HANDICAP CONDITIONS AND THEIR MANAGEMENT

Developmental disability is not a term denoting clinical diagnosis but a grouping, established for the purpose of planning programme. Terms like mental retardation and epilepsy, on the other hand imply specific clinical diagnosis that fall into broad grouping know as developmental disabilities. The term handicapped in somewhat more inclusive than developmental disabilities but it is not the most acceptable term. Disabled is preferred and includes all forms of so called handicapping conditions. The dental condition of handicapped children may be directly or indirectly related to their physical or mental disabilities. The child born with cleft lip and palate or both may suffer from dental problems of great complexity and severity. MR children and those with cerebral palsy heart disease and bleeding disorders may not have specific dental problems but their physical or mental handicappers often hinder good oral hygiene and dietary habits, thereby creating a serious threat to their oral health. Defination A disabled child is one who has mental, physical, medical, or social conditions that prevents the child from achieving full potential when compared to other children of the same age. WHO defines handicapped individual as one who over an appreciable

time is prevented by physical or mental condition from full participation in normal activities of his age group, including those of a social, recreational, educational, and vocational nature. !

American Public Health Association APHA!

"A child who cannot within limits play, learn, work, or do things other children of his age can do, he is hindered in achieving his full physical, mental and social potentialities#. Harris "efine" # terms$ !$ Im%airment lacking part of body or all limbs or having defective

limbs, organ or mechanism of body. %$ Disablement& in loss or reduction in functional ability. '$ Han"ica% Mental Han"ica% Mental handicap is states of arrested or incomplete development of mind. Ph&sical Han"ica% ()* +!,-%$ states that child one who over an appreciable period of time is prevented by physical or mental conditions from full participation compared to children of same age group including social, recreational, vocational nature. Classification I) Franks and Winter (1974) a$ .lind or partially sited. b$ Deaf or partially deaf. c$ /ducationally subnormal. d$ Malad0usted. is the disadvantage or restriction caused by disability.

e$ /pileptic. f$ 1hysically handicapped. g$ Defect of speech. h$ 2enile. II! Hollo'a& an" S'allo' ()*+! Divided into ' categories3 a$ Mental handicap. b$ 1hysical handicap. c$ Medical disability or disabilities. III! No'a, ()-.!

4lassified into a$ 1hysically handicapped. b$ Mental retardation. c$ 4ongenital defect +2A./, 5allots tetralogy$. d$ Metabolic and systemic disorders e.g., DM. e$ 4onvulsive disorders. f$ 4hildhood autism. g$ .lind and deaf. h$ )emophilia. Mana/ement of a han"ica%%e" chil" "urin/ "ental treatment 2ince hospital visits or previous appointments with physician fre6uently result in the development of apprehension in the patient,

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additional time with the parent and child is needed to establish rapport and dispel anxiety. 7f patient cooperation can8t be obtained, the dentist must consider alternatives such as physical restraints to perform dental procedures. Ph&sical restraints 1hysical restraint is only one means of behaviour control to achieve an ade6uate level of dental treatment. 1arents must be uniformed and given consent before use of physical restraints. 1hysical restraints is useful for managing extremely resistant patients who need dental care. 4ommon mechanical aids for maintaining the mouth open are3 & & 1added and wrapped tongue blades. Molt mouth prop allows accessability to opposite side of the

mouth and operates on reverse scissor action. Disa"0anta/es 1in/er /uar" Disa"0anta/e 9ip and palatal laceration and luxation of teeth. 7t fits on the dentists finger. 9imited mobility of dentists hand.

Rubber bite bloc, Mc,esson bite bloc,s! These fit on occlusal surfaces of the teeth and stabili:e the mouth in open position. .ody control is gained through variety of methods and techni6ues like3 2o"& & & 1apoose board. Triangular sheet.

& & & & & & & Hea" & & &

1edi wrap. .ean bag dental chair. /xtra assistant. 1osey straps. <elcro straps. Towel and tape. /xtra assistant. 5orearm body support. )ead positioner. 1lastic bowl. 1hysical restraints should never be used as punishment. An

E3tremities

explanation of their benefits should be presented by the dentist before their use. The mouth prop can be identified as "tooth chair#, pediwrap as "safety robe# and restraining strap as safety but careful explanation should be given to patients, that physical restraints minimi:es accidental in0ury and allow the needed dental work to be done. Pre0ention of han"ica%%e" chil" 1revention is the most important consideration in ensuring good dental health for any dental patient. !$ )ome care control of pla6ue, tooth brushing and flossing.

%$ Diet and nutritional counseling. Home care The parents have a initial responsibility for establishing good oral hygienic in home.

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Reinforcement of good home dental

care and follow up

observations can be provided through news papers, radio, T<. & 7f child is institutionali:ed, the staff should be instructed in the proper dental care programme. & Although independent brushing is not contraindicated, parents and staff should known that unsurprised oral hygiene procedures in disabled children can have serious dental conse6uences. & 2ince disabled patients have gross motor deficiencies, thus ability to brush is hampered. *ne techni6ue often recommended is the hori:ontal scrub method because it is easy and yielded good result. Diet an" nutrition$ Diet and nutrition influence dental caries by affecting the types and virulence of the microorganism in dental pla6ue, the resistance of teeth and supporting structures and properties of saliva in oral cavity e.g. conditions associated with difficulty in swallowing, such as severe cerebral palsy, may re6uire patient on li6uid diet. 1articular emphasis should be placed on discontinuation of bottle by !% months of age after teeth begin to erupt, to decrease the likelihood of nursing caries. T4PES O1 TRANS1ER !$ 2lide board transfer. %$ *ne person transfer '$ Two person transfer. !$ 2lide border transfer covered for patients who have good upper

body strength and control but little or low lower body strength3 =

a$ Remove footrests and side arm nail. b$ Raise dental chair arm. c$ 1lace the wheel chain with brakes as close as to the dental chair, is the patient is hemiplegic position dental chair to his strong side. d$ Ad0ust height of the dental chair corresponding to the height of the wheel chair. e$ 1atients and eat but and place slide board under the patient. f$ >eep wheel chair from tipping while patient transfers. g$ 1lace patients legs into position in the dental chair once he has transfer. %$ *ne person transfer for patients who have moderate strength or paraplegic,

body control, but may fluid slide board to tracing patients with cerebral palsy, muscular dystrophy. a$ Remove footrests on wheel chair and side arm. b$ Raise the arm of dental chair.

c$ 1lace the wheel chair at approximately '?@ angle to the dental chair to facilitate kivotar type motion during transfer. d$ 2it the brakes and ad0ust the height of dental corresponding to the wheel chair. e$ 7nfaster, patients seat belts and block the patients knee and foot closest to the dental chair with your knee and foot closes to dental chair.

f$ )ave the patients place his hands around your neck while you hold patients waste or belt. g$ *n the predetermined signal help the patient stand, using his blocked knee and food as a pivot. h$ 2lowly pivot the direction of the dental chair and let the patient down into the chair. i$ 1lace patients legs and body in proper position in the chair. '$ Two person transfer used for patients with severely limited motor

function in all extremities when using this teeth remember to keep the back and left with the legs. a. 5ollow B!8 through BA8 for the slide board transfer. b. Remove the head rest on the dental chair. c. *ne person approaches the patient from behind and has the patients cross his arms by possible, place your arm under the patients arm fits and grab the opposite wrist with each hand. a$ The second person is responsible for lifting and guiding the lower limbs and should bend at the legs so as to lift with the legs, not the back. b$ *n a predetermined signal ask the patient to pur his elbows into his body and both persons doing the transfer lift the patient straight up stop for a second before you move laterally to the dental chair. c$ Move laterally to dental chair, making so to clear any obstacles and lower the patient.

