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CTICE

This article about special care dentistry in the middle years considers peoplewho have Downs syndrome and cerebral palsy and those who have cardiacand respiratory disease. The increased life expectancy of people with Downssyndrome, currently 50-60 years, is reflected in the chan in population profileand needs of these individuals. The preventive and dental treatment of mostpeople with Downs syndrome and cerebral palsy can be met in eneral dentalpractice. !owever, those people with profound disability, anxiety or learnindisability may re"uire either a shared approach to care or referral for specialistcare. #ardiac and respiratory disease occur commonly in the eneralpopulation both in middle and older a e roups and the dental team will meetincreasin numbers of people with these conditions. The procedures and dru sused in dentistry can a ravate heart disease and it is important that thedental team are aware of the common cardiac condi tions and theirmana ement, as well as how to best mana e the oral care of this roup. $lso,they have a role to play in the provision of oral health advice, smo%in

cessation and dietary advice. This is particularly important as poor oral hy ienehas been lin%ed to respiratory patho en colonisation and dental pla"ue mayact as a reservoir for aspiration pneumonia in susceptible individuals.

&'enior Dental (fficer in 'pecial#are Dentistry, Dorset !ealthcare)!' *oundation Trsut, DentalDepartment, #anford !ealth#entre, +oole, Dorset, !& D/12#hairperson of the 'pecialist

$dvisory 3roup in 'pecial #areDentistry4'enior ecturer and#onsultant in 'pecial #areDentistry, Department of 'edationand 'pecial #are Dentistry, in s#olle e ondon Dental 7nstitute,*loor 16, 3uys Tower, ondon,'8& 9T : ecturer and #onsultantfor ;edically #ompromised+atients, Division (ne4'pecial#are Dentistry, Dublin Dental'chool and !ospital, incoln+lace, Dublin 1, 7reland2#orrespondence to< Dr =anice*is%e8mail stt.nhs.u%

DOI: 10.1038/sj.bdj.2008.850? British Denta !"#rna2008$ 205: 35%&3'1

This second article onseamless care for people intheir middle yearsconsiders two conditionswhich have traditionally

been considered withchildhood and young adult

conditions, and twoconditions that havetraditionally beenassociated with older

people. The first two cerebral palsy and Downssyndrome are included inthis article to reflect theincreasing life expectancyof people with these conditions and the subsequentchange in their population

profile and needs. Thelatter two conditions cardiac and respiratorydisease now occurcommonly in middle age aswell as in older age and theden tal team will seeincreasing numbers of

people with theseconditions.

1. CEREBRA(PA()*

Cerebral palsy C!" is anumbrella termencompassing a group ofnon#progres siveneurological and physicaldisabilities caused bydamage or a lesion to achilds brain early in thecourse of development,either in utero , during

birth or in the fi rst fewmonths of infancy. $ Thedamage to the brain iscaused mainly by hypoxia,trauma and infection but

genetic and

biochemical factorshave also

been sug

gested. $

!re#natalris% factorsinclude

preeclampsia,irradiation,a maternalage of lessthan &' orover (),andinfectionssuch ascytomegalovirus,rubella andsyphilis.!eri#natalris% factorsincludetrauma,

breach birth or prolonged

delivery. $,&

Damagemay also

be caused post#natallyfollowinginfectionssuch asencephali

tis andmeningitisduring

infancy.*therris%factorsincludecerebralischaemia,haemorrhage andhypoxiasecondar y totrauma,respirator ydistress,hypother

mia orhypoglyc

aemia. $,&

Cerebr al palsyis themostcommoncongenital causeof

physicalimpairment, $

with anincidence ofapproximately&.) per$,'''live

births in

developed

countries. &

!rimarilyit is adisorderofvoluntary

moment,whichresults ina widespectrumof disabilityrangingfromvirtuallyunnoticea

ble

physicalimpairment. +t mayaffect onlyone limbmonoplegia", bothlowerlimbsparaplegia", oneupper and

one lowerlimb onthe samesidehemiplegia" or allfour limbsequallyquadriplegia". $

There arefour main

types ofC! Table$", the


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featur esofwh

icharegover ned

bytheareaof

bra

indamage.&,(

Dia+n"sis

Diagnosisisusuallymadefrom

clinicalsigns,suchaswea% ness

inoneormorelim

bs,

abnormal gaitwith onefoot orlegdragging,excessiv

edroolingordifficulties inswallowing and

poorcontroloverhand andarm

movement. *therimpairmentswhichmayaccompany C!includevisual,hearingandspeechimpairments,epilepsy,droolingandlearningdisability. -essthan)' ofindividuals withC! havealearningdisability andindeedmany

peoplearehighly

intelligent andwelleducated, thoughseverelyimpairedspeech


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duetodys

praxiaordys

ph

asiaandsensor yim

pairments

canmisleadsomeunwaryobservers

.$

/lthoughC!is anon#

progressivedisorder,othersecondar ycomplicationsmayoccur

and canincluderespiratorycomplications,secondarydigestive

system problems refluxandconstipation",

bladderinfections and%idneyinfections, s%in

problems on

pres


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,CP-

sur eareasand

per i#orallyfromdrooling,andmuscu

lo#s%eletal

pro blemssuchasarthritis,dislocationsanddef or mities.)

