The prevalence of CP in the United States and internationally is 1.5 to 2.0 cases per 1000 births, a rate that has remained constant for nearly 40 years despite technological advances in neonatal care.

Only 40-50% of cases can be determined to have an exact aetiology, with 30% having no known risk factors. CP can be associated with factors occurring in the prenatal, perinatal, and postnatal periods. Approximately 70-80% of cases are linked to prenatal factors, while lack of oxygen at birth is responsible for about 10% of CP cases. Postnatal factors also contribute to fewer cases (Karaseridis & Dermata, 2023).

Prenatal: Prematurity (gestational age less than 36 weeks), low birth weight (less than 2500 g), maternal epilepsy, hyperthyroidism, pre-eclampsia, drug abuse, trauma, multiple pregnancies, and placental insufficiency (Miamoto et al., 2011).

Perinatal: Premature rupture of membranes, prolonged and difficult labor, vaginal bleeding at the time of admission for labor, and bradycardia (Miamoto et al., 2011).

Postnatal (0-2 years): Central nervous system infection (encephalitis), hypoxia, seizures, coagulopathies, and neonatal hyperbilirubinemia (Miamoto et al., 2011).

There are various classifications of CP, with one widely accepted system being the Hagberg classification. This system categorizes CP based on both the clinical presentation and the topographical distribution of movement impairments:

Pyramidal (Based on Affected Extremities):

Hemiplegia: Involves one arm and one leg on the same side of the body.

Diplegia: Affects both legs.

Tetraplegia/Quadriplegia: Impacts all four limbs.

Extrapyramidal or Topographical (Based on the Nature of the Disorder or Involuntary Movement):

Spastic (Dystonic): The most common type, accounting for 70% of CP cases, characterized by increased muscle tone in one or more limbs. It often results from pyramidal (upper motor neuron) damage. Children with spastic CP may also experience intellectual disability, seizures, and difficulty speaking and swallowing (Jones et al., 2007).

Dyskinetic (Athetoid): A movement disorder involving involuntary, purposeless movements of the face, arms, and trunk. It affects 20% of CP cases and is associated with damage to the basal ganglia or thalamus (deep motor neurons). Symptoms include abnormal swallowing, chewing, and speech patterns. Up to 78% of affected individuals have normal intelligence, and 50% achieve some degree of ambulation (Jones et al., 2007).

Ataxic: Caused by damage to neurons in the cerebellum, leading to poor balance, lack of coordination, depth perception issues, oral motor difficulties, tremors, and unsteady gait (Jones et al., 2007).

Mixed: In some cases, patients exhibit symptoms of more than one type of CP. The most common combination is spastic and athetoid CP. Mixed CP accounts for 10% of all cases (Jones et al., 2007).

The neuromuscular problems inherent in CP can significantly affect oral health in several ways:

Malocclusion: The prevalence of malocclusion in CP patients ranges from 59% to 92%. Factors such as uncoordinated jaw movements, hypotonia of the orofacial muscles, mouth open posture, and mouth breathing contribute to malocclusion, with most cases classified as Angle’s Class II. Spastic patients have an increased incidence of open bite (Wasnik et al., 2020).

Traumatic Dental Injuries: Children with CP are at high risk for dental trauma due to factors like Class II malocclusion, seizures, and involuntary head movements. The incidence of dental trauma in CP patients can reach up to 60%, with fractures of enamel and dentine being common (Wasnik et al., 2020).

Bruxism: Bruxism is prevalent in CP children, particularly those with severe motor and cognitive deficits. It is often related to abnormal proprioception, leading to tooth abrasion and flattened biting surfaces. Bruxism-related factors include involuntary movements, male gender, and gastroesophageal reflux (Wasnik et al., 2020).

Dental Caries: Patients with CP are at an increased risk of developing dental caries due to various factors, including motor and cognitive deficits, which negatively impact their quality of life. However, research on caries incidence in CP patients is mixed (Wasnik et al., 2020).

