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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 221-224

Periodontal health status in hospitalized cerebral palsy patients of rural Punjab

1 Department of Periodontology, Christian Dental College, Ludhiana, Punjab, India
2 Department of PMR, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication17-Jul-2018

Correspondence Address:
Anushi Mahajan
Department of Periodontology, Christian Dental College, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_27_18

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Introduction: Cerebral palsy (CP) is an important neurological condition that originates in early childhood but affects individuals throughout the life. It leads to specific motor skill problems, delay in developmental milestones, and physical limitations such as abnormal muscle tonus, reflexes, and persistent infantile reflexes. Periodontal disease is the most prevalent oral condition in hospitalized CP patients. These patients are at a higher risk of periodontal disease due to physical and cognitive impairment. The lack of awareness and availability of oro dental care facilities in rural areas is also a hindrance in this regard. Objective: The objective of the present study was to evaluate the periodontal health status and treatment needs of hospitalized CP patients of rural Punjab. Methodology: Periodontal health status and treatment needs of hospitalized CP patients were determined by epidemiological indices. Questionnaires were filled by the patient's parents/attendants about the home-care oral hygiene measures and dietary habits of the patient. All patients were given nonsurgical periodontal therapy with reenforcement of oral hygiene measures as a part of our treatment plan. Results and Conclusion: From this study, it was concluded that periodontal disease is prevalent in hospitalized cerebral-palsied patients. Treatment needs for such patients include assisted oral health care, pain management, and constant psychosocial support. The inclusion of a dental healthcare professional in the management team would help improve the quality of life in these hospitalized cerebral-palsied patients.

Keywords: Caries, hospitalized cerebral palsy, oral health, periodontitis

How to cite this article:
Mahajan A, Mathangi S, Singh G. Periodontal health status in hospitalized cerebral palsy patients of rural Punjab. CHRISMED J Health Res 2018;5:221-4

How to cite this URL:
Mahajan A, Mathangi S, Singh G. Periodontal health status in hospitalized cerebral palsy patients of rural Punjab. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jul 6];5:221-4. Available from: http://www.cjhr.org/text.asp?2018/5/3/221/236892

  Introduction Top

Cerebral palsy (CP) is the term used to describe a group of disorders, which affect movement and posture, causing activity limitation, which are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain.[1] CP usually presents with asymmetric gross motor function or unusual muscle stiffness or floppiness.[2] It may manifest disorders of intellect, attention, memory, specific motor skill problems, delay in developmental milestones, and physical limitations such as abnormal muscle tonus and persistent infantile reflexes [Figure 1] and [Figure 2]a, [Figure 2]b. There may be also a high risk of epilepsy and dysfunction of respiratory, gastrointestinal, and other nonneural systems.[3],[4],[5],[6],[7],[8]
Figure 1: Muscular stiffness in spasticity

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Figure 2: (a and b) Persistent infantile reflexes: Symmetric tonic neck reflex

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Oral manifestations presented in these patients include dental caries, periodontitis, malocclusion, bruxism, and drooling of saliva. Periodontal disease is the most prevalent oral condition in hospitalized mentally challenged patients.[9],[10] These patients are at a higher risk of periodontal disease due to physical and cognitive impairment.

Aim and objective

The present study was carried out with the objective to evaluate the periodontal health status and treatment needs of hospitalized CP patients of rural Punjab, India.

  Materials and Methods Top

Study design

The present study was carried out with the ethical clearance and approval from the Institutional Research and Ethical Committee. A total of 47 CP children of rural Punjab who were admitted were included in the study. The children were hospitalized for postsurgical physiotherapy under the physical medicine and rehabilitation department for curing their disabilities. Both males and females were a part of the study.

