Management of BD pathologies in disabled children

Management of BD pathologies in disabled children

O

1.  INTRODUCTION

Children with disabilities are particularly predisposed to the development of oral pathologies, and for this population, the prevalence of dysmorphoses, periodontal diseases and caries is higher than for the general population. Furthermore, their care in the dental practice requires taking into account their cognitive problems, their anxiety, their psychomotor difficulties and the risk of comorbidity linked to their systemic disorders as well as oral pathologies linked to their general health. The oral health of these children poses a specific problem that requires a specific preventive approach.

2.  Definition of disability

The very term “Handicap” comes from the English “Hand in cap” and refers to a gambling model current in the 16th century. and bet on a hat. A handicap refers to an unfavorable, negative situation, a “bad draw.”

According to Larousse, disability is defined as an “infirmity or deficiency, congenital or acquired.”

Players traded items to each other 

3. Disability classification 

 In 1980, the WHO proposed three levels of analysis to characterize disability and established the International Classification of Disabilities (ICIDH): 

-The deficiency: which corresponds to the lesion aspect of the handicap,

-Incapacity: which represents its functional aspect, 

-The disadvantage: which corresponds to the situational aspect of the handicap. 

        4- Consequences of disability on oral health 

           4. 1 Infectious diseases 

               4.1.1 Caries disease 

Is multifactorial and consists of a demineralization process leading to the destruction of the hard tissues of the tooth. It is the result of interactions between the oral ecosystem and the calcified dental tissues. In some children, we note the presence of oral aversions making this gesture impossible. Autistic children, for example, have hypersensitivity of the oral sphere and sometimes refuse any intrusion at the level of the mouth. On the other hand, the various psychomotor disorders affecting these children, can limit the self-administration of oral care and make the involvement of a third party mandatory. The frequency and quality of brushing can then be called into question. 

 Dietary factors also play a significant role in the development of caries. Dietary intake is quite unpredictable in these children. In addition, some children are treated long-term with medications that contain varying amounts of sugar. Other medications, such as neuroleptics, used in severe epileptics, for example, cause more or less severe xerostomia and therefore increase the risk of caries by eliminating the protective role of saliva.

Several aggravating factors can be noted:

• Poor oral hygiene and the presence of tartar 
• Certain immunodeficiency syndromes 
• Insufficient stimulation during chewing (children with gastrostomy in particular) 
• Taking certain medications such as antiepileptics, which can cause gingival hyperplasia, sometimes delaying the appearance of teeth

Children with Down syndrome are a particularly at-risk population. Indeed, Down syndrome is responsible for immunodeficiency, fragility, and premature aging of periodontal tissue, increasing the risk of periodontal disease ranging from gingivitis to tooth loss. 

2. Traumatic pathologies

Dental trauma must also be taken into account, which can take the form of a dental fracture, mucosal trauma such as a bite, etc. The etiology of these pathologies is diverse and varied, but we can already note: 

• Delayed motor development and epileptic seizures that promote falls 
• Lingual and/or labial interposition 
• The various malocclusions encountered and in particular open bites or maxillary pro-alveoli particularly exposing the incisors. 
• Self-mutilation, which some children may exhibit, sometimes leading to self-inflicted trauma.

3. Functional disorders

Breathing is physiologically done through the nose, but in some children, this breathing is supplemented by the mouth. This is called mouth breathing. People with Down syndrome are particularly affected due to their skeletal characteristics (hypoplasia of the mid-face). This is not without consequences at the general level: the child has an adenoid facies (long face and half-open mouth), repeated ENT infections and a low-set tongue. At the oral level, there is a dry mouth increasing the risk of caries and periodontitis as well as frequent malocclusions (maxillary endognathia in particular).

These malocclusions also fall into the category of craniofacial anomalies, which have functional consequences for the child. Certain major syndromes, such as Crouzon, Marfan, or Pierre Robin, are characterized by disrupted dental eruption sequences, supernumerary teeth, or even agenesis, disorders that compromise masticatory function.

Swallowing disorders range from sucking-swallowing incoordination to gastroesophageal reflux and choking. These gastroesophageal refluxes can cause quite severe dental erosion and sometimes lead to avulsions. These swallowing disorders are caused by etiologies such as oral-facial dysmorphosis or prematurity. 

In extreme cases, these disorders require medical teams to resort to gastrostomy, or enteral feeding. This increases the risk of oral disorders because self-cleaning by saliva is no longer performed in the mouth. Oral stimulation through chewing is lost. The risk of caries is then zero, but the risk of periodontal disease is increased. 

Finally, salivary incontinence can be found in 15 to 30% of disabled children, according to the authors. It can be linked to psychomotor disorders, a lip occlusion defect, or even a flexed head posture.

4. Dental anomalies

These are the anomalies of:

-Hypomineralization-type structure in more than a hundred syndromes, mostly of an ectodermal nature: junctional epidermolysis bullosa, tricho-dento-osseous syndrome, X-linked hypophosphatemic rickets, etc.  

-Number (agenesis, supernumerary teeth) – Shape, size (microdontia, short roots) –

 -Eruption (eruption delay, anarchic eruption order)

5. Dental erosion

Related to regurgitation

5-Oral care needs in the population with disabilities 

The need for care among this population is present but often encounters difficulties of a behavioral nature or of adapted infrastructure. 