Dental Erosion: Dental erosion is common in CP patients, often linked to gastroesophageal reflux disease (GERD). Erosion primarily affects the molars and incisors, with frequent consumption of acidic beverages exacerbating the condition (Wasnik et al., 2020).

Dysphagia: Dysphagia, or difficulty swallowing, is a common problem in people with CP. It increases the risk of caries due to prolonged food retention in the mouth and using semi-soft foods that adhere to teeth (Wasnik et al., 2020).

Drooling: Drooling is a significant issue for individuals with CP, influenced by hypotonia, open bite, and the inability to close the lips. Some anti-epileptic medications, such as Clonazepam, can worsen drooling (Wasnik et al., 2020).

Dental care for children with CP requires addressing various challenges, including apprehension, communication difficulties, and limited physical control. Treatment should be tailored to the patient’s specific needs.

When managing dental treatment for children with cerebral palsy, their physical control and muscle coordination must be carefully considered. If a child can sit in the dental chair and open their mouth independently, they may be treated like any other patient. However, those with more severe physical limitations may need additional support.

Chair Adjustment and Positioning: The dental chair should be adjusted with care, often tipping it well back to provide a secure and stable position. Children with significant spasticity or head-and-neck involvement may require further control and support. For these patients, it may be helpful to have a parent or assistant hold them on their lap. In some cases, immobilization devices may be necessary to ensure safety.

Wheelchair Accommodation: If the patient uses a wheelchair and prefers to remain in it, dental treatment can often be performed without transferring them to the dental chair. This provides a sense of security and minimizes unnecessary movements.

Managing Sudden Movements: Children with cerebral palsy may experience muscle stiffening or spasms triggered by sudden movements. Therefore, precautions should be taken to anticipate these reactions and maintain patient safety.

Instrument Safety: A finger guard and steel mirror are recommended to avoid injury. When using sharp instruments, extra caution is needed to prevent accidental injury during sudden spasms or movements.

Sedation Considerations:

• Neck Stability: Children with cerebral palsy often experience poor muscle control or hypotonia, leading to unstable neck positioning. When administering conscious sedation, proper head and neck support is essential to prevent injury and ensure a patent airway. Specialized equipment or positioning techniques may be required.

• Airway Management: Due to the potential for respiratory and swallowing muscle involvement, airway management during sedation can be challenging. A comprehensive evaluation of the child's respiratory function is critical before sedation.

• Individualized Approach: Each child's unique health condition, level of cooperation, and potential risks must be carefully assessed to determine the best approach to sedation or alternative treatment methods

Malocclusion: Correcting malocclusion in CP patients can be challenging, especially in those with moderate or severe forms of the condition. Orthodontic treatment may be limited due to caries and enamel hypoplasia risk. Success depends on the patient or caregiver's ability to maintain consistent daily oral hygiene (Wasnik et al., 2020).

Traumatic Dental Injuries: Preventive measures for dental trauma in CP patients include using mouth guards, cushioning objects, and ensuring safe wheelchair transport. Caregivers should be educated about providing proper emergency care following dental injuries (Wasnik et al., 2020).

Periodontal Disease: Caregivers should be instructed on proper daily oral hygiene practices, including antimicrobial agents like chlorhexidine, which may be applied using a spray bottle or toothbrush to accommodate swallowing difficulties (Wasnik et al., 2020).

Dental Caries: Preventive measures for dental caries include encouraging regular water consumption, using sugar-free medications, rinsing with water after medication, and recommending alternatives to cariogenic foods. Fluoride treatments and pit and fissure sealants are also beneficial (Wasnik et al., 2020).

Prenatal history:

KM's mother was healthy during pregnancy; no medications were taken apart from the standard supplements, and her diet was regular; no special diet was followed.

Natal history:

MK was born at full term with no neonatal jaundice. However, the delivery was difficult and prolonged, leading to cerebral palsy caused by hypoxic cerebral injury. Also, the back of his head was injured during the delivery.

