Oral Considerations and Care for Children with Cerebral Palsy

Cerebral Palsy is the second most common neurological impairment in childhood (Darby, Walsh p. 804). It is not considered a specific diagnosis, but it is more accurately used to describe a broad, defined group of neurological and physical problems. The severity of these problems can vary from having only minor difficulty with fine motor skills, such as grasping and managing something with their hands, or it can include significant muscle problems in all four limbs, mental retardation, seizures, and difficulties with vision, speech, and hearing.

The signs of cerebral palsy are not usually noticeable at birth. Delays in developing normal, predictable developmental stages, especially in the first 18 months of life, may be an indicator of cerebral palsy. If a child does not develop certain skills by the ages shown in parenthesis, there may be some concern:

  • Sits well, unsupported (6-10 months)
  • Babbles (baby talk--6-8 months)
  • Crawls (9-12 months)
  • Finger feeds, holds bottle (9-12 months)
  • Walks alone (12-18 months)
  • Uses one or two words other than "da-da" or "ma-ma" (12-15 months)
  • Walks up and down steps (24-36 months)
  • Turns pages in books: removes shoes and socks (24-30 months)

There are three types of cerebral palsy, and they are categorized by their associated motor impairments:

    Spastic palsy: These children have stiff or rigid muscles on one side of the body. Or, they may have it in all four limbs, sometimes including the throat, mouth, and tongue. People with this form may have legs that turn inward and scissor as they walk, or arms that are flexed and positioned against their bodies. Many also have difficulty speaking, mental retardation, and seizures.

    Dyskinetic or athetoid palsy: This type of palsy is characterized by abnormally decreased muscle tone and strength. They have slow, uncontrolled writhing movements. They may experience frequent changes in muscle tone in all areas of their body. Muscles may be normal during sleep, and rigid during waking hours. People with this type of palsy may also have difficulty speaking.

    Ataxic palsy: This is a more rare type of cerebral palsy and people with this type have problems with balance and depth perception. They have a unsteady, wide-based gait. And some have tremors and abnormally decreased muscle tone and strength.

    Combined palsy: Relects a combination of the above types.

Everyone who has palsy has problems with movement and posture. It is important to remember that their limbs move often. When they try to move, their muscles often tense, and uncontrolled movements will increase.

  • Help your child to relax. Keep the area you wish to brush his or her teeth calm and supportive. Relaxation will not stop uncontrolled body movements, but it may reduce how often they occur and their intensity.
  • Keep your child in the center of the chair and allow him or her to settle into a comfortable position. A bean bag chair may be helpful. Pillows or props may help. Or if in a wheelchair, some wheelchairs recline or are molded to the body for extra comfort. Be sure to use head support.
  • Do not use restraints, unless absolutely necessary for safety. Restraints should never be used as a convenience.
  • Watch your child's movements and look for patterns to help you anticipate direction and intensity. Blend your movements with those of your child and work around them.
  • Softly cradle your child's head during toothbrushing. Be gentle and slow if you need to turn the child's head.
  • Exert gentle but firm pressure on your child's arm or leg if it begins to shake.
  • Maintain clear pathways when helping someone with palsy to a treatment area, either at a dental office, or at home.

    In general, children with cerebral palsy are susceptible to the same dental and oral diseases as other children; however, several conditions are more common or more severe in this population.

    Dental Caries: Because children with cerebral palsy generally have inadequate oral hygiene, they are more susceptible to cavities. Also, because they are mouth-breathers (dries the oral tissues and plaque sticks more readily), take medications that dries their mouth, may have enamel hypoplasia (incomplete calcification of enamel), and food pouch (due to an inability to swallow properly) they are more at risk for dental caries (cavities). Because children with disabilities are particularly difficult to treat dentally, it is even more important than ever that the parent be exceptionally careful about their child's diet.

    • Sticky foods should be restricted to mealtimes, and sugary foods and snacks should be avoided. The child should be encouraged to eat "detergent" foods (i.e., apples, carrots, etc.)(grate them if necessary).
    • It is helpful for children taking medications that reduce saliva or contain sugar to have their caretaker or parent ask for medications that are sugar-free when available, and to drink plenty of water after taking their medicine.
    • Offer children something other than sweets as incentives or rewards.
    • If your child pouches food, be sure to inspect the mouth after eating or dose of medicine. Remove the food or medicine by rinsing with water, sweeping the mouth with a finger wrapped in gauze, or use a disposable foam applicator swab.
    • Be sure to have your child using a fluoride product as recommended by your dental professional, and have sealants placed on permanent molar teeth.

