ISSN: 2320-5407 Int. J. Adv. Res.

10(02), 1067-1083

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/14314

DOI URL: http://dx.doi.org/10.21474/IJAR01/14314

RESEARCH ARTICLE
DENTAL MANAGEMENT OF CEREBRAL PALSY

Dr. Mayanglambam Leleesh1, Dr. Rani Somani2, Dr. Dilip Kumar3, Dr. Payel Basu1, Dr. Oinam Renuka1,
Dr. Grace Thanglienzo1 and Dr. Sarath Kumar3
1. Post Graduate Student, Department of Pediatric and Preventive Dentistry, Divya Jyoti College of Dental
Sciences and Research.
2. Professor and Head, Department of Pediatric and Preventive Dentistry, Divya Jyoti College of Dental Sciences
and Research.
3. Associate Director, Max Lab, Max Super Speciality Hospital, Saket, New Delhi-India.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Cerebral palsy is a term used to describe a group of permanent and
Received: 21 December 2021 progressive disorders affecting movement and posture that result from
Final Accepted: 24 January 2022 injury or insult to the developing brain. It is the most common motor
Published: February 2022 disability of childhood, with a worldwide incidence of 1.5 to 3 per 1000
live births. Children with cerebral palsy posses a significant higher risk
Key words:-
Cerebral Palsy, Motor Disorder, Oral Health of dental disease due to the greater difficulty for them to perform
effective oral hygiene and care. Dentists dealing with them should
possess thorough knowledge of this condition and their implications in
order to formulate safe and effective dental preventive and treatment
plans.This article will help the dentist to understand all the aspects related to the
dental management of patients with cerebral palsy and apply it in clinical
practice.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Cerebral palsy is the most common motor disability in childhood (Cerebral Palsy Alliance Research Foundation,
2018), with a worldwide incidence of 1.5 to 3.0 per 1000 live births. 1,2The International Concensus (2007) describes
cerebral palsy as - A group of permanent disorders of the development of movement and posture, causing activity
limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.
The motor disorder of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition,
communication and behaviour by epilepsy, and by secondary musculoskeletal problem. This disturbances includes
respiratory difficulties, speech impairment, oral motor impairment, digestive issues, vision impairment, hearing
impairment, learning difficulties and epilepsy.

Oral health in children with cerebral palsy is impacted significantly by their neuromuscular and neurodevelopmental
disabilities, leading them to have a higher risk of dental disease due to the greater difficulty for them to perform or
receive effective oral hygiene and oral care. In addition parents anxiety in relation to the problem associated with the
child‘s disability frequently delays dental care which causes significant oral disease to develop. 3 It is often a great
challenge for a dental practitioner to manage a patient with cerebral palsy and deliver a successful outcome. A
detailed knowledge, innovative and problem solving approach play an important role in promotion of the oral health
in these individuals. The dentist should also focus on educating and encouraging the parents and the caregivers of
the child for good home oral health practice and maintenance of oral hygiene. Once the dentist becomes familiar

Corresponding Author:- Dr. Mayanglambam Leleesh 1067

Address:- Post Graduate Student, Department of Pediatric and Preventive Dentistry, Divya
Jyoti College of Dental Sciences and Research.
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with the special needs of the child and with the parent‘s concern, the dental management can also be quite pleasing
and rewarding.

Definition
Cerebral palsy describes a group of permanent disorders of the development of movement and posture, causing
activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant
brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition,
communication, and behavior; by epilepsy, and by secondary musculoskeletal problems (Rosenbaum et al ,2007)

Epidemiology
The average incidence of cerebral palsy is estimated to range between 1.5 and 3.0 per 1000 live births. These values
change among selected groups of patients, depending on various risk factors. Although there have been some
changes in patterns of cerebral palsy in the last four decades in developed countries, there has been a disappointing
lack of significant decrease in frequency of CP. The numbers of children with more severe forms of CP are
increasing, mainly in the group born prematurely as a result of greater survival of these children to an age when CP
can be diagnosed.4 Researchers have theorized that a greater incidence of multiple births and increased survival rates
for extreme low birth weight infants in recent years may account for some of this inability to lower CP rates. An
estimated 87% to 93% of children who have CP are now living into adulthood, which increases prevalence in the
adult population.

History
Dr.William John Little, an English surgeon was the first person to study cerebral palsy extensively. In 1853, he
published lectures in a monograph entitled, ‗‗On the Nature and Treatment of the Deformities of the Human
Frame‘‘. This was perhaps the first book dedicated entirely to the subject of deformities in children, which later
came to be known as cerebral palsy. He highlighted that the condition was caused by problems during delivery and
believed that it resulted from post-partum asphyxia, which distorted the blood flow and in this way damage the
child‘s brain.