Maintain support of the patients head until the dental chair headrest is replaced. MENTA5 RETARDATION MR! Definations Mentally challenged child&American Association of Mental Deficiency +AAMD$ and reported by )olmes et al "subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behaviour. MR is general term applied to persons whose intellectual development is significantly lower than that of normal persons and whose ability to adapt to their environment is conse6uently limited. Ca%ute defined subaverage general intellectual functioning "as

developmental or intelligence 6uotient +7D$ that is below A? and represents % or more standard deviation +72DE!- or != patients$ from a mean of !??. (hen this level of intellectual functioning exists concurrently with "impairment in adaptive behaviour# the inference is that the MR person does not possess the independence and social responsibility excepted within age and cultural group with the limit of !C years of age. Thus, to diagnose MR he should possess3

!$ An 7D score of more than % 2D below the mean +7D below A?$. %$ An accompanying impairment in adaptive behaviour. '$ Manifestations of both before !C years of age.

Classification !$ Mil"l& retar"e" is one, who because of low intelligence, cannot

derive full benefit from regular education. 7n academic environment these children are classified as educable mentally retarded +/MR$. /ducational programs for such children are generally simplified versions of regular school program and usually lead to literacy and attainment of necessary skill for employment. Most children +C?F$ of them in this group will function acceptably as adults. %$ Mo"eratel& retar"e" children who are capable of some education

and partial independence but who are not accepted to experience full independence as adults. /ducational programs for such children, who are known as Trainable mentally retarded +TMR$. 5ocus on basic skills, classification are often designed, furnished like home and the curriculum includes, dressing, grooming, cooking, table setting, feeding and cleaning. These children leave in a sheltered home with trained personnel. Classification of MR
De/ree of MR S2 Mild =A&-% I6 WISC8R =,&-/MR +/ducable 2hould be able MR$ to speak well, enough for communication TMR +trainable$ <ocabulary language skills such that can communicate at Treat as normal child, mild sedation or nitrous oxide sedation Mild to moderate sedations restraints and reinforcements, GA in severe dental School classification Communication S%ecial re7uirements

Moderat e

-!&'=

-;&;?

!?

basic level 2evere or '- and ', and Hon&trainable profound below below

decay.

Mute or 2ame as for communication moderately retarded in grunts, no skills

Classifie" MR into$ !$ 7diot 7D below %7D %- to -?

%$ 7mbecile

'$ Moron 7D -? to %? Accor"in/ AAMD !$ Mildly or educably retarded 7D =, to -%$ Moderately or trainably retarded 7D -; to ;? '$ 2everely retarded 7D ', to %;$ 1rofoundly retarded 7D below %WHO "i0i"e" into # cate/ories$ !$ Mild subnormality with 7D of -? to =, and mental age in adult C to !% years. %$ Moderately subnormality with 7D of %? to ;, and mental age in adult ' to A years. '$ 2evere subnormality with 7D ? to !, and mental age in adult g ? to % years. #! Se0erel& or %rofoun"l& retar"e" The child is often not trainable and re6uires supervision by trained support personnel. These are confined to institutions. They

!!

communicate with grunts, they lack communicable skills or they are mute. Etiolo/& The etiologic classifications3 (! Prenatal Genetic diseases. Maternal and fetal infections. >ernicterus 5etal alcohol syndrome.

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+! Natal .irth in0uries 7nfection 4erebral trauma )emorrhage Anoxia )ypoglycemia #! Postnatal 4erebral infections. 4erebral trauma 1oisoning 4erebral vascular accidents. 1ost immuni:ation encephalopathy Malnutrition Dental treatment for MR 1roviding dental treatment for MR person re6uires ad0usting to social, intellectual and emotional immaturity. The dentist should assess the degree of MR by consulting the patients physician. The following procedure have proved beneficial in establishing dentist&patient rapport. !$ Give a brief tour of the office before attempting treatment. 7ntroduce the patient to the staff. This will reduce the fear of unknow. !'

%$ 2peak slowly and in simple terms. Make sure the patient has understood the explanations. '$ Give one instruction at a time. Reward the patient after successful completion of procedure. ;$ 9isten carefully to the patient, as the MR persons have less communicative skill and hence the dentist must be sensitive to the gestures. -$ >eep appointment short. Gradually progress to the different procedures. =$ 2chedule the patient early in the day. A$ The medical history provides information regarding the cause and extent of the patients retardation. C$ 1remedications can be helpful in allowing the anxieties of the retarded patient decrease. EPI5EPS4 The term epilepsy, which refers to a symptom, not a disease, is of Greek origin and means "to 2ei:e#. <arious disorders may cause abnormal neuronal discharge in the brain that may induce a sei:ure. Etiolo/& Helson et al described sei:ures disorders in children, divided into % groups idiopathic and symptomatic. In i"io%athic& the epilepsies cannot be attributed to demonstrable structural lesion of the brain and are fre6uently a genetic origin. In s&m%tomatic group associated with pathology of the brain due to

developmental anamolies, in0ury or disease of the brain. !;

Sei9ures can be classifie"$ (! Gran" mal sei9ures They are generali:ed, usually occurring with tonic and clonic phases of muscular spasm. & & & & & & Their onset is rapid. The patient loses consciousness and becomes pale. 1upils dilate, eyeballs roll upwards or to one side. There is rapid contraction of 0aw muscles. micturation and defecation may occur. 1atients experiences cyanosis during tonic phase +contraction of muscles lasts for %?&;? seconds$. & The clonic phase +alternating contractions and relaxation$ lasts for variable periods. & 1atient awaken from the sei:ure with severe headache and in general state of confusion. +! Petit mal These appear between ' years of age and puberty, more in girls & & & & & There is transient loss of consciousness. *ccurs once or twice a month or several hundred times a day. They last for '? seconds. Ipward rolling of eyes. Drooping or rhythmic nodding of head, 6uivering of trunk of thumbs.

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Ps&chomotor sei9ures They are difficult to recogni:e and control. & & & There is loss of postural tone. There are no clonic and tonic movements. The dentist should prevent the patients from in0uring himself.

1ocal Sei9ures These sei:ures are produced by in0ury to the brain +trauma, toxic agents$ & & & They are referred to as Jacksonian sei:ures. They are sensory or motor and are clonic in nature. The muscles most fre6uently involved are the most speciali:ed for voluntary movements in the hand, face, tongue. Dental Mana/ement Most convulsive disorders are controlled through medication and pose few problems in dental treatment. The dentists should ask the following 6uestions during history taking of all sei:ures patients. !$ (hat was the age of the patient at the time of onset of the sei:ure. %$ )ow many types does the patient have. '$ (hat is the fre6uency of sei:ures. ;$ Does the patient tend to in0ure himself during the attack. -$ Do the sei:ures occur at any particular time of the day.

!=

=$ )ow does the patient act immediately preceeding the sei:ure and after the sei:ure is over. A$ (hat type of medications is the patients taking and when is it taken. Durin/ the treatment & 2ince anxiety is fre6uently precipitating factor, premedication with minor tran6uili:ers can be considered. & & & The drug regime of the patient should be evaluated. The use of mouth prop is mandatory during treatment. The dental units must be pushed away from the working field. 7n case the patient during tonic phase of sei:ure to avoid in0ury. & They ma0or concern of the dentist during sei:ure is to ensure that patients does not suffer physical harm. & & 9oosen the patients clothing. Turn the patients head to the side, pull the rubber dam material on youngs frame to evacuate the oral secretions. & Always talk to the patients, where he is, who are you, every thing is fine. 7f his restorative procedure have already stated, either tempori:e or complete the procedure, unless some in0ury has occurred or systemic parameters are not within normal range. & 7f appliance are indicated for tooth movements or tooth replacement purpose & fixed type is preferred.

Appoints should be given 0ust after the patient has taken daily medications.

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CERE2RA5 PA5S4 Helson et al used the term cerebral palsy to describe a group of nonprogressive disorders resulting from malfunction of motor centers and pathways of the brain. These are characteri:ed by paralysis, weakness, incoordination, or other aberrations of motor function that have their origin prenatally, during birth, or before the 4H2 has reached relative maturity +before age -$. A person with cerebral palsy characteristically has a motor disability that is manifested as a loss or impairment of voluntary muscle, weakness, stiffness or paralysis, poor balance or irregular gait and uncoordinated or involuntary movements. Etiolo/& & & & & & & & Decreased oxygenation of the developing brain. 4omplications of labor or delivery. 7nfections of the brain&encephalitis, meningitis, toxemias. 4ongenital defects of brain. Accidents resulting in trauma to the head. 1remature births. 1oisoning with certain drugs. The term commonly used to designate involved areas of the body. !$ Monoplegia involvement of one limb only. %$ )emiplegia involvement of one side of the body. '$ 1araplegia involvement of both legs only.