    Malocclusion: This is a term used when the upper teeth do not "fit" the lower teeth properly. In children with cerebral palsy this is due to muscular imbalances. An open bite (teeth do not meet at all) with protruding front teeth is common and usually caused from tongue thrusting (the tongue pushes forward when they swallow). The open bite may be severe enough that they cannot close their lips, which contributes to excessive drooling.

    This condition can be corrected with orthodontics (braces). However, correcting this problem with moderate or severe cerebral palsy is, unfortunately, almost impossible because of the enamel hypoplasia (incomplete calcification of enamel) and higher risk of caries. The child should be evaluated on an individual basis, however, and a developmental disability in and of itself should not be a barrier to orthodontic treatment.

    • If your child can tolerate braces, good oral hygiene assisted by you, the parent or caregiver, is essential for the success of the orthodontic treatment.
    • Be aware that protruding front teeth are more easily displaced, fractured, or avulsed (knocked out). Parents and caregivers should be informed of procedures for accidents involving these kinds of accidents to the mouth. (Link to In Case of Emergencies).

    Dysphagia: This is a term meaning "difficulty with swallowing," and is often a problem for children with cerebral palsy. Food may stay in the mouth longer than usual which increases the risk for cavities. Also, many caregivers feed these children semi-soft foods, which aids in swallowing, but sticks more readily to the teeth contributing to a higher risk for cavities. Coughing, gagging, choking, and aspiration are other concerns and may make oral care difficult.

    • Try to keep breathing passages open by placing your child in a slightly upright position with the head turned to one side during oral care.
    • In the dental office, be sure to use suction as often as the patient will tolerate. Use a rubber dam when it is indicated, but you may want to introduce it slowly over a few appointments.
    • Again, make sure to inspect the child's mouth after eating and remove any residual food.

    Drooling: Hypotonia (abnormally decreased muscle tone or strength) contributes to drooling, as well as the open bite as mentioned previously. This affects social interaction as well as daily oral care.

    Bruxism: Stress-induced, involuntary behavior of grinding the teeth together which can cause the teeth and supporting bone to wear away (periodontal or gum disease). It can also cause headache, muscle spasms, and facial, neck, and shoulder pain. In children with cerebral palsy, bruxism can be intense and persistent and can cause their teeth to eventually wear away prematurely. Gagging or swallowing problems may make a mouth guard uncomfortable and unwearable.

    Hyperactive bite and gag reflexes: Introduce brushing, or flossing aids gently into the mouth. Consider using a mouth prop. Make dental appointments early in the morning before eating or drinking, if possible. You can minimize the gag reflex by placing your child's chin in a neutral or down-ward position.

    Gastroesophageal reflux: Sometimes children with cerebral palsy have a backward or return flow of stomach contents into the esophagus. The acids from the stomach contents can erode the teeth making them weak and sensitive. This can happen even if your child/patient is on a feeding tube. Consult your physician for managing the reflux, and

    • Keep your child in a slightly upright position when trying to brush his/her teeth.
    • Make sure your child rinses with plain water or a water and baking soda solution (buffers the acids) at least four times a day.
    • Make sure to use a fluoride toothpaste or gel every day.

    Other considerations: As if all the above is not enough, there are other considerations in helping and treating children (patients in general) with cerebral palsy. Many have hearing loss or are deaf. Children with hearing problems may appear to be stubborn because of their seeming lack of response to a request. It is important to maintain eye contact when speaking to your child. And remember to eliminate background noise (such as the T.V. or radio) when speaking to your child.

    Many children also have dysarthria, an abnormal speech resulting from an impairment of the muscles that are involved with speech. Be patient. Allow time for your child to express himself or herself. Remember that it is a difficulty in speaking and does not necessarily reflect the level of intelligence of your child.

    Visual impairments affect a large number of children and people with cerebral palsy. Most common is when the eyes are crossed or misaligned (strabismus). Consequently, persons with cerebral palsy may develop visual motor skills, such as hand-eye coordination later than other people. This may make toothbrushing learning slow and difficult. Remember to help and supervise you child at all times during their oral care routine.

