. In FPIES, there is a clinical definition. For EoE, histological analysis of oesophageal biopsies makes the diagnosis after elimination of differential diagnoses. Treatment involves avoiding the allergen responsible until tolerance is acquired. With the exception of EoE, the course of the disease is favourable in the first 2–3 years of life. There is a risk of developing functional intestinal disorders and atopic diseases. EoE is a chronic disease, with possible cases of remission in paediatrics. The main complications are oesophageal stenosis, food impaction and oesophageal perforation.

Longitudinal Outcomes in Noonan Syndrome

Longitudinal Outcomes in Noonan Syndrome

Outpatient Infant Botulism in the United States, 1976-2021

To characterize cases of outpatients with infant botulism (IB) in the US identified by the Infant Botulism Treatment and Prevention Program at the California Department of Public Health from 1976 through2021. Outpatient IB cases were defined as patients presenting with an illness consistent with the known paralyzing action of botulinum neurotoxin and with laboratory confirmation. Outpatient cases were distinguished from the majority of patients with IB by the atypical fact that they did not require hospitalization throughout the course of their illness. Of the 4372 cases of IB identified by the Infant Botulism Treatment and Prevention Program over a 45-year period (1976-2021), 17 (0.4%) were outpatient cases. Most (11/17; 65%) cases occurred in California. The median age at disease onset was 20weeks (range=6 to 55weeks). The most common symptom among cases was constipation (16/17; 94%). Most patients (16/17; 94%) had at least one cranial nerve palsy, manifested as decreased head control, ptosis, weak cry, or poor suck. Outpatient IB occurs nationwide, although clinical diagnosis may be difficult because the severity of symptoms do not necessitate hospitalization or more comprehensive clinical intervention. Identification of outpatient cases requires an astute clinician and a capable, willing diagnostic testing laboratory. It is likely that more outpatient cases of IB are occurring than are presently recognized in infants mildly affected by this disease. Healthcare providers should consider the possibility of IB when presented with a previously well infant with failure to thrive, poor feeding, constipation, mild hypotonia, or cranial nerve palsy.

Enhanced oral absorption and biodistribution to submandibular salivary glands of D-limonene in Sprague Dawley rats via a liquid-lipid formulation approach.

Decreased saliva production due to salivary gland damage can result in difficulty speaking and swallowing, significantly reducing quality of life for head and neck cancer patients receiving radiotherapy. It is therefore imperative that treatment options are available to mitigate the effects of these debilitating side effects. D-limonene, a naturally occurring terpene, has shown protective effects on saliva production during radiotherapy treatment of mice, however the lipophilic nature of the molecule has necessitated a high oral dose to facilitate sufficient absorption. In this study, lipid-based drug delivery systems have been utilised to formulate D-limonene in order to reduce undesirable gastrointestinal side effects and increase solubility for enhanced absorption. Lipid-based formulations produced up to 180-fold increased solubility over pure D-limonene, coupled with enhanced storage stability and protection against oxidation. Furthermore, pharmacokinetic evaluation of optimised lipid-based formulations in Sprague Dawley rats displayed up to a 51.25-fold increase in bioavailability relative to pure oral D-limonene. Finally, elevated levels of lipid-formulated D-limonene were localised within the submandibular salivary glands, indicating potential for local action on saliva production. Overall, the administration of D-limonene utilising lipid-based formulations shows significant promise for advancing prevention and treatment strategies for xerostomia.

Characterization of feeding practices in children

Introduction: nutrition, in addition to being the basis of a set of eating habits, adheres to the need with which food intake must meet the daily needs demanded by life and physical activity.Objective: to characterize eating practices in children.Method: a review of the available literature in databases such as SciELO, Scopus and ClinicalKey was carried out, from which a total of 15 related articles were consulted, empirical methods such as logical history and analysis and synthesis were used.Results: individuals in charge of children should wash their hands before preparing food and those of children before eating. Food should be preserved and stored safely and served immediately after preparation. Poor feeding practices and infections, often aggravated by poverty, humanitarian crises and conflicts, deprive them of adequate nutrition. Nutritional status is based on being the result of the intake and energy needs in the body, expressing a degree of well-being of people.Conclusions: a diet must be ensured that includes all the necessary foods to satisfy the nutritional and energy needs of the child in order to avoid diseases and ensure an optimal state of health