After an informed written consent, periodontal health status and treatment needs of patients were determined by epidemiological indices using a diagnostic set of instruments. The indices that were recorded were Greene and Vermillion (1960) Oral Hygiene index, Bokenkamp (1994) gingival enlargement index, Klein, Palmer, Knutson (1938) DMFT (Decayed, Missing, Filled Teeth) index in permanent dentition and Grubbel (1994) deft (Decayed, Extracted, Filled Deciduous Teeth) index in deciduous dentition. Malocclusion and drooling of saliva were also recorded.

  Results Top

The study population comprised 35 males and 12 females. Of these, 23 were in their mixed dentition period, 13 in permanent period, and 11 in primary dentition period. Majority of the patients were spastic diplegic followed by spastic quadriplegic [Table 1]. Among the total of 47 cases, 37 recorded moderate-to-poor oral hygiene scores [Table 2]. Four cases in which patients were on antiepileptic drug carbamazepine exhibited gingival enlargement [Table 3]. Drooling of saliva was seen in four cases. Only one case presented traumatic injury in the form of the fractured central incisor. Malocclusion was observed in few cases [Table 4].
Table 1: Study population

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Table 2: Oral hygiene scores

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Table 3: Gingival hyperplasia

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Table 4: Malocclusion

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  Discussion Top

There are few studies in the literature that have observed the oral health status of CP patients, but no known data are available regarding the periodontal status of hospitalized CP patients in a rural background.

In the present study, 79% of patients had moderate-to-poor oral hygiene. Periodontal manifestations were a result of a complication of oral habits, physical disabilities, malocclusion, and gingival hyperplasia. Motor and mental alterations, dyskinetic movements, the presence of aberrant oral reflexes, and alterations in intraoral sensitivity are detrimental factors for mechanical plaque removal in CP patients.[11],[12]

Almost all patients in this study had the spastic type of CP. Oral features of spastic patients include tensely reclined head, tense facial movements, open mouth, hypertonic, and cigar-shaped tongue with tongue thrusting. The upper lip is underdeveloped and malalignment of teeth may be seen. All these features attribute to poor oral hygiene, dietary inadequacies, malocclusion, mouth-breathing, and carious teeth that contribute to gingivitis.

Drooling of saliva was observed in four patients in this study. The reasons for this are considered to be a result of swallowing defect leading to the accumulation of saliva in the oral cavity.[13] Drooling does not affect caries index but leads to poor oral hygiene index scores as compared to those in whom drooling of saliva is absent.[14]

Gingival hyperplasia was attributed to the fact that some of these patients with seizure disorders were on long-term anti-epileptics leading to drug-induced gingival overgrowth.

The study showed high def and DMF scores [Table 5] and [Table 6]. The systemic medications prescribed in CP are rich in sucrose. Furthermore, poor mechanical plaque control and mouth-breathing are various contributing factors to high caries index in these patients. Thus, it is recommended that tooth-brushing is carried out in these patients after every medicinal dose and they switch-over to sugar-free medicines whenever available.
Table 5: Results of def score

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Table 6: Results of permanent dentition Decayed, Missing, Filled

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According to a systemic review,[15] only those powered tooth-brushes that worked with a rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes. In another study,[16] the tooth-brush handles were modified in length and size. The individually modified toothbrush appears to be an effective means to improve the oral hygiene and gingival health of CP patients.

The lack of awareness and availability of oro dental care facilities in rural areas is also a hindrance in this regard. It is, therefore, suggested that there should be the inclusion of a dentist in the primary health-care team treating CP patients.

It has been reported for chemical plaque control in physically challenged children, out of the three delivery systems of chlorhexidine (rinses, gels, and sprays) available; the gel form showed maximum efficacy in comparison to the other two.[17] The use of 0.5% chlorhexidine gel indicated no undesirable shift in Enterobacteriaceae, Staphylococcus, and yeasts.[18]

In this study, all cooperative, ambulatory patients were given nonsurgical phase-I therapy comprising excavation of caries, fluoride application, restoration of carious teeth, scaling, and oral prophylaxis. Powered toothbrushes and 0.2% chlorhexidine digluconate mouthwashes were prescribed for the patients with poor oral hygiene. Patients and their attendants were given oral hygiene instructions.

