HANDICAP CONDITIONS AND THEIR MANAGEMENT

Developmental disability is not a term denoting clinical diagnosis

but a grouping, established for the purpose of planning programme. Terms

like mental retardation and epilepsy, on the other hand imply specific

clinical diagnosis that fall into broad grouping know as developmental

disabilities.

The term handicapped in somewhat more inclusive than

developmental disabilities but it is not the most acceptable term.

Disabled is preferred and includes all forms of so called

handicapping conditions.

The dental condition of handicapped children may be directly or

indirectly related to their physical or mental disabilities. The child born

with cleft lip and palate or both may suffer from dental problems of great

complexity and severity. MR children and those with cerebral palsy heart

disease and bleeding disorders may not have specific dental problems but

their physical or mental handicappers often hinder good oral hygiene and

dietary habits, thereby creating a serious threat to their oral health.

Defination

A disabled child is one who has mental, physical, medical, or social

conditions that prevents the child from achieving full potential when

compared to other children of the same age.

WHO – defines handicapped individual as one who over an appreciable

time is prevented by physical or mental condition from full participation in

normal activities of his age group, including those of a social, recreational,

educational, and vocational nature.

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American Public Health Association (APHA)

“A child who cannot within limits play, learn, work, or do things

other children of his age can do, he is hindered in achieving his full

physical, mental and social potentialities”.

Harris defined 3 terms:

1) Impairment – lacking part of body or all limbs or having defective

limbs, organ or mechanism of body.

2) Disablement- in loss or reduction in functional ability.

3) Handicap – is the disadvantage or restriction caused by disability.

Mental Handicap

Mental handicap is states of arrested or incomplete development of

mind.

Physical Handicap

WHO (1952) states that child one who over an appreciable period of

time is prevented by physical or mental conditions from full participation

compared to children of same age group including social, recreational,

vocational nature.

Classification

I) Franks and Winter (1974)

a) Blind or partially sited.

b) Deaf or partially deaf.

c) Educationally subnormal.

d) Maladjusted.

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e) Epileptic.

f) Physically handicapped.

g) Defect of speech.

h) Senile.

II) Holloway and Swallow (1982)

Divided into 3 categories:

a) Mental handicap.

b) Physical handicap.

c) Medical disability or disabilities.

III) Nowak (1964)

Classified into

a) Physically handicapped.

b) Mental retardation.

c) Congenital defect (SABE, Fallots tetralogy).

d) Metabolic and systemic disorders e.g., DM.

e) Convulsive disorders.

f) Childhood autism.

g) Blind and deaf.

h) Hemophilia.

Management of a handicapped child during dental treatment

Since hospital visits or previous appointments with physician

frequently result in the development of apprehension in the patient,

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additional time with the parent and child is needed to establish rapport and

dispel anxiety.

If patient cooperation can’t be obtained, the dentist must consider

alternatives such as physical restraints to perform dental procedures.

Physical restraints

Physical restraint is only one means of behaviour control to achieve

an adequate level of dental treatment. Parents must be uniformed and given

consent before use of physical restraints.

Physical restraints is useful for managing extremely resistant

patients who need dental care.

Common mechanical aids for maintaining the mouth open are:

- Padded and wrapped tongue blades.

- Molt mouth prop – allows accessability to opposite side of the

mouth and operates on reverse scissor action.

Disadvantages – Lip and palatal laceration and luxation of teeth.

Finger guard – It fits on the dentists finger.

Disadvantage – Limited mobility of dentists hand.

Rubber bite block (Mckesson bite blocks)

These fit on occlusal surfaces of the teeth and stabilize the mouth in

open position.

Body control is gained through variety of methods and techniques like:

Body- Papoose board.

- Triangular sheet.

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- Pedi wrap.

- Bean bag dental chair.

- Extra assistant.

Extremities- Posey straps.

- Velcro straps.

- Towel and tape.

- Extra assistant.

Head- Forearm body support.

- Head positioner.

- Plastic bowl.

Physical restraints should never be used as punishment. An

explanation of their benefits should be presented by the dentist before their

use. The mouth prop can be identified as “tooth chair”, pediwrap as “safety

robe” and restraining strap as safety but careful explanation should be

given to patients, that physical restraints minimizes accidental injury and

allow the needed dental work to be done.

Prevention of handicapped child

Prevention is the most important consideration in ensuring good

dental health for any dental patient.

1) Home care – control of plaque, tooth brushing and flossing.

2) Diet and nutritional counseling.

Home care

The parents have a initial responsibility for establishing good oral

hygienic in home.

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- Reinforcement of good home dental care and follow up

observations can be provided through news papers, radio, TV.

- If child is institutionalized, the staff should be instructed in the

proper dental care programme.

- Although independent brushing is not contraindicated, parents and

staff should known that unsurprised oral hygiene procedures in

disabled children can have serious dental consequences.

- Since disabled patients have gross motor deficiencies, thus ability to

brush is hampered. One technique often recommended is the

horizontal scrub method because it is easy and yielded good result.

Diet and nutrition:

Diet and nutrition influence dental caries by affecting the types and

virulence of the microorganism in dental plaque, the resistance of teeth and

supporting structures and properties of saliva in oral cavity e.g. conditions

associated with difficulty in swallowing, such as severe cerebral palsy, may

require patient on liquid diet.

Particular emphasis should be placed on discontinuation of bottle by

12 months of age after teeth begin to erupt, to decrease the likelihood of

nursing caries.

TYPES OF TRANSFER

1) Slide board transfer.

2) One person transfer

3) Two person transfer.

1) Slide border transfer – covered for patients who have good upper

body strength and control but little or low lower body strength:

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a) Remove footrests and side arm nail.

b) Raise dental chair arm.

c) Place the wheel chain with brakes as close as to the dental

chair, is the patient is hemiplegic position dental chair to his

strong side.

d) Adjust height of the dental chair corresponding to the height

of the wheel chair.

e) Patients and eat but and place slide board under the patient.

f) Keep wheel chair from tipping while patient transfers.

g) Place patients legs into position in the dental chair once he

has transfer.

2) One person transfer – for patients who have moderate strength or

body control, but may fluid slide board to tracing – paraplegic,

patients with cerebral palsy, muscular dystrophy.

a) Remove footrests on wheel chair and side arm.

b) Raise the arm of dental chair.

c) Place the wheel chair at approximately 30° angle to the

dental chair to facilitate kivotar type motion during transfer.

d) Sit the brakes and adjust the height of dental corresponding

to the wheel chair.

e) Infaster, patients seat belts and block the patients knee and

foot closest to the dental chair with your knee and foot closes

to dental chair.

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f) Have the patients place his hands around your neck while

you hold patients waste or belt.

g) On the predetermined signal help the patient stand, using his

blocked knee and food as a pivot.

h) Slowly pivot the direction of the dental chair and let the

patient down into the chair.

i) Place patients legs and body in proper position in the chair.

3) Two person transfer – used for patients with severely limited motor

function in all extremities when using this teeth remember to keep

the back and left with the legs.

a. Follow ‘1’ through ‘7’ for the slide board transfer.

b. Remove the head rest on the dental chair.

c. One person approaches the patient from behind and has the patients

cross his arms by possible, place your arm under the patients arm

fits and grab the opposite wrist with each hand.

a) The second person is responsible for lifting and guiding the

lower limbs and should bend at the legs so as to lift with the

legs, not the back.

b) On a predetermined signal ask the patient to pur his elbows

into his body and both persons doing the transfer lift the

patient straight up stop for a second before you move

laterally to the dental chair.

c) Move laterally to dental chair, making so to clear any

obstacles and lower the patient.

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Maintain support of the patients head until the dental chair headrest

is replaced.

MENTAL RETARDATION (MR)

Definations

Mentally challenged child-American Association of Mental

Deficiency (AAMD) and reported by Holmes et al “subaverage general

intellectual functioning which originates during the developmental period

and is associated with impairment in adaptive behaviour.

