Management of upper limb spasticity in children with cerebral palsy

Clinical examination and decision-making in the spastic upper limb is a complicated process. This article discusses key principles and strategies for assessment and management of these patients. The main aims of treatment are to improve function, appearance and facilitate caring. Key decision-making factors are the patient's age (with anti-spasticity procedures being preferred in the younger and rebalancing and stabilizations in older patients), degree of spasticity (pure spasticity being treated with neurectomies and contractures with surgical releases) and degree of voluntary control (high voluntary control doing better with rebalancing procedures and stabilizations doing better in those with little voluntary control). With careful planning, good patient selection and appropriate choice of treatment, patients typically experience improved quality of life and benefit from surgical intervention.     

Occurrence of bruxism in a sample of Brazilian children with cerebral palsy

Bruxism has been reported to exist in many children with cerebral palsy; however, only a few studies confirm this fact. The objective of this study was to determine the rate of bruxism in children with cerebral palsy and to relate its presence to the following factors: kind of cerebral palsy, gender, age, dentition, degree of malocclusion. oral mucous membrane trauma, trismus, and number of wear facets on specific teeth. The guardians of 121 children with cerebral palsy between the ages of 4 and 9 years were interviewed and the children were clinically examined. Bruxism was detected in 69.4% of the children and reported by 57% of the guardians. In 4-and 5-year-old children, the rate of wear facets was small. Children with athetosis and spastic tetraplegia had a higher rate of bruxism than all others.     

Frequency of parafunctional oral habits in patients with cerebral palsy

Cerebral palsy (CP) is one of the most frequent conditions encountered in the daily practice of dentists who treat special-needs patients and it seems that parafunctional oral habits are often present in such individuals. The aim of this study was to investigate the frequency of occurrence of parafunctional habits in individuals with CP. Sixty-five patients with CP were evaluated through a questionnaire and clinical observation, regarding the following habits: pacifier-sucking, finger-sucking, biting objects, tongue interposition, and bruxism. The results showed that nine (13.8%) patients presented with pacifier-sucking, four (6.1%) showed finger-sucking, 12 (18.4%) had the habit of biting objects, 27 (41.5%) presented with tongue interposition, and 24 (36.9%) had eccentric bruxism. The significance of the presence of oral parafunctional habits in individuals with CP, revealed in this study, justifies the need to establish protocols for adequate prevention and clinical intervention in order to minimize the deleterious consequences that may result from such habits.     

Use of cryotherapy to enhance mouth opening in patients with cerebral palsy

This study was conducted to assess the effect of cryotherapy on masseter spasticity on mouth opening, which is required for oral hygiene and dental treatment. The inter-incisal distance was measured before cryotherapy in 24 patients with cerebral palsy who had spasticity of the tetraparesis type. Ice was then applied on the skin surface with sliding movements over the masseter, bilaterally for one minute. Interincisal distance was then measured again. The results showed a significant increase of the inter-incisal distance after the application of cold to the masseter. We conclude that the action of cryotherapy on the masseter muscle produced a temporary reduction of spasticity, facilitating access to the occlusal and palatal surfaces of the maxillary molars. This improved access can be useful during dental treatment as well as preventive dental care such as oral hygiene.     

Failure of tooth eruption in two patients with cerebral palsy and bruxism—a 10-year follow-up: a case report

The aim of this paper was to analyze delayed tooth eruption in two children with cerebral palsy who had severe bruxism and to determine whether treatment could influence tooth eruption and alignment. Extraction of primary teeth was carried out and orthodontic treatment was considered due to severe tooth wear of primary teeth, lack of space, and development of a class III malocclusion.
Analysis was based on clinical examination, photographs, radiographs, and dental casts.
In both patients, early mixed dentition was delayed for more than 5 years. Calcification and root development of posterior permanent teeth corresponded with the chronological age. Root resorption of the severely abraded primary teeth and eruption of their successors were delayed or failed. Eruption of permanent teeth occurred slowly after primary teeth were extracted. Orthodontic treatment succeeded in one patient, achieving a normal overjet in combination with a successful orofacial therapy.
The disturbed exfoliation of abraded primary teeth and failure of tooth eruption of the posterior teeth could be linked to the systemic pathology and to bruxism. At age 20, eruption of the canines and premolars remained questionable.     