Tr eat

ent

0hilethe

reisnocur e,therapy

canhel

pchildr en,adultsa

ndtheirf amiliesman agethe

pr o

blemsthatcer

e br al

palsy

presents.12obaththerapyisver y

po pularand isatra

ns#disciplinaryap

proachusingspecialisedhandlingand

postur etec

hniquestoencour agemorecontr oll

ed patter nsofmoveme


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nt.Combinedwith

physi

othera

py,occupationaltherapyandspeechandlanguagetherapy it

canchangetheclinical

presentation

ofC!.)

3 plints,orth

o paedicsur ger

yandmedica tionssuchasmuscler elaxantsar eusedtor eliev

emusclestif fnessand

toreduce

painandcontortions.$

2etween&)#('

of peoplewith

C!haveepilepsyandta% erelate

ddrugtherapy.$

Dietaryadvice is

requir edwherenutritionor


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swallowingiscompro

mised.

-if

eex

pectancyinC!has


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increasedsignificantlyinthelastdec#ades,howeverres

pir atoryinf ectionsarecommo

nandaspiration

pneumoniais ama

4orcauseofdeath. $

0heelchairdesign

andassistivedevices

canhel

pto

pr ovideadegr

eeofinde

pend

ence

5igs$an

d&".

Or a

andd

enta

ea

t#res

!eoplewithC!willencounterthesameoralanddentaldiseaseastheres

t ofthe po pulation,howeverthereare

additionalfactor ssuchasaccess

todentalcar eand


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sup por t incar ryingoutdaily

livingactivities,whichcanresultinhig

herlevelsofuntreateddiseaseand

toothloss.3cope,thenationalvoluntaryand

political

bodyforC!,wor%sactivelyoncampaig

nsto1geteq

ualandma% e1r i

ghtsar eality./t

thetimeofwritingitwasr unninganonlinec

am paignsee%ingout1disab

lism,whichitdescri

besas1discr imi

natory,op

pressiveorabusive

be

haviourarisingfromthe

beliefthatdisabled

per sonsareinf eriortoothers.&

+twillonly


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beamatteroftime

bef ore

theiractiveandongoingresear ch

highlightstheinequalityinoral

healthandactsaccordingly.

Ther earemany

potentialcausesofinc

reasedris%ofdental

diseaseinC

!.Theyinclude6

Devel o

pment al

abnor malitie

s

themaxillar yar

chisfr eque

ntlytaperedorovoidan

dtheup

perincisorsmay

belabiall

yinclined,ma%ingoralhygienedif ficult.$

Theincidenceofmaloc

clusion ishighanddelayederu

ption, poororomuscularco#


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ordination,lac%ofade

quatelipsealandoralha

bits

oftonguethr ustcontri

butetothi

s.$,

(,

U ncont rol ledmovement

characteristicsymptomsofthemovementdisordermay

be

o bser vedintheor of acialandcer vicalmuscle

s,7

includings

p

asticityofthetem

por omandi

bular

4ointT89"musculature.(

5acialgrimacing,dys

phagiaandswallowingdif ficulties

arecommon(

and

4awdislocati

onduetospontaneoussubluxation

mayoccur.$,

Bru

xis


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mandtoothwear

thesearecommoninC!,especiallyinthoseindividualswithathetoidC!.(

-ossoftoothtissuemay

beexacer

bated

byerosionduetogastro#oesophagealrefl

ux,whichisalsocommon.$,

P eri

od ont ald isea

se

isr e

portedi

nahigh

pr o

port

ionof

peo

plewithC!which


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aff ectstheirup

perlim

bsandmanualdexterity.!re#dis

posingfactor sto

per i#odontaldiseaseinthisgroupincludemouth

breathing,gingivalhy

per plasiasecondar ytotheuseof

phenytoin

f orthetr eatmen

tofe

pile

psy:

a

ndincr easedf

oodr etentionwh

ichisexacer

bated

bydif ficultiesinora

lself#car eand

plaqueremo

val.(,

Theincreasinguseof1peg

percutaneousendosco

picgastrono

my"feedinghashel

pedim

prove

thenutritionalstatusof

pat


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ientswithswallowingdif

ficulties,

buttheneedforregularan

dmeticulousoralhygienehasnot

beenaddressedeventhoughDi

c%setal. ;

haveshownthatcalculus

for mationissignif ican

tlymor er a

p

idintu

be#f ed

patients.;

Thisisim

portantas

poor

or alhealthin

pat

ientswithdys

phagiahasfrequently

bee

nassociatedwiththedevelopme

ntofaspiration

pneumonia.

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