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Common oral findings in dental patients with cerebral palsy.

Cerebral palsy is the most common neuromuscular disability in children, first described in 1861 by English surgeon William Litt1e. (1), (2) It is a non progressive, chronic neurological condition that impairs movement and motor function. (3) Cerebral palsy is caused by damage to the central nervous system during brain development prenatally, perinatally or postnatally. (1)

Several factors have been shown to either cause or increase the likelihood of developing cerebral palsy. These include head injuries due to a fall or child abuse, preterm labor, an insufficient supply or oxygen to an infant's or new born's brain during pregnancy or delivery, stroke and infection. (1) Diagnosis requires a thorough physical examination and medical history review (1) Symptoms, which generally start to appear before two years of age, include stiff posture, excessive crying, trouble eating or hypotonia. (2), (3) As the child grows older, impairments can range from mild to severe and include uncontrollable movements of the hands, feet, arms, legs or face; difficulties in articulation; urinary incontinence; sudden muscle spasms; poor coordination and trouble with balance. (1), (3) Many individuals with this disorder face difficulties on a daily basis due to these impairments. Physical, speech and behavioral therapy, as well as special education, have shown to be beneficial for management of cerebral palsy. (1)

Several studies have addressed the prevalence of oral conditions associated with cerebral palsy, including poor oral hygiene, traumatic dental injuries, bruxism, sialorrhea and malocclusion. It is important for dental professionals to be aware of these common oral findings to help prevent or treat them.

Dentistry and Cerebral Palsy

Dental care for patients with cerebral palsy can be quite difficult due to their sometimes limited cognitive and physical capacities. Difficulties during dental treatment include communicating with the patient, stabilizing or restraining the patient from sudden movements, changing the patient's position to avoid excessive gagging and the need to schedule shorter, more frequent appointments. (1) While all these factors may be potential barriers to adequate dental care, the oral findings associated with cerebral palsy are optimally addressed with professional care. (2), (3)

Poor Oral Hygiene

Good oral hygiene habits may be difficult for individuals with cerebral palsy due to involuntary physical movements, orolacial motor dysfunction and spasticity in masticatory muscles. (4) The inability to adapt a toothbrush to the teeth adequately or to floss effectively results in insufficient removal of plaque and residual food.4 Patients with cerebral palsy may also have trouble with home care due to their hyperactive gag reflex; poorly controlled use of a toothbrush or floss could result in gagging or vomiting. Many individuals with cerebral palsy are at a higher risk for oral diseases due to poor oral hygiene. (5) However, caregivers typically help these individuals perform daily oral hygiene. Because caring for individuals with cerebral palsy can be stressful for caregivers, oral hygiene sometimes goes neglected. (4)

Traumatic Dental Injuries

Traumatic dental injuries are prevalent in about 20 percent of the general population with cerebral palsy, and about 57 percent of children with cerebral palsy, with female patients often experiencing more injuries than male patients. (2), (6) Dental trauma occurs due to several factors, including uncontrolled motor coordination, involuntary physical movements, oral pathological reflexes and slower response to moving or nonmoving obstacles, as a result of delayed motor control. (6) Individuals with cerebral palsy may also suffer from seizures or Class II malocclusion, which can lead to dental injuries.2 Fractures of the enamel and dentin are the most common types of injuries, with maxillary central incisors affected most often! Enamel defects commonly seen on permanent teeth suggest that luxation of primary teeth is common. (7)

Bruxism

In patients with cerebral palsy, bruxism is a common oral habit that decreases with age. (8) It is suggested that bruxism is more common in patients with cerebral palsy who have severe intellectual disabilities, MOSE likely due to problems with dopamine function. (2) Patients with cerebral palsy are likely to experience bruxism due to unbalanced oral myofunctional disturbances,

Strive continued

spasticity, hyperactive masticatory muscles, malocclusion and emotional stress. (9) Individuals who grind or clench their teeth can experience masseter hypertrophy, headaches, dental wear, limited mouth opening and trismus. (9)

Sialorrhea

Sialorrhea (drooling) is another common finding in patients with cerebral palsy. These individuals are not producing excess saliva, but are instead unable to swallow their saliva due to oromotor dysfunction. (2), (10) Treatments For sialorrhea, such as surgery, medications and injections of botulinum toxin A work by reducing the amount of saliva, so these treatments would be inappropriate for patients with cerebral palsy. (10) Research has found that sialorrhea makes it more difficult to swallow food, which results in more Food residue left in the mouth after swallowing. (10) Additionally, sialorrhea can cause perioral chapping, infections and dehydration. (2) Since drooling is not a social norm, these individuals may struggle with the psychological consequences of embarrassment and feeling insecure. (2) Research has also shown that children with cerebral palsy who drool tend to swallow less often and have worse functional skills, lower nonverbal intelligence and more severe oral motor involvement compared to children with cerebral palsy who do not drool. (10)

Maloccluslon

Cerebral palsy is a major risk factor for malocclusion. (11) The prevalence of malocclusion in patients with cerebral palsy ranges from 59 percent to 92 percent, with Class II being the most common angle classification. (2) The severity of malocclusion usually depends on the severity of cerebral palsy impairments. (11)