Autonomic nervous system in individuals with cerebral palsy: a controlled study

J Oral Pathol Med (2011) 40 : 576–581 Background: Disturbances in homeostatic functions have been observed in individuals with cerebral palsy (CP), possibly resulting from autonomic dysfunction. Salivary flow rate and saliva composition are controlled by the autonomic nervous system, and CP individuals exhibit alterations in salivary parameters that suggest autonomic impairment. This study aimed to investigate cardiac parameters as indicative of autonomic disturbances, possibly associated with salivary changes observed in CP individuals. Methods: Ninety individuals with CP were compared with 35 sibling volunteers with no neurological damage (CG). Twenty‐four‐hour ECG/Holter monitoring (SEER^® Light; GE Medical Systems, Milwaukee, WI, USA) and 12‐lead electrocardiographic recordings were performed on the CP and control groups. Total saliva was collected, and the salivary flow rate and total protein concentration were determined. Results: Cerebral palsy (CP) individuals presented a significant reduction in salivary flow rate (P < 0.01) and increased protein concentrations (P < 0.01) compared to CG. Twenty‐four‐hour Holter ECG analysis showed differences for high frequency (HF), low frequency (LF) and LF/HF ratio between the groups, with the CP group presenting higher HF and LF values and lower LF/HF. Electrocardiographic parameters showed a statistically significant difference for heart rate, and its correlates, and mean corrected QT interval between the groups studied (P < 0.05). Snoring was frequent among CP patients. ECG and autonomic changes were independently associated with CP. Conclusion: Individuals with cerebral palsy present cardiovascular changes principally manifested as disturbed sympathovagal balance. These autonomic dysfunctions could contribute to the salivary changes observed.     

Association between anticonvulsant drugs and teeth‐grinding in children and adolescents with cerebral palsy

The relation between teeth‐grinding and the use of drugs acting on the central nervous system of cerebral palsy (CP) patients has not yet been described. The aim of this research was to evaluate the presence or absence of teeth‐grinding (sleep and/or awake periods) in normal and in CP children and adolescents, as well as the association of teeth‐grinding and use of anticonvulsant drugs. The sample consisted of 207 children and adolescents, divided into three groups: G1, individuals with CP who did not take anticonvulsant drugs; G2, individuals with CP administered medications on a regular basis; and CG, normal individuals. Logistic regression analyses were performed to evaluate the association of teeth‐grinding with some variables. No significant statistical differences were observed regarding the presence or absence of teeth‐grinding when G1 and G2 were compared. However, compared with the CG, a statistically significant difference was determined, with the CG showing fewer children presenting teeth‐grinding (P < 0·001). Among those children/adolescents prescribed drug therapy, the barbiturate group showed a greater frequency of teeth‐grinding. CP children and adolescents show a greater and significant presence of grinding of the teeth compared with normal individuals. Subjects taking barbiturate drugs showed greater presence of teeth‐grinding, than those who were taking medications from the other groups of anticonvulsant drugs.     

Prevalence of dental trauma in patients with cerebral palsy

This study presents the findings of a record review that evaluated the prevalence of dental trauma in patients with cerebral palsy and evaluated its possible relationship with age, type of palsy, and epilepsy. The dental records of 2,200 patients with special needs admitted to the special care clinic of the School of Dentistry of Araçatuba/UNESP, Brazil, between 1998 and 2003 were reviewed. Of the records that were analyzed, 500 patients who had cerebral palsy were selected for this study. Information regarding age, gender, type of palsy and dental trauma was collected and statistically analyzed. It was observed that 10.6% of the subjects (n = 53) had sustained dental trauma. The number of traumatized teeth was 84. Enamel or enamel/dentin fractures were the most frequent types of traumatic injury (84.9%). The permanent maxillary central incisors were the most commonly affected teeth (50%). The frequency of traumatic injuries showed no significant correlation (p> .05) with the type of cerebral palsy or gender and they were more frequent in subjects between the ages of 0 and 12 years. Having epilepsy was not a statistically significant risk factor (p> .05) for dental trauma.     

Traumatic injuries to the teeth in young individuals with cerebral palsy

Abstract –  The purpose of the study was to assess the characteristics of dental trauma in individuals with cerebral palsy (CP). The study group consisted of 68 individuals (36 boys and 32 girls) who visit daily a school dedicated for children with CP. Their age ranged between 7 and 21 years with a mean age of 12.6 years. The majority (74%) required a wheel chair for mobility, 13% used a walker and the others were able to walk with crutches or without aid. The parents were asked to complete a questionnaire regarding their child's age, gender, medical history, and history of dental trauma. The teeth were evaluated clinically for evidences of past injuries to the teeth, enamel defects in the permanent incisors, scars on the chin and size of overjet. Thirty-nine individuals (57%) had signs of trauma to the permanent teeth. Sixty-eight teeth, mostly the maxillary central incisors, were injured. Boys were slightly less affected than girls, 56% (20/36) and 59% (19/32), respectively. Fracture of enamel and dentine was the most common type of injury (62%). Scars on the chin were detected in 28% of the individuals but only one had fractures of the molar (primary) teeth. The overjet ranged between −3.0 and +14 mm but no correlation could be found between the size of the overjet and tendency to injure the teeth. Localized enamel defects were detected on the labial surface of 13 teeth in nine individuals, probably due to luxation injuries to the primary incisors. The prevalence of dental injuries in a group of individuals with CP was found to be much higher than that of healthy populations despite the fact that CP individuals do not take part in violent sport activities as healthy children do. This should alert caregivers to carry out a profound investigation of the events that result in dental injuries in disabled individuals and suggest methods to reduce this type of morbidity.     