MR is general term applied to persons whose intellectual

development is significantly lower than that of normal persons and whose

ability to adapt to their environment is consequently limited.

Capute – defined subaverage general intellectual functioning “as

developmental or intelligence quotient (IQ) that is below 70 and represents

2 or more standard deviation (ISD=15 or 16 patients) from a mean of 100.

When this level of intellectual functioning exists concurrently with

“impairment in adaptive behaviour” the inference is that the MR person

does not possess the independence and social responsibility excepted

within age and cultural group with the limit of 18 years of age.

Thus, to diagnose MR – he should possess:

1) An IQ score of more than 2 SD below the mean (IQ below 70).

2) An accompanying impairment in adaptive behaviour.

3) Manifestations of both before 18 years of age.

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Classification

1) Mildly retarded – is one, who because of low intelligence, cannot

derive full benefit from regular education. In academic environment

these children are classified as educable mentally retarded (EMR).

Educational programs for such children are generally simplified

versions of regular school program and usually lead to literacy and

attainment of necessary skill for employment.

Most children (80%) of them in this group will function

acceptably as adults.

2) Moderately retarded – children who are capable of some education

and partial independence but who are not accepted to experience full

independence as adults. Educational programs for such children,

who are known as Trainable mentally retarded (TMR). Focus on

basic skills, classification are often designed, furnished like home

and the curriculum includes, dressing, grooming, cooking, table

setting, feeding and cleaning. These children leave in a sheltered

home with trained personnel.

Classification of MR

Degree of MR

IQ School classification

Communication Special requirements

SB WISC-R

Mild 67-52 69-55 EMR (Educable MR)

Should be able to speak well, enough for communication

Treat as normal child, mild sedation or nitrous oxide sedation

Moderate

51-36 54-40 TMR (trainable)

Vocabulary language skills such that can communicate at

Mild to moderate sedations restraints and reinforcements, GA in severe dental

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basic level decay.

Severe or profound

35 and below

39 and below

Non-trainable Mute or communication in grunts, no skills

Same as for moderately retarded

Classified MR into:

1) Idiot – IQ below 25

2) Imbecile – IQ 25 to 50

3) Moron – IQ 50 to 20

According AAMD

1) Mildly or educably retarded – IQ 69 to 55

2) Moderately or trainably retarded IQ 54 to 40

3) Severely retarded – IQ 39 to 25

4) Profoundly retarded – IQ below 25

WHO divided into 3 categories:

1) Mild subnormality with IQ of 50 to 69 and mental age in adult 8 to

12 years.

2) Moderately subnormality with IQ of 20 to 49 and mental age in

adult 3 to 7 years.

3) Severe subnormality with IQ 0 to 19 and mental age in adult g 0 to 2

years.

3) Severely or profoundly retarded

The child is often not trainable and requires supervision by

trained support personnel. These are confined to institutions. They

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communicate with grunts, they lack communicable skills or they are

mute.

Etiology

The etiologic classifications:

1) Prenatal

Genetic diseases.

Maternal and fetal infections.

Kernicterus

Fetal alcohol syndrome.

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2) Natal

Birth injuries

Infection

Cerebral trauma

Hemorrhage

Anoxia

Hypoglycemia

3) Postnatal

Cerebral infections.

Cerebral trauma

Poisoning

Cerebral vascular accidents.

Post immunization encephalopathy

Malnutrition

Dental treatment for MR

Providing dental treatment for MR person requires adjusting to

social, intellectual and emotional immaturity.

The dentist should assess the degree of MR by consulting the

patients physician.

The following procedure have proved beneficial in establishing

dentist-patient rapport.

1) Give a brief tour of the office before attempting treatment. Introduce

the patient to the staff. This will reduce the fear of unknow.

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2) Speak slowly and in simple terms. Make sure the patient has

understood the explanations.

3) Give one instruction at a time. Reward the patient after successful

completion of procedure.

4) Listen carefully to the patient, as the MR persons have less

communicative skill and hence the dentist must be sensitive to the

gestures.

5) Keep appointment short. Gradually progress to the different

procedures.

6) Schedule the patient early in the day.

7) The medical history provides information regarding the cause and

extent of the patients retardation.

8) Premedications can be helpful in allowing the anxieties of the

retarded patient decrease.

EPILEPSY

The term epilepsy, which refers to a symptom, not a disease, is of

Greek origin and means “to Seize”. Various disorders may cause abnormal

neuronal discharge in the brain that may induce a seizure.

Etiology

Nelson et al described seizures disorders in children, divided into 2

groups idiopathic and symptomatic.

In idiopathic- the epilepsies cannot be attributed to demonstrable

structural lesion of the brain and are frequently a genetic origin.

In symptomatic – group associated with pathology of the brain due to

developmental anamolies, injury or disease of the brain.

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Seizures can be classified:

1) Grand mal seizures

They are generalized, usually occurring with tonic and clonic phases

of muscular spasm.

- Their onset is rapid.

- The patient loses consciousness and becomes pale.

- Pupils dilate, eyeballs roll upwards or to one side.

- There is rapid contraction of jaw muscles.

- micturation and defecation may occur.

- Patients experiences cyanosis during tonic phase (contraction of

muscles lasts for 20-40 seconds).

- The clonic phase (alternating contractions and relaxation) lasts for

variable periods.

- Patient awaken from the seizure with severe headache and in

general state of confusion.

2) Petit mal

These appear between 3 years of age and puberty, more in girls

- There is transient loss of consciousness.

- Occurs once or twice a month or several hundred times a day.

- They last for 30 seconds.

- Upward rolling of eyes.

- Drooping or rhythmic nodding of head, quivering of trunk of

thumbs.

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Psychomotor seizures

They are difficult to recognize and control.

- There is loss of postural tone.

- There are no clonic and tonic movements.

- The dentist should prevent the patients from injuring himself.

Focal Seizures

These seizures are produced by injury to the brain (trauma, toxic

agents)

- They are referred to as Jacksonian seizures.

- They are sensory or motor and are clonic in nature.

- The muscles most frequently involved are the most specialized for

voluntary movements in the hand, face, tongue.

Dental Management

Most convulsive disorders are controlled through medication and

pose few problems in dental treatment.

The dentists should ask the following questions during history

taking of all seizures patients.

1) What was the age of the patient at the time of onset of the seizure.

2) How many types does the patient have.

3) What is the frequency of seizures.

4) Does the patient tend to injure himself during the attack.

5) Do the seizures occur at any particular time of the day.

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6) How does the patient act immediately preceeding the seizure and

after the seizure is over.

7) What type of medications is the patients taking and when is it taken.

During the treatment

- Since anxiety is frequently precipitating factor, premedication with

minor tranquilizers can be considered.

- The drug regime of the patient should be evaluated.

- The use of mouth prop is mandatory during treatment.

- The dental units must be pushed away from the working field. In

case the patient during tonic phase of seizure to avoid injury.

- They major concern of the dentist during seizure is to ensure that

patients does not suffer physical harm.

- Loosen the patients clothing.

- Turn the patients head to the side, pull the rubber dam material on

youngs frame to evacuate the oral secretions.

- Always talk to the patients, where he is, who are you, every thing is

fine.

If his restorative procedure have already stated, either temporize or

complete the procedure, unless some injury has occurred or systemic

parameters are not within normal range.

- If appliance are indicated for tooth movements or tooth replacement

purpose – fixed type is preferred.

- Appoints should be given just after the patient has taken daily

medications.

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CEREBRAL PALSY

Nelson et al used the term cerebral palsy to describe a group of

nonprogressive disorders resulting from malfunction of motor centers and

pathways of the brain. These are characterized by paralysis, weakness,

incoordination, or other aberrations of motor function that have their origin

prenatally, during birth, or before the CNS has reached relative maturity

(before age 5).

A person with cerebral palsy characteristically has a motor disability

that is manifested as a loss or impairment of voluntary muscle, weakness,

stiffness or paralysis, poor balance or irregular gait and uncoordinated or

involuntary movements.

Etiology

- Decreased oxygenation of the developing brain.

