CEREBRAL PALSY- DENTAL MANAGEMENT OF A 12YR OLD. BY DR IYORZOR STANLEY O

1. PG Seminar
Topic : Discuss how you would plan the long term
dental management of a 12year old girl who
presents to your clinic with cerebral palsy
Dr Stanley O Iyorzor.

2. Outline

3. Introduction
• Cerebral["brain"] palsy["paralysis"](CP) is a developmental
neuromuscular disorder
• Caused by damage to the brain, usually occurring in
Prenatal-70-80%(birth asphyxia), perinatal natal and post
natal time periods.
• It's a central nervous system (CNS) disorder of movement,
coordination, and posture, reflecting a nonprogressive
abnormality or insult to the immature brain.

4. • Incidence being 2 to 2.5 per 1000 live births.
• Common in males.
• Motor disorders of CP are often accompanied by
disturbances of sensation, perception, cognition,
communication, behavior, by epilepsy and by secondary
musculoskeletal problems.
• Providing oral care to people with cerebral palsy requires
adaptation of the skills we use everyday

5. Types
• SPASTIC 70% : exaggerated muscle contraction when
stimulated. Limited control neck muscles-- head rolls
• ATHETOSIS 15%: Involuntary succession of slow, twisting, or
writhing involuntary movements (athetosis) or quick, jerky
movements(choreoathetosis
• ATAXIC: Poor sense of balance and difficulty in grasping objects
• HYPOTONIA : Flaccid muscles
• RIGIDITY : Muscles in constant state of contraction.
• MIXED

6. Case
• Sex: Female(rare, ?aesthetic concern)
• Age: 12 years- ?late mixed dentition stage, delayed
milestone.
• Condition: Cerebral palsy
• Parents/Guardian: Not specified.
• Informant: Patient, parent or Guardian
• Presenting complaints: ?routine followup/check,? Tooth
ache, ?poor aesthetics(? female), ? Trauma/fracture(from
fall due to impaired balance)...

7. AIMS AND OBJECTIVE OF
MANAGEMENT
• To gain patient compliance/cooperation
• Control pain
• Treat patient
• Improve aesthetics
• Restore function
• Instil positive dental behaviour
• Improve quality of Life
• Prevention
• Follow up

8. Special Considerations
• Oral health -some different normal peers
• Dental disease /treatment may be life-threatening;
• Modifications required for treatment plans
• Need for special facilities
• Treatment may be time-consuming (opt for simpler
treatments)

9. MANAGEMENT
• History : presenting complain
• Risk factors for CP- asphyxia, abdominal trauma and
vascular insults.
• seizures in postnatal period, abuse(shaken baby syndrome
and head injury).
• Medical history : medical care providers,
hospitalizations/surgeries, anesthetic experiences, current
medications(?sweetened syrup-cariogenic), immunization
status(?anti-tetanus status)

10. • O&G: asphyxia, premature birth (<32 weeks or <2500
gm),infection,placental abruption and instrument delivery.
• Review of systems(CVS,CNS,MSS)
• family and social histories: (?familial)
• dental history: ?first visit, ?cooperation
• Caries-risk assessment - dietary chart performed
• At each patient visit, history updated.

11. General Examination
• Mental retardation. (60%)
• Seizure disorders. ( 30% to 50%) –
• Sensory deficits or dysfunctions. Impairment of hearing
/eye disorders (35%)
• Speech disorders -lack of control of speech muscles.
• Joint contractures- Abnormal limb postures and
contractures during cos of disuse of muscle groups.
• Scissors gait and toe walk.

12. Dental Examination
• Poor oral hygiene, increased periodontal disease, drug induced
gingival enlargement-phenytoin;
• Malocclusion (skeletal class II + anterior open-bite);
• Tongue thrust and mouth breathing;
• Tendency to bruxism; TMJ disorder.
• Increase in caries prevalence
• Increased prevalence of anterior trauma;
• Enamel hypoplasia;
• Heightened gag reflex and perioral sensitivity;
• Drooling;
• Decreased parotid flow rate.
• Tooth erosion -- Gastric reflux

13. Investigation/Records
• RADIOGRAPHS -Options :
• Anterior occlusal projection
• Lateral jaw projection
• Buccal bite wing projection-
• foss is attached through a hole made in the tab, to facilitate
retrieval of the film if it falls toward the pharynx
• Snap-A-Ray bite wing projection (placed in holder)
• CLINICAL PHOTOGRAPHS.

