|Year : 2015 | Volume
| Issue : 1 | Page : 25-27
Assessment of traumatic dental injuries in patients with cerebral palsy
A Dubey1, PA Ghafoor2, M Rafeeq2
1 Department of Pedodontics and Preventive Dentistry, Rungta College of Dental Sciences, Bhilai, Chhattisgarh, India
2 Department of Neurology, MES Medical College, Perinthalmanna, Kerala, India
|Date of Web Publication||9-Jan-2015|
Dr. A Dubey
Department of Pedodontics and Preventive Dentistry, Rungta College of Dental Sciences, Kohka- Kurud road, Bhilai - 490 024, Chhattisgarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Cerebral palsy is an umbrella term for a group of conditions characterized essentially by motor dysfunctions that may be associated with sensory or cognitive impairment. Such children tend to have a higher incidence of traumatic dental injuries than the general population. This increased incidence is often attributed to poor muscular co-ordination that predisposes individuals with Cerebral palsy to trauma Aim: The study was conducted to assess different dental injuries and the risk factors for dental trauma to occur in patients with cerebral palsy. Materials and Methods: The study comprised 70 children and adolescents with cerebral palsy attending special school in Durg and Bhilai city between 7 and 18 years of age. Results: Dentinal fracture was seen in 40% of cases. Few cases had tooth displacement, discoloration, and pulpal involvement. Conclusion: Dentists should be well aware of the possible dental injuries in such patients. Preventive measure measures should be taken by health care provider to reduce traumatic exposure.
Keywords: Ataxia, cerebral palsy, class II malocclusion, dyskinesis, traumatic dental injury
|How to cite this article:|
Dubey A, Ghafoor P A, Rafeeq M. Assessment of traumatic dental injuries in patients with cerebral palsy. J Indian Soc Pedod Prev Dent 2015;33:25-7
|How to cite this URL:|
Dubey A, Ghafoor P A, Rafeeq M. Assessment of traumatic dental injuries in patients with cerebral palsy. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Nov 15];33:25-7. Available from: http://www.jisppd.com/text.asp?2015/33/1/25/148969
| Introduction|| |
Cerebral palsy (CP) is a disorder of voluntary movement and posture caused by damage to the developing brain and affects 2-2.5 per 1000 of the population.  Cerebral palsy is an "umbrella term" covering a group of non-progressive, but often changing motor disorders that occur during early stages of life due to damage to the brain.  The commonest cause of CP remains unknown in 50% of the cases; prematurity remains the commonest risk factor. 
In ancient times, CP was attributed to supernatural causes, such as God's wrath, witchcraft, and the "evil eye". In the mid-19th century, CP was recognized as a medical disorder of infancy. Little described CP, which for some time was termed Little's disease, and proposed protracted labor as the cause. Osler later coined the term cerebral palsy. Freud attributed the disorder to brain injury from various causes, including prenatal events, and emphasized that extended labor was not the exclusive or even principal cause. Additionally, Freud conceptually united the various non-progressive motor deﬁcit syndromes related to brain abnormalities of children into one nosology. 
CP may be broadly divided into spastic and aspastic type. Spastic CP refers to patients presenting stiffness of muscles and awkward movement. Non-spastic CP comprised ataxic (lack of motor coordination), athetoid (ceaseless involuntary writhing movements), and mixed conditions. 
Spastic subtypes are further divided into unilateral (affecting one side of the body) and bilateral (affecting two sides of the body). 
Children with CP suffer from multiple problems and potential disabilities such as mental retardation, epilepsy, feeding difficulties, and ophthalmologic and hearing impairments. Screening for these conditions should be part of the initial assessment. Up to 36% of children with CP have epilepsy, with onset in the first year of life in 70%. Focal seizures with or without secondary generalization are most common with frequently focal EEG abnormalities. 
Clinical diagnosis of CP has traditionally been based on neurological examination, stable course, and the absence of an underlying genetic disorder. The neurological deﬁcits correlate to some degree with the location of structural damage.  A comprehensive history for risk factors and genetic background, complete physical and neurological examinations are mandatory for accurate diagnosis. Serial developmental evaluations may be necessary in the young child for proper diagnosis and follow up. 
More than 80% of children with CP show neuroimaging abnormalities, most commonly isolated white-matter damage (associated with bilateral spasticity and ataxia). Combined gray and white matter abnormalities correlate most often with hemipleiga, whereas isolated gray-matter abnormality is rare. In 17% of children with CP no imaging abnormality is seen. The increasing availability of sensitive techniques, such as diffusion tensor imaging, that can be used to detect and characterize aberrant brain pathways might make identiﬁcation of CP possible before clinical signs appear. 