- Complications of labor or delivery.

- Infections of the brain-encephalitis, meningitis, toxemias.

- Congenital defects of brain.

- Accidents resulting in trauma to the head.

- Premature births.

- Poisoning with certain drugs.

The term commonly used to designate involved areas of the body.

1) Monoplegia involvement of one limb only.

2) Hemiplegia involvement of one side of the body.

3) Paraplegia involvement of both legs only.

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4) Diplegia involvement of both legs with minimum involvement of

both arms.

5) Quadriplegia involvement of all the limbs.

Classification CP

1) Spastic (70% of cases).

- Caused by lesion in the cerebral cortex.

- Hyper irritability of involved muscles resulting in exaggerated

contraction when stimulated.

- Characterized by tense, contracted muscles.

- Limited control of neck muscles, resulting in head roll.

- Lack of control of the muscles supporting the trunk, resulting in

difficulty in maintaining upright posture.

- Lack of co-ordination of intraoral perioral, and masticatory

musculature. Possibility of impaired chewing and swallowing,

speech impairment, drooping of saliva.

2) Athetosis (25% of the cases)

- Caused by lesion in the basal ganglion.

- Slow writhming involuntary movements and interferes with normal

muscle action.

- Muscle normal with no spasticity.

- Involuntary movements.

- Neck musculature frequently involved resulting in excessive

movement of the head.

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- Uncontrolled jaw movements, abrupt closure of jaw and bruxism.

- Perioral musculature frequently hypotonic with mouth breathing

drooling of saliva.

- Speech problems.

3) Ataxia (10% of the cases)

- Caused by lesion in cerebellum.

- Disturbance in equilibrium – staggering gait, stumbling, difficulty in

grasping objects.

- Possibility of tremors and uncontrolled trembling on attempting

voluntary tasks.

4) Rigidity (5% of the cases)

- Caused by lesion in basal ganglion.

- Constant rigidity.

- Voluntary movements slow and stiff.

- Patients resistant to flexor and extensor movements with contraction

of agonist and antagonist.

5) Tremors (5% of the cases)

- Caused by lesion in basal ganglion.

- Repetitive, rhythmic involuntary contraction of flexor and extensor

muscles.

Orodental characteristics associated with CP

1) Spastic

- Limited head movement.

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- Hypertoxicity of facial muscles.

- Slow jaw movements.

- Spastic tongue thrust.

- Constricted maxillary and mandibular arches.

- Unilateral cross bite.

2) Athetoid

- Excessive head movement.

- Quick jaw movements.

- Grimacing and drooping.

- Mouth breathing.

- Tongue protruding.

- Bruxism.

- High, narrow palate vault.

- Malocclusions.

- Anterior open bite.

- Poor swallowing.

3) Ataxia

- Lack of balance.

- Slow tremor like head movements.

- Tongue protrusion and anterior openbite.

- Drooling and grimacing.

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General disabilities with CP

- Speech disorders – 50% - 75%

- Mental retardation – 45%.

- Visual defects – 20% to 50%.

- Seizures – 35% to 60%

- Deafness – 10 to 30%.

Dental problems:

- Periodontal disease.

- Dental caries.

- Malocclusions.

- Trauma.

- Bruxism.

Dental management

1) Consider treating patient confined to a wheel chair. Many express

such preference for young patients, the wheel chair may be tipped

back into dentists lap.

2) If a patient is to be transferred to the dental chair, ask about a

preference for the mode of transfer.

3) Make an effort to stabilize the patients head throughout all phases of

dental treatment.

4) Try to place and maintain the patient in the midline of dental chair

with arms and legs as close to body.

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5) Keep patients back slightly elevated to minimize difficulties in

swallowing (not in supine position).

6) On placing the patient on dental chair determine patients degree of

comfort and assess the position of extremities do not force the limbs

to unnatural position, consider pillows and towels for support.

7) Use physical restraints judiciously for controlling failing

movements.

8) For control of involuntary jaw movements choose from variety of

mouth props and finger splints.

9) To avoid startle reflex reaction, avoid such stimuli as abrupt

movements, noises and lights without forewarning the patients.

10)Introduce intraoral stimuli slowly to avoid eliciting a gag reflex.

11)Use rubber dam for restorative procedures.

12)Work efficiently, and minimize patient time in chair to decrease

fatigue of involved muscles.

13)Pre medication is a useful modality in management in case of fear

and apprehension.

14)If the patient is difficult to manage, GA is considered.

DEAFNESS

Deafness is a handicap that is often overlooked.

Almost inevitably, speech in affected. If the impairment is severe

enough that dentists and child cannot communicate verbally, the dentist

must use sight, taste and touch to communicate and allow the child to learn

about dental experiences.

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The causes for hearing loss

1) Prenatal factors

- Various infections – rubella, influenza.

- Ototoxic drugs.

- Congenital syphyllis.

- Heredity (waardenbarg syndrome).

2) Perinatal factors

- Prematurity.

- Birth injury.

- Anoxia.

3) Post natal factors

- Various infections – mumps, measles influenza, poliomyletis,

meningitis.

- Injuries.

- Ototoxic drugs – aspirin, streptomycin, neomycin, kanamycin.

Dental Management

1) Prepare the patient and parent before the first visit.

2) Through the parent, determine during the initial appointment how

the patient desires to communicate, thus decreasing the child fears.

3) Assess speech and language ability and degree of impairment by

taking a complete history.

4) Face the patient and speak at natural pace and directly to the patient,

so that the patient can lip read.

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5) Watch the patients expression make sure the patient understands

what dental equipments is, what is going to happen and how it will

feel.

6) Reassure the patient with physical contact, hold the patients hand

initially.

7) Employ tell-show-do approach, allow the patient to see the

instruments and demonstrate how they work: E.g. vibrations of

handpiece, scratching of explorer, scooping of excavator, texture of

rubber dam.

8) Use smiles and reassuring gestures to build up confidence and

reduce anxiety.

9) Avoid blocking the patients visual field.

10)Adjust the hearing aid (E.g., the patient has one) while the

handpiece is the operation since hearing aids amplify the sounds.

BLINDNESS

A person is considered to be affected by blindness if the visual

acuity does not exceed 20/200 in better eye, with correcting lens or if the

acuity is greater than 20/200 but accompanied by visual field of no greater

than 20 degrees.

Etiology of Blindness

Prenatal causes

- Optic atrophy.

- Micropthalmus.

- Cataracts.

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- Colobomas – defective growth.

- Dermoid and other tumors.

- Toxoplasmosis.

- Cytinegalic inclusion disease.

- Syphilis.

- Rubella.

- TB meningitis.

- Developmental abnormalities of the orbit.

Post natal causes

- Trauma.

- Retrolental fibroplasia.

- Hypertension.

- Premature birth.

- Polycythemia vera.

- Hemorrhage disorders.

- Leukemia.

- Diabetes mellitus.

- Glaucoma.

Blindness is one disorder that may result in frequent hospitalization,

separation from family and slow social development.

Dentist should relize that congenitally blind children need greater

display of affection and love early in life. Explanation is accomplished

through touching and hearing, reinforcement takes place through smelling

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and tasting. The modalities of listening touching, tasting and smelling are

important for blind children.

Reports reveal that motor activity affects the development of

language and perception. Blind children tend to have more accidents than

other children while acquiring motor skills.

Trauma to anterior teeth, gingival inflammation because of inability

to see and remove plaque.

Before initiating treatment for blind dentist should keep following

points in mind.

1) Determine the degree of perception of the light (visual impairment)

e.g., can the patient tell light from dark.

2) Avoid expressions of pity or references to blindness as an affliction.

3) In maneuvering the patient to the operatory ask the patient for

assistance. Do not grab, move, stop without verbal warning.

4) Describe the office setting. Always give the patient adequate

descriptions before performing treatment procedures.

5) When making physical contact, do so reassuringly.

6) Introduce other office personnel very informally.

7) Allow the patient to ask questions about the course of treatment and

answer them.

