Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 6 (2013) 243–249 DOI 10.3233/PRM-140262 IOS Press
243
Case Report
Dental management of early childhood caries in spastic quadriparesis: A case report and clinical guidelines Kavita Hotwania,∗ and Krishna Sharmab a
Department of Pedodontics and Preventive Dentistry, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India b Department of Orthodontics and Dentofacial Orthopaedics, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India
Accepted 17 October 2013
Abstract. Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior. Spastic quadriparesis is the most severe form of spastic cerebral palsy. The present report describes the management of a 5-year-old patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients so as to provide comprehensive dental care. Keywords: Early childhood caries, spastic quadriparesis, dental management
1. Introduction Spastic quadriparesis is the most severe form of spastic cerebral palsy. Cerebral palsy (CP) is a permanent physical condition that affects movement. In the mid-1800s, Dr. William John Little pioneered the study of CP using his own childhood disability as an inspiration. This condition was known as Little’s disease until William Osler coined the term cerebral palsy in 1888. Dr. Sigmund Freud, the father of psychoanalysis, proposed the idea that CP might result from abnormal fe∗ Corresponding author: Kavita Hotwani, Department of Pedodontics and Preventive Dentistry, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India. E-mail: hotwani.kavita@ gmail.com.
tal development, decades before the medical field embraced the concept [1]. CP describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior [2]. Multiple studies have found the prevalence of CP to be 2.4 per 1,000 [3]. The etiology of CP is multifactorial and includes prenatal causes (genetic diseases, embryonic anomalies), perinatal (hypoxia, Rh incompatibility, premature birth, underweight at birth, etc.), and postnatal (infections, trauma, etc.). In 30% of the cases, the risk fac-
c 2013 – IOS Press and the authors. All rights reserved 1874-5393/13/$27.50
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K. Hotwani and K. Sharma / Dental management of early childhood caries in spastic quadriparesis
tors can be traced. The frequency is 10 times higher in premature children and 25 times higher in small for gestational age children [4,5]. CP is classified into four types: spastic, dyskinetic, hypotonic, and mixed, with spastic being the most common type. Spastic quadriparesis represents the most severe form of spastic cerebral palsy and is characterized by a motor disturbance that affects both of the extremities [6]. Children with CP face a number of dental problems, including multiple carious teeth, periodontal problems, malocclusion, and bruxism. Inadequate function of the masticatory system in these children causes problems with mastication and inhibits self-cleansing. Constant consumption of mushy food as a result of disabilities in mastication results in a more frequent appearance of dental caries [7]. Additionally, the lower salivary flow rate, pH, and buffer capacity observed in these patients increases the risk of oral disease in this population. The higher incidence of caries in this population is also due to orofacial motor dysfunction and dietary inconsistencies. Taking care of an individual with CP is a potential source of continual burden for caregivers, and there is a positive correlation observed between caries prevalence in individuals with CP and the burden on their caregivers [8–10]. We report the management of a 5-year-old patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients required to provide comprehensive dental care.
2. Case report A 5-year-old patient reported to the department of pediatric dentistry with the chief complaint of pain and swelling in lower right posterior region of jaw. On clinical examination, it was found that patient had multiple carious lesions. The medical report suggested that the patient was a previously diagnosed case of spastic quadriparesis (Fig. 1). On further evaluation, it was discovered that the patient had been receiving occupational therapy since age four. A review of relevant medical records showed a history of premature birth with caesarian delivery, meconium stained liquor, and birth asphyxia. Detailed natal history taken during the dental visit revealed the presence of jaundice at birth and a NICU stay of 21 days. The patient was cyanosed, history of
Fig. 1. Patient with spastic quadriplegia, scissoring gait, open mouth posture, and spastic upper and lower limbs. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
seizures was reported, and the patient received blood transfusion at birth. On clinical examination, spasticity was present in both the upper and lower limbs. The plantar reflex was exaggerated and milestones of development were delayed. Scissoring gait was present, posture was imbalanced and uncoordinated and the patient exhibited slurred speech and open mouth posture. Intraoral examination showed ankyloglossia, generalized gingival inflammation, and gingival abscess present in the primary mandibular right second molar. On examination, dental caries was observed in the primary maxillary right and left central incisors and primary mandibular right and left first molars. The primary maxillary and mandibular right and left first molars were grossly decayed. Grade I mobility was present in the primary maxillary right first molar (Fig. 2). Intraoral periapical radiographs were taken. However, due to the patients’ spasticity, blurring of the radiographs was observed. The patient’s dietary history was also recorded and was found to be imbalanced with increased sugar exposure.
