DEVELOPMENTALLY DISABLED CHILD

PRESENTED BY:KHUSHBU BEZALWAR

FINAL YEAR PART 2

CONTENTS:• What is developmental disability?• Define: Disabled child• Attitude towards disabled child - Parenteral - Patient• AAPD guidelines on management of dental patient for

special health care needs• Classification• Cerebral palsy• Epilepsy• Down’s syndrome• Child autism• Mental retardation • Hearing loss• Visual impairment

WHAT IS DEVELOPMENTAL DISABILITY?

Developmental disability is diverse group of chronic conditions that are due to mental or physical impairments that begins before an individual reaches adulthood.

DISABLED CHILD

According to WHO – Disabled child is one who over an appreciable time is prevented by physical or mental condition from full participate in normal activities of his age group , including those of a social , recreational , educational, vocational in nature.

ATTITUDE TOWARDS DISABLED CHILD

PARENTERAL ATTITUDE Parents seems to go through several

emotional and psychological stages after becoming aware that their child is handicap . Their initial feeling shock and depression .Parent also describe stress associated with social habit includes starring discomfort inappropriate ignoring . Most parents also reported that the where able to adjust better with difficulties of child after knowing their clinical condition. Basically if a parent believes in good dental care and prevention of dental disease ,he will provide care to his child irrespective of his disability.

PATIENT ATTITUDE The comment from a person afflicted

with a progressively depilating disease – “I don’t want to be consider abnormal and I don’t want to be limited in reaching my full potential .I don’t want to be consider inferior. Don’t embarrass me by asking to do something that is obvious I can’t do ,yet give me every opportunity to do all I can”.

AAPD GUIDELINES:

The AAPD values the unique qualities of each person and need to ensure maximal health attainment for all, regardless of developmental disability or other special health care needs .

The guideline is intended to educate health care providers , parents about the management of oral health care needs to the individual who require special health care needs.

CLASSIFICATION : Franks and Winter (1974) Blind or partially sited a) Deaf or partially deafb) Educationally subnormalc) Maladjustedd) Epileptice) Physically handicapped f) Defect of speechg) Senile

Holloway and Swallow (1982)a) Mental handicapb) Physical handicapc) Medical disability

Nowak(1964)a) Physically handicappedb) Mental retardationc) Congenital defectsd) Metabolic and systemic disordere) Convulsive disorders f) Childhood autismg) Blind and deafh) Haemophilia

CEREBRAL PALSY

CLINICAL MANIFESTATION OF CEREBRAL PALSY

Abnormality of muscle tone No control over movements Muscle weakness Contractual deformities Spasticity and loss of coordination Apraxia Impaired sensation of movement Impaired proprioception

ORAL MANIFESTATIONS

Child may have gastro oesophageal reflux as well as episodes of vomiting. It can lead to dental erosion or loss of tooth structure.

Gingival overgrowth due seizure medications. Oro facial findings include the head is tensely

reclined. The mouth is open and facial movements are tensed.

Uncoordinated movements of tongue. Jaw dislocation. Tongue thrusting during swallowing and

speaking.

MANAGEMENT Patient is transferred to the dental chair , the two

person lift is recommended. Make an effort to stabilize patient’s head through all

phases of dental treatment. Keep the patient’s back slightly elevated to minimize

swallowing. For control of involuntary jaw movements , choose

from of variety of mouth props.

To minimize the reflex reaction avoid stimuli such as abrupt movements , noises and lights.

Introduce intraoral stimuli slowly to avoid eliciting a gauge reflex.

To modify radiographic techniques used in children in cerebral palsy are the 45% oblique head plates, the reverse bitewing.

Consider a use of rubber dam. A highly recommended technique for restorative procedure.

HOME DENTAL CARE

Choose a well lit location so that you can look into your child’s mouth.

Always support the head while brushing the child’s teeth. Parents should help to brush their children’s teeth

everyday, after every meal. Brush the tongue , since this will prevent halitosis.

Up to the age of three, parents should only use baby tooth cleanser to avoid fluorosis discolouration of adult teeth.

Children should have their first oral/dental health evaluation by the age of twelve months or within six months of eruption of first tooth.

EPILEPSY

A group of disorders characterized by chronic, recurrent , and paroxysmal changes in neurologic function caused by abnormalities in the electrical activity of the brain.

Each episode of neurologic dysfunction is called a seizure.