8) Allow the patient who wears eyeglasses to keep them on for

protection.

9) Avoid sight references.

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10)Rather than tell-show-do approach, invite the patient to touch, taste,

or smell.

11)Describe in detail instruments and objects to be placed in patients

mouth.

12) Demonstrate rubber cup on patients fingernail.

13)Holding the patients hand promotes relaxation.

14)Since strong taste may be rejected use smaller quantities of dental

materials with such characteristics.

15)Explain the procedure of oral hygiene and then place the patients

hand on yours as you slowly guide the tooth brush.

16)Use audiocassettes for explaining specific dental procedures and

decrease chair time.

17)Avoid unexpected loud noises.

18)Limit the dental care to one dentist.

Down’s Syndrome

Synonyms – Mongolism, Trisomy 21

It is one of the most common chromosomal disoders.

Etiology

Chromosomal abnormalities is Trisomy 21 or presence of extra

autosome (Thompson 1973).

Incidence : 1.5 in 1000 births.

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Features

Body growth : small stature due to retardation in appositional and

endochondral growth.

Head : Microcephaly with prominence of forehead, shortening of

anteroposterior diameter flattening of the occiput.

Eye :

- Upward, outward slant and epicanthal folds.

- Speeling of iris (brush field spots).

- Hypoplasia of iris.

- Chronic inflammation of conjunction.

Orbit :Smaller than normal.

Face :

- Round flat face.

- Flat nasal bridge.

- Upper facial height decreased.

Mouth:

- Under development of maxilla contributes to open mouth and

protruding tongue.

Tongue :

- Normal at birth.

- Older patients – fissured or macroglossia.

Teeth:

- Microdontia.

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- Conical tooth.

- Over retention of primary teeth.

- Aberrant eruption pattern.

- Anadontia, oligodontia, supernumerary teeth.

Palate : Narrow and high vault.

Limbs:

- Short, broad hand digits and feet.

- Wide space between first and 2nd toe.

- Synductaly of fifth finger.

Ears – Anamolies in formation of external ear.

Skin : Dry, hyperkeratosis common.

Neck : Broad and short.

Nervous system

- Level of intelligence – mild to severe.

- General movements slow, sluggish, clumsy.

- Unsteady gait.

- Feet kept wide apart.

Periodontal status – Prevalence of periodontal disease is higher than

normal populations.

Systemic condition

- Cardiac diseases – 27-35%.

- Increased incidence of abnormality in WBC.

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- Increase incidence of RTI.

- Congenital heart disease, respiratory tract infection in 1st 5 years.

Common malformation

- Articular spethal defects.

- Insufficiency of AV value.

- Ventricular septal defect.

(Should follow the guidelines for SABE coverage).

Management

DS patients can be treated in dental office with tolerant and

sympathetic approach.

- Most of them are affectionate and cooperative, cheerful and well

behaved.

- Decreased resistance to infection should be considered while

treating.

Heart Diseases

Heart diseases can be divided into:

a) Congenital.

b) Acquired.

Because individuals with heart disease require special precautions

during dental treatment such as antibiotic coverage for prevention of

SABE, a dentist should closely evaluate the medical history to ascertain

CVS status.

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Congenital Heart Disease

Incidence – 9 in 1000 birth.

Types:

a. Venticular septal defect.

b. Patent duction arteriosus.

c. Fallots tetralogy.

d. Transposition of great vessels.

e. Artral septal defect.

f. Pulmonary stenosis.

g. Coartation of aorta.

h. Aortic stenosis.

i. Tricuspid atresin.

Etiology:

- Unknown.

- Aberrant embryonic development of normal structure.

- Failure of structure to progress beyond embryonic development.

Others

- Maternal rubella infection.

- Chronic maternal alcohol abuse.

Types

- Cyanotic

- Acyanotic

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Acyanotic is divided into 2 groups:

1st group – defects that cause left to right shunting of blood.

- Includes – VSD, ASD

CF

- Murmurs.

- H failure.

- Pulmonary congestion.

- Heart murmur.

- Labored breathing.

- Cardiomegaly.

2nd group

- Defect caused by obstruction.

- E.g., stenosis of aorta.

CF

- Labored breathing.

- CCF.

Cyanotic congenital heart disease

Characterized by right to left shunting of blood within the heart.

- Cyanosis occurs during mild exertion e.g., fallouts tetralogy,

transposition of vessels pulmonary stenosis.

CF

- Cyanosis

33

- Hypoxic cells.

- Poor physical development.

- Heart murmurs.

- Clubbing of fingers.

Acquired heart disease

Rheumatic fever:

- Inflammatory disease that occurs as a delayed sequela of pharyngeal

injection.

- Caused by streptococci.

- Infection can involve heart, joints, skin, CNS, subcutaneous tissue.

- Occurs commonly between 6 to 15 years.

- Prevalent in temperate zone and high altitude.

- Carditis develop in 50% of patients.

Jones criteria in diagnosis of RF

Major manifestation Minor manifestations Supporting evidences

Carditis polyarthritis chorea

Erythema margination

Subcutaneous nodulus

- Fever

- Arthralgia.

- Previous history.

- RF or heart disease

- Increased erythocyte SR (E.S.R.)

- +ve c-reactive protein.

- Prolonged PR interval.

Evidence of preceeding streptococcal infection.

Positive throat culture group A streptococcus.

Infective bacterial endocarditis

34

Characterized by microbial infection of heart valves or endocardium

in proximity to congenital or acquired cardiac defects.

Divided into : - Acute

- Subacute

Acute – disease that usually occurs as a result of microorganism of high

pathogenicity, causing erosive destruction of valves.

Microorganisms

- Staphylococcus.

- Streptococcus group.

- Pneumococcus.

Subacute – In contrast SABE develops in persons with preexisting

congenital cardiac disease.

- Commonly caused by Viridans streptococci.

CF

- Embolization.

- Microorganism may colonize on endocardium.

Symptom

- Irregular fever.

- Malaise.

- Anorexia.

- Weight loss.

- Arthalgia.

- Cardiac murmurs.

35

- Painful fingers, toes, skin lesions.

Lab findings

- Leukocytosis.

- Increased ESR

- Bacterimia.

Precipitating factors

1) Dental manipulation – induce gingival bleeding.

2) Incision and drainage of infected tissues.

3) Tonsillectomy.

4) Bronchoscopy.

5) GI instrumentation.

6) UT instrumentation.

7) IV catheters.

8) Valvular prosthesis.

Dental Management

- History.

- Medical and physical examination.

- Discuss with the physian.

- Adequate antibiotic therapy.

- Cardiopulmonary resuscitation equipment should be available.

36

Following considerations:

1) Pulp therapy for primary teeth is not recommended – therefore,

increase incidence of chronic infection – extrusion and SM.

2) Endo therapy – in permanent teeth can usually accomplished and

performed adequately.

3) Patients with cardiac pacemakers with existing congenital defect or

disease prophylactic antibiotic coverage to prevent SABE is not

indicated.

HEMOPHILLIA

This is most common congenital blood coagulation disorders which

produces serious bleeding episodes.

This is caused due factor VIII (A) deficiency and factor IX (B)

deficiency.

Hemophilia is inherited as an X linked recessive tract. Therefore all

males who possess the defective X chromosome have clinical

manifestations of disease and females are caries.

Another bleeding disorder, frequently confused with hemophilia is

Von Willebrand disease. This disease is inherited via autosomal dominant

gene affecting males and females. The person with this disease have mild

deficiency of factor VIII and abnormal platelet function.

37

Classification of hemophilia

Degree % of VIII and IX

Characteristics

Severe <1 May be frequent spontaneous bleeding into joints and muscles.

Moderate 1-5 Occasional spontaneous joint bleeding, minor trauma may initiate hemorrhage.

Mild 5-35 Significant hemorrhage only after major insult such as extraction.

Dental management of hemophilia

The dental treatment of a patient with hemophilia necessitates

thorough understanding of this patients disorder. It is important that the

nature of disorder be determined through interviews with parents and

childs physician. Before starting the treatment, the dentists should

undertake thorough medical history about this disease.

