International Scholarly Research Network

ISRN Dentistry
Volume 2011, Article ID 146915, 4 pages
doi:10.5402/2011/146915

Case Report
Bruxism Control in a Child with Cerebral Palsy

Cristiana Aroeira G. R. Oliveira,1 Viviane Andrade Cancio de Paula,1

Maristela Barbosa Portela,1, 2 Laura Salignac Guimarães Primo,1
and Gloria Fernanda Castro1, 3
1 Department of Paediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro,
Rio de Janeiro, 21941-901/RJ, Brazil
2 Department of Clinics and Pediatric Dentistry, Fluminense Federal University (UFF), Niterói, Brazil
3 Caixa Postal 68066 Cidade Universitária (CCS), Rio de Janeiro RJ, CEP: 21941-971, Brazil

Correspondence should be addressed to Gloria Fernanda Castro, [email protected]

Received 22 September 2010; Accepted 4 November 2010

Academic Editors: J. H. Jeng and C. Robinson

Copyright © 2011 Cristiana Aroeira G. R. Oliveira et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Cerebral palsy (CP) is one of the most severe childhood disabilities due to a lesion in the developing brain. Oral conditions often
observed in this pathogenic are a tendency for the delayed eruption of permanent molars, higher percentages of malocclusion and
parafunctional habits, including bruxism. The significance of oral conditions observed in CP patients demonstrates the need for
intensive home and professional care for these individuals. This paper presents a 7-year-old boy, with cerebral palsy, severe mental
retardation, who had high abrasion wear of the primary teeth related to bruxism. Dental care was carried out under oxide-induced
sedation, and management of the bruxism was achieved after the use of a resin acrylic protective appliance fixed on both sides of
the mandibula. The treatment performed offered efficiency advantages, was clinically viable, and should be a valuable option to
practitioners considering appliance therapy to control parafunctional behavior.

1. Introduction been reported to be as high as 21%, but its incidence in PC

is still unknown [7]. Many factors may be involved in the
Cerebral palsy (CP) is a severe childhood disability, charac- etiology of this parafunctional activity such as spasticity [8];
terized by a nonprogressive motor disorder of posture and unbalanced oral myofunctional disturbance[3, 5], backbone
movement due to a lesion in the developing brain [1]. The dysfunction with the head projected forward, which changes
prevalence of this clinical condition among children aged 3– the contact between the teeth and predisposes hyperactivity
10 years has been reported to be 2.4 in every 1000 live-borns of the main masticatory muscles (temporal and masseteric)
[2], being significantly higher in males and black people. [9], lack of control of the mandibular posture which can
The most common disorders associated with CP are mental worsen in periods of emotional stress [10]; sleep disorders
retardation, sensory limitations, epilepsy, speech disorders [11]; use of neuroleptics [5] and malocclusion [12]. Some of
and hearing loss [3]. The more common oral conditions in these changes are very common in children with PC [5].
individuals with CP include higher mean decayed, missing The mastigatory musculature spasticity of CP can inter-
and filled surfaces index, higher plaque index, tendency for fere with daily activities such as tooth brushing, cleaning of
delayed eruption of permanent molars, malocclusion [4], as the oral cavity and eating [7]. The treatment for this para-
well as high rates of bruxism [5]. functional activity includes restorative treatment, occlusal
Bruxism means grinding or gnashing of the teeth [6]. adjustment[9], the use of oral splints, pharmacological
This rhythmic grinding can cause masseter hypertrophy, treatments and dental extraction [6]. The most severe cases
headaches, temporomandibular joint destruction, and tooth require a multidisciplinary input, including pediatricians,
wear. The incidence of bruxism in the general population has psychiatrists, paediatric dentists, and/or oral surgeons [13].
2 ISRN Dentistry