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245
Table 1 Phase-wise treatment plan 1 2 3
Medical/systemic phase Emergency treatment Preventive phase
4
Preparatory phase
5
Corrective phase
– – – – – – – –
Maintenance phase
– – – –
6
Evaluation for fitness Access opening and abscess drainage of primary mandibular right second molar under antibiotic coverage Oral prophylaxis Fluoride application with varnish Diet counseling and home care instructions Pulpectomy of primary mandibular right and left second molars and maxillary left first molar Extraction of primary maxillary right first molar Glass ionomer restoration of primary maxillary right and left second molar and primary mandibular right and left first molars Stainless steel crown with primary mandibular right and left second molars and maxillary left first molar Band and loop space maintainer with primary maxillary right second molar Strip crowns with primary maxillary right and left central incisor and left lateral incisor Re-evaluation after 3 months
Fig. 2. Preoperative intra-oral photographs. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
Fig. 3. Postoperative intra-oral photographs. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
A final diagnosis of early childhood caries was made [11]. After thorough medical evaluation, consent was obtained from the pediatrician for dental treatment under local anaesthesia. A treatment plan was formulated and initiated in phases (Table 1). The restorative and endodontic therapy was carried out under local anaesthesia. Adequate consideration was given to the appointment scheduling as well as treatment timing. All procedures were carried out with parental presence in the dental operatory. Behavior management techniques used included tell, show, do and proper patient positioning and stabilization with towel rolls. Parents were guided on oral hygiene measures and dietary modification. The treatment resulted in drastic improvements in the patient’s oral health (Figs 3, 4).
quadriplegia is the most common type of CP, reported in about 51.5% cases in the North Indian population [12]. The primary deformity in spastic quadriparesis affects both the upper and lower limbs. Spasticity is manifested as hyperirritability of muscles, resulting in exaggerated contraction when stimulated. The muscles are tense and contracted. The hand and arm are flexed and held in against the trunk. The foot and leg may be flexed and rotated internally, which results in a limping gait with circumduction of the affected leg [13]. The present case exhibited all of these characteristic features. Patients with CP tend to have limited control of the neck muscles, which results in head roll and a lack of control of the muscles supporting the trunk – this, in turn, results in difficulty maintaining an upright posture [14]. Spastic children can also exhibit a lack of coordination of intraoral, perioral, and masticatory musculature, impaired chewing and swallowing, and excessive drooling [7]. Early childhood caries is the presence of one or more decayed (non-cavitated or cavitated lesions), missing
3. Discussion Spastic CP is the most common type of cerebral palsy, occurring in about 70% of all cases. Spastic
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(due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger [15]. In the present case, all primary molars and primary incisors were carious. The condition was exaggerated in the presented patient due to a combination of poor oral hygiene, a sugar-rich diet, poor salivary clearance, and spastic facial musculature. The treatment protocol followed in the present case involved comprehensive restorative, endodontic, and orthodontic therapy for complete oral rehabilitation. Prophylactic antibiotic therapy was initiated because the patient reported with a gingival abscess. The potential for a dentist to treat a palsic child and to give the patient appropriate dental care depends on his or her grade of disability. Normally, about 14% of children with CP are able to cooperate with dentists, similar to the majority of healthy children. Fifty-three percent of CP children require specially adaptated dental treatment, and, in most cases, it is not possible to perform all necessary dental procedures. Moreover, in 33% of children dental treatment is not possible without the use of general anesthesia [16]. In the dental office, children with spastic CP have difficulties in cooperating due to their high sensitivity to physical contact and neuromotor response to unusual stimuli such as noise, artificial light, and position of the dental chair. In the present case, the dental procedures were performed under local anaesthesia on the dental chair with a modified behavior management protocol. Sedation and general anaesthesia were ruled out as the child, although limited in movement, was very cooperative and mentally fit. Head stabilization was achieved using a towel and parental assistance was utilized at each step of dental procedure. Care was taken so as to avoid jerky movements and short appointments were scheduled in morning.
4. Oral manifestations in CP [13,14,17] 4.1. Periodontal disease Periodontal disease and poor oral hygiene occurs with great frequency in persons with CP. Often the patient will not be physically able to brush or floss adequately. When another individual must provide oral hygiene measures for the person, they may be performed infrequently and inadequately. Diet may also be significant; children who have difficulty chewing and swallowing tend to eat soft foods, which are easily swallowed and are high in carbohydrates. Patients
Fig. 4. Restoration of aesthetics and smile. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