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;$ Diplegia involvement of both legs with minimum involvement of both arms. -$ Duadriplegia involvement of all the limbs. Classification CP (! & & S%astic :;< of cases!= 4aused by lesion in the cerebral cortex. )yper irritability of involved muscles resulting in exaggerated contraction when stimulated. & & & 4haracteri:ed by tense, contracted muscles. 9imited control of neck muscles, resulting in head roll. 9ack of control of the muscles supporting the trunk, resulting in difficulty in maintaining upright posture. & 9ack of co&ordination of intraoral perioral, and masticatory musculature. 1ossibility of impaired chewing and swallowing, speech impairment, drooping of saliva. +! & & Athetosis +>< of the cases! 4aused by lesion in the basal ganglion. 2low writhming involuntary movements and interferes with normal muscle action. & & & Muscle normal with no spasticity. 7nvoluntary movements. Heck musculature fre6uently involved resulting in excessive movement of the head.

!,

& &

Incontrolled 0aw movements, abrupt closure of 0aw and bruxism. 1erioral musculature fre6uently hypotonic with mouth breathing drooling of saliva.

& #! & &

2peech problems. Ata3ia (;< of the cases! 4aused by lesion in cerebellum. Disturbance in e6uilibrium grasping ob0ects. staggering gait, stumbling, difficulty in

&

1ossibility of tremors and uncontrolled trembling on attempting voluntary tasks.

.! & & & &

Ri/i"it& >< of the cases! 4aused by lesion in basal ganglion. 4onstant rigidity. <oluntary movements slow and stiff. 1atients resistant to flexor and extensor movements with contraction of agonist and antagonist.

>! & &

Tremors >< of the cases! 4aused by lesion in basal ganglion. Repetitive, rhythmic involuntary contraction of flexor and extensor muscles.

Oro"ental characteristics associate" 'ith CP (! & S%astic 9imited head movement.

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& & & & & +! & & & & & & & & & & #! & & & &

)ypertoxicity of facial muscles. 2low 0aw movements. 2pastic tongue thrust. 4onstricted maxillary and mandibular arches. Inilateral cross bite. Athetoi" /xcessive head movement. Duick 0aw movements. Grimacing and drooping. Mouth breathing. Tongue protruding. .ruxism. )igh, narrow palate vault. Malocclusions. Anterior open bite. 1oor swallowing. Ata3ia 9ack of balance. 2low tremor like head movements. Tongue protrusion and anterior openbite. Drooling and grimacing.

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General "isabilities 'ith CP & & & & & 2peech disorders -?F & A-F

Mental retardation ;-F. <isual defects 2ei:ures Deafness %?F to -?F.

'-F to =?F !? to '?F.

Dental %roblems$ & & & & & 1eriodontal disease. Dental caries. Malocclusions. Trauma. .ruxism.

Dental mana/ement !$ 4onsider treating patient confined to a wheel chair. Many express such preference for young patients, the wheel chair may be tipped back into dentists lap. %$ 7f a patient is to be transferred to the dental chair, ask about a preference for the mode of transfer. '$ Make an effort to stabili:e the patients head throughout all phases of dental treatment. ;$ Try to place and maintain the patient in the midline of dental chair with arms and legs as close to body.

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-$ >eep patients back slightly elevated to minimi:e difficulties in swallowing +not in supine position$. =$ *n placing the patient on dental chair determine patients degree of comfort and assess the position of extremities do not force the limbs to unnatural position, consider pillows and towels for support. A$ Ise physical restraints 0udiciously for controlling failing

movements. C$ 5or control of involuntary 0aw movements choose from variety of mouth props and finger splints. ,$ To avoid startle reflex reaction, avoid such stimuli as abrupt movements, noises and lights without forewarning the patients. !?$7ntroduce intraoral stimuli slowly to avoid eliciting a gag reflex. !!$Ise rubber dam for restorative procedures. !%$(ork efficiently, and minimi:e patient time in chair to decrease fatigue of involved muscles. !'$1re medication is a useful modality in management in case of fear and apprehension. !;$7f the patient is difficult to manage, GA is considered. DEA1NESS Deafness is a handicap that is often overlooked. Almost inevitably, speech in affected. 7f the impairment is severe enough that dentists and child cannot communicate verbally, the dentist must use sight, taste and touch to communicate and allow the child to learn about dental experiences.

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The causes for hearin/ loss (! Prenatal factors & & & & <arious infections *totoxic drugs. 4ongenital syphyllis. )eredity +waardenbarg syndrome$. rubella, influen:a.

+! Perinatal factors & & & 1rematurity. .irth in0ury. Anoxia.

#! Post natal factors & <arious infections meningitis. & & 7n0uries. *totoxic drugs aspirin, streptomycin, neomycin, kanamycin. mumps, measles influen:a, poliomyletis,

Dental Mana/ement !$ 1repare the patient and parent before the first visit. %$ Through the parent, determine during the initial appointment how the patient desires to communicate, thus decreasing the child fears. '$ Assess speech and language ability and degree of impairment by taking a complete history. ;$ 5ace the patient and speak at natural pace and directly to the patient, so that the patient can lip read.

%;

-$ (atch the patients expression make sure the patient understands what dental e6uipments is, what is going to happen and how it will feel. =$ Reassure the patient with physical contact, hold the patients hand initially. A$ /mploy tell&show&do approach, allow the patient to see the instruments and demonstrate how they work3 /.g. vibrations of handpiece, scratching of explorer, scooping of excavator, texture of rubber dam. C$ Ise smiles and reassuring gestures to build up confidence and reduce anxiety. ,$ Avoid blocking the patients visual field. !?$Ad0ust the hearing aid +/.g., the patient has one$ while the handpiece is the operation since hearing aids amplify the sounds. 25INDNESS A person is considered to be affected by blindness if the visual acuity does not exceed %?K%?? in better eye, with correcting lens or if the acuity is greater than %?K%?? but accompanied by visual field of no greater than %? degrees. Etiolo/& of 2lin"ness Prenatal causes & & & *ptic atrophy. Micropthalmus. 4ataracts.

%-

& & & & & & & &

4olobomas

defective growth.

Dermoid and other tumors. Toxoplasmosis. 4ytinegalic inclusion disease. 2yphilis. Rubella. T. meningitis. Developmental abnormalities of the orbit.

Post natal causes & & & & & & & & & Trauma. Retrolental fibroplasia. )ypertension. 1remature birth. 1olycythemia vera. )emorrhage disorders. 9eukemia. Diabetes mellitus. Glaucoma. .lindness is one disorder that may result in fre6uent

hospitali:ation, separation from family and slow social development. Dentist should reli:e that congenitally blind children need greater display of affection and love early in life. /xplanation is accomplished through touching and hearing, reinforcement takes place through smelling %=

and tasting. The modalities of listening touching, tasting and smelling are important for blind children. Reports reveal that motor activity affects the development of language and perception. .lind children tend to have more accidents than other children while ac6uiring motor skills. Trauma to anterior teeth, gingival inflammation because of inability to see and remove pla6ue. .efore initiating treatment for blind dentist should keep following points in mind. !$ Determine the degree of perception of the light +visual impairment$ e.g., can the patient tell light from dark. %$ Avoid expressions of pity or references to blindness as an affliction. '$ 7n maneuvering the patient to the operatory ask the patient for assistance. Do not grab, move, stop without verbal warning. ;$ Describe the office setting. Always give the patient ade6uate descriptions before performing treatment procedures. -$ (hen making physical contact, do so reassuringly. =$ 7ntroduce other office personnel very informally. A$ Allow the patient to ask 6uestions about the course of treatment and answer them. C$ Allow the patient who wears eyeglasses to keep them on for protection. ,$ Avoid sight references.

