PHYSICALLY HANDICAPPED

CHILDREN
 DEFINITION
Special Health Care Needs
AAPD (2013) -“any physical, developmental, mental, sensory, behavioral,
cognitive, or emotional impairment or limiting condition that requires medical
management, health care intervention, and/or use of specialized services or
programs. The condition may be congenital, developmental, or acquired
through disease, trauma, or environmental cause and may impose limitations
in performing daily self-maintenance activities or substantial limitations in a
major life activity. Health care for individuals with special needs requires
specialized knowledge, as well as increased awareness and attention,
adaptation, and accommodative measures beyond what are considered
routine.” 2
DENTAL HANDICAP-
AAPD (1996) states: a person should be considered dentally
differently-abled if pain, infection, or lack of functional
dentition affects following :
1. Restricts consumption of a diet adequate to support
growth and energy needs.
2. Delays or alters growth and development.
3. Inhibits performance of any major life activity including
work, learning, communication and recreation.

DISABLED PERSON (AMERICANS DISABILITIES ACT of

1990)
An individual is disabled if the person:
1. Has a physical or mental impairment that
substantially limits one or more major life activities.
2. Has a record of such an impairment
3. Is regarded as having such an impairment 3
 Common oral health problems in special health
care needs children
1. Delayed, accelerated or inconsistent tooth eruption
2. Dental caries
3. Periodontal disease
4. Malocclusion
5. Abnormal oral habits – bruxism, mouth breathing, tongue thrusting,
food pouching, picking at the gums
6. Tooth anomalies like- variation in size, shape and number of teeth
7. Trauma and injury
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 CLASSIFICATION
FRANK AND WINTER Holloway and
Nowak(1964) Agerholm(1975) New classification
(1974) Swallow(1982)
• Blind or partially • Physically • Mental handicap • Intrinsic handicap – • Developmentally
sighted differently-abled = one from which disabled
polio • Physical handicap person cannot be
• Deaf or partially • Mentally differently- separated
deaf abled = retardation • Medically
• Medical disability
• Congenital = cleft • Extrinsic handicap compromised
• Educationally palate – person can be
subnormal • Metabolic = removed ( social
juvenile diabetes deprivation)
• Maladjusted • Systemic=
hemophilia
• Convulsive =
• Epileptic
epilepsy
• Communication =
• Physically deafness
differently-abled
• Osseous disorders
= rickets
• Defect of speech • Malignant
disorders =
• Senile leukemia
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1. INTELLECTUAL DISABILITY
(MENTAL RETARDATION)

It is defined by the American Association of Mental Deficiency (AAMD)-

 Sub/average general intellectual functioning, which originates during the
developmental period and is associated with impairment in adaptive
behavior.

MD is the most common developmental disability that can be idiopathic and

challenging.
Mental Retardation: is defined as an overall intelligence quotient lower than
70, associated with functional deficit in adaptive behavior, such as daily-
living skills, social skills communication. Three levels of impairment were-
1. Idiot- development arrested at age 2 years old
2. Imbecile- development equivalent to 2 - 7 years old at maturity.
3. Moron- development equivalent to 7-12 years old at maturity.
 Standard formula for
computing IQ
IQ= (MA/CA)X 100
• MA = Mental Age
IQ Classification Guide
• CA = Chronological Age
Etiologic factors for MR
Characteristics of MR
SB-IV Stanford Binet Inteligence Scale
WISC-III Wechsler Intelligence scale for children
 CLINICAL MANIFESTATIONS
Tensely reclined head, abnormal behaviour, and poor
mobility
Retained primitive reflexes and delayed milestones
Increased tone in limbs and persistent fisting
Hand preference during first 2 yrs of life.

ORAL MANIFESTATIONS
• Advanced cases of Early Childhood Caries because of poor oral
hygiene and cariogenic diet patterns.
• Present with multiple anomalies of facial structures also eruption
time, sequence, number, presence of malocclusion and enamel
hypoplasia.
• Also higher prevalence of periodontal disease 11
 Treatment Considerations
The dentist must first asses the child’s mental level so as to gauge the level of
cooperation to be expected and make adjustments accordingly -
1. Short attention span, restlessness, hyperactivity and erratic emotional
behavior characterize MR patients undergoing dental treatment.
2. Familiarize MR patients to the dental office and dental staff so as to reduce
his /her fear before undertaking any dental treatment.
3. Allow the patient to bring one favorite item into the clinic.
4. Speech must be slow, simple.
5. Only one instruction at a time should be given.
 Treatment Considerations
6. Reward patient with compliments after the procedure is completed.
7. Carefully listen to these patients as they have difficulty in
communicating.
8. Appointments should be short and scheduled during the early part of
the day.
9. Children should be managed with a blend of kindness and firmness.
10. Permanent restorations and preventive procedures with regular visits.
11. TSD and TLC approach in mild cases whereas sedation in moderate
cases.
12. GA is advised in severe cases where any level of cooperation cannot
be achieved.
 2. DOWN’S SYNDROME
Described by John Langdon Down (1865)
One of the most recognizable malformation syndromes.
Occurs due to Trisomy of chromosome 21(95%),
translocation (4%) and mosaicism (1%) .

