A review of cerebral palsy for the oral health professional

Biochemical and Microbiological Aspects of the Oral Cavity of Children and Young People with Neurological Impairment and Oropharyngeal Dysphagia

The components and the salivary flow have a direct influence on the composition of the oral microbiota of children and young people with oropharyngeal dysphagia, and studies have already demonstrated the excessive accumulation of supragingival dental calculus in individuals with enteral nutrition. This study aimed to compare the oral hygiene, biochemical, and microbiological aspects of the oral cavity of children and young people with neurological impairment and oropharyngeal dysphagia. Forty children and young people with neurological impairment and oropharyngeal dysphagia were enrolled and divided into two groups: group I, encompassing 20 participants fed via gastrostomy; and group II, encompassing 20 participants fed via the oral route. Oral hygiene and salivary pH and flow were assessed, and a polymerase chain reaction was performed to evaluate the messenger RNA expressions of Porphyromonas gingivalis, Tanerella forsythia, and Treponema denticola. In groups I and II, the mean Oral Hygiene Index-Simplified scores were 4 and 2, respectively, showing a significant difference; the mean Calculus Index scores were 2 and 0, respectively, showing a significant difference; and the mean pH was 7.5 and 6.0, respectively, showing a significant difference. Bacterial analysis indicated no association between the two groups. It can be concluded that children and young people who use gastrostomy had a poorer oral hygiene, greater dental calculus deposition, and higher salivary pH. The saliva of patients in both groups contained Porphyromonas gingivalis, Tanerella forsythia, and Treponema denticola.

Cerebral palsy: Oral manifestations and dental management

Cerebral palsy is a set of non-progressive neuromuscular disorders caused by defects in the developing fetal brain. Its prevalence is about 2:1000. Although CP does not directly result in any particular oral abnormalities, some conditions are more prevalent or severe in CP patients than in the general population. The purpose of a paediatric dentist is to promote overall oral health wellness and to motivate parents and other primary caregivers to practice good oral hygiene at home. The aim of this article is to provide a general overview of dental health issues that affect people with CP and to analyze key preventative and practical management techniques for this common comorbidity.

Comparison of Malocclusion Prevalence, Type and Severity between Cerebral Palsy and Healthy Subjects: A Prospective Case-Control Study

Background: To analyze the prevalence, type and severity of malocclusions in a group of patients with cerebral palsy (CP) using a facial and occlusal analysis and the Dental Aesthetic Index (DAI). Methods: A prospective, case–control study was made of two groups, a cerebral palsy and a control group, with the determination of the facial and occlusion analysis in the three spatial planes. The Dental Aesthetic Index (DAI) was used to assess the severity of malocclusion. Results: The patients with CP presented a higher prevalence of increased facial lower third height and a greater tendency towards right-side canine and molar class II malocclusion, narrower transverse relationship and crossbite. The DAI scores were statistically significantly higher in the CP group. Increased physical impairment in the CP group was associated to greater DAI scores. Conclusions: The prevalence and severity of malocclusion were significantly greater in the CP group. The type of malocclusion predominantly found in these patients was molar class II, with open bite, increased overjet and a narrow arch. The CP group also presented mixed breathing with higher DAI scores and decreased facial lower third height.

Bruxism in children and adolescents with cerebral palsy

This study aims to summarize the existing evidence from primary studies in order to answer the following question: "are children and adolescents with cerebral palsy (CP) frequently affected by bruxism?". For such, databases Web of Science, Medline (via PubMed), Lilacs, SciELO, Scopus and Wiley Online Library were used, with the keywords “Cerebral Palsy” and “Bruxism” alone and in combination, without the restriction of the publication date. The search included all articles published until May 2020. A total of 229 publications were found, of which 12 were selected, after careful analysis. Retrospective data analyses, cross-sectional studies and observational case-control studies published in English and with samples composed of children and/or adolescents were included. Case reports, literature reviews and studies whose sample consisted of adults-only were excluded. In the evaluated studies, bruxism was present in all samples with cerebral palsy. However, oral signs and symptoms resulting from this parafunction were reported only in three studies, in which the presence of dental wear and pain was evaluated. Therefore, bruxism in children and adolescents with cerebral palsy is a frequent oral condition, however, knowledge about the associated and risk factors for the occurrence of this problem in these patients remains limited.

Spontaneous Swallowing Frequency, Dysphagia, and Drooling in Children With Cerebral Palsy

OBJECTIVE

To evaluate relationships between spontaneous swallowing frequency, dysphagia, and drooling in children with cerebral palsy. Spontaneous swallowing frequency was predicted to be inversely related to both dysphagia and drooling among children with cerebral palsy. A secondary objective compared patterns among spontaneous swallowing frequency, drooling, and age in healthy children vs children presenting with cerebral palsy.

DESIGN

Cross sectional study.

SETTING

Children with cerebral palsy were tested at a Cerebral Palsy Reference Center in a university hospital. Healthy children were tested in their home setting.

PARTICIPANTS

Twenty children with cerebral palsy were recruited from the local registry for cerebral palsy children and purposive sampling among parents. A group of 30 healthy children was recruited by purposive sampling among family, friends, and the local community. Children below 1 year of age up to 5 years of age were included in the healthy group. This age range was targeted to maximize the potential for drooling in this group.

MAIN OUTCOME MEASURES

Both groups provided data on spontaneous swallowing frequency (swallows per minute, or SPM), dysphagia, and drooling. Motor impairment was documented in the children with cerebral palsy.

RESULTS

SPM was significantly lower in children with cerebral palsy. Among children with cerebral palsy, SPM correlated significantly with dysphagia severity and trended toward a significant correlation with drooling at rest. In this subgroup, SPM was not correlated with age or degree of motor impairment. Dysphagia was significantly correlated with drooling at rest and both dysphagia and drooling at rest were correlated with degree of motor impairment. The 2 groups did not differ in the degree of drooling at rest. Among healthy children, age but not SPM demonstrated a significant inverse correlation with drooling quotient at rest.