with CP who take phenytoin to control seizure activity may have a degree of gingival enlargement. Gingival enlargement occurs in about 50% of patients receiving the drug, although different authors have reported incidences between 3% and 84.5%. The pathogenesis of gingival enlargement induced by phenytoin is not known, but some evidence links it to a direct effect on specific, genetically predetermined subpopulations of fibroblasts, inactivation of collagenase, and plaqueinduced inflammation [18]. In the present case, generalized gingival inflammation was evident; however, no sign of enlargement was observed. 4.2. Dental caries The data are conflicting regarding the incidence of dental caries in patients with CP as compared to the incidence in the general population. Some authors report increased prevalence of dental caries [17,19], while others found a lower prevalence than in populations without CP [20]. The contributory factors might be poor masticatory muscular control that encourages food stagnation in the buccal and labial sulci and poor manual dexterity as observed in most individuals with CP. Some authors attributed the high prevalence of dental caries to prolonged use of medications such as anticonvulsants, which have high sugar content, are viscous, and taken at night [21,22]. In a study carried out in Brazil, the high caries prevalence was attributed to poor socioeconomic conditions, irrespective of type of CP, and a high frequency of sugar consumption [19]. Santos et al. [10] reported that children with CP had a higher mean decayed, missing, and filled surfaces index, as well as a higher plaque index for both sexes in permanent dentition. Subramaniam et al. [23] reported mean deft and DMFT values of 2.51 and 0.73, respec-
K. Hotwani and K. Sharma / Dental management of early childhood caries in spastic quadriparesis
tively, in CP patients. They also observed a significant correlation between salivary pH and dental caries in the primary dentition of CP children. Moreira et al. [24] reported that children with CP who present with intellectual disabilities have a larger number of dental cavities than children with CP without intellectual disabilities. These results suggest that intellectual disability can be considered a contributing factor for the development of dental caries in patients with CP. 4.3. Malocclusions The prevalence of malocclusions in patients with CP is approximately twice that in the general population. Commonly observed conditions include noticeable protrusion of the maxillary anterior teeth, excessive overbite and overjet, open bites, and unilateral crossbites. A primary cause may be a disharmonious relationship between intraoral and perioral muscles. Uncoordinated and uncontrolled movements of jaws, lips, and tongue are observed with greater frequency in patients with CP. This may result in impaired chewing and swallowing, excessive drooling, tongue thrust, and speech impairment. 4.4. Bruxism Bruxism is commonly observed in patients with CP. Severe occlusal attrition of the primary and permanent dentition may be noted, with the resulting loss of vertical interarch dimension. Temporomandibular joint disorders may be sequelae of this condition in adult patients. Others report parafunctional oral habits in CP patients including pacifier-sucking, finger-sucking, biting objects, and tongue interposition [25]. 4.5. Trauma Patients with CP are more susceptible to trauma, particularly to the maxillary anterior teeth. This is related to the increased tendency to fall, along with a diminished extensor reflex to cushion such falls, and the frequent increased flaring of the maxillary anterior teeth. Susceptibilities also include aspiration and ingestion of a foreign body. It is reported that the teeth most affected by traumatic dental injuries in CP patients are the maxillary central incisors, and enamel fracture was the most frequent type of injury in these patients [26].
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5. Clinical guidelines for dental prevention and management 5.1. Preventive protocol Oral health in CP patients may not be perceived to be important by parents or caregivers, but dental disease and its consequences may pose further threats to these already compromised individuals. Therefore, the prevention of oral disease should be given high priority, and the principal aim should be oral health promotion and education. If dental health awareness and care are instituted early, complicated treatment needs requiring a special work force, facilities, and effort can be kept to a minimum. The insufficient provision of dental care specifically programmed for palsic patients has been reported as a longstanding condition. Waldman et al. [27] stated that dentists have not been fully integrated into the interdisciplinary healthcare team assisting CP patients, and that the syllabus of dental schools usually does not provide adequate experience for managing patients with disabilities. Primary prevention approaches should be taught to the staff and caregivers and, when appropriate, to the individual patient. Emphasis should be placed on oral hygiene because it influences norms and behavior. It is suggested that educational programs about oral health intervention should be based on the introduction of regular oral hygiene practices and use of fluoride toothpaste. Oral hygiene programs including supervised tooth-brushing sessions for CP patients can be carried out to train parents and caregivers. Special emphasis is placed on toothbrush modification for the spastic child, as these patients are often unable to perform adequate oral hygiene due to motoric or mental dysfunction. Modifications of regular toothbrushes to cope with grip or arm extension problems are recommended. Additional angulation can be provided to the brush as necessary. Additionally, the grip can be modified by perforating a rubber ball and passing the handle of the toothbrush through it. The brush can also be banded to the hand with a Velcro strap. Foam rubber can be rolled around the handle. The recommendation for use of an automatic electric brush has proven helpful and more efficient in many cases, especially when the parent/guardian carries out brushing for a dependent child. The use of antimicrobial mouthwashes has proven problematical for those individuals with CP who cannot rinse and expectorate. Alternative methods of delivery, such as a spray or gel, have proven helpful. Diet counseling is important, especially in pa-
