SHCN-1

Prevalence of dental problems in various disorders:

 Dental caries: deafness, multiple disability, (specific learning disability)

 Gingivitis: Multiple disability, multiple schlerosis

 ASD: crowding (crowded letters)

 Blindness: trauma

 C.Palsy: class1

 Intellectual disability: periodontal dis

Home dental care

 Brush:
 Parents should brush child teeth after every meal in infants and also in older children
who are unwilling or physically uncooperative
 Use correct tooth brushing technique, safely immobilizing child, check for stabilized
positions, that permit firm control and support of child along with his head.
 Parents should cleanse incisors daily with soft cloth or gauze or an infant toothbrush;
also clean tongue to reduce halitosis.

 Paste: pea size

 Medicines: Nearly 100% of children’s medications contain sucrose, which increase risk of
developing dental caries hence they should have their teeth cleansed, after each dose of
medication.

BEHAVIOUR GUIDANCE

 Challenging, as communication may be limited due to anxiety, impaired hearing or vision,

intellectual disability, lack of understanding of dental care, or fatigue from multiple medical
visits.

 Non stimulating environment is ideal- Loud music, excessive conversation should be

eliminated to support behavior.

 When non-pharmacologic techniques including protective stabilization are ineffective then

sedation/GA can be practiced. Whereas towel treatment and HOME – not recommended (g-
already low bcoz of disability)

 TSD (basic), distraction, desensitization, (g-remaining tech cant understand)

 Reinforcement increases probability of response.
Protective stabilization
Uncooperative children
Sedation (N2O) (uncontrolled, aggressive, or
impulsive behaviors)
General anesthesia

C.palsy-mainly physical and intellectual, Autism- mainly behavioral and intellectual

CEREBRAL PALSY/ LITTLE’S DISEASE (day- oct 6)

(palsy means grp of diseases, opp. To heading- tremors, intellectual disability, sensory (visual, speech)
In both classif =1p, etiology (pre and post natal (less in CP), clinical signs (ABC (more in CP)), manage
(management is about home care and movements (wheel chair, positions, reflexes), augmentative;
whereas in autism manage behavior)

 Most common physically disabling condition (g-palsy) (order of heading)

 First described – WILLIAM LITTLE (1862).
 American Academy of Cerebral Palsy (AACP) was formed in 1947 (g-little people independ).
AMERICAN ACADEMY FOR CEREBRAL PALSY AND DEVELOPMENTAL MEDICINE:
 Development disorder defined as a syndrome consisting of abnormal devt of movement and
posture, causing activity limitations that are attributed to nonprogressive disturbances,
occurred in developing fetal or infant brain.
 Motor disorders are often accompanied by disturbances of speech, sensation (g-visual,deaf),
cognition, communication and seizure disorder. (medical)
 Constricted mandibular and maxillary arches so unilateral posterior crossbite, Class II Div II (g-
c-c-c-) (dental)
 Spastic tongue thrust
CLASSIFICATIONS: which part, how it is reacting, walk, reason (etiology)
1)Topographic classification of cerebral palsy
Gross Motor Function Classification System

2) Physiologic classification of cerebral palsy

A. Spastic: 60-70% (most common) (g-stiff leading to slow)
 (Hypertonicity with) stiffness of facial muscles, tongue (cigar shape) and orbicularis
(Head roll- Limited control of neck muscles)
 Slow jaw movement with open mouth so drooling of saliva, Impaired chewing, swallowing so
Spastic tongue thrust
 Constricted mandibular and maxillary arches so unilateral posterior crossbite, Class II Div II
with open bite
B. Athetosis: (Dyskinetic) 25% (g-involun, slow)
 Involuntary slow movement with muscular involvement , most often, not associated with
convulsions
 (head drawn back with bull-type neck)
 Wide opened mouth leading to jaw dislocation, drooling
 Poor swallowing and sucking due to impaired muscles of deglutition so Tongue protruding
between teeth, shows spontaneous wave-like movements
 High, narrow palatal vault, mouth breathing and Bruxism
 Class II, Division I malocclusion
C. Ataxia: 10% (taxi lo volun, bt becomes uncoordinated, tremors lo brain involved not muscle)
  voluntary uncoordinated movements with no muscular involvement, often associated with
tremor like head movements e.g. difficulty in grasping objects
 drooling (Hypotonic orbicular muscles).
D. Rigidity: 5%
 Caused by a lesion in basal ganglion
 Stiff, slow and Voluntary movements (g-ssv)
 Patient is resistant to flexor and extensor movements.
E. Tremors: 5%
 Caused by a lesion in cerebellum
 Repetitive, rhythmic, involuntary contraction of flexor and extensor muscles. (g-rri)
F. Mixed : 10%
 Combination of characteristics of more than one type of cerebral palsy (e.g. mixed spastic-
athetoid quadriplegia).
3) Gross Motor Function Classification System

