Oral and Dental Problems of Children with Cerebral Palsy II - Some Questions Answered

Dr Sharat Chandra Pani

In the last post we saw how the neuromuscular status of children with Cerebral Palsy (CP) can influence oral hygiene. In today's post we answer some of the questions we have received from parents regarding dental needs of children with CP.

My child is two years old and has cerebral palsy and West Syndrome. I've been worried about his oral hygiene. He often wakes in the night and I give him cerelac. He has a little and sleeps off. I give him water afterwards but I'm sure that doesn't wash down everything. His teeth have become discoloured and he seems to have cavities too. Sometimes when I try to wipe his teeth with a wet gauze, he gets nauseous. He has hypersensitivity around the mouth area and cries while eating too. What I can do for him?

EK Mumbai

This question addressess several commonly faced concerns of parents of children with CP. Firstly, the concern about oral hygeine. The oral hygiene of children with CP is bound to be poor when compared to children without CP. Having accepted this fact parents must decide how best to prevent further damage to the teeth.

The epileptic seizures that accompany West syndrome, often mean that the child has been on anti-epileptic syrups since infancy. The importance of cleaning the mouth after intake of the syrup cannot be overemphasized. These syrups are a high source of sugar and their effect on the teeth can be far more deleterious than any sugar containing food. 

I would not recommend continuing with cerelac  beyond the first year of life. While it is an easy to prepare meal and children often like the taste, parents must remember that it is also a source of hidden sugar which can further compromise the child's dental health. An alternate source of nutrition such as ragi porridge would definitely reduce your child's sugar exposure.

Hypersensitivity of the oral mucosa is a problem faced by many children with CP. But you must remember that touching the palate, or oral mucous membrane is not necessary in order to clean the teeth. Furthermore, parents must learn to differentiate between a mild irritation, and a gagging or choking. Most children with CP will exhibit some amount of irritation, and you must persist with cleaning the teeth. If however the child is gagging or choking, then you may have to explore alternatives to brushing that will cause less irritation.

Lastly I would recommend an initial check up visit with your Pediatric Dentist. Some if not all the caries in your child's mouth are likely to be in the initial stage. Therefore a simple restoration will save your child from a lot of discomfort. Some of the lesions would also be reversible, and i would recommend an application of a topical fluoride varnish to prevent further decay.

My son is 12 years old and has Spastic Diplegia, his teeth seem forwardly placed. I would like to get  braces for my son's teeth. Is this advisable?

SS Bangalore

Children with Cerebral palsy tend to have proclined teeth and constricted dental arches. The cause for this is usually the force exerted by the facial muscles. Imagine a tight muscle that is continuously pinching your child's face; the result is a set of teeth that are set in a narrow arch and forwardly placed. There is no contraindication for orthodontic treatment. Orthodontic treatment or braces will definitely set the teeth straight, but they won't correct the forces that the muscles on your son's face are exerting. While you will definitely see a better alignment of the teeth after orthodontic treatment, the narrow arch and the general facial features that accompany Spastic Cerebral Palsy are more difficult to treat. Even if they are treated, there is every possiblity that the muscle forces on the teeth will cause a relapse of the original state. My take on Orthodontic treatment for children with CP is this; go for it if you want to correct the alignment of the teeth, but don't expect miracles.

Dental Care for Special Children II - The Role of Preventive Mouthwashes

Dr.Sharat Chandra Pani

In the last post in this series we spoke about the small things you can do for your child that will go a long way in preventing dental disease. We also spoke about the possible use of specific mouthrinses which have the potential to prevent dental disease in your child. Today we look at the evolution of these mouth rinses and also at the rinse that suits your child the best.

What are Mouthwashes?

