Pediatric  Dental   Health

• Cerebral palsy is not a single disease, but a group of disorders that occur when a baby’s brain is damaged.
• There are more than 100,000 children and adolescents in the U.S. who have cerebral palsy.
• The prevalence of severe C.P. is around 2 for every 1,000 live births.
• The total annual cost of cerebral palsy to the United States is $5 billion.
  
  WHAT ARE THE TYPES OF CEREBRAL PALSY?
• Cerebral palsy may be classified according to the resulting problems with posture and control of movement.
• The classifications are: spastic, hypotonic, and athethotic.
• Spastic: above-normal tone or stiffness of the muscles of the body.
• Hypotonic: weak, “floppy,” lacking normal muscle tone.
• Athetotic: slow, writhing, involuntary movements of hands and feet. Athetosis is caused by problems in the extrapyramidal system of the brain.
• Cerebral palsy may also be classified according to the motor disability associated with it, such as:
  hemiplegia, diplegia, dyskinesia, and quadriplegia.
• Spastic hemiplegia: one-sided neurologic defect. The arm is more affected than the leg.
• Spastic diplegia: scissoring walking pattern, with toe-walking.
• Dyskinesia: difficulty walking, with some spasticity.
• Spastic quadriplegia: all limbs are affected, with multiple medical complications.
  
  WHAT CAUSES CEREBRAL PALSY?
• The cause of cerebral palsy is poorly understood, but it is most likely caused by a variety of factors.
• Cerebral palsy can be associated with prenatal, perinatal, or postnatal events.
• Prenatal factors cause 70-80% of cases of cerebral palsy. The developing brain is subject to injury at any time, due of its complexity and vulnerability.
• The most common finding in children with cerebral palsy is prenatal injury to the portion of the brain lying next to the middle cerebral artery.
• The clinical finding of prenatal brain injury - leukomalacia - predicts cerebral palsy better than the ultrasonic finding of intracranial hemorrhage. Periventricular leukomalacia is the medical term used to describe death of the white matter of the brain in the area of the lateral ventricles.
• Recent studies have shown that difficulties during birth and delivery are not a common cause of cerebral palsy.
  
  WHAT ARE THE PRENATAL RISK FACTORS FOR CEREBRAL PALSY?
• Prematurely born infants have a higher incidence of cerebral palsy than babies born at term.
• The rate of cerebral palsy is at least 25 times higher among infants who weigh less than 1,500 g at birth, compared to full-sized newborns.
• Any infection of the pregnant mother, such as rubella (German measles) or dental infection, causes a risk to the unborn child.
• Maternal drug or alcohol abuse.
• Maternal thyroid disorder.
  
  HOW IS CEREBRAL PALSY DIAGNOSED?
• After birth, ultrasonic examination of the brain of a premature infant may reveal cerebral abnormalities, such as hyperechoic and hypoechoic lesions.
• After birth, hypoechoic areas which appear on ultrasonic images of a baby’s brain can predict future problems, such as motor dysfunction related to movement and coordination.
• A physical examination of an infant with cerebral palsy may reveal:
  spasticity of the limbs,
  arms or legs which appear to be locked in an abnormal position,
  lack of normal balance,
  or an abnormal walking pattern in older children.
• A large portion of children with cerebral palsy experience significant feeding and swallowing problems during the first 12 months of life. This finding often preceeds the diagnosis of cerebral palsy.
  
  HOW IS CEREBRAL PALSY TREATED?
• Cerebral palsy cannot be cured, but the most important part of therapy is maintaining current function, and developing new function.
• Treatment usually includes a combination of:
  speech therapy,
  occupational therapy,
  prescription drugs,
  surgery,
  and counseling.
• Rehabilitation medicine (physiatry) can help manage spasticity and coordinate therapy.
• Medication may relieve movement difficulties and spasticity. Baclofen and diazepam are two examples of such medications.
• Anticonvulsants are used to control seizures.
• Intramuscular neurolysis using phenol, and intramuscular blocks using botulinum A toxoid (Botox), may reduce spasticity.
• Neurosurgery can help decrease spasticity by cutting 1-a sensory nerve fibers (selective dorsal rhizotomy procedure).
  
  HEALTH PROBLEMS IN CHILDREN WITH CEREBRAL PALSY
• Thirty percent of children with cerebral palsy have some degree of mental retardation
• Twenty-five percent cannot walk.
• Approximately one third of children with cerebral palsy have epilepsy. Up to fifty percent of children with hemiplegic cerebral palsy have epilepsy.
• Many children experience failure to thrive, due to feeding and swallowing problems.
  