It was until 1887 that the term cerebral palsy was applied to the condition that Dr. Little studied. The term was
coined by Sir William Osler, who wrote a book entitled ― Cerebral Palsies of Children‖.5 To some extent, Osler
agreed with Little on the etiology of cerebral palsy. He favored the hypothesis that trauma leading to ‗‗meningial
hemorrhage and compression of brain and spinal cord‘‘ was a major cause of cerebral palsy.

The third major contribution to the cerebral palsy literature was that of Sigmund Freud (1856–1939). Agreeing with
Little, Freud asserted that asphyxia and birth trauma could lead to brain damage; however, Freud went a step further.
Extending Little‘s explanations, he noted that since the same abnormal processes of birth frequently produce no
effects, diplegia still may be of congenital and may be merely a symptom of deeper effects influencing the
development of the fetus. He proposed that difficulties during labor and delivery, including asphyxia might be the
result of early developmental defects of the brain rather than the causes of cerebral palsy
A B C

Fig1:-(A,B,C): A:Dr.William Little John(1810-1894), B:Dr. williamosler (1905-1919), C:Dr. Sigmund Frued (1856-
1939).
Classification
A. Based On The Body Parts Impaired

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1. Quadriplegic: All four limbs affected

2. Diplegic: Both the legs affected, legs are more severely impaired than the arms.
3. Hemiplegic: Arm and leg on one side affected
4. Monoplegic: Any one limb affected
5. Triplegic: Both the legs and any one arm affected
B. Based on area of brain damaged
1. Spastic: Increased stiffness in the muscles. Spastic CP is the most common form of the disorder. It occurs due to
the damage to the cerebral cortex of the brain.
2. Dyskinetic: Abnormal movements of the body. Dyskinetic cerebral palsy occurs when, basal ganglia, the part of
the brain responsible for controlling the voluntary movements is damaged
3. Ataxic : Clumsy movements and poor balance, caused due to damage to the Cerebellum.
4. Hypotonic: Hypotonic cerebral palsy also occurs when there is injury to the Cerebellum. Hypotonia is opposite of
spasticity.
5. Mixed: Mixed cerebral palsy is when the symptoms of two or more of the above types co-exist.
C. Functional Classification System
1. Gross motor function classification system (GMFCS) :
The GMFCS is a simple, five-level, ordinal grading system created to describe the gross motor function of an
individual with CP. The five levels are :
a. Level I-Walks without limitations.
b. Level II-Walks with limitations.
c. Level III-Walks using hand-held mobility device.
d. Level IV-Self mobility with limitations; may use powered mobility.
e. Level V-Transported in a wheelchair.(Fig:2)

2. Manual Ability Classification System (MACS) :

MACS is used to describe the typical use of both hands and upper extremities for children from 4 to 18 years of
age. It is also a simple, five-point ordinal classification system
a. Level I-Handles objects easily and successfully
b. Level II-Handles most objects but with somewhat reduced quality
c. Level III-Handles objects with difficulty, needs help to prepare and/or modify activities
d. Level IV-Handles a limited selection of easily managed objects in adapted situations
e. Level V- Does not handle objects

3. Communication function classification system (CFCS):

The CFCS classifies the everyday communication performance of an individual into five levels. 6
a. Level I- Effective sender and receiver with unfamiliar and familiar partners
b. Level II-Effective, but slower-paced sender or receiver with unfamiliar and familiar partners.
c. Level III-Effective sender and effective receiver with familiar partners.
d. Level IV- Inconsistent sender and/or receiver with familiar partners.
e. Level V-Seldom effective sender and receiver with familiar partners.

4.The Eating and Drinking Ability Classification System (EDACS) :

The EDACS assesses the eating and drinking safety and eating and drinking efficiency. It also comprises of levels:
a. Level I-Eats and drinks safely and efficiently
b. Level II-Eats and drinks safely but with some limitations to efficiency
c. Level III-Eats and drinks with some limitations to safety, may also be limitations to efficiency
d. Level IV-Eats and drinks with significant limitations to safety
e. Level V-Unable to eat and drink safely-tube feeding may be considered to provide nutrition.

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Fig 2:- Gross motor function classification system (GMFCS).

Etiology
Following is the brief overview of the causes and risk factors for cerebral palsy.

1. Prenatal (Before birth)

Causes:
Abnormal development of brain and brain malformations – These are also known as congenital malformations
Some examples are :Schizencephaly , Cerebral dysgenesis and Chromosomal abnormalities.

