Developmentally disabled child
- 1. DEVELOPMENTALLY DISABLED CHILDS U B M I T T E D TO : D E PA R T M E N T O F P E D O D O N T I C S SUBMITTED BY : PRABHJOT KAUR ROLL NO. 22342 BDS FINAL YEAR
- 2. CONTENTS:INTRODUCTION DEVELOPMENTAL DISABILITY DISABLED CHILD DOWN’S SYNDROME INCIDENCE/PREVALENCE PREDISPOSING FACTOR AND CAUSES GENERAL MANIFESTATION ORAL MANIFESTATION DENTAL TREATMENT CEREBRAL PALSY ETIOLOGY CLASSIFICATION:-1) SPASTIC 2) ATHETOSIS 3) ATAXIA 4) RGIDITY 5) TREMORS 6) ATONIA 7) MIXED DENTAL PROBLEMS TREATMENT
- 3. DOWN’S SYNDROME This is one of the most recognizable malformation syndromes. It may occur due to trisomy of chromosome 21(95%), translocation(3%) or due to mosaicism(2%). INCIDENCE/PREVALENCE It is found to occur 1 in every 600 live birth. With the advancement in the diagnostic techniques, proportion of cases diagnostic techniques , proportion of cases diagnosed prenatally increased from 3% to 60% in younger women. In a study done in Australia the birth prevalence of down syndrome patients has declined from 1986 to 2004 PREDISPOSING FACTORS AND CAUSES Advanced maternal age, uterine and placental abnormalities and chromosomal aberrations
- 4. GENERAL MANIFESTATIONS: • SKULL: Brachycephalic (round) skull resulting in a flattened face and occiput. • Presence at birth of third fontanelle just anterior to the posterior fontanelle. • Flat nasal bridges with a small maxilla.
- 5. • EYES: oblique palpebral fissures with prominent epicanthic folds. • Brushfield’s spots appear on the iris in a ring concentric with the pupil. • Scanty eyelashes. • Cataracts, squint and nystagmus are common.
- 6. • EARS: Dysplastic ears with abnormal pinna. • NECK: Short and broad with excess skin posteriorly.
- 7. • MUSCLES AND JOINTS: Hypotonicity and Hyperextensibility. • IQ: often severally retarded with an IQ of 25-50.
- 8. ASSOCIATED CONGENITAL ABNORMALITIES • Congenital heart lesions are found in about 50% (atrial septal defect, atrioventricular canal and VSD)
- 12. • Multiple immunological defects affecting the skin, GIT and respiratory tracts. • Acute lymphoblastic leukemia is 20 times more common in these children. • Hypothyroidism and Alzeimer’s disease
- 13. ORAL MANIFESTATION • MOUTH: Small drooping mouth • Open mouth posture
- 14. • Tongue: protrusive, fissured tongue. • Circumvallate papillae may be enlarged, but filiform papillae may be absent. • Macroglossia.
- 15. • LIPS: thick, dry, fissured. • OCCLUSION: anterior open bite and crossbite, class III tendency. • Small maxilla.
- 16. • PALATE: often appears high with horizontal palatal shelves. • Bifid uvula, cleft lip and palate.
- 17. • ERRUPTION OF TEETH: Retarded. • Early shedding of deciduous teeth. • TEETH: Hypodontia, especially third molars and maxillary lateral incisors. • Microdontia. • Hypocalcification and hypoplastic defects. • Low incidence of caries.
- 18. • PERIODONTIUM: Severe, early onset 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.
- 19. DENTAL TREATMENT • These children are mentally retarded and require appropriate treatment. • Incidence of cardiac disease associated with down’s syndrome is 40% and will require adequate prophylaxis. • Increased incidence of leukemia and acute and chronic infections of the upper respiratory tract can also alter treatment. • Children are generally affectionate and cooperative and present no special problems during management. • Nitrous oxide analgesia or TSD in mildly apprehensive patients can be used, general anesthesia in severe resistance to dental treatment. • Preventive procedure along with chlorohexidine mouthwash may be beneficial. • Pulp treatment in deciduous teeth is contraindicated in patients with cardiac problems because of the risk of bacteremia, whereas in permanent teeth it can be considered if an adequate apical seal can be obtained.
- 20. CEREBRAL PALSY • This is one of the most severely handicapping conditions affecting childhood. Cerebral palsy is defined as a non-progressive lesion which occurs in the developing brain before, during or after birth, leaving the child with a variety of neurological problem. 50% of these children die in infancy or require institutional care. The motor deficit is fully evident only as the child develops. • The condition manifests itself as a number of neuromuscular dysfunctions and involves muscle weakness, stiffness, paralysis , poor balance, irregular gait and uncoordinated or involuntary movement. There is a loss of voluntary muscle control. One newborn in approximately 200 live births is affected.
- 21. ETIOLOGY • Any factor that causes decreased oxygenation to the developing brain can lead 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 , heavy metal and drug positioning, any trauma to the head, premature birth with CNS abnormality are the common causes.
