International Journal of Oral Health Sciences

REVIEW ARTICLE
Year
: 2021  |  Volume : 11  |  Issue : 2  |  Page : 88--94

Cerebral palsy: Pediatric dentistry perspective – A review


S V S G Nirmala1, Saikrishna Degala2, Sivakumar Nuvvula1,  
1 Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, JSS Dental College and Hospital, Mysore, Karnataka, India

Correspondence Address:
Dr. S V S G Nirmala
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore - 524 003, Andhra Pradesh
India

Abstract

Cerebral palsy is one of the most severely handicapping conditions affecting irregular gait childhood. This condition manifests itself as a number of neuromuscular dysfunctions and involves muscle weakness, stiffness, paralysis, poor balance irregular gait, and uncoordinated or involuntary movement. These children may have higher risk of caries due to their inability to maintain good oral hygiene, intake of soft and cariogenic food, increased prevalence of enamel hypoplasic defects on the teeth. Periodontal diseases occur with great frequency, as they are unable to brush and floss adequately, they may also be on phenytoin to control seizure activity which is a cause of some degree of gingival hyperplasia. Malocclusion occurs twice, bruxism is commonly seen in athetoid type, and due to the nature of disorder, these children are more susceptible to trauma, especially of the maxillary anteriors. They have excessive drooling and difficulty in swallowing. Spastic children present with spastic tongue thrust, Class II DIV 2 malocclusion with unilateral crossbite. Athetoid patients presents with mouth breathing and anterior open bite. Many patients prefer to be treated in the wheel chair, which may be tipped back into the dentist's lap, head should be stabilized throughout the procedure, use physical restraints for control of failing extremities, mouth props, and finger splints can be used for control of involuntary jaw movements, avoid abrupt movements, lights and noises to minimize startle reflex reactions. Local anesthetic can be used with care, rubber dam can be used to protect the working area from hyper active tongue movements, and gauge shield should be used during extraction to avoid aspiration. Premedication can be used to reduce hypertonicity, involuntary movement, and anxiety; general anesthesia can be used as a last resort. This article discusses about etiology, clinical features along with management of children with cerebral palsy.



How to cite this article:
Nirmala S V, Degala S, Nuvvula S. Cerebral palsy: Pediatric dentistry perspective – A review.Int J Oral Health Sci 2021;11:88-94


How to cite this URL:
Nirmala S V, Degala S, Nuvvula S. Cerebral palsy: Pediatric dentistry perspective – A review. Int J Oral Health Sci [serial online] 2021 [cited 2022 Jul 1 ];11:88-94
Available from: https://www.ijohsjournal.org/text.asp?2021/11/2/88/337501


Full Text



 Introduction



Cerebral palsy is defined as a nonprogressive lesion which occurs in the developing brain before, during, or after birth, leaving the child with a variety of neurological problems. The motor deficit is fully evident only as the child develops. One newborn in approximately 200 live births is affected.[1]

This belongs to a group of related disorders which overlap both etiologically and clinically and come under the heading of syndromes of cerebral dysfunction and which also includes types of mental deficiency and epilepsy.[2] A particular diagnostic label is given where that aspect predominates, and in cerebral palsy, it is the neuromotor, but it may not be the sole effect of the original casual factor or the factors; for example, a cerebral palsied child may suffer from convulsions, and in both cerebral palsied and epileptic groups, there may be varying degrees of mental deficiency.[3]

 Etiology



The cause of the cerebral palsy may be apparent in some cases and may have occurred before, during, or after birth. Hemorrhage and possibly viral infections during pregnancy, fetal anoxia, prematurity, birth trauma, kernicterus, and tubercular meningitis are more common causes and some are familial. There are cases, however, where no obvious cause can be discovered so that the term “brain-damaged child” is not really suitable.[4]

The degree of involvement of the neuromotor system differs highly from those who are impressed so slightly that they can lead normal lives to those who are severely affected that they essential be totally institutionalized.[5] The incidence in Britain and Scandinavia is 1.0–2.1/1000 children of school age and in the USA, it is 1.5–3.0/1000 of all ages.[6]

The term “cerebral palsy” itself covers a variety of disorders which are classified according to the type of motor disturbance as follows:[7]