Risk Factors
a. Infection to the mother - Rubella, Cytomegalovirus and Toxoplasmosis. 7,8
b. Intrauterine infection
c. Medication - medications like Phenytoin, that is used to treat epilepsy
d. Teratogens- alcohol, nicotine, cocain ETC
e. Injury to fetal brain

2. Labor and delivery (natal)

Risk factors
a. Prematurity –The underlying basis of most neurodevelopmental sequelae in the preterm infant is white matter
damage, collectively called perinatal leukoencephalopathy. This term encompasses germinal matrix
hemorrhage(GMH), periventricular hemorrhage(PVH), intraventricularhemorrhage(IVH), periventricular
hemorrhagic infarction, and periventricular leukomalacia (PVL). Preterm infants are prone to GMH, PVH, and

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IVH because their cerebral circulation is sensitive to changes of blood pressure. Large GMH/IVH, in turn,
causes obstruction of the terminal veins, resulting in hemorrhagic infarction. 9 Loss of oligodendrocytes affects
nerve cell growth, which, in turn, impairs myelination.(Fig:3)
b.

Fig 3:- Events leading to cerebral palsy in preterm infant.

c. Low birth weight - Children weighing less than 2500 gms

d. Injury at birth – due to use of devices for delivery, use of suction to assist in delivery, rupture of uterus and
breech presentation (baby is in the inverted position in the uterus)
e. Multiple births - Twins, triplets, and other multiple births have a higher risk for CP.
f. Infection.

3. Perinatal (Immediately after birth)

Risk factors
a. Asphyxia (lack of oxygen) – Birth asphyxia refers to lack of oxygen supply to the infant brain. It occurs when
the organ of gas exchange (placenta or lungs), fails at the time of birth, resulting in oxygen deprivation
(hypoxia), hypercarbia, and metabolic acidosis. Asphyxia leads to alterations in cerebral blood flow in a
homeostatic attempt to maintain circulation to more vital areas. There is no damage if blood flow to the brain is
maintained. If, on the other hand, blood flow is compromised (ischemia), depriving oxygen supply, cell death
results due to release of free radicals and amino acids such as glutamate. 8(Fig 4)

Fig 4:- Events leading to cerebral palsy in term infants due to birth asphyxia.

b. kernicterus– Neonatal jaundice is the most common complication of the newborn period, usually caused by
unconjugated hyperbilirubinaemia
c. Epilepsy –. A seizure may cause irreversible brain damage. Epilepsy is often associated with cerebral palsy.
d. Hydrocephalus - Hydrocephalus is a condition where there is excessive accumulation of fluid in the ventricles
(cavities) of brain.

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4. Early Childhood
a. Traumatic Brain Injury (TBI) – Injury to the head or brain of a child due to physical trauma (falls, accidents etc.)
may result in cerebral palsy..
b. Infections – Infection to the brain of the infant like meningitis and encephalitis
c. Epilepsy – Seizures that occur within the first year of life may lead to severe irreversible brain damage leading to
cerebral palsy(Flowchart 1).

RISK FACTORS

PRENATAL PERINATAL POSTNATAL

CONGENITAL LABOUR COMPLICATIONS HYPOGLYCEMIA

INFECTIONS (TORCH)
BACTERIAL AND VIRAL METABOLIC DISEASES
TERATOGENIC NEONATAL INFECTIONS
HEAD TRAUMA
AGENTS
KERNICTERUS
BACTERIAL & VIRAL
INTRAUTERINE
PREMATURITY INFECTIONS
HYPOXIA

MULTIPLE PERIVENTRICULAR
PREGNANCIES LEUKOMALACIA

MATERNAL HYPOXIA OR ANOXIA

HYPOTHYRODISM &
LOW BIRTH WEIGHT
HYPERTHYROIDISM

Flowchart 1:- Risk factors and aetiology of cerebral palsy.

Clinical Signs And Symptoms

Cerebral palsy is a disorder with a diverse clinical picture. The signs and symptoms vary depending on the type and
severity of the brain damage. The signs of cerebral palsy are the effects that can be observed and tested by the
clinician. The symptoms of cerebral palsy differ in type and severity from one person to the next, and may even
change in an individual over time. Common symptoms exhibited by children with cerebral palsy includes:
1. Lack of muscle coordination when performing voluntary movements (ataxia).
2. Stiff or tight muscles and exaggerated reflexes(spasticity).
3. Walking on the toes, a crouched gait, or a ―scissored‖ gait.
4. Variations in muscle tone, either too stiff or too floppy.
5. Difficulties swallowing or speaking.
6. Shaking (tremor) or random involuntary movements.
7. Delays in reaching motor skill milestones(Table 1)
8. Difficulty with precise movements such as writing or buttoning a shirt. 10

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Table 1:- Gross motor developmental milestones.