The following paper reports a severe case of bruxism in a instead of the semisolid diet that he had before treatment.
child with cerebral palsy and discusses the treatment given. The patient was periodically followed up in order to remove
and clean the appliances, apply topical fluoride and instruct
2. Case Report the parents on oral hygiene. Six months later, the eruption
of permanent central incisors of both jaws could be noted
A seven-year-old boy with spastic cerebral palsy (type and at the one year (Figure 4) review the crowns of these
quadriplegia, the severest CP) was brought to the Pediatric teeth were more exposed. The child remains under continued
Dentistry Department of the Federal University of Rio intervention through a multidisciplinary team.
de Janeiro, Brazil because his parents complained of the
repeated grinding which was damaging his teeth and gums. 3. Discussion
The parents reported during anamnesis that the pregnancy
and parturition were normal and he was born in 40th week Individuals with CP tend to develop accentuated involuntary
of gestation. When he was 5 days old he spent 11 days in the muscle tonus in orofacial muscles and other muscles and
neonatal intensive care unit because of icterus with moderate often show various types of stereotypy [16], especially when
bilirubin levels and he needed a blood transfusion. they lack any other occupation, as in this case, where the
The child was under medical treatment during his first child occupied himself by grinding his teeth for a large
year of life because of convulsive crises. He has always been part of the day. Lindqvist and Heijbel [16] observed that
cared for by his parents for all daily actives. The child has abnormal dental wear is closely related to a low level of
been followed up by a multidisciplinary team including mental development [17] and severe dental wear indicates
pediatrician, physiotherapist, psychologist and neurologist. that CP children have more pronounced bruxism than
Medicines taken by the patient daily included Gardenal, normal children [8, 9].
Lorenal, Motile and Rivertril. In this case, clinical signs as lip biting or small ulcers were
Clinically, there were no extraoral findings of note. not found, even though they have been reported as clinical
Intraoral examination revealed a mixed dentition and good signs of bruxism [6, 18].On the other hand, the patient
oral hygiene. All deciduous teeth presented severe dental presented limited mouth opening or trismus, an inherent
wear, indicating a pronounced bruxism. The enamel had characteristic of bruxism [18].
been worn away on large areas of anterior cusps and There is contradictory information in the literature
mastigatory primary molar surfaces. Because of the poor regarding the incidence of oral diseases in patients with CP.
participation of the patient, the size of movements could According to Brown and Schodel [17], these controversies are
not be measured. He had no salivary drooling and had due to the failure of the criteria used to choose the population
an adequate swallow in spite of evidence of facial and to be studied as well as the absence of control groups. Santos
hypoglossal nerve dysfunction. His parents reported he used [4] observed a high-risk for dental caries in CP children.
to eat ordinary food, but in the last six months they had However, no carious lesions were diagnosed in the patient
noticed he appeared in pain while eating so he was only able described in the present case. This may be explained because
to eat puréed food. the parents had received oral hygiene and diet instructions
As the molars had extensive teeth surface losses, stainless in a pediatric clinic when the child was very young and they
steel crowns were the proposed treatment for the primary have always been very careful with the child’s oral hygiene.
molars under local anesthesia and nitrous oxide-induced Dental treatment for handicapped patients presents
sedation (N2 O) [14]. At the first appointment, the treatment multiple difficulties. They are often treated under general
of the right molars was carried out and four stainless steel anesthetic or deep sedation, which has many disadvantages
crowns were cemented on the primary molars. Seven days [19]. Yoshida et al. [14] presented a study pointing out
later the same treatment was performed on the left primary the beneficial properties of nitrous oxide-(N2 O-) induced
molars. A week later a protective oral appliance was designed sedation performed during dental treatment on CP patients.
for covering all the maxillary molars, in order to reduce The authors decided to carry out the dental procedures on
the bruxism and prevent injuries to the soft tissues [15]. the patient using N2 O sedation considering the procedure
Impressions were made with a silicone material to obtain a was of short duration, the difficulties involved in local
working model (Figure 1) and two acrylic resin appliances hospital admission and the safety of the technique [20].
were made (Figures 2 and 3) under N2 O sedation. At the In studies of bruxism in mentally retarded children in
following appointment, the protective appliance was fixed the literature, the term “abnormal abrasion” has varying
on both sides of the mandibular teeth by means of ionomer implications; so treatment for the oral injuries caused by this
cement. The parents were educated on the proper oral parafunctional activity may include restorative techniques,
hygiene measures to be adopted and the need for regular dental extractions [21], and the use of oral protective
dental visits in the future. After a period of two weeks, appliances [22]. The first choice was to restore the primary
grinding behavior had decreased significantly and no further molars with stainless steel crowns because of their high
damage to the dentition were seen. His parents reported degree of dental wear. This procedure was not sufficiently
that the child had received the appliance well and he no effective, since the patient continued to grind his teeth
longer ground his teeth (the bruxism had been controlled with great force. Therefore it was decided to make fixed
with concomitant alleviation of symptoms); feeding had acrylic appliances to reduce the bruxism. Although the
improved, because he was able to consume solid foods appliance was cemented, the parents were instructed to
ISRN Dentistry 3

(a) (b) (c)

Figure 1: Inicial models. Lateral and frontal vision. The high abrasive wear of primary teeth and the delayed eruption of permanent incisors
can be seen.

Figure 2: Frontal vision after the adaptation of stainless steel

crowns, showing the eruption of the permanent incisors. Figure 4: One-year-review: the crowns of permanent central
incisors can be seen.

described, with positive results [15, 23]. The bruxism was

reduced and the parents related that activities like eating and
sucking became easier for the patient. It probably occurred
because the resin appliance increased vertical dimension and
the occlusal parameters had been established, so the patient
was able to have a better functional occlusal activity.
In a later followup, the eruption of permanent first
molars and incisors was observed, indicating the success of
the treatment. As the child gets older, the appliance can be
extended to other teeth if necessary, as his future neurological
condition cannot be predicted.
Figure 3: Models used to make the oral appliances before being Early diagnosis and interventions of parafunctional
cemented on the patients primary molars. habits in individuals with CP is important to reduce invasive
treatment and worse complications for the patient. This
paper also highlights that oral protective appliances can be
verify the stability of the appliance in order to avoid the clinically viable and effective for the prevention of bruxism.
risk of aspiration. Although the appliance was cemented, Furthermore, this case illustrates the importance of the
before choosing this treatment option, the authors discussed treatment by a dental team in patients with cerebral palsy.
the risk of aspiration with the child’s parents. They were
instructed to verify the stability of the appliance and to keep it Acknowledgment
cleaned. Although there are few studies concerning the use of
oral devices directly with children, an oral appliance applied The authors thank Fundação Carlos Chagas Filho de Amparo
to prevent the self-mutilation of the lower lip in a mentally à Pesquisa do Estado do Rio de Janeiro (FAPERJ) for the
handicapped patient with Moebius syndrome, has been financial support (Proc. E-26/100.645/2008).
4 ISRN Dentistry

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