Some research has also shown an increase in overjet and anterior open bite in patients with cerebral palsy. (2) Malocclusion commonly occurs in the presence of musculoskeletal abnormalities, altered cranial base relationships, premature tooth eruption and uncoordinated movements of the lips and tongue." Research has shown that Class II malocclusion can result in hypotonia of the orofacial musculature, causing tongue thrusting, poor swallowing reflexes and mouth breathing. (2)

Conclusion

Accessing and receiving dental care is one of the many challenges individuals with cerebral palsy face. To provide the best oral health care for these individuals, dental professionals must be aware of the mental and physical limitations these patients exhibit. Some of the most common disorders associated with cerebral palsy include intellectual disability, sensory limitations, epilepsy, speech disorders and hearing loss.9 Therefore, dental professionals must be prepared to communicate with these patients differently than with other patients, and they should be aware of complications that may arise during dental treatment. Additionally, dental professionals must be able to modify dental care to accommodate the patient's disability. (2) Since many of these patients rely on wheelchairs, crutches or walkers, dental professionals must know how to safely transfer these patients to the dental chair. (7) The safety and comfort of these patients are the most important components of dental treatment.

A dental professional who encounters a patient with cerebral palsy who has any of the common oral findings will need to formulate an effective treatment plan that addresses the patient's special needs. For example, patients who clench or grind their teeth may not be able to use a mouth guard due to their hyperactive gag reflex. Patients with traumatic injuries may benefit from a tooth saving kit. Orthodontic treatment may be contraindicated for patients with cerebral palsy who have malocclusion, due to their poor oral hygiene: the combination of biofilm accumulation and orthodontic treatment could result in gingivitis, decalcification and caries.

Familiarity with the common oral findings in these patients is the starting point for providers' ability to manage these issues and may also serve to promote collaboration with other professionals involved in the patient care. New ways to prevent and treat these complications will improve both oral and systemic health for patients with cerebral palsy.

DENTAL PROFESSIONALS MUST BE PREPARED TO COMMUNICATE WITH THESE PATIENTS DIFFERENTLY AND BE AWARE OF COMPLICATIONS THAT MAY ARISE DURING DENTAL TREATMENT.

References

(1). Cleves C, Lee JW, Kabongo ML. Cerebral palsy, Philadelphia: Elsevier, Inc., 2014. Accessed through https://www-clinicalkey-com.ezpl.lib.umn.edu/.

(2). Dougherty NJ. A. review of cerebral palsy for the oral health professional. Dent. Clin. North Am. 2009; 53 (2) : 329-38.

(3). Darby ML, Walsh MM. Dental hygiene theory and ractice. 3rd ed. St. Louis; Saunders; 2010. pp. 904-6.

(4). Santos MT1, Biancardi M, Guare

RO, Jardim JR.. Caries prevalence in patients with cerebral palsy and the burden of caring for them. Spec Care Dent. 2010; 30 (5) : 206-10.

(5.) Dos Santos MT, Nogueira ML. Infantile reflexes and their effects on dental caries and oral hygiene in cerebral palsy individuals. J Oral Rehabil. 2005; 32 (12) : 880-5.

(6.) Dos Santos MT, Souzo CB. Traumatic dental injuries in individuals with cerebral palsy. Dent Traumatol. 2009: 25 (3) : 290-4.

(7.) Holan G, Peretz B. Efrat j, Shapira Y. Traumatic injuries to the teeth in young. individuals with cerebral palsy. Dent Traumatol. 2005; 21 (2) : 65-9.

(8.) Ortega AO, Guimarks AS, Ciamponi AL, Marie SK. Frequency of parafunctional oral habits in patients with cerebral palsy. J Oral Rebabil. 2007; 34 (5) : 323; 43.

(9.) Oliveira CA, de Paula VA, Portela MB. et at. Bruxism control in a child with cerebral palsy. ISRNerwork Dent. 2011; 2011: 146915. doi:

(10.) 5402/2011/146915. Epub 2010 Dec I.

(10.) Senner JE, Logemann J. Zecker S. Gaebler-Spira D. Drooling, saliva production, and swallowing in cerebral palsy. Dev Med Child Neurol. 2004; 46 (12) : 801-6.

(11.) Miamoto CB, Ramos-Jorge ME, Pereira LI et al.: Severity of malocclusion in patients with cerebral palsy: determinant factors. Am J Orrhod Dentofacial Orthop. 2010; 138 (4) : 394. el -394.e5.

Angela Losasso, BSDH, is a recent graduate from the University of Minnesota Department of Dental Hygiene program in Minneapolis, Minn. She also has a Bachelor of Science in Neuroscience, which she received in 2012 from the University of Si Thomas in St. Paul, Minn.

The faculty mentor for this edition of Strive is Cynthia. L.stull, MDH, clinical assistant professor in the Division of Dental Hygiene, Department of Primary Dental Care at the University of Minnesota.
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Title Annotation:STRIVE
Author:Losasso, Angela M.
Publication:Access
Geographic Code:1USA
Date:Dec 1, 2014
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