Early signs of cerebral palsy

1. The child may develop difficulties in feeding, sucking and swallowing.
2. The child may show slower or delayed development compared to other children.
3. Child‘s body may stiffen when carried, dressed, washed, or during play.
4. It may be difficult to carry the child as the body is too flail and floppy.
5. The arm and leg movements of the child are diminished and the child may find it difficult to grip the toes or his
hands.
6. The child may show some signs of impaired communication. The child may not respond when his name is
called.
7. The child may not be able to use both his hands together in a coordinated manner .

Signs associated with variation in the tone of the muscles

The most common and easily noticeable sign of cerebral palsy is abnormal muscle tone. The tone of the muscles is
the tension in the muscles required to bring about movement.

Abnormalities of the tone are demonstrated as following signs:

Hypotonia– Characterized by reduced tension in the muscles, exhibited as flaccid, relaxed and floppy babies

Hypertonia – Characterized by increased muscle tension. The movements are slow and laborious and sometimes not
possible as the antagonist muscles fail to relax.

Dystonia – Dystonia is characterized by fluctuating muscle tone. At rest the tone may seem normal but initiation of
voluntary activity may lead to sudden stiffness.

Mixed tone– In some children arms and legs may show increased tone on voluntary movement whereas the trunk
may be hypotonic.

Clonus – clonus is uncontrolled jerky muscle contractions that cause rapid tapping movement of the feet or flapping
movement at the wrist.

Signs associated with abnormal reflexes

Infants with cerebral palsy have been known to manifest persistence or delay in the disappearance of primitive
reflexes and pathologic or absent postural reactions. Some of the common reflexes that may persist till later in the
childhood are as follows(Fig5):

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• Palmer grasp reflex – This reflex should disappear between 4 to 6 months. It is characterized by closing of the
fist as the palm of the infant is touched.
• Tonic labyrinthine reflex – This reflex should disappear by three and half years of age. The tonic labyrinth
reflex shows the baby with abducted shoulders, flexed elbows, adducted extended hips, and extended knees and
ankles. This posture primarily occurs with the baby in the supine position.

Palmer grasp reflex Tonic labyrinth reflex

Moro reflex(startle reflex) Assymetrical tonic neck reflex

Parachute reaction Foot placing reflex

Fig 5:- Some of the common reflexes that may be absent or persist till later in the childhood.
1. Moro (startle) reflex – Moro‘s reflex usually integrates in 6 months. The Moro reflex is initiated with a loud
noise, that causes the child to have full extension of the head, neck, and back. The shoulders abduct and the
elbows extend. The legs also have full extension. After a short time, the pattern reverses and the head, neck, and
spine flex; the arms are brought to the midline; and the legs flex.
2. Asymmetrical tonic neck reflex – Usually this reflex should disappear at the age of 6 months. This reflex
characterized by straightening of the arm and legs on the side where the neck turns and flexing of elbow and
knee on the opposite side.
3. Parachute reaction – It is initiated by holding the child at the pelvis and tipping his head down. As the child is
lowered toward the floor, he extends the arms as if he were going to catch himself with his arms. This self-
protection response should be present by 11 months of age.
4. Placing reflex – This reflex should disappear by 5 months. As the infant is held upright and the heels touch the
surface of the ground the legs curl up.

Associated Conditions
While the motor deficit in cerebral palsy is predominant, a number of associated conditions are frequently present
and must be considered in the overall developmental needs of the affected child.A systemic review in 2012 11comiled

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information on the rates of co-occuring impairments, diseases and functional limitations in children with cerebral
palsy. The result showed:
1. 3 in 4 were in pain
2. 1 in 2 had an intellectual disability
3. 1 in 3 could not walk
4. 1 in 3 had a hip displacement
5. 1 in 4 could not talk
6. 1 in 4 had epilepsy
7. 1 in 4 had a behaviour disorder
8. 1 in 4 had bladder control problems
9. 1 in 5 had a sleep disorder
10. 1 in 10 were blind
11. 1 in 15 were tube-fed
12. 1 in 25 were deaf (Fig 6)

Fig 6:- the comordities of cerebral palsy and evidence based treatment.

Diagnosis
The diagnosis of cerebral palsy involves the following steps:
a. Observations by parents: It is important for the parents to observe the child for presence of any of the early
signs and symptoms of cerebral palsy. If the child presents with any of suspected signs or symptoms, attention
needs to be sought.
b. Birth history: A detailed birth history should be taken in which series of questions regarding the risk factors
for cerebral palsy are asked to identify the probable risk factors.
c. Developmental history: The developmental history of the child is asked to find out about any delay in
performing motor tasksin comparison with normal standards.
d. Motor examination: A detailed physical examination is carried out to evaluate ability to perform various motor
tasks, variations in the tone of muscles, impaired coordination and presence of abnormal involuntary
movements.
e. Reflex testing: Clinician will then check for the presence of any abnormal reflexes or persistence of primitive
reflexes later than the normal age.