- 22. CLASSIFICATION • I. Based on anatomical involvement Monoplegia-involvement of one limb only Hemiplegia-involvement of one side of the body Paraplegia-involvement of both legs only Quadriplegia-involvement of all the four limbs • II. Based on neuromuscular involvement spasticity athetosis ataxia mixed
- 24. SPASTIC CEREBRAL PALSY • Approximately seen in 70% of the cases • Increased motor tune resulting in stiffness and difficulty in moving limbs • Increased deep tendon and stretch reflexes • Involvement of cerebral cortex • The foot and leg flexed and rotated resulting in a limping gait with circumduction of the affected leg • Lack of control of neck muscles, trunk muscles and intraoral muscles • Impaired chewing and swallowing with speech problems • The involved muscle show hyperirritability, exaggerated contractions when stimulated; tense muscles • Excessive drooling, persistent tongue thrust and speech impairments
- 27. ATHETOSIS • Approximately in 15% of cases • Involvement of basal ganglia • Uncontrolled voluntary muscle contraction • Generalized delay in motor development and the child may show drooling, dysphagia, speech difficulties and grimacing • Hypertonicity of the neck musculature with excessive movement of head leading to held back head with mouth open and tongue protruded • Peri-oral muscles hypotonic with mouth breathing and bruxism • Most often not associated with convulsion or mental retardation • Characterized by slow twisting or writhing involuntary movement or quick jerky movement and constant uncontrolled motion of involved muscle • Frequent uncontrolled jaw movement are seen that causes abrupt closing of the jaw or severe bruxism
- 28. ATAXIA • Approximately in 5% of cases • Involved muscles unable to contract completely • Involvement of cerebellum • Lack of balance leading to staggering gait • Visual organs may be involved
- 29. RIGIDITY • Resistance to passive movements • Basal ganglia involved • Voluntary movement are slow and stiff TREMORS • Shaking of parts of the body • Involvement of basal ganglia
- 30. ATONIA • Characterized by soft, flabby muscles MIXED • Approximately 10% of cases • Combination of characteristics of more than one type of cerebral palsy
- 31. DENTAL PROBLEMS • DENTAL CARIES : Most children may have a higher caries rate than normal children. This may be due to their inability to maintain good oral hygiene or due to the tendency to overindulge them with soft and cariogenic food and also due to the increased prevalence of enamel hypoplastic defects on their teeth.
- 32. • PERIODONTAL DISEASES: Occur with a great frequency, as the patient is unable to brush or floss adequately. Due to difficulty in chewing and swallowing, children tend eat soft food that are high in carbohydrates. They may also be on phenytoin to seizure activity which is a cause of some degree of gingival hyperplasia.
- 33. • MALOCCLUSION: Occur twice as often than in the average population. commonly noticed are protrusion of the maxillary anterior teeth, excessive overjet and overbite, open bites and unilateral crossbites, the cause being the disharmonious relationship between intraoral and perioral musculature. In spastics, class II div 2 malocclusion is observed, along with constricted maxillary and mandibular arches. In the athetoid group class II div I malocclusion is seen along with a high and narrow palatal vault.
- 34. • BRUXISM: Commonly seen in athetoid cerebral palsy resulting in severe attrition, loss of vertical dimension and temporomandibular joint disorders.
- 35. • TRAUMA: Due to the nature of the disorder, these children are susceptible to trauma, especially of the maxillary anterior teeth • Children may have excessive drooling and difficulty in swallowing. • Spastic cerebral palsy patients present with spastic tongue thrust, constricted mandibular and maxillary arches, class II div 2 malocclusion (75%) usually with a unilateral crossbite. • Athetoid cerebral palsy patients present with mouth breathing, tongue protruding between the teeth and lips , bruxism, high and narrow palate and anterior open bite.
- 36. TREATMENT • Through medical and dental history should be taken, along with consultation with the child’s physician. • Maintain a calm, friendly and professional atmosphere; be empathetic about the child’s problems. • Many patients can and prefer to be treated in the wheelchair, which may be tipped back into the dentist’s lap. • The patient’s head should be stabilized throughout the procedure and the back should be elevated to reduce swallowing problems. • Use physical restrains judiciously for control of flailing extremities. • A variety of mouth props and finger splints can be used for control of involuntary jaw movements.
- 37. • Avoid abrupt movements, lights and noises to minimize startle reflex reactions and introduce intraoral stimuli slowly to avoid gag reflex. • Local anesthetic can be used with care and stabilization against any sudden movement by the child. • Rubber dam can be used to protect the working area from hyperactive tongue movement, although floss should be attached to small objects such as cotton rolls that can become dislodged. • Gauze shields should be used during extraction to avoid tooth aspiration. • Premedication can be used to reduce hypertonicity, involuntary movement and anxiety. • General anesthesia can be used as a last resort if the case is not manageable chairside. • Do permanent restorations and preventive
- 38. CONCLUSION • There is now unanimous agreement that children with special needs have poor oral hygiene, together with a higher prevalence of periodontal disease and dental caries, more than normal individual. • Along with chemical plaque control measures, mechanical plaque control like the use of powered toothbrushes can greatly help these individuals to have better oral hygiene. • HOME dental care should be reviewed periodically and the preventive regimen should be discussed and modified according to the age of the child.
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