CONCLUSIONS

Spontaneous swallowing frequency is related to dysphagia and drooling in children with cerebral palsy. The pattern of relationships among spontaneous swallowing frequency and drooling is different between children with cerebral palsy and younger healthy children.

Prevalence of bruxism in adults with cerebral palsy institutionalized in Lisbon

OBJECTIVE

To determine the prevalence of bruxism in individuals with cerebral palsy (CP) and evaluating the various factors associated METHODS: One hundred and ten adults diagnosed with CP were selected from six institutions for people with special needs. Data were collected through oral examinations using the diagnostic criteria proposed by the American Academy of Sleep Medicine and the modified scale of Asworth RESULTS: Of the total sample, spastic tetraplegia was the most common type and half of the population presents severe intellectual disability. The prevalence of bruxism was 74,5%. Wear facets were observed in 67.9% of the sample, 59.1% of which were brilliant. There was a positive association between mixed bruxism (MB) and the spasticity classification. Through a logistic regression it was found that the risk of having MB and general bruxism (GB) is greater in individuals who have shiny wear facets.

CONCLUSIONS

In the present study the high prevalence of GB indicates there is an urgent need for treatment options in people with CP. More studies are needed with standardized diagnostic protocols and representative samples to evaluate the factors that influence the presence of bruxism in this population and to establish an appropriate treatment planning.

Oral health status and microbial load of Streptococcus mutans in children with Cerebral palsy in a tertiary care hospital in Delhi

BACKGROUND

Cerebral palsy (CP) is a childhood debilitating condition which impairs the physical and mental ability of an individual to maintain oral health.

AIM

The objective of the present study was assessment of dental neglect and burden of treatment needs of children affected with CP as compared to normal children in a tertiary care hospital in Delhi.

SETTINGS AND DESIGN

A sample size of 104 children of age group of 6-14 years was selected, in which 52 children of CP (case group) and 52 normal school children (control group) were recruited.

MATERIALS AND METHODS

Children from both groups were examined, and calculation of drug master files (DMFS), defs, oral hygiene index (OHI), and gingival index was done. The presence of trauma and malocclusion was assessed. Present caries activity was assessed by the level of Streptococcus mutans present in saliva in both groups. Treatment needs were then assessed based on intraoral findings.

STATISTICAL ANALYSIS

Data were analyzed by SPSS 20.0 software. Student's t-test and nonparametric statistical tests such as Chi-square test and Mann-Whitney test were used as per the nature of variables studied for statistical analysis with the level of significance denoted at P < 0.05.

RESULTS

The mean DMFS, gingival index, OHI, and treatment needs were observed to be higher in the CP group. Increased S. mutans levels were observed in saliva of CP patients. Defs score, trauma, and malocclusion were not statistically significantly higher in CP group as compared to the control group.

CONCLUSION

Cerebral palsy group had a poor oral and gingival health, a higher DMFT and burden of treatment needs and an increased risk of further caries progression due to high caries activity indicated by increased level of salivary Streptococcus mutans than the control group.

Effect of cerebral palsy and dental caries on dental plaque index, salivary parameters and oxidative stress in children and adolescents

PURPOSE

The aim of the present study was to investigate the effect of cerebral palsy and dental caries on dental plaque index, salivary parameters and oxidative stress in children and adolescents.

METHODS

Seventy children and adolescents aged 2-20 years were divided into four groups: neurotypical controls-inactive caries (NCIC; n = 19); neurotypical controls-active caries (NCAC; n = 16); cerebral palsy-inactive caries (CPIC; n = 19); and cerebral palsy-active caries (CPAC; n = 16). The visible dental plaque index was determined after drying the tooth surfaces and without any mechanical or chemical disclosing methods. Salivary pH and buffer capacity were measured 1 hour after collection using a digital pH meter. Saliva was used to evaluate oxidative status based on the levels of reactive species, lipid peroxidation and non-enzymatic antioxidants (reduced glutathione and vitamin C).

RESULTS

The CPIC and CPAC groups had lower salivary pH and a higher visible dental plaque index. CP was also associated with an increase in salivary levels of markers of oxidative stress and the modulation of salivary levels of non-enzymatic antioxidants.

CONCLUSION

Cerebral palsy exerts an influence on the salivary profile, oral health and oxidative stress. The individuals with CP had more acidic saliva and a higher dental plaque index, which were positively correlated with caries activity. CP was associated with high salivary levels of reactive species and lipid peroxidation, demonstrating an imbalance in salivary redox that was particularly associated with caries activity. These factors facilitate the development of oral diseases in individuals with cerebral palsy.

Cuidados em saúde bucal a crianças e adolescentes com paralisia cerebral: percepção de pais e cuidadores

Resumo Objetivou-se avaliar os cuidados em saúde bucal de crianças/adolescentes com Paralisia Cerebral (PC) segundo a gravidade, através da percepção dos pais/cuidadores. Estudo série de casos realizado em serviços de saúde de Pernambuco com 94 mães/cuidadores de sujeitos com PC entre 5 e 18 anos. Avaliaram-se fatores socioeconômicos, demográficos, cuidados em saúde bucal e uso de serviços odontológicos (SO). O Sistema de Classificação da Função Motora Grossa mostrou 67% com comprometimento motor grave. Indivíduos com PC grave tiveram frequência significantemente maior de pertencerem a famílias com renda mais baixa (89%, p < 0,001), residirem no interior (44%, p < 0,005), terem dificuldades de transporte (60%, p = 0,04) e acessibilidade aos SO (88%, p = 0,009) e maior necessidade de higiene bucal (67%, p = 0,008) realizada pelas mães (94%, p < 0,001). Apesar das barreiras de acesso aos SO, o mesmo foi facilitado para aqueles com PC grave, com uso precoce dos SO, mas com baixa oferta de dentistas e de humanização. Esses resultados informam problemas relacionados aos cuidados diários em saúde bucal, contexto de vida das famílias, de apoio institucional e de qualidade dos SO a serem enfrentados com políticas públicas socioeconômicas e de saúde integrais inclusivas e equânimes.

