Authored by Vidhu Bhatnagar*
Abstract
Cerebral Palsy (CP) is a central nervous system disorder which is caused due to damage to the developing brain usually occurring in perinatal period. There could be multifactorial etiology with various factors such as maldevelopment of the brain, perinatal stroke, prenatal infection, genetic disorder, ischemic insult in utero or prematurity, thrombophilic disorders, teratogenic exposures, multiple gestations ,maternal fever, exposure to toxins, abdominal trauma, malformation of brain structures, abnormal fetal presentation, instrument delivery, hyperbilirubinemia, meningitis, chronic lung disease, shaken baby syndrome as the possible causes. The children inflicted with CP are at a higher risk for developing oral manifestations such as Early Childhood Caries (ECC) due to poor oral hygiene, intake of soft diet, difficulty in chewing and swallowing and increased use of sugary oral medications. Behavioural challenges due to associated mental retardation demands pharmacological management under General Anaesthesia (GA) and we present a case series of successful management of Severe ECC in five children diagnosed with CP managed with full mouth rehabilitation under GA. The aim is to highlight importance of counselling, preoperative preparation of patients, surgical modalities and postoperative rehabilitation.
Keywords: Intellectual disability; Dental caries; Tooth, Deciduous; Rehabilitation; Central Nervous System Diseases
Introduction
Cerebral Palsy (CP) is a brain disorder which is caused due to damage to the developing brain usually occurring before or shortly after birth. It is neither progressive nor communicable and causes defects in the central nervous system leading to abnormal motor function, muscle tone and movements [1]. The etiology can be attributed to risk factors which manifest during perinatal period [2]. It has been attributed to multifactorial etiology with various factors such as maldevelopment of the brain, perinatal stroke, prenatal infection, genetic disorder, ischemic insult in utero or prematurity, thrombophilic disorders, teratogenic exposures, multiple gestations, maternal fever, exposure to toxins, abdominal trauma, malformation of brain structures, abnormal fetal presentation, instrument delivery, hyperbilirubinemia, meningitis, chronic lung disease, shaken baby syndrome etc. as its possible causes [3,4]. This condition has been classified into various types, most commonly into three major categories which are pyramidal (Spastic), Extrapyramidal and Mixed [5]. The children inflicted with CP are at a higher risk to develop oral manifestations such dental caries and plaque accumulation as compared to general population due to a variety of factors which result in poor oral hygiene, their dietary patterns such as soft diet, difficulty in chewing and swallowing and increased use of oral medications also contribute to the higher risk [6].
There is also an increased incidence of various oral conditions such as gingival hypertrophy, hypoplastic teeth and injuries to upper front teeth in these children [7]. Associated behavioural challenges and the extent of oral manifestations necessitates pharmacological management under General Anaesthesia (GA) to manage defects due to Early Childhood Caries (ECC) [8,9]. The administration of GA has inherent risks, and these children are at an increased risk to develop perioperative hypothermia, hypotension, delayed emergence from general anaesthesia, seizures, and airway-related morbidity [10]. We present a case series of successful management of Severe ECC in children diagnosed with CP managed with full mouth rehabilitation under GA with an aim to highlight the various treatment modalities, GA approach and counseling of parents and guardian involved in full mouth rehabilitation of children with ECC requiring full mouth rehabilitation. These children require a multidisciplinary approach involving the Pediatrician, Pediatric Dentist and Anaesthesiologist for effective delivery of care.
Case Report1
A 5-year-old male child, a diagnosed case of spastic type CP was brought with the complaint of pain in the upper and lower back tooth region for the past 6 months. History of child having difficulty in chewing food and the child appeared malnourished. Patient was not responsive to verbal commands and was undergoing treatment and physiotherapy for CP. The patient was taken to another center for dental treatment earlier, but treatment could not be accomplished due to behavioral issues of the child. The post-natal history of the child revealed a delayed birth cry and subsequent intubation and admission in NICU for seven days. On examination; Intra Oral Examination revealed dental caries in relation to 51,52,5 3,54,55,61,62,64,65,74,75,84 and 85, pulpal involvement was found in relation to 52,54,62,64,74,84,85 and 75 was found to be grossly destructed. However, airway examination could not be carried out as patient was not responding to verbal commands. The child was positioned on his parent to provide restraint and the mouth was stabilized using mouth gags to perform the intra oral examination. A provisional diagnosis of chronic irreversible pulpitis in relation to 54, 52, 62, 64, 74, 75, 84, 85, dental caries 51,54,61,64 and grossly destructed 75 was made (Figure 1 (a and b)). The vital parameters appeared normal however auscultation of chest revealed crackles in basal regions bilaterally.
The treatment plan was devised for complete rehabilitation which included preparatory phase in which the parents were counseled, and dietary instructions were given, a corrective phase which included endodontic treatment and restoration of all restorable teeth and a surgical phase which included extraction of unsavable tooth was drawn out. This treatment plan was discussed with the parents and informed consent was obtained from the parents and Pre anaesthetic checkup (PAC) was performed.
Treatment protocol
In the surgical phase patient was intubated nasally and pulpectomy was carried out on 54,52,62, 64,74, 84 and 85, composite restorations were carried out on 55,52,51,61,62,65,84 and stainless-steel crowns were placed on 54,74,85. The grossly destructed 75 was extracted after injection of 2% lignocaine adrenaline 1:80,000 (Figure 1 (c and d)). Hemostasis was achieved; and preventive care was administered using 2% sodium fluoride gel. The perioperative period was uneventful and extubation on table performed after removing the throat pack and patient monitored in Post Anaesthesia Care Unit (PACU) with the parents and later shifted to ward. The details of GA approach are discussed separately for all the patients together.