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!?$Rather than tell&show&do approach, invite the patient to touch, taste, or smell. !!$Describe in detail instruments and ob0ects to be placed in patients mouth. !%$ Demonstrate rubber cup on patients fingernail. !'$)olding the patients hand promotes relaxation. !;$2ince strong taste may be re0ected use smaller 6uantities of dental materials with such characteristics. !-$/xplain the procedure of oral hygiene and then place the patients hand on yours as you slowly guide the tooth brush. !=$Ise audiocassettes for explaining specific dental procedures and decrease chair time. !A$Avoid unexpected loud noises. !C$9imit the dental care to one dentist. Do'n?s S&n"rome 2ynonyms Mongolism, Trisomy %!

7t is one of the most common chromosomal disoders. Etiolo/& 4hromosomal abnormalities is Trisomy %! or presence of extra autosome +Thompson !,A'$. Inci"ence 3 !.- in !??? births.

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1eatures .ody growth 3 small stature due to retardation in appositional and endochondral growth. )ead 3 Microcephaly with prominence of forehead, shortening of anteroposterior diameter flattening of the occiput. /ye 3 & & & & Ipward, outward slant and epicanthal folds. 2peeling of iris +brush field spots$. )ypoplasia of iris. 4hronic inflammation of con0unction.

*rbit 32maller than normal. 5ace 3 & & & Round flat face. 5lat nasal bridge. Ipper facial height decreased.

Mouth3 & Inder development of maxilla contributes to open mouth and protruding tongue. Tongue 3 & & Teeth3 & Microdontia. %, Hormal at birth. *lder patients fissured or macroglossia.

& & & &

4onical tooth. *ver retention of primary teeth. Aberrant eruption pattern. Anadontia, oligodontia, supernumerary teeth.

1alate 3 Harrow and high vault. 9imbs3 & & & /ars 2hort, broad hand digits and feet. (ide space between first and %nd toe. 2ynductaly of fifth finger. Anamolies in formation of external ear.

2kin 3 Dry, hyperkeratosis common. Heck 3 .road and short. Ner0ous s&stem & & & & 9evel of intelligence mild to severe.

General movements slow, sluggish, clumsy. Insteady gait. 5eet kept wide apart. 1revalence of periodontal disease is higher than

Perio"ontal status normal populations. S&stemic con"ition & & 4ardiac diseases

%A&'-F.

7ncreased incidence of abnormality in (.4.

'?

& &

7ncrease incidence of RT7. 4ongenital heart disease, respiratory tract infection in !st - years.

Common malformation & & & Articular spethal defects. 7nsufficiency of A< value. <entricular septal defect. +2hould follow the guidelines for 2A./ coverage$. Mana/ement D2 patients can be treated in dental office with tolerant and sympathetic approach. & Most of them are affectionate and cooperative, cheerful and well behaved. & Decreased resistance to infection should be considered while treating. Heart Diseases )eart diseases can be divided into3 a$ 4ongenital. b$ Ac6uired. .ecause individuals with heart disease re6uire special precautions during dental treatment such as antibiotic coverage for prevention of 2A./, a dentist should closely evaluate the medical history to ascertain 4<2 status.

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Con/enital Heart Disease 7ncidence T&%es$ a. <enticular septal defect. b. 1atent duction arteriosus. c. 5allots tetralogy. d. Transposition of great vessels. e. Artral septal defect. f. 1ulmonary stenosis. g. 4oartation of aorta. h. Aortic stenosis. i. Tricuspid atresin. Etiolo/&$ & & & Inknown. Aberrant embryonic development of normal structure. 5ailure of structure to progress beyond embryonic development. , in !??? birth.

Others & & T&%es & & 4yanotic Acyanotic Maternal rubella infection. 4hronic maternal alcohol abuse.

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Acyanotic is divided into 2 groups: (st /rou% & C1 & & & & & & Murmurs. ) failure. 1ulmonary congestion. )eart murmur. 9abored breathing. 4ardiomegaly. defects that cause left to right shunting of blood. <2D, A2D

7ncludes

+n" /rou% & & C1 & & 9abored breathing. 445. Defect caused by obstruction. /.g., stenosis of aorta.

C&anotic con/enital heart "isease 4haracteri:ed by right to left shunting of blood within the heart. & 4yanosis occurs during mild exertion e.g., fallouts tetralogy, transposition of vessels pulmonary stenosis. C1 & 4yanosis

''

& & & &

)ypoxic cells. 1oor physical development. )eart murmurs. 4lubbing of fingers.

Ac7uire" heart "isease Rheu atic !ever: & 7nflammatory disease that occurs as a delayed se6uela of pharyngeal in0ection. & & & & & 4aused by streptococci. 7nfection can involve heart, 0oints, skin, 4H2, subcutaneous tissue. *ccurs commonly between = to !- years. 1revalent in temperate :one and high altitude. 4arditis develop in -?F of patients.

@ones criteria in "ia/nosis of R1

MaAor manifestation 4arditis chorea polyarthritis Minor manifestations & & & & & & & 5ever Arthralgia. 1revious history. R5 or heart disease 7ncreased erythocyte 2R +/.2.R.$ Lve protein. 1rolonged interval. c&reactive 1R Su%%ortin/ e0i"ences /vidence of preceeding streptococcal infection. 1ositive throat culture group A streptococcus.

/rythema margination 2ubcutaneous nodulus

Infecti0e bacterial en"ocar"itis ';

4haracteri:ed by microbial infection of heart valves or endocardium in proximity to congenital or ac6uired cardiac defects. Divided into 3 & Acute & 2ubacute Acute disease that usually occurs as a result of microorganism of high

pathogenicity, causing erosive destruction of valves. Microor/anisms & & & 2taphylococcus. 2treptococcus group. 1neumococcus. 7n contrast 2A./ develops in persons with preexisting

Subacute

congenital cardiac disease. & C1 & & /mboli:ation. Microorganism may coloni:e on endocardium. 4ommonly caused by <iridans streptococci.

S&m%tom & & & & & & 7rregular fever. Malaise. Anorexia. (eight loss. Arthalgia. 4ardiac murmurs. '-

&

1ainful fingers, toes, skin lesions.

5ab fin"in/s & & & 9eukocytosis. 7ncreased /2R .acterimia.

Preci%itatin/ factors !$ Dental manipulation induce gingival bleeding. %$ 7ncision and drainage of infected tissues. '$ Tonsillectomy. ;$ .ronchoscopy. -$ G7 instrumentation. =$ IT instrumentation. A$ 7< catheters. C$ <alvular prosthesis. Dental Mana/ement & & & & & )istory. Medical and physical examination. Discuss with the physian. Ade6uate antibiotic therapy. 4ardiopulmonary resuscitation e6uipment should be available.

'=

Following considerations: !$ 1ulp therapy for primary teeth is not recommended increase incidence of chronic infection %$ /ndo therapy therefore,

extrusion and 2M.

in permanent teeth can usually accomplished and

performed ade6uately. '$ 1atients with cardiac pacemakers with existing congenital defect or disease prophylactic antibiotic coverage to prevent 2A./ is not indicated. HEMOPHI55IA This is most common congenital blood coagulation disorders which produces serious bleeding episodes. This is caused due factor <777 +A$ deficiency and factor 7M +.$ deficiency. )emophilia is inherited as an M linked recessive tract. Therefore all males who possess the defective M chromosome have clinical manifestations of disease and females are caries. Another bleeding disorder, fre6uently confused with hemophilia is <on (illebrand disease. This disease is inherited via autosomal dominant gene affecting males and females. The person with this disease have mild deficiency of factor <777 and abnormal platelet function.

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Classification of hemo%hilia De/ree 2evere Moderate Mild < of BIII an" IC N! !&-&'Characteristics May be fre6uent spontaneous bleeding into 0oints and muscles. *ccasional spontaneous 0oint bleeding, minor trauma may initiate hemorrhage. 2ignificant hemorrhage only after ma0or insult such as extraction.

