Management of oral and dental pathologies in children with disabilities
The term “disabled” is rejected today.
In terms of oral health, these are patients for whom a physical, mental or medical impairment prevents a traditional relationship of oral care or hygiene.
Currently, the term “patients with disabilities” is used.
- GENERAL INFORMATION ON CARE
Any care requires the agreement of the person(s) in charge of the child.
The child with a disability is generally monitored by a team and integrated into a structure.
Dialogue with those around them is essential, on the one hand, to gather information about the child and on the other hand, to have an information and prevention action at the level of habits.
oral hygiene, diet, interception of various disorders.
- Anamnesis
Knowledge of the medical file (pathologies, treatments, previous interventions) is essential. The dentist must be considered an integral part of the healthcare team and the first step is to contact the attending physician or pediatrician.
It is important to assess the motivation and needs of the patient and those around them. Interviewing should not be limited to purely medical matters.
The way in which the patient feeds or is fed provides indications of expected pathologies and treatment directions.
- Oral examination
The oral examination should not only follow the broad outlines of the clinical examination of any child but also include the specific search for associated pathologies.
- Care and prevention actions
The role of the dentist is to carry out the necessary care without multiple sessions or general anesthesia.
Patients with disabilities have the same right as others to the best possible treatment.
When two treatments or materials are in the balance, the choice must be made on the one with the best resistance over time.
Likewise, the implementation of monitoring and prevention adapted to the patient and their environment is an obligation.
The materials and techniques must be adapted to the child’s disability and level of autonomy.
An electric toothbrush can be a help, if the user (child or parent) has learned how to use it.
When the deficiency is more severe, such as a bedridden child, oral hygiene is ensured by the parents, using a toothbrush, compress or a rubber finger cot.
- CHILD WITH DOWN SYNDROME
- General information
Trisomy 21 is the most common chromosomal abnormality.
It affects 1 child in 700 to 800 births (5 births per day).
It is also sometimes called Down syndrome. There are three forms: free and homogeneous, translocation and free, combining physical manifestations and intellectual deficiency of varying severity depending on the person (average IQ of 40-45 for 86% of them).
Life-threatening risks can arise when the cardiac anomaly, encountered in 40% of cases, is associated with a risk of infective endocarditis.
The rules for EI prophylaxis must be applied.
Similarly, spinal cord compression can in some cases represent a danger for the patient and, more often, discomfort which will lead to choosing a semi-reclining, or even sitting, position rather than lying down.
One of the consequences of immunosuppression associated with Down syndrome is the frequency of periodontal damage.
especially since oral hygiene is difficult to ensure due to the lack of manual dexterity and the lack of cooperation of the patient. Gingivitis is regularly
encountered. It often takes the form of a linear gingival erythema classically associated with immunodepression.
Extension to the underlying bone is more common than in the general population, in the form of aggressive periodontitis. Tooth loss is all the more rapid when the dental roots are short and the tongue is in propulsion, destabilizing the anterior teeth.
- Clinical examination
The cranial skeletal characteristics give the patient with trisomy 21 a very recognizable appearance with a flat profile, flattened cranial base and occipital bone, as well as brachycephaly. Morphological anomalies are observed: short nose, small ears.
- Oral characteristics:
Dental anomalies in number, size, shape and
Eruption is common. Crowns are generally more globular in shape and conoid teeth are more common than in the rest of the population. Delayed eruption of primary and permanent teeth is common. Tooth wear is often rapid due to bruxism and frequent erosion related to gastroesophageal reflux.
Hypotonia, motor coordination problems and congested airways in many ENT problems have functional consequences, the most notable of which are:
lip hypotonia, low position and protrusion of the tongue, mouth breathing and atypical swallowing.
- Support
The role of the practitioner is to inform those around them of these different characteristics, to establish screening, a
interception and prevention of these problems and ensuring care.
- Palatal plate therapy : its primary goal is
to activate hypotonic areas (lips, tongue) and to develop new tongue positioning habits.
The principle is to create a palatal plate which will be held in place by suction effects before the appearance of
first teeth and by hooks as soon as the teeth are in place. The plate is regularly changed according to the child’s growth.
- Action on the periodontium : control of dental plaque (or bacterial biofilm) is essential to prevent
the onset or persistence of gingivitis. Implementing appropriate oral hygiene is essential.
- Care : Cooperation varies greatly between parents, allowing or not allowing care while awake or under conscious sedation, particularly at MEOPA.
General anesthesia remains the last resort for both children and adults.
- CHILD WITH CEREBRAL MOTOR INFIRMITY
- General information
Cerebral palsy (CP) results from early brain damage (antenatal or perinatal up to the age of 2 years).
We speak of cerebral palsy when intellectual faculties are affected.
Generally speaking, the practitioner encounters patients with hypotonia or, more frequently, hypertonia with a more or less marked absence of movement control.