CLASSIFICATION International league against epilepsy has

classified epileptic seizures as follows: Partial or focal seizures 1. Simple partial seizures 2. Complex partial seizures 3. Secondary generalized partial seizure

Primary generalized seizure 1. Tonic clonic ( grand mal ) 2. Tonic 3. Absence ( petit mal ) 4. Atypical absence 5. Myoclonic

6. Atonic 7. Infantile spasms

Status epilepticus 1. Tonic-clonic status 2. Absence status 3.Epilepsipartialis continua

Recurrent patterns 1. Sporadic 2. Cyclic 3. Reflex

ORAL MANIFESTATIONS Soft tissue lacerations of tongue or buccal

mucosa Facial fractures Trauma to teeth – avulsion, luxation , fractures Subluxation of TMJ

INJURIES DUE TO DRUG THERAPY

Gingival hyperplasia Recurrent aphthous like ulceration Anomalous dental development like small teeth,

delayed eruption. Cervical lymphadenopathy. Secondary infection of the fibrous overgrowth when

oral hygiene practices are neglected resulting in friable and hemorrhagic tissues.

DENTAL MANAGEMENT Complete medical history Stress management counselling and therapy Avoid dental chair light. Appropriate drug therapy for seizure Use of antiepileptics with care and management

of their side effects

OFFICE MANAGEMENT Supine position of chair, protection from injury by

moving sharp objects away. Insertion of mouthprop of rubber or plastic to

prevent tongue biting. Maintenance of patent airway. Use of suction to avoid aspiration. Give oxygen. If conditions do not improve admit to hospital.

DENTAL TREATMENT Short appointments Importance of tooth brushing procedures and

regular dental reviews must be stressed Fixed type of appliances are indicated for tooth

movement and replacement.

DOWN’S SYNDROME Most recognizable malformation syndrome –

occurs due to trisomy of chromosome 21 (95%), translocation (3%), or due mosaicism (2%).

Incidence – 1 in 600 live births

PREDISPOSING FACTORS AND CAUSES Advanced maternal age Uterine and placental abnormalities Chromosomal aberrations

GENERAL MANIFESTATIONS Skull brachycephalic skull Presence of third fontanelle just anterior to posterior fontanelle Flat nasal bridge with small maxilla

Eyes : oblique palpebral fissures with prominent epicanthic fold. Brushfield’s spot on iris Scanty eyelashes Cataract, squint, nystagmus.

Ears: Dysplastic ears with abnormal pinna .

Neck : short and broad with excess skin posteriorly.

Hands : Broad and short (clinodactyly) with a single transverse palmar crease (simian crease). Short in curved little finger. Multiple loops on finger tips.

Muscle and joints: Hypotonicity and hyperextensibility.

IQ : Retarded IQ of 25 – 50.

Congenital abnormalities 1. Heart lesions ( atrial septal defect, atrioventricular canal and VSD ). 2. Duodenal atresia. 3. Atlantoaxial instability. 4. Umbilical hernia. 5. Multiple immunological defect affecting skin, GIT and respiratory tract. 6. Acute lymphoblastic leukemia is 20 times more common. 7. Hypothyroidism and Alzheimer’s disease.

Brush field spots

Clinodactyly

ORAL MANIFESTATIONS Mouth small drooping mouth open mouth posture

Tongue Protrusive, fissured (scrotal) tongue. Circumvallate papillae may be enlarged but filiform papillae may be absent. Macroglossia.

Lips :Thick , dry , fissured.

Occlusion : Anterior open bite and crossbite , class III Tendency. Small maxilla.

Palate : Often appears high with horizontal palatal shelves (omega palate) Bifid uvula , cleft lip and palate.

Eruption of teeth : Retarded early shedding of deciduous teeth.

Teeth : Hypodontia , especially 3rd molar and maxillary lateral incisor. Microdontia. Hypocalcification. Hypoplastic defects. Low incidence of caries.

DENTAL TREATMENT Adequate prophylaxis Increased incidence of leukemia and acute and

chronic infection of upper respiratory tract can also alter treatment.

Children are affectionate and cooperative. Nitrous oxide in mildly apprehensive patients can

be used.

Preventive procedures along with chlorhexidine mouthwash is beneficial.

Pulp treatment is contraindicated in deciduous teeth in patient with cardiac problem.

Orthodontic management of malocclusion in children with Down’s Syndrome is problematic.

General anaesthesia is frequently employed to facilitate treatment.

All restorative treatment is indicative . Attention to presence of erosion and developmental defects of dentin is essential.

In periodontal disease optimal oral hygiene ,routine review, routine prophylaxis is indicated.

In Down’s Syndrome patient there is often a delay in language development is generally perceived that patients tend to understand more than their verbal skills.

DEAFNESS Etiology : Prenatal 1. Viral infection ( rubella & influenza )2. Ototoxic drugs3. Congential syphilis4. Heredity

Perinatal1. Toxemia late in pregnancy2. Birth injuries3. Prematurity4. Erythroblatosis foetalis5. Anoxia

Postnatal :

1. Injuries2. Ototoxic drugs ( streptomycin, kanamycin, aspirin )3. Viral infection (measles, mumps, chickenpox, influenza, meningitis, poliomyelitis).