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tients with CP who have a significant decay problem. Issues of diet consistency and sugar content of liquid medications are of particular concern. More frequent recall dental visits may also be indicated if the decay rate is high. The increased use of sealants and professional and/or home-use fluoride preparations is helpful. In the high-risk population, pit and fissure sealants should be applied to permanent teeth soon after eruption, as these measures are highly effective in preventing occlusal caries, and parents should be advised of the need for regular monitoring and maintenance of fissure sealants. For professional use, fluoride varnishes are the safest and most practical method for the patient, and their use should be recommended. The amount of ingested fluoride has been shown to be much less with fluoride varnish therapy than with applications of fluoride gel. Fluoride varnish is an almost ideal preventive dental agent for children with poor tolerance to dental procedures. Overall, well-organized pediatric and dental preventive care is imperative in preventing escalation of dental diseases, as well as in maintaining general health, in children with CP [13]. 5.2. Behavioral guidelines The degree of intellectual disability varies with each child with CP. Some children may have normal cognition, while others may have a severe cognitive deficit. It is therefore important to explain each dental procedure at a level that the child understands. The instructions used must be short and clear instructions. The child should be given only one direction at a time. The dentist should listen to the child actively and must be sensitive to communication methods the child uses, including gestures and verbal/nonverbal requests. Consultation with the caregiver should be performed if the dentist is unable to understand patient’s speech. Lights, sounds, and sudden movements that trigger primitive reflexes or uncontrolled movements should be minimized. The patient should be informed of any stimulus before it appears [13]. According to Santos et al. [28], the presence of head, arm, and leg movements requires postures that inhibit the increase in spasticity, abnormal reflexes, and movement patterns in CP patients. The authors performed such postures to facilitate normal muscle tone on the dental chair as per neurodevelopmental treatment approach. Assistive stabilization and postural maintenance were achieved in this patient by positioning the head in the midline by one of the dental staff over a head support (positioning device) located at the occipital level. Also, maintenance
of bent and juxtaposed upper limbs in the midline was carried out with the help of Velcro straps. Maintenance of bent lower limbs decreasing the hip angle to 120 degrees in relation to the trunk (coxofemoral angle) was performed using soft foam rolls as positioning devices, such as for support under the knees. In addition, the maintenance of an open mouth was achieved with the use of mouth props. These approaches can be utilized for successful dental treatment in CP patient. 5.3. Treatment considerations [13] The dentist should consider treating a patient who uses a wheelchair in the wheelchair. If a patient is to be transferred to a dental chair, the preference for the mode of transfer should be enquired. If the patient has no preference, a two-person lift is recommended [29]. The dentist should make an effort to stabilize the patient’s head throughout all phases of dental treatment. The CP child can be treated with a progressive series of behavioral management techniques including “tellshow-do” communication, assistive stabilization, oral premedication, and general anesthesia. The majority of these patients can be treated in the clinic with assistive stabilization. This involves wrapping the child’s arms at the center of the chest, stabilizing the head in a normal position, and placing a roll under the child’s knees to allow the legs to remain comfortably bent. The CP patient can be placed and maintained in the midline of the dental chair, with arms and legs as close to the body as feasible. The patient’s back should be slightly elevated to minimize difficulties in swallowing. When placing the patient in the dental chair, the patient’s degree of comfort should be determined and the position of the extremities should also be assessed. The patients’ limbs should not be forced into unnatural positions. The use of pillows, towels, and other measures for trunk and limb support should be considered. Stabilization must be judiciously utilized to control flailing movements of the extremities. A variety of mouth props can be used for control of involuntary jaw movements. All intraoral stimuli should be introduced slowly so as to avoid eliciting a gag reflex or to make it less severe. Sedation or general anesthesia may be an option for more complex patients. In conclusion, the dental team must work efficiently and quickly and minimize patient time in the chair to decrease fatigue of the involved muscles [13]. 6. Conclusion Children with various forms of CP and other disabling conditions require comprehensive, efficient,
K. Hotwani and K. Sharma / Dental management of early childhood caries in spastic quadriparesis
and well-organized management strategies, and dental management of these patients is no exception. The present case reports a patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients so as to provide comprehensive dental care.
Conflict of interest The authors report no conflict of interest.
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Kavcic A, Vodusek DB. A historical perspective on cerebral palsy as a concept and a diagnosis. Eur J Neurol. 2005 Aug; 12(8): 582-7. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007 Feb; 109: 8-14. Hirtz D, Thurman DJ, Gwinn-Hardy K, Mohamed M, Chaudhuri AR, Zalutsky R. How common are the “common” neurologic disorders? Neurology. 2007 Jan 30; 68(5): 326-37. Yoshida M, Nakajima I, Uchida A. Characteristics of lowerjaw-position sensation with respect to oral-jaw functions in patients cerebral palsy. Pediatric Dental Journal. 2004; 14(1): 23-8. Cerebral Palsy. National Center on Birth Defects and Developmental Disabilities 2002 [cited; Available from: http:// www.cdc.gov]. Wikipedia contributors. Cerebral palsy. Wikipedia, The Free Encyclopedia. Nallegowda M, Mathur V, Singh U, Prakash H, Khanna M, Sachdev G, et al. Oral health status in Indian children with cerebral palsy – a pilot study. Am J Physical Med Rehabil. 2005; 16: 1-4. Rodrigues dos Santos MT, Bianccardi M, Celiberti P, de Oliveira Guare R. Dental caries in cerebral palsied individuals and their caregivers’ quality of life. Child Care Health Dev. 2009 Jul; 35(4): 475-81. Santos MT, Guare RO, Celiberti P, Siqueira WL. Caries experience in individuals with cerebral palsy in relation to oromotor dysfunction and dietary consistency. Spec Care Dentist. 2009 Sep-Oct; 29(5): 198-203. Santos MT, Biancardi M, Guare RO, Jardim JR. Caries prevalence in patients with cerebral palsy and the burden of caring for them. Spec Care Dentist. 2010 Sep-Oct; 30(5): 206-10. Vadiakas G. Case definition, aetiology and risk assessment of early childhood caries (ECC): A revisited review. Eur Arch Paediatr Dent. 2008 Sep; 9(3): 114-25.
