Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons¹ with cerebral palsy.

Cerebral palsy

Terminology used in this Advisory

Resources consulted

• Cerebral Palsy: Hope Through Research: National Institute of Neurological Disorders and Stroke

Cerebral palsy, also termed spastic paralysis, spastic hemiplegia, spastic diplegia, and spastic quadriplegia, is a single condition or a group of disorders that 

1. is incurable
2. occurs in children in the first years of life and persists for the rest of their lives
3. manifests as 
   1. motor development delayed
   2. coordination impairment
   3. intellectual disability 
   4. involuntary movement
   5. limb stiffness
   6. primitive reflexes persistence 
   7. seizures 
4. may involve brain and nervous system functions such as 
   1. hearing
   2. learning
   3. moving
   4. seeing
   5. speaking
   6. thinking
5. exists as several different types 
   1. spastic hemiplegia/hemiparesis 
   2. spastic diplegia/diparesis
   3. dyskinetic cerebral palsy 
   4. ataxic cerebral palsy 
   5. spastic quadriplegia/quadriparesis 
   6. mixed types.

Other terminology used in this Advisory is as follows.

1. Bruxism 
   1. comprises clenching, grinding, and gnashing of teeth
   2. is common in children with cerebral palsy
   3. may be associated with temporomandibular joint disorders.
2. Clinical terminology relating to
   1. movement disorder
      1. ataxic, impaired balance and coordination
      2. athetoid, writhing movements
      3. spastic, stiffness of muscles
   2. effect on limbs
      1. hemiparesis, hemi = half, meaning only one side of the body, paresis = weakened
      2. hemiplegia, hemi = half, meaning only one side of the body, plegia = paralyzed
      3. quadriplegia, quad = four,  plegia = paralyzed
      4. quadriparesis, quad = four, paresis = weakened.
3. Dopamine, a chemical messenger, which
   1. supports brain processes that control 
      1. movement
      2. emotional response
      3. ability to experience pleasure and pain 
   2. may be deficient in cerebral palsy because of harm to certain types of brain cells.
4. Drooling in cerebral palsy, is believed  
   1. to result from problems with swallowing
   2. not to result from excessive production of saliva.
5. Epilepsy, temporal lobe epilepsy, seizure disorder, a brain disorder 
   1. characterized by seizures that recur over time
   2. caused by episodes of disturbed brain activity that temporarily alter attention or behaviour.
6. Pica 
   1. is the compulsive eating of non-edible substances, such as sand, dirt, and paint chips
   2. damages 
      1. tooth structure
      2. oral soft tissue.
7. Pouching
   1. is the harbouring of food or medication between the cheek and teeth 
   2. contributes to dental decay and/or oral lesions.
8. Rh incompatibilities 
   1. occurs when
      1. the mother’s Rh blood type, either positive or negative, differs from that of the fetus 
      2. the mother develops antibodies which destroys the blood cells of the fetus
   2. are routinely tested for and treated as part of prenatal care.
9. Rumination 
   1. comprises re-chewing, regurgitation, and re-swallowing of previously ingested food
   2. brings 
      1. excess of acidic contents of the stomach into the mouth and in contact with tooth surfaces
      2. demineralization and loss of tooth structure.
10. Seizure, convulsion
    1. is manifested as sudden alteration of behaviour, minor physical signs, thought disturbances, or a combination of such symptoms 
    2. results from a temporary change in the electrical functioning of the brain, in particular the cortex
    3. occurs with various conditions, including
       1. cerebral palsy
       2. epilepsy
       3. head injury
       4. brain tumour
       5. brain maldevelopment
       6. genetic disorder
       7. infectious illness
       8. fevers
    4. has oral risks including
       1. chipping of teeth
       2. biting of the tongue or inside of cheeks
    5. in some 50 percent of persons in which it occurs has no identifiable cause.
11. Tremor, an involuntary shaking movement, that
    1. is often most noticeable in the hands and arms
    2. may affect almost any
       1. body part including the head
       2. body function including the voice
    3. is of three main types
       1. resting tremors, which 
          1. are present when the muscles are at rest
          2. disappear or diminish when the affected muscles are moved 
       2. intention tremors, which 
          1. occur at the end of an intended movement
          2. are absent while the affected body part is at rest
       3. action tremors, which occur when the arm or leg is held against gravity in one position for a period of time.
12. Types of cerebral palsy 
    1. spastic hemiplegia/hemiparesis, which
       1. typically affects the arm and hand on one side of the body
       2. also may affect the leg 
       3. causes, variously 
          1. delay in development of walking
          2. walking on tip-toe 
          3. short and thin arms
          4. curvature of the spine
          5. seizure
          6. speech impediment
       4. leaves intelligence unimpaired
    2. spastic diplegia/diparesis, which 
       1. causes muscle stiffness, that
          1. chiefly affects the legs, causing
             1. the toes to point up
             2. scissor-like movements of the legs
             3. need for walkers or leg braces 
          2. less severely affects the arms, though it may bring clumsiness of the hands
       2. leaves intelligence and language skills unimpaired
    3. dyskinetic cerebral palsy, which
       1. causes 
          1. athetoid movements of hands, feet, arms, or legs, which lead to difficulties
             1. sitting upright
             2. walking
             3. coordinating muscle movements involved in speaking
          2. may be associated with hyperactivity in the muscles of the face and tongue, leading to 
             1. grimacing
             2. drooling of cerebral palsy
       2. rarely affects intelligence
    4. ataxic cerebral palsy, which
       1. is rare
       2. affects balance and depth perception
       3. impairs coordination
       4. causes an unsteady gait with the feet wide apart
       5. creates difficulties with fast or precise movements, such as writing or fastening buttons
       6. intention tremor 
    5. spastic quadriplegia/quadriparesis, which
       1. is the most severe form of cerebral palsy
       2. is often associated with intellectual disability of some degree
       3. is caused by widespread damage to the brain or significant brain malformations
       4. causes 
          1. severe stiffness of the limbs 
          2. floppy neck
          3. inability to walk
          4. problems speaking and being understood
          5. seizures
    6. mixed types, in which symptoms do not correspond to any one type of cerebral palsy.

