Dental health of children with cerebral palsy

Abstract

Cerebral palsy (CP) is a common chronic motor disorder with associated cognitive, communicative, and seizure disorders. Children with CP have a higher risk of dental problems creating signi cant morbidity that can further a ect their wellbeing and negatively impact their quality of life. Screening for dental disease should be part of the initial assessment of any child with CP. e objective of this article is to present an updated overview of dental health issues in children with CP and outline important preventative and practical strategies to the management of this common comorbidity. Providing adequate oral care requires adaptation of special dental skills to help families manage the ongoing health issues that may arise. As oral health is increasingly recognized as a foundation for general wellbeing, caregivers for CP patients should be considered an important component of the oral health team and must become knowledgeable and competent in home oral health practices.

Full text

Dental health of children with cerebral palsy
Basil M. Jan, dental student, Mohammed M. Jan, MB.Ch.B, FRCP(C).
314
Disclosure. e authors declare no conflicting interests,
support or funding from any drug company.
Neurosciences 2016; Vol. 21 (4) www.neurosciencesjournal.org
Cerebral palsy (CP) is a common pediatric disorder
occurring in approximately 2-2.5 per 1000 live
births.1 It is a chronic motor disorder resulting from
a non-progressive (static) insult to the developing
brain.2 e motor disorders associated with CP are
often accompanied by disturbances in coordination,
cognition, communication, and seizure disorders.3,4
Children with CP are at increased risk of developing
dental problems as compared with healthy controls.5
is can create significant morbidity that can further
affect the wellbeing of these compromised children and
negatively impact their quality of life.6 Screening for
these conditions should be part of the initial assessment.
e objectives of this article are to present an updated
overview of dental health issues in children with CP and
outline important preventative and practical strategies
to the management of this common comorbidity.
Predisposition to dental disease in CP. Studies have
shown that the more severe the neurological insult
in children with CP, the higher is the risk of dental
disease.7,8 is results from multiple factors including
motor and coordination difficulties, as well as limited
oral care and hygiene. Various possible predisposing
factors are summarized in Table 1. ese include
mental retardation, which is more common in children
with severe CP particularly in those with epilepsy or
cortical abnormalities on neuroimaging.9 Children with
mental retardation are dependent on their caregiver
for maintaining oral and dental hygiene making
them at higher risk for dental disease. In addition,
approximately 30% of CP patients are undernourished,
OPEN ACCESS
ABSTRACT
       
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 
         
    

 
    




Cerebral palsy (CP) is a common chronic motor
disorder with associated cognitive, communicative,
and seizure disorders. Children with CP have a
higher risk of dental problems creating significant
morbidity that can further affect their wellbeing and
negatively impact their quality of life. Screening for
dental disease should be part of the initial assessment
of any child with CP. e objective of this article is to
present an updated overview of dental health issues in
children with CP and outline important preventative
and practical strategies to the management of this
common comorbidity. Providing adequate oral care
requires adaptation of special dental skills to help
families manage the ongoing health issues that may
arise. As oral health is increasingly recognized as
a foundation for general wellbeing, caregivers for
CP patients should be considered an important
component of the oral health team and must become
knowledgeable and competent in home oral health
practices.
Neurosciences 2016; Vol. 21 (4): 314-318
doi: 10.17712/nsj.2016.4.20150729
From the Department of Pediatrics, Faculty of Medicine, King
Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
Address correspondence and reprint request to: Prof. Mohammed M.
Jan, Department of Pediatrics, Faculty of Medicine, King Abdulaziz
University, Jeddah, Kingdom of Saudi Arabia. Tel. +996 12 6401000
Ext. 20208. E-mail: mmjan@kau.edu.sa