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Singhi P, Saini AG. Changes in the Clinical Spectrum of Cerebral Palsy over Two Decades in North India – An Analysis of 1212 Cases. J Trop Pediatr. 2013 Jun 19. [13] McDonald RE, Avery DR. Dentistry for the child and adolescent. 7th ed. New York: Mosby 1998. [14] Gormley MEJ, Krach LE, Piccini L. Spasticity management in the child with spastic quadriplegia. Eur J Neurol. 2001 Nov; 8 Suppl 5: 127-35. [15] American Academy of pediatric Dentistry, Originating Council: Definition of Early Childhood Caries (ECC): Pediatr Dent 2003; 25: 9. [16] Grzic R, Bakarcic D, Prpic I, Jokic NI, Sasso A, Kovac Z, et al. Dental health and dental care in children with cerebral palsy. Coll Antropol. 2011 Sep; 35(3): 761-4. [17] Rodrigues dos Santos MT, Masiero D, Novo NF, Simionato MR. Oral conditions in children with cerebral palsy. J Dent Child. 2003; 70(1): 40-6. [18] Newman MG, Takei H, Perry R. Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology. 11th ed: Saunders 2011. [19] De Camargo MA, Antunes JL. Untreated dental caries in children with cerebral palsy in the Brazilian context. Int J Paediatr Dent. 2008 Mar; 18(2): 131-8. [20] Nielsen LA. Caries among children with cerebral pals. Proceedings of the 9th Congress of the International Association of Dentistry for the Handicapped. Philadelphia, PA. August 7-10, 1988. [21] Siqueira WL, Santos MT, Elangovan S, Simoes A, Nicolau J. The influence of valproic acid on salivary pH in children with cerebral palsy. Spec Care Dentist. 2007 Mar-Apr; 27(2): 64-6. [22] Chambers HG, Weinstein CH, Mubarak SJ, Wenger DR, Silva PD. The effect of valproic acid on blood loss in patients with cerebral palsy. J Pediatr Orthop. 1999 Nov-Dec; 19(6): 792-5. [23] Subramaniam P, Babu KL, Rodriguez A. Relation of salivary risk factors to dental caries in children with cerebral palsy. J Clin Pediatr Dent. 2010 Summer; 34(4): 355-60. [24] Moreira RN, Alcantara CE, Mota-Veloso I, Marinho SA, Ramos-Jorge ML, Oliveira-Ferreira F. Does intellectual disability affect the development of dental caries in patients with cerebral palsy? Res Dev Disabil. 2012 Sep-Oct; 33(5): 15037. [25] Ortega AO, Guimaraes AS, Ciamponi AL, Marie SK. Frequency of parafunctional oral habits in patients with cerebral palsy. J Oral Rehabil. 2007 May; 34(5): 323-8. [26] dos Santos MT, Souza CB. Traumatic dental injuries in individuals with cerebral palsy. Dent Traumatol. 2009 Jun; 25(3): 290-4. [27] Waldman HB, Perlman SP. Children with disabilities are aging out of dental care. ASDC J Dent Child. 1997 Nov-Dec; 64(6): 385-90. [28] Santos MT, Manzano FS. Assistive stabilization based on the neurodevelopmental treatment approach for dental care in individuals with cerebral palsy. Quintessence Int. 2007 Sep; 38(8): 681-7. [29] Rosenblith S, Murphy DC. Ergonomic considerations for the care of special patients. N Y State Dent J. 2001 May; 67(5): 30-34.
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Case Report
Dental management of early childhood caries in spastic quadriparesis: A case report and clinical guidelines Kavita Hotwania,∗ and Krishna Sharmab a
Department of Pedodontics and Preventive Dentistry, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India b Department of Orthodontics and Dentofacial Orthopaedics, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India
Accepted 17 October 2013
Abstract. Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior. Spastic quadriparesis is the most severe form of spastic cerebral palsy. The present report describes the management of a 5-year-old patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients so as to provide comprehensive dental care. Keywords: Early childhood caries, spastic quadriparesis, dental management
1. Introduction Spastic quadriparesis is the most severe form of spastic cerebral palsy. Cerebral palsy (CP) is a permanent physical condition that affects movement. In the mid-1800s, Dr. William John Little pioneered the study of CP using his own childhood disability as an inspiration. This condition was known as Little’s disease until William Osler coined the term cerebral palsy in 1888. Dr. Sigmund Freud, the father of psychoanalysis, proposed the idea that CP might result from abnormal fe∗ Corresponding author: Kavita Hotwani, Department of Pedodontics and Preventive Dentistry, Sharad Pawar Dental College, Sawangi, Wardha, Maharashtra, India. E-mail: hotwani.kavita@ gmail.com.
tal development, decades before the medical field embraced the concept [1]. CP describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior [2]. Multiple studies have found the prevalence of CP to be 2.4 per 1,000 [3]. The etiology of CP is multifactorial and includes prenatal causes (genetic diseases, embryonic anomalies), perinatal (hypoxia, Rh incompatibility, premature birth, underweight at birth, etc.), and postnatal (infections, trauma, etc.). In 30% of the cases, the risk fac-
c 2013 – IOS Press and the authors. All rights reserved 1874-5393/13/$27.50
244
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tors can be traced. The frequency is 10 times higher in premature children and 25 times higher in small for gestational age children [4,5]. CP is classified into four types: spastic, dyskinetic, hypotonic, and mixed, with spastic being the most common type. Spastic quadriparesis represents the most severe form of spastic cerebral palsy and is characterized by a motor disturbance that affects both of the extremities [6]. Children with CP face a number of dental problems, including multiple carious teeth, periodontal problems, malocclusion, and bruxism. Inadequate function of the masticatory system in these children causes problems with mastication and inhibits self-cleansing. Constant consumption of mushy food as a result of disabilities in mastication results in a more frequent appearance of dental caries [7]. Additionally, the lower salivary flow rate, pH, and buffer capacity observed in these patients increases the risk of oral disease in this population. The higher incidence of caries in this population is also due to orofacial motor dysfunction and dietary inconsistencies. Taking care of an individual with CP is a potential source of continual burden for caregivers, and there is a positive correlation observed between caries prevalence in individuals with CP and the burden on their caregivers [8–10]. We report the management of a 5-year-old patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients required to provide comprehensive dental care.