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f. Administering special tests: If there are any abnormalities identified in the above, special investigations such
as MRI and CT scan are done to identify the cause and the area of brain damage.

The diagnosis of CP however is not always straightforward. Only those Children who are severely affected, or who
have a known risk factor, are diagnosed at an early age. Children with mild symptoms are often diagnose very late.
Early diagnosis of CP is important. It enables timely access to diagnostic specific early intervention when the
greatest neuroplastic gains are possible. The 3 tools with best predictive validity for detecting cerebral palsy at an
early age, before 5 months‘ corrected age are:
(1) Magnetic resonance imaging (MRI) (86%-89% sensitivity)
(2) The Prechtl Qualitative Assessment of General Movements (GMs) (98% sensitivity) and
(3) The Hammersmith Infant Neurological Examination (HINE) (90% sensitivity) 12

1. Magnetic Resonance Imaging:

Magnetic resonance imaging (MRI) is an important tool in the assessment of a child with cerebral palsy (CP). It is
usually recommended as the first diagnostic step after medical history taking. Brain MRIs have been reported to
detect abnormal findings in about 85–86% of children with CP. Subtle white matter lesions, myelination of the
posterior limb of internal capsule (PLIC), and cerebellar lesions are findings for which brain MRI is superior to
other imaging modalities. Mercuriet al. 13 reported that the myelination of Posterior limb of internal capsule is a good
predictor of motor outcome.

2. Prechtl Qualitative Assessment Of General Movements(GMs):

The Hans Prechtl assessment of general movements(GMs) is considered as the gold-standard method in the early
diagnosis of CP, with 98% of specificity and 95% of sensitivity at three months. The Prechtl method is based on the
qualitative analysis of the infant‘s spontaneous movements at three different stages :
1. the preterm period starting from the 26th week
2. the full-term period at approximately the 40th week in corrected age, and
3. nursing infants, that is, at 12 weeks calculated from the 40th week.

From 11 to 16 weeks post birth, GMs present as so-called fidgety movements that are described as being a
continuous stream of small and fluent movements occurring irregularly over the body. The appearance of fidgety
movements represents a phase in the re-organization of motor function that leads to the goal-directed motor
activities. According to various research evidences, absent or abnormal fidgety movements are predictive of CP
with 95–98% accuracy. Combining GMs with brain MRI has reportedly led to sensitivity and specificity of up to
100% in a cohort of extremely preterm infants. 12,14

3.Hammersmith Infant Neurological Examination (HINE)

The HINE is a simple, scoreable, standardised clinical neurological examination for infants between two and
twntyfour months of age. It assists in the early detection, diagnosis and prognosis of infants at risk of developing
cerebral palsy. There are three parts of HINE , a neurological examination (which is scored), developmental
milestones and behaviour ( which is not scored). The scoreble neurological examination includes twenty-six items
divided into five domains, assessing cranial nerve function, posture, quality and quantity of movements, muscle tone
and reflexes and reactions. Each item is scored individually (0,1,2 or 3). A subcore can be given for each section and
the overall score is calculated by summing up all the twenty-six items (Range 0-78) with higher scores indicating
better neurological performance.

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Infants has risks for Cerebral palsy ? RISK FACTOR

MATERNAL RISKS : Thyroid,
preclampsia, infection, multiple births,
placental abnormalities
NO YES BORN PREMATURE : < 28 WEEKS
(10%)
SS < 37 WEEKS(0.7%)
TERM BORN: Encepalopathy, head injury,
healthy with no known risks
Infant has abnormal motor development?
MOTOR ASSESSMENT
AGE: 20 WEEKS ( CORRECTED)
GENERAL MOVEMENTS
ASSESSMENT :
95% predivtive. An abnormal score of ―
cramped synchronized‖ before 8 weeks
N O YES corrected , followed by an abnormal score
of ―absent fidgety‖ at 10-20 weeks
corrected age is 98% predictive of cerebral
palsy
HAMMERSMITH-INFANT
NEUROLOGICAL
Infant has abnormal neuroimaging? ASSESSMENT(HINE) :
GMFCS III –IV score <40
GMFCS I-III SCORE 40-60
90% predictive of cerebral palsy

ABNORMAL NEUROIMAGING
N O YES Periventricular white matter injury
Cerebral malformation
Grey matter injury
Intracranial hemorrhage
NOT Infection
CEREBRAL Non specific
CEREBRAL
PALSY
PALSY

Flowchart 2:- Evidence-based decision-making algorithm for diagnosing cerebral palsy early.