Overview of cerebral palsy

Resources consulted

• Cerebral Palsy Fact Sheet: College of Dental Hygienists of Ontario
• Cerebral Palsy: eMedicineHealth
• Cerebral Palsy: Hope Through Research: National Institute of Neurological Disorders and Stroke

Cerebral palsy

1. Affects about 1 in 400 babies (and more than 34,000 Ontarians, with an average age of 30 years), including those whose condition is considered mild
2. in children is 
   1. the commonest physical disability
   2. accompanied by seizures in about half of the children diagnosed with cerebral palsy
3. includes
   1. congenital cerebral palsy, a condition
      1. in which the child is born with cerebral palsy though it may remain undetected for months or years after birth
      2. that was in the past attributed to oxygen lack during birth, but extensive research indicates that birth defects involving asphyxia account for only 5 to 10 percent of babies born with congenital cerebral palsy  
   2. acquired cerebral palsy, a condition
      1. in which the cerebral palsy begins after birth
      2. for which an explanation can be established with reasonable certainty, such as
         1. brain damage in the first few months or years of life
         2. brain infections such as 
            1. bacterial meningitis
            2. viral encephalitis
         3. head injury from 
            1. child abuse
            2. fall
            3. motor vehicle accident
   3.  multiple causes, such as
      1. fetal injury
      2. genetic abnormalities
      3. maternal infections or fevers
4. results from four types of harm in the brain 
   1. damage to the white matter of the brain 
   2. abnormal development of the brain 
   3. bleeding in the brain, including fetal stroke 
   4. damage caused by a lack of oxygen in the brain
5. occurs as six main types  
6. has causes and risk factors that include
   1. events that may occur during pregnancy and delivery that increase the risk of baby’s being born with cerebral palsy but which do not make cerebral palsy an inevitable consequence of such events, including  
      1. low birth-weight, premature birth and smallness for gestational age
      2. multiple births 
      3. virus infections during pregnancy which can infect the uterus and placenta, such as 
         1. cytomegalovirus
         2. herpes 
         3. rubella 
         4. toxoplasmosis
      4. Rh incompatibility
      5. exposure to toxic substances during pregnancy, such as methyl mercury
      6. thyroid abnormalities, mental retardation, or seizures in mothers 
      7. complications during labour and delivery, and immediately after delivery, including
         1. breech presentation 
         2. difficult labour and delivery that causes brain damage or abnormalities 
         3. jaundice that, when untreated, may 
            1. kill brain cells 
            2. cause deafness
            3. cause cerebral palsy 
      8. seizures in an infant 
   2. injuries or abnormalities of the brain, which may occur
      1. at any time during the first two years of life, when the infant’s brain is still developing
      2. when parts of the brain are injured by hypoxia of unknown origin
      3. during early infancy as a result of several conditions, including
         1. brain hemorrhage
         2. brain infection
            1. encephalitis
            2. herpes simplex
            3. meningitis
         3. head injury
         4. infection in the mother during pregnancy, such as rubella
         5. severe jaundice
   3. prematurity of infants, which slightly increases the risk of cerebral palsy
   4. causes that remain undetermined
7. is associated with signs and symptoms that
   1. may first be noticed by parents who see that the child is delayed in 
      1. crawling
      2. reaching
      3. rolling
      4. sitting
      5. walking
   2. may 
      1. be more pronounced in the arms or the legs
      2. be unilateral 
      3. involve both the arms and legs more or less equally
   3. usually are recognized prior to the age of two years, and may be recognized as early as 3 months
   4. vary 
      1. from person to person
      2. from mild to severe
      3. according to the types of cerebral palsy and which variously include
         1. movement challenges, such as
            1. athetotic movements of the hands, feet, arms, or legs while awake, and which worsen under stress
