PHYSICALLY HANDICAPPED

CHILDREN

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.”

Special Health Care Needs

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DEFINITION

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 impairment3

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 (1974)

• Blind or partially sighted

• Deaf or partially deaf

• Educationally subnormal

• Maladjusted

• Epileptic

• Physically differently-abled

• Defect of speech

• Senile

Nowak(1964)

• Physically differently-abled = polio

• Mentally differently-abled = retardation

• Congenital = cleft palate

• Metabolic = juvenile diabetes

• Systemic= hemophilia

• Convulsive = epilepsy

• Communication = deafness

• Osseous disorders = rickets

• Malignant disorders = leukemia

Holloway and Swallow(1982)

• Mental handicap

• Physical handicap

• Medical disability

Agerholm(1975)

• Intrinsic handicap –one from which person cannot be separated

• Extrinsic handicap –person can be removed ( social deprivation)

New classification

• Developmentally disabled

• Medically compromised

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1. MENTAL RETARDATION

(INTELLECTUAL DISABILITY)

• 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 Classification Guide• MA = Mental Age

• CA = Chronological Age

IQ= (MA/CA)X 100

Etiologic factors for MR

Characteristics of MRSB-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.

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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

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.

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.

Treatment Considerations

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

• Advanced maternal age,

• Uterine and placental abnormalities

• Chromosomal aberrations.

Risk of Down’s syndrome per live birth

with advanced maternal age

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.

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.

Oral Manifestations

• 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.

Dental Treatment

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

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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

• Impaired chewing and swallowing

• Hypertonicity of facial muscles

• Slow jaw movement

• Hypertonic orbicular muscles

• Spastic tongue thrust

• Drooling of saliva

• Constricted mandibular and maxillary arches

• Usually Class II Div 2 malocclusion, with

unilateral posterior crossbite

CLINICAL MANIFESTATIONS

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ORAL MANIFESTATIONS

• Child may have gastro oesophageal

reflux as well as episodes of vomiting.

Leading to dental erosion or loss of

tooth structure.

• Gingival overgrowth due to seizure

medications.

• Abnormalities of muscle tone

• Delayed milestones

• No control over movements

• Muscle weakness

• Spasticity, loss of coordination.

• Retention of primitive reflexes

• Poor development of gross and fine

motor control

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

abnormalities in the electrical activity of the brain.

• Etiology-

– Idiopathic

– Symptomatic- pathology of the brain due to

malformation, injury or disease.

Prevalence

• <1%

• 75% no

known

etiology

• Higher

frequency in

males

Classification

1. PARTIAL OR FOCAL SEIZURES-

1. SIMPLE PARTIAL SEIZURES

2. COMLPLEX PARTIAL SEIZURES

3. SECONDARY GEN. PARTIAL SEIZURES

2. PRIMARY GENERALIZED SEIZURES-

1. TONIC-CLONIC (GRAND-MAL)

2. TONIC

3. ABSENCE (PETIT-MAL)

4. ATYPICAL ABSENCE

5. INFANTILE SPASMS

3. STATUS EPILEPTICUS-

1. TONIC - CLONIC

STATUS

2. ABSENCE STATUS

4. RECURRENT PATTERNS-

1. SPORADIC

2. CYCLIC

3. REFLEX

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

• 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.

• Mouth prop can be used to prevent tongue biting.

• Patient be shifted so that he/she cannot harm himself.

• Maintain a patent airway.

• Suction may be useful to avoid aspiration of secretions.

• If convulsions don’t stop then DIAZEPAM 1mg/kg IV be given slowly

upto 10mg. Give oxygen.

• 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.

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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.

Types Autism

CDC

ASPERGER’S SYNDROME PERVASIVE

DEVELOPMENTAL DISORDER, NOT

OTHERWISE SPECIFIED(PDD-NOS)

AUTISTIC DISORDER

DSM-IV

RETT SYNDROME

CHILDHOOD DISINTEGRATIVE

DISORDER

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ManifestationsClinical:

• 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.

TREATMENT

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• 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.