Oral hygiene and oral status of institutionalized children with motor and intellectual disabilities

The oral hygiene and oral status of children with severe disabilities with both nutritional and respiratory complications who were institutionalized at Karugamonoie (KNI), a facility for children with disabilities, were investigated in this study. Their oral hygiene management was solely dependent on caregivers and nurses at the institution. Thirty children (13 females, 17 males; average age, 7.6 years) who had a tracheotomy and feeding tube (gastrostomy, nasogastric, or jejunostomy feeding tube) were included in the study. As for oral characteristics, poor control of tongue movement, anterior open-bite, abnormal strain of facial muscles, dry mouth, and swallowing dysfunction were found in 63.3%, 63.3%, 13.3%, 20.0%, and 100.0%, of the children, respectively. The mean ± standard deviation Decayed, Missing, Filled Teeth score was 0.13 ± 0.57. The Gingival Index (GI) showed that the children had mild (53.3%) to moderate (46.7%) gingivitis. The Simplified Oral Hygiene Index was excellent in 50.0% of the children, good in 23.3%, fair in 20.0%, and poor in 6.7% of the children. These indices were satisfactory in general except for GI management, which may have been hampered by abnormal oral functions and anterior open-bite. In conclusion, oral hygiene management of children with nutritional and respiratory complications at KNI was shown to be of high quality even without on-site intervention by dental specialists.

The relationship between special needs and dental trauma. A systematic review and meta-analysis

BACKGROUND/AIMS

Understanding the risk factors for dental injuries is essential to develop prevention strategies. The aim of this study was to perform a systematic review and meta-analysis to determine whether people with special needs (SN) have a higher incidence of traumatic dental injury (TDI).

MATERIALS AND METHODS

Electronic searches were performed with no language or date restrictions in the following databases: PubMed, Lilacs, BBO, Scopus, Web of Science, Cochrane Library and Open Gray. According to the PECOS strategy, observational studies that investigated subjects with and without SN and its association with TDI episodes were included. Quality assessment and bias control were carried out according to Fowkes and Fulton guidelines. A meta-analysis was performed by sub-grouping studies according to the type of SN, with the odds ratio (OR) also being calculated (P ≤ .05). The evidence was quality tested using the GRADE approach.

RESULTS

After titles and abstracts were examined, and full texts were read, 28 studies were included in the qualitative synthesis and 27 in the meta-analysis. Three studies were classified with high methodological quality and the others had methodological problems. No associations were determined between TDI and autism spectrum disorder, epilepsy and mental disability (OR 1.12 [0.70, 1.78], OR 1.28 [0.13, 12.27] and OR 1.04 [0.20, 5.35], respectively, P > .05). A positive association (P < .05) was found between TDI and hyperactivity disorder, cerebral palsy, 21 trisomy, various conditions of SN and in pooled results (OR 2.67 [1.22, 5.87], OR 1.89 [1.06, 3.37], OR 6.18 [2.24, 17.05], OR 1.69 [1.18, 2.41], OR 1.61 [1.16; 2.22], respectively).The certainty of evidence ranged from very low to low.

CONCLUSIONS

In general, people with SN had a higher chance of having TDI with very low certainty of evidence. People with ADHD and cerebral palsy had a higher chance of TDI.

Short-term impact of an oral health program for adults with cerebral palsy

AIM

To evaluate the impact of an oral health program for institutionalized individuals with cerebral palsy (CP) and their caregivers, after 2 and 6 months.

METHODS

Sixty-two CP individuals in four homes were selected for intervention group (n = 31) and control group (n = 31). An oral hygiene practices questionnaire was applied to all caregivers at the baseline. Both groups received awareness sessions, practical demonstration of toothbrushing and adaptive techniques with role-play. In the study group, individual oral hygiene monitoring was also performed in the first 2 months. A gingival and an oral hygiene indexes were performed at the beginning, after 2 and 6 months of intervention.

RESULTS

There was a significant reduction of gingival (p < 0.001) and oral hygiene (p < 0.001) indexes at 2 and 6 months in the intervention group with the most significant reductions at 2 months. Caregivers reported opening the mouth (84.6%) and swallowing toothpaste (61.5%) as the most important difficulties in performing toothbrushing.

CONCLUSION

It was found that frequent and individualized monitoring of plaque control was essential to reduce dental plaque and gingivitis levels and that awareness sessions were not enough to produce clinically significant result.

Oral health outcomes for people with cerebral palsy: a scoping review protocol

OBJECTIVE

This review aims to systematically map the literature reporting on oral health outcomes experienced by people with cerebral palsy.

INTRODUCTION

At present, there are no documented systematic reviews reporting on oral health outcomes for people of all ages with cerebral palsy. Subsequently, there are no clear guidelines, frameworks or detailed oral health recommendations for people with cerebral palsy. Considering the importance of oral health on general well-being and quality of life, it is important that it is not overlooked when focusing on patient-centered care for people with cerebral palsy.

INCLUSION CRITERIA

Studies that focus on oral health, including dental diagnosis, trauma and/or treatment, facial pain, saliva, and sleep apnea, and/or make statements regarding oral health pertaining to cerebral palsy will be considered for inclusion inthis scoping review.

METHODS

This review will be conducted in accordance with the guidelines outlined by JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). Articles published in any language will be considered for inclusion, with no restriction on publication date. The search databases will include the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, Embase and Dentistry and Oral Science. A search of gray literature will also be conducted. Extracted data relevant to the scoping review will be performed by two reviewers.