a. Level I – Walks without limitations

b. Level II – Walks with limitations
c. Level III – Walks using a handheld mobility device
d. Level IV – (Self-mobility with limitations may use) powered mobility
e. Level V – Transported in a manual wheelchair.
4) Etiologic classification of cerebral palsy (full sim to MI)

 Pre natal: Genetic disease- kernicterus/cretinism, maternal/ fetal infections, toxins-

congenital malformation of brain
 Natal- birth injuries/ trauma, hemorrhage/hypoxia/anoxia/ hypoglycemia and infections
 Post natal: cerebral injuries/trauma, viral infections, toxins/poisoning

Three most common reactions, which a dentist should recognize, are

 In many patients with cerebral palsy, certain neonatal reflexes may persist long, after which
they disappear. This is due to subcortical dominance of infant’s behavior which later
suppressed by higher centers of nervous system.
 Asymmetric tonic neck reflex - If pt’s head is suddenly turned to one side, arm and leg on
same side extend and stiffen, whereas limbs on opposite side flex.
  Tonic labyrinthine reflex - If pt’s head suddenly falls back while the patient is supine, back
stiffens and arches backward; legs and arms stiffen and straighten out, and then brought
together with fingers curled. (g-lab back fall, head stratch so all stretch)
 Startle reflex - Frequently seen, consists of sudden, involuntary, forceful body movements, in
response to loud noises or unexpected movements by others.

DENTAL DEFECTS SEEN IN CEREBRAL PALSY: ABCDEF-STM

Anamolies, bruxism/tongue trust, caries and class2, drooling, enamel defects and erosion,
Fractures- TDI, sialorrhea, TMJ disorders, malocclusion
1) common 2) etiology 3) in which conditions more/CF 4) Manage
1)Bruxism

 Common in CP

 Minear hypothesized that bruxism in CP is related to problems with dopamine function but
not related to local factors, such as malocclusion

 Sleep disorders in CP may predispose to development of nocturnal bruxism, particularly in

severe visual impairment (any time is same in visual imp). Also predominant in those with
severe motor and cognitive deficits.
2) Dental caries
• They are at increased risk of dental caries which affects negatively their quality of life.
• increased risk is seen in cognitive and motor deficits
• (Ferreira de Camargo et al. found that the incidence of caries among children and adolescents
with CP is high, but Quintela and Alfredo concluded that individuals with CP have less chance
of having caries than the individuals in the comparison groups)
3) Drooling:

 Occurs in 30% of cases of CP,

 Usually not due to increased saliva production/ aggravating lesion, but Secondary to mouth
opening and/or swallowing difficulties.

 Lead to aspiration, skin irritation, and articulation difficulties.

 Controlling mouth open and Anticholinergic (anti cool ie., anti water) medicines such as
glycopyrrolate and scopolamine; surgical re-routing of salivary ducts. Recent studies suggest
botulinum toxin injection into parotid and submandibular glands, to reduce extreme drooling.
4) Dental erosion
• common in CP predisposing with GERD (gastroesophageal reflux disease ).
 •  Abanto et al. concluded that dental erosion in CP children is associated with recurrent
consumption of soft drinks and powdered juices. Studies found that 73% of CP patients with
dental erosions had a history of GERD. 
• Most of the affected teeth observed in the CP group were, lower and upper molars (58%) and
upper incisors (54%).
5) Silorrhoea

 Reid et al., predisposing factors:

 Absence of cervical control,

 Severe difficulties in gross motor coordination/function,

 Epilepsy,

 Intellectual disability, lack of speech,

 Open anterior bite, and dysphagia.

