Oral and Dental Problems of Children With Cerebral Palsy III - The Drooling of Saliva

The drooling of saliva is an embarrassing situation for both patient and care giver. An accompanying condition, seen in many forms of Cerebral Palsy, drooling can not only reduce the quality of life of your child but also have an adverse psychological impact.

What is Drooling?

Drooling is the spilling of saliva onto the lips, chin or in severe cases even onto the child's clothing. Drooling in cerebral palsy is not due to the production of excess saliva, it is caused because the child's muscles do not allow for a proper swallow. 

What are the effects of drooling?

Apart form the obvious social embarrassment, drooling can lead to a foul smell due to the accumulation of saliva in the corners of the mouth, soiling of the clothes and in very severe cases aspiration pneumonia. Aspiration pneumonia occurs when the lack of muscle coordination results in saliva entering the child's lungs. This saliva then acts as a source of infection that causes pneumonia. This condition can be life threatening.

Does drooling depend on the severity of CP?

To some extent it does. The worse the co-ordination between your child's nerves and  muscles, the worse is the drooling. But surprisingly drooling has no correlation with the intelligence or learning ability of your child. Children who have no intellectual disability often suffer from drooling. This makes drooling a particularly embarrassing problem. Drooling may prevent children from making friends at school or prevent them from expressing themselves.

How can we treat drooling?

In Many cases the severity of drooling reduces with age, even completely regressing in a few cases. The primary aim of the treatment of drooling should be to improve the strength and co-ordination of the child's facial muscles. In many western countries, drugs or injections to reduce the flow of saliva have been tried. These methods are described as successful because they reduce the flow of saliva and thus improve the quality of life of the patient. However these drugs can have a devastating effect on the teeth of the child.

If not drugs then what?

Drugs are not the only form of treating drooling. Parents must remember that since drooling is a neuromuscular problem, it will often get better as your child's muscles get stronger. In many children the severity of drooling reduces with age. Therefore it is not advisable to start the child on medications early. Exercises to help the child achieve closure of the mouth greatly help reduce the severity of drooling.  Speech therapy improves the child's control over the muscles of the tongue and also reduces the severity of drooling. 

Will my child require surgery to control the problem?

Surgery is often viewed as a last resort, when all other treatment has failed, in order to prevent aspiration pneumonia. Surgery may be of two types, firstly the surgeon may reduce the secretion of saliva, by repositioning the duct of the salivary gland or by removing the gland itself. This reduces the production of saliva, but leaves the child's mouth prone to infection, as it is devoid of the protective nature of the saliva. The second, more complicated surgery, involves the bypass of the oral cavity during feeding, ensuring that the child is fed directly through a tube inserted into the stomach; a procedure called a gastrostomy. This type of surgery is reserved for children who have had multiple episodes of aspiration pneumonia and is the exception and not the rule.

What the future holds

The use of Botox  for the management of drooling has been receiving a lot of attention in western countries. The drug more famous for its cosmetic uses, has a selective action on salivary glands. And even though it reduces the salivary flow, researchers claim that it is safer and has fewer side effects on the mouth than routinely used drugs. 

Another interesting  approach has been the use of oral appliances. Dentists often use the forces of the muscles to promote growth of the bones or help a child over come  habits like thumb sucking. Research shows that modified versions of these appliances can promote muscle coordination in Cerebral Palsy. While they cannot be used in the severe forms of Cerebral Palsy, they are said to be effective in milder forms. They are especially useful in children with no intellectual disability, who can understand the purpose of the appliance.

For Further Queries you can contact me;

Dr Sharat Chandra Pani

Consultant Pediatric and Preventive Dentist

Senior Lecturer

KVG Dental College

Sullia India

+919886374024

sharatpani@hotmail.com

 

Oral and Dental Health of Children with Cerebral Palsy I - Understanding Their dental Problems

Cerebral palsy (CP) is a term used to describe a group of chronic conditions affecting body movements and muscle coordination.  It is caused by damage to one or more specific areas of the brain, usually occurring during fetal development, or during infancy.  It can also occur before, during or shortly following birth.The condition affects as many as 1 in every 500 children and is  the most commonly occuring neuromuscular disorder. It is not a disease but a condition, and while it cannot be "treated" in the conventional sense, the adoption of 

various therapeutic and preventive measures can certainly improve the quality of life of the individual with cerebral palsy. Over the past three decades, the awareness about the management of children with CP in India has increased dramatically and with that the so has their life expectancy.Where 30 years ago a child with  severe CP would have been given " Five years at most" today such children go on to live for 20 to 30 years. Studies show that with proper medical care the life expectancy for individuals with mild forms of CP is comparable to the general population.