Clinical and x-ray oral evaluation in patients with congenital Zika Virus

OBJECTIVE

The aim of this study was to investigate possible malformations in the soft, bone and/or dental tissues in patients with congenital Zika Virus (ZIKV) by clinical and x-ray evaluation.

METHODOLOGY

Thirty children born with ZIKV and 30 children born without ZIKV (control group) were included in the study. Patients were evaluated over 24 consecutive months according to the variables: sex, age, cleft palates, soft tissue lesions, alveolar ridge hyperplasia, short labial and lingual frenums, inadequate posture of the lingual and perioral muscles at rest, micrognathia, narrow palatine vaults, changes in the teeth shape and/or number, sequence eruption, spasms, seizures and eruption delay were evaluated. Chi-square test, Student's t-test and nominal logistic regression were used (p<0.05).

RESULTS

Among the 30 babies examined, the mean age of the first dental eruption was 10.8±3.8 with almost two-thirds of the children (n=18, 60%) experiencing eruptions of their first tooth after 9 months of age, nine children (30%) had inadequate lingual posture at rest, more than half of the children (n=18, 60%) had short labial or lingual frenums. ZIKV babies showed a high prevalence of clef palate (p<0.001), inadequate lingual posture at rest (p=0.004), micrognathia (p=0.002), changes in the shape and/or number of teeth (p=0.006), alteration in sequence of dental eruption (p<0.001) and muscles spasms (p=0.002). The delay eruption was associated with inadequate lingual posture at rest (p=0.047), micrognathia (p=0.002) and changes in the shape and/or number of teeth (p=0.021). The delayed eruption (p=0.006) and narrow palatine vaults (p=0.008) were independently associated with ZIKV. Moreover, female patients showed the most narrow palatine vaults (p=0.010).

CONCLUSIONS

The children with ZIKV showed a greater tendency to have delayed eruption of the first deciduous tooth, inadequate lingual posture and short labial and lingual frenums.

Effects of treatments for drooling on caries risk in children and adolescents with cerebral palsy

Background

Neuromuscular impairment makes individuals with cerebral palsy (CP) more prone to drooling. Among the treatment options, there are procedures that interfere with saliva production. It is imperative to evaluate the effect of the different modalities since the reduction in salivary flow rate/production may exacerbate the risk of dental caries.

Material and Methods

The aim of this study was to compare the effects of different treatments for drooling on caries risk and salivary parameters in children and adolescents with CP.

Study design

A total of 142 children and adolescents with CP, aged 6 to 18 years, were assigned to groups based on the different treatments they had received for drooling: G1—anticholinergic drugs (n = 18), G2—botulinum toxin injection (n = 16), G3—salivary glands surgery (n = 16), G4—no treatment (n = 42), and G5—non-drooling subjects (n = 50). All participants were evaluated on the Simplified Oral Hygiene Index, and for the prevalence of dental caries (decayed, missing, and filled teeth index and white spot lesions). Unstimulated whole saliva was collected, and salivary flow rate and osmolality were measured. Chi-square, ANOVA and Poisson regression were calculated. Prevalence ratios and their respective 95 % confidence intervals were obtained. The significance level was fixed at 5%.

Results

No differences were found in the decayed, missing, and filled teeth index (p = 0.128) and Simplified Oral Hygiene Index (p = 0.674) among the different groups. G3 presented significantly higher percentages of WSL (p<0.001), lower values of salivary flow rate (p<0.001), and higher values of osmolality (p<0.001). The white spot lesion prevalence ratio was higher only for G3 (Prevalence ratio = 14.36; IC 95% = 4.64-44.40; p<0.001).

Conclusions

Children and adolescents with CP who had received surgical treatment for drooling exhibited higher number of white spot lesions because of the reduced salivary flow rate and higher salivary osmolality.

Key words:Cerebral palsy, saliva, sialorrhea, dental caries, osmolar concentration.

Oral health and associated factors among preschool children with special healthcare needs

OBJECTIVE

To investigate the oral health status and associated factors among preschool children with special healthcare needs.

SUBJECTS AND METHODS

This was designed as a cross-sectional study. Dental examination was provided to 383 children at Special Child Care Centres. Covariates of interest included children's age, developmental profile, oral health-related behaviours and family social-economic status. The association between children's dental caries experiences, dental plaque deposition and gingival health status were analysed by negative binomial regression, multiple factor ANOVA and binary logistic regression when appropriate.

RESULTS

The proportion of children with caries, gingival inflammation and plaque were 30.3%, 89.6% and 95.0%, respectively. Final regression models indicated that (a) tooth decay was associated with dental visit experiences, night bottle-feeding habit, fluoridated toothpaste and monthly income; (b) plaque deposition was associated with intellectual functioning, practical skills, night bottle-feeding habit, use of toothpaste, initiation of toothbrushing habit, toothbrushing duration and additional cleaning habit; (c) gingival status was associated with children's intellectual functioning and toothbrushing frequency.

CONCLUSIONS

Poor oral hygiene status existed among preschool children with special healthcare needs. Children's oral health status was associated with their developmental profile, oral health-related behaviours and social-economic status.

Validation of the Spanish version of the Franciscan Hospital for Children Oral Health-Related Quality of Life questionnaire

Background

The Franciscan Hospital for Children Oral Health-Related Quality of Life questionnaire (FHC-OHRQOL-Q) is an instrument designed specifically for parents and caregivers of patients with special needs that has not yet been applied in Spain. The aim of this study was to adapt it to Spanish and evaluate its reliability and validity in patients with intellectual disability (ID) treated under general anesthesia.

Material and Methods

The study was conducted in two different stages: a) cross-cultural adaptation of the original questionnaire, and b) cross-sectional study on 100 parents and caregivers who completed the piloted FHC-OHRQOL-Q. The patients were examined according to the WHO methodology. Dental treatments performed were recorded. Statistical tests were used to evaluate reliability (internal consistency) and validity (content, criterion, construct and discriminant) of the instrument.