DENTAL PROBLEMS AND TREATMENT Poor oral hygiene. During pre-appointment interview, manner of

communication should elicited along with a detailed medical history.

Measures for reducing anxiety of the patient should be undertaken.

Speak directly facing the patient in a normal tone without using slang.

Adjust the hearing aid while using handpiece as all sound may be amplified.

Use the tell-show-do, positive reinforcement and modelling behaviour modification techniques.

Pretreatment sedation or even general anesthesia may be required for more serious behavioural management problems.

CHILDHOOD AUTISM Autism is a mental condition present from early

childhood, characterized by great difficulty in communicating and forming relationship with other people and in using language and abstract concepts.

Autism spectrum disorder consists of five types which include autism disorder asperger’s syndrome,rett’s disorder,childhood disintegrative disorder,pervasive developmental disorder.

ETIOLOGY Genetic-3 to 8 percent recurrence risk if a family

already has a autistic child Syndromes-fragile- x , Rett syndrome Medical conditions-tuberous sclerosis complex Prenatal factors- intrauterine rubella,cytomegalo

inclusion disease Postnatal factors-infantile spasm, herpes

simplex.

CLINICAL FEATURES These children seem

to be self sufficient and introvert and want to be alone.

They have little or no attachment with their parents.

They may typically display affection or anger with a toy.

DENTAL FINDINGS Higher susceptible to caries Bruxism Damaging oral habits such as tongue thrusting,

lip biting Gingivitis and poor oral hygiene Texture sensitivity - it leads to consumption of

refined and high sugar diet

TREATMENT Allow autistic child to bring comfort items such as

toys. Make a first appointment short and positive. Approach the child in quiet , non-threatening manner. Avoid loud noises. Invite child to sit alone in dental chair to become

familiar with treatment setting. Talk in direct , short phrases . Talk calmly. Behaviour modifications technique that is use of

positive reinforcement to promote desirable behaviour.

Some autistic child can be calm by moderate pressure by using a papoose board to wrap the child.

MENTAL RETARDATION It is defined as the over all intelligence quotient

lower than 70,associated with functional deficit in adaptive behavior , such as daily living skills , social skills and communications.

Intelligence quotient(IQ) that is below 70 and represent two or more standard deviations from a mean of 100.

ETIOLOGY

CLINICAL MANIFESTATION Tensly reclined head,abnormal behavior and poor

mobility. Increased tone in the limbs and persistent fisting Hand preference during first 2 years of life is a

sign of hemiplegic CP. As the child grows a typical clinical picture of

abnormal body movement establishes.

ORAL MANIFESTATIONS Advanced cases of baby bottle tooth decay/early

childhood caries , prescription-medication-induced dental decay.

Altered salivary flow and tooth decay ,”placating” tooth decay , malocclusions , fractured and non vital teeth , soft tissue complications and bruxism.

Major loss of tooth structure , leading to an eventual extraction , can affect developing speech patterns.

Unmonitored food consumptions. Abnormal jaw development , marked alterations

in mastication , poor esthetics. Poor dental hygiene , dental plaque and gingivitis

calculus, intense halitosis. Gingival overgrowth.

MANAGEMENT Allow a patient to bring a favorite item for example toy Be repetitive , speak slowly and in simple terms. Give only 1 instruction at a time. Reward the patient with compliment after successful

completion of procedure. Actively listen to patient. Keep the appointment short. Gradually progress to more difficult procedures after the

patient has become accustomed to the dental environment.

Invite the parent to the operatory for assistance and to aid in communication with patient .

Schedule the patient early in a day when the dentist , the staff and the patient will not be fatigue.

VISUAL IMPAIRMENT It is a consequence of the functional loss of vision Communication tips- -Use audio cassete tapes and braille dental pamphlets explaining specific dental procedure to supplement information and decrease chair time. -Maintain a relaxed atmosphere -face the patient and speaks slowly - Keep conversation simple -Provide a well-lit room -Indicate when you move from one place to another or leave the room -Avoid distractions

TREATMENT Determine the degree of visual impairment If companion accompanies the patient , find out if

companion is an interpreter. Establish rapport Do not grab , move or stop the patient without verbal

warning. Always give the adequate description before

performing treatment procedures. Allow the patient to ask questions about the course of

treatment and answer them keeping in mind that the patient is highly individual , sensitive and responsive.

Invite the patient to touch , taste or smell recognizing that things are acute.

REFERENCES Textbook of Pediatric Dentistry- Nikhil

Marwah -Third Edition Textbook of Pedodontics- Shobha

Tandon - Second Edition.

THANK YOU!!!!