Prevalence of Foot and Mouth Disease in Cattle of District Buner, Pakistan

Background: Foot and Mouth disease (FMD) is infectious disease in cattle caused by a virus of the family Picornaviridae, also known as Rhino virus. The disease is characterized by large fever, appears lesions in the buccal cavity due to lesions in buccal mucosa the cattle face the difficulties in feeding. Affected animals have a high temperature, which is followed by the development of blisters chiefly in the mouth and on the feet. This disease cause loss of appetite, loss of weight, reduce milk production, miscarriage also occurs in this disease and sometime it may lead to death mostly in young ones. Objective: This study aimed to assess the Prevalence of Foot and mouth disease in district Buner. Methods: The present study was conducted on the Prevalence of Foot and Mouth disease in district Buner, Pakistan during August 2023 to August 2024. During the outbreak we were visited to the local community, DVM doctors. Livestock office of district Buner, veterinary assistance, Doctors etc. In this outbreak large number of economic loses were reported of FMD among the farmers community. Results: During the study a total of (n=3565) cases of animals (cattle) of Foot and mouth disease were reported, in which (n=439) (12.3%) death cases were reported. The total recovered cases of Foot and Mouth disease were (n=2817). During the outbreak there are around (36612) cattle were vaccinated in district Buner. The study area was divided into six different tehsils. Conclusion: The most affected tehsil during the outbreak was Mandanr. Tehsil Gadezi are highly effected in which (n=1105) cases were reported with mortality rate of (n=9.5%). The most rear effected tehsil was Gagra in which only (n=286) cases of FMD were reported with mortality rate (n=17.4%).

Diphtheria Outbreak in Serang City, Banten, Indonesia, 2024: Epidemiological Investigation and Response

Diphtheria is an infectious disease and often causes outbreak. Despite a significant global decrease in diphtheria cases due to effective vaccines, there's still a risk transmission for individuals who unvaccinated or incompletely vaccinated. A positive culture for Corynebacterium diphtheriae was reported in a diphtheria suspect in Serang City and an outbreak investigation was carried out. This study aimed to investigate the outbreak, identify risk factors, and recommend control measures. Data were collected through interviews and field observations to close contacts consist of household contacts, neighbors and school and we reviewed immunization coverage from the Public Health Center. Based on the investigation, it was shown that a 6 years-old male with signs and symptoms of Fever, Sore Throat, Swollen Neck, Pseudomembrane, difficulty swallowing, mouth ulcers, cough and vomiting, and positive results for toxigenic corynebacterium diphtheriae var intermedius. Risk factors for transmission are low immunization coverage, high population density, and mobilization. No additional cases were identified, but some close contacts were at risk of transmission due to unvaccinated. We recommend implementing Outbreak Response Immunization (ORI) as a critical measure to interrupt transmission.

Obstructive Sleep Apnea and a Maxillomandibular Advancement: Does Maxillomandibular Advancement have more success than nonsurgical treatment in decreasing OSA?

Introduction: Takotsubo syndrome (TTS) is a cardiomyopathy triggered by emotional or physical stress. This case report presents a unique instance of TTS associated with myasthenia gravis (MG) in which myasthenic crisis developed after TTS diagnosis and not before. Case Description: A 73-year-old man presented with difficulty swallowing, dysphonia, and dyspnea, showing moderate-severe left ventricular dysfunction. Blood tests revealed elevated troponin and BNP levels, while the ECG at the arrival showed an ST-elevation in anterior leads. Coronary angiography showed normal aspect of coronary vessels. Echocardiography confirmed TTS with apical ballooning. After few days, myasthenic symptoms emerged leading to a myasthenic crisis. The patient improved with acetylcholinesterase inhibitors and was discharged with pyridostigmine and prednisone. Follow-up revealed complete resolution of left ventricular dysfunction. Discussion: MG rarely affects the heart, but in this case, it led to TTS. Notably, TTS occurred before the myasthenic crisis, emphasizing the need for cardiac monitoring in patients with new neurological diagnoses and acute respiratory.