Results

The mean age was 24 years (range=4-71 years). The most frequent causes of ID were psychomotor retardation (25%) and cerebral palsy (24%). The items most frequently answered by parents and caregivers were eating and nutrition problems (80%) and bad breath/taste (57%). Reliability (Cronbach’s alpha coefficient) was considered excellent (alpha=0.80-0.95). The analysis of the factorial validity yielded similar results to the original questionnaire. The high response rate of items (>96%) allowed content validity. Criterion validity was confirmed by a significant correlation with questions on oral health and oral well-being. Discriminant validity was demonstrated by the significant association of ≥21.5 years of age with worse oral symptoms (p=0.034) and parental concerns (p=0.005), DMFT index ≥3 with daily life problems (p=0.02), ≥4 decayed teeth with daily life problems (p=0.001), and >2 dental extractions with oral symptoms (p=0.000), daily life problems (p=0.002) and parent´s perceptions (p=0.043).

Conclusions

The FHC-OHRQOL-Q in Spanish is a reliable and valid instrument to apply in clinical practice to evaluate the impact of OHRQOL in mostly adult patients with ID, accessible to Spanish-speaking parents and caregivers.

Key words:Oral health-related quality of life, intellectual disability, cross-cultural validation, psychometric properties, validation, questionnaire.

Hyperexcitability of brain stem pathways in cerebral palsy

Individuals with cerebral palsy (CP) experience impairments in the control of head and neck movements, suggesting dysfunction in brain stem circuitry. To examine if brain stem circuitry is altered in CP, we compared reflexes evoked in the sternocleidomastoid (SCM) muscle by trigeminal nerve stimulation in adults with CP and in age/sex-matched controls. Increasing the intensity of trigeminal nerve stimulation produced progressive increases in the long-latency suppression of ongoing SCM electromyography in controls. In contrast, participants with CP showed progressively increased facilitation around the same reflex window, suggesting heightened excitability of brain stem pathways. We also examined if there was altered activation of cortico-brain stem pathways in response to prenatal injury of the brain. Motor-evoked potentials (MEPs) in the SCM that were conditioned by a prior trigeminal afferent stimulation were more facilitated in CP compared with controls, especially in ipsilateral MEPs that are likely mediated by corticoreticulospinal pathways. In some participants with CP, but not in controls, a combined trigeminal nerve and cortical stimulation near threshold intensities produced large, long-lasting responses in both the SCM and biceps brachii muscles. We propose that the enhanced excitatory responses evoked from trigeminal and cortical inputs in CP are produced by heightened excitability of brain stem circuits, resulting in the augmented activation of reticulospinal pathways. Enhanced activation of reticulospinal pathways in response to early injury of the corticospinal tract may provide a compensated activation of the spinal cord or, alternatively, contribute to impairments in the precise control of head and neck functions.

NEW & NOTEWORTHY This is the first study to show that in adults with spastic cerebral palsy, activation of brain stem circuits by cortical and/or trigeminal afferents produces excitatory responses in anterior neck muscles compared with inhibitory responses in age/sex-matched controls. This may reflect a more excitable reticulospinal tract in response to early brain injury to provide a compensated activation of postural muscles. On the other hand, a hyperexcitable brain stem may contribute to impairments in the precise control of head and neck functions.

Oral Health Status among Children with Cerebral Palsy in Dubai, United Arab Emirates

Objectives:

The purpose of this study was to assess the oral health status of children with cerebral palsy (CP) in Dubai, United Arab Emirates (UAE).

Materials and Methods:

Eighty-four CP and 125 healthy children were recruited from special needs centers and private/public schools in Dubai. A dental examination for decayed-missing-filled teeth in primary dentition (dmft)/Decayed-Missing-Filled teeth in permanent dentition (DMFT) indices, simplified oral hygiene index, calculus index (CI), and oral debris index was conducted. In addition, assessments of occlusal, dentofacial, soft tissue anomalies and erosion were conducted. Statistical analysis was conducted using SPSS for Windows, version 20.0 (SPSS Inc., Chicago, IL, USA).

Results:

DMFT/dmft scores were comparable in both groups. CI was significantly higher among children with CP. CP patients had a significantly higher proportion of anterior open bite, anterior spacing, Class II molar Angle malocclusion, trauma, high-arched palate, tongue thrust, lymphadenopathy, angular cheilitis, macroglossia, drooling, and erosion as compared to controls.

Conclusions:

The study highlighted peculiar characteristics and needs for the CP patients in Dubai, UAE.

Risk factors for dental caries among children with cerebral palsy in a low-resource setting

AIM

To describe the oral health status and investigate factors affecting dental caries experience among children with cerebral palsy (CP) in rural Bangladesh.

METHOD

A cross-sectional study was conducted among children with CP who are part of the Bangladesh Cerebral Palsy Register (BCPR) study. Caries experience was measured by identifying decayed, missing, and filled teeth for deciduous and permanent teeth (dmft/DMFT). Clinical periodontal index, body mass index, oral hygiene behaviour, masticatory ability, and dietary habits were recorded. CP motor types and severity of functional mobility (Gross Motor Function Classification System [GMFCS]) were assessed.

RESULTS

Of 90 children with CP (mean age 9y 7mo, range 2-17y, 37.8% female and 62.2% male), 35% of 2 to 6 year olds, and 70% of 7 to 11 year olds (p=0.014) experienced caries (dmft+DMFT>0). The mean values (standard deviation [SD]) of dmft and DMFT were 2.46 (3.75) and 0.72 (1.79) respectively. After adjusting for age and sex, binary logistic regression analysis showed a significant relationship with dental caries for children who had quadriplegia (odds ratio [OR] 5.56, p=0.035), tooth cleaning less than one time/day (OR 0.08, p=0.016), using toothpowder or charcoal for cleaning (OR 7.63, p=0.015), and snacking between meals more than one time/day (OR 6.93, p=0.012).

