Disease/Medical Condition CEREBRAL PALSY Date of Publication: Dec. 20, 2017 (also known as “CP”; the spastic form of CP is also known as “spastic paralysis”; includes “ spastic CP”, “dyskinetic/choreo-athetoid CP”, “ataxic CP”, and “mixed CP .”) Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No. ■ Is medical consult advised? No, — assuming patient/client is already under medical care for cerebral palsy, which is well managed, and — assuming that seizure disorder (if any) is well controlled. Is the initiation of invasive dental hygiene procedures contra-indicated?** Possibly, but not typically. ■ Is medical consult advised? .............................................. See above. Yes, if patient/client has a history suggestive of a need for pre-procedure medication for calming, involuntary muscle movement control, seizure control, or other behavioural challenges. ■ Is medical clearance required? .......................................... Possibly (e.g., if there are significant involuntary muscle movements creating a safety concern for the dental hygienist and/or the patient/client, or if there is significant risk of seizure). ■ Is antibiotic prophylaxis required? ...................................... No. ■ Is postponing treatment advised? ....................................... Possibly (e.g., if there are significant involuntary muscle movements creating a safety concern for the dental hygienist and/or the patient/client; also depends on severity and level of control of co-morbid seizure disorder, as well as presence/absence of oral pathology — such as tooth fractures — that may need to be addressed prior to dental hygiene treatment). Oral management implications ■ Most persons with mild or moderate forms of cerebral palsy can be treated successfully in the general practice dental hygiene setting. However, provision of oral care often requires adaptation of routine skills. ■ Patients/clients in wheelchairs may be more easily treated in the wheelchair deploying wheelchair-lock wheels. A sliding board can be used to support back, head, and neck, while reclining the wheelchair if possible. ■ If a patient/client needs to be transferred from a wheelchair to the dental chair, the dental hygienist should ask about preferences such as pillows, padding, or other aids to ease the transfer. Placing the dental chair at a 45 degree angle can help protect the airway by avoiding the supine position. ■ Patients/clients taking muscle relaxants (e.g., baclofen and benzodiazepines) or anti-spasmodics (e.g., clonidine) are at increased risk of hypotension, dizziness, and/or ataxia. To reduce the likelihood of a fall, the patient/client should be assisted to and from the chair. The dental hygienist should also be cautious when adjusting the dental chair, with inclination occurring slowly for re-equilibration. ■ The degree of intellectual disability, if any, varies with each patient/client. Therefore, explanation of procedures and dental hygiene education should be tailored according to the individual needs of the patient/client. The dental hygienist should be empathetic regarding the patient/client’s frustrations and concerns. Consistency in all aspects of oral care (including the same dental hygienist and operatory over time) contributes to improved cooperation. ■ Dysarthria1 is common, and the dental hygienist should be patient and allow time for the patient/client to express himself/ herself. ■ Limbs should not be forced into unnatural positions. The patient/client should be allowed to settle into a position that is comfortable and does not interfere with dental hygiene treatment. 1 Dysarthria is difficult or unclear articulation of speech due to impaired movement of the muscles used for speech production. cont’d on next page... Disease/Medical Condition CEREBRAL PALSY (also known as “CP”; the spastic form of CP is also known as “spastic paralysis”; includes “ spastic CP”, “dyskinetic/choreo-athetoid CP”, “ataxic CP”, and “mixed CP ”) Oral management implications (cont’d) ■ The patient/client’s involuntary muscle movements may create a safety issue for the dental hygienist, and proactive measures should be taken to address this. The dental hygienist should try to anticipate the patient/client’s movements, blending professional movements with those of the patient/client or working around them. ■ For the most part, uncontrolled body movements should be tolerated, rather than attempting to stop them. Firm, gentle pressure can be applied to calm shaking limbs, particularly in children. ■ Lights, sounds, and sudden movements that trigger primitive reflexes2 or uncontrolled movements3 should be minimized. The patient/client should be informed about a stimulus before its appearance. Although relaxation will not