Dental mana/ement of hemo%hilia The dental treatment of a patient with hemophilia necessitates thorough understanding of this patients disorder. 7t is important that the nature of disorder be determined through interviews with parents and childs physician. .efore starting the treatment, the dentists should undertake thorough medical history about this disease. 7t is especially important to avoid tissue laceration or other intraoral trauma. The following patients are important in treating the patient. !$ The relief of anxiety has been shown to be beneficial in maintaining hemostasis by premedication, nitrous oxide inhalation, hypnosis.

7M trans6uili:ing analgesic agents in contraindicated as it can cause hematoma. %$ 7n absence of factor replacement, intraligamental in0ection may be used. .lock anesthesia is not recommended, local infiltration can be easily administered after single infusion of factor replacement.

'C

'$ Teeth can be cleaned by rubber cup minor haemorrhage can be controlled with local mechanism such as direct pressure. 5or minor hemorrhage topical application of bovine thrombin may be used. ;$ Most of restorative procedure and pulp therapy on deciduous teeth can be successfully completed without discomfort through use of acetaminophen with iodemic with nitrous oxide inhalaton. Hemo%hilia 7f the child with hemophilia sustain oral trauma with excessive bleeding following modalities. !$ )emorrhage associated with laceration of *MM continued until epitheli:ation is complete. %$ 9aceration which re6uires suturing repeated doses of factor which level of at least %-F of normal is maintained /&A4A infusion continued until the wound is healed. '$ /xtraction of primary teeth or permanent, factor <777 infusion of !??F of normal and loading dose of /&A4A maintenance dose of /&A4A for A to !? days. /xtraction of teeth begin within ! hour after infusion. Ad0unct local measures to control bleeding should be considered. 9ike avitum or oxidi:ed cellulose material impregnated with bovine thrombin. 1atient must be give very specific instruction weeks strict diet for % single dose factor

cocnentrate that raises the level of factor -?F of normal /&A4A

!st %% hours li6uid diet. Dairy products should not be allowed as

they leave film residue. Hext week soft diet after !? days normal diet.

',

E8amino ca%eri aci" E8ACA! As ad0unct to factor replacement therapy. 7n hemophilic patient, there is normal 5ibrinolytic mechanism but generation of thrombin necessary for clot is decreased. Thus, the clots get dislodged. The fibrinolytic mechanism is inhibited by /&A4A to form stable clots. Desmo%ressin acectate & Antidiuretic hormone causes increased levels factors <777.

;$ 1articular care must be taken in placement of 7*1A films and use of high suction or saliva e0ector. -$ The use of rubberdam with greatly assist in protection of soft tissues clamps with subgingival extension should be avoided. =$ 4onventional pulp therapy is preferable to tooth extraction. 7ntrapulpal in0ection can be used to reduce pain. )emorrhage from pulp chamber can be reduced by pressure packs. Dental care Pre0enti0e Dentistr& 1revention of dental diseases re6uires a combination of diet, pla6ue control regular continuing professional care. 1arents should be made aware that as gingival health improves, minor bleeding caused by brushing will stop or treated by topical bovine thrombin. 5lossing should be taught only to those parents and patients who appear capable of mastering the techni6ues. 7n severe hemophilias, fluoride therapy, to be done every ' months using custom trays.

;?

Perio"ontal "isease Treatment of the periodontium is one of the most neglected aspects of children. 2imple dental prophylaxis and topical fluoride application can be easily done in severe hemophiliases provided meticulous care is exercised to prevent gingival trauma. 4alculus may be removed in stages in order to reduce bleeding risk. 7nitially, gross supragingival scaling is done, allowing the gingival inflammation to subside, as the inflammation resolves remaining calculus can be removed. 5or deep scaling, replacement therapy should be used prior to the treatment. Restorati0e Dentistr& /xtra care should be taken to avoid soft tissue in0ury. Routine use of rubber dam is helpful in protecting patients lips and tongue from trauma, clamps such as ivory Ho. CA and !;A should be avoided for gingival damage, clamps such as 22 white Ho.%%. %?!. /xtra care must be taken during passing the rubber dam through contact points with dental floss to avoid "snapping# of floss into interproximal gingiva. 2tainless steel crowns can be avoided when possible to prevent gingival bleeding and laceration. En"o"ontic %roce"ures These are highly recommended in children to lower the need for extaction. 1ulp bleeding can be controlled easily without replacement therapy. /xtra care is taken to prevent periapical trauma. ;!

Oral sur/er& 1rior to surgical procedures, missing blood factor is replaced. During extraction procedure. 9ucas and others advocate combination of absorbable hemostatic agents and topical bovine thrombin. 9ucas, saturates oxidi:ed regenerated cellulose with bovine thrombin dissolved in ?.-F sodium percarborate solution. After socket is dried, surgicel is used to fill the socket within ! mm of the surface lucas then covered the wound with splint. Ortho"ontics Although bands should be avoided when possible, much can be done with adhesive brackets or removable appliance in orthodontic management of malocclusion. 7n severe bleeders however, it is not suggested that bands be used on any teeth. ADTISM 7n !,;; >aner described clinical syndrome in children to which negave name infantile autism. )e described that one symptom with the disease was an viability to relate approximately to the people and situations. These childrens are seem to be self sufficient and introverted and want to be left alone. & & & They have no attachment to parents. They relate poorly to persons. They remain occupied water moving or shining ob0ects such as keys, spinning tops for hours.

;%

7n !,C?, diagnostic and statistical manual of mental disorders published by A1A listed autism as neurological disorders, caused by physical disorder of the brain. 7ncidence Etiolo/& & 9otter +!,==$ postulated that personalities attitudes and behaviour %.-F in !???? population >anueer and 9esser !,-C.

of the child8s parents contibute the autism. & & .akwin and .akwin early manifestation of childhood schirophamia. 4hildren who have been brought up in institution where they received no stimulation and totally deprived. 1eatures & & 9anguage impaired invariability. >ammer

%K'rd achieve active functional speech but !K'rd remain without functional language. +Robin son and Milins !,A=$.

& & &

/ven the speech is a ac6uired they hardly speak. (hen speech is present they repeat the word or phase. They have difficulty in saying yes.

2eha0iour & & & & 7ntense desire to maintain consistency in the environment. 7nappropriate reachers to fearful situations. 1rone to transforms and aggressive or destructive behaviour. .i:arre behaviour makes dental management difficult.

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Mana/ement 9oovoos et al +!,A;$ reported behaviour modification techni6ues. The key to all behaviour modification programs lies in the positive reinforcement to promote desirable behaviour. 7n early stages, sweet foods can serve as desirable rewards. 7n later stages of modifying behaviour such oral rewards should be changed to social rewards, such as pat on the back or a hug. & & 7n the interest of time , premedication of ketammic in useful. GA is method of choice.

Cleft 5i% an" Palate 4left lip with cleft palate is severe birth defect occurring in newborn infants. 4left lip and cleft palate are among common congenital malfunctions occurring in orofacial region. The variable morphology of the congenital anamoly ranges from soft tissue defect involving either lip or soft palate with complete separation of the oral and nasal cavities. The associated defects with this are malformed teeth, malocclusions, impairment of speech, middle ear infection, IRT7. Inci"ence & & & & *ne in A-?&!??? newborns in I2A. 7n whites 7n blacks one is C?? births. one in %??? births.

Japanese & one in -?? births.

;;

& & &

4left lip and palate lengthen account for -?F of all cases. 7solated cleft lip and palate occur in %-F each. Males are commonly affected. A number of classification have been proposed but one of them have

been universally accepted. I! Group 7 bilateral. Group 77 Group 777 II! 1ost alveolar clefts Alveolar clefts involves soft and hard palates. Da0is an" Ritchie ()++! 1realveolar clefts lip clefts only with unilateral, median and

complete clefts of palate, ridges and lip.

