Dental Considerations for Cerebral Palsy

Dental Hygiene III

Larissa Henecke

June 27th, 2017

 In the mid-1800s Dr. John Little, who used his own childhood disabilities as

inspiration for his research, discovered Cerebral Palsy (CP). It is now estimated that

764,000 people have CP in the US. CP is a non-progressive disorder that occurs when

there is neurological damage to the fetal or infant brain that prevents it from developing

properly. The word “cerebral” refers to the cerebrum of the brain, which regulates motor

function and “palsy” describes paralysis of voluntary body movements. Common causes

of CP are bacterial and viral infections, brain hemorrhaging, lack of oxygen to brain,

prenatal exposure to alcohol or drugs, and head injuries during birth or infancy. There are

many symptoms and signs of CP that occur in varying severities depending on the injury.

Commons signs are problems with movement, stiff muscles, jerky reflexes, tremors, lack

of coordination, drooling, problems swallowing or sucking, difficulty with speech,

delayed motor skill development, and gastrointestinal problems. Other conditions that

may also be commonly present along with CP include epilepsy, vision or hearing

impairment, learning disabilities, autism, chronic pain, ADHD, speech disorders, or

mental health disorders. (About, 2017)

There are four main types of CP. The most common is spastic which makes up

70% of cases. It is most commonly characterized by stiff or rigid muscles, legs that are

turned inward, or arms that are flexed and against their bodies. Many also experience

intellectual disabilities, seizures, or difficulty speaking. The second type, dyskinetic, is

noted by slow, uncontrolled, squirming movements and tremors. They may also have

speech disorders. Ataxic is often characterized by problems with balance and depth

perception, along with an unsteady gait. The last type, combined form, is a combination
of all types. Every person with CP exhibits problems with movement and posture.

Severity of all cases is dependent on the injury and the individual. (About, 2017)

There is currently no cure for CP, but there are many treatments that can help

children and adults live a full life. Patients with CP should have a multidisciplinary team

of specialists to assist in their treatment. This team should include neurologists,

orthopedic surgeons, physical therapists, respiratory therapists, speech therapists,

nutritionists, occupational therapists, and psychologists. They may also be placed on

medication to help control their symptoms. Common medications are anticonvulsants,

muscle relaxants, nerve blocks, Botox, Benzodiazepines, and Baclofen, given for muscle

spasms. Anticholinergic drugs help with involuntary movements. Medications of

incontinence, acid reflux, or behavioral disorders also may be given. Side effects of the

medications given for CP include fatigue, drowsiness, loss of coordination, dizziness,

headache, dry mouth, and nausea. (About, 2017)

Cerebral Palsy does not directly cause any oral abnormalities, but there are many

conditions that are more common and severe in people with CP. Periodontal disease is

more prevalent due to poor oral hygiene, physical ability, malocclusion, and medications

causing gingival hyperplasia. Dental caries are also common due to lack of oral hygiene,

mouth breathing, dry mouth caused by medication, and food pouching. Malocclusion is

usually seen with association to musculoskeletal problems. The patient may have an open

bite with protruding anterior teeth potentially caused by tongue thrusting. This also

creates an inability to close the lips and creates excessive drooling. Dysphagia, or

difficulty swallowing, can often be a problem for people with CP. This means food may

stay in the mouth longer, creating a higher caries risk. Bruxism is also common, which
causes a permanent wearing away of the tooth surface. Mouth guards or splints may not

be ideal due to CP patient’s difficulty swallowing and strong gag reflexes. Trauma or

injury to the mouth from accidents or falls are also important to keep in mind with CP

patients, due to lack of coordination and stability when walking. (Chin, 2009)

Many modifications can be made to dental appointments to make the experience

more comfortable for both the CP patient and the provider. Barriers that may be

experienced by any special need patient, including CP patients, in the dental office are

language barriers, vision or hearing problems, low oral health literacy, dental anxiety, or

lack of wheelchair accessibility. To overcome language, vision, or hearing barriers,

nontraditional ways of communication can be used. Facial expressions, body language,

and tone of voice are all important for the clinician to keep in mind when communicating

with a CP patient. The clinician also needs to be aware of the patient’s verbal and

nonverbal ways of communication to make sure messages are effectively communicated.

When discussing treatment plans the clinician needs to make sure they use terms that are

appropriate for the patient’s comprehension level. Using the tell-show-do method may

help calm patient’s anxieties. Patients who are in wheelchairs should not be transferred if

it is not necessary. When possible the wheelchair should be modified to mimic the dental

chair or the clinician should stand-up during the dental procedure. (Moore, 2016) This

helps to prevent risks with transfer and workplace injuries. Other considerations during

the dental appointment may include making the treatment environment calm and relaxed

with minimal distractions, observing patients movements and looking for patterns in

muscle spasm so they can be anticipated and worked around, keep appointments short
with frequent breaks, being empathetic toward the patient, and being patient. (Chin,

2009)

When discussing homecare the clinician must again evaluate the patient’s abilities

and comprehension level. Clinicians should talk to the parent or caregiver to determine

the intellectual ability of the patient. All homecare instructions should be simple, spoken

slowly, and given one at a time. Demonstrations may help the patient remember.

Encourage independent daily oral hygiene care, but share the oral hygiene instructions

given to the patient with the caregiver. A power toothbrush or floss holder may aid in

daily homecare. Discuss dietary considerations with caregivers, such as alternatives to

cariogenic foods and using water to rinse their mouth after meals. Recommend

preventative treatments such as fluoride and sealants and explain how they are beneficial

in preventing dental caries. (Chin, 2009)

Having the knowledge and understanding of Cerebral Palsy, what it is and how it

affects the patient, helps the dental team better care for CP patients. With slight

modifications to the appointment, treatment, and homecare instructions, the dental care

experience can be made more enjoyable for the dental team, the caregiver, and most

importantly the patient.

 References

About Cerebral Palsy. (2017). Retrieved June 22, 2017, from

http://www.cerebralpalsy.org/

Chin, M., Fenton, S., Lyons, R., Miller, C., Perlman, S., & Tesini, D. (2009). Practical

Oral care for people with cerebral palsy. Bethesda, MD: National Institute of

Dental and Craniofacial Research.

Moore, T. A. (2016). Dental care for patients with special needs. Decisions in

Dentistry, 2(9), 50-53.