6) Traumatic dental injuiries
• Common
• Due to impaired motor coordination/ seizures and also because Children with CP have a high
prevalence of Class II malocclusion with prominent maxillary incisors, incompetent lips.
• Fracture of enamel and dentine

MANAGEMENT
Home dental care:

 similar to general home care (above)

 Premedication- Chlordiazepoxide hydrochloride (librium).

Dental (controlling movement and reflexes):

 Consider treating a patient who uses a wheelchair in the same itself. In case of transferring to
dental chair, two person lift is recommended. Tipped backed position of dental chair is secure
to patients particularly of ataxia type.

 Stabilize patient’s head, through all phases of dental treatment with patient’s back slightly
elevated (supine position), to minimize swallowing. Tipped backed position of dental chair is
secure to patients particularly of ataxia type.

 To minimize startle reflex, avoid stimuli, such as abrupt movements, noises and lights, without
forewarning patient.
  To avoid/ make gag reflex less severe introduce intraoral stimuli slowly. Children with cerebral
palsy may have a severe gag reflex making it difficult to take dental radiographs.
Two modified radiographic techniques are:
o 45 degree oblique head plate, and reverse bitewing technique (buccal).

Augmentative communication

 Effective way of communication between pediatric dentist and child with cerebral palsy.

 Communicating by supplementing spoken words or sounds in non-speaking people.

 Approximately 1,200 pictographs are stored in computer discs- COMPIC system (Computer
Pictographs for Communication)

 Prior to use in clinical setting, patient must already have practiced and trained, provided by
members of team such as speech pathologist, classroom teachers, and parents at home.

 Disadvantages:

 Difficulty in interpreting a long sequence,

 Difficulty in distinguishing between similar pictographs,

 Need for training

AUTISM (April 2)
(Kanner’s syndrome, Infantile psychosis, Childhood schizophrenia)
(they want to be alone, Self injurious)
Definition:
• Pervasive developmental disorder defined behaviourally as a syndrome (g-even CP) consisting
of
• abnormal development of social skills (lack of interest in peers, withdrawal)
• limitations in the use of interactive language (speech as well as nonverbal
communication), and
• sensorimotor deficits (inconsistent responses to environmental stimuli) (g-c.palsy di).
• Children undergo abnormal brain development, from early infancy. Children start out with,
slightly smaller heads than average, then undergo explosive brain growth, with more severe
cases having more severe growth. Brain may be 10-15% larger than normal.

History:
  Word autism is derived from a Greek word “autos,” – self ie., describes characteristic feature
of this disorder ie., withdrawl from people ie., from social reactions, even from parents
“ismos,” – (state of self-absorbed to the) exclusion of everyone around them.

 Leo Kanner published first systematic description of early infantile autism- complex
neuromuscular developmental disorder, that appears during first 3 years of life.

 Incidence: 7 per 10,000 persons.

Males > females - 4:1. (g-akh)

 Itard’s- Found a violent child, (with no language skills,) who related other people as if they
were objects and described him as “wild boy of Aveyron”
THEORIES (instead of AAPD of CP)
(Kanner- stated that, biological deficits are responsible for theories of autism.)
1.Refrigerator mother theory:
Emotionless parenting style was most common etiology.
2.Weak central coherence theory: (central part only)
Autism is characterized by, weak or absent drive, for global coherence.
Child focus on constituent parts, rather than in totality.
Example if we show an image to autistic children, they may focus on details at local level rather
than focusing on whole global level.
3.Theory of Executive dysfunction ability to maintain appropriate problem solving set for
attainment of future goal.
4.Mind hypothesis:
Children fails to attribute mental states to themselves and others, and fail to measure mental
state of others.
5.Cognitive Complexity and Control Theory (CCC) is a hybrid theory that states that executive
function is related to theory of mind (in typical and atypical individuals) because both (theory of
mind and executive ability) involve higher order rule use.
CLASSIFICATION:
ICD-10 (International Classification of Diseases) classifies this disorder into 10 subtypes.
Overactive disorder, Childhood autism,
Asperger, Childhood Disintegrative Disorder, Pervasive Developmental Disorders (unspecified), other
Pervasive Developmental Disorders, Pervasive Developmental Disorders, Atypical autism, retts
syndrome,
Other classif:
Subtypes of ASD are:
Autism Disorder:
 Lack interest in others
 They show severe language problems
 Repetitive behaviours
 Irrational routines
Asperger/ High Functioning Autism:
 They have relatively strong verbal skills
 Obsessive interests
 But have trouble with, social situations and sharing enjoyment
Childhood Disintegrative Disorder (CDD):
 Show normal growth and development for 2-4 years
 Thereafter, autism-like symptoms develop
Pervasive Developmental Disorders (PDD):
 Rett’s Disorder: Similar to CDD, but occurs earlier and mostly in girls
 Atypical autism: less severe social impairments