Case Report2
A 4-year-old male child, a diagnosed case of CP was brought by his parents with complaints of signs of pain and difficulty in chewing food by the child. History by parents revealed premature delivery at 34 weeks of gestation and low birth weight of 1900gms. The child had delayed milestones and was on a semisolid diet (high on carbohydrates and sucrose) prepared in a mixer which could be the major cause behind Severe ECC. On examination; Intra Oral Examination revealed extensive damage to the deciduous dentition, dental Caries with pulpal involvement in relation to 51,52,53,54,61,62,63,64,74,85. The 84 was grossly destructed and Dental Caries not involving the pulp was seen in relation to 73,83 (Figure 2 (a and b)). The lower left deciduous second molars i.e 75 had not erupted fully in the oral cavity and corelated to the finding of delayed milestones. Radiographic investigation in the form of Radiovisiograph (RVG) was carried out with the help of parental help to restrain the child and this confirmed the final diagnosis (Figure 2e).
A treatment plan was devised, parents were counseled, and dietary instructions were given in preparatory phase, corrective phase which included endodontic treatment and restoration of all restorable teeth and a surgical phase which included extraction of unsavable tooth was drawn out. Informed consent was obtained from the parents and PAC was carried out. In the surgical phase patient was orally intubated and throat pack. The child was scrubbed and draped; oral hygiene measures were carried out using a toothbrush. Pulpectomy was carried out on 51,52,53,54,61,62,63,64,74,85. All the molars were restored with stainless steel crowns except 84 and 75. The 84 had to be extracted after injecting 2% lignocaine adrenaline 1:80,000 and hemostasis was achieved with placement of resorbable sutures in situ. The lower left second molar 75 which was partially erupted was restored with pit and fissure sealant. 51, 52,61,62 were restored with strip crowns after placement of fibre posts at the coronal one third of the 52, 62 to build tooth structure. The upper and lower deciduous canines were restored with light cure composite restorations (Figure 2 (c and d)). Preventive protocol was instituted using 2% sodium fluoride gel in disposable trays applied intraorally. The perioperative period was uneventful, extubation on table performed after removing the throat pack and patient monitored in PACU along with parents and later shifted to ward.
Case Report3
A 7-year-old male child, a diagnosed case of CP was brought by his parents with the chief complaint of refusal to eat food. On examination it was found that the child had deep dental caries in relation to 65, 74, 85. There was a restoration in 75 and 84 was grossly destructed (Figure 3 (a & b)). The treatment plan was devised for complete rehabilitation: preparatory phase in which the parents were counseled, and dietary instructions were given, a corrective phase which included endodontic treatment and restoration of all restorable teeth and a surgical phase which included extraction of unsavable tooth was drawn out. This treatment plan was discussed with the parents and informed consent was obtained from the parents & PAC was performed. The child was taken up for full mouth rehabilitation under GA and intubated orally. Pulpectomies were done on 65,74,75,85 followed by placement of stainless-steel crowns. Grossly destructed 84 was extracted (Figure 3 (c & d)). Topical fluoride application using 2% Sodium Fluoride gel was done as a part of the preventive protocol. On completion of the procedure the child was extubated uneventfully and transferred to PACU and later shifted to ward.
Case Report4
A 5-year-old male child diagnosed with CP and mental retardation was brought by parents with complaints of pain in oral cavity. The patient was extremely uncooperative and hence a thorough preoperative oral examination was not possible. A treatment plan was devised, which included thorough intra oral examination on operation table after GA and proceeding as per the examination. PAC was carried out and informed consent taken from parents. In the operating room (OR) child was intubated nasally as the oral cavity was very small and oral intubation would have led to difficulty in proper delivery of treatment. The child was examined and found to have generalized hypoplasia (Figure 4 (a & b)). Pulpectomy was done on 55,65,74,85. Stainless steel crowns were placed on 54,55,64,65,74and 85 with the aim to reduce loss of tooth structure already compromised due to the presence of hypolalsia. Light Cure Composite restorations were done on all the anterior teeth and finally topical fluoride application 2% sodium fluoride gel was done (Figure 4 (c & d)). The child was extubated on table and handed over to the parents in PACU and regular follow up routine was instituted.
Case Report5
A 13-year-old girl child, a diagnosed case of CP, was brought by her parents with complaints of child having discomfort in eating and thus avoided chewing food on the right side. The child made minimal eye contact but understood basic verbal instructions. The child was examined on the dental chair and was found to have root stumps of 15,16,26. Calculus was present on the lower anterior teeth (Figure 5 (a & b)). The patient was extremely anxious and uncooperative and hence a thorough preoperative oral examination was not possible. A treatment plan was devised, which included thorough intra oral examination on operation table after GA and proceeding as per the examination. PAC was carried out and informed consent taken from parents. In the OR, patient was intubated orally. The preventive protocol in the form of pit and fissure sealant application was done on 14,17, 24, 25, 27. Gross oral prophylaxis was carried out. The root stumps of 15,16,26 was extracted, and hemostasis was achieved (Figure 5 (c & d)). The child was extubated on table and monitored in PACU.
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