            2. tremors
            3. unsteady gait
            4. loss of coordination
            5. floppiness of muscles, especially at rest
            6. joints that are unduly loose
         2. other brain and nervous system symptoms, such as
            1. decreased intelligence or learning disabilities, which are  common, but not inevitable
            2. speech problems 
            3. hearing problems
            4. vision problems
            5. seizures
            6. pain, which 
               1. occurs chiefly in adults
               2. may be difficult to manage
         3. eating and digestive challenges, such as
            1. difficulty 
               1. sucking or feeding in infants
               2. chewing and swallowing in older children and adults
               3. swallowing, at all ages
            2. vomiting
            3. constipation
            4. gastrointestinal reflux disease (CDHO Advisory)   
         4. other challenges, which include 
            1. drooling of cerebral palsy
            2. abnormally slow growth
            3. breathing difficulties
            4. urinary incontinence, loss of bladder control
8. is clinically 
   1. diagnosed chiefly on the basis of significant delays in motor development
   2. investigated by
      1. blood tests
      2. CT scan of the head
      3. electroencephalogram (EEG)
      4. full neurological examination
      5. hearing testing
      6. MRI of the head
      7. neuroimaging 
      8. testing of cognitive function in adolescents and adults
      9. vision testing
9. is treated 
   1. by controlling the effects and challenges because no cure is known
   2. with the intention of 
      1. minimizing comorbidities, complications and associated conditions
      2. maximizing independence, requiring a team approach that includes
         1. regular schools for children, wherever feasible
         2. assistive devices, such as
            1. eye glasses
            2. hearing aids
            3. muscle and bone braces
            4. walking aids
            5. wheelchairs
            6. computer-assisted augmentative and alternative communication
         3. services, such as
            1. primary care
            2. oral healthcare
            3. occupational therapy
            4. physical therapy
            5. speech therapy
         4. specialties such as
            1. gastroenterology
            2. neurology
            3. psychiatry
            4. psychology
            5. respirology
   3. with self-care and home care, to emphasize
      1. adequacy of nutrition
      2. appropriate physical exercise
      3. bowel care (stool softeners, fluids, fibre, laxatives, regular bowel habits)
      4. protection of joints from injury
      5. safety in the home
   4. medications
   5. with surgery to
      1. control gastroesophageal reflux (CDHO Advisory) 
      2. cut certain nerves from the spinal cord to help with pain and muscle stiffness
      3. place feeding tubes
      4. relieve joint contractures
10. is considered 
    1. largely unpreventable by good prenatal care in its congenital form because this 
       1. can be prevented only in certain specific circumstances, including
          1. pre-pregnancy vaccination against rubella
          2. management of Rh incompatibilities early in pregnancy
       2. continues to occur despite good prenatal care 
    2. preventable in its acquired form in children by safety precautions to reduce the risk of accidental injury, such as
       1. car seats for infants and toddlers
       2. bicycle helmets for young children
       3. supervision of babies and young children during bathing
11. is associated with a prognosis that reflects the lifelong nature of the disorder which 
    1. does not curtail life expectancy
    2. entails disability that in adults
       1. is mostly compatible with community living
          1. independently
          2. with various levels of help
       2. may be so severe that it requires long-term, specialized care. 
12. invokes important social considerations, for which support groups are important
    1. Canada
       • Ontario Federation for Cerebral Palsy
    2. US
       • Cerebral Palsy Associations of New York State
       • United Cerebral Palsy
       • U.S. Centers for Disease Control and Prevention