Post-natal history:

KM was breastfed for six months and then transitioned to bottle-fed formula milk and sugary juice until two years old. The mother described the feeding style as "on demand." After weaning, KM started drinking from a cup and consuming rooibos tea with added sugar and sugary juices.

Medical history:

KM was diagnosed with Cerebral palsy and epilepsy; he takes Epilim200mg tabs bds. Side effects: Stomach pain, Gingival enlargement, Nausea and vomiting, Diarrhea, Dry mouth, Tremors, Drowsiness, Headache, Weight gain, and Hair loss.

No Known allergies.

Dental history and oral hygiene practice:

On August 22, 2019, KM had his first dental visit after being referred by Dr. Thomas from Tygerberg's early childhood development department. The reason for the referral was multiple fillings and cleaning due to spontaneous gingival bleeding. Unfortunately, KM was uncooperative during the first visit, which hindered the dentist's ability to complete the diagnosis and treatment plan. However, during the second visit on August 29, the diagnosis and treatment plan were successfully completed, and it was decided to take him to GA.

The GA procedure took place on October 1, 2019. The dental procedures under GA included:

- Filling tooth 55 with compomer

- Filling tooth 54 with compomer

- Filling tooth 75 with compomer

- Filling tooth 85 with compomer

- Sealing teeth 36&46 with Clinpro sealant.

KM's mom brushes his teeth once a day, very early in the morning before she goes to work because he is still sleepy, so it's easier to brush his teeth. He tends to fidget, and it's easier to manage if he's drowsy. She attempts to floss his teeth at night while he is sound asleep, but not every day.

When I first met KM, he was playing with other kids in the waiting area. However, when he entered the clinic, he appeared anxious. KM has a cognitive disability and attends a special school. Despite his challenges, he has formed many friendships and communicates using a combination of some words and gestures.

KM presents with a symmetrical face but exhibits several notable extra-oral features. He experiences significant drooling and maintains an open-mouth posture. Poor head control often results in a forward head posture. Speech difficulties, including dysarthria, affect his articulation and clarity of speech. Involuntary grimacing and unusual facial expressions are also observed. KM struggles with maintaining lip closure, contributing to drooling and speech difficulties. He shows involuntary movements such as twitching or repetitive motions. Additionally, KM has a rash around the mouth, potentially exacerbated by constant drooling.

There were no abnormalities in the tongue, frenum, or mucosa. However, there was visible plaque along with mild gingival inflammation, food impaction, and gingival enlargement, specifically in the lower anterior sextant.

16: Occlusal attrition

55: Mobility grade 2

14: Partially erupted

53: Sound

12: Sound

11: Uncomplicated crown fracture. According to KM's mom, he is not experiencing pain, and there were no other signs of pathology, such as a draining fistula, abscess, or swelling.

21: Sound

63: Sound

24: Partially erupted

65: Occlusal caries cavitated

26, 36, 75, 74: Occlusal attrition

33: Partially erupted

32, 31, 41, 42: Sound

43: Partially erupted

85: Occlusal attrition

46: Sound

Due to KM's involuntary movements, we could not perform the orthopantomography, bitewings, or periapical views.

According to Frankl's behaviour rating scale, KM's attitude was negative (Shao et al., 2016).

Treatment sequence: Address the primary concern: the fractured 11 and the gingival bleeding.

The behaviour management technique used was modelling. KM was allowed to observe other children being treated by the faculty (with the permission of their guardians), the same kids he was playing with in the waiting area before the clinical session. After watching them, he agreed to sit in the dental chair. His mother mentioned that she distracts him by making funny voices when brushing his teeth, so we utilized that, which proved very helpful.

• Preventive Phase:

Oral hygiene education:

With the use of a disclosing agent, active brushing and flossing were demonstrated.