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Dental health in cerebral palsy … Jan B & Jan M
www.neurosciencesjournal.org
affecting their dental health.10 e leading cause of
poor nutrition appears to be pseudo-bulbar palsy,
affecting the coordination of sucking, chewing, and
swallowing. Excessive drooling (sialorrhea) also results
from pseudo-bulbar palsy, however, it may also be
related to increased production of saliva secondary to an
irritating oral lesion, such as dental caries or infection.11
In addition, gastroesophageal reflux disease (GERD) is
another common problem in children with CP causing
regurgitation, vomiting, and possible aspiration.12 e
GERD affects the dental health and results in dental
erosions.13
Specific dental manifestations: Dental Caries. In
general, many factors contribute to the development of
dental caries including biological, economic, cultural,
environmental and social factors.14 Patients with CP are
at increased risk of developing dental caries affecting
negatively their quality of life.15 Children with more
severe neurological insult are at a greater the risk.16
e degree of cognitive and motor deficits is directly
proportional to the likelihood of developing dental
caries.17 Severe motor incoordination affects the ability
to perform adequate oral hygiene and cognitive deficits
makes cooperation for effective oral care more difficult.18
Periodontal disease. Several studies have shown
that gingival hyperplasia and associated bleeding
occurs with higher frequency in children with CP.19,20
is high frequency may be due to the same factors
predisposing to dental caries and leading to biofilm
buildup.21 Difficulties in conducting daily oral hygiene,
intraoral sensitivity, and oro-facial motor dysfunction
are the main contributing factors.22 Another important
factor is the use of antiepileptic drugs, particularly
phenytoin.23 Gingival hyperplasia is predictive for
periodontal diseases. It tends to occur in children with
spastic quadriplegic CP, particularly with advancing
age. Choreothetoid CP may also be associated with
periodontal disease as a result of the continuous
uncontrolled movements of the head making oral
hygiene more difficult.24
Dental erosion. Dental erosion is a progressive loss
of hard dental tissue resulting from a chemical (non-
bacterial) process.25 Gastroesophageal reflux disease is
the single most important cause of dental erosions noted
in up to 55% of patients.26 In one study, 75% of children
with reflux on a 24-hour esophageal pH monitoring had
moderate to severe erosion.27 Dental erosion is common
in patients with CP who are predisposed to GERD.
Another study found 73% of CP patients with dental
erosions had history of GERD.28 Swallowing difficulties
and recurrent chest infections were associated with
the development of dental erosion in another study.29
Enamel erosion that affects the posterior dentition may
be the first indication of GERD. However, both primary
and permanent teeth can be affected, most commonly
the upper molars, lower molars and upper incisors.
Continuous chemical exposure may gradually result
in the extension of the dental erosions. Early effective
treatment of GERD is critical to avoid irreversible
dental damage.30 Prevention, early identification, and
intervention are needed to prevent permanent damage.
Sialorrhea. Drooling of saliva (sialorrhea) appears
to be the consequence of a dysfunction in the
coordination of swallowing mechanisms (pseudo-
bulbar palsy) and mouth opening. Drooling is not
socially accepted and can produce significant negative
effects on the psychosocial health and quality of life.31 It
occurs in up to 30% of children with CP.32 Sometimes
drooling is related to an irritating lesion, such as
dental caries or throat infection, resulting in increased
production of saliva. Severe drooling may get worse
with some antiepileptic drugs, such as clonazepam,
leading to aspiration syndrome, skin irritation, and
articulation difficulties.32 Management of this difficult
Table 1 - Factors possibly predisposing to dental disease in children with cerebral palsy.
Predisposing factors Mechanism
Motor weakness or incoordination Inability to maintain oral hygiene
Depending on a caregiver for self care risk of dental trauma
Mental retardation Inability to maintain oral hygiene
Depending on a caregiver for self care
Pseudo-bulbar palsy Chewing and swallowing difficulties
Risk of dental caries and erosions
Excessive drooling (sialorrhea)
Gastroesophageal reflux disease Recurrent regurgitation and vomiting causing dental erosions
Malnutrition Poor calcium intake
Vitamin D deficiency