It is especially important to avoid tissue laceration or other intraoral

trauma.

The following patients are important in treating the patient.

1) The relief of anxiety has been shown to be beneficial in maintaining

hemostasis – by premedication, nitrous oxide inhalation, hypnosis.

IM transquilizing analgesic agents in contraindicated as it can cause

hematoma.

2) In absence of factor replacement, intraligamental injection may be

used. Block anesthesia is not recommended, local infiltration can be

easily administered after single infusion of factor replacement.

38

3) Teeth can be cleaned by rubber cup minor haemorrhage can be

controlled with local mechanism such as direct pressure. For minor

hemorrhage topical application of bovine thrombin may be used.

4) Most of restorative procedure and pulp therapy on deciduous teeth

can be successfully completed without discomfort through use of

acetaminophen with iodemic with nitrous oxide inhalaton.

Hemophilia

If the child with hemophilia sustain oral trauma with excessive

bleeding following modalities.

1) Hemorrhage associated with laceration of OMM – single dose factor

cocnentrate that raises the level of factor 50% of normal E-ACA

continued until epithelization is complete.

2) Laceration which requires suturing repeated doses of factor which

level of at least 25% of normal is maintained E-ACA infusion

continued until the wound is healed.

3) Extraction of primary teeth or permanent, factor VIII infusion of

100% of normal and loading dose of E-ACA maintenance dose of

E-ACA for 7 to 10 days.

Extraction of teeth begin within 1 hour after infusion.

Adjunct local measures to control bleeding should be considered.

Like avitum or oxidized cellulose material impregnated with bovine

thrombin.

Patient must be give very specific instruction – strict diet for 2

weeks – 1st 22 hours liquid diet. Dairy products should not be allowed as

they leave film residue. Next week soft diet after 10 days – normal diet.

39

E-amino caperi acid (E-ACA)

As adjunct to factor replacement therapy. In hemophilic patient,

there is normal Fibrinolytic mechanism but generation of thrombin

necessary for clot is decreased. Thus, the clots get dislodged. The

fibrinolytic mechanism is inhibited by E-ACA to form stable clots.

Desmopressin acectate

- Antidiuretic hormone – causes increased levels factors VIII.

4) Particular care must be taken in placement of IOPA films and use of

high suction or saliva ejector.

5) The use of rubberdam with greatly assist in protection of soft tissues

clamps with subgingival extension should be avoided.

6) Conventional pulp therapy is preferable to tooth extraction.

Intrapulpal injection can be used to reduce pain. Hemorrhage from

pulp chamber can be reduced by pressure packs.

Dental care

Preventive Dentistry

Prevention of dental diseases requires a combination of diet, plaque

control regular continuing professional care. Parents should be made aware

that as gingival health improves, minor bleeding caused by brushing will

stop or treated by topical bovine thrombin.

Flossing should be taught only to those parents and patients who

appear capable of mastering the techniques.

In severe hemophilias, fluoride therapy, to be done every 3 months

using custom trays.

40

Periodontal disease

Treatment of the periodontium is one of the most neglected aspects

of children. Simple dental prophylaxis and topical fluoride application can

be easily done in severe hemophiliases provided meticulous care is

exercised to prevent gingival trauma.

Calculus may be removed in stages in order to reduce bleeding risk.

Initially, gross supragingival scaling is done, allowing the gingival

inflammation to subside, as the inflammation resolves remaining calculus

can be removed. For deep scaling, replacement therapy should be used

prior to the treatment.

Restorative Dentistry

Extra care should be taken to avoid soft tissue injury.

Routine use of rubber dam is helpful in protecting patients lips and

tongue from trauma, clamps such as ivory No. 8A and 14A should be

avoided for gingival damage, clamps such as SS white No.22. 201.

Extra care must be taken during passing the rubber dam through

contact points with dental floss to avoid “snapping” of floss into

interproximal gingiva.

Stainless steel crowns can be avoided when possible to prevent

gingival bleeding and laceration.

Endodontic procedures

These are highly recommended in children to lower the need for

extaction.

Pulp bleeding can be controlled easily without replacement therapy.

Extra care is taken to prevent periapical trauma.

41

Oral surgery

Prior to surgical procedures, missing blood factor is replaced.

During extraction procedure.

Lucas and others advocate combination of absorbable hemostatic

agents and topical bovine thrombin.

Lucas, saturates oxidized regenerated cellulose with bovine

thrombin dissolved in 0.5% sodium percarborate solution. After socket is

dried, surgicel is used to fill the socket within 1 mm of the surface lucas

then covered the wound with splint.

Orthodontics

Although bands should be avoided when possible, much can be

done with adhesive brackets or removable appliance in orthodontic

management of malocclusion. In severe bleeders however, it is not

suggested that bands be used on any teeth.

AUTISM

In 1944 Kaner described clinical syndrome in children to which

negave name infantile autism. He described that one symptom with the

disease was an viability to relate approximately to the people and

situations. These childrens are seem to be self sufficient and introverted

and want to be left alone.

- They have no attachment to parents.

- They relate poorly to persons.

- They remain occupied water moving or shining objects such as

keys, spinning tops for hours.

42

In 1980, diagnostic and statistical manual of mental disorders

published by APA listed autism as neurological disorders, caused by

physical disorder of the brain.

Incidence – 2.5% in 10000 population – Kanueer and Lesser 1958.

Etiology

- Lotter (1966) – postulated that personalities attitudes and behaviour

of the child’s parents contibute the autism.

- Bakwin and Bakwin early manifestation of childhood schirophamia.

- Children who have been brought up in institution where they

received no stimulation and totally deprived. – Kammer

Features

- Language – impaired invariability.

- 2/3rd achieve active functional speech but 1/3rd remain without

functional language. – (Robin son and Milins 1976).

- Even the speech is a acquired they hardly speak.

- When speech is present they repeat the word or phase.

- They have difficulty in saying yes.

Behaviour

- Intense desire to maintain consistency in the environment.

- Inappropriate reachers to fearful situations.

- Prone to transforms and aggressive or destructive behaviour.

- Bizarre behaviour makes dental management difficult.

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Management

Loovoos et al (1974) reported behaviour modification techniques.

The key to all behaviour modification programs lies in the positive

reinforcement to promote desirable behaviour.

In early stages, sweet foods can serve as desirable rewards.

In later stages of modifying behaviour such oral rewards should be

changed to social rewards, such as pat on the back or a hug.

- In the interest of time , premedication of ketammic in useful.

- GA is method of choice.

Cleft Lip and Palate

Cleft lip with cleft palate is severe birth defect occurring in newborn

infants.

Cleft lip and cleft palate are among common congenital

malfunctions occurring in orofacial region. The variable morphology of the

congenital anamoly ranges from soft tissue defect involving either lip or

soft palate with complete separation of the oral and nasal cavities.

The associated defects with this are malformed teeth, malocclusions,

impairment of speech, middle ear infection, URTI.

Incidence

- One in 750-1000 newborns in USA.

- In whites – one is 800 births.

- In blacks – one in 2000 births.

- Japanese - one in 500 births.

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- Cleft lip and palate lengthen account for 50% of all cases.

- Isolated cleft lip and palate occur in 25% each.

- Males are commonly affected.

A number of classification have been proposed but one of them have

been universally accepted.

I) Davis and Ritchie (1922)

Group I – Prealveolar clefts – lip clefts only with unilateral, median and

bilateral.

Group II – Post alveolar clefts – involves soft and hard palates.

Group III – Alveolar clefts – complete clefts of palate, ridges and lip.

II) Fitz and Gibbon (1930)

1) Cleft of the soft palate.

2) Cleft of soft and hard palate.

3) Cleft of the soft and hard palate with single hard lip.

4) Cleft of soft and hard palate, with double hairlip and deteched

premaxillae.

5) Cleft of soft and hard palate, edentulous.