2. Case report A 5-year-old patient reported to the department of pediatric dentistry with the chief complaint of pain and swelling in lower right posterior region of jaw. On clinical examination, it was found that patient had multiple carious lesions. The medical report suggested that the patient was a previously diagnosed case of spastic quadriparesis (Fig. 1). On further evaluation, it was discovered that the patient had been receiving occupational therapy since age four. A review of relevant medical records showed a history of premature birth with caesarian delivery, meconium stained liquor, and birth asphyxia. Detailed natal history taken during the dental visit revealed the presence of jaundice at birth and a NICU stay of 21 days. The patient was cyanosed, history of
Fig. 1. Patient with spastic quadriplegia, scissoring gait, open mouth posture, and spastic upper and lower limbs. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
seizures was reported, and the patient received blood transfusion at birth. On clinical examination, spasticity was present in both the upper and lower limbs. The plantar reflex was exaggerated and milestones of development were delayed. Scissoring gait was present, posture was imbalanced and uncoordinated and the patient exhibited slurred speech and open mouth posture. Intraoral examination showed ankyloglossia, generalized gingival inflammation, and gingival abscess present in the primary mandibular right second molar. On examination, dental caries was observed in the primary maxillary right and left central incisors and primary mandibular right and left first molars. The primary maxillary and mandibular right and left first molars were grossly decayed. Grade I mobility was present in the primary maxillary right first molar (Fig. 2). Intraoral periapical radiographs were taken. However, due to the patients’ spasticity, blurring of the radiographs was observed. The patient’s dietary history was also recorded and was found to be imbalanced with increased sugar exposure.
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245
Table 1 Phase-wise treatment plan 1 2 3
Medical/systemic phase Emergency treatment Preventive phase
4
Preparatory phase
5
Corrective phase
– – – – – – – –
Maintenance phase
– – – –
6
Evaluation for fitness Access opening and abscess drainage of primary mandibular right second molar under antibiotic coverage Oral prophylaxis Fluoride application with varnish Diet counseling and home care instructions Pulpectomy of primary mandibular right and left second molars and maxillary left first molar Extraction of primary maxillary right first molar Glass ionomer restoration of primary maxillary right and left second molar and primary mandibular right and left first molars Stainless steel crown with primary mandibular right and left second molars and maxillary left first molar Band and loop space maintainer with primary maxillary right second molar Strip crowns with primary maxillary right and left central incisor and left lateral incisor Re-evaluation after 3 months
Fig. 2. Preoperative intra-oral photographs. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
Fig. 3. Postoperative intra-oral photographs. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
A final diagnosis of early childhood caries was made [11]. After thorough medical evaluation, consent was obtained from the pediatrician for dental treatment under local anaesthesia. A treatment plan was formulated and initiated in phases (Table 1). The restorative and endodontic therapy was carried out under local anaesthesia. Adequate consideration was given to the appointment scheduling as well as treatment timing. All procedures were carried out with parental presence in the dental operatory. Behavior management techniques used included tell, show, do and proper patient positioning and stabilization with towel rolls. Parents were guided on oral hygiene measures and dietary modification. The treatment resulted in drastic improvements in the patient’s oral health (Figs 3, 4).
quadriplegia is the most common type of CP, reported in about 51.5% cases in the North Indian population [12]. The primary deformity in spastic quadriparesis affects both the upper and lower limbs. Spasticity is manifested as hyperirritability of muscles, resulting in exaggerated contraction when stimulated. The muscles are tense and contracted. The hand and arm are flexed and held in against the trunk. The foot and leg may be flexed and rotated internally, which results in a limping gait with circumduction of the affected leg [13]. The present case exhibited all of these characteristic features. Patients with CP tend to have limited control of the neck muscles, which results in head roll and a lack of control of the muscles supporting the trunk – this, in turn, results in difficulty maintaining an upright posture [14]. Spastic children can also exhibit a lack of coordination of intraoral, perioral, and masticatory musculature, impaired chewing and swallowing, and excessive drooling [7]. Early childhood caries is the presence of one or more decayed (non-cavitated or cavitated lesions), missing
3. Discussion Spastic CP is the most common type of cerebral palsy, occurring in about 70% of all cases. Spastic
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(due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger [15]. In the present case, all primary molars and primary incisors were carious. The condition was exaggerated in the presented patient due to a combination of poor oral hygiene, a sugar-rich diet, poor salivary clearance, and spastic facial musculature. The treatment protocol followed in the present case involved comprehensive restorative, endodontic, and orthodontic therapy for complete oral rehabilitation. Prophylactic antibiotic therapy was initiated because the patient reported with a gingival abscess. The potential for a dentist to treat a palsic child and to give the patient appropriate dental care depends on his or her grade of disability. Normally, about 14% of children with CP are able to cooperate with dentists, similar to the majority of healthy children. Fifty-three percent of CP children require specially adaptated dental treatment, and, in most cases, it is not possible to perform all necessary dental procedures. Moreover, in 33% of children dental treatment is not possible without the use of general anesthesia [16]. In the dental office, children with spastic CP have difficulties in cooperating due to their high sensitivity to physical contact and neuromotor response to unusual stimuli such as noise, artificial light, and position of the dental chair. In the present case, the dental procedures were performed under local anaesthesia on the dental chair with a modified behavior management protocol. Sedation and general anaesthesia were ruled out as the child, although limited in movement, was very cooperative and mentally fit. Head stabilization was achieved using a towel and parental assistance was utilized at each step of dental procedure. Care was taken so as to avoid jerky movements and short appointments were scheduled in morning.