 Spasticity



Approximately seen in 70% of cases. This type occurs in over one-half of all cerebral palsied patients and is due to damage involving the pyramidal tracts, resulting in impairment of the ability to control voluntary movements. There is an exaggerated stretch reflex and increased tendon jerks. There is appearance of severe muscular stiffness and the planned movement of an affected limb results in a hyperactive tendon reflex. This is particularly seen when a rapid movement is anticipated, but it is less with a slow passive movement.[8]

The child may be described as paraplegic, with involvement of both lower limbs, quadriplegic or tetraplegic, with involvement of all four limbs, hemiplegic, with an arm and leg on the same side affected. The term “double hemiplegia” infers that all four limbs are involved but the arms more severely than the legs. Lack of control of neck muscles, trunk muscles, and intraoral muscles, impaired chewing and swallowing with speech problems. The involved muscle shows hyperirritability, exaggerated contractions when stimulated, tense muscles. Excessive drooling persistent tongue thrust.[9],[10],[11],[12],[13]

Up to 36% of children with CP have epilepsy, with onset in the 1st year of life in 70%.[13] Every effort should be made to avoid sedation before EEG as this may affect the result of the test.[14] Epilepsy can be an indicator of the severity of neurological injury (quadriplegic CP) or cortical insult (hemiplegic CP).[15] Children with spastic diplegic CP are at a lower risk for epilepsy mainly because their pathology predominantly involves the periventricular white matter.[16]

 Athetosis



This is the second most common type of cerebral palsy, accounting for approximately one-sixth of the cases and kernicterus plays a large part in its causation. It is characterized by frequent involuntary and often inco-ordinated movements of the muscles which may give the appearance of writhing. Facially, this may result in grimacing, drooling, speech defects, and other problems. Most often associated with convulsions or mental retardation and frequent uncontrolled jaw movements are seen that cause abrupt closing of the jaw or severe bruxism.[17],[18]

 Rigidity



This is an uncommon type in which there is resistance to passive movement, though this may sometimes be overcome by sudden action. The majority of these children are mentally defective.[19]

 Ataxia



It is also less common, this is due to disturbance of the equilibrium and difficulty in grasping objects. Sitting erect may be difficult.[7]

 Tremor



It is also uncommon. It involves the whole body with constant rhythmic movements and other members of the family may be affected.

 Mixed



These are the cases in which more than one type of effect is apparent and there is difficulty in making a clear diagnosis.

This group of children presents a very substantial social and medical problem and their numbers are sufficient to justify specific local arrangements in any large area of population. There are broadly four grades of general care needed for these children. Those who are mentally competent can attend normal school as their physical handicap tends to be slight. Those who have a significant handicap should be able to attend special school or center where all types of rehabilitation should be available. If geographically possible, they should be living at home but where the distance is too great for daily travelling, then residential facilities should be available. The in educable child should, if possible, be able to attend daily at an “occupation center” where he can be given simple training, both for his own sake and to relieve his family of part of the burden. Those who are grossly handicapped, both physically and mentally, are of course usually institutionalized. Unfortunately, complete services of this kind are not available everywhere that they are needed but inquiry at a local health department will usually provide information as to the existence of both public and private facilities for such patients.[19],[20]

 Oral Condition



Dental caries

Most of the surveys that have been carried out on the caries experience of these children show that it is only marginally higher than in normal controls. There is, however, striking difference with in the d. e. f and D. M. F ratios, with a higher figure for decayed and missing teeth in the cerebral palsied child, balanced by a higher number of filled teeth in the normal control. This is a reflexion of the type of dental care received by the two groups and is further shown by the types of fillings present, those in the cerebral palsied patients been of a simpler type than those in the normal.[21]

There is a higher incidence of enamel hypoplasia of the primary dentition, particularly in those patients with a history of prematurity or kernicterus, as might be expected.[22]

Periodontal disease

More than three quarters of the children have some degree of gingivitis, the incidence being higher in older children than in the younger groups. The greatest occurrence is in the spastic group and the least in the athetoids. Severe periodontal disease with pocketing occurs in 10% of cases. Those patients whose medical problems include convulsive episodes may well be taking one of the dilantin group of drugs, and as a result, cases of hypertrophic gingivitis occur and account for a number of the severe periodontal conditions. Oral hygiene in cerebral palsied patients is usually rather poor. One survey of 253 such patients gives the status as 15% good, 45% fair, and 40% poor. The problem of maintaining good oral hygiene in many of these children can be very great. Oral clearance with tongue, lips, and cheeks is often abnormal, swallowing may be difficult, and drooling may occur. The mechanics of tooth brushing may be so difficult as to discourage perseverance either by patient or parent. The type of diet may also mitigate against oral cleansing as children with affected muscles of mastication and deglutition tend to eat soft, easily-swallowed foods, with a very high proportion of carbohydrate. Those who are domiciled at home and are not properly supervised may have a degree of vitamin deficiency from such an ill-balanced diet with some periodontal signs.[23],[24],[25]