Incidence/ prevalence –
1 in every 600 live births.
Prenatally diagnosed (from 3% to 60%) in younger patients.
Birth prevalence has declined from 1986 to 2004 (study
done in Australia).
 Predisposing Factors

Mother’s age –
If 20 then 1 in 2300
If 34-39 then 1 in 280
If 45-50 then 1 in 45
Risk of Down’s syndrome per live birth
Advanced maternal age, with advanced maternal age

Uterine and placental abnormalities

Chromosomal aberrations.
 General Manifestations
1. SKULL-
1. Brachycephalic resulting in flattened face and occiput.
Lack of supraorbital ridges.
2. Presence at birth of third fontanelle
3. Flat nasal bridges with a small maxilla.
4. Obstructed and narrower passage- mouth breather
2. EARS-
1. Dysplastic ears with abnormal pinna.
3. NECK-
1. Short and broad with excess skin posteriorly.
1. EYES-
1. Oblique palpebral fissures with
prominent epicanthic folds (mongloid
features)
2. Brushfield’s spots appear on the iris in
a ring like concentric with the pupil.
3. Scanty eyelids
4. Cataract, squint, nystagmus.
HANDS-
Broad and short with a single transverse
palmar crease (simian crease)
Short incurved little finger
IQ- 25-50
Associated congenital abnormalities-
Cong. heart diseases (ASD, VSD, AVC)
Duodenal atresia
Atlantoaxial instability
Umbilical hernia
Multiple immunological defects affecting the skin, GIT and
respiratory tracts.
Acute lymphoblastic leukemia is 20 times more common.
Hypothyroidism
Alzheimer’s disease
 Oral Manifestations
1. MOUTH-
1. Small drooping mouth.
2. Open mouth posture
2. TONGUE-
1. Protrusive, Fissured tongue
2. Circumvallate papillae are enlarged but filiform papillae
are absent.
3. Macroglossia
3. LIPS-
1. Thick, dry, fissured.
 Oral Manifestations
4. OCCLUSION-
1. Anterior open bite and crossbite, class III tendency
2. Small maxilla
5. PALATE-
1. High with horizontal palatal shelves
2. Bifid Uvula, cleft lip and cleft palate
6. ERUPTION-
Retarded
Early shedding of deciduous teeth
 Oral Manifestations
7. TEETH-
Hypodontia, especially third molars
Microdontia
Hypocalcification and hypoplastic defects
Low incidence of caries
8. PERIODONTIUM-
Severe, early onset of periodontal disease due to local factors like
poor oral hygiene, tooth morphology, and malocclusions and systemic
factors like decreased humoral response reduced chemotaxis,
impaired phagocytosis, poor circulation etc.
 Dental Treatment
• These children are MR (10%) and require appropriate treatment.
• Incidence of cardiac disease associated with DS is 40% and will require
adequate prophylaxis
• Increased incidence of Leukemia and acute and chronic infections of the URTI
can also alter treatment.
• Children are usually affectionate & cooperative. Do not present problems
during management.
• N2O analgesia or TSD in mildly apprehensive patients can be used; GA in
severe cases.
• Preventive procedures along with CHX may be beneficial.
• Pulp treatment in deciduous teeth is contraindicated in cardiac patients
because of the risk of bacteremia, whereas it can be considered with an
adequate apical seal.
 3. CEREBRAL PALSY

• Most severely handicapping condition affecting childhood.