  SPECIAL ORAL AND DENTAL HEALTH CONCERNS FOR CHILDREN WITH CEREBRAL PALSY
• Orofacial dysfunction is a severe health problem, as well as a problem for acceptance by peers and society.
• Cerebral palsied children have drooling, eating, drinking, and speaking disorders.
• More than 90% of children with cerebral palsy have oral motor dysfunction. The severity of oral dysfunction makes it difficult for some cerebral palsied children to be adequately nourished.
• Drooling is not due to excessive production of saliva, but to a poor and disorganized swallowing pattern.
• There is abnormal neuromuscular coordination of the tongue, lips, and cheeks - which leads to poor dental alignment and periodontal problems.
• Trauma of the face and mouth occur much more frequently in children who have cerebral palsy.
• Children with cerebral palsy may demonstrate self injurious behavior, including:
  tongue, cheek, and lip biting;
  finger, arm, and hand chewing.
• Protective oral appliances may be useful in combating self-injurious behavior.
• Children who are affected by cognitive disability or mental retardation often practice damaging oral habits, including:
  bruxism, rumination, pouching, and pica.
• Bruxism:
  This is clenching, grinding, and gnashing of teeth. It is a frequent finding in children with cerebral palsy. The treatment for bruxism may include the use of a soft or hard mouth guard – if the child can tolerate it.
• Rumination:
  this is the re-chewing, regurgitation, and re-swallowing of previously ingested food. This habit causes the acidic contents of the stomach to travel up into the mouth, and bathe the teeth in acid. Rumination can lead to demineralization, and loss of tooth structure.
• Pouching:
  This is the placement of food or medicine between the cheek and teeth for a long period of time. This habit can cause dental decay.
• Pica:
  This is the compulsive eating of non-edible substances, including: sand, dirt, and paint chips. Pica can lead to destruction of tooth structure and damage of oral soft tissue.
  
  ORAL FINDINGS IN CHILDREN WITH CEREBRAL PALSY
• Children with cerebral palsy frequently have gastroesophageal reflux, as well as episodes of vomiting. Either problem can lead to dental erosion, or loss of tooth structure.
• Gingival overgrowth, due to seizure medications, is a frequent problem in children with cerebral palsy.
• Orofacial findings in spastic cerebral palsy:
  The head is tensely reclined.
  The mouth is open, and facial movements are tense.
  The tongue is hypertonic and cigar-shaped.
  There is tongue thrust during swallowing and speaking.
  Since the upper lip is underdeveloped, it does not produce enough pressure on the front teeth to align them correctly.
• Orofacial findings in athetotic cerebral palsy:
  The tongue shows spontaneous wave-like movements.
  There may be an abrupt and wide opening of the mouth, which can lead to jaw dislocation.
  There is an uncoordinated movement of tongue, jaw, and face muscles.
• Orofacial findings in hypotonic cerebral palsy:
  The tongue is large, flat, and protruded.
  Facial movements are weak, and the upper lip is inactive.
  
  THE ROLE OF THE DENTIST
• The dentist should try to schedule appointments for children with cerebral palsy early in the day.
• Obtain the child’s medical history before the first appointment so that any necessary medical consultations can be arranged.
• Try to develop a good rapport with the child.
• Gain the cooperation of the cerebral palsied child by using behavior management techniques such as: tell-show-do, positive reinforcement, and voice control.
• A child with severe cognitive disability may require repetition of commands and requests, which will enhance comprehension.
• A child with severe visual impairment needs a verbal description of the planned dental procedures. This will help prevent fear and anxiety.
• Communication can also be accomplished using nonverbal techniques, especially for children with hearing impairment
• The dentist may need to use sedation techniques to calm a child – if the child’s medical situation permits. Some children can only be treated under general anesthesia, however.
• Children with cerebral palsy may have a severe gag reflex – making it difficult to take dental radiographs.
• Two modified radiographic techniques for use in children with cerebral palsy are:
  the 45 degree oblique head plate, and the reverse bite wing (buccal technique).
• In the oblique plate radiographic technique:
  a film cassette is held against the patient’s cheek. The patient’s had is rotated and tilted. The x-ray cylinder is placed just inferior and posterior to the angle of the mandible on the opposite side of the face.
• In the buccal bite wing technique:
  the film packet is placed between the teeth and the cheek. The x-ray cylinder is then placed below the lower border of the mandible on the opposite side of the face.
• When dental treatment is performed, stainless steel crowns are often used when the posterior teeth have caries.
• Fixed bridgework is usually not done for patients with cerebral palsy because of the increased risk of falling and dental injury. Patients with frequent seizures should normally not have fixed bridgework done because of the possibility of damage to the supporting teeth or bone during a seizure-related fall.
• The dentist should discuss the option of myofunctional therapy for young children who have orofacial and tongue hypotonia. This treatment may increase the muscle tone of the lips, as well as keep the tongue inside of the mouth.
• The dentist should instruct parents on proper home dental hygiene procedures.
• Counsel parents about growth and development of the teeth and orofacial structures.
• Provide relevant dietary counseling.
• Periodic dental recall appointments are highly recommended in order to supervise and evaluate a patient’s oral hygiene. Recall appointments also allow the dentist to monitor any gingival overgrowth which may be caused by anti-seizure medications.
  