    Cerebral palsy may be accompanied with seizures, which can many times be controlled with anticonvulsant medications. However, the mouth is always at risk during a seizure and children may chip their teeth, or bite their tongue or cheeks. Also, seizure medications, such as phenytoin may cause the gums to "over grow" (hyperplasia). If this is noticed, talk to the child's physician to see if there is an alternative drug. Be advised that the gums may need to be surgically corrected in time. Again, good oral hygiene helps to keep this side-effect under control.

    To Help Maintain Good Oral Health For Your Child With Cerebral Palsy:

    • First of all, assess your child's abilities and tailor your home care accordingly.
    • Keep your oral care routine as much as possible.
    • Ask your doctor if sugarless medications are available.
    • Brush at least twice a day, once in the morning and once in the evening before bed. Brushing after eating is preferable, but not always convenient, so have your child rinse with water after eating or taking medication.
    • Sweeping the mouth with a finger wrapped in gauze after eating or taking medication is also helpful, especially if your child pouches food.
    • If your child has difficulty with spitting, do not use toothpaste with fluoride. Use either a toothpaste without fluoride, or plain water, or dry brush.
    • Use a soft bristled brush and remember that toothbrushes can be modified to accommodate your child's abilities.
    • Bicycle grips come in different sizes, weights, and shapes and can be used to help your child grasp the toothbrush. They are also cleaned easily and for that reason preferred to a tennis ball or Styrofoam ball.
    • Toothbrushes can be extended by taping to a ruler, if needed.
    • Toothbrushes can be heated under warm or hot water, and then bended to a more adaptable angle.
    • If your child cannot hold a toothbrush in his/her hand, a Velcro universal strap can be used.
    • Power-assisted toothbrushes may be helpful, depending on your child's abilities. Or, they may be helpful for the parent or caretaker to use on the child.
    • Floss aids can be similarly modified as the toothbrush. Consult with your occupational therapist and/or dental hygienist.
    • Discuss the type of fluoride therapy that best suits your child and his/her needs with your dentist or hygienist, and be sure to follow their recommendations.
    • If your child has GERD (gastroesophageal reflux), rinse with water or preferable water with baking soda at least four times a day.
    • If your child takes an anticonvulsant, be aware that a side-effect is that it causes the gums to over-grow.
    • Many prescription and over-the-counter drugs also cause xerostomia (dry mouth). This can cause an increase in decay and can make your child's mouth very uncomfortable. In addition to fluoride therapy, there are aids to help with dryness, such as Biotene products, and artifical saliva products. Ask your dentist or hygienist for his/her recommendations.
    • Be aware that your child might be susceptible to yeast infection if he or she is taking antibiotics and has drug (medication) induced dry mouth. If you suspect or are unsure whether or not your child may have candidiasis, check with your dentist.
    • If your child has hydrocephalus, and has a shunt that empties into the vasculature he/she may need to take antibiotics before his/her dental appointment. Be sure to check with your physician (who surgically placed the shunt).
    • Make sure you know what to do in case of an emergency for accidents involving oral trauma, and be sure to notify your dentist.
    • Begin taking the child at the same time as brothers and sisters. When the child starts at a sufficiently young age, not only will he be accustomed to going to a dental office, but chances are that no treatment will be necessary for the first few visits which will help to gain the child's confidence.
    • Most important, keep regular check-ups for your child at the dentist's office. He or she may need more frequent cleanings and check-ups than usual. Remember a healthy mouth helps to maintain a healthy body and good self image!

    Sources:

    • Dental Hygiene Theory and Practice (2nd ed.) Norfolk, VA: Michele Darby, BSDH, MS, Margaret Walsh, RDH, MS, MA, EdD.,2003, pp 764-779.
    • Practical Oral Care for People With Cerebral Palsy, National Institute of Dental and Craniofacial Research, NIH Publication No. 04-5192, May 2004.
    • Handbook of Pediatric Dentistry (2nd ed.) Mosby: Angus C. Cameron, BDS,MDSc, FRACDS FICD, Richard P. Widmer, BDSc, MDSc, FRACDS FICD. 2003, pp272.
    • Clinical Practice of the Dental Hygienist, (8th ed.) Boston, MA, Esther M. Wilkins, BS, RDH, DMD., 1999, pp 781-782.

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