INTERPRETATION

Early oral health preventive care is required for children with CP because dental caries is highly prevalent in these children.

Oral Health Quality of Life in Children with Cerebral Palsy: Parental Perceptions

OBJECTIVE

To assess the parents' perception of the oral health-related quality of life (OHRQOL) in children with Cerebral Palsy (CP) and compare it with normally developing children.

STUDY DESIGN

63 children with CP were recruited from 8 disability centers, and 99 healthy controls were recruited from 5 elementary schools. The ages of the children in both groups were from 6-12 years. The Franciscan Hospital for Children Oral Health-Related Quality of Life (FHC-OHRQOL) was used to measure the OHRQOL and an oral examination was conducted in the schools/centers of the children to assess the teeth, gingival health, and oral hygiene.

RESULTS

The FHC-OHRQOL showed a significant difference in 3 out of 4 sections indicating lower OHRQOL in the CP group. The examination showed no significant difference in the dental and gingival health and in the level of oral hygiene.

CONCLUSION

The OHRQOL of children with CP is significantly lower than that of normally developing children although the oral health status of children with CP is not significantly different from that of normally developing children.

Use of different oral hygiene strategies in children with cerebral palsy: A comparative study

Background:

Cerebral palsy (CP) is described as a group of conditions usually occurring in childhood, where children have motor dysfunction and are unable to adequately master the necessary techniques of plaque control, which ultimately leads to dental caries and periodontal problems.

Aims:

The objective of this study was to educate the parents/caretakers/institution staff and children with CP about the different preventive home care measures and to evaluate the oral hygiene and gingival health status of these children before and after the institution of different preventive home care measures.

Materials and Methods:

A total of 64 individuals with CP, aged between 6 and 18 years, were examined for their oral hygiene and gingival health status, after which the parents/caretakers received a health education program. The children were then randomly divided into four groups. Each group was administered a specific preventive home care measure (mechanical and chemotherapeutic) to be followed for a period of 6 weeks, and the oral hygiene and the gingival health status were recorded at the end of 1 week, 2 weeks, and 6 weeks. The data were then subjected to statistical analysis.

Results:

In the sample of 64 children diagnosed with CP, the mean OHI(S) score among the groups of children who were given different preventive home care measures was compared at baseline, 1 week, 2 weeks, and 6 weeks. Group 4 showed a marked reduction in the OHI(S) score measured from baseline to 6 weeks, when compared to the other three groups which wa statistically very highly significant (P < 0.001) The mean MGI score was compared at baseline, 1 week, 2 weeks, and 6 weeks home, Group 4 showed a marked reduction in the MGI score measured from baseline to 6 weeks, when compared to the other three groups. When the mean MGI score was compared from baseline to 6 weeks, there was a gradual decrease in the MGI score, which was statistically highly significant between baseline and 1 week (P < 0.05) and statistically very highly significant between 1 and 2 weeks (P < 0.001). However, this improvement was not statistically significant between 2 and 6 weeks (P > 0.05).

Conclusion:

A combined mechanical and chemotherapeutic measure is highly recommended to maintain the oral hygiene and gingival health of these special children because of their difficulties and their limited abilities to control dental plaque.

Caracterização dos pacientes e procedimentos executados no serviço de atendimento a pacientes com necessidades especiais da Faculdade de Odontologia de Araraquara – UNESP

ResumoObjetivoCaracterizar os pacientes atendidos e os procedimentos realizados no Serviço de Atendimento a Pacientes com Necessidades Especiais da Faculdade de Odontologia de Araraquara (FOAr) – UNESP.MetodologiaA partir dos prontuários odontológicos dos pacientes atendidos em nível ambulatorial entre 2007 e 2013, foram obtidas informações em relação a idade no início do tratamento, tipo de deficiência, medicamentos usados, número de sessões de atendimento e número e tipo de procedimentos odontológicos realizados.ResultadoDos 232 prontuários analisados, observou-se que mais da metade dos pacientes (56,0%) apresentava deficiência mental, paralisia cerebral ou anomalias congênitas determinadas por agentes infecciosos, com deficiência mental associada. Entre as anomalias congênitas, a mais prevalente foi a Síndrome de Down (9,9%). Apenas 20% dos pacientes iniciaram o tratamento antes dos dez anos de idade e 62,0% faziam uso de anticonvulsivantes, antipsicóticos, ansiolíticos, antiepilépticos e antidepressivos. Foram realizados 4.506 procedimentos odontológicos, sendo 37,6% preventivos e 62,4% curativos (Restauradores, 28,0%; Periodontais, 13,9%; Endodônticos, 9,7%; Cirúrgicos, 9,1%; Protéticos, 1,7%). Observou-se também que, para a maior parte dos pacientes (63%), foram necessárias até dez sessões para a realização do tratamento.ConclusãoOs pacientes que procuraram tratamento odontológico no Serviço de Atendimento a Pacientes com Necessidades Especiais da FOAr apresentavam, na sua maioria, deficiências com envolvimento neurológico. Apesar de esse serviço priorizar os procedimentos preventivos, a maior parte dos procedimentos executados foi curativa, o que está diretamente relacionado com a procura tardia pelo tratamento odontológico.

Mechanical control of biofilm in children with cerebral palsy: a randomized clinical trial

BACKGROUND

Dental biofilm removal is difficult and can be ineffective in individuals with cerebral palsy.

OBJECTIVE

Determine the effectiveness of brushing with an electric toothbrush on and off in comparison with manual brushing for the removal of biofilm in children aged four to 16 years with cerebral palsy.