III) Vean (1931) classification of cleft lip and cleft

palate

a) Cleft lip

Class I – unilateral notching of vermillion border but not extending

into the lip.

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Class II – unilateral notching of the vermillion border with cleft

extending into the lip but the floor of the nose.

Class III – unilateral cleft the vermillion border of the lip, extending

into the floor of the nose.

Class IV – Any bilateral cleft lip whether this be incomplete

notching or complete clefting.

b) Cleft palate

Class I – involves only the soft palate.

Class II – involves only the soft and hard palate, but not alveolar

process.

Class III – involves both soft and hard palate and the alveolar

process oneside of the premaxillary area.

Class IV – involves the soft and hard palate and continues through

the alveolus on both sides of premaxilla, leaving a free and mobile.

46

IV) Fogh – Anderson (1942)

Group I – Harelip – single, double

Group II – Harelip and cleft palate – single, double.

Group III – Cleft palate

V) Olinger classification (1952)

Class I – fissure in azygos uvuale

Class II – Fissure in uvuale

Class III – Fissure in soft palate

Class IV – Fissure in soft and hard palates.

Class V – unilateral cleft, fissure in the soft and hard palates, then alveolar

ridge at junction of maxilla and premaxilla accompanied by cleft lip.

Class VI – bilateral cleft, fissure in soft and hard palates through the

alveolar ridge at the junction of the maxillae, accompanied by cleft lip.

VI) Kernahan and Stark (1953)

This pattern is widely accepted and utilized.

Group I – (clefts of primary palate anterior to inclusive foramin)- Cleft of

the tip (CL), all forms of degrees of cleft lip, and combination cleft lip and

cleft alveolar process.

Group II – Cleft lying posterior to incisive foramin on degrees of clefts of

soft and hard palates.

Group III – Combination of clefts of both primary and secondary palates

involves combination of group I and group II.

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Subdivision

Group I

1) Unilateral cleft lip – incomplete

2) Unilateral cleft lip – complete

Group II

1) Cleft lip involving the soft palate only.

2) Cleft lip involving the soft palate and hard palate.

Group III

1) Unilateral cleft lip with complete cleft of soft and hard palate.

2) Bilateral cleft lip with complete cleft of soft and hard palate.

VII) International confederation for plastic and

reconstructive surgery 1968

Group I – clefts of anterior palate (primary)

a) Lip right / left

b) Alveolus right / left

Group II – clefts of anterior and posterior palate

c) Lip right and left.

d) Alveolus – right and left.

e) Hard palate – right and left

Group III – clefts of posterior (secondary) palate

a) Hard palate – right and left.

b) Soft palate median

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Etiology

Extent etiology of CCP is still unknown but few accepted theories.

1) Exogenous tract factors

Like – Rubella

Thalidomide drugs

2) Mulant genese and chromosomal aberration.

Mutant genes – ectodermal dysplasia

Chromosomal aberrations – D-trisomy and E-trisomy

3) Multifactorial causes

Contribution of both with heredity.

Pathogenesis

Cleft lip

According to mesodermal deficiency theory the lip and premaxilla

in their early forms as an ectodermal good in which 3 masses of mesoderm

are present. Normally these masses grow and limit to form the upper lip

and premaxilla, but failure of the growth leads to infiltration of the

ectodermal head a consequent weakening of this delicate membrane

induces a rupture of the head and a cleft lip results.

Cleft palate

This commonly accepted that cleft palate results from the failure of

the palatal shelves to meet and fuse in the midline.

49

Causes are:

1) Failure to displace the tongue from between the shelves may

prevents closure.

2) Fusion may be prevented because shelves are too narrow to meet in

the midline or because of other structural defects.

3) Normal palatal shelves may not meet in the midline is an individual

ha an incisally wide head.

Oral findings

- Natal or neonatal teeth with complete or bilateral cleft palate.

- Congenitally missing teeth.

- Supernumerary teeth.

- Ectopic eruption of deciduous lateral incisor.

- Anomalies in morphology.

- Enamel hypoplasia.

- Microdontia, macrodontia.

- Fusion of teeth.

- Lateral facial profile convex.

- Rotation of teeth.

Extraoral features

Defects of extremities syndectyl (webbed fingers) and malformation

of lower extremities.

Upper respiratory tract infection.

50

Congenital heart disease.

Hearing problems caused by middle ear infections speech

impairment.

Evaluation of the child

Careful history of pregnancy, labour, delivery, and family history.

- Look out for congenital abnormalities.

- If present eyes to gene therapists, so that etiology and mech can be

explained.

Other consultation should be addressed depending on the physical

examination by EMT, opthalmologist, cardiologist, pediatrician prior to

surgery.

Also refer the child to psychologist, speech pathologist, radiologist.

Pre surgical management (counseling)

It is extremely important because almost all the patients have same

concerns. This will help the parents to warmup.

Feeding

First goal is to prepare the child for surgical response of lip. Before

surgery the child should have following criteria – 10 weeks, weight 10

pounds and 10 gms of tbl spoon – ‘3 times law’.

Feeding plates

Feeding problems arise in the case of bilateral and unilateral cleft. A

feeding plate can be made to cover the roof of the mouth to prevent food

entering nasal cavity.

51

Stage (maxillary orthopedic stage) birth to 18 months

Feeding problems are often associated with clefts, making it

difficult to maintain adequate nutrition.

- Insufficient suction to pure milk excessive out intake, nasal

discharge.

McNeil (1950) – Obturator

Advantages

1) Provides false palate against which the infant can suck reducing

feeding problems.

2) Provides maxillary cross arch stability and prevents arch collapse.

3) Orthopedic moulding cleft segments in to approximation before

bone grafting.

Indications

- Complete cleft tip and palate.

- Maxillary orthopedic moulding of segment after surgical closure of

lip.

Procedure:

- Impression of maxillary arch is made in stock tray.

- The infant is held upright during impression to prevent, aspiration of

excess material.

- Appropriate emergency equipment, forced oxygen, suction and

airway management system should be available.

52

Fabrication

- Block out all the undercuts with wax.

- Separating media is applied.

- Fabrication of the appliances using self cure resin.

Clinical management (Birth – 3 months)

- Area of excessive pressure relived.

- Maintaining hygiene.

- Recall the after 2 days of initial placement.

- Recall every 15 to 1 month.

The primary function of cleft palate clinic are to evaluate and

planning of rehabilitative needs of his patient. To obtain optimal

rehabilitation each number of the discipline involved have general problem

faced by other members of the team, is excessive and prolonged

orthodontic treatment required in separate stages:

1) Infancy before initial surgical repair of lip.

2) During primary and mixed dentition stage.

3) During late mixed dentition and early permanent dentition stage.

4) In later teeths after the complication of facial growth in conjunction

with orthognathic surgery.

Infant Orthopedics

If presurgical movement is indicated it is carried out 3 to 6 weeks of

age that lip closure can be carried out 10 weeks. A passive plate similar to

orthodontic retainer is used for months after lip closure.

53

Later primary and early mixed dentition treatment

The result from surgical correction of lip closure some constitution

across the anterior parts of maxillary arch is created.

Orthodontic intervention is often unnecessary until permanent

incisors begin to erupt. There is tendency that maxillary anterior erupted

rotation and with crossbite. This can be corrected by fixed and removable

appliance.

Pre-surgical orthopedics:

The growth potential of the nasal septum is extremely powerful

when the lip is normal, the forces are directed anteriorly along the midline.

If there is a muscle pull to one side because of a unilateral cleft these two

forces combine to pull the major segment to non cleft side.

Therefore if an opposing force to nasal septum and to the muscle

pull can be applied the distortion can be minimized. If at the same time a

shearing force can be applied to minor segment, the major and minor

segments of the alveolus and lip can pulled together. This makes the task of

plastic surgeon repairing the lip defect much easier. The active force can be

provided by 3 pieces of tape joined together by 2 elastic bands. The central

portion of the tape tends to cup the premaxilla in bilateral cleft case thus

stabilizing the segment strapping should be applied immediately after birth

and continue till the time of surgery. In this way tension in the tissues is

minimized version facial skin as the repeated changing of the strapping

54

means that the tape must be removed from the face this can result in the

skin becoming sore using a barrier dressing or leaving an additional piece

of tape on the face minimizes the effects of this recurrent trauma.