Multimedia and images

• Dental Hygiene and Cerebral Palsy

Comorbidity, complications and associated conditions

Resources consulted

• Cerebral Palsy: An Overview | American Academy of Family Physicians
• NINDS Cerebral Palsy Information Page: National Institute of Neurological Disorders and Stroke

Comorbid conditions are those which co-exist with cerebral palsy but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions of cerebral palsy

1. create in combination with cerebral palsy childhood’s commonest physical and developmental disabilities, which
   1. may not be apparent in early life
   2. require recognition and treatment appropriate for the person’s circumstances
   3. should be regarded as major disorders
2. include potentially severe challenges which 
   1. include neurodevelopmental disorders, such as
      1. behavioural challenges
      2. epilepsy, and other types of seizures
      3. learning difficulties
      4. sensory impairments
         1. visual impairment
         2. hearing impairment
      5. speech and communications impairment
   2. involve motor and movement disorders, such as
      1. functional gastrointestinal abnormalities that contribute to 
         1. bowel obstruction
         2. vomiting
         3. constipation
      2. movement and motor disabilities
         1. evolution of muscle tone from floppiness to stiffness in the first 5 years of life
         2. feeding difficulties, including
            1. pneumonia caused by choking
            2. nutrition-related disorders, such as
               1. inadequate nutrition (CDHO Advisory)
               2. osteoporosis (CDHO Advisory)
   3. arise from skeletal disorders and injuries, such as
      1. hip dislocation
      2. arthritis of the hip joint
      3. joint contractures
      4. spinal curvature
      5. falls
   4. create social and psychosocial impairments of the quality of life for 
      1. individuals, such as 
         1. underemployment
         2. social stigmatization
         3. mobility limitations that act as barriers to 
            1. community and social participation
            2. public transportation
      2. families, such as
         1. burdens on families, including 
            1. stress
            2. coping with the complexities of the individual’s and the family’s needs, short-term and long-term
         2. inadequacies in appropriate support in the form of
            1. counselling
            2. trustworthy, comprehensible and usable information and instruction.

Oral health considerations

Resources consulted

• American Academy of Pediatric Dentistry 2021-2022 Oral Health Policies & Recommendations (The Reference Manual of Pediatric Dentistry): American Academy of Pediatric Dentistry
• Cerebral palsy, a review for dental professionals: Southern Association of Institutional Dentists
• Dental Care Every Day: A Caregiver’s Guide: National Institute of Dental and Craniofacial Research
• Epilepsy in dental practice: Journal of the Irish Dental Association, at p 176
• Practical Oral Care for People With Cerebral Palsy: National Institute of Dental and Craniofacial Research 
• Special Care: An Oral Health Professional’s Guide to Serving Young Children with Special Health Care Needs| National Maternal and Child Oral Health Resource Center
• Special Needs Fact Sheets for Providers and Caregivers: School of Dentistry, University of Washington 

Oral health considerations, especially for children with cerebral palsy, include the following.