Management Of Cerebral Palsy

Unfortunately, there is no cure for CP. It is a lifelong disorder that requires a range of long-term therapies and
interventions. The goal of management of cerebral palsy is therefore not to cure or to achieve normalcy but to
increase functionality, improve capabilities, and sustain health in terms of locomotion, cognitive development, social
interaction, and independence. This is best done by early, intensive management via a mulidisciplinary team
approach. A modern team approach focuses on total patient development, which encompass rehabilitation,
pharmacologic treatments, surgical treatments, mechanical aids, and management of various associated medical
conditions.

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1. Rehabilitation
A. Physical Therapy
One of the first interventions recommended for a CP patient is physical therapy. Physical therapists (PT) are health
care professionals specializing in movement that aims to optimize quality of life through exercises, hands-on care,
and education (American Physical Therapy Association, 2019). Physical therapists will begin by doing an initial
assessment of the patient to evaluate what skills will need to be addressed for each patient and come up with a plan
of care. Physical therapists prescribe individualized plans of care for patients with a goal of managing pain,
promoting movement, increasing function, and decreasing chances of future complications. Various physical therapy
includes :

i. Gait analysis
Gait analysis is a systematic measurement used to identify and evaluate human movement. Modern gait are based
on four disciplines: Visual inspection, quantitative analysis, biomechanical analysis and electromyography(EMG).
Observing the patient‘s gait analysis enables the physical therapist to watch the patient‘s coordination, balance,
strength, posture, flexibility and endurance all at once.
ii. Constraint-induced movement therapy
It involves restraint of the unaffected limb to encourage the use of affected limb during the therapeutic tasks. This is
particularly useful in management of hemiplegic patient, wherein the patient tends to use only the limb that is
unaffected.
iii. Hand-arm bimanual intensive training (HABIT)
It is also benificial for hemiplegic CP where the child is trained to use both hands together through repetitive tasks
such as drumming, and pushing a rolling pin.
iv. Electrical stimulation
The electrical stimulations used to increase muscle strength in children with CP are neuromuscular electric
stimulation and threshold electrical stimulation (Kerr et al., 2004). 15

B. Occupational Therapy
An occupational therapist works with patients to develop the skills needed for activities of daily living . Activities
of daily living typically include self-care (grooming, dressing, feeding, etc.), play, and fine motor skills (writing,
holding small items etc.) (Rezaie&Kendi, 2020). An Occupational therapist will spend more time on smaller, fine
motor skills such as the movement of the fingers as opposed to a physical therapist who tends to work on bigger,
gross motor skills such as walking. However, this does not mean that there will never be any overlap between these
two—an occupational and physical therapist can both be working on the same skills with the patient (Cerebral Palsy
Guide, 2020).

C. Speech Therapy
Another type of intervention commonly utilized by patients is speech and language pathology, or speech therapy.
Speech therapy has a goal of improving the patient‘s capacity for communication, saliva control, and eating,
drinking, and swallowing (Cerebral Palsy Alliance Research Foundation). Speech and language therapists observe,
diagnose, and treat the communication disorders associated with CP. Speech therapist help improve your child‘s
ability to speak clearly or communicate using alternative means such as an augmentative communication device or
sign language. They may also help with difficulties related to feeding and swallowing.

2. Drug Treatments
Some of the most common oral medications prescribed for CP patients are: centrally acting drugs such as Baclofen
and Tizanidine; peripherally acting drugs such as dantrolene sodium; and anticonvulsants such as Benzodiazepines
and Diazepam. Medications may also be administered through injections or pumps, which include botulinum toxin
injection, intrathecal baclofen pump, and alcohol or phenol injections—that all have chemodenervation effects
(Chang et al., 2013).

3. Surgery
Though this is typically not the first intervention chosen, surgical procedures are still an option for some CP
patients. Surgery is discussed with the patient‘s health care team and caregiver(s) when the other treatment
interventions are no longer helping the patient. The common operations include muscle lengthening, tendon
lengthening, tendon transfer, tenotomy/myotomy, osteotomy, arthrodesis, selective dorsal rhizotomy, and operations
to address comorbidities of CP such as cochlear implants and gastrostomy (Cerebral Palsy Guide, 2020).

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4. Orthotics, Adaptive Equipments, And Assistive Technology

According to the United States Individuals with Disabilities Education Act (IDEA), the term ―assistive technology
device‖ means any item, piece of equipment, or product system, whether acquired commercially off the shelf,
modified, or customized, that is used to increase, maintain, or improve functional capabilities of a child with a
disability.3 (Table 2)

5. Management Of Associated Problems

Various members of the team are involved in the management of associated problems. The clinical psychologist
helps with management of behavior problems using behavior modification techniques, psychotherapy, family
counselling, etc. The orthopedic surgeon helps with prevention and correction of musculoskeletal problems, e.g.,
braces to prevent scoliosis, tendon release and lengthening, etc. The audiologist and ENT specialist takes care of
hearing and speech problems, provision of hearing aids. The ophthalmologist provides remedies for
oculovisualproblemscorrective glasses, squint surgery, etc. High technology devices like electronic feeding devices,
computerized speech systems and cochlear implants are available for children with CP in Western countries.