A retrospective descriptive cross-sectional study of Oral Dosage Form Administered in The Form of Suspension to ICU Patients at Hospital X

Patients in the intensive care unit were often very sick and had lost consciousness. Because they had trouble swallowing, individuals with reduced awareness frequently depended on enteral tubes (NGT) for their daily medical and nutritional requirements. Since not all medications were accessible in parenteral forms, patients who relied on enteral tubes often had issues, including drug stability. Many problems arose in clinical usage when the medication was crushed or suspended and put into the NGT, including drug obstruction in the enteral tube and a reduction in drug stability as a result of the dose form being altered, making the drug unstable. Thus, this study aimed to ascertain the stability of oral suspension medications given to intensive care unit patients. The medical records of intensive care unit patients who had received oral medication therapy at X Hospital in Jakarta were examined retrospectively using a cross-sectional, descriptive approach. According to the statistics, coated tablets accounted for 68% of the most frequently used oral medication preparations. It was highly likely that crushing the coated tablets and administering them via NGT had resulted in tube obstruction. Additionally, 59.26% of the medications used had exhibited hygroscopic qualities, and several had been readily hydrolyzed. Based on these findings, it was concluded that oral medications, particularly crushed-coated tablets, could negatively affect drug stability. Active substances with hygroscopic properties and those prone to hydrolysis were also identified as potential contributors to instability.

The Effect of Feeding Rules Counseling with Flipcharts on Maternal Knowledge about Overcoming Feeding Difficulties During MP-ASI

Feeding dificulties are the frequent problem encountered in infants aged 6-24 months, and one of which is mothers' knowledge in feeding practices. Therefore, providing counseling on feeding rules to mothers is crucial to address the feeding difficulties in infants. Feeding rules are basic eating guidelines designed to train internal eating regulation and provide a structured feeding schedule. The media used is flipchart. This Research is conducted to analyze the effect of counseling on feeding rules using a flipchart on mothers' knowledge in addressing feeding difficulties during complementary feeding (MP-ASI). This is a quantitative Research with a pre-experimental one-group pre-posttest design. A purposive sampling is used to collect data from 69 respondents who meet inclusion criteria: mother with infants aged 6-24 months experiencing feeding difficulties in Lama Village, Hamparan Perak Subdistrict, Deli Serdang Regency. The findings reveal that counseling on feeding rules using a flipchart has a significant effect on mothers' knowledge in addressing feeding difficulties during complementary feeding (MP-ASI), as indicated by the Paired T-Test statistical test with a p-value of 0.000 (&lt;0.05). It is expected that mothers with infants having feeding problems are able to perform feeding rules to address the feeding issues. Furthermore, the results of the Research are expected to serve as an evaluation for healthcare workers to enhance counseling on feeding rules in the community.

Simulation of Flax Threshing Process by Different Forms of Threshing Drums in Combined Harvesting

Flax, an important oil and fiber crop, is widely cultivated in temperate and sub-frigid regions worldwide. China is one of the major producers of flax, with Gansu Province predominantly practicing cultivation in hilly areas. However, common issues such as feeding difficulties, stem entanglement, and low threshing efficiency significantly restrict the improvement of planting efficiency. This study addresses the key technical challenges in flax combine harvesting in hilly regions by developing a discrete element model of the flax plant and utilizing DEM-FEA co-simulation technology. The performance of two threshing drum models (T1 and T2) was analyzed, focusing on motion trajectory, stress distribution, and threshing effects. The simulation results show that the T2 model, with its combination of rib and rod tooth design, significantly improves threshing and separation efficiency. The loss rate was reduced from 5.6% in the T1 model to 1.78% in the T2 model, while the maximum stress and deformation were significantly lower, indicating higher structural stability and durability. Field validation results revealed that the T1 model had a total loss rate of 3.32%, an impurity rate of 3.57%, and an efficiency of 0.09 hm2/h. In contrast, the T2 model achieved a total loss rate of 2.29%, an impurity rate of 3.39%, and an efficiency of 0.22 hm2/h, representing a 144.4% improvement in working efficiency. These findings indicate that the T2 model has a higher potential for flax harvesting in hilly and mountainous regions, especially in improving threshing efficiency and operational stability, providing an important theoretical basis for optimizing threshing equipment design.

Short- and Long-Term Swallowing Outcomes in Head and Neck Cancer Patients Receiving TORS and Adjuvant Therapy.

Dysphagia (difficulty swallowing) is a common morbidity resulting from the treatment of head-and-neck squamous-cell carcinoma (HNSCC) due to surgery and chemoradiation. Transoral robotic surgery (TORS) is a minimally invasive surgical technique for the management of HNSCC, which ideally avoids many of the known complications of open surgery. Research describing physiologic swallowing impairment after surgery using videofluoroscopy is lacking. We evaluated videofluoroscopic swallowing studies of 37 patients who received TORS for head and neck cancer using a validated scoring tool, the Modified Barium Swallow Impairment Profile (MBSImP), at three time points including baseline. Patients had worsened physiologic impairments in the immediate post-operative and late post-operative periods, particularly in components related to airway protection. Many patients also had baseline swallowing impairment. Further research is required to elucidate dysphagia at discrete time points before and after treatment as well as with different and evolving adjuvant therapy protocols.