• Definition- Non-progressive lesion which occurs in the developing brain
before, after or during birth leaving the child with a variety of neurological
problems.
• American Academy for Cerebral palsy & Developmental Medicine- A group
of disorders of the development of movement and posture, causing activity
limitations that are attributed to nonprogressive disturbances that
occurred in the developing fetal or infant brain.
• 50% of these children die in infancy or require institutional
care.
• Condition manifests itself as a number of neuromuscular
dysfunctions and involves muscle weakness, stiffness,
paralysis, poor balance, irregular gait and uncoordinated or
involuntary movement.
• I in 200 live births is affected.
 Etiology
• Due to decreased oxygenation in the developing
brain leading to damage of the brain
• Complications of labor or delivery
• Infections of the brain like meningitis, encephalitis
• Toxemia of pregnancy
• Congenital defects of the brain
• Kernicterus
• Any trauma to the head
• Premature birth with CNS abnormality are the
common causes.
• Child Abuse
 SPASTIC
• More than 60-70% of cases
• Cause – lesion in cerebral cortex
• Tendency for muscles to maintain a state of contraction
and for antagonists to lengthen, producing flexion
deformities, particularly in the large joints.
• Limited control of head muscles – ‘HEAD ROLL’
• Spastic quadriplegia associated with convulsions and MR

• Increased motor tone- stiffness • Spastic tongue thrust

• Impaired chewing and swallowing • Drooling of saliva
• Hypertonicity of facial muscles • Constricted mandibular and maxillary arches
• Slow jaw movement • Usually Class II Div 2 malocclusion, with
• Hypertonic orbicular muscles unilateral posterior crossbite 27
 Clinical
Manifestations
• Abnormalities of muscle tone Oral
• Delayed milestones Manifestations
• No control over movements
• Muscle weakness
• Child may have gastro oesophageal
• Spasticity, loss of coordination.
reflux as well as episodes of
• Retention of primitive reflexes
vomiting. Leading to dental erosion
• Poor development of gross and
or loss of tooth structure.
fine motor control
• Gingival overgrowth due to seizure
medications.

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 Dental Problems
DENTAL CARIES-
Higher caries rate then normal children due to their inability to
maintain good oral hygiene, or due to parents tendency to overindulge
Soft cariogenic diet, Due to increased prevalence of Enamel
hypoplastic defects on their teeth.
PERIODONTAL DISEASE-
Occurs with a great frequency as the patient is unable to brush or
floss.
Also on Phenytoin to control seizure activity which is a cause of some
degree of gingival hyperplasia.
MALOCCLUSIONS-
occurs twice as often.
Protrusions of maxillary anterior teeth, excessive overjet and overbite,
open bites, and unilateral cross bites.
Also Class II Div 2 maloccusion is observed.
BRUXISM-
Atheoid cerebral palsy resulting in severe attrition, loss of vertical
dimension and TMJ.
TRISMUS-
Due to susceptibility to trauma.
Excessive drooling and difficulty in swallowing.
 Dental Treatment
• Through medical and dental history should be taken.
• Maintain a calm friendly and professional atmosphere with patient.
• Many patients prefer to be treated in wheelchair which can be
tipped back into dentist’s lap.

• Patient’s head should be stabilized throughout procedure and back

should be elevated to reduce swallowing problems.
• Use physical restraints judiciously for control of extremities.
• Mouth props and finger splints
• Sudden noises and light can stimulate the startle reflex
reactions in patient
• LA be used with care & stabilization against sudden movement.
• Rubber dam used to protect working area from hyperactive
tongue movements.
• Gauze sheilds
• Premedication can be used to reduce hypertonicity, anxiety.
• GA is used as a last resort.
 4. EPILEPSY

• Group of disorders characterized by chronic, recurrent and

paroxysmal changes in neurologic function caused by Prevalence
abnormalities in the electrical activity of the brain. • <1%
• 75% no
• Etiology- known
Idiopathic etiology
• Higher
Symptomatic- pathology of the brain due to malformation, frequency in
injury or disease. males
 Classification
1. PARTIAL OR FOCAL SEIZURES- 3. STATUS EPILEPTICUS-
1. SIMPLE PARTIAL SEIZURES 1. TONIC - CLONIC STATUS
2. COMLPLEX PARTIAL SEIZURES 2. ABSENCE STATUS
3. SECONDARY GEN. PARTIAL SEIZURES 4. RECURRENT PATTERNS-
2. PRIMARY GENERALIZED SEIZURES- 1. SPORADIC
1. TONIC-CLONIC (GRAND-MAL) 2. CYCLIC
2. TONIC 3. REFLEX
3. ABSENCE (PETIT-MAL)
4. ATYPICAL ABSENCE
5. INFANTILE SPASMS
ABSENCE SEIZURES CONSISTS OF –