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problem is not very effective and includes a trial of an
anticholinergic medication, such as glycopyrrolate and
scopolamine. Side effects include irritability, sedation,
blurred vision, and constipation.33 Scopolamine is also
available as a skin patch. Surgical re-routing of salivary
ducts is an option, however, it may lead to increased
aspiration.33 Botulinum toxin injection into the parotid
and submandibular glands may be effective in reducing
excessive drooling.34
Bruxism. Bruxism, the habitual grinding of teeth,
is a common problem in children with CP, particularly
those with severe motor and cognitive deficits.35
Bruxism may lead to teeth abrasion and flattening
of biting surfaces. e exact mechanisms causing
the development of this habit is not fully known,
however, it is likely a self-stimulatory behavior and
could also be related to abnormal proprioception in
the periodontium.36 It is known that children with CP
are predisposed to such abnormal behaviors including
finger sucking and other mouthing habits. Local dental
factors, such as malocclusion, should be excluded. As
well, sleep disorders may predispose to the development
of nocturnal bruxism, particularly in those with severe
visual impairment.37 Disturbed and fragmented sleep
is very disruptive to the parents as a result of frequent
nocturnal awakenings. Medications that improve the
sleep-wake cycle, such as melatonin, should be used and
may also result in improved daytime behavior.37
Traumatic dental injuries. Motor deficits and
epilepsy increase the risk of physical injuries in children
with CP. Malocclusion with prominent maxillary
incisors and incompetent lips represent local risks that
further predisposing to dental trauma.38 e risk varies
between 10-20% and can reach 60% in patients with
drop attacks.39 In addition to facial injury, these children
are predisposed to fracture of enamel and dentine.40
Malocclusion. Malocclusion has been reported
with increasing frequency in children with CP, most
commonly over-bite and anterior open-bite.41 ese
abnormalities have been reported to get worse with
age.42 Mouth breathing, lip incompetence and long
face are contributing factors.43 Pseudo-bulbar palsy,
oro-facial incoordination and hypotonia could further
add to the risk of developing malocclusion.
Enamel defects. Children with CP are at an increased
risk for having developmental enamel defects.44 Around
40% of affected children were born prematurely
(<37 weeks). ese enamel defects are located in a
symmetrical manner in both primary incisors and first
molars.
Temporomandibular joint (TMJ) disorders. Children
with CP are at a significantly higher risk for developing
signs and symptoms of TMJ disorders.45 Male gender,
the presence and severity of any malocclusion, mouth
breathing, and mixed dentition were all identified as
risk factors for developing signs and symptoms of TMJ
disorders in CP patients.
Dental management. Some practical challenges are
commonly encountered when handling children with
CP. ese include apprehension, fear from strangers, and
communication difficulties.46 Effective communication
with such children during dental assessment should
take in consideration their developmental age and any
associated auditory, visual or speech disorders. Cognitive
and attention deficits can also contribute to cooperation
difficulties. Special seating and positioning adjustments
are needed for children with abnormal posture. e
dental chair should allow careful adjustment to provide
the needed stability and support. Tipping the chair well
back is often needed in spastic and athetoid CP patients
with more manual control. Supportive and relaxed
approach can help in improving the child’s cooperation.46
A useful tip is to schedule the visit early in the day and
allow sufficient time to establish appropriate interaction
during such encounters.47 e dentist may not establish
much during the first visit that may be used mainly to
establish mutual confidence and have a preliminary
assessment. Assistance from the parents and dental
assistant is often needed particularly for immobilization
and during X-ray procedures. Patients with more severe
spasticity involving the head and neck may be best
evaluated on the parent’s lap.48 Head position can be
also maintained in the midline by the help of Velcro
straps. Open mouth can be maintained with the use of
mouth props and the dentist should try their best to be
gentle, caring, and avoid sudden movements that may
trigger muscle spasm or stiffening. A finger guard and a
steel mirror are preferred to avoid injury or shattering.
Sharp instruments should be used with extreme caution
to prevent injury. ere are no reservations on using
local anesthesia. CP patients often have difficulty rinsing
appropriately necessitating the provision of water spray
and suction device. Orthodontic or prosthetic parts are
advisable only if the disability is mild to minimize the
risk of breakage and aspiration.
Sedation & anesthesia. Children with CP may be
difficult to handle and uncooperative during dental
assessment and management. Sedation and anesthesia
is frequently needed in such situations, particularly if
invasive procedures are needed.49 History of respiratory
difficulties and seizures represent a particular challenge.

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Assessment by the concerned specialty (pediatrics,
anesthesia, and/or neurology) is often needed prior to the
required procedure. If the procedure is associated with
prolonged period of decreased oral intake, intravenous
antiepileptic drugs can replace the oral medications.
Drugs like phenobarbitone or phenytoin can be used,
however, a loading dose should be initiated before the
procedure for optimal effects.50 Once the patient is able
to take the oral drugs, IV drugs can be weaned quickly.
Many drugs can be used to induce sedation and
anesthesia including benzodiazepines, nitrous oxide,
narcotics, and propofol.51 Most children with CP and
severe mental disability do not tolerate initial facemask
prior to IV sedation. However, nasal or facemask can
be utilized in milder cases to avoid the fear and anxiety
associated with IV insertion. Oxygen saturation should
be monitored by pulse oximetry and the airway should
be protected throughout the procedure. Children
with CP are at an increased risk of aspirating dental
filling materials, debris from preparation of the tooth,
or even an extracted tooth. is is in addition to
excessive salivation and water spray used for cooling
instruments.51 A throat shield should always be used to
further protect the airway in these cases. Postoperative
care include keeping the child with CP restrained until
he or she is able to respond to verbal commands or
become fully consciousness. IV cannulas and monitor
should be removed as soon as possible as they add to the
child’s fear and anxiety. Most patients with CP tolerate
such procedures and sedation well with minimal
postoperative complications.52
Prevention. Home dental care and hygiene should
be promoted from early on. Parents should learn to start
gently daily cleansing of the incisors with a soft cloth or
an infant soft toothbrush. For older children who are
unwilling or physically unable to cooperate, the dentist
should teach the parent proper brushing techniques
and ways to safely restrain the child when necessary.
e child is placed in the parent’s lap to stabilized the
head with one hand while using the other hand to brush
the teeth. An older child may recline on a chair or bed
and the parent angles the head backward with one hand
while the teeth are brushed with the other hand. More
extreme restraining by both parents is needed for the
more difficult child.53 e patient’s hands may have to
be restrained by a second or third person for effective
oral cleansing.53 To encourage independence of children
with milder motor disabilities, an electric toothbrush
may be utilized effectively.
In conclusions, as oral health is increasingly
recognized as a foundation for general wellbeing,
caregivers for CP patients should be considered an
important component of the oral health team and must
become knowledgeable and competent in home oral
health practices. Such practices can significantly affect
the child’s quality of life and control dental costs.
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