SPINA BIFIDA

Presentation and Management ofPatients at Texas Scottish Rite

Hospital for ChildrenDallas, TX

Susan McGuire, DDS

April 19, 2013

Assistant Professor, Department of Pediatric Dentistry, Texas A&M University Baylor College of Dentistry, Dallas, TX

Assistant Director, Special Needs Dental Clinic,

Texas Scottish Rite Hospital for Children, Dallas, TX

SPINA BIFIDA

• Overview of Condition• Texas Scottish Rite Hospital for

Children–Medical Management– Dental Management

Spina Bifida

• One of most common congenital birth defects

• 1-2 per 1000 births worldwide

• 1500-2000 births in USA annually

• Prevalence–Hispanics>Caucasians>African Americans– Girls>Boys

Overview

Formation of Neural Tube• During the first 3-4 weeks, specific cells

form a narrow tube that becomes the foundation of the spinal cord, brain

bone and tissues.

• At 28 days of gestation, neural tube closed.

• If the tube does not close properly anywherealong its entire length, then a neural tube defect will form at the open location. Overview

Etiologies• 95% do not have any family history • Maternal – Age– Obesity – Diabetes– Seizure medications

• Folic acid deficiencies– 0.4 mg/day

Overview

Diagnosis in utero

• Measurement of maternal serum alpha-fetoprotein (MSAFP)– If elevated at 16-18 weeks of gestation can

indicate defects

• Ultrasound examination – 18 weeks

• Amniocentesis– Use amniotic fluid alpha fetoprotein (AFAFP)

and acetylcholinesterase (AFAChE) to confirm

Overview

Neural Tube Defects• Affect the brain’s development and leave

the spinal cord vulnerable to damage • • Paralyze or weaken

associated muscles and affect organs

• Two Types– Closed– Open

Overview

Closed Neural Tube Defects• Localized and confined to the spine;

brain rarely affected• Neural tissue not exposed; spinal defect

fully covered by skin• May remain undetected for years,

especially in absence of cutaneous markers

• Types:– Lipomyelomeningocele– Lipomeningocele– Tethered cord

Overview

Open Neural Tube Defects

• Involve the entire CNS

• Neural tissue exposed with associated CSF leakage

• Skin covering not intact

• Visible at birth; majority discovered during pregnancy

Overview

Spina Bifida• Characterized by the incomplete development

of the brain, spinal cord and/or meninges

• Nerves located below malformation are affected, resulting in loss of sensation and paralysis.

• Complications may be minor physical problems to severe physical and mental disabilities.

• Types:– Anencephaly– Occulta– Meningocele– Myelomeningocele

Overview

Spina Bifida Occulta

• Mildest and most common form• One or more vertebrae are malformed• Opening in spine is covered by a layer of skin.

• Rarely causes disabilities or symptoms

• Often undetected unless visible exterior sign is present– Tuft of hair, dimple, birthmark, bulge at site of

malformation

Overview

Meningocele

• Meninges protrude from the spinal opening• May or may not be symptomatic• Noticeable bulge on back• Repaired surgically• Usually no resultant paralysis

Overview

Myelomeningocele

• Most severe and rarest form

• Occurs when the spinal cord is exposed through the opening in the spine

• Results in partial or complete paralysis of the parts of the body below the spinal opening

Overview

Treatment of Spina Bifida

• Surgery to close defect within 24 to 48 hours of birth

Medical Management

Treatment of Spina Bifida

•Before surgery, the child must handled carefully to reduce further damage to exposed spinal cord

•Lifelong treatment for other organ system disturbances secondary to damage to spinal cord or spinal nerves

Medical Management

Team Approach to Management at Texas Scottish

Rite Hospital (TSR)

• Neurosurgeon• Developmental Pediatrician• Neurologist• Urologist• Orthopedic Surgeon• Dentist• Other services involved:– Psychology, Child Life, Orthotics, PT, OT,

Dietary, Family Services

Medical Management

Associated Impairments• Arnold-Chiari II malformation• Hydrocephalus• Seizure disorders• Bladder and bowel incontinence• Musculoskeletal Deformities• Learning disabilities• Altered wound healing• Latex allergy/risk

Medical Management

• Downward displacement of the cerebellum, cerebral tonsils, brainstem, and 4th ventricle through the foramen magnum and into cervical space

• Results in compression and elongation of nerves and tissue responsible for vital functions including respirations and protective reflexes

Medical Management

Arnold-Chiari II Malformation

Medical Management

Normal Malformation

Arnold-Chiari II Malformation

• Symptomatic in about 33% of affected persons – Difficulty swallowing– Inspiratory stridor– Stiffness or spasticity of arms or hands– Poor balance and coordination

• Leading cause of death in spina bifida population

Arnold-Chiari II Malformation

Medical Management

Hydrocephalus• 80-90% develop hydrocephalus• Abnormal accumulation of CSF • Increased intracranial pressure– Progressive enlargement of the head– Convulsion– Mental disability

Medical Management

Shunts• Placed to relieve

intracranial pressure• Types:– Ventriculoperitoneal (VP)– Ventriculoatrial (VA)– Ventriculopleural– Ventriculo-gall bladder

• VP shunts empty CSF directly into the abdominal cavity, bypassing the venous circulation.