ARTICLE: Caries prevalence in patients with cerebral palsy and the burden of caring for them

The aim of this study was to investigate the correlation between caries prevalence in individuals with cerebral palsy (CPG) and the burden on their caregivers (CGCP) compared to nondisabled individuals (CG) and their caregivers (CGCG). In a cross‐sectional assessment, 65 subjects with cerebral palsy were evaluated for their caries prevalence. The CGCP answered the Caregiver Burden Scale (CBS) questionnaire. Using the same methodology, 58 CG were evaluated and CGCG replied to the questionnaire. The CGCP had statistically significant higher scores on general strain, isolation, disappointment, environment, and total scores using the CBS questionnaire. The CPG had significantly higher values using the Decayed, Missed and Filled (DMF) index than the CG. Values for the CBS domains in general strain and disappointment and DMF index were found to have a statistically significant correlation. Taking care of an individual with CP is a potential source of continual burden for caregivers, and there is a positive correlation between caries prevalence in individuals with CP and the burden on their caregivers.     

The hip in cerebral palsy

Hip displacement in children with cerebral palsy (CP) is a complex problem and requires a multidisciplinary team approach. It is the most common orthopaedic problem in the non-ambulatory group of children and causes significant pain, which can be prevented or treated with appropriate management. Hip subluxation occurs due to asymmetrical muscle imbalance in the context of abnormal proximal femoral morphology. Work from CP registries has shown strong correlation between Gross Motor Function Classification System (GMFCS) level and rate of hip displacement. This has led to the development of preventative surveillance programmes. This review focuses particularly on non-ambulatory patients (GMFCS IV/V) and the options open to the paediatric orthopaedic surgeon in managing associated hip displacement. Surgical strategies can be broadly grouped into preventative, reconstructive and salvage options.     

Risk factors for dental caries in children with cerebral palsy

This study was conducted to examine the oral condition and the salivary and microbiological parameters associated with dental caries in 62 children with cerebral palsy, who came from households of low socioeconomic status (Study Group). This group had mixed (6 to 11 years old) and permanent (11 to 16 years old) dentition. Dental examinations were performed to measure dental caries, plaque index, salivary levels of mutans streptococci and lactobacilli, salivary flow rate, pH of stimulated saliva, and buffer capacity of saliva. A group of 67 non-handicapped children from similar socioeconomic backgrounds also were examined using these parameters (Control Group). Data were analyzed statistically by non-parametric tests and by correlation. The results showed that children with cerebral palsy who had permanent dentitions had a higher mean decayed, missing and filled surfaces index, as well as a higher plaque index for both sexes. Microbiological examination revealed higher levels of mutans streptococci among Study Group subjects with mixed dentition than in the Control Group. Also, lactobacillus counts were higher in the Study Group, regardless of sex or dentition. With respect to salivary flow rate, pH and buffering capacity, lower mean values were obtained for the Study Group.     

Prevalence of developmental enamel defects in children with cerebral palsy

Enamel defects observed in primary anterior teeth of 123 children with congenital cerebral palsy (CP) born 1983 through 1985 in four northern California counties were categorized using an adaptation of the Developmental Defects of Enamel Index. Nineteen children (15%) had crowns or loss of tooth substance (LTS) due to attrition. Missing enamel (ME) including horizontal groove, was observed in 39 children (32%). Twenty-four children without ME (20%) had enamel pits, vertical grooves, or colored enamel opacities. Forty-one (33%) had clinically normal enamel. ME children did not differ significantly from those with normal enamel with respect to race, sex, singleton vs twin, severity or type of CP, or presence of dysmorphic features. ME children more often had shorter gestational ages than children with normal enamel. More ME children, even those who were not low in birth weight, were reported by parents to have required neonatal intensive care.     

The influence of valproic acid on salivary pH in children with cerebral palsy

The purpose of this open-label, crossover study was to measure salivary pH after the oral administration of distilled water, a 10% sucrose solution, and valproic acid to a population of 10 children with cerebral palsy. Salivary pH was measured just prior to giving the solutions and then every five minutes for 60 minutes. The criticai pH was defined at 5.5, below which dental demineralization occurs. In this population, valproic acid decreased salivary pH to below the criticai pH for an extended period of time (mean - 4.32 at 20 minutes) when compared to mean salivary pH after administration of distilled water (7.11 at 20 minutes) and a 10% sucrose solution (5.96 at 20 minutes). Recovery from this low pH to above the criticai level did not occur until after 50 minutes and furthermore did not recover to baseline, neutral levels, for the duration of this study (60 minutes). Our results suggest that children with cerebral palsy, a population with a tendency toward reduced salivary function, have a compromised ability to buffer the oral administration of an exogenous acid. This can result in an increased susceptibility to demineralization and caries of the teeth.