ASSOCIATIVE CONDITIONS AND CO-MITIGATING FACTORS

ORAL HEALTH

Although cerebral palsy does not cause oral abnormalities, those with the cerebral palsy have a greater tendency than the general population to have oral hygiene conditions. In particular, a child’s teeth may look crowded, vary in size and shape, and be misaligned (malocclusion), and the child may incur damage from grinding his or her teeth (bruxism). Children with cerebral palsy are also prone to bacterial infections (periodontal disease), redness and swelling (gingivitis), and damage to the mouth due to trauma.

Aspects of Cerebral Palsy Make a Child More Susceptible to Oral Health Conditions

Some aspects of cerebral palsy make a child more susceptible to oral health conditions. A child who experiences frequent seizures, for example, is more prone to head and mouth trauma, grinding of the teeth, and biting of the lips or cheeks.

Children who aren’t able to control facial muscles have trouble swallowing (dysphagia) and chewing. This inability to coordinate facial muscles also makes it difficult to brush, rinse, floss, constrict drool, and clear food pouches after a meal.

Misalignment of the “bite” (upper and lower teeth), referred to as malocclusion, is commonly found in children with cerebral palsy. Frequently, the lower teeth rest outside the upper teeth, providing less protection for the jaw and tongue. Malocclusion can cause abnormal facial appearance, misalignment of teeth, breathing through the mouth, drooling, and difficulties in biting and chewing.

Those with Cerebral Palsy are Prone to Tooth Decay

Bacterial plaque can form on teeth exposed to a considerable amount of acid, particularly in those who have gastroesophageal reflux; those who aspirate, vomit, or drool; and those with trouble swallowing and chewing. Medication is often sugary and attaches to tooth enamel. In addition, children with cerebral palsy may take longer than normal to consume a meal, causing food to stay in the mouth longer and thereby increasing the potential for cavities. Coughing, gagging, choking, and aspiration contribute to bacteria build-up. These circumstances, if not properly maintained or prevented, may lead to tooth decay.

These circumstances increase the opportunity for bacteria to colonize on teeth, placing the child at risk for tooth decay, dental caries and periodontal disease if not properly cared for or prevented. Dental caries require fillings. Periodontal disease can lead to loss of teeth. Tooth decay can be avoided with proper oral hygiene.

Some Dental Practitioners Specialize in Special Needs

Parents or legal guardians may be reluctant to seek dental treatment if their child has problems in opening the mouth, swallowing, chewing, or biting. Their fears may be misplaced as there are a host of providers who specialize in special needs.

Some professionals that specialize in the particular difficulties mentioned above, include:

  • Dentists provide cleanings, fillings, and limited surgical procedures, as well as fluoride and sealant treatments to protect the teeth.
  • Orthodontists specialize in dental displacement and treatment of malocclusions, while periodontists treat bacterial plaque, gingivitis and infections.
  • Cosmetic dentistry improves the appearance of a smile, and dietitians develop specialized diets that offer food alternatives, feeding instructions, and appropriate food textures.
  • Speech and language pathologists help an individual develop facial muscle control and coordination, thereby improving the ability to swallow without choking, inhaling, and aspirating food and liquids.

Choosing professionals with experience and training in the treatment of children with special needs is recommended when seeking care. Oral care practitioners will likely consult with the child’s primary care physician to coordinate primary care treatment. Special care will be required for the use of any pharmaceuticals – those used during the procedure as well as those provided in case of emergency. Breathing difficulties, seizure status, acid reflux, and sedation constraints may affect the dental practitioner’s treatment protocol.

Safety is a primary concern of those with special needs training. Safety precautions require training in CPR, clearing breathing pathways, supporting involuntary body movements, controlling shakes and seizures, and reducing the risk of aspiration. The practitioner trained in special needs is prepared for contingencies.

Trained professionals accommodate treatment in the wheelchair or better understand how to transfer the patient to the dental chair while accounting for the individual’s physical requirements.

Trained individuals also provide a calm, relaxing and supportive atmosphere, allow extra time to explain procedures slowly, and provide repeated, simple instructions for short-term memory capacity. They monitor breathing, especially in those unable to communicate. For those with communication challenges, trained professionals seek ways in which the patient is able to communicate discomfort or concerns.

The focus of everyday care, as well as long-term care, will help optimize functionality and thwart bacterial build-up and infections. Those trained in special needs may have helpful information and education materials to assist caretakers with daily oral hygiene measures.