METHODS

A crossover, randomized, simple-blind, clinical trial was conducted. The examiner was blinded to the brushing method (G1: manual; G2: electric toothbrush on; and G3: electric toothbrush off). The order was determined randomly. The participants (n = 40) were examined before and after brushing performed by caregivers using the Turesky-Quigley-Hein biofilm index. Statistical analysis involved the paired t-test, Wilcoxon, Kruskal-Wallis, and anova tests.

RESULTS

Biofilm was significantly reduced with the three brushing methods (P < 0.001) (mean reductions: 47.6% in G1; 47.4% in G2; 44.5% in G3). Significant differences were found between G1 and G3 (P < 0.001) and between G2 and G3 (P = 0.007). No significant difference was found between G1 and G2 (P = 0.06).

CONCLUSION

All methods reduced biofilm. Effectiveness was similar between manual brushing and with the electric toothbrush on, whereas both these methods achieved better results in comparison with the electric toothbrush switched off.

Comparison of oral health status between children with cerebral palsy and normal children in India: A case-control study

Background:

The aim of the present research was to describe and compare the oral health of children with cerebral palsy (CP) with the normal children in India.

Materials and Methods:

Fifty children with CP of the age range 7-17 years and fifty normal children were selected for the study. An oral examination was carried out and decayed, missing, and filled teeth (dmft/DMFT) index, oral hygiene index-simplified (OHI-S) index, Angles malocclusion were charted along with other significant dental findings. Data were analyzed using Student's t-test and Kruskal–Wallis one-way ANOVA test.

Results:

The mean dmft/DMFT of the CP group was 4.11 ± 2.62, while that of controls was 2.95 ± 2.75, which showed higher caries prevalence in the CP group. There was a significant association between the dmft/DMFT (P = 0.03), OHI-S (P = 0.001), and Angles Class 2 malocclusion and CP.

Conclusions:

Cerebral palsy group had higher caries, poor oral hygiene and Class 2 malocclusion when compared to controls primarily because of their compromised general health condition and also less dental awareness. Effort should be made for better organization of preventive dental care and promoting dental health of this challenged population.

Dental caries and periodontal disease in Brazilian children and adolescents with cerebral palsy

The aim of the present study was determine the prevalence and factors associated with dental caries and periodontal disease in Brazilian children and adolescents with cerebral palsy (CP). This is a cross-sectional study conducted with 80 patients ranging in age from 2 to 18 years old. Oral exams were conducted by an examiner with records of DMFT, dmft, Gingival Bleeding Index (GBI) and Community Periodontal Index (CPI). The statistical analysis used Poisson Regression with robust variance estimation (α = 0.05). The prevalence of dental caries was 59.3%, with DMFT and mean dmft of 1.71 ± 2.42 and 2.22 ± 3.23, respectively. The mean GBI was 22.44%, and in the CPI, the prevalence of gingival bleeding, calculus, shallow and deep pockets were 94.73%, 79.62%, 12.90% and 3.22%, respectively. The caregiver’s educational level of less than eight years were associated with the dental caries experience (PR = 1.439; 95%CI = 1.09–1.89). The periodontal alterations were associated with female sex (PR = 0.82; 95%CI = 0.69–0.97), caregiver’s educational level of less than eight years (PR = 1.15; 95%CI = 1.03–1.29), poor oral perception (PR = 0.89; 95%CI = 0.80–0.98), serious communication problem (PR = 0.87; 95%CI = 0.76–0.99) and athetoid type of CP (PR = 0.85; 95%CI = 0.75–0.97). The patients with CP presented high dental caries experience and periodontal alterations, which were associated with their demographic, socioeconomic, oral health perception and systemic information.

Cerebral palsy: a dental update

Special and medically compromised patients present a unique population that challenges the dentist’s skill and knowledge. Providing oral care to people with cerebral palsy (CP) requires adaptation of the skills we use everyday. In fact, most people with mild or moderate forms of CP can be treated successfully in the general practice setting. This article is to review various dental considerations and management of a CP patient.

How to cite this article: Sehrawat N, Marwaha M, Bansal K, Chopra R. Cerebral Palsy: A Dental Update. Int J Clin Pediatr Dent 2014;7(2):109-118.

Association between executive/attentional functions and caries in children with cerebral palsy

The aim of the present study was to evaluate the existence of an association between attention/executive functions and the development of dental caries in individuals with cerebral palsy (CP). Seventy-six children with CP were selected from a physical rehabilitation center and a school serving children with disabilities. The control group was made up of 89 children without neurological impairment. Socioeconomic status, presence of teeth with cavities due to caries, degree of motor impairment and intellectual, executive and attentional functions were assessed. Mean age of participants was 8.9 years (SD=3.56). The CP group had a significantly lower performance (p<0.05, Mann-Whitney test) on the intelligence, attentional function and executive function tests in comparison to the control group. Controlling for the clinical diagnosis (CP or control group), motor impairment and intellectual function, the significant explanatory variables for the presence of teeth with cavities were performance on the Complex Rey figure test (OR=0.941) and the Digit Span subtest of the Wechsler Intelligence Scale for Children in backward order (OR=0.581). After controlling for intellectual function, clinical diagnosis and motor impairment, deficits in executive and attentional functions increased the odds of developing dental caries in children with cerebral palsy.

Does intellectual disability affect the development of dental caries in patients with cerebral palsy?

The aim of this study was to evaluate if the severity of intellectual disability is a factor that affects the development of dental cavities in patients with cerebral palsy. This cross-sectional study was conducted on 165 individuals who were selected from a physical rehabilitation center, a special public school and a regular public school. Of these, 76 individuals had been diagnosed with spastic cerebral palsy and 89 had no neurological impairment. The subjects were matched based on age and gender and selected randomly by lottery. All patients were examined to determine the number of dental cavities, and tested for their intellectual functioning (Raven Test) and motor abilities. The study showed that children with CP who presented with intellectual disabilities had a larger number of dental cavities than children with CP without intellectual disabilities. Considering intellectual functioning and motor impairment in the multivariate logistic regression, only intellectual functioning was found to have a significant effect on the development of dental cavities. These results suggest that intellectual disability can be considered a contributing factor for the development of dental caries in patients with cerebral palsy.

