You all must be wondering why a Consultant Child Neurologist is writing a blog on Oral Health in children, which normally is a domain of my esteemed dental colleagues. However, before I answer that, for those who haven’t come across Cerebral Palsy let me briefly explain to you what it is.
Cerebral palsy(CP),one of the most common cause of physical disability in children, is a group of complex neurological disorders caused by non-progressive injury to the developing brain which leads to abnormalities of movement and posture. CP may be associated with uncontrolled body movements, seizures/epilepsy, balance-related abnormalities, sensory dysfunction, and intellectual disability. The prevalence of CP is approximately 2.1 per 1000 live births and is commonly seen in extreme premature babies.
As a Consultant in Child Neurology, one of the most common requests I receive is to review children with CP for one reason or the other. So, reverting back to the opening question, I was asked to see Alice (not real name), a 7-year-old girl with CP admitted to the pediatric ward in one of the hospitals I work in. She was suffering from severe Epilepsy (seizures), spasticity (muscle tightness) and had a specific type of CP called "Combined Spastic-Dystonic Cerebral Palsy".
For those who are not aware of types of CP, there are different types of cerebral palsy as follows
1. Spastic CP
The most common type which presents with stiff muscles on one limb of the body or in all four limbs, sometimes including the tongue, and pharynx affecting swallowing. Children with this form of cerebral palsy may have abnormal walk or in severe cases, wheel chair bound. Children with spastic CP may also have intellectual disability, seizures, and difficulty speaking and swallowing.
2. Dystonic-Athetoid (Dyskinetic) CP
Dystonic type of CP is a “non-spastic” form and is associated with muscle tone that fluctuates between being loose and tight. Children can become very rigid, back arch (banana posture), hold breath, tachycardic, and may need Intensive care admission due to “Dystonic Crisis”. Athetoid (hyperkinetic) CP presents with relaxed muscles during sleep, with some involuntary jerking (chorea) or writhing (athetosis) movements.
3. Ataxic CP
This is less common and is marked by problems with balance and depth perception, as well as an unsteady, wide-based gait.
4. Combined CP
Usually a mix of Spastic and Dyskinetic CP.
A brief history from Alice’s parents along with a complete Neurological examination was carried out on Alice. She was found to be extremely rigid, was back-arching continuously (like a banana), had high fever, sweaty, flushed skin, tachycardic (high heart rate), and very high respiratory rate. She was clearly in “Dystonic Crisis”. My Pediatric colleagues had already looked for every possible cause of fever including infection markers in blood which had all returned normal. Her condition deteriorated over the course of the day in spite of adequate management, therefore she needed to be transferred to Pediatric Intensive care to monitor her breathing pattern as she was started on stronger medications to improve her Dystonia.
Children with Dystonic CP can be very challenging to manage as their tone keeps on fluctuating. The Dystonia can get worse for various reasons, one of the commonest being pain.Many of them are unable to communicate the cause of their pain, common reasons being Hip girdle pain due to dislocation, tummy pain because of constipation,severe gastroesophageal reflux etc. The other common reasons for worsening dystonia in children with Dystonic CP are infection, fever, respiratory tract infection, and certain medications.
Alice had been thoroughly investigated for all the common causes listed above so we went back to the rule number one of Pediatric Neurology: TAKE A COMPREHENSIVE HISTORY!. We spoke to the parents again carefully unpicking any causes of pain, and that’s when the parents mentioned that Alice has Bruxism and was sticking her tongue out quite a bit over the past week which was unusual for her. We had a thorough look in her mouth where we found the “cause” for her dystonia. Alice had a quite a few carious teeth and one of them was severely jagged. Her tongue was rubbing vigorously against the sharp tooth leading to a large tongue ulcer. This ulcer in turn was causing her excruciating pain leading to the “dystonic crisis”.
Children with CP have a higher risk of dental disease partly due to difficulties in maintaining effective oral hygiene and partly because health care professional and parents are “focusing” on other pressing demands like seizures, muscle tone, physical disability, etc. Dental Caries is one of the most common oral health issues, with studies (Sedky 2018) reporting Dental Caries up to 55% of children with CP presenting to dentists. The common causes of caries in children with CP include inadequate oral hygiene, mouth breathing, excessive drooling, medication side effects, enamel hypoplasia, and food pouching.A recent study (Akhter et al 2019) assessed Oral-Health related Quality of Life index in school going children with CP. This study revealed Dental caries was 7-times higher in children with CP and children had frequent tooth pain, bad breath, trouble sleeping, avoiding smiling, all of which had a negative impact on their Quality of life.
Bruxism or Teeth Grinding is also common in CP and other neurobehavioral disorders like Autism, can be intense and persistent and cause the teeth to wear prematurely. It commonly causes teeth to become jagged which can lead to injury of surrounding oral mucosa. Periodontal disease (Gum problems) and Malocclusion (Misaligned teeth) are other oral health problems frequently seen in children with CP.
Alice was seen promptly by Oral Surgeons, who removed the “culprit” tooth and advised further plans for her oral health. Alice’s dystonia rapidly improved within 48 hours and was subsequently discharged home after 5 days.
Oral health issues are common in children with CP and are usually underrated and underestimated. A concerted effort by all Health Professionals looking after kids with CP is paramount to unpick any abnormalities at the earliest before they start affecting their physical and mental well being.