4. Oral manifestations in CP [13,14,17] 4.1. Periodontal disease Periodontal disease and poor oral hygiene occurs with great frequency in persons with CP. Often the patient will not be physically able to brush or floss adequately. When another individual must provide oral hygiene measures for the person, they may be performed infrequently and inadequately. Diet may also be significant; children who have difficulty chewing and swallowing tend to eat soft foods, which are easily swallowed and are high in carbohydrates. Patients
Fig. 4. Restoration of aesthetics and smile. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/PRM140262)
with CP who take phenytoin to control seizure activity may have a degree of gingival enlargement. Gingival enlargement occurs in about 50% of patients receiving the drug, although different authors have reported incidences between 3% and 84.5%. The pathogenesis of gingival enlargement induced by phenytoin is not known, but some evidence links it to a direct effect on specific, genetically predetermined subpopulations of fibroblasts, inactivation of collagenase, and plaqueinduced inflammation [18]. In the present case, generalized gingival inflammation was evident; however, no sign of enlargement was observed. 4.2. Dental caries The data are conflicting regarding the incidence of dental caries in patients with CP as compared to the incidence in the general population. Some authors report increased prevalence of dental caries [17,19], while others found a lower prevalence than in populations without CP [20]. The contributory factors might be poor masticatory muscular control that encourages food stagnation in the buccal and labial sulci and poor manual dexterity as observed in most individuals with CP. Some authors attributed the high prevalence of dental caries to prolonged use of medications such as anticonvulsants, which have high sugar content, are viscous, and taken at night [21,22]. In a study carried out in Brazil, the high caries prevalence was attributed to poor socioeconomic conditions, irrespective of type of CP, and a high frequency of sugar consumption [19]. Santos et al. [10] reported that children with CP had a higher mean decayed, missing, and filled surfaces index, as well as a higher plaque index for both sexes in permanent dentition. Subramaniam et al. [23] reported mean deft and DMFT values of 2.51 and 0.73, respec-
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tively, in CP patients. They also observed a significant correlation between salivary pH and dental caries in the primary dentition of CP children. Moreira et al. [24] reported that children with CP who present with intellectual disabilities have a larger number of dental cavities than children with CP without intellectual disabilities. These results suggest that intellectual disability can be considered a contributing factor for the development of dental caries in patients with CP. 4.3. Malocclusions The prevalence of malocclusions in patients with CP is approximately twice that in the general population. Commonly observed conditions include noticeable protrusion of the maxillary anterior teeth, excessive overbite and overjet, open bites, and unilateral crossbites. A primary cause may be a disharmonious relationship between intraoral and perioral muscles. Uncoordinated and uncontrolled movements of jaws, lips, and tongue are observed with greater frequency in patients with CP. This may result in impaired chewing and swallowing, excessive drooling, tongue thrust, and speech impairment. 4.4. Bruxism Bruxism is commonly observed in patients with CP. Severe occlusal attrition of the primary and permanent dentition may be noted, with the resulting loss of vertical interarch dimension. Temporomandibular joint disorders may be sequelae of this condition in adult patients. Others report parafunctional oral habits in CP patients including pacifier-sucking, finger-sucking, biting objects, and tongue interposition [25]. 4.5. Trauma Patients with CP are more susceptible to trauma, particularly to the maxillary anterior teeth. This is related to the increased tendency to fall, along with a diminished extensor reflex to cushion such falls, and the frequent increased flaring of the maxillary anterior teeth. Susceptibilities also include aspiration and ingestion of a foreign body. It is reported that the teeth most affected by traumatic dental injuries in CP patients are the maxillary central incisors, and enamel fracture was the most frequent type of injury in these patients [26].