Mouthwashes serve as an adjunct  to toothbrushes and floss in maintaining oral hygiene. The mouthwash has come a long way since the days of the ancient Greeks - who used Donkey's milk, and the Portuguese - who preferred human urine. A mouthwash is a liquid medicament, with an active chemical ingredient that reduces the levels of harmful bacteria in your child's mouth. They assume a great significance in the oral health of children who cannot; or will not; brush.

The first modern mouthwashes, such as the popular 'Listerine'  marketed as "anti-halitosis" rinses were high in their alcohol content. While they do reduce the number of harmful bacteria, they have an efficacy of only around 20% and, because of their alcohol content are not suitable for children. Indeed for the greater part of the 20th century, mouthwashes were viewed as cosmetic rather than therapeutic agents,

What is a therapeutic mouthwash and how does it help my child?

A therapeutic mouthwash is a mouthwash that has a stronger action than a cosmetic mouthwash and contains certain chemicals that are selective for specific groups of harmful bacteria. Broadly they may be divided into

• Antiplaque/antigingivitis rinses - that fight gum disease
  
• Anticariogenic rinses - that prevent tooth decay

most modern therapeutic rinses provide a combination of both the actions, although some may be more specific than others. There are several types of therapeutic mouthwashes available on the market. We look at the two which are the most widely recommended.

Chlorhexidine

Chlorhexidine Gluconate is a chemical that destroys harmful oral microorganisms and is a constituent of several therapeutic mouthwashes. Used in concentrations ranging from 0.12% to 0.2% it is highly effective in controlling gum disease. Studies have shown that the rinse is also effective against the bacteria Streptococcus mutans, which is one of the main causative agents of dental caries. Chlorhexidine is also safe if accidentally ingested. The only drawback of chlorhexidine is that if it is used for over 2 weeks it causes a staining of the teeth and also increases the chances of causing deposits on the teeth. Chlorhexidine, while effective in maintaining the oral health of children who are unable to brush has definite side effects and must be used only under the supervision of a preventive dentist who is well versed with protocols for long term chlorhexidine use.

For a complete list of Chlorhexidine rinses avaiable in India click on the link below  http://www.cimsasia.com/Page.aspx?menuid=mimssearch&searchcategory=DRUGNAME&searchstring=chlorhexidine+mouthwash

Fluorides

 If you were to look up fluorides on the Internet, you would find yourself in the middle of a heated debate, with one group trying to convince you that there is no greater wonder drug for your child's teeth while another tells you how it will destroy everything; from your child's bones to his heart and kidneys. I will take neither side.

Fluoride is an element that is found in the earth's crust and eventually finds it's way into our water. In concentrations of 0.7 to 1.2 parts per million, it strengthens the teeth, stops the growth of bacteria and therefore prevents tooth decay. But if one were to consume an excess of the element, it would result in a discoloration of the teeth, and as the concentration increases it can cause effects on bone, heart and kidney.

The safest way to harness the beneficial properties of fluoride would therefore lie in not ingesting the fluoride but in using topical applications of fluoride. One of these topical applications is the use of fluoride mouthrinses. While fluoride mouthrinses have been shown to greatly reduce tooth decay, and are certainly useful in children with medical conditions such as congenital heart disease or renal failure, I would not recommend their use in children with severe neuromuscular disorders such as some cases of cerebral palsy, as they may end up ingesting far more mouthwash than is acceptable. Although the one-time ingestion a cap full of fluoride mouthrinse is not fatal or even dangerous, a prolonged daily ingestion can be dangerous. A safer delivery system of fluoride in such children would be the use of a professionally applied fluoride varnish.

To view the different fluoridated mouthwashes available in India, click on the link below    http://www.cimsasia.com/Page.aspx?menuid=mimssearch&searchcategory=DRUGNAME&searchstring=fluoride+mouthwash

To summarize, medicated mouthwashes can greatly improve the oral hygiene of a child with special health care needs. However the parents must be aware of the simple fact; A mouthrinse is no good if your child can't rinse! In the next post of this series we will look at the role of fluoride in preventing dental disease in your child.

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