There are a number of solutions to the problem depending on the cause and the
severity of the condition. In a child who is erupting primary teeth it may be possible
to fit an occlusal splint, provided that sufficient teeth are available for retention.
Fabrication of the splint may necessitate a short general anaesthetic for impression-
taking. Alternatively, addition of glass ionomer cement to the occlusal surfaces of the
primary molars, to open the occlusion and prevent the teeth contacting the soft tissues,
may be successful. If only anterior primary teeth are present then composition,
moulded over the offending tooth surfaces as a temporary splint, may break the habit
and allow healing (1158HFig. 17.19 (a) and (b)). If the problem is more severe and a splint is
not feasible, it is sensible to extract the primary teeth involved. In the permanent
dentition, rounding-off the pointed or sharp tooth surfaces and/or fitting a splint is
usually successful. During the acute phase the use of a topical analgesic such as
0.15% benzydamine hydrochloride (Difflam) in spray form increases mouth comfort
prior to eating; and 0.2% chlorhexidine gluconate solution (Corsodyl) swabbed
around the mouth or applied as a gel on a finger promotes more rapid healing by
keeping the area clean. Ensuring that the child has plenty of fluids is of paramount
importance as small, debilitated children rapidly become dehydrated.
The other area of concern to parents and carers is drooling. For some disabled
children this can be excessive, although surgery to divert the submandibular flow
more posteriorly may alleviate the problem. However, this is not always successful
and carries the risk of increasing caries prevalence as a result of the greatly
diminished salivary volume. The use of acrylic training plates that encourage the
formation of an oral seal as well as promoting a more active swallowing mechanism
so that saliva does not pool in an open mouth may be helpful (1159HFig. 17.20). Concurrent
work with speech and language therapists will help with the necessary therapy that is
fundamental to the success of such treatment. Anecdotal case reports support the use
of these plates, but few studies have been published that give objective data on their
success. However, one relatively non-interventional method of reducing saliva flow is
the use of hyoscine hydrobromide, a drug which blocks parasympathetic transmission
to the salivary glands. It is applied as a patch behind the ear and changed every three
days.
Diet
Considerations on dietary aspects have been covered in the section on intellectual
impairment (1160HSection 17.2.4). Some children, because of a failure to thrive, will be fed
through a gastrostomy site. If the child is exclusively fed via this route, they will tend
to accumulate large deposits of calculus. These need to be removed from surfaces
adjacent to the gingival margins in particular. This can be difficult unless there is
good cooperation from the patient; an impaired airway makes the safe removal of
such deposits hazardous, with the risk of inhalation of calculus. The gastrostomy site
can be useful also for sedative drugs, especially bitter intravenous sedation drugs that
might otherwise not be tolerated orally. However, such sedation procedures need to be
carried out in specialist units.