The suspected diagnosis is based on clinical findings and the failure to reach appropriate developmental milestones for the patient's age
There is general consensus of an upper age limit of 2 years for the onset of the non‐progressive brain disturbance and five years for a clinical or developmental diagnosis
Diagnostic brain imaging tests, including computed tomography and magnetic resonance imaging, can be of use
An electroencephalogram, genetic analysis and metabolic tests may also be undertaken
Management
Physical therapy and occasionally orthopaedic surgeryTable 1.1.1 Considerations for dental management.Risk assessmentInvoluntary movements and contractions – these can increase further with stress and local stimuliAbnormal gag/bite reflexAbnormal swallowing and cough reflexAspiration riskEpilepsyCriteria for referralReferral to a specialised clinic or hospital centre is determined by:Factors related to the severity of the patient's general condition (e.g. respiratory distress, uncontrolled seizures)Factors that significantly limit access for dental procedures (e.g. pathological reflexes and uncontrolled movements)Access/positionPatients who present in wheelchairs may have treatment provided without transfer, particularly if there is a wheelchair platform available (Figure 1.1.4)If they are transferred to the dental chair, the patients will need to be stabilised with pillowsConsider safe immobilisation of the head using vacuum cushions/supports with consentCommunicationFrequent difficulties in verbal communicationNon‐verbal language might sometimes need to be interpretedThe level of comprehension can be normalConcentration may be poorConsent/capacityCapacity may be intactDo not make assumptions due to the physical signs/symptoms or impaired verbal communicationClinical holding may be required (e.g. to reduce involuntary arm movements) – this must be appropriately risk assessed, undertaken by trained staff, consented and documentedRegular medication may be sedative and hence impair capacityAnaesthesia/sedationLocal anaesthesiaNot contraindicated, although involuntary movements may make delivery challengingSedationConscious sedation can help control anxiety, nausea and lingual dystoniaMedical consultation is recommended if the patient takes neuroleptics, is already taking benzodiazepines or has respiratory difficultiesGeneral anaesthesiaMay be indicated if the movements are uncontrollable or there is a lack of co‐operation (the risk/benefit should be assessed)Dental treatmentBeforeThe need for conscious sedation should be anticipated and consent for any intervention undertaken prior to thisOrthodontic treatment planning should consider the impact of increased muscle toneDuringConsider the use of atraumatic mouth openers, protective thimbles and stainless steel/plastic mirrors (involuntary contractions)Fixed prostheses are generally preferable over removable prostheses (due to difficulties inserting the prosthesis, involuntary movements and the risk of fracture in patients with epilepsy)AfterClose follow‐up after completion of orthodontic therapy as relapse is more frequentDrug prescriptionConsider the associated systemic complications and concurrent medicationsCaution with the use of benzodiazepines if the patient is already taking sedation medicationEducation/preventionInvolve the relatives and caregivers where possibleAn electric or adapted manual toothbrush should be consideredRegular oral prophylaxis/calculus removalFluoride treatmentDietary counsellingTable 1.1.2 Classification and characteristics of cerebral palsy.Type (lesion location)FrequencyClinical presentationSubtype/area involvedSpastic (upper motor neuron) 70–80%Muscle hypertonia Contracture HyperreflexiaMonoplegic: one extremityParaplegic: legsHemiplegic: one arm and one ipsilateral legDouble hemiplegic: all extremities but more in the armsDiplegic: all extremities but more in the legsTetraplegic: all extremitiesAthetoid (basal ganglia) 15%Vermiform movements Muscle hypertoniaChorea (restless, fidgety, dancing movement): face, chest and extremitiesAthetosis (slow, writhing movement): hands and feetChoreoathetosis: generalisedAtaxic (cerebellum) 10%Abnormal equilibrium and gait
Drug treatment for tone/movement disorders, including baclofen, trihexyphenidyl, gabapentin, diazepam, clonidine and botulinum toxin
Neurosurgical interventions, including selective rhizotomy and electrode implantation in the basal ganglia
Epilepsy control, speech therapy and hearing and vision support
Special education and occupational therapy
Prognosis
The life expectancy for cerebral palsy may be reduced in relation to the number and severity of the associated disabilitiesFigure 1.1.5 (a) Spastic cerebral palsy. (b) Hand deformity calls for adaptive tools (e.g. adapted toothbrush handle).
If gross and fine motor functioning, independent feeding, mental and visual capacities are severely impaired, survival to 40 years of age may be as low as 40%
Causes of early death may include pulmonary aspiration and pneumonia, accidents, associated disorders (e.g., congenital heart disease) and delayed recognition of illness
A World/Transcultural View
The prevalence of cerebral palsy is estimated at 1.9/1000 live births in China, 2.1/1000 in Europe and 3.6/1000 in the US. This variability is probably an expression of the predominant aetiological factors. For example, cerebral palsy among the Jewish population is due mostly to premature births, while among the Arab population, the condition is especially attributed to consanguinity and genetic factors
In low‐ and medium‐income countries such as India, there are educational and healthcare deficiencies in terms of the principles of the International Classification of Functioning, Disability and Health, while in higher‐income countries such as Canada, the parents of children with cerebral palsy perceive a more conducive environment and express a more social outlook on their children's health
Recommended Reading
1 Abeleira, M.T., Outumuro, M., Diniz, M. et al. (2016). Orthodontic treatment in children with cerebral palsy. In: Cerebral Palsy – Current Steps (ed. M.K. Gunel), 129–140. Rijeka, Croatia: Intech.
2 Bensi, C., Costacurta, M., and Docimo, R. (2020). Oral health in children with cerebral palsy: a systematic review and meta‐analysis. Spec. Care Dentist. 40: 401–411.
3 Cahlin, B.J., Lindberg, C., and Dahlström, L. (2019). Cerebral palsy and bruxism: effects of botulinum toxin injections‐a randomized controlled trial. Clin. Exp. Dent. Res. 5: 460–468.
4 Cardoso, A.M.R., de Medeiros, M.M.D., Gomes, L.N. et al. (2018). Factors associated with health and oral health‐related quality of life of children and adolescents with cerebral palsy. Spec. Care Dentist. 38: 216–226.
5 Colver, A., Fairhurst, C., and Pharoah, P.O. (2014). Cerebral palsy. Lancet 383: 1240–1249.
6 Jan, B.M. and Jan, M.M. (2016). Dental health of children with cerebral palsy. Neurosciences. 21: 314–318.
7 Rai, T., Ym, K., Rao, A. et al. (2018). Evaluation of the effectiveness of a custom‐made toothbrush in maintaining oral hygiene and gingival health in cerebral palsy patients. Spec. Care Dentist. 38: 367–372.
8 Vpk, V., Mohanty, V.R., Balappanavar, A.Y. et al. (2020). Effectiveness of different parenting interventions on oral hygiene of cerebral palsy children: a randomized controlled trial. Spec. Care Dentist. 40: 335–343.
1.2 Epilepsy
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario