1
Physical Disability
1.1 Cerebral Palsy
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 24‐year‐old patient attends your dental practice with acute pain from a lower right molar tooth. Two courses of antibiotics prescribed by the general medical practitioner have been ineffective. She attends alone and has used a private taxi that has been able to accommodate her wheelchair.
Medical History
- Spastic cerebral palsy
- Degenerative disc disease and spondylosis of the cervical spine
- Adjustment disorder (presented after divorce; undergoing follow‐up by psychiatry)
Medications
- Trihexyphenidyl hydrochloride
- Baclofen
- Bromazepam
- Lormetazepam
- Mirtazapine
- Omeprazole
Dental History
- Irregular dental attender – avoided attending as she is anxious that dental treatment will make her gag
- No experience of local anaesthesia to enable dental treatment in the dental clinic setting
- Previous dental treatment provided under general anaesthesia on 2 occasions, when she was a child
- Good level of co‐operation
- Brushes her teeth regularly herself, although she admits difficulty accessing the posterior teeth due to her gag reflex and involuntary movements
Social History
- Lives alone and is not currently working
- Divorced and does not have a good relationship with her ex‐husband’s family; no children or close family
- A caregiver visits every morning to help with basic activities of daily life
- Wheelchair user (Figure 1.1.1)
- Limited financial resources
Oral Examination
- Involuntary movements of the jaw
- Moderate sialorrhoea – saliva does not spill over the vermilion border
- Pronounced gag reflex
- Mouth in very poor condition, with numerous carious teeth and deposits of calculus (Figure 1.1.2)
- Caries: #11, #15, #17, #21, #22, #25, #26, #27, #35, #37, #41, #42, #44, #45 and #48
- Tenderness on palpation: #48; no associated swelling
- Missing teeth: #36, #46 and #47
Radiological Examination
- Orthopantomogram – artefacts due to the patient’s movement
- Supplemented by long‐cone periapical radiography anteriorly
- Endodontic treatment of #11 and #21 (obturation satisfactory; no periapical radiolucent areas)
- Extensive, deep and unrestorable caries in #15 and #48 (with pulpal involvement)
- Restorable caries in #17, #22, #25, #26, #27, #35, #37, #41 and #44
- Recurrent caries associated with the dental fillings in #16, #42 and #45
- Missing teeth #36, #46 and #47
Figure 1.1.1 Patient with spastic cerebral palsy and preserved intellectual ability in the dental practice.
Figure 1.1.2 Extensive caries upper central incisors.
Structured Learning
- The #48 is painful on palpation and you suspect periapical periodontitis. The patient’s temperature is not elevated and there is no associated lymph node enlargement. What emergency management would you propose and why?
- It is important to treat the dental infection urgently to reduce the risk of significant morbidity and life‐threatening sequelae, including Ludwig’s angina
- However, within the last 20 years, antimicrobial resistance has become a significant issue with prescribed antibiotics/dosages being ineffective
- Hence it is important to remove the source of infection, establish drainage and prescribe analgesics
- Further effective antibiotics may also enable successful dental intervention at a later date, namely effective local anaesthesia followed by removal of the infected pulpal contents or by extraction of the tooth
- Drainage of an associated abscess should also be considered if swelling develops
- The patient has received appropriate and high‐dose antibiotics and requests that you attempt to extract the tooth the same day. Although she has no previous experience with local anaesthesia, she appears to be co‐operative and has capacity. What would you discuss with her?
- Extraction of #48 is the preferred treatment option as:
- The use of rotary instrumentation for caries removal is associated with increased risk due to the posterior position of the tooth, uncontrolled movements and increased gag reflex
- There is limited access to allow for endodontic treatment (e.g. due to difficulties accessing the posterior sections of the mouth)
- The patient struggles to access her posterior teeth for cleaning
- As this is an urgent procedure, the dental extraction can be attempted in the dental chair
- Given her considerable dental treatment needs, this can be followed up by the provision of non‐urgent procedures (e.g. restorations) provided in a hospital setting under general anaesthesia
- Prosthetic rehabilitation and subsequent follow‐up/treatment sessions should be performed in the dental clinic, if possible
- Extraction of #48 is the preferred treatment option as:
- What factors are considered important in assessing the risk of managing this patient?
- Social
- Lack of available escort
- Transport difficulties when attending dental clinic/hospital
- Limited financial means
- Medical
- Neck position compromised by the dental chair and by problems in the cervical spine; consider the option of treating the patient in her wheelchair
- Risks associated with general anaesthesia may be increased in patients with cerebral palsy (hypothermia, hypotension)
- Adjustment disorder may reduce compliance and manifest as increased anxiety/tearfulness
- Dental
- Local stimuli and stress can increase involuntary movements
- Gag reflex
- Limited access to the oral cavity
- Sialorrhoea compromises operatory field isolation
- Poor self‐cleansing of the oral cavity
- Unsupervised oral hygiene habits
- Social
- The patient requests premedication/sedation. What do you need to consider when selecting the correct approach?
- The patient is already taking oral benzodiazepines
- Hence, a medical consultation is required before proceeding, given the risk of synergy with some of the drugs the patient is taking, i.e. the effects can be increased when midazolam is combined with bromazepam
- Given the absence of chronic respiratory problems, nitrous oxide may be used
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