1. While cerebral palsy does not cause unique oral abnormalities, it is associated with various oral abnormalities that are more common or more severe in persons with cerebral palsy than in the general population.
2. Oral healthcare is one part of the overall care for cerebral palsy; the dental hygienist is one member of the team.
3. The uncontrolled body movements that are common in cerebral palsy create complications for patients/clients because, when they attempt to help by moving their limbs or bodies during the Procedures, their muscles may tense thereby increasing uncontrolled movements.
4. Primitive reflexes are common in cerebral palsy and 
   1. create complications for oral care because the patient/client’s efforts to control them may make them more intense
   2. are most commonly observed during oral care as the 
      1. asymmetric tonic neck reflex, which responds when the head is turned, and which causes the arm and leg on
         1. the side towards which the head is turned to stiffen and extend
         2. the opposite side to flex 
      2. tonic labyrinthine reflex, which responds when the neck is extended with the patient/client supine, causing
         1. the legs and arms also to extend
         2. the back and neck to arch 
      3. startle reflex, which responds to any surprising stimulus 
         1. such as noises, lights, or a sudden movement 
         2. by triggering uncontrolled, often forceful movements involving the whole body
      4. hyperactive bite and gag reflexes, which call for care in introducing instruments into the mouth.
5. Oral motor dysfunction, which occurs in the vast majority of children with cerebral palsy, may 
   1. be sufficiently severe to lead to undernutrition because of impairment of eating and drinking
   2. create the drooling of cerebral palsy
   3. result in disorders of speaking
   4. lead to poor dental alignment and periodontal problems associated with abnormal neuromuscular coordination of the tongue, lips, and cheeks. 
6. Face and mouth trauma, which occurs commonly in children with cerebral palsy, and which may arise from one or both of
   1. cerebral palsy
   2. physical abuse.
7. Self-injurious actions or behaviour, including
   1. biting of tongue, cheek, and lip
   2. chewing of fingers, hands and arms  
   3. bruxism
   4. rumination
   5. pouching
   6. pica.
8. Oral findings encountered in children with cerebral palsy include 
   1. dental decay, the incidence of which is disputed, which seems
      1. chiefly due to poor oral hygiene resulting from inability to adequately brush and floss
      2. associated with other factors, such as
         1. anti-drooling medications
         2. enamel hypoplasia
         3. food retained in the mouth for too long
         4. mouth breathing
         5. soft diet
   2. dental erosion or loss of tooth structure associated with
      1. gastroesophageal reflux disease (CDHO Advisory), which 
         1. increases thermal sensitivity
         2. causes pain
      2. episodes of vomiting
   3. periodontal disease and gingivitis, which are estimated to be three times higher than in the general population, and which are attributed to
      1. poor oral hygiene
      2. gingival overgrowth, as a side effect of certain seizure medications
   4. malocclusion, associated with 
      1. abnormal muscle and tongue movements, which are responsible for tongue thrust and mouth breathing
      2. the anterior open bite which
         1. with the protruding splayed anterior teeth, abnormal muscle movements and posture problems are responsible for much of the observed trauma to anterior teeth 
         2. leads to tooth fractures and avulsions
   5. delayed eruption of permanent teeth
   6. oral hypersensitivity to touch, taste, or smell
   7. prolonged and exaggerated bite reflexes
   8. in the particular types of cerebral palsy
      1. spastic hemiplegia/hemiparesis, spastic diplegia/diparesis, spastic quadriplegia/quadriparesis
         1. head, tensely reclined
         2. mouth open; facial movements, tense
         3. tongue, hypertonic and cigar-shaped
         4. tongue thrust during swallowing and speaking 
         5. front teeth misalignment, due to insufficient pressure from upper lip underdevelopment for correct alignment 
      2. dyskinetic cerebral palsy
         1. tongue, spontaneous wave-like movements
         2. tongue, jaw, and face muscles, uncoordinated movement 
         3. mouth, abrupt and wide opening risking jaw dislocation
      3. ataxic cerebral palsy 
         1. tongue, large, flat and protruded
         2. facial movements, weak
         3. upper lip, inactive.
9. Care of the dental hygiene patient/client involves
   1. scheduling 
      1. short appointments early in the day for children with cerebral palsy 
      2. periodic recall appointments for 
         1. evaluation of oral hygiene
         2. monitoring for gingival overgrowth caused by anticonvulsant medications