Sudden cessation of the ongoing conscious activity without

convulsive muscular activity or loss of postural control.
Brief lapses of consciousness or awareness.
Lasts for a few seconds to minutes.
6-14 years old, common.
TONIC-CLONIC SEIZURES OF-
Starting without warning.
Sudden loss of consciousness, a tonic contraction of the muscles, loss
of postural control, respiration arrests and patient becomes cyanotic,
pupils dilate, eyeballs roll upwards or to the side, face becomes
distorted.
After 30-sec tonic phase followed by clonic phase of several minutes
duration wherein the muscles are violently contracted, with profuse
salivation, perspiration and involuntary bladder and bowel evacuation.
Contractions become less violent and gradually cease. Child then
remains stuporous and goes into a deep sleep.
 Oral manifestations of Epilepsy
Injuries caused by the fit-
 Soft tissue lacerations of the tongue or buccal mucosa.
 Facial fractures.
 Trauma to the teeth- avulsion, luxation, fractures.
 Subluxation of the TMJ.
Injuries due to drug therapy-
 Gingival hyperplasia
 Recurrent aphthous like ulceration
 Small teeth, delayed eruption
 Cervical lymphadenopathy.
 Secondary infections of the fibrous overgrowth due to neglection.
 Dental Management
1. Complete medical history be acquired regarding type & frequency of
seizure episodes prior to treatment.
2. Reduce stress on patients with sedation. Diazepam is drug of choice
because it has anticonvulsant properties
3. Use of dental chair light is avoided.
4. Avoid seizure promoting drugs such as phenothyazines, IV local
anaestheitcs.
5. Appropriate drug therapy for seizures.
6. Due to use of antiepileptic medication (dialntin sodium), typical gingival
fibrous gingival hyperplasia may occur. Surgical removal be done. Child’s
physician be consulted.
 Office management of Seizures
1. If seizure occurs on dental chair, chair is lowered to a supine position.
The patient is protected from injuring himself by moving sharp objects
way, wrapped tongue blade is placed to prevent tongue bite.
2. Mouth prop can be used to prevent tongue biting.
3. Patient be shifted so that he/she cannot harm himself.
4. Maintain a patent airway.
5. Suction may be useful to avoid aspiration of secretions.
6. If convulsions don’t stop then DIAZEPAM 1mg/kg IV be given slowly
upto 10mg. Give oxygen.
7. If condition doesn’t improve admit in hospital.
 Dental Treatment

• Appointments should be kept short.

• Importance of oral hygiene maintenance by brushing twice
daily.
• If Appliances are indicated then for tooth movement or tooth
replacement then fixed type only are advised.
 5. CHILDHOOD AUTISM

Autism is a mental condition present from early childhood,

characterized by great difficulty in communicating and
forming relationship with other people and in using
language and abstract concepts.
• Etiology: Genetic -3 to 8 % recurrence risk if a family
already has a autistic child.
• Syndromes- Fragile- X, Rett syndrome.
• Medical conditions- tuberous sclerosis complex.
• Prenatal factors- intrauterine rubella, cytomegalo
disease.
• Postnatal factors- infantile spasm, herpes simplex. 41
 TYPES

AUTISM

CDC DSM-IV

ASPERGER’S
AUTISTIC
SYNDROME PERVASIVE RETT SYNDROME CHILDHOOD
DISORDER
DEVELOPMENTAL DISINTEGRATIVE
DISORDER, NOT DISORDER
OTHERWISE
SPECIFIED(PDD-NOS)

42
 Manifestations
Clinical:
• Inability to read and comprehend the feelings.
• Delayed language development, echolalia (repeating words).
• Repetitive motions, strict adherence to routines, attachment to
unusual objects.
• Self injurious behaviours.

Dental Findings
• Higher susceptible to caries.
• Bruxism
• Non- nutritive chewing
• Erosion
• Damaging oral habits such as tongue thrusting, lip biting.
• Gingivitis and poor oral hygiene
• Texture sensitivity - it leads to consumption of refined and high sugar diet. 43
 TREATMENT
• Allow autistic child to bring comfort items such as toys.
• Make a first appointment short and positive.
• Approach the child in quiet, non-threatening manner.
• Avoid loud noises.
• Invite child to sit alone in dental chair to become familiar with
treatment setting.
• Talk in direct , short phrases . Talk calmly.
• Behaviour modifications technique that is use of positive
reinforcement to promote desirable behaviour.
• Some autistic child can be calm by moderate pressure by using a
papoose board to wrap the child.
44