1it9 an" Gibbon ()#;! !$ 4left of the soft palate. %$ 4left of soft and hard palate. '$ 4left of the soft and hard palate with single hard lip. ;$ 4left of soft and hard palate, with double hairlip and deteched premaxillae. -$ 4left of soft and hard palate, edentulous.

I! %alate a) 4lass 7

Bean ()#(! classification of cleft li% an" cleft

Cleft lip unilateral notching of vermillion border but not extending

into the lip.

;-

4lass 77

unilateral notching of the vermillion border with cleft

extending into the lip but the floor of the nose. 4lass 777 unilateral cleft the vermillion border of the lip, extending

into the floor of the nose. 4lass 7< Any bilateral cleft lip whether this be incomplete

notching or complete clefting. b) 4lass 7 4lass 77 process. 4lass 777 involves both soft and hard palate and the alveolar Cleft palate involves only the soft palate. involves only the soft and hard palate, but not alveolar

process oneside of the premaxillary area. 4lass 7< involves the soft and hard palate and continues through

the alveolus on both sides of premaxilla, leaving a free and mobile.

;=

III!

1o/h E An"erson ().+!

Group 7 )arelip single, double Group 77 Group 777 IB! 4lass 7 4lass 77 4lass 777 4lass 7< 4lass < )arelip and cleft palate 4left palate Olin/er classification ()>+! fissure in a:ygos uvuale 5issure in uvuale 5issure in soft palate 5issure in soft and hard palates. unilateral cleft, fissure in the soft and hard palates, then alveolar single, double.

ridge at 0unction of maxilla and premaxilla accompanied by cleft lip. 4lass <7 bilateral cleft, fissure in soft and hard palates through the

alveolar ridge at the 0unction of the maxillae, accompanied by cleft lip. B! Fernahan an" Star, ()>#! This pattern is widely accepted and utili:ed. Group 7 +clefts of primary palate anterior to inclusive foramin$& 4left of

the tip +49$, all forms of degrees of cleft lip, and combination cleft lip and cleft alveolar process. Group 77 4left lying posterior to incisive foramin on degrees of clefts of

soft and hard palates. Group 777 4ombination of clefts of both primary and secondary palates

involves combination of group 7 and group 77.

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Sub"i0ision Group 7 !$ Inilateral cleft lip incomplete %$ Inilateral cleft lip complete Group 77 !$ 4left lip involving the soft palate only. %$ 4left lip involving the soft palate and hard palate. Group 777 !$ Inilateral cleft lip with complete cleft of soft and hard palate. %$ .ilateral cleft lip with complete cleft of soft and hard palate. BI! International confe"eration for %lastic an"

reconstructi0e sur/er& ()-* Group 7 clefts of anterior palate +primary$ a$ 9ip right K left b$ Alveolus right K left Group 77 clefts of anterior and posterior palate c$ 9ip right and left. d$ Alveolus right and left. right and left

e$ )ard palate Group 777

clefts of posterior +secondary$ palate a$ )ard palate right and left.

b$ 2oft palate median

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Etiolo/& /xtent etiology of 441 is still unknown but few accepted theories. !$ /xogenous tract factors 9ike Rubella

Thalidomide drugs %$ Mulant genese and chromosomal aberration. Mutant genes ectodermal dysplasia D&trisomy and /&trisomy

4hromosomal aberrations '$ Multifactorial causes

4ontribution of both with heredity. Patho/enesis Cleft li% According to mesodermal deficiency theory the lip and premaxilla in their early forms as an ectodermal good in which ' masses of mesoderm are present. Hormally these masses grow and limit to form the upper lip and premaxilla, but failure of the growth leads to infiltration of the ectodermal head a conse6uent weakening of this delicate membrane induces a rupture of the head and a cleft lip results. Cleft %alate This commonly accepted that cleft palate results from the failure of the palatal shelves to meet and fuse in the midline.

;,

4auses are3 !$ 5ailure to displace the tongue from between the shelves may prevents closure. %$ 5usion may be prevented because shelves are too narrow to meet in the midline or because of other structural defects. '$ Hormal palatal shelves may not meet in the midline is an individual ha an incisally wide head. Oral fin"in/s & & & & & & & & & & Hatal or neonatal teeth with complete or bilateral cleft palate. 4ongenitally missing teeth. 2upernumerary teeth. /ctopic eruption of deciduous lateral incisor. Anomalies in morphology. /namel hypoplasia. Microdontia, macrodontia. 5usion of teeth. 9ateral facial profile convex. Rotation of teeth.

E3traoral features Defects of extremities syndectyl +webbed fingers$ and malformation of lower extremities. Ipper respiratory tract infection. -?

 4ongenital heart disease. )earing problems caused by middle ear infections speech impairment. E0aluation of the chil" 4areful history of pregnancy, labour, delivery, and family history. & & 9ook out for congenital abnormalities. 7f present eyes to gene therapists, so that etiology and mech can be explained. *ther consultation should be addressed depending on the physical examination by /MT, opthalmologist, cardiologist, pediatrician prior to surgery. Also refer the child to psychologist, speech pathologist, radiologist. Pre sur/ical mana/ement counselin/! 7t is extremely important because almost all the patients have same concerns. This will help the parents to warmup. 1ee"in/ 5irst goal is to prepare the child for surgical response of lip. .efore surgery the child should have following criteria pounds and !? gms of tbl spoon B' times law8. 1ee"in/ %lates 5eeding problems arise in the case of bilateral and unilateral cleft. A feeding plate can be made to cover the roof of the mouth to prevent food entering nasal cavity. !? weeks, weight !?

-!

Sta/e ma3illar& ortho%e"ic sta/e! birth to (* months 5eeding problems are often associated with clefts, making it difficult to maintain ade6uate nutrition. & 7nsufficient suction to pure milk excessive out intake, nasal discharge. McNeil ()>;! E Obturator A"0anta/es !$ 1rovides false palate against which the infant can suck reducing feeding problems. %$ 1rovides maxillary cross arch stability and prevents arch collapse. '$ *rthopedic moulding cleft segments in to approximation before bone grafting. In"ications & & 4omplete cleft tip and palate. Maxillary orthopedic moulding of segment after surgical closure of lip. Proce"ure$ & & 7mpression of maxillary arch is made in stock tray. The infant is held upright during impression to prevent, aspiration of excess material. & Appropriate emergency e6uipment, forced oxygen, suction and airway management system should be available.

-%

1abrication & & & .lock out all the undercuts with wax. 2eparating media is applied. 5abrication of the appliances using self cure resin.

Clinical mana/ement 2irth E # months! & & & & Area of excessive pressure relived. Maintaining hygiene. Recall the after % days of initial placement. Recall every !- to ! month. The primary function of cleft palate clinic are to evaluate and planning of rehabilitative needs of his patient. To obtain optimal rehabilitation each number of the discipline involved have general problem faced by other members of the team, is excessive and prolonged orthodontic treatment re6uired in separate stages3 !$ 7nfancy before initial surgical repair of lip. %$ During primary and mixed dentition stage. '$ During late mixed dentition and early permanent dentition stage. ;$ 7n later teeths after the complication of facial growth in con0unction with orthognathic surgery. Infant Ortho%e"ics 7f presurgical movement is indicated it is carried out ' to = weeks of age that lip closure can be carried out !? weeks. A passive plate similar to orthodontic retainer is used for months after lip closure.