  HOME DENTAL CARE FOR CHILDREN WITH CEREBRAL PALSY
• Choose a well-lit location so that you can look into your child's mouth.
• No matter what position you are using for brushing your child's teeth, remember to always support the head.
• Give lots of praise while brushing your child's teeth.
• Parents should help brush their children's teeth every day, after every meal. Brush the tongue, since this will help prevent halitosis.
• Parents can help make children's teeth more decay-resistant by using an ADA-approved children's toothpaste. Place only a pea-sized drop of toothpaste on the toothbrush.
• Up to the age of three, parents should only use baby tooth cleanser – to avoid fluorosis discoloration of the adult teeth.
• Children taking oral medications should have their teeth cleansed after each dose of medication. Nearly 100% of children's medications contain sucrose, which can increase the risk of developing dental caries.
• Children should have their first oral/dental health evaluation by the age of 12 months, or within 6 months of the eruption of the first tooth.
• Parents should not let their children drink fruit juice or sweetened drinks from a bottle or "tippy" cup, since this prolongs the exposure of teeth to harmful sugar.
• Parents should provide healthy, balanced meals for children. Plenty of healthy snacks should be available for children. They should limit the amount of sugar-laden foods and snacks in the diet. Cheese products actually fight dental caries.
  
  DOES OROFACIAL REGULATION THERAPY HELP?
• The orofacial regulation therapy concept includes:
  functional diagnostics of oral sensorimotor dysfunctions;
  a special manual stimulation and facilitation program, which helps to control and improve head and body posture;
  the use of removable activating palatal plates, and other orthodontic appliances.
• Treatment using these activating orthodontic appliances should only be done in conjunction with a special physiotherapy program.
• Description of the myofunctional appliance for spasticity:
  It includes a stimulating palatal plate, which helps to reduce tongue thrust.
  This removable appliance is worn every day, about one hour at a time, for a total of four hours each day. This “palatal button” appliance is not worn during sleep or feeding, however.
  This appliance may be modified, later on, to include upper lip stimulators.
• Description of the myofunctional appliance for hypotonia:
  It acts by stimulating the facial “motor points.”
  The upper lip may be stimulated with “bumpers” which are attached to a “vestibular wire.”
  
  CONCLUSION
• Parents and caretakers should seek out physical, occupational, speech, dental, and other professional therapists.
• One organization which can provide additional assistance is:
  The United Cerebral Palsy Associations,
  1660 L Street NW,
  Suite 700,
  Washington DC 20036,
  1-800-872-5827,
  http://www.ucpa.org
  
  An article in Pediatric Dentistry described an intraoral appliance which decreases drooling in children who have cerebral palsy. The appliance resembles an orthodontic retainer, which has a movable rolling bead. The bead is attached at the posterior aspect of the appliance.
  
  The myofunctional appliance described in the journal article is a modification of the original “Castillo-Morales palatal plate,” which is provided for cerebral palsy patients. The movable rolling bead must be placed where the patient’s tongue touches the palate during swallowing. The bead can be placed either on the side of the palate, or in the middle – depending on the child’s swallowing pattern.
  
  Inga CJ, Reddy AK, Richardson SA, Sanders B: Appliance for chronic drooling in cerebral palsy patients. Pediatric Dentistry. May 2001; 23:(3) 241-242
  
  
  

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