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5. Clinical guidelines for dental prevention and management 5.1. Preventive protocol Oral health in CP patients may not be perceived to be important by parents or caregivers, but dental disease and its consequences may pose further threats to these already compromised individuals. Therefore, the prevention of oral disease should be given high priority, and the principal aim should be oral health promotion and education. If dental health awareness and care are instituted early, complicated treatment needs requiring a special work force, facilities, and effort can be kept to a minimum. The insufficient provision of dental care specifically programmed for palsic patients has been reported as a longstanding condition. Waldman et al. [27] stated that dentists have not been fully integrated into the interdisciplinary healthcare team assisting CP patients, and that the syllabus of dental schools usually does not provide adequate experience for managing patients with disabilities. Primary prevention approaches should be taught to the staff and caregivers and, when appropriate, to the individual patient. Emphasis should be placed on oral hygiene because it influences norms and behavior. It is suggested that educational programs about oral health intervention should be based on the introduction of regular oral hygiene practices and use of fluoride toothpaste. Oral hygiene programs including supervised tooth-brushing sessions for CP patients can be carried out to train parents and caregivers. Special emphasis is placed on toothbrush modification for the spastic child, as these patients are often unable to perform adequate oral hygiene due to motoric or mental dysfunction. Modifications of regular toothbrushes to cope with grip or arm extension problems are recommended. Additional angulation can be provided to the brush as necessary. Additionally, the grip can be modified by perforating a rubber ball and passing the handle of the toothbrush through it. The brush can also be banded to the hand with a Velcro strap. Foam rubber can be rolled around the handle. The recommendation for use of an automatic electric brush has proven helpful and more efficient in many cases, especially when the parent/guardian carries out brushing for a dependent child. The use of antimicrobial mouthwashes has proven problematical for those individuals with CP who cannot rinse and expectorate. Alternative methods of delivery, such as a spray or gel, have proven helpful. Diet counseling is important, especially in pa-
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tients with CP who have a significant decay problem. Issues of diet consistency and sugar content of liquid medications are of particular concern. More frequent recall dental visits may also be indicated if the decay rate is high. The increased use of sealants and professional and/or home-use fluoride preparations is helpful. In the high-risk population, pit and fissure sealants should be applied to permanent teeth soon after eruption, as these measures are highly effective in preventing occlusal caries, and parents should be advised of the need for regular monitoring and maintenance of fissure sealants. For professional use, fluoride varnishes are the safest and most practical method for the patient, and their use should be recommended. The amount of ingested fluoride has been shown to be much less with fluoride varnish therapy than with applications of fluoride gel. Fluoride varnish is an almost ideal preventive dental agent for children with poor tolerance to dental procedures. Overall, well-organized pediatric and dental preventive care is imperative in preventing escalation of dental diseases, as well as in maintaining general health, in children with CP [13]. 5.2. Behavioral guidelines The degree of intellectual disability varies with each child with CP. Some children may have normal cognition, while others may have a severe cognitive deficit. It is therefore important to explain each dental procedure at a level that the child understands. The instructions used must be short and clear instructions. The child should be given only one direction at a time. The dentist should listen to the child actively and must be sensitive to communication methods the child uses, including gestures and verbal/nonverbal requests. Consultation with the caregiver should be performed if the dentist is unable to understand patient’s speech. Lights, sounds, and sudden movements that trigger primitive reflexes or uncontrolled movements should be minimized. The patient should be informed of any stimulus before it appears [13]. According to Santos et al. [28], the presence of head, arm, and leg movements requires postures that inhibit the increase in spasticity, abnormal reflexes, and movement patterns in CP patients. The authors performed such postures to facilitate normal muscle tone on the dental chair as per neurodevelopmental treatment approach. Assistive stabilization and postural maintenance were achieved in this patient by positioning the head in the midline by one of the dental staff over a head support (positioning device) located at the occipital level. Also, maintenance
of bent and juxtaposed upper limbs in the midline was carried out with the help of Velcro straps. Maintenance of bent lower limbs decreasing the hip angle to 120 degrees in relation to the trunk (coxofemoral angle) was performed using soft foam rolls as positioning devices, such as for support under the knees. In addition, the maintenance of an open mouth was achieved with the use of mouth props. These approaches can be utilized for successful dental treatment in CP patient. 5.3. Treatment considerations [13] The dentist should consider treating a patient who uses a wheelchair in the wheelchair. If a patient is to be transferred to a dental chair, the preference for the mode of transfer should be enquired. If the patient has no preference, a two-person lift is recommended [29]. The dentist should make an effort to stabilize the patient’s head throughout all phases of dental treatment. The CP child can be treated with a progressive series of behavioral management techniques including “tellshow-do” communication, assistive stabilization, oral premedication, and general anesthesia. The majority of these patients can be treated in the clinic with assistive stabilization. This involves wrapping the child’s arms at the center of the chest, stabilizing the head in a normal position, and placing a roll under the child’s knees to allow the legs to remain comfortably bent. The CP patient can be placed and maintained in the midline of the dental chair, with arms and legs as close to the body as feasible. The patient’s back should be slightly elevated to minimize difficulties in swallowing. When placing the patient in the dental chair, the patient’s degree of comfort should be determined and the position of the extremities should also be assessed. The patients’ limbs should not be forced into unnatural positions. The use of pillows, towels, and other measures for trunk and limb support should be considered. Stabilization must be judiciously utilized to control flailing movements of the extremities. A variety of mouth props can be used for control of involuntary jaw movements. All intraoral stimuli should be introduced slowly so as to avoid eliciting a gag reflex or to make it less severe. Sedation or general anesthesia may be an option for more complex patients. In conclusion, the dental team must work efficiently and quickly and minimize patient time in the chair to decrease fatigue of the involved muscles [13]. 6. Conclusion Children with various forms of CP and other disabling conditions require comprehensive, efficient,
K. Hotwani and K. Sharma / Dental management of early childhood caries in spastic quadriparesis
and well-organized management strategies, and dental management of these patients is no exception. The present case reports a patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients so as to provide comprehensive dental care.
Conflict of interest The authors report no conflict of interest.
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