Epilepsy is a common clinical feature. Screening is generally early. Management is provided by a multidisciplinary team, often excluding dentists.
- Oral characteristics
The risk of caries varies among children with cerebral palsy. However, periodontal disease is common, a consequence of the difficulty in maintaining good oral hygiene. Gum growth following the use of antiepileptic drugs is regularly observed.
Prevention involves controlling the biofilm, appropriate brushing supplemented by antiseptic agents, prophylactic cleaning and regular scaling.
Trauma is common; poor posture or gait control, epileptic seizures, as well as wear and tear from bruxism and self-mutilation.
- Support
Mouth opening is sometimes poorly controlled, as are movements of the head and the rest of the body in the chair.
These phenomena completely or partially cease when the equimolar mixture of oxygen and
nitrous oxide (MEOPA) for treatment sessions under conscious sedation.
- CHILDREN WITH PERVASIVE DEVELOPMENTAL DISORDERS
- General information
Among neuropsychological disorders, autism is a disease that is still poorly understood, the expression of which remains very variable from one individual to another. We also speak of “Pervasive Developmental Disorders (PDD)” grouped into
“autism spectrum disorder (ASD)”.
- Oral characteristics
Autism is considered a predictor of high caries risk. Several factors may explain this risk:
Drugs that cause a lack of saliva;
A predilection for soft/sweet foods;
Poor oral hygiene;
The need for outside help in brushing teeth;
There are no specific oral characteristics or symptoms associated with this disease.
- Support
The first step should be an interview with the parents. The sessions are repeated in the same order to give the child some guidance.
Preparation of the child with autism using photos describing the office and the session, which gives the child reference points.
In some cases, conscious care is not possible. Conscious sedation using MEOPA is a solution, but failures are not uncommon.
General anesthesia remains the last resort for patients most resistant to treatment.
- CHILD WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER
- General information
Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder defined by the presence of inattention and/or hyperactivity that is more frequent and severe than in individuals at the same stage of development.
ADHD is a complex and multifactorial disorder caused by the confluence of different psychophysiological, genetic, biochemical and environmental risk factors.
The therapeutic strategy is multidisciplinary, based on the overall assessment of the child and the family.
- Oral characteristics:
Children with ADHD are at greater risk than others for head injuries and multiple injuries.
Children taking amphetamines have an increased risk of developing gingival hyperplasia.
More bruxism and dental attrition are observed in children with ADHD than in other patients.
- Support
The practitioner must behave firmly. All cognitive-behavioral methods can be used, including the “explain, show, do” technique and positive reinforcement. Appointments should preferably be scheduled in the morning, when the child, less tired, will be more attentive. Treatment sessions should be short to avoid overtaxing the child’s attention.
Local anesthesia should be particularly effective and painless. Good cooperation should be rewarded at the end of the session.
Depending on the child’s behavior, cooperation, difficulty and number of treatments to be performed, pharmacological sedation techniques (sedative premeditation, MEOPA) are
indicated and, as a last resort, general anesthesia.
The prevention advice given to parents is repeated to the child.
THE Parent-supervised tooth brushing should last longer than for children of the same age.
- CHILD WITH SENSORY DEFICIENCY
- Visual impairment
a-Oral repercussions
The oral condition of visually impaired children is no different from that of a child without impairment.
b-Support
All treatments can be performed. The patient must be warned before any contact or use of instruments that could surprise them and trigger a defensive reflex.
- Hearing impairments
- Oral repercussions
As with visually impaired children, there are no specific oral repercussions.
- Support
It is necessary to plan longer treatment sessions than usual. It is necessary to avoid background noise and a
too loud sound environment, as well as suction.
CONCLUSION
Early guidance must be established, because there is no point in adding dental handicap.
Parents will be informed about food hygiene, brushing and the need for visits every 4 months for young patients and every 6 months for adolescents and young adults.
BIBLIOGRAPHY
1-Barkley RA. et al. International consensus statement on ADHD.J Am Acad Child Adolesc Psychiatry 2002; 41:1389
2-Dorin M. et al. Assessment of oral health needs of children and adolescents attending an institute
medical-educational services for children and adolescents with multiple disabilities in France. Prat Organ Soins 2006; 37:299-312
3-Sixou JL. Oral-dental aspects of trisomy 21 in children. Arch Pediatr 2008; 852-854
4-SixouJL.et al. The child with a disability. In Clinical Pediatric Odontology JPIO 2012
Management of oral and dental pathologies in children with disabilities
Wisdom teeth can cause infections if not removed in time.
Dental crowns protect teeth weakened by cavities or fractures.
Inflamed gums can be a sign of gingivitis or periodontitis.
Clear aligners discreetly and comfortably correct teeth.
Modern dental fillings use biocompatible and aesthetic materials.
Interdental brushes remove food debris between teeth.
Adequate hydration helps maintain healthy saliva, which is essential for dental health.