In certain patients, treatment could not be given as they were uncooperative in their postsurgical healing phase and were undergoing rigorous physiotherapy. Second, it was difficult for patients with disabilities of lower extremities to be seated in the conventional dental chairs.

  Conclusion Top

The prevalence of compromised oral health status warrants the need for supervised care by a dentist with the capacity for appropriate interventions at the desired times. A multidisciplinary approach to improve the oral hygiene, arrest tooth decay and thus, increase the quality of life of CP patients in rural areas is suggested.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: The definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007;109:8-14.  Back to cited text no. 1
Rosenbaum P. Cerebral palsy: What parents and doctors want to know. BMJ 2003;326:970-4.  Back to cited text no. 2
Aicardi J. Epilepsy in brain-injured children. Dev Med Child Neurol 1990;32:191-202.  Back to cited text no. 3
Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, et al. Practice parameter: Diagnostic assessment of the child with cerebral palsy: Report of the quality standards subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2004;62:851-63.  Back to cited text no. 4
Crothers B, Paine RS. The Natural History of Cerebral Palsy. Cambridge, MA: Harvard University Press; 1959.  Back to cited text no. 5
Ellison PH. Neurologic development of the high-risk infant. Clin Perinatol 1984;11:41-58.  Back to cited text no. 6
Ingram TT. Paediatric Aspects of Cerebral Palsy. Edinburgh, UK: Churchill-Livingston; 1964.  Back to cited text no. 7
Robinson RO. The frequency of other handicaps in children with cerebral palsy. Dev Med Child Neurol 1973;15:305-12.  Back to cited text no. 8
Brown JP. The efficacy and economy of comprehensive dental care for handicapped children. Int Dent J 1980;30:14-27.  Back to cited text no. 9
Francis JR, Stevenson DR, Palmer JD. Dental health and dental care requirements for young handicapped adults in Wessex. Community Dent Health 1991;8:131-7.  Back to cited text no. 10
Rodrigues dos Santos MT, Masiero D, Novo NF, et al. Infantile reflexes and their effects on dental caries and oral hygiene in cerebral palsy individuals. J Oral Rehabil 2005;32:880-5.  Back to cited text no. 11
Anagnou-Vareltzides A, Tsami A, Mitsis FJ. Factors influencing oral hygiene and gingival health in Greek schoolchildren. Community Dent Oral Epidemiol 1983;11:321-4.  Back to cited text no. 12
Tahmassebi JF, Curzon ME. The cause of drooling in children with cerebral palsy – Hypersalivation or swallowing defect? Int J Paediatr Dent 2003;13:106-11.  Back to cited text no. 13
Hegde AM, Shetty YR, Pani SC. Drooling of saliva and its effect on the oral health status of children with cerebral palsy. J Clin Pediatr Dent 2008;32:235-8.  Back to cited text no. 14
Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, et al. Manual versus powered toothbrushing for oral health. Cochrane Database Syst Rev 2005;(2):CD002281.  Back to cited text no. 15
Soncini JA, Tsamtsouris A. Individually modified toothbrushes and improvement of oral hygiene and gingival health in cerebral palsy children. J Pedod 1989;13:331-4.  Back to cited text no. 16
Francis JR, Addy M, Hunter B. A comparison of three delivery methods of chlorhexidine in handicapped children. II. Parent and house-parent preferences. J Periodontol 1987;58:456-9.  Back to cited text no. 17
Pannuti CM, Lotufo RF, Cai S, Saraiva Md Mda C, de Freitas NM, Falsi D, et al. Effect of a 0.5% chlorhexidine gel on dental plaque superinfecting microorganisms in mentally handicapped patients. Pesqui Odontol Bras 2003;17:228-33.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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