DENTAL CARE
Tooth decay is one of the most common diseases of childhood (18). Almost 80% of CSHCN in the United States are reported to need dental care (19), and as few as 10% of dentists report that they serve this population (20). Tooth decay and poor dental hygiene in children with disabilities are related to swallowing problems, drooling, and gastroesophageal (GE) reflux. Many medications are given with sweeteners to increase palatability and increase risk of tooth decay; others cause gingival hyperplasia (eg, phenytoin) or decrease saliva production. Routine dental care of a child or adolescent with severe developmental disabilities may be challenging for parents and caregivers due to an oral aversion, a tonic bite reflex, or the inability of the child to follow instructions to open his or her mouth. Other daily care activities, such as administration of multiple medications or respiratory treatments, may make dental hygiene less of a priority. Once a child takes over the care of his or her own teeth, the quality of cleaning may not be optimal because of cognitive and physical limitations.
Dental health of children with CP compared to children with other disabilities is most frequently described in the literature. The incidence of dental caries in children with CP is similar to the general population, although the quality of the caries is different. The size of the carious lesions is greater than what is seen in typical children (21-23). Periodontal disease is more prevalent in children with CP, likely due to the presence of gingival hyperplasia from those receiving phenytoin (24). Malocclusion and developmental enamel defects were also more common in children with CP (25-29). Erosion of primary and permanent teeth has been attributed to chronic GE reflux. The severity of erosion has been correlated with the duration of the GE reflux disease, frequency of vomiting, pH of the acid, and the quality and quantity of saliva (30-33). Despite the fact that children with CP do not participate in high-risk activities as frequently as their able-bodied peers, dental trauma is more common (34,35). These injuries, most commonly to the maxillary incisors, are related to trauma during transfers or falls.
There is little information about dental problems for children with spina bifida. An important issue that must be addressed at each visit is to ensure that the dental office or operating room provide a latex-free environment (36). Families may need to remind the dentist and hygienist of the child's risk for an allergic reaction to latex. Latex-free gloves must be available to reduce the risk of an allergic reaction. Boys with DMD can have malocclusion with anterior and posterior open bites, which are associated with lip incompetence, mouth breathing, and macroglossia. Deteriorating oral muscle function as the child gets older is associated with increased plaque and calculus formation and gingival inflammation, but not necessarily with the presence of dental caries (37,38). Boys with DMD have a greater risk of malignant hyperthermia when anesthesia is used for dental care (39,40).
Routine examinations and cleaning to maintain optimal dental hygiene should be performed by a dentist comfortable in the care of children with special needs. Some of the dental care may need to be accomplished under anesthesia in order to obtain the maximum benefit. Combining dental procedures with other necessary procedures, such as a brainstem auditory evoked response (BAER), local injections with phenol or botulinum toxin, or certain orthopedic procedures, may limit the exposure to anesthetic agents. The AAP Policy Statement on oral health care states that CSHCN be referred to a dentist as early as 6 months of age and no later than 6 months after the eruption of their first tooth, or 12 months of age (whichever comes first) (41). Visits will provide the dentist with the opportunity to provide specific education to the family to allow for optimal dental care.