 Malocclusion



Cerebral palsied children have a higher incidence of malocclusion than usual due to the abnormal muscular activity present in these patients. It may be related to the degree of tonicity of the muscles of the face, mastication or deglutition, and to abnormal function or involuntary movement of structures influencing the dental arches. Thus, the spastic type, with hypertonicity of the lip and facial musculature has a preponderance of Angle's Class II division 2 malocclusion with crowding, and sometimes unilateral cross-bite. The athetoid, on the other hand, has hypotonic lips and sometimes drooling, and tends to have an Angle's Class 2 division 1 malocclusion with a high narrow palate and tongue thrust, producing an anterior open bite. In addition, any case may be complicated by the early loss of primary or permanent teeth.[26],[27],[28],[29],[30]

 Trauma



The dental condition may be further afflicted by trauma. Falls are not in frequent in children with incomplete muscular controls and traumatic injuries to incisors occur. This is likely to be more common in the athetoid with proclined incisors which are always more susceptible to such damage.[31] Bruxism may be severe in some patients, most commonly in the athetoid.[32],[33]

Dental treatment

Good dental care in cerebral palsied children and especially those with any head or neck involvement is essentially important in the

They have masticatory difficulties which are increased with loss of teeth. This would contribute further to nutritional deficienciesMany of these children will never be able to wear dentures because of muscular disabilitySpeech problems are increased by loss of teethEmotional aspects should not be overlooked. A child whose dental needs are brushed aside or otherwise neglected will be more frustrated than one whose dental esthetics and conservative treatment are met to the same extent as his normal siblings.

Unfortunately, comprehensive dental care for these patients is not at a matter of routine arrangement in all areas, but the dental practitioner can contribute greatly to this service.[34]

 Problems of Treatment



A child who is so slightly affected that he can attend normal school may be treated as a normal child patient in a dental practice, while those who are so severely handicapped both physically and mentally as to be totally institutionalized or usually only suitable for extractions and good nursing care in relation to oral hygiene. If a child is able to attend a special school or center, then he is capable of being helped. The child with any degree of head or neck involvement presents problems of dental care and they may be roughly divided in to difficulties deriving from his mental, physical and dental states.

 Mental Difficulties



Apprehension

This can be a real problem at first until the child becomes familiar with both the dentist and the type of treatment. It particularly applies to a child who is domiciled at home and who rarely meets anyone but members of his own family. The child at a special school or center is more used to meeting others. The spastic child is especially prone to apprehension.

Difficulty of communication

There may be auditory or visual defects which make chairside talk and explanations difficult, or the child may have a speech defect which makes his replies incomprehensible. The dentist must not assume any intelligence deficiency in such cases without other evidence.

Low intelligence

In patient of below normal intelligence, communication and understanding may be difficult to attain when attempting to obtain co-operation.

Distractibility

In some patients with cerebral dysfunction, there is restlessness and a deficient ability to concentrate. Trivial things tend to distract the attention of the patient.[35]

Convulsions

A number of cerebral palsied children suffer from some degree of convulsions. Although anxiety could precipitate such an attack, the patient is almost certainly receiving drugs which control the condition, and such an episode is rare in the dental chair.

 Physical Difficulties



Postural position

A patient with some degree of ataxia will not be able to sit in the dental chair unaided because of disturbance of equilibrium. The athetoid and those spastic patients with involvement of neck muscles have difficulty in achieving or maintaining the normal sitting posture with head positioned on the headrest.[36]

Ability to co-operate

As a general rule, a child who can walk in to the surgery, even with some help, sit in the dental chair and open his mouth, can be treated without real difficulty. Children with greater involvement than this particularly of the head and neck may provide serious problems of co-operation, not because of unwillingness, but because of inability to produce the required muscular actions.