In the case of bilateral clefts, the lateral segments tend to

approximate, resulting in the blocking out of the premaxilla. To prevent

this an oral plate must be fitted to stabilize or even move the lateral

segments buccally when the cleft of palate is unilateral, an active plate can

be used to stabilize or prevent collapse of the segments and narrowing of

the maxillary arch.

One type of expansion plate is constructed on a cast that has been

cut and the segments reposition by upto 3mm. Alternatively a plate with a

spring in the anterior region and a hinge in the posterior region can be

fabricated to give a differential expansion.

An active plate unlike the passive feeding plate must be worn at all

times. This plate is kept in position by the action of the tongue, the force

generated by the baby acting together an extraoral were “whiskers” which

are taped to babys face.

Orthodontics

The goal of orthodontic treatment is to provide an aesthetically

acceptable and healthy dentition for life and to contribute positively to the

55

general facial form and appearance. An orthodontist working with clefts,

children before starting treatment two important parameters.

1. First with regard to the timing of orthodontic treatment.

2. Most patients have complex orthodontic problems dental problems

specific to cleft and palate.

1. Congenitally missing teeth.

It has shown that children who have clefts of the maxilla have a

higher incidence of congenitally missing teeth. This is true not only the

immediate area of cleft but also the contralateral side and the opposing arch

in complete unilateral clefts.

2. Supernumerary teeth

A greater incidence of supernumerary teeth in the cleft lip and palate

patient. The maxillary lateral incisor area is affected most often, especially

when it is in the direct line of the cleft. When cleft occurs it affects the

angle of the lateral incisor and can split it in two.

The teeth are ectopic in position smaller in size and expandable.

3. Other tooth anomalies

These include:

a. Fused.

56

b. Irregularities of tooth size, ectopic eruption, malformation of

individual teeth delayed eruption of mandibular teeth

ankylosis of teeth adjacent to the site of the cleft lack of bony

base over which teeth might be moved.

Presurgical period

When pre-operative orthopedic treatment was introduced at many

clefts center in 1950’s.

The above principles and objectives its adoption was resisted for the

following reasons:

1. The surgeons felt they did not need it.

2. At the time pre-surgical orthopedic treatment was introduced.

3. The teem particularly the orthodontist were worried that pre-surgical

orthopedics may have a adverse effect on maxillary growth.

Pre surgical orthopedic treatment has now been used extensively in

Europe and limited states for over 30 years.

Treatment Procedures

Orthodontic care is considered here in 3 phases, during the primary,

mixed and the permanent dentition.

57

Primary dentition phase

The extent of a malocclusions is usually lees apparent in the primary

dentition. Then in the permanent dentition, treatment is difficult in the

primary dentition because of the lack of good teeth for anchorage.

- The presence of a bulky appliance in the mouth may

contribute to speech problems.

- The level of cooperation that can be expected from a child of

this age is fairly limited.

- In addition as children grows relapse commonly occurs.

Even when there is evidence of a high arching palate due to lateral

collapse or retrusion of the maxilla it is usually better not to perform any

active treatment in the primary dentition.

Mixed dentition phase

By the mixed dentition stage most of not all of the anterior teeth in

the region of the cleft will have erupted. They are frequently malformed,

hypoplastic and erupt in ectopic positions or missing the rationale of

treatment was to reduce cross bites and create functional environment. As a

general rule orthodontic treatment during the mixed dentition limits itself

maxillary arch.

58

For example in complete, unilateral and bilateral clefts if buccal

segments crossbite exists to reduce the first. If the maxillary central

incisors erupt in lingual version or rotated and ectopic. This requires

another phase of treatment.

If the maxillary first permanent molars erupt in crossbite and lateral

incisors in lingual version, this to necessitates, additional treatment. There

are number of techniques available for reduction of bilateral buccal

crossbites.

1. Quad helix appliance.

2. A rapid maxillary expansion device.

Permanent dentition phase

By the permanent dentition stage growth is nearing completion and

magnitude of any deformity can be readily assessed. Hence this is the most

appropriate time for performing orthodontic therapy.

There may be abnormalities in the position of the teeth or the jaws.

In the case of later the discrepancies can be considered in 3 planes:

1. Transverse.

2. Anteroposterior.

3. Vertical.

The transverse relationship may be such that a posterior crossbite.

This is usually more in the region of the minor segment adjacent to the

59

cleft. The collapse of the arch may be due to repair of the lip. It is more due

to scar tissue arising from the palatal repair which has restricted lateral

maxillary growth.

Because of the lack of bony union between the segments of the

maxilla, they can be easily moved using a fixed appliance that is cemented

directly to the teeth. This approach limits the degree of tooth tipping.

When there is a severe anterior cross bite, expansion may be

required using a roped palatal expansion type of appliance.

For correction of a posterior crossbite, a quadhelix type of appliance

is used. There is no midline suture to open in posterior region, this

expansion can be performed more slowly. An alternative is an appliance

that caps the teeth and has a screw anteriorly and a hinge posteriorly to

achieve differential expansion of the arch.

Speech and language

All children with cleft palate requires such therapy to overcome the

difficulties associated with trying to generate intraoral pressure and to

overcome hyper or hyponasality. In the time between repairing the lip and

palate, the child begins to develop oral movements before speech. This is

pronounced between 12-18 months of age. Repair of the palate should not

be delayed beyond this period because in the majority of cases acceptable

speech can be achieved following surgery at this stage.

60

Immediately after birth, the child will start to experiment with sound

production. These early babblings are the beginning of speech. The speech

therapist can advise the parents to encourage the child by reading to them

and naming objects when moving around the house or in the street. All

times it is essential that the child is allowed to practice speaking. The

parents need to be counseled by a speech therapist so that they fitting

palate in the childs mouth on a long term basis before palatal repair may

have some beneficial effects in that it allows the tongue to function in an

area approximating to the shape of the future mouth.

Multispeciality team management

White house had described, clinical team as a close cooperative

democratic, multiprofessional lenion development to a common purpose

the best treatment of fundamental needs of a patient. In order to improve

function and appearance of various parts of face and oral cavity that are

affected by this defect and associated psychological problems, different

specialists must work in close collaboration to treat these children. The

team include a plastic surgeon, a pedodontist an ENT surgeon an

orthodontist, a speech therapist, oral surgeon and a prosthodontist.

The role of individual specialists

Primary function of plastic surgeon is to prepare clefts of lip and

palate and to improve function of the soft palate and appearance of lip and

61

nose. He may be required to deepen the labial sulcus and in bilateral cleft

cases, reposition the premaxilla. Because of early treatment performed by

plastic surgeon, parents become acquainted with him and he makes a useful

team leader.

The pediatric dentist is responsible for constructing feeding plates

and advising parents on feeding techniques for the neonate. He provides

restorative and preventive dentistry including dietary advice and topical

fluoride applications during childhood.

The ear, nose and throat surgeons performs aural examinations and

assesses the hearing by using impedance and compliance tests. This is

essential if the child is to communicate and learn at the normal rate. If

necessary surgical procedures can be used to protect ears and maintain

them in a healthy state, the role of ENT surgeon is limited after the age of 7

years because most of early hearing problems should have ceased. Hearing

improves when the tensor palati muscles take over from levator palati

muscle as the primary muscles responsible for opening the Eustachian

tube.

The orthodontist is usually responsible for performing presurgical

dental orthopedics and when necessary early correction of malalignment in

the incisions and correction of discrepancies in the labial segment

relationship. Crowding and malalignments are corrected in the full

62

permanent dentition and teeth are often moved orthodontically to move

favourable position for the retention of a prosthesis.