stop involuntary body movements, it may reduce intensity and frequency. ■ The tonic labyrinthine reflex may be prevented by keeping the patient/client’s head supported and flexed, maintaining the chair in the upright position, and folding the patient/client’s hands at midline. Management involves bringing arms forward, separating legs, and massaging shoulders. ■ The asymmetric tonic neck reflex may be prevented by using rear operating position and stabilizing the head in midline. Management involves placing face in midline and helping flex extended arm and leg. ■ The startle reflex may be prevented by informing the patient/client before lowering, raising, or tilting the dental chair. ■ The patient/client’s head should be softly cradled during treatment. If the patient/client’s head needs to be turned, this should be done gently and slowly. ■ An early morning appointment, before eating or drinking, benefits a patient/client with a gagging problem. Hyperactive gag and bite reflexes necessitate gentle, slow introduction of dental hygiene instruments into the mouth. A mouth prop may be helpful. The chin should be placed in a neutral or downward position to mitigate hyperactive gag reflex. ■ Appointments should ideally be short with frequent breaks. Muscle relaxants may be indicated if long procedures are needed. If extensive dental treatment is required, persons with CP may need sedation, general anaesthesia, or hospitalization4. ■ Patients/clients who are tube-fed are at high risk of aspiration in the dental chair. Therefore, such patients/clients should be positioned as upright as possible, utilizing low amounts of water with high volume suction. ■ Seizure management protocol should be in place prior to arrival of patients/clients at risk. ■ Gastroesophageal reflux is common, and therefore the dental hygienist should be alert for teeth sensitivity and signs of erosion. ■ Xerostomia can be managed with saliva substitutes. ■ Malocclusion should prompt orthodontic needs assessment, followed by treatment as feasible. ■ Mouth guards should be considered for treatment of bruxism if gagging and dysphasia permit comfortable and practical use. 2 Primitive reflexes are common and may complicate oral care. There are 3 main types of such reflexes: asymmetric tonic neck reflex (when a patient/client’s head is turned away from the midline, the arm and leg on that side extend and stiffen while the contralateral arm and leg flex); tonic labyrinthine reflex (when the neck is tilted backwards losing support or is extended while a patient/client is lying on his or her back, the legs and arms extend and stiffen while the back and neck arch); and startle reflex (any surprising stimulus can trigger uncontrolled, often forceful movements involving the whole body). 3 Emotional stress can worsen involuntary movements in dyskinetic CP, including grimacing and squirming. 4 While local anaesthetics can generally be used without adverse reaction, some muscle relaxants and anticholinergics used in management of CP can cause central nervous system (CNS) depression and potentiate other CNS depressants used in dentistry. Therefore, conscious sedation is generally not recommended. However, general anaesthesia, with appropriate precautions, may be required to accomplish restorative or surgical treatment. cont’d on next page... 2 Disease/Medical Condition CEREBRAL PALSY (also known as “CP”; the spastic form of CP is also known as “spastic paralysis”; includes “ spastic CP”, “dyskinetic/choreo-athetoid CP”, “ataxic CP”, and “mixed CP ”) Oral management implications (cont’d) ■ Manual dexterity should be assessed to develop an oral self-care plan. An adapted toothbrush or electric toothbrush, as well as floss holder, may be indicated. ■ The caregiver should be engaged regarding oral home care, especially so in the case of a child with CP5. Brushing in a supine position with a mouth prop may prove useful. Rinsing with fluoride or chlorhexidine should be monitored. ■ Persons with CP are prone to falls or accidents that result in trauma and injury to the mouth. Therefore, the dental hygienist can be proactive in suggesting a tooth-saving kit (e.g., in group homes) and in giving specific directions on what to do if a permanent tooth is knocked out. ■ Because physical abuse often presents as oral trauma and occurs more commonly in persons with developmental disabilities than the general population, the dental hygienist should be alert to suspicious oral trauma during the examination. Findings should be noted in the chart and any suspected abuse or neglect in children should be reported to the Children’s Aid Society as required by law6. Oral manifestations ■ The more severe the neurological insult, the higher is the risk of dental and other oral