In the spastic patient, muscular stiffness tends to disappear when sitting still and relaxed but when effort is made to bring muscles into action to open the mouth, there is excessive reaction and the lip muscles, though producing some degree of opening, may be so strongly contracted and tense as to provide a barrier to the examination of the oral cavity. Producing sufficient separation of the dental arches is a similar problem.

In the athetoid, the constant involuntary muscle movements make treatment difficult, the facial and masticatory muscles producing jerks and perhaps sudden closure.[37]

Dental caries

The dental caries rate is only marginally higher than the normal but conservation is far more important because of the greater problems that may be found in relation to prosthesis. Unfortunately, the greater are the difficulties of conservation, the less likely is the patient to be able to wear an appliance, but if the physical and mental problems can be overcome, then the conservation itself provides no real difficulty. Patients with severe bruxism and tendencies to clench and jerk are not suitable for a prosthetic or orthodontic appliance unless it can be made unbreakable.[23]

Support the head while brushing, put only a pea size toothpaste up to 4 years of age as the swallowing reflex is not developed and the patient tends to digest it. Encouraging swishing after medication as avoid fruit juice as it increases sugar exposure. Prefer anticariogenic diet, especially cheese products. Counsel parents about maintain oral hygiene, preventive measures like fluoride and importance of recall visits. Oral hygiene is always a real problem but is extremely important in the preventive field. Drug therapy of the dilantin group can produce a persistent hypertrophic gingivitis.[36]

 Dental Management



Introduction to the surgery

Before seeing the child for the first time, the dentist should seek information from his physician as to his condition. He needs to know the type of neuromotor involvement and how severe, any history of convulsions, drug therapy, other sensory defects such as visual or auditory, and an estimate of his level of intelligence. With this knowledge, the dentist is able to adjust his attitude to the needs of that particular patient. The approach should be friendly and sympathetic but firm and confident. Any lack of assurance is sensed by the child and produces an adverse attitude. Patience and persistence are of prime importance, and if necessary several visits should be given to the establishment of a friendly relationship and confidence, with examinations and simple explanations, before real treatment is started. The aim should be toward a team effort between the dentist and child with the latter doing his share and being fully aware of it.

 Posture



Many of the cerebral palsied patients can sit in the dental chair, but this should be tipped back somewhat, so that there is a feeling of greater security against falling forward. A chair-side assistant may be needed in some cases to control the head movements when the dentist is working from the front of the patient. From the back, however, the dentist can usually achieve this control by holding the head between his left arm and body, while still having his wrist and hand free.

The use of retaining straps for support is strongly advocated by some but condemned by others. Such a support should be helpful with the very strong provision that the child understands that it is for support and not for restraint and does not regard it with aversion.

There are patients who can be controlled more easily and more completely if seated on the lap of a parent or assistant. If the parent is sensible and co-operative and has a real understanding of what is being done, then he or she is a suitable person to provide the control and the child is more assured. If the parent is not considered the right person, such support can be given by an assistant. The child is seated on her knee, with his legs between those of the helper to control him if necessary. He leans back with his head against the helper's shoulder or headrest and is held quietly with the helper's arms round the body and arms of the child. Another assistant may be needed to provide further support or control of the head.

 Examination



The patient should be encouraged to relax and all anticipated actions should be explained and demonstrated first. Sudden movements can precipitate muscle reaction and a smooth prepared approach is essential. In the spastic, an attempt to open the mouth by the patient may produce severe muscle contraction, but if he is taught to do this with slow pressure by the dentist, this can sometimes be overcome. Fingers should not be allowed to come between the teeth in cases where the jaws may clench unless a steel finger guard is used. A thimble can be useful but it must be of steel and not of some softer metal. It is advisable to attach a piece of chain or cord to it by drilling a small hole near the rim so that if it is lost from the finger, there is no danger of it being swallowed. In such cases, a glass mirror can be dangerous to the patient, for shattered, it may not be possible to recover the pieces of glass without hospitalization and a general anesthetic. A stainless steel mirror is advisable. Care should be exercised in the placing of a sharp probe so that if the jaws should close, the point is not a hazard to the soft tissues. Radiograph films are difficult to position and to keep still, though possibly bitewings may give a better chance of success. If so, then the detection of interproximal caries is much simplified.[34]