This increased life expectancy has meant that dental care for these children can no longer be viewed as a luxury. Finding a dentist who is trained to treat a child with CP can be difficult, and is almost always (especially in severe cases) expensive. A parent must therefore look out for early signs of dental disease and try their level best to prevent the disease.

 

What Effect Does Cerebral Palsy Have on your Child's Mouth?

Cerebral Palsy and Tooth Decay

The severeity of caries in your child can depend on the level of preventive care

Cerebral palsy by itself does not cause tooth decay. Despite some common misconceptions, CP does not make the teeth more brittle or deficient in calcium. The increased tooth decay seen in children with CP is a direct result of poor oral hygiene. Children with CP have weak co-ordination of the oral muscles. This means that the child cannot swallow as effectively as others, resulting in the accumulation of food in the mouth which increases the risk of 

dental caries or tooth decay. Further, the sweet liquid syrup medications that children with CP are often prescirbed for either epilepsy, or as muscle relaxants, also increase the chance of caries.

Prevention:

Some amount of tooth decay in children with severe cerebral palsy is inevitable, but the severeity of the disease can certainly be controlled, a few points to note are

1. Vigorous maintenance of oral hygiene: Start as soon as the first tooth erupts, with a piece of gauze wrapped around your finger. Avoid touching the palate or floor of the mouth.Due to a sensitive oral mucosa, the child may show violent resistance if  these areas are touched.    
2. By the age of 2 1/2 years, shift to a soft baby brush, you can also start using a pea size drop of any special child toothpaste(See my first post on preventive care). Avoid regular toothpaste as their peppermint flavor may irritate the gums. Their high fluoride content also increases the risk of long term fluoride ingestion by the child.
3. The best time to take your child to the pediatric dentist is by 1 year of age. Any defect in your child's teeth or inadequacy of oral hygeine measures are best spotted early.
4. As soon as your child's teeth have erupted (by three years of age) a coat of flouride varnish to protect them against decay is advisable. Note that the sticky nature of the varnish prevents accidental ingestion of fluoride and is recommended over gels or solutions that your dentist may offer.
5. A fluoridated mouthwash is NOT recommended if your child has difficulty in spitting or swallowing.

Cerebral Palsy and Gum Disease

 Inability to cleanse the oral cavity with the tongue can have devastating effects on the gums. Almost all children with cerebral palsy will have moderate to severe gum disease which can manifest as, bad breath, bleeding from the gums(especially while brushing) and in very severe cases a loosening of the the teeth. Brushing the teeth regulary is the first and most important step in preventing gum disease. However if the child's swallowing pattern is severely compromised then it may not be enough. Therapeutic mouthwashes such as chlorhexidine can reduce the bacteria that cause gum disease but here again the parent should administer them only under the guidance of a dentist who is aware of long term protocol. Though chlorhexidine has almost no systemic adverse effects, it can cause staining of the teeth and increased deposits if used injudiciously. (For more details youcan see the post on therapeutic mouthrinseshttp://specialchilddentistry.blogspot.com/2008/10/dental-care-for-special-children-ii.html)

Several studies have shown that chlorhexidine sprays are effective in children who have problems with rinsing. However these are not yet commercially available in India.

Cerebral Palsy and the Dentition

Children with cerebral palsy often have teeth that protrude. The cause for this protrusion is an imbalance in the muscle forces that are responsible for balanced development of the face. This combined with a tendency to fall, results in a high chance of damage to the Incisors. Parents should take care to supervise the children so as to prevent trauma. Damaged incisors can often result in an inflammation of the teeth which would require root canal treatment.

Enamel hypoplasia: Some but not all children with CP suffer from poorly 

developed teeth or Enamel Hypoplasia. Hypoplastic teeth are weaker and more prone to tooth decay. The cause of hypoplasia is usually the stress factors that occured during or immediately after the birth of the child. The condition is irreversible and there is no treatment.

Cerebral Palsy and Drooling of Saliva

Children with many forms of cerebral palsy may suffer from drooling of saliva. Drooling may be particularly embarrasing for parents and children alike. It results due the poor swallowing ability and weak muscles of the child and is NOT THE RESULT OF EXCESSIVE SALIVA. Since the condition affects even children with mild forms of CP who have no other intellectual disablity, it may be a barrier to them integrating with other children. Parents must however remember that reducing the the salivary flow with drugs does not help treat the condition and has an extremely harmful effect on the teeth of the child.

This post has only briefly touched upon the various oral conditions that are seen in children with cerebral palsy. In future posts i will explain in detail certain conditions and the treatment options available.

For Further Queries you can contact me;

Dr Sharat Chandra Pani

Consultant Pediatric and Preventive Dentist

Senior Lecturer

KVG Dental College

Sullia India

+919886374024

sharatpani@hotmail.com