The speech therapist advises the parents about communication

problems and demonstrates method of encouraging the child to speak

properly. When necessary treatment is provided to overcome problems

such as hypernasality, nasal fricatives defects articulation due to inability

of patient to build up sufficient pressure.

The social worker can help by giving support advice and looking

after many siblings.

Prosthodontist replaces, restores orofacial structures that may be

congenitally missing or malformed non living materials are used to restore,

enhance form and anatomy he fabricate appliance to rehabilitate

mastication deglutition, speech and oral esthetics. They may incorporate a

palatal expansion or an obturator to occlude any residual palatal defect.

The psychologist assists by counseling both parents and child at

different times to help them, minge and cope with their problems.

The oral and maxillofacial surgeon evaluates all patients for facial

form and function and jaw position many cleft patients have a skeletal

malocclusion that can be treated by conventional orthodontics and requires

surgical correction. The surgical placement of primary and secondary

alveolar cleft bone graft is another important role of the surgeon. These

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grafts aid in dental rehabilitation of the patient. The grafted bone supports

the teeth adjacent to the cleft site and provides bone through which teeth

may except.

Treatment schedule summary and the specialists treating a patient

with a cleft lip and palate:

Birth : Pedodontist may construct feeding plate and initiate pre-surgical

dental orthopedics. Team members are introduced to parents and

emphasize need for adequate weight gain so child attain necessary stage of

development before lip surgery.

3 months of age- surgical repair of lip bilateral cleft lip cases may be

repaired as a two stage procedure.

6 months – preventive dentistry begins.

15-18 months surgical repair of palate speech therapist assess.

2 years – plastic surgeon review surgical result orthodontist examines teeth

and soft tissues, especially noting relationships of anterior segments and

depth of labial sulcus in the cleft region. ENT surgeon assesses hearing and

examines tympanic membrane speech therapist continue to monitor speech.

Pedodontist stresses importance of good dental health.

3 years – dental check ups at 4 months intervals other team members

review regress annually.

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4 years – ENT surgeon usually performs aduiography and compliance tests

and if necessary places grommet tubes in ear drums. Speech therapy starts

for children with speech and hearing problems.

7 years – Early correction of malalignment of an anterior teeth and labial

segment relationship.

9 years – surgical lip and nose revision to improve appearance.

12 years – orthodontists correct malocclusion and treats crowding and

malalignments. Expansion of maxillary arch may be necessary teeth may

be moved so as to create space for bone graft or for fixed removable

prosthesis.

16 years – plastic surgery to improve the appearance of nose, the oral

surgeon may form a Lefort 1 maxillary osteotomy to correct retrusive

appearing maxillo, replacement of missing teeth with fixed bridge or

removable prosthesis.

16 years onwards – prosthodontists and restorative dentist prove regular

dental care.

Dental management of the cleft patient

The child patient with a cleft lip and palate offers challenges to the

pediatric dentist. The children undergo surgical and dental procedures more

frequently making them more anxious in the dental office. Change in the

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innervation of the maxilla and post surgical scar tissue make the local

anesthesia difficult the anesthetic scar from missing teeth an incomplete

alveolus also managed until the establishment of the permanent dentition.

As part of a cleft palate team and pediatric dentists mission is to

protect and supervise. The eruption of permanent teeth. The tasks that one

can be expected to perform include the following:

1. Construction of infant feeding and orthopedic appliances.

2. Education of parents to the dental needs and care of this child.

3. Introduction of the child to environment.

4. Prevention of dental caries.

5. Guidance of the developing primary and secondary dentition.

6. Restorative dentistry for the primary and secondary dentition.

7. Management of problems unique to the cleft side.

8. Education of the child and parents to the maintenance of good oral

hygiene.

Establishing good communication between the child and the dentist

is the first step in helping the child develop a positive attitude towards the

dental office experience.

Home rinses can be used for the child who wears an orthodontic and

prosthodontic appliance.

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As the permanent teeth erupt, those teeth with a deep pit or fissure

should be considered for occlusal sealants.

Local Anesthesia

The use of local anesthesia is an important factor in the successful

development of pediatric dental care. The tissue over the injection site is

implied with a dry gauze and a cotton tip applicator dipped in a topical

anesthetic is applied to the injection site. 20% Benzocaine is the most

common topical anesthesia used. It has an onset of action of 30 seconds.

Oral surgery

A common problem with infiltration anesthesia in the cleft

population is the anesthetizing a tooth in or near the cleft area. Usually the

tissue surrounding the tooth is tightly bound down and prevents infiltration

of anesthetic for these teeth injection of the anesthetic into the periodontal

space is recommended. A special syringe for this injection prevents

breakage of the anesthesia catridges, due to the higher injection pressure is

required. This technique is useful for the extraction of supernumerary

maxillary teeth.

Preventive and Restorative Dentistry

As a rule initial visit to the dentist is made when the patient is

between 2 and 3 years old. At this time deciduous dentition is developing

and surgical closure of the clefts have been completed one of the first few

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visits child should be examined receive light prophylaxis, allowed to

familiarize himself with dentist and his surroundings because of shape of

surgically treated palate some difficulty may arise in taking radiographs.

However it is essential that these diagnostic aids to be obtained

approximately 4 years of age of four years for detection of caries and

determination of supernumerary congenitally missing or malformed teeth.

The caries rate is patients with cleft lip and palate is theoretically

same as for any other patient. However, the use of intraoral appliances for

long periods increases caries susceptibility to monitor the oral health care

more frequent recalls at 3-4 month intervals are necessary professional

applications to topical fluorides must be given regularly pit and fissure

sealants must used on all permanent teeth and in the primary dentition in

selected cases. Reinforcement of oral hygiene instructions and dietary

advice must be rigorously checked and emphasized restorative care should

be provided before carious lesions become extensive topical and local

anesthesia should be used whenever indicated.

Many of these children are mouth breathness because of deviation

of nasal septum that is frequent by associated with facial oral clefts.

Interference with their breathing during operative procedures may create a

high degree of anxiety in these parents. The dentist can overcome this

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problem by reassuring the patient by limiting the use of cotton rolls or by

the use of a rubber dam with large air holes.

Early parental education and optimal systemic fluoride use can help

to decrease this type of cones. The filled composite restorative resins are

used primarily when esthetics are concern. In the cleft population this

material is useful in restoring nursing bottle incisors and hypoplastic

anterior teeth children with cleft palate have a needed to wear maxillary

appliances such as an nance arch or space maintainer. These appliances are

used to maintain space and replace missing teeth in the anterior region. If

child is extremely incorporate and has poor oral hygiene, placing a chrome

steel crown on the abutment tooth aids in the fitting of the retentive band.

Pulp therapy

The treatment of pulpally involved teeth is important to the cleft

palate in order to maintain arch integrity and remove infection in the

primary dentition treatment of pulpally involved teeth depends on the

degree of inflammation present and the dental age of the tooth.

Teeth that will soon exfoliate should be extracted rather than

restored supernumerary teeth in the cleft area should be evaluated for

function and esthetics with the addition of acrylic teeth. Removable

Hawley’s type appliances are indicated for the replacement of anterior

teeth if the child is cooperative.

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d)

Child Abuse and Neglect

Definition – Finding of inhibited, non accidental injuries

Classified

- Sexual

- Physical

- Emotional

Sexual

- In house abuse

- Out house abuse

In house – prevalent than out house- incist or molestation by slip fathers,

friends of parents.

20% of sexually abused or molested during childhood.

STD – and finding of unexplained injuries around genitalia.

15% abused are male and less than 10 year old.

Emotional

Physical abuse

- History of alleged accident described by caretaker is not compatible

with observed physical injury or pattern injuries. E.g. intra cranial

hge.

Contributing factor – delay in seeking medical care, history of poorly

explained injuries and evidence of child neglect.

Intracranial injuries – result of blows or kicks.

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Intercranial injuries – with no marks – vigorous shaking of child –

whiplash injuries and pure take hge within brain.

Retinal hemorrhage – funduscopic examination.

Injuries – hge, bruises, black eyes, belt marks.

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