        5-1 Preventive strategy for children with disabilities

The preventive strategy must be adapted to the severity of the disability and the child’s surrounding environment through individualized prophylaxis:  

           5-1-1 Action on food 

• A balanced diet must be established: limiting the consumption of refined sugar.
• Limit food intake: 3 to 5 meals per day and avoid snacking: it is important to prevent early cavities from early childhood by raising parents’ awareness of the risks associated with nighttime feedings of sugary bottles.
• It has been found that children who are institutionalized have very few cavities, this is certainly due to the absence of snacking, consumption of candy and soda .

            5.1.2 Appropriate oral hygiene

• Brushing will be done by a third person if the child cannot do it.
• Brushing frequency: 3 times a day after meals, with preference given to brushing in the evening.
• Mechanical means to be used: the toothbrush must be adapted to the person using it, in this case a child with a disability (small head size, handle adapted to the difficulty of gripping). The use of an electric toothbrush is possible if the cooperation and disability of the patient allow it to avoid any risk of injury to the mucous membranes.
• If brushing is not possible, using a compress coated with fluoride toothpaste or soaked in a fluoride mouthwash is recommended to remove plaque.
• Fluoride-based brushing aids are recommended, in the form of toothpaste, mouthwash, or fluoride gels. Molecules based on chlorhexidine, hexetidine, sanguinarine, and stannous fluoride are recommended. These aids should only be used if the child is able to spit to avoid the risk of drug resistance.
• If cooperation and disability allow, additional means, such as floss and interdental brushes, are desirable.
• Manual brushing techniques including the roller method are not always applicable, and a rotation method can be considered.

             5.1.3 Fluorine 

The choice of fluoride vectors, their dose, their form and their frequency of administration must be based on the terrain and the caries risk. A review of fluoride intake and an assessment of caries risk are essential before any prescription to avoid the risks of therapeutic overdose responsible for dental fluorosis. 

            5.1.4 Medical monitoring and follow-up 

One to four annual medical visits are required. These visits will include a clinical examination to screen for cavities and other oral pathologies, plaque control, and the application of fluoride or chlorhexidine gels, varnish, and pit and fissure sealing.

          5.1.5. Individualized prophylaxis 

The importance of the disability will be the key to the implementation of this individualized prophylaxis. 

Importance of disability	Hygiene measures
Patient able to understand and perform simple actions	Good oral hygiene is possible, it can be done individually under the supervision of the supervisor or not.
Patient able to understand but unable to perform simple actions	The entourage or supervisor must carry out the brushing
Patient unable to understand but accepting the idea of ​​hygiene	The entourage or supervisor must carry out the brushing
Patient unable to understand or accept the idea of ​​hygiene	The hygiene factor is very difficult to control; cleaning with a compress soaked in chlorhexidine and/or fluoride solution will be the only option. Prevention will be essentially based on controlling dietary intake and prescribing general fluoride.

    5.2 Practitioner’s attitude towards a child with a disability

A visit to the dentist by a parent of a child with a disability is always an emergency for that parent, and the care provided must be adapted to the clinical situation, which is often experienced as a tragedy, rightly or wrongly, for the family.

Solutions to these children’s dental problems are often complex and beyond the scope of general dentistry. If the dentist cannot treat the patient, their duty is to refer them to a specialized center, where an oral care program adapted to this population can be established. 

The dentist can intervene without the active cooperation of the patient and it is the patient’s relational possibilities, the degree of urgency and the multiplicity of care which will guide the choice of the mode of intervention, it will be:

– Mindfulness: the vigil state, when possible, remains the preferred mode of intervention because it is compatible with diagnostic and therapeutic techniques.

– Sedative premedication: Premedication can be an interesting alternative to avoid a more serious intervention, but it is a procedure that has its indications and risks. It can be administered orally, rectally, or intravenously. However, the pharmacokinetic effects vary greatly from one child to another.

– Conscious sedation: this state is achieved using an equimolar mixture of oxygen and nitrous oxide (MEOPA). This is the ideal indication for the treatment of highly anxious people.

– General anesthesia: this method of intervention has the advantage of not requiring any cooperation from the patient and of being able to carry out all the care in a single session.

6.  CONCLUSION

Access to dental care for patients with disabilities is limited by their difficulties in cooperating in the dental office environment, by their inability to express their pain in a way that is understandable to the practitioner, by the inability of those around them to perceive their discomfort and by the lack of suitable care structures nearby. The state of progress of diagnosed oral pathologies suggests that the experience of oral pain is regularly underestimated for these patients, these are factors that suggest and encourage us to strengthen our preventive action with regard to this at-risk population. Above all, they are people with a body that is failing them! 

7. Bibliography 

1-Anastasio D, Hein-Halbgewachs L, Droz D, Gerard E. Disability and dentistry : proposals for the future. Odonto-Stomatological News 2007;239:277-287.

2- Mylène Zind. Care for children with disabilities in Sweden: the role of dental hygienists. Life Sciences [q-bio]. 2020. ffdumas-03115369f.

3-Chantal Naulin ifi Clinical Pediatric Dentistry, CDP 2021.

4- Chloé Villain. Oral care in pediatric dentistry: retrospective analysis of children treated in an oral medicine department. Life Sciences [q-bio]. 2021. ffdumas-03560846f.

Management of BD pathologies in disabled children

  Untreated cavities can cause painful abscesses.
Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

Management of BD pathologies in disabled children