ETIOLOGY:
No single cause has been identified.
It may also be an, early manifestation of childhood schizophrenia.

 Genetics: Mutations in SHANK3 gene is responsible for making connections in brain necessary
for language development.
 Syndromes associated with autism are: Downs syndrome, Fragile-X and Rett syndrome
 (Medical Conditions: Tuberous sclerosis.)
 Prenatal Factors: Intrauterine rubella and cytomegalic inclusion disease.
 Postnatal Factors: phenylketonuria, herpes simplex (and encephalitis.)
 Rodier 2002, Bauman and Kemper 2003 – stated, autism origins from abnormal development
of brain, in prenatal life.
 Howlin and Moore 1997: correlated autism with enlarged gray matter volumes.
CLINICAL SIGNS:

 1. Hyperactivity/passiveness
 Oversensitive/undersensitive ie Inappropriate laughing/crying
  2. Decreased interest in others, Do not recognize others interests,feelings and beliefs ie
cant empathize with others.
 Prefer to be alone
 3. Strange attachment with objects/ Inappropriate playing with toys
 Abnormal repetitive behaviour
 4.Delayed sound (delayed da,da,ma-ma) and speech devt (Poor speech)-mouth
 Echolalia/Repetitive speech: Delayed or immediate parroting of heard words; use of
“you” when referring to self.
 Language difficulties
 Only two-thirds of autistic children, achieve some functional speech, while others remain
without functional language throughout their lives.
 Even if speech is acquired, children do not enjoy this activity and speak infrequently.
 5. Self injurious behavior involves:
 Head banging on hard surfaces such as walls or floor, pulling hair, Eye poking and cornea
scratching
 Pinching, scratching, Slapping or punching face or head
 biting skin/gums and
 Auto extraction
Dental findings in autistic child are: ABC-GSTM- same in MI) (s for self injuries)
 Developmental anomalies. (g-due improper hygiene so present in all)
 Oral habits – bruxism (leading to occlusal attrition), tongue thrusting, picking at gingiva and lip
biting.
 Dental caries
 Traumatic ulcerated lesions (due to self-injury from..)
 gingivitis and periodontitis.
 malocclusion
 Poor oral hygiene and poor masticatory abilities.
(Early signs and symptoms for diagnosis of autism:
 Baby doesn’t babble or gesture and lacks eye contact with its mother, by the age of 12
months.
 Resists being held/cuddled by its mother.
 Baby appears to be deaf.
 And doesn’t say single words, by the age of 16 months.)
Behavioral Tips For Dentists :
 Multiple, short, morning appointments (as crowding wont be there-next p).
  Don’t crowd child- as they are hypersensitive to loud noises and sudden movements; keep
music as an aid. (autism)
 Prior to first appointment, familiarize patient with environment-Invite child to sit alone in
dental chair to become familiar with treatment setting. (all)
 Invite parent/caregiver to dental operatory to assist and help in commu.
 Keep sentences short and simple -1 instruc, re instruct, visual instruct, written home care
instructions and Use of bright and colorful educational material as ADHD children were
extremely forgetful. Careful with gestures and verbal requests (for MR and ADHD).
 End with a positive note or reward patient with compliments
 Ask parent to rehearse procedure at home prior to dental visit
 Use same treatment room and same people.
Management of autistic child:
1)Communication
 Establish trust and builds needed cooperation.
 Ability to understand and follow directions, learn new things, and express their wants and
needs may be difficult for some patients with autism.
 So they require assistive communicative devices, such as Smart/Scan 32 pro, augmentative
communication device or PECS or visual pedagogy (expain them here)
 Visual pedagogy/ story book:

 Many autistic children are visual learners.

 Involves series of colored photographs, describing step-by step dental visit and tooth
brushing, to introduce oral hygiene.

 In this, individuals come to know what steps have been completed and which are
remaining, thus, reduces apprehension in children, by understanding sequence of
procedures.
Modelling:
2)TSD- Explain every treatment before it happens as it makes sense to them.
TPD:
3) Distraction
 Holding special toys /Watching favourite cartoon,audio- listening to music, audiovisual, magic
tricks.
 Autistic patients with high intellectuality can be distracted by soothing and be relaxed enough
to undergo the procedure.
Desensitization- Kopel suggested familiarizing child with basic dental procedures in home.
4) Positive Reinforcement:
 Early stages: sweet foods as desirable rewards.
 Latter stages: Social rewards, such as, pat on the back or a hug is effective.
Protective stabilization:
 Some children can be calmed by moderate pressure, such as, using papoose board to wrap
the child.
5)Sensory Techniques: (smell, tastehearing, visual)
 During dental visit, any drastic exposure to senses like smell, taste, visual, auditory,touch
stimuli, should be least,
 Pertaining to oral hygiene, objectionable taste of toothpaste, and sensation of toothbrush
may hinder the effect of brushing.
SADE:
Ear-Noise disturbances may be exaggerated in busy dental facilities with multiple operating
units in the same room.
• Eyes- Autistic children may cover their eyes or squint under light exposure.
• Touch- hypersensitivity in intraoral and perioral regions, and therefore experience
frustration by a light touch or even fall back during dental examination
• Emotional discomfort/aggressiveness of patient due to surrounding distracting stimuli may be
minimized by sensory adaptation of the clinical environment by providing relaxing light
conditions, rhythmic music, and deep pressure in the dental setting, which diminished
adverse patient reactions and enhanced positive participation.
MSE/Snoezelen
• An Artificially Created Environment
• Devoted to Stimulation of all the Senses
• A Safe and Comfortable
6)Aversive Techniques: a)Voice control
 however, autistic patients with hearing deficits, would not be good candidates.
 Phrases such as “eyes to me,” “look at me,” “hands on tummy,” or “feet straight out” can be
used to elicit appropriate behaviors.
b)Hand-over-mouth exercise is rarely used, as it may be misconstrued as assault.
7)Pharmacological Management:
 Commonly prescribed antidepressant, Fluoxetine causes serious allergic reactions like,
swelling of tongue, throat, and face, making prophylaxis difficult.
 Local anesthesia with vasoconstrictor should not be given when methyl-phenidate is used, as
it may lead to tachycardia or a hypertensive episode.
Conscious sedation: has variable effect on autistic child.
 Drugs include Versed, Vistaril, Demerol, Chloral Hydrate, and Nitrous Oxide.

Rudra & Raina (2017):

 Prevalence of ASD in India ranges from 0.15% to 1.01%
 That is, one in 125 children in 3-6 years and 1 in 85 children in 6-9 years of age.
 Prevalence in rural areas was 0.90%, 0.6% in hilly regions, 1.01% in urban areas, 0.1% in tribal
areas and 0.61% in coastal regions.
 Effectiveness of a preparatory aid in facilitating oral assessment in a group of Saudi children
with autism spectrum disorders in Central Saudi Arabia
 Murshid EZ (2017)., Parents expressed positive opinions regarding use of preparatory aids in
dental environment.
 Approximately half of ASD children benefit from preparatory aid, used according to parents’
opinion.
 Follow up survey showed, improvement in parent’s dental knowledge and oral hygiene
practices.
 Communication Application for Use During the First Dental Visit for Children and
Adolescents with Autism Spectrum Disorders
CONCLUSION
 Establishment of dental care for CSHCN presents unique challenges to dental staff.
 Dentists dealing with them should possess, thorough knowledge of unusual medical and
orofacial abnormalities and their implications; should cooperate with different medical
specialists, in order to formulate safe and effective dental preventive and treatment plans.
 Disabled children should be considered special, and dental operatory should have accessible
armamentarium to them for a useful dental visit.
TAKE HOME MESSAGE
 Treatments that should be avoided in autistic children
 Use of fluorides
 Composites
 Exposure to dental products with glutin and casein