Nutritional Risk Screening and Nutritional Assessment for Children with Cerebral Palsy: a Review of the Current Research Status and Future Directions.

Although the primary impairment involved in Cerebral palsy (CP) is motor function, malnutrition is also common. However, there is a lack of tool recommendations for early malnutrition risk screening in children with CP, and the means of nutritional intervention for children with CP are also limited. This study systematically searched the literature about clinical nutrition related content of cerebral palsy in Pubmed, MEDLINE, Embase, and the Cochrane Library in Jan 2024 and by hand searching, and we checked reference lists and citations to identify additional studies. Search terms include cerebral palsy, children, diagnosis, prediction, malnutrition, nutritional risk screening, nutritional assessment, nutritional support. Additions are marked in red in the modified version. The timing of diagnosis of CP has been moving forward, and some new diagnostic tools have been developed. Nutritional status is correlated with regional economic level, but there is still a malnutrition rate of nearly 30% in developed countries. Severe restrictions in terms of gross motor function, swallowing dysfunction, feeding difficulties, cognitive impairment, and insufficient energy intake are common risk factors for malnutrition in children with CP. Z-score should be calculated in combination with measurement indicators in the assessment of physical development of children with CP. The nutritional outcomes of children with CP can be improved by various means, including diversified a Nutrition Support Team (NST) interventions. The incidence of malnutrition in children with CP is high, which needs to be paid more attention. More effective malnutrition risk screening tools need to be developed for children with CP to guide the implementation of comprehensive and personalized nutritional interventions and improve malnutrient-related outcomes.

Breastfeeding Journeys: Comparing Mothers' Experiences with Autistic and Neurotypical Infants.

Breastfeeding is a complex task that requires proficiency at several key developmental skills to feed successfully. It is unclear how Autism Spectrum Disorder (ASD) affects an infant's breastfeeding experience and conflicting reports exist on shortened breastfeeding duration in infants later diagnosed with ASD. The purpose of this study was to describe the experiences of mothers breastfeeding both their autistic and neurotypical children to better understand the differences in their breastfeeding experiences and maternal and infant factors that contributed to breastfeeding cessation in their autistic child. Twenty-four mothers of an autistic child who had feeding difficulties in the first 12 months of life, initiated breastfeeding, and also had a neurotypical child participated in semi-structured interviews regarding breastfeeding initiation, cessation, and challenges encountered during breastfeeding. Analysis revealed four major themes: (1) the struggle with latch, including infant behavior that hindered latching; (2) breastfeeding challenges, including problematic breastfeeding behavior by the infant; (3) cessation of breastfeeding, including physical symptoms of the infant that lead to breastfeeding cessation; and (4) breastfeeding the neurotypical sibling, including mother's detection of different breastfeeding behaviors in neurotypical and autistic child. Breastfeeding behaviors described by mothers may indicate early signs of autism including early sensory sensitivity, lack of regulation, repetitive behaviors, and impaired social behaviors. Further research is needed to discern if these breastfeeding behaviors can be used to help identify early signs of autism and employed as additional surveillance for neurodevelopmental concerns at a young age.

The influence of the structure of the masticatory system on the presence and severity of the gag reflex in children with cerebral palsy.

Dysphagia, prevalent in 90% of children with neurological disorders, poses risks of medical complications and is associated with cognitive and psychosocial challenges. The absence of the sucking-swallowing reflex and variations in the gag reflex contribute to feeding difficulties. This study focuses on examining the impact of the gag reflex on the masticatory system structure in children with cerebral palsy, aiming to assess its significance. This observational study investigated the gag reflex and soft palate shape in 25 children with cerebral palsy (average age: 14 years). Inclusion criteria considered specific levels of the Eating and Drinking Ability Classification System (EDACS) and the Gross Motor Function Classification System (GMFCS). Exclusion criteria comprised hypotension, inflammation and tumors. The Castillo-Morales questionnaire assessed variables and statistical analysis (Spearman's rank correlation and non-parametric tests) utilizing PQStat v. 1.8.6.120 software. Findings did not reveal an association between the absence of the gag reflex and abnormal palate structure in children. Our results showed a correlation between higher tension of the buccinator muscles and mobility of the tongue on the structure of the palate. Children with neurological disorders, such as cerebral palsy, are a diverse group requiring specialized orthodontic treatment and close interdisciplinary collaboration.