contemplated. Children who spend long periods in one position may be predisposed to
pressure sores, therefore lengthy procedures in the dental chair without a break are
best avoided.
Hypoplastic teeth can be very sensitive, particularly to extreme cold. Patients can
experience acute discomfort during tooth preparation or ultrasonic scaling (even when
the affected teeth are distant from the operating site), merely from the cold produced
by high volume aspiration. The use of a desensitizing agent like Duraphat fluoride
varnish or fissure sealing the symptomatic surface can be helpful if a restoration is not
indicated. Hypoplastic enamel does not have the same ordered prism structure as
normal enamel and, despite acid etching, may not provide optimum retention for
conventional resins. In this situation, glass ionomer cements may be a more suitable
alternative.
Some less severely disabled children will have little or no intellectual impairment but
will have a degree of spasticity or rigidity. This may prevent them from co-operating
fully with dental procedures, despite their willingness to do so, and they may be
helped by nitrous oxide sedation (1155HChapter 4). Such sedation may also help diminish
an exaggerated gag reflex.
17.3.4 Home care
Oral hygiene
Physical impairment may hinder oral hygiene procedures and for the child who has
gingival enlargement the problem may be compounded. Most children require help
with brushing until they are 7 years or older, but for the child with physical limitations
this may be a permanent commitment on the part of carers. Limited or bizarre muscle
movements prevent normal mouth clearing and food is often left impacted in the vault
of the palate. This is readily removed with the end of a toothbrush handle or a spoon
handle, but carers need to be aware of the potential for this, otherwise food residues
may be left in the oral cavity for days. Powered toothbrushes may be helpful for a
child with limited dexterity, not only because of the relative efficiency of cleaning but
also because of the larger size of the handle of most of these brushes.
When normal limb movement is impaired or absent and/or normal speech is
impossible, the mouth assumes an even greater importance as a means of holding
mouthsticks to grasp pens or to operate a variety of equipment. It is vital the dentition
is maintained to the highest standard as the successful use of such mouthsticks is
reliant on having a good occlusal table for balanced contact (1156HFig. 17.17).
Children with cerebral palsy, especially where there is accompanying intellectual
impairment, will on occasion adopt a habit of self-mutilation by chewing soft tissues
around the mouth (1157HFig. 17.18). This can be triggered by teething, although often no
cause may be found. It is distressing for the parents as the child is obviously in pain
from the ulcerated areas and may refuse all food and drink, but there is little they can
do to break the habit. It may be helpful to discuss the child's medication with their
physician as the prescription of a drug to reduce muscle tonus, which can be an
exacerbating factor in this situation, could be considered.