-'

9ater primary and early mixed dentition treatment The result from surgical correction of lip closure some constitution across the anterior parts of maxillary arch is created. *rthodontic intervention is often unnecessary until permanent incisors begin to erupt. There is tendency that maxillary anterior erupted rotation and with crossbite. This can be corrected by fixed and removable appliance. Pre8sur/ical ortho%e"ics$ The growth potential of the nasal septum is extremely powerful when the lip is normal, the forces are directed anteriorly along the midline. 7f there is a muscle pull to one side because of a unilateral cleft these two forces combine to pull the ma0or segment to non cleft side. Therefore if an opposing force to nasal septum and to the muscle pull can be applied the distortion can be minimi:ed. 7f at the same time a shearing force can be applied to minor segment, the ma0or and minor segments of the alveolus and lip can pulled together. This makes the task of plastic surgeon repairing the lip defect much easier. The active force can be provided by ' pieces of tape 0oined together by % elastic bands. The central portion of the tape tends to cup the premaxilla in bilateral cleft case thus stabili:ing the segment strapping should be applied immediately after birth and continue till the time of surgery. 7n this way tension in the tissues is minimi:ed version facial skin as the repeated changing of the strapping

-;

means that the tape must be removed from the face this can result in the skin becoming sore using a barrier dressing or leaving an additional piece of tape on the face minimi:es the effects of this recurrent trauma. 7n the case of bilateral clefts, the lateral segments tend to approximate, resulting in the blocking out of the premaxilla. To prevent this an oral plate must be fitted to stabili:e or even move the lateral segments buccally when the cleft of palate is unilateral, an active plate can be used to stabili:e or prevent collapse of the segments and narrowing of the maxillary arch. *ne type of expansion plate is constructed on a cast that has been cut and the segments reposition by upto 'mm. Alternatively a plate with a spring in the anterior region and a hinge in the posterior region can be fabricated to give a differential expansion. An active plate unlike the passive feeding plate must be worn at all times. This plate is kept in position by the action of the tongue, the force generated by the baby acting together an extraoral were "whiskers# which are taped to babys face. Ortho"ontics The goal of orthodontic treatment is to provide an aesthetically acceptable and healthy dentition for life and to contribute positively to the

--

general facial form and appearance. An orthodontist working with clefts, children before starting treatment two important parameters. !. 5irst with regard to the timing of orthodontic treatment. %. Most patients have complex orthodontic problems dental problems specific to cleft and palate. 1" #ongenita$$y issing teeth"

7t has shown that children who have clefts of the maxilla have a higher incidence of congenitally missing teeth. This is true not only the immediate area of cleft but also the contralateral side and the opposing arch in complete unilateral clefts. 2" %upernu erary teeth A greater incidence of supernumerary teeth in the cleft lip and palate patient. The maxillary lateral incisor area is affected most often, especially when it is in the direct line of the cleft. (hen cleft occurs it affects the angle of the lateral incisor and can split it in two. The teeth are ectopic in position smaller in si:e and expandable. &" 'ther tooth ano a$ies

These include3 a. 5used.

-=

b. 7rregularities of tooth si:e, ectopic eruption, malformation of individual teeth delayed eruption of mandibular teeth ankylosis of teeth ad0acent to the site of the cleft lack of bony base over which teeth might be moved. Presur/ical %erio" (hen pre&operative orthopedic treatment was introduced at many clefts center in !,-?8s. The above principles and ob0ectives its adoption was resisted for the following reasons3 !. The surgeons felt they did not need it. %. At the time pre&surgical orthopedic treatment was introduced. '. The teem particularly the orthodontist were worried that pre&surgical orthopedics may have a adverse effect on maxillary growth. 1re surgical orthopedic treatment has now been used extensively in /urope and limited states for over '? years. Treatment Proce"ures *rthodontic care is considered here in ' phases, during the primary, mixed and the permanent dentition.

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Primar& "entition %hase The extent of a malocclusions is usually lees apparent in the primary dentition. Then in the permanent dentition, treatment is difficult in the primary dentition because of the lack of good teeth for anchorage. & The presence of a bulky appliance in the mouth may contribute to speech problems. & The level of cooperation that can be expected from a child of this age is fairly limited. & 7n addition as children grows relapse commonly occurs.

/ven when there is evidence of a high arching palate due to lateral collapse or retrusion of the maxilla it is usually better not to perform any active treatment in the primary dentition. Mi3e" "entition %hase .y the mixed dentition stage most of not all of the anterior teeth in the region of the cleft will have erupted. They are fre6uently malformed, hypoplastic and erupt in ectopic positions or missing the rationale of treatment was to reduce cross bites and create functional environment. As a general rule orthodontic treatment during the mixed dentition limits itself maxillary arch.

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5or example in complete, unilateral and bilateral clefts if buccal segments crossbite exists to reduce the first. 7f the maxillary central incisors erupt in lingual version or rotated and ectopic. This re6uires another phase of treatment. 7f the maxillary first permanent molars erupt in crossbite and lateral incisors in lingual version, this to necessitates, additional treatment. There are number of techni6ues available for reduction of bilateral buccal crossbites. !. Duad helix appliance. %. A rapid maxillary expansion device. Permanent "entition %hase .y the permanent dentition stage growth is nearing completion and magnitude of any deformity can be readily assessed. )ence this is the most appropriate time for performing orthodontic therapy. There may be abnormalities in the position of the teeth or the 0aws. 7n the case of later the discrepancies can be considered in ' planes3 !. Transverse. %. Anteroposterior. '. <ertical. The transverse relationship may be such that a posterior crossbite. This is usually more in the region of the minor segment ad0acent to the

-,

cleft. The collapse of the arch may be due to repair of the lip. 7t is more due to scar tissue arising from the palatal repair which has restricted lateral maxillary growth. .ecause of the lack of bony union between the segments of the maxilla, they can be easily moved using a fixed appliance that is cemented directly to the teeth. This approach limits the degree of tooth tipping. (hen there is a severe anterior cross bite, expansion may be re6uired using a roped palatal expansion type of appliance. 5or correction of a posterior crossbite, a 6uadhelix type of appliance is used. There is no midline suture to open in posterior region, this expansion can be performed more slowly. An alternative is an appliance that caps the teeth and has a screw anteriorly and a hinge posteriorly to achieve differential expansion of the arch. S%eech an" lan/ua/e All children with cleft palate re6uires such therapy to overcome the difficulties associated with trying to generate intraoral pressure and to overcome hyper or hyponasality. 7n the time between repairing the lip and palate, the child begins to develop oral movements before speech. This is pronounced between !%&!C months of age. Repair of the palate should not be delayed beyond this period because in the ma0ority of cases acceptable speech can be achieved following surgery at this stage. =?

7mmediately after birth, the child will start to experiment with sound production. These early babblings are the beginning of speech. The speech therapist can advise the parents to encourage the child by reading to them and naming ob0ects when moving around the house or in the street. All times it is essential that the child is allowed to practice speaking. The parents need to be counseled by a speech therapist so that they fitting palate in the childs mouth on a long term basis before palatal repair may have some beneficial effects in that it allows the tongue to function in an area approximating to the shape of the future mouth. Multis%ecialit& team mana/ement (hite house had described, clinical team as a close cooperative democratic, multiprofessional lenion development to a common purpose the best treatment of fundamental needs of a patient. 7n order to improve function and appearance of various parts of face and oral cavity that are affected by this defect and associated psychological problems, different specialists must work in close collaboration to treat these children. The team include a plastic surgeon, a pedodontist an /HT surgeon an orthodontist, a speech therapist, oral surgeon and a prosthodontist. The role of in"i0i"ual s%ecialists 1rimary function of plastic surgeon is to prepare clefts of lip and palate and to improve function of the soft palate and appearance of lip and

=!

nose. )e may be re6uired to deepen the labial sulcus and in bilateral cleft cases, reposition the premaxilla. .ecause of early treatment performed by plastic surgeon, parents become ac6uainted with him and he makes a useful team leader. The pediatric dentist is responsible for constructing feeding plates and advising parents on feeding techni6ues for the neonate. )e provides restorative and preventive dentistry including dietary advice and topical fluoride applications during childhood. The ear, nose and throat surgeons performs aural examinations and assesses the hearing by using impedance and compliance tests. This is essential if the child is to communicate and learn at the normal rate. 7f necessary surgical procedures can be used to protect ears and maintain them in a healthy state, the role of /HT surgeon is limited after the age of A years because most of early hearing problems should have ceased. )earing improves when the tensor palati muscles take over from levator palati muscle as the primary muscles responsible for opening the /ustachian tube. The orthodontist is usually responsible for performing presurgical dental orthopedics and when necessary early correction of malalignment in the incisions and correction of discrepancies in the labial segment relationship. 4rowding and malalignments are corrected in the full

=%

permanent dentition and teeth are often moved orthodontically to move favourable position for the retention of a prosthesis. The speech therapist advises the parents about communication problems and demonstrates method of encouraging the child to speak properly. (hen necessary treatment is provided to overcome problems such as hypernasality, nasal fricatives defects articulation due to inability of patient to build up sufficient pressure. The social worker can help by giving support advice and looking after many siblings. 1rosthodontist replaces, restores orofacial structures that may be congenitally missing or malformed non living materials are used to restore, enhance form and anatomy he fabricate appliance to rehabilitate mastication deglutition, speech and oral esthetics. They may incorporate a palatal expansion or an obturator to occlude any residual palatal defect. The psychologist assists by counseling both parents and child at different times to help them, minge and cope with their problems. The oral and maxillofacial surgeon evaluates all patients for facial form and function and 0aw position many cleft patients have a skeletal malocclusion that can be treated by conventional orthodontics and re6uires surgical correction. The surgical placement of primary and secondary alveolar cleft bone graft is another important role of the surgeon. These ='

grafts aid in dental rehabilitation of the patient. The grafted bone supports the teeth ad0acent to the cleft site and provides bone through which teeth may except. Treatment schedule summary and the specialists treating a patient with a cleft lip and palate3 (irth 3 1edodontist may construct feeding plate and initiate pre&surgical dental orthopedics. Team members are introduced to parents and emphasi:e need for ade6uate weight gain so child attain necessary stage of development before lip surgery. ' months of age& surgical repair of lip bilateral cleft lip cases may be repaired as a two stage procedure. = months preventive dentistry begins.

!-&!C months surgical repair of palate speech therapist assess. % years plastic surgeon review surgical result orthodontist examines teeth

and soft tissues, especially noting relationships of anterior segments and depth of labial sulcus in the cleft region. /HT surgeon assesses hearing and examines tympanic membrane speech therapist continue to monitor speech. 1edodontist stresses importance of good dental health. ' years dental check ups at ; months intervals other team members

review regress annually.

=;

; years

/HT surgeon usually performs aduiography and compliance tests

and if necessary places grommet tubes in ear drums. 2peech therapy starts for children with speech and hearing problems. A years /arly correction of malalignment of an anterior teeth and labial

segment relationship. , years !% years surgical lip and nose revision to improve appearance. orthodontists correct malocclusion and treats crowding and

malalignments. /xpansion of maxillary arch may be necessary teeth may be moved so as to create space for bone graft or for fixed removable prosthesis. != years plastic surgery to improve the appearance of nose, the oral

surgeon may form a 9efort ! maxillary osteotomy to correct retrusive appearing maxillo, replacement of missing teeth with fixed bridge or removable prosthesis. != years onwards dental care. Dental mana/ement of the cleft %atient The child patient with a cleft lip and palate offers challenges to the pediatric dentist. The children undergo surgical and dental procedures more fre6uently making them more anxious in the dental office. 4hange in the prosthodontists and restorative dentist prove regular

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innervation of the maxilla and post surgical scar tissue make the local anesthesia difficult the anesthetic scar from missing teeth an incomplete alveolus also managed until the establishment of the permanent dentition. As part of a cleft palate team and pediatric dentists mission is to protect and supervise. The eruption of permanent teeth. The tasks that one can be expected to perform include the following3 !. 4onstruction of infant feeding and orthopedic appliances. %. /ducation of parents to the dental needs and care of this child. '. 7ntroduction of the child to environment. ;. 1revention of dental caries. -. Guidance of the developing primary and secondary dentition. =. Restorative dentistry for the primary and secondary dentition. A. Management of problems uni6ue to the cleft side. C. /ducation of the child and parents to the maintenance of good oral hygiene. /stablishing good communication between the child and the dentist is the first step in helping the child develop a positive attitude towards the dental office experience. )ome rinses can be used for the child who wears an orthodontic and prosthodontic appliance.

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As the permanent teeth erupt, those teeth with a deep pit or fissure should be considered for occlusal sealants. 5ocal Anesthesia The use of local anesthesia is an important factor in the successful development of pediatric dental care. The tissue over the in0ection site is implied with a dry gau:e and a cotton tip applicator dipped in a topical anesthetic is applied to the in0ection site. %?F .en:ocaine is the most common topical anesthesia used. 7t has an onset of action of '? seconds. Oral sur/er& A common problem with infiltration anesthesia in the cleft population is the anestheti:ing a tooth in or near the cleft area. Isually the tissue surrounding the tooth is tightly bound down and prevents infiltration of anesthetic for these teeth in0ection of the anesthetic into the periodontal space is recommended. A special syringe for this in0ection prevents breakage of the anesthesia catridges, due to the higher in0ection pressure is re6uired. This techni6ue is useful for the extraction of supernumerary maxillary teeth. Pre0enti0e an" Restorati0e Dentistr& As a rule initial visit to the dentist is made when the patient is between % and ' years old. At this time deciduous dentition is developing and surgical closure of the clefts have been completed one of the first few =A

visits child should be examined receive light prophylaxis, allowed to familiari:e himself with dentist and his surroundings because of shape of surgically treated palate some difficulty may arise in taking radiographs. )owever it is essential that these diagnostic aids to be obtained approximately ; years of age of four years for detection of caries and determination of supernumerary congenitally missing or malformed teeth. The caries rate is patients with cleft lip and palate is theoretically same as for any other patient. )owever, the use of intraoral appliances for long periods increases caries susceptibility to monitor the oral health care more fre6uent recalls at '&; month intervals are necessary professional applications to topical fluorides must be given regularly pit and fissure sealants must used on all permanent teeth and in the primary dentition in selected cases. Reinforcement of oral hygiene instructions and dietary advice must be rigorously checked and emphasi:ed restorative care should be provided before carious lesions become extensive topical and local anesthesia should be used whenever indicated. Many of these children are mouth breathness because of deviation of nasal septum that is fre6uent by associated with facial oral clefts. 7nterference with their breathing during operative procedures may create a high degree of anxiety in these parents. The dentist can overcome this

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problem by reassuring the patient by limiting the use of cotton rolls or by the use of a rubber dam with large air holes. /arly parental education and optimal systemic fluoride use can help to decrease this type of cones. The filled composite restorative resins are used primarily when esthetics are concern. 7n the cleft population this material is useful in restoring nursing bottle incisors and hypoplastic anterior teeth children with cleft palate have a needed to wear maxillary appliances such as an nance arch or space maintainer. These appliances are used to maintain space and replace missing teeth in the anterior region. 7f child is extremely incorporate and has poor oral hygiene, placing a chrome steel crown on the abutment tooth aids in the fitting of the retentive band. Pul% thera%& The treatment of pulpally involved teeth is important to the cleft palate in order to maintain arch integrity and remove infection in the primary dentition treatment of pulpally involved teeth depends on the degree of inflammation present and the dental age of the tooth. Teeth that will soon exfoliate should be extracted rather than restored supernumerary teeth in the cleft area should be evaluated for function and esthetics with the addition of acrylic teeth. Removable

)awley8s type appliances are indicated for the replacement of anterior teeth if the child is cooperative.

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d$ Chil" Abuse an" Ne/lect Definition Classifie" & & & 2exual 1hysical /motional 5inding of inhibited, non accidental in0uries

Se3ual & & 7n house abuse *ut house abuse prevalent than out house& incist or molestation by slip fathers,

7n house

friends of parents. %?F of sexually abused or molested during childhood. 2TD and finding of unexplained in0uries around genitalia. !-F abused are male and less than !? year old. Emotional 1hysical abuse & )istory of alleged accident described by caretaker is not compatible with observed physical in0ury or pattern in0uries. /.g. intra cranial hge. 4ontributing factor delay in seeking medical care, history of poorly

explained in0uries and evidence of child neglect. 7ntracranial in0uries result of blows or kicks.

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7ntercranial in0uries

with no marks

vigorous shaking of child

whiplash in0uries and pure take hge within brain. Retinal hemorrhage 7n0uries funduscopic examination.

hge, bruises, black eyes, belt marks.

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