14. Factors Affecting Treatment.
• Presence/Degree or degree of mental retardation
• Type of diseased teeth: Deciduous(exfoliating)/Permanent
• Location of teeth: Anterior(aesthetics)
• Presence of complicating disorders: Seizure,Visual/ Hearing
impairment
• Social economic status: Finance

15. Pre operative treatment
• DENTAL OFFICE ACCESS:
• Wheel chair ramps
• Handicapped parking spaces
• Accessibility of dental offices and operatories
• Barrier free facilities to accommodate people with varying kinds
of disabilities
• Adjustable dental chairs to match various wheel chair designs
• MULTIDISCIPLINARY APPROACH
• Consult with her other care providers e.g pediatrician - key
• Assess medications, sedation, Anaesthetist-GA, special
restrictions / preparations required/appointment schedule.

16. Operative dental care
• Mental assessment: Severe retardation can,t cope with
challenge simple tasks. Usually G.A
• Informed consent/assent must be taken.
• Behavioural management
• Brief tour/Acquaintance with staff
• e.g communication or tell show do
• Patient may be treated in wheel chair if present.

17. • Protective stabilization(mouth prop, head-papoose
board head positioner, limbs-velcro straps) when
traditional behaviour guidance techniques are not
adequate.
• Without forcing limbs in unnatural position
• Effective sedation or GA if protective stabilization not
feasible
• Keep back slightly elevated to minimize swallowing
difficulties

18. Treatment considerations
• Ensure her preference to help avoid gag reflex with appliances
(may use NO sedation if uncontrollable)
• To minimize startle reflex reaction, avoid abrupt movements,
noises, lights without forewarning
• Use of rubber dam/suction for restorative procedures.
• Short appointment time in chair to decrease fatigue involved
muscles
• ?hearing problem: interpreter, show-feel-do, adjust hearing aid
before hand piece sounds.
• ? visual problem: tell-feel-do, sun glasses(photophobia), audio and
braille dental aids.

19. Treatment of Oral health problems
1. Periodontal disease.: Scaling & polishing, home care/
tooth brushing(modified brush handles)
2. Dental caries: restore with GIC(fluoride), extraction,
stainless steel crown.
3. Malocclusion: Orthodontic treatment(for mild cases),
Anticipatory guidance(as ortho. may worsen oral
hygiene)
4. Dysphagia
5. Drooling: speech therapist, acrylic training plate(if doesnt
provoke gagging); hyoscine hydrobromide
drug(antisialogogue patch)
6. Bruxism: mouth guard/bite splints

20. PREVENTION
• PREVENTIVE STRATEGIES
• Education of parents/caregivers critical
• Develop individualized oral hygiene program that takes into
account the unique disability of the patient.
• HOME CARE
• Tooth brushing twice daily with fluoridated toothpaste
(Horizontal scrub tech for children with gross motor deformities)
• If sensory issues cause taste /texture toothpaste intolerable, use
fluoridated mouth rinse with toothbrush
• Flossing
• Brush with modified handle
• Electric tooth brush (if poor fine motor skills)

21. • FLUORIDE ADVICE:
• Supplements for optimal caries protection
• Fluoride mouthwash on a toothbrush instead of paste if of
paste intolerance
• 1000-1500 p.p.m. of fluoride paste (pea-sized amount)
from time tooth eruption onwards.

22. • DIET AND NUTRITION
• Assess diet (Diet sheet)
• Educate parents/guardians (Stop late night snacking after
brushing)
• A non-cariogenic diet should be discussed for long term
prevention of dental disease
• Advice to limit carbonated drinks are erosive to teeth.
• consult physician for sugar-free medicines

23. • Sealants -pits and fissures (of permanent 2nd molars).
• Topical fluorides may be indicated when caries risk is
increased.
• Interim therapeutic restoration (ITR), with GIC that release
fluoride, may be useful both preventive and therapeutic
approaches
• Anticipatory guidance about risk of trauma (eg, seizure
disorders or motor skills/coordination deficits), mouth
guard fabrication,

24. • May be a victim of physical abuse, sexual abuse, and
neglect(report)
• FOLLOWUP
• Recall visits If severe dental disease every 2-3 months for
• Counseling /ensure compliance to instructions
• Routine examination/surveillance
• Radiography to assess treatment success and identify incipient
caries every 6months
• Professional topical fluoridation (every 3months)
• Clean appliances.

25. • BARRIERS
• (e.g.)Finance, transportation
• Communicate to community-based resources and advocacy
groups for special needs patients
• REFERRALS
• e.g. Speech therapist (drooling); gastroenterologist (GERD);
Orthopedic surgeon(Scoliosis).
• SUPPORT GROUPS: for her, her parents/guardians and family
members

26. Conclusion
• Cerebral palsy is a complex group of motor abnormalities
and functional impairments that affect muscle coordination
.
• Providing oral care to people with cerebral palsy requires
adaptation of the skills used every day in practice.
• Emphasis on prevention, early detection and prompt
treatment of oral diseases and followup is key in its long
term dental management