• Hypersensitivity to loud noisesMedical Management

Hydrocephalus

Seizure Disorders

• Occur in approx 15% of patients

• Usually generalized tonic-clonic type

• Responds well to anticonvulsant medication

• Recurrent seizure activity may indicate shunt blockage or infection.

Medical Management

Hydrocephalus

Learning Disabilities

• At least 80% havenormal intelligence

• Cognitive dysfunctions correlated to: –Hydrocephalus and related complications– Level of lesion• Upper level lesions associated with

mental retardation Medical Management

Hydrocephalus

Learning Disabilities

• Dysfunctions include:– Short attention span– Decreased arm and

hand function– Poor eye-hand coordination– Memory deficits

Medical Management

Hydrocephalus

Bladder and Bowel Incontinence

• Urinary complications- Hydronephrosis, incomplete emptying of the

bladder, urinary reflux, infections and incontinence

- May lead to renal damage - Patients frequently use catheters and antibiotics.

• Altered GI motor and sensory function– Impairs peristalsis– Leads to constipation, impaction and bowel

incontinence– Patients frequently require added fiber to diet.

Medical Management

Musculoskeletal Deformities

• Paralysis may lead to deformities• 90% of patients with defect above sacral level

develop:– Scoliosis– Kyphosis

• Surgery often required to correct spinal curvatures.

• Loss of muscle strength and inactivity may lead to pathological fractures.

Medical Management

Obesity

• 40% of patients • Due to– Impaired mobility– Decreased energy expenditure– High carbohydrate

food “rewards”

Medical Management

Altered Wound Healing

• Altered skin integrity over spine and cord• Altered sensory function below the level

of the lesion results in risk of skin breakdown throughout life

• Common risk factors– Reduced mobility– Nutritional status– Bowel and urinary

incontinence

Medical Management

Latex Allergy/Risk

• 70% exhibit symptoms• Predisposition to latex allergy unknown– Increased need for

health careshuntsother allergies.

Medical Management

Dental Management

As dentists, how do we manage all of these medical complications in providing dental care to the spina bifida patient?

Dental Management

Obtain Medical History

• Medical conditions• Allergies

– Latex, Drugs

• Past surgical history – Shunt– Spinal instrumentation

• Medications – Antibiotics, anticholinergics, sympathomimetics,

anticonvulsants and stool softeners

• Family history• Appropriate consults

Dental Management

Dental Implications of Spina Bifida Associated Impairments

• Latex Allergy/Risk– Requires latex-free environment

• Medications – Anticonvulsants• Make sure patient has taken Rx to minimize

risk of seizure– Antibiotics• May need to switch ABX if required for

shunt (VA) or spinal instrumentation

Dental Management

Dental Implications of Spina Bifida Associated Impairments• Shunt

– Avoid putting pressure on shunt while treating patient

– May exhibit sensitivity to loud noises

• Seizures– Make sure anticonvulsant medication taken

• Nausea, drowsiness• Gingival hyperplasia

– Anxiolysis/Sedation medications may need to be reduced

– Know proper protocol to manage seizure• Broken teeth, tongue lacerations

Dental Management

Dental Implications of Spina Bifida Associated Impairments

• Bladder and Bowel Incontinence– Empty prior to dental treatment

• Scoliosis/Kyphosis– Spinal instrumentation requires ABX

• Paralysis– Postural hypotension likely, best not to treat

patient supine– If chair-bound, treat in chair, tilt chair back

Dental Management

Dental Implications of Spina Bifida Associated Impairments• Obesity

– For anxiolysis/sedation, use ideal weight for patient

• Feeding/Swallowing Issues– Gastrostomy tube: Increased calculus formation– Tracheostomy: Protect airway

if patient unable to respond protectively• Minimize use of water• Use suction judiciously

Dental Management

Oral Complications

• Poor oral hygiene– Involuntary movements– Lack of motor skills– Vomit reflex during brushing

• Dental caries– Poor nutrition– Reduced salivary flow– Long-term use of medications

Dental Management

Oral Complications

• Gingivitis– Increased plaque

• Gingival hyperplasia– Anticonvulsant medications

• Periodontal disease– Increased calculus

Dental Management

Treating patients • Wheelchair bound patients

– Can be left in wheelchair• Sliding board can help with

supporting the patient’s head

• Wheelchair transfer to dental chair• 2-person lift

– Under arms– Legs

Dental Management

Anticipatory Guidance• Chlorhexidine gluconate mouthwash for

gingival/periodontal issues– May use as rinse or brush on tissues

• Fluoride for decreasing caries incidence– Apply fluoride at all prophylactic

appointments

• Preventive Restorations– Sealants effective to reduce occlusal caries

Dental Management

Recall Schedule

• Individualized for patient’s needs• Close observation of patients and regular

dental exams are important • 2, 3 or 4 month recall schedule can be

beneficial

Dental Management

Home Care

•Common Positions– Child positioned in front of

adult. Adult cradles the child’s head with one hand and uses other to brush.

