Dentistry has become an important part in the multi-disciplinary approach in providing health care for patients with cerebral palsy and the severe handicapping conditions that frequently accompany this neuromuscular disorder. While great strides have been made in access to care, as well as the scope of dental treatment for cerebral palsy patients, the education of patients, parents, and health care providers remains a challenge. The dental specialty of pediatric dentistry has led the way in developing educational programs and treatment strategies for cerebral palsy patients.
This brief review will provide an overview of the dental problems associated with cerebral palsy. There is a wealth of information available on the internet, and through local, state and national dental organizations addressing in detail, all aspects of the diagnosis and treatment of dental disease in the cerebral palsy patient. A resource list will follow this review.
In general, children with cerebral palsy are susceptible to the same dental and oral diseases as other children, but there is a greater degree of susceptibility to disorders of the supporting structures and occlusion in children with cerebral palsy. Dental caries and periodontal disease are the most common forms of dental disease. Both are caused by oral bacteria, which attach to the tooth, and form a sticky mass called bacterial plaque. Plaque products such as acids produce dental caries (cavities), and other bacterial products trigger an inflammatory process in the gum tissue, which can lead to a loss of gum tissue and bone support for the tooth, and finally result in the loss of the tooth. Control of the oral bacterial plaques, and a concurrent reduction of dental disease are therapeutic goals in the dental management of the cerebral palsy patient.
An index called the DMF Index (D = decay, M = Missing, F = Filled) is often used to determine the incidence, prevalence and frequency of dental caries (cavities) in a population. The results of these surveys may differ, depending upon the study groups. However, survey results in general, indicate that cerebral palsied children as a group, are no more susceptible to decay than are non-cerebral palsied children.
GINGIVAL AND PERIODONTAL DISEASE
Surveys in the USA as well as other countries have found a greater prevalence of gingival and periodontal disease in patients with cerebral palsy. However, in areas where programs for complete dental care have been established, prevalence of these diseases in cerebral palsy patients is lower. Oral bacteria attach to the tooth surface, form a sticky dental plaque, and produce soluble products, which then trigger an inflammatory response in the patients’ gingival (gum) tissue. When this inflammation extends into the underlying gum and bone, a loss of support for the tooth occurs, and loss of the tooth may be the final result.
Control of the oral musculature, involuntary muscular activity, and an inability to perform oral hygiene procedures contribute to the increased incidence of gingival disease. In cerebral palsy patients with a seizure disorder, the potential for gingival problems is further complicated. The anti-seizure medications, especially phenytoin sodium (Dilantin), have a strong association with gingival overgrowth. The gingival overgrowth in turn, complicates oral hygiene procedures, making control of dental plaque more difficult.
The prevalence of malocclusion (protrusion of teeth, severe attrition / grinding, cross-bite and open-bite) is higher in the cerebral palsy patient. The prevalence increases with age, and appears to be related to oral muscular influences, both hyper and hypotonic, and the extent of neurologic involvement.
Other oral problems include speech, chewing and swallowing, with impairment of the attendant oral muscle function. Frequently, the cerebral palsy patient will also have a hyper-active gag reflex, and a high percentage of young children with cerebral palsy suffer enamel hypoplasia (incomplete calcification) of the primary teeth, reflecting an early disturbance in the development of enamel and dentin.
A personal oral hygiene home care regimen, tailored by the dentist or dental hygienist, specifically for the cerebral palsy patient, is an essential component of a comprehensive oral health care program. Good oral hygiene, accompanied by early and regular dental examinations and treatment will enhance good dental health in the cerebral palsy patient.
The development of mechanical toothbrushes, modification of toothbrush handles/ grips, oral anti-microbial agents and topical and systemic fluorides, have all enhanced home care results. The active participation of the parent and patient, with training specialized for each, and with frequent re-enforcement of training, will go a long way towards achieving and maintaining oral health.
For maximum effectiveness, dentistry for the cerebral palsy patient must include a complete plan of preventive procedures. There is good evidence that most dental disease can be prevented. The successful application of sound preventive procedures and regular follow-up tends to lessen time and treatment for each patient.
Dental Schools, Dental Hygiene Schools, and Dental Specialty Training Programs are graduating dental practitioners with the knowledge and skills, to provide excellent dental care for the cerebral palsy patient.
Hospital dental clinics, dental specialist offices, and general dentist offices provide varying degrees of specialized care for the cerebral palsy patient. As the level of cerebral palsy involvement increases, the level of training and skills necessary to manage the patient increases. Dental examinations at an early age are part of a multi-desciplinary approach to the medical/dental assessment of the cerebral palsy patient. This will dictate the level of dental expertise necessary to provide dental treatment. At each level, the appropriate equipment, instrumentation, medications and a dental team suitable for the patient will be available.
Family Dentist
Local Dental Society – telephone number in classified section of telephone book.
American Dental Association – www.ada.org (for general information)
General Information
Dental School Information
Dental School – Department of Pediatric Dentistry
American Academy of Pediatric Dentistry – www.aadp.org
e-mail aapdinfo@aapd.org
American Society of Dentistry for Children – e-mail asdckids@aol.com
National Foundation of Dentistry for the Handicapped (303) 534-5360
Cerebral Palsy – A Developmental Disability
Ed. WM Cruickshank, Syracuse University Press 1976
ISBN 0-8156-2168-X
Dentistry in Cerebral Palsy and Related Handicapping Conditions
SN Rosenstein, Charles Thomas Publisher
ISBN 0-398-03710-8
Dentistry for the Handicapped Patient
AJ Nowak, CV Mosby Co.
ISBN 0-8016-3671-X