      3. to enable the child’s medical history to be obtained and discussed prior to the first appointment so that any necessary medical consultations can be arranged with reference to 
         1. medications
         2. sedation for medical procedures
         3. risks of seizures
         4. history of gastrointestinal reflux disease (CDHO Advisory)  
   2. developing rapport with the patient/client by
      1. helping communications with persons with speech problems with
         1. sufficient time to make themselves understood
         2. conversation that includes parents and family caregivers
         3. recognition that a speech problem may conceal a normal intelligence 
      2. gaining cooperation of the child with techniques such as
         1. positive reinforcement
         2. voice control 
      3. enhancing comprehension for a child with severe cognitive impairment by repetition of commands and requests 
      4. providing spoken description of the Procedures for a child with severe visual impairment to allay fear and anxiety 
      5. communicating with visual techniques for children with hearing impairment 
      6. considering sedation techniques or muscle relaxants for calming the child
   3. obtaining cooperation in the dental chair, which variously requires
      1. taking account of the intellectual disability of the particular child by providing explanations of the Procedures that are understandable by the child
      2. using short, clear instructions one direction at a time
      3. placing dental instruments slowly into the mouth with the child’s chin in downward position to mitigate hyperactive gag reflex
      4. considering use of a mouth prop
      5. listening actively, with sensitivity to the communication methods relied on by the child, including gestures, and consultation with the caregiver as required
      6. developing trust between the oral healthcare  personnel and the child
      7. maintaining consistency in staffing, operatory, and appointment times from one visit to another  
      8. using the Tell-Show-Do approach prior to the Procedures, as appropriate 
      9. exerting firm but gentle pressure to calm shaking limbs while not
         1. forcing limbs into unnatural positions
         2. attempting to stop uncontrolled body movements
      10. giving the patient/client advance warning of sudden lights, sounds, and movements, which should be minimized  
   4. preparing for the options of
      1. transferring of the patient/client from wheel chair to dental chair
      2. performing the Procedures in the wheel chair 
   5. understanding and combating fear of having the mouth examined
   6. recognizing clinical circumstances in which 
      1. specialist dental appliances may be helpful, and recommending appropriate referrals
      2. medical advice is needed and making the appropriate referral
   7. placing the dental chair at 45 degrees to protect airway by avoiding the supine position 
   8. providing padding or restraints as required
   9. moving the dental chair only slowly to avoid spastic muscle responses 
   10. managing 
       1. severe gag reflex 
       2. dysphagia, which creates risk from coughing, gagging, choking, and aspiration 
   11. reviewing office procedures for 
       1. seizure management during treatment 
       2. reporting suspected abuse
   12. explaining to the parent or caregiver 
       1. the ways in which oral healthcare is made less distressing to the child
       2. the importance of starting oral healthcare early
          1. cleansing mouth and gums with a clean damp cloth prior to tooth eruption
          2. with a small soft tooth brush and water after first tooth appears 
          3. optimum posture and seating arrangements including wheel chairs
       3. that fixed bridgework is usually not done with cerebral palsy because of the risk of dental injury from falls, especially with a history of seizures 
       4. the option of myofunctional therapy for young children to 
          1. increase the muscle tone of the lips
          2. keep the tongue inside of the mouth 
       5. growth and development of the teeth and orofacial structures 
       6. the role of oral health in nutrition 
   13. counselling 
       1. on home dental hygiene procedures
       2. on daily use of chlorhexidine or other antimicrobial agents and fluorides, as required
       3. that includes discussion of the role of enamel loss in tooth decay with the intention of avoiding needless feeling of neglect on the part of parents or family caregivers.

1. Promoting health through oral hygiene for persons who have cerebral palsy.
2. Reducing the adverse effects, such as stress and miscommunications, by
   1. taking account of the nature and effects of cerebral palsy
   2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
   3. using appropriate techniques of communication
   4. providing advice on scheduling and duration of appointments.
3. Reducing the risk that oral health needs are unmet.

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III