2 The patient has received appropriate and high‐dose antibiotics and requests that you attempt to extract the tooth the same day. Although she has no previous experience with local anaesthesia, she appears to be co‐operative and has capacity. What would you discuss with her?Extraction of #48 is the preferred treatment option as:The use of rotary instrumentation for caries removal is associated with increased risk due to the posterior position of the tooth, uncontrolled movements and increased gag reflexThere is limited access to allow for endodontic treatment (e.g. due to difficulties accessing the posterior sections of the mouth)The patient struggles to access her posterior teeth for cleaningAs this is an urgent procedure, the dental extraction can be attempted in the dental chairGiven her considerable dental treatment needs, this can be followed up by the provision of non‐urgent procedures (e.g. restorations) provided in a hospital setting under general anaesthesiaProsthetic rehabilitation and subsequent follow‐up/treatment sessions should be performed in the dental clinic, if possible
3 What factors are considered important in assessing the risk of managing this patient?SocialLack of available escortTransport difficulties when attending dental clinic/hospitalLimited financial meansMedicalNeck position compromised by the dental chair and by problems in the cervical spine; consider the option of treating the patient in her wheelchairRisks associated with general anaesthesia may be increased in patients with cerebral palsy (hypothermia, hypotension)Adjustment disorder may reduce compliance and manifest as increased anxiety/tearfulnessDentalLocal stimuli and stress can increase involuntary movementsGag reflexLimited access to the oral cavitySialorrhoea compromises operatory field isolationPoor self‐cleansing of the oral cavityUnsupervised oral hygiene habits
4 The patient requests premedication/sedation. What do you need to consider when selecting the correct approach?The patient is already taking oral benzodiazepinesHence, a medical consultation is required before proceeding, given the risk of synergy with some of the drugs the patient is taking, i.e. the effects can be increased when midazolam is combined with bromazepamGiven the absence of chronic respiratory problems, nitrous oxide may be used
5 The patient requests oral prosthetic rehabilitation after her teeth are extracted/stabilised. What options would you discuss?If oral hygiene improves:Removable prostheses can be difficult to insert and, with oral dyskinesias, are more unstable, potentially causing injuries to the mucosa/obstruction of the airway if dislodgedFixed implant‐supported or tooth‐supported prostheses are preferable; these can be limited to the anterior/aesthetic zones to allow for improved appearance and easier access for cleaningThe cost of these options needs to be consideredIf oral hygiene remains poor and the dental caries risk remains high:It may be preferable to accept the gaps rather than compromise further teethAlternatively, a removable dental prosthesis may be attempted as this is reversible and can be removed to allow access for cleaningFurthermore, teeth can be added to the partial denture, if further dental extractions become necessaryThis may be better than implant‐supported measures if there are financial limitations
6 Drooling (sialorrhoea) is a common consequence of cerebral palsy among patients with difficulties swallowing saliva. What medication is this patient taking that could be of benefit?Trihexyphenidyl hydrochloride is an anticholinergic drug and hence reduces saliva productionThis medication may also be effective for reducing dystonia or improving upper arm function in patients with cerebral palsy
7 What are the most widely used therapeutic modalities for sialorrhoea?Physiotherapy for swallowing and postural re‐educationDrugs: anticholinergic agents (scopolamine, atropine, glycopyrrolate) or botulinum toxinSurgery: Wharton's duct relocation, excision of a submandibular gland or selective neurectomy
General Dental Considerations
Oral Findings
Delayed eruption of primary dentition
Enamel hypoplasia
Bruxism and abnormal dental attrition
Gingivitis and periodontal disease
Anterior tooth trauma due to falls
Spontaneous dislocation or subluxation of the temporomandibular joint
Malocclusion (anterior open bite and Angle class II‐1) (Figure 1.1.3a)
Sialorrhoea/drooling, promoted by the head position and difficulties swallowing saliva (Figure 1.1.3b)
Dental Management (Figure 1.1.4)
The dental treatment plan is determined more by the disease severity (e.g. severity of the spasticity) and its comorbidities (e.g. respiratory impairment) than by the type of cerebral palsy (Table 1.1.1)
Dental manipulation and stress can intensify the uncontrolled movements
Section II: Background Information and Guidelines
Definition
Cerebral palsy is a group of permanent disorders of the development of movement and posture, resulting from non‐progressive disturbances (structural abnormalities) that occurred in the developing foetal or infant brain. It is the most common form of chronic motor disability in childhood, with an estimated prevalence of 2.0–3.5 cases per 1000 live births in developed countries.
Figure 1.1.3 (a) Severe malocclusion with anterior open bite. (b) Sialorrhoea/drooling.
Aetiopathogenesis
The condition is attributed to structural brain abnormalities and hypoxia due to cerebrovascular insufficiency
This may occur during the prenatal, perinatal or postnatal periodsPrenatal: infections, exposure to toxins and multiple pregnanciesPerinatal: traumatic births and prematurity (especially for infants weighing less than 2500 g)Postnatal: infections, intracranial haemorrhages and kernicterus
Clinical Presentation
Cerebral palsy is subdivided into spastic, dyskinetic (including dystonic) and ataxic forms, depending on the area of the brain that is mainly involved (Table 1.1.2; Figure 1.1.5)Figure 1.1.4 Patients who present in wheelchairs may have treatment provided without transfer.
In over 50% of patients, it is accompanied by disturbances of sensation (visual and auditory defects), perception, cognition, communication and behaviour
Epilepsy and musculoskeletal problems may also be present
Diagnosis