Condições de saúde bucal e acesso ao tratamento odontológico de pacientes com paralisia cerebral atendidos em um centro de referência do Nordeste - Brasil

OBJETIVO: avaliar a ocorrência de cárie dentária e necessidades de tratamento em crianças com paralisia cerebral atendidas no setor de Odontologia de um centro de referência do Nordeste do Brasil (Associação À Criança Deficiente; Recife-Brasil); e conhecer suas principais dificuldades no acesso ao tratamento odontológico. MÉTODO: a amostra foi composta por livre demanda de 167 pacientes de seis a 12 anos. A experiência de cárie foi avaliada de acordo com os critérios da Organização Mundial de Saúde. RESULTADOS: a grande maioria das crianças (70,7%) apresentava paralisia cerebral do tipo espástica. Dos que tiveram dificuldades no acesso ao tratamento (46,1%), a maioria relatou a falta de profissional capacitado (34,1%). A prevalência de cárie foi de 61,1% na dentição decídua e 26,3% na permanente. Aproximadamente 60% dos pesquisados necessitavam de algum tipo de tratamento da cárie. Observou-se que, em comparação com estudos realizados em outras regiões do Brasil, as crianças pesquisadas apresentaram experiência de cárie mais elevada. CONCLUSÃO: verificou-se a necessidade de melhorar a assistência odontológica a esses pacientes, principalmente no interior do estado, de forma quantitativa, qualitativa e integrada com ações multidisciplinares.

The CP-MST, a malnutrition screening tool for institutionalized adult cerebral palsy patients

BACKGROUND & AIMS

Progress in management of cerebral palsy (CP) patients has helped to increase life expectancy, but has also revealed nutritional consequences of this disability. The aims of this study were to determine the prevalence of malnutrition in long-term-institutionalized adult patients with CP and to propose specific malnutrition screening tool.

METHODS

Practitioners at 15 specialized institutions hosting CP patients assessed their nutritional status and completed a binary questionnaire containing thirteen questions related to factors suspected of increasing malnutrition. Moderate malnutrition was defined as the following: loss of weight (%) ≥ 5 to <10 or BMI ≥ 16 to <18.5 or albuminemia (g/l) ≥ 30 to <35. Markers of malnutrition were identified by bivariate analysis (ANOVA and Chi-square). Stepwise factorial discriminant analysis was used to determine the best subset of parameters for use in computation of a screening score.

RESULTS

A total of 365 patients age 35.7 ± 9.0 years were identified. Malnutrition was severe in 25%, moderate in 33% and absent in 42% of cases. The four strongest factors associated with malnutrition were used to build a three-level malnutrition screening tool for CP adult patients (CP-MST) as follows: body weight < 40 kg (10 points), sitting position uncomfortable or impossible (4 points), partial or total help to feed (4 points) and suspicion of gastro-esophageal reflux (3 points), (P < 0.0001): A screening score higher than 10 points indicated high risk with malnutrition probability of 90%, and detected 37% of malnourished patients. Conversely, a score equal to 0 excluded severe malnutrition in 90% of cases.

CONCLUSION

In light of the fact that 58% of these patients were malnourished, the CP-MST would appear to be useful for detecting malnutrition, underlining the need for a multidisciplinary approach in CP patients.

Oral health in preschool children with cerebral palsy: a case-control community-based study

International Journal of Paediatric Dentistry 2010; 20: 330-335 Objectives. To assess and compare the oral health status of preschool children with and without cerebral palsy (CP). Methods. Preschool children with CP (72) were recruited from 23 Special Child Care Centers in Hong Kong. An age (+/-3 months) and gender matched sample of preschool children from mainstream preschools were recruited as the control group. Dental caries status, gingival health status, tooth wear, developmental defect of enamel, malocclusion, dental trauma and oral mucosal health were assessed and compared between the two groups. Results. Significant differences in gingival health status were found between children with and without CP (mean plaque index scores, P = 0.001 and mean gingival index scores, P < 0.05). Tooth wear involving dentine was more prevalent among CP children (P < 0.001), as were evidence of anterior open-bite (P < 0.001) and oral mucosal lesions (P < 0.05). Children with and without CP had similar caries experiences (P > 0.05), prevalence of enamel defects (P > 0.05) and dental trauma (P > 0.05). Conclusions. Differences of oral health status exist among preschool children with and without CP. Preschool children fare worse in terms of gingival health, tooth wear, oral mucosal health and malocclusion.

Health- and oral health-related quality of life among preschool children with cerebral palsy

OBJECTIVES

To assess the health- and oral health-related quality of life of preschool children with cerebral palsy (CP) and to determine their inter-relationship between the two quality of life measures.

METHODS

A total of 144 preschool children with and without CP were invited to participate in the case-control study. Health-related quality of life was assessed by the Pediatric Quality of Life Inventory Version 4.0 (PedsQL™ 4.0) and oral health-related quality of life by the Early Childhood Oral Health Impact Scale (ECOHIS). Differences in PedsQL™ 4.0 and ECOHIS scores were determined between the groups, and correlation between PedsQL and ECOHIS were explored.

RESULTS

Significant differences in overall scores of PedsQL™ 4.0 (P < 0.001) and in overall scores of ECOHIS (P < 0.05) were apparent between the two groups. In terms of health- and oral health-related quality of life, preschool children with CP fared worse than the age-gender-matched control group. There was a positive albeit weak correlation (r = 0.203, P < 0.05) between PedsQL™ 4.0 and ECOHIS scores.

CONCLUSIONS

Differences in health- and oral health-related quality of life exist among preschool children with CP. Correlation between health- and oral health-related quality of life could at best be described as weak.