Scaling and Polishing

Fluoride application: 4 times per year as MG is a high caries risk child.

Diet analysis: A 3-day diary.

Fissure sealant:

 16,26,36,46

• Restorative treatment:

Restoration of the fractured 11

• Prosthetics: Mouthguard.

KM exhibits incompetent lips and an increased overjet of approximately 6 mm. This, combined with incisor protrusion and inadequate lip coverage, significantly elevates the risk of dental trauma. Studies have indicated that this condition raises the overall risk of dental injury by about 21% (Cobourne et al., 2022). A mouthguard is an effective protective appliance, shielding the teeth from potentially traumatic impacts by absorbing and dissipating energy (de Wet et al., 1999). Moreover, KM's involuntary movements further heighten his vulnerability to dental trauma. A mouthguard is a conservative and highly suitable method for reducing self-injurious behaviour and protecting the oral tissues from injury (Pak et al., 2008).

First Visit

We were unable to use a rubber dam as KM refused it. However, we achieved good isolation using cotton rolls and suction. Although he initially struggled to tolerate the suction, he eased up after observing other children being treated with it. Tooth 11 was treated by fitting an Odus Pella crown former, using a 21-crown former due to availability. The morphology was adjusted during the finishing step. The procedure included etching and applying a bonding agent, followed by the application of composite A2 shade, the only shade available at the time. The treatment was completed with polishing and finishing. KM was very pleased after seeing his tooth fixed.

KM was very excited and motivated. We began by reiterating oral hygiene instruction (OHI) and oral health education (OHE). Silver diamine fluoride (SDF) was applied to tooth 65. SDF has been successfully used to halt the progression of carious lesions, particularly in individuals who cannot tolerate invasive treatment, such as children, the elderly, those with medical conditions, and those requiring additional care and support (Bridge et al., 2021).

• KM missed his scheduled appointment, and unfortunately, we lost contact with his mother. It appears she has changed her phone number, as the one listed in our system is no longer in service. 

• APD 2019. Pediatric restorative dentistry. The reference manual of pediatric dentistry. American Academy of Pediatric Dentistry Chicago.

• COBOURNE, M. T., DIBIASE, A. T., SEEHRA, J. & PAPAGEORGIOU, S. N. 2022. Should we recommend early overjet reduction to prevent dental trauma? British Dental Journal, 233, 387-390.

• DE WET, F. A., HEYNS, M. & PRETORIUS, J. 1999. Shock absorption potential of different mouth guard materials. The Journal of prosthetic dentistry, 82, 301-306.

• HEALTH, N. I. O. 2008. Practical Oral Care for People With Cerebral Palsy.

• JONES, M. W., MORGAN, E., SHELTON, J. E. & THOROGOOD, C. 2007. Cerebral palsy: introduction and diagnosis (part I). Journal of Pediatric Health Care, 21, 146-152.

• MIAMOTO, C. B., RAMOS-JORGE, M. L., FERREIRA, M. C., OLIVEIRA, M. D., VIEIRA-ANDRADE, R. G. & MARQUES, L. S. 2011. Dental trauma in individuals with severe cerebral palsy: prevalence and associated factors. Brazilian oral research, 25, 319-323.

• PAK, E.-K., KIM, K.-C., CHOI, S.-C. & PARK, J.-H. 2008. Application of the modified-mouthguard to prevent self-injurious behaviors in a child with cerebral palsy: a case report. Journal of the Korean Academy of Pediatric Dentistry, 35, 351-356.

• SHAO, A., KAHABUKA, F. & MBAWALLA, H. 2016. Children’s behaviour in the dental setting according to Frankl behaviour rating and their influencing factors. J Dent Sci, 1, 1-12.

• WASNIK, M., CHANDAK, S., KUMAR, S., GEORGE, M., GAHOLD, N. & BHATTAD, D. 2020. Dental management of children with cerebral palsy-a review. Journal of Oral Research and Review, 12, 52-58.