Table 2:- Examples of orthoses, adaptive equipment and assistive technology devices.

Dental Management
Children with CP are more prone to caries, periodontal disease, inadequate oral hygiene, and decreased access to
daily preventive care and routine dental visits. To compound this problem, delivery of dental care for these patients
can be challenging.Consequently, dentists dealing with them should possess thorough knowledge of the medical and
orofacial abnormalities and their implications and should liaise with different medical specialists in order to
formulate safe and effective dental preventive and treatment plans.

The latest revised recommendations (AAPD) to reduce the risk of developing oral diseases and oral health care for
children with Special health care needs (SHCN) include:
(1) Establishing dental home at an early age.
(2) Patient assessment.
(3) Creating an environment conducive for the child to receive care.
(4) Providing comprehensive oral health education and anticipatory guidance to the child and caregiver.

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(5) Providing preventive and therapeutic services including behavior guidance and a multidisciplinary approach
when needed.
(6) Attention to detail for all aspects of care including scheduling appointments, assessment, treatment planning,
consent, education and anticipatory guidance, treatment, recalls, and transition of care when the patient reaches
adulthood.

Some Important Considerations During Dental Examination And Treatment Of A Child With CP:
1. The dental chair must be adjusted carefully, and most of these patients are best treated with the chair tipped
back to give a position of security, especially to those with ataxia. The spastic type of a patient having fairly
severe head-and-neck involvement will require even more control and support and can be achieved by seating
the child in knee to knee position of the dentist and the parent/caregiver(fig6)
2. If the patient is using a wheelchair, he/she should be considered to be treated in the wheelchair itself.
3. The first dental visit should be used mainly to establish mutual confidence and have a preliminary assessment.
The following appointments should be made early in the day so as to allow sufficient time to establish
appropriate interaction between the child and the dentist.
4. Open mouth can be obtained and maintained with the use of mouth props
5. The dentist should try to be gentle and caring, and he should avoid sudden movements which may trigger
muscle stiffening or spasm.
6. A finger guard and a use of steel mirror are preferred to avoid injury. Sharp instruments when used should be
used with extreme caution so as to prevent injury.
7. The approach should be a team effort involving mutual efforts between dentists, hygienist, assistant, patient,
family, and other persons who are having impact on patient‘s life. 16

Fig 6:- The knee-to-knee position for toothbrushing and examination.

Management of common oral conditions in children with cerebral palsy

Bruxism
Bruxism is a common occurrence in children with CP. There is no definitive treatment or cure for bruxism, and it is
important to recognize the reasons behind each patient‘s habit in order to choose an effective treatment modality.
Mouthguards can be used to protect the teeth but they will not stop or cure the condition. Botulinum toxin has been
used with some success in children and adults with CP. Cognitive and behavioral approaches (stress reduction,
counseling, lifestyle changes, etc. show promise, but at this point, there are many limitations to their application.

Sialorrhea
Sialorrhea (drooling or ptyalism) refers to unintentional saliva leakage outside of the mouth. It is considered normal
physiological phenomenon in healthy infants. It typically diminishes by 1.5–3 years of age, at the time of maturation
of orofacial motor functions. Persisting beyond age of 4 years, the salivary incontinence is deemed pathological.

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1. Anticholinergic medicaments, such as atropine,scopolamine/hyoscine, and glycopyrronium bromide can be

prescribed to reduce the saliva production.
2. Botulinum toxin injections: A recent study by Hung AS et al, 2021 17 concluded that botulinum A injections are
a safe, reversible, effective treatment for drooling control in children with cerebral palsy that can offer
effectiveness for more than 3 months with few side effects.
3. Surgical management: Surgery is irreversible and should be undertaken only in severe cases where other
alternatives have been proved unsuccessful.

Dental Erosion
Dental erosion is defined as an irreversible loss of tooth structure associated with chemical dissolution of
hydroxyapatite crystals, caused by extrinsic or intrinsic acids, without involvement of cariogenic microorganisms or
acid produced by plaque bacteria. Medical referral can help with management of GERD, modification of dietary
choices, and reduction of harmful habits and behaviors. Dental management involves enhancement of protective
factors and improvement of salivary mechanisms. Topical application of fluoride agents and remineralizing products
[e.g., casein phosphopeptide–amorphous calcium phosphate (CPP–ACP)]18 can improve the resistance of the tooth
structures to acidic challenges. Regular patient recall for professional fluoride therapy and prescription of high-
concentration (5000 ppm) fluoride toothpaste can also help prevent dental erosion.