– Child in wheelchair. Adult sits behind it. Lock the wheels

and tilt chair into the lap.

Dental Management

Oral Hygiene Tips• Horizontal scrub toothbrushing

technique recommended.– Electric toothbrush– Customized toothbrush handles– Toothettes

• Use of floss holders assists with flossing

Dental Management

Behavior Management

• Behavior management techniques become more important in these patients!

• Patients and their families generally exhibit anxiety due to frequency of medical interventions.

• It is important to spend additional time with parent and child to establish rapport.

Dental Management

Behavior Management

• Parental Anxiety– Talk to the parent and find out their

expectations– Tour the office– Introduce staff

Dental Management

Behavior Management• Patient Anxiety

– Schedule early in day

– Actively listen to patient

• Verbal/Non-verbal

– Speak at patient IQ level

– Keep appointments short

– Gradually progress to more complicated procedures

– Reward patient after successful completion of procedures

Dental Management

Delivery of Care• Immobilization– Effective way to diagnose and deliver

dental care• Helps protect patient, dentist, and staff• Make sure parents have clear

understanding of use• Make sure you obtain proper

informed consent• Includes parental assistance, extra

personnel, mouth props, papoose board

Dental Management

Sedation

• Neurologically handicapped patients may be unable to cope with dental treatment

• Individualized for each patient• Review any changes in medical history• Review allergies• Review medications

– Confirm patients have taken regular medications themorning of procedure.

Dental Management

• All medication doses determined by weight– Obese patients, use ideal body weight/height

• Calculation: Height cm2 X 1.65 / 1000 = Kg

• Consider decrease in dosage of sedative agent by 1/3 for patients taking benzodiazepines,

barbiturates, valproic acid, MAO inhibitors, elective serotonin re-uptake inhibitors

• Must include reversal agent and doses

Dental Management

Sedation

• Sedation is contraindicated for ASA Type III and IV patients, or any other patient not cleared by his/her physicians.

• Amount of dental work needed would require more than 2 sedation appointments.

• Failed sedation attempt

Dental Management

General Anesthesia

General Anesthesia

• Complete physical work-up for each patient prior to general anesthesia

• Must follow NPO guidelines• Benefits must outweigh risks!

Dental Management

General Anesthesia

• More aggressive treatment– Ext vs. Endo therapy– SSCs vs. Class IIs– Amalgam vs. composite– Limit occlusal anatomy • Plaque accumulation

– Sealants

Dental Management

Summary• Know your patient’s medical history– Surgeries– Medications– Allergies

• Obtain necessary consults– Need for ABX

• Be aware of patient’s anxiety level– Consider sedation/GA

• Emphasize prevention.• MOST OF ALL, be patient, understanding,

and compassionate.

QuestionsThank you

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printing, May 1998, p. 529-552.• Centers for Disease Control and Prevention. Spina Bifida. Available at

http://www.cdc.gov/ncbddd/spinabifida/data.html. Accessed March 25, 2013.• Ekmark EM. Risky Business: Preventing skin Breakdown in Children with Spina Bifida. Journal

Pediatric Rehabilitation Medicine. 2009; 2:37-50.• Foster MR. Spina Bifida. Available at http://emedicine.medscape.com.article/311113. Accessed March

26, 2013.• Jaccarino J. The Patient with Special Needs: General Treatment Considerations. Available at

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St. Louis, MO, 1992, p. 373-388.• Mayo Clinic. Spina Bifida. Available at http://www.mayoclinic.com. Accessed February15, 2013.• National Institute of Neurological Disorders and Stroke. Spina Bifida. Available at

www.ninds.nih.gov/disorders/spina_bifida/spina_bifida.htm. Accessed March 15, 2013.• Practical Oral Care for People with Developmental Disabilities. Available at www.nidcr.nih.gov.• Queiroz AM, Saiani RA, Rossi CR, Gomes-Silva JM, Belson-Filho P. Oral Findings and Dental Care in a

Patient with Myelomeningocele: Case Report of a 3-Year Old Child. Brazilian Dental Journal, 2009, 20(5), p. 434-438.

• Spina Bifida Association. Available at www.spinabifidaassociation.org/site/c.evKRI7OxIoJ8H/. Accessed February 15, 2013.

• Scofield, JC, Campbell, PR. Integrating the Spina Bifida Patient into the General Dental Practice. The Journal of Practical Hygiene, May/June 2001, p. 27-31.

• Steifel, DJ. Dental care Considerations for Disabled Adults, Special Care Dentistry, 2002, 22(3), p. 265-395.