 Conservation



With the understanding and confidence of the patient, conservation should be possible with or without local anesthesia and certainly in those with reasonable intelligence. Some type of mouth prop is usually essential, but care must be taken that it is of a type and in a position which makes displacement difficult. If a simple nonadjustable prop is not used at maximum opening, it is dislodged when the patient opens a little further or by pressure of the tongue. A ratchet-type gag with scissor handles is useful, especially if the tooth-bearing surfaces are covered with soft metal or hard rubber to minimize the discomfort and slip on the teeth. Any such covering should be part of the gag and not detachable. The gag can be controlled by the assistant who is supporting the head. The patient should be allowed frequent rests from the open mouth position.[35]

A water spray and saliva ejector or sucker are essential in clearing the field of debris quickly since mouth rinsing is not feasible. A tongue retractor may be needed in some cases, especially when treating mandibular teeth. Prefer placing stainless steel crowns over restorations, especially molars, it is often helpful in keeping the field clear and dry to place a rubber dam clamp (without rubber dam) on the tooth being treated or the adjacent one. This can be placed and removed very speedily at need, and controls the position of cotton wool rolls, saliva ejector, and even the tongue to some extent.[36]

While the majority of cerebral palsied patients can be successfully treated in this way, there is a number for whom this is not so either for emotional or for physical reasons. If day admission is possible, then adequate premedication may overcome the difficulties. Alternatively, the whole of the conservation may be done under general anesthesia. This is the preferred method, especially for initial course of treatment since a long series of visits is eliminated and the child made dentally fit. Once this is attained, routine maintenance may be done more easily.[37]

 Periodontal Disease



The treatment of periodontal disease is based on normal methods, and those children who are on dilantin therapy may present one of the greatest problems by virtue of the resulting hyperplastic gingivitis. In severe cases of the latter, consultation with the physician may produce the possibility of an alternative drug regime. Some of these patients may have had a very ill-balanced diet, consisting largely of carbohydrates. If any marked degree of periodontal disease exists, then vitamin supplementation should be considered with the physician.[38]

 Orthodontics



Simple orthodontic treatment should be carried out wherever possible within the limits of the patient tolerance, always bearing in mind the hazards of breakages in some of the cases. Consultation with an orthodontist on compromised treatment is often helpful.

 Prosthetics



When the provision of a prosthesis is considered necessary and advisable, its design may need to be compromised on both its level of efficiency and its appearance. The dentist must also take into account case of management and the possibility of frequent replacement. Fixed partial denture is contraindicated.

The dentist may be asked to assist in the rehabilitation of a quadriplegic patient with the construction of a mouthpiece to hold a tool. This is made in acrylic and closely resembles an Andresen appliance. Following alginate impressions and a bite record, models are cast in stone and articulated in occlusion. Undercuts are eliminated and the teeth waxed over to form bite blocks with thin but flat occlusal coverage. These are then processed in acrylic separately and then fitted in the mouth, adjusting as needed. The occlusal surfaces are trimmed until the vertical separation of the teeth is reduced to about 1.0 mm. They are then sealed together with cement wax and removed from the mouth. The union of the two acrylic blocks is then completed with cold cure acrylic. The anterior surfaces of the appliance between the lips can now be built up with cold cure acrylic to provide a holder for the required tool. This may be in the nature of a rod to use as the pressure tool on the keyboard of a type writer, in which case the acrylic extension is drilled at the required angulations, usually about 45 degrees below the horizontal, for the insertion of the rod. Alternatively, the acrylic may be drilled through completely to take a straw so that the patient can accomplish some self-feeding, likewise training and exercising his muscles in sucking and blowing.[38]

 Oral Hygiene Practices



Oral hygiene must receive the greatest attention, and for many of the patients, a battery-operated toothbrush is strongly recommended. If used by the patient, it should have a switch which does not require sustained pressure to operate it but remains on once triggered. These toothbrushes are more easily and efficiently used by the parent or nurse when the patient is unable to do so.[39]

Prevention of dental caries in these patients is so extremely important that the supply of fluoride tablets in nonfluoride areas must be recommended and should start as early as the syndrome is evident. They can be taken easily at the recommended dose when crushed in orange juice or other drink.

 Conclusion



It is challenging task for pediatric dentist although, cerebral palsy is a complex disorder which frequently needs special care, knowledge of the specific classes, and musculoskeletal features of the condition. Hence, their quality of life is improved.

Availability of data and materials

All data and materials available as part of the article, and no additional source data are required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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