Dysphagia
Difficulty in swallowing or dysphagia is a condition in which muscles used for swallowing are weakened. Some
children with cerebral palsy may be completely unable to swallow or may find it difficult to swallow liquids, foods
or saliva. ● Medicines – drugs such as metaclopramide may help gastrointestinal motility and improve swallowing.
●Oromotor exercises – Speech therapists will evaluate and plan an exercise program to facilitate swallowing.

Temporomandibular Disorders
Temporomandibular disorder (TMD) is a group of conditions affecting the temporomandibular joint (TMJ), the
muscles of mastication, and the associated anatomical structures. Temporomandibular management strategies are
focused on reduction/elimination of pain, improvement of function, and ultimately of the patient‘s quality of life.
Conservative approaches include:
1. Patient education and behavioral management—such as modifying habits, training in relaxation and conscious
avoidance of excessive jaw movements,
2. Physical therapy—such as muscle exercise regimens, application of transcutaneous electrical nerve stimulation,
massage, thermo-/coolant therapy and iontophoresis.
3. Therapeutic medication—nonsteroidal anti-inflammatories, muscle relaxants, and anxiolytics.
4. Occlusal splints, which reduce parafunctional habits due to occlusion alteration, providing orthopedic stability
of the TMJ.

Traumatic Dental Injuries

The accentuated risk factors associated with traumatic dental injuries in children with CP include frequent falls,
collisions, seizures, tooth grinding, overjet, and a lack of lip seal. The treatment of traumatized teeth and the
prevention of future trauma should be of primary importance. A pedodontist should educate the parents, teachers,
and caregivers in correct emergency care of CP patients after traumatic injury, to search for preventive measures,
such as the use of mouth guards and safe transport of these individuals in wheelchairs. The dentist should emphasize
the caregivers that traumas require immediate specialized attention and explain the procedures to follow if a
permanent tooth is knocked out. Instructions should be given to the caregivers to find any missing pieces of a
fractured tooth.

Dental Caries
Increased prevalence of dental caries is seen in patients with cerebral palsy. 19,20The common risk factors for these
increased prevalence includes mouth breathing, sialorrhea, effects of medication, enamel hypoplasia, food pouching
and inability to maintain proper oral hygiene. Caution patients or their caregivers about medicines that reduce saliva
or contain sugar. Suggest that patients drink water often, take sugar-free medicines when available, and rinse with
water after taking any medicine. Advise caregivers to offer alternatives to cariogenic foods and beverages as
incentives or rewards. For people who pouch food, talk to caregivers about inspecting the mouth after each meal or
dose of medicine. Remove food or medicine from the mouth by rinsing with water, sweeping the mouth with a
finger wrapped in gauze, or using a disposable foam applicator swab. Recommend preventive measures such as

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fluorides and sealants, silver diamineflouride and calcium phosphopeptide amorphous calcium phosphate (CCP-
ACP).
Periodontal Disease
Periodontal disease is common in people with cerebral palsy due to poor oral hygiene and complications of oral
habits, physical abilities, and malocclusion. Another factor is the gingival hyperplasia caused by medications.
Involve the patient in hands-on demonstrations of brushing and flossing. Talk to caregivers about daily oral hygiene.
A power toothbrush or a floss holder can simplify oral care. Emphasize that a consistent approach to oral hygiene is
important. Explain that some patients benefit from the daily use of an antimicrobial agent such as chlorhexidine.
Recommend an appropriate delivery method based on your patient‘s abilities. Rinsing, for example, may not work
for a patient with swallowing difficulties or one who cannot expectorate. In such cases, Chlorhexidine applied using
a spray bottle or toothbrush can be equally efficacious.

Conclusion:-
Cerebral palsy is the most common physical disability in children and so there is increase interest in CP and its
search for better possible treatments has been on the rise. Knowing the possible causes and risk factors for CP can
help to diagnose this disorder, as well as possible associated disorders, at an earlier age.

Children with CP have a considerably higher prevalence of oral diseases as compared to otherwise healthy childrens
due to lack of oral health education, exposure to treatment, and prevention measures such as fluoride supplements
and dental sealants. The oral health of children with CP has always been found poor when compared to otherwise
healthy children. The establishment of dental care for these individuals presents a unique challenge. As it is rightly
said ― Oral health is the mirror to General health‖ , therefore the role of a dentist is enormous. Dentists dealing with
them should possess thorough knowledge of the unusual medical and orofacial abnormalities and their implications
in order to formulate safe and effective dental preventive and treatment plans.

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