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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:

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

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.

    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.

    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.

    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

    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:

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