Traumatic dental injuries (TDI) in CP individuals can result from mental retardation, poor motor coordination, inability to control abrupt body movements, presence of involuntary physical movements, oral pathological reflexes such as the biting reflex during feeding, spasticity in masticatory muscles, or a slower response to surrounding obstacles. 
| Materials and Methods|| |
The study comprised 70 children and adolescents with cerebral palsy attending special school in Durg and Bhilai city between 7 and 18 years of age [Table 1]. The patients were examined by the physician and neurologist along with their medical records to record clinical subtype for CP. Neurologist also assessed level of intellectual impairment.
All the patients were examined by a single investigator using mouth mirror and CPI probe to record the different dental injuries in the patients and the risk factors for dental trauma to occur.
| Results|| |
Most of the patients had spastic type of palsy [Table 2]. The IQ of the CP children [Table 3] was low with majority falling below 50 (62.8 %). Skeletal/dental Class II malocclusion was most common (64.2 %), whereas class III malocclusion was rare [Table 4]. Many risk factors for dental trauma to occur were seen. Lack of lip seal along with raised overjet was observed in many individuals. History of repeated seizures was also given by many children [Table 5]. Fracture involving both enamel and dentine in majority of patients [Table 6]. Enamel chipping or fracture limited to enamel was also seen in many cases (25.7%). Very few cases of avulsion and root fracture were seen.
| Discussion|| |
CP is classiﬁed according to the nature of the motor impairment revealed by neurological examination (paresis, hypertonia, hypotonia, dystonia, dyskinesia, and ataxia), the area of presumed cerebral dysfunction (pyramidal or extra pyramidal), and the parts of the body affected (e.g., all four extremities, both legs, or one side of the body). Pyramidal lesions are most clearly associated with spasticity, hypertonia, and increased deep-tendon reﬂexes, and frequently with overﬂow reﬂexes (e.g., crossed adductor spread) and an extensor plantar response. Extrapyramidal lesions are often associated with choreoathetosis and dyskinesias (and other forms of abnormal regulation of tone), abnormal postural control, and coordination deﬁcits. Movement abnormalities are classiﬁed as athetoid, choreiform, or dystonic, alone or in various combinations. 
In the present study, majority of cases fell under spastic type. In the dental office, children with spastic CP have difficulties in cooperating, due to their high sensitivity to physical contact and neuromotor response to unusual stimulus such as noise, artificial light, and position at the dental chair. 
Intellectual impairment is considered present where the IQ is <70; and considered severe where the IQ is <50.  There is a relationship between the severity of CP and mental retardation. Children with spastic quadriplegic CP have greater degrees of mental retardation than children with spastic hemiplegia. Other factors associated with increased cognitive impairment include epilepsy and cortical abnormalities on neuroimaging.  In the present study, majority of children had poor IQ level.
Class II malocclusion was most common in the present study. Similar results have been seen in previous studies. The main risk factors associated with the severity of malocclusion in cerebral palsy patients have been determined to be mouth breathing, lip incompetence, and long face. 
Regarding the risk factors associated to dental trauma, the most common are falls, collisions, automobile accidents, seizures, tooth grinding, dental caries, accentuated overjet, and a lack of lip seal. The uncontrolled movements of the head that are characteristic of cerebral palsy increase the risk of dental trauma, since the teeth may strike against hard objects. Thus, lip seal seems to act as a protective factor. Increased overjet along with lip incompetency made the children more prone for dental insult, recurrent seizures, and night grinding as seen in present study also makes the children prone for dentofacial injuries.
According to a study by Holan et al. (2005), the prevalence of dental injuries in a group of individuals with cerebral palsy was much higher than that of healthy population, despite the fact that children with cerebral palsy do not take part in violent sport activities as normal children do.  Fracture involving enamel and dentine was the most common finding in present study. Similar finding were seen in a study by Alhammad.  Few teeth were discolored as probably they had become non vital due to contusion injury following fall or blow against a hard object.
Few children had hypoplastic enamel limited to single tooth. These children were put under turner's hypoplasia. Two children gave history of tooth avulsion following fall.
| Conclusion|| |
CP is a prevalent, disabling condition. Neurologists and dentists treating children and adults must be familiar with the clinical manifestations and common comorbidities, and with the optimum treatments to effectively participate in the multidisciplinary management team.  Cerebral palsied children seek friendliness as much as other children, they respond favorably to encouragement, warmth and personal interest and try to reciprocate and cooperate. 
Treatment of traumatized teeth and prevention of future trauma should be of prime importance.
The dental profession should educate the parents, teachers, and caregivers in correct emergency care after traumatic injury.
Further studies should be taken to evaluate the relation between severity of cerebral palsy and TDI. Studies can also be conducted to find if there is any relation with drooling saliva and the incidence of dental injury in cerebral palsy.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]