The Child’s Primary Caretaker is Responsible for Daily Oral Hygiene

The child’s primary caretaker will be responsible for supervising daily oral hygiene. This includes brushing, flossing and rinsing regularly throughout the day, particularly after liquid, solid or medication intake. If rinsing with water is not an option, sweeping the mouth with a gauze-wrapped finger, or using a disposable applicator swab may be helpful. Caregivers should also schedule regular check-ups for dental cleanings, fluoride treatments and sealants.

The child’s registered dietician, dental practitioner, and speech and language pathologist may lend advice on how best to support the child’s oral functioning, food intake, and oral hygiene to maintain oral health.

Conditions related to oral health include:

  • Bruxism
  • Dental caries (cavities, tooth decay)
  • Drooling (sialorrhea)
  • Dysphagia
  • Gingivitis
  • Malocclusion
  • Mouth trauma
  • Periodontal disease

Budgeting may be required, especially for those without dental health insurance coverage. Most dental practitioners today have payment plan options and dental care packages.

Every Child’s Condition Is Unique

The list of possible primary, secondary, and associative conditions, as well as co-mitigating factors, can be grouped into categories, but not all conditions will be experienced by an individual with cerebral palsy. Some may encounter conditions not listed, as well.

Cerebral palsy can take a mild, moderate, or severe form depending on a host of factors. The type, location, and extent of impairment are considered, as well as any associative conditions and co-mitigating factors, when creating a treatment plan. Over the course of the person’s life, he or she may encounter any number of associative or co-mitigating factors.

Cerebral palsy is non-progressive, meaning the brain injury or malformation will not progress in severity. However, secondary conditions resulting from the brain damage may develop and change over time. For example, brain injury can cause facial muscle impairment which doesn’t change over time. Chewing, swallowing and aspiration can occur when facial muscles are impaired. Aspiration can lead to pneumonia, and pneumonia is a health condition that can become worse or better over time.

Impairments can change with – or without – proper management. As a person ages, the muscular-skeletal structure may age prematurely depending on postural conditions, care, treatment and therapy. Other health conditions or life circumstances may also affect the individual’s condition over time. These can include access to health care, health insurance benefits, exposure to toxins, new health conditions, socialization, exercise, and traumatic accidents or events.

MyChild™ lists the possibilities in hope of providing families with a better understanding of the types of conditions – and categories of conditions – an individual with cerebral palsy may encounter over their lifespan. An overview of the different types of professionals likely to treat these conditions is also contained here. It should be noted that MyChild™ does not dispense medical advice. Any conditions your child may experience should be discussed with his or her medical team for proper diagnosis and treatment. In the case of emergencies, contact 911 immediately.

ASSOCIATIVE CONDITIONS AND CO-MITIGATING FACTORS Proper Terminology

Because the terminology used is so specific, yet remarkably similar, terms such as primary, secondary, associative and co-mitigating conditions are used interchangeably, yet incorrectly. It is helpful to know the difference between the terms when attempting to understand cerebral palsy.

Primary condition - These are a direct result of the brain lesion or brain malformation. Primary conditions affect motor coordination, motor control, muscle tone, posture and balance. Gross motor, fine motor, and oromotor functioning are also considered primary conditions of cerebral palsy.

Secondary condition - Primary conditions, in turn, may lead to secondary conditions such as inability to chew, inability to swallow, breathing difficulties, bladder and bowel control issues, and communication difficulties. If the brain lesion or malformation that caused cerebral palsy did not exist, these secondary conditions would not be present.

Associative conditions - Research has shown that individuals with cerebral palsy often have associative conditions not caused by the same brain injury or malformation which caused cerebral palsy, but proven to be common with individuals who have cerebral palsy. If the brain injury or malformation that caused the cerebral palsy did not occur, these conditions may still be present in the individual. Associative conditions include intellectual impairment, epileptic seizures, hearing impairment, and vision impairment.

Co-mitigating factors - An individual may also have health conditions separate from cerebral palsy. Unlike associative conditions, researchers have not concluded that these conditions have a high correlation to cerebral palsy. Co-mitigating factors exist regardless of cerebral palsy. Examples of co-mitigating conditions of cerebral palsy include autism, attention deficit hyperactivity disorder (ADHD), and asthma.

Associative Conditions and Co-Mitigating Factors

There are eight major categories of associative conditions and co-mitigating factors. To learn more about them, click one of the following: