Caries experience in individuals with cerebral palsy in relation to oromotor dysfunction and dietary consistency

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<ul><li><p>O R O M O T O R D Y S F U N C T I O N A N D C A R I E S I N C E R E B R A L P A L S Y</p><p>A R T I C L E</p><p>A B S T R A C TThe aim of this study was to investigatecaries experience in individuals withcerebral palsy (CP) who have oromotordysfunction and relate it to age anddietary consistency. Noninstitutionalizedindividuals with CP (n 108) aged 419 years (mean: 10 years, 1 month SD4 years, 5 months) were recruited forthis study. Subjects who were severelyimpaired (35.2%) had orofacial motordysfunction most frequently, followed bythose who were slightly affected(27.7%), moderately affected (20.4%),and very slightly affected (16.7%). Agewas a statistically significant factor fororomotor dysfunction (p 0.007), withthe youngest individuals having themost severe oromotor problems. Dietaryconsistency and oromotor function werestatistically significant influence on theDMF index (p 0.0352). The highesttotal DMF values were measured forindividuals who were severely impairedand also the youngest, as well as forthose receiving liquid diets. Early reha-bilitation, intervention, and preventionare important for these individuals.</p><p>Caries experience in individuals withcerebral palsy in relation to oromotordysfunction and dietary consistency</p><p>Maria Teresa Botti Rodrigues Santos, DDS, PhD;1* Renata Oliveira Guare,DDS, PhD;1 Paula Celiberti, DDS, Dr. Med. Dent, PhD student;2 Walter LuizSiqueira, DDS, PhD3</p><p>1Post-Graduate Professor, Discipline of Dentistry, Persons with Disabilities Division, Universidade</p><p>Cruzeiro do Sul, So Paulo, Brazil; 2Department of Orthodontics and Pediatric Dentistry, School of</p><p>Dentistry, University of So Paulo (USP), So Paulo; 3Schulich Dentistry, Schulich School of Medicine</p><p>and Dentistry, The University of Western Ontario, London, Ontario, Canada.</p><p>*Corresponding author e-mail:</p><p>Spec Care Dentist 29(5): 198-203, 2009</p><p>Caries is a multifactorial disease;caries risk assessment should includefactors that may affect caries develop-ment.8 These factors involve past andcurrent caries experience, diet, fluorideexposure, presence of cariogenic bacteria,salivary status, general medical history,and sociodemographic influences and</p><p>should be included in the patientsassessment.8</p><p>Food consistency, sugared beverages,and long-term oral medications withxerostomic potential,4,9 individuals associated oromotor dysfunction as wellas their difficulties with maintainingdaily oral hygiene may explain the high</p><p>I n t r oduc t i onCerebral palsy (CP) describes a group of movement and posture development disor-ders attributed to nonprogressive disturbances in the developing fetal or infant brain,causing activity limitations. The motor disorders of CP are often accompanied by dis-turbances of sensation, cognition, communication, perception, behavior, and seizuredisorders.1 Oromotor dysfunction and oral-ingestive problems, such as uncoordi-nated control mechanisms of orofacial and palatolingual musculatures,2 are oftenobserved in individuals with CP; these disorders vary from mild to severe.3 Such dis-abilities are expressed by drooling, coughing, choking, rejection of solid food, andfood loss and spillage during eating. Difficulties in spoon-feeding, biting, chewing,drinking from a cup, drinking with a straw, swallowing, and clearing are alsoobserved.2</p><p>Individuals with CP who have severe oromotor impairments are frequently unableto ingest solid food that leads to an exclusively liquid or semisolid diet.4 Food consis-tency contributes to growth and nutritional disturbances to some degree, especially atan early age, and may also cause a significant impact on oral health.5 Therefore, timelynutritional rehabilitation and preventive measures in oral health may significantlyimprove the quality of life of these individuals, as well as preventing harmful and nox-ious habits, including bottle-feeding.6 Carrying out adequate daily oral hygiene onindividuals with CP can be difficult for caregivers, due to the patients persistent patho-logical biting reflex.7</p><p>KEY WORDS: cerebral palsy, caries,oral motricity, orofacial motor functionassessment scale (OFMFAS), diet consis-tency</p><p>2009 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2009.00092.x</p><p>198 Spec Care Dent is t 29(5 ) 2009</p><p>scd_092.qxd 8/29/09 7:11 AM Page 198</p></li><li><p>Santos et a l . Spec Care Dent is t 29(5 ) 2009 199</p><p>O R O M O T O R D Y S F U N C T I O N A N D C A R I E S I N C E R E B R A L P A L S Y</p><p>incidence of caries and periodontal disease found in persons with CP.10-14</p><p>However, oromotor impairment in indi-viduals with CP as a risk factor in cariesexperience has yet to be elucidated.</p><p>Thus, the aim of this study was toevaluate the inter-relationship betweencaries experience, oromotor dysfunction,age, and dietary consistency in individu-als with CP.</p><p>Mate r i a l and me thodsSelection and inclusion criteriaIndividuals seeking dental treatment atthe outpatient dentistry service of theRehabilitation Center Lar Escola SoFrancisco (LESF), So Paulo, Brazil,between February 2004 and March 2005were selected for this study. These indi-viduals were undergoingmultidisciplinary rehabilitative treat-ments in the LESF, had received amedical diagnosis of CP, were noninstitu-tionalized, and were between the ages of4 and 19 years. A signed informed con-sent was obtained from the individualsparents or guardians so that they couldparticipate in the study.</p><p>This study was approved by theEthics in Human Research Committee ofthe Federal University of So PauloSchool of Medicine, Brazil, under proto-col number 0425/03.</p><p>After approval, 108 individuals withCP (50 females and 58 males) aged 419 years (mean age 10 years 1 month SD4 years 5 months), living in So Paulo,Brazil (0.7 mg/L F in water supply),were enrolled in the study.</p><p>Assessment of orofacial motorfunctionThe assessment of an individuals orofa-cial motor function was performed byone examiner in accordance with theOrofacial Motor Function AssessmentScale (OFMFAS).15 For OFMFAS assess-ment, the subject was positioned in thebest sitting position possible, in a venti-lated room, with trunk and pelvisaligned, while avoiding hip hyperexten-sion. The shoulder girdle was kept</p><p>forward, with abduction of the scapulae,and the cervical spine was elongated.</p><p>The examiner assessed voluntaryfacial movements, such as opening andclosing the mouth, jaw protrusion, andlateral movement as well as elevating thetongue and moving it laterally into eachcheek; determining lip muscle strength(puff out the cheeks/maintain pressure);glossopharyngeal, vagal and hypoglossalmotor activity; and rapid coordinatedjaw, lip, tongue, and palatal movementby saying AH. Oral reflexes that are</p><p>abnormal in children, such as sucking,tonic biting, gagging, and rooting werealso evaluated (Figure 1). During theassessment of all voluntary tasks, theexaminer showed the subjects how eachmovement should be done. A subjectsfinal OFMFAS score was obtained bytotaling all the sub-item values. Subjectswere then classified as severely impaired(score 19), moderately impaired (scorebetween 20 and 31), slightly impaired(score between 32 and 41), or veryslightly impaired (score 42).</p><p>1. Jaw mobility Subtotal:</p><p>a) voluntary jaw opening </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>b) jaw opening </p><p> midline = 2 right / left deviation = 1 inconsistent = 0 </p><p>c) opening against resistance </p><p> normal / adequate = 2 weak = 1 unable to determine = 0 </p><p>d) closing against resistance </p><p> normal / adequate = 2 weak = 1 unable to determine = 0 </p><p>2. Voluntary jaw protrusion Subtotal:</p><p> a) yes = 2 no = 0 unable to determine = 0 </p><p> b) midline = 2 right / left deviation = 1 inconsistent = 0 </p><p>3. Voluntary lateral jaw movements Subtotal:</p><p>a) right </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>b) left </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>c) presence of involuntary jaw movements during jaw lateral movements </p><p> yes = 0 no = 2 </p><p>4. Rapid coordinated jaw movements Subtotal:</p><p>a) tooth tap </p><p> present = 2 slow/slows with time/irregular/erratic = 1 unable P/D = 0 </p><p>b) lateral jaw excursion </p><p> present = 2 slow/slows with time/irregular/erratic = 1 unable P/D = 0 </p><p>5. Voluntary facial movements Subtotal:</p><p>a) show teeth </p><p> symmetrical = 2 right / left weakness = 1 unable P/D = 0 </p><p>b) pucker lips</p><p> symmetrical = 2 right / left weakness = 1 unable P/D = 0 </p><p>Figure 1. Orofacial Motor Function Assessment Scale (OFMFAS).</p><p>scd_092.qxd 8/29/09 7:11 AM Page 199</p></li><li><p>200 Spec Care Dent is t 29(5 ) 2009 Oromotor dys funct ion and car ies in cerebra l pa lsy</p><p>O R O M O T O R D Y S F U N C T I O N A N D C A R I E S I N C E R E B R A L P A L S Y</p><p>Assessment of oral health and caries experienceAfter receiving a new toothbrush anddentifrice, caregivers were instructed onhow to correctly brush teeth. Then, eachsubject had his or her teeth brushed bythe respective caregiver while undersupervision. Next, the air-dried teethwere examined under artificial light, withthe use of a plane intraoral mirror and around-ended dental probe.</p><p>Oral health status assessment wasperformed by one trained and calibratedexaminer, in accordance with standardprocedures.16 Caries experience wasassessed using the DMF/dmf index forpermanent and primary dentition,respectively. For children with mixeddentition, both dmf and DMF wererecorded. Decayed (D), missing (M), andfilled (F) teeth were also assessed andscored individually. Decayed teeth wereassessed only when a cavity was present.Teeth exhibiting white spot lesions wereconsidered sound.</p><p>In order to evaluate intraexaminerreproducibility, 10 random subjects wereexamined at a 7-day interval; the exam-iner had no access to or knowledge ofthe subjects previous oral health status.No radiographic examinations weremade. The Kappa statistic was measuredat 0.89.</p><p>Assessment of dietary consistencySubjects enrolled in this study periodi-cally consulted an audiologist (LarEscola So Francisco). These profession-als prescribed the dietary consistency foreach subject after assessing the subjectsfeeding difficulties, in order to avoidchoking and food aspiration. Dietaryconsistency was divided into threegroups.</p><p> Solid food: This food consistency isnormally offered to individuals withno oromotor dysfunction and con-sists of food pieces that need to bechewed.</p><p> Semisolid food: Food with a paste-likeconsistency, but with pieces ofcrushed, kneaded or triturated foods.Figure 1. Continued.</p><p>6. Lip muscle strength: puff out cheeks/maintain pressure Subtotal:</p><p> present and strong = 2 present and weak = 1 unable P/D = 0 </p><p>7. Rapid coordinated lip movements Subtotal:</p><p>a) protrusion/retraction of lips </p><p> present = 2 slow/slows with time/irregular/erratic = 1 unable P/D = 0 </p><p>b) pa-pa-pa-pa-pa-pa </p><p> present = 2 slow/slows with time/irregular/erratic = 1 unable P/D = 0 </p><p>8. Glossopharyngeal and vagal motor activity Subtotal:</p><p> ah! </p><p> symmetrical = 2 right / left weakness = 1 unable P/D = 0 </p><p>9. Rapid coordinated palatal movements Subtotal:</p><p> mm-bah, mm-bah </p><p> adequate = 2 poor = 1 unable P/D = 0 </p><p>10. Hypoglossal motor: voluntary tongue movements Subtotal:</p><p>tongue protrusion </p><p>a) yes = 2 no = 0 unable to determine = 0 </p><p>b) midline = 2 right/left deviation = 1 inconsistent = 0 </p><p>11. Voluntary elevation and lateralization of tongue Subtotal:</p><p>a) back incisors = ttt </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>b) back soft palate = ing </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>c) right corner of the mouth </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>d) left corner of the mouth </p><p> yes = 2 no = 0 unable to determine = 0 </p><p>12. Rapid coordinated movements of tongue Subtotal:</p><p>a) t-t-t-t-t </p><p> present = 2 rhythm slows with time/erratic = 1 unable P/D = 0 </p><p>b) k-k-k-k-k </p><p> present = 2 rhythm slows with time/erratic = 1 unable P/D = 0 </p><p>13. Oral abnormal reflexes Subtotal:</p><p>a) sucking </p><p> present = 0 absent = 2 </p><p>a) tonic biting </p><p> present = 0 absent = 2 </p><p>a) gagging </p><p> present = 0 absent = 2 </p><p>a) rooting </p><p> present = 0 absent = 2 </p><p>TOTAL:* P/D = perform or determine</p><p>scd_092.qxd 8/29/09 7:11 AM Page 200</p></li><li><p>Cereals, vegetables, cookies, or breadcrushed into milk and triturated, orfinely pulled meat are examples ofsemisolid food.</p><p> Liquid food: Food must be homoge-neous, smooth, and without chunks.This consistency is obtained throughmixing, beating, or blending foodwith the use of a blender. Fruits,soups, cooked vegetables, and meatcan be prepared like this, but after-ward, they must be strained.Custards and yogurts are also indi-cated.</p><p>To assess the consistency of the sub-jects diet, the caregivers were askedwhich of the three consistencies was pre-scribed by the audiologist and whetherthis was in accordance with the realdietary habits of these individuals.</p><p>Statistical analysisOne-factor analysis of variance was usedto analyze the equality hypothesis amongthe four OFMFAS classifications, withmultiple comparisons, using theBonferroni test. The KruskallWallis testwas used when the supposition of datanormality was rejected, with multiplecomparisons analyzed using the Dunntest. To verify the homogeneity of maleand female subjects in relation to propor-tions, the Chi-square and Fisher exacttests were used.17 The significance levelwas set at p 0.05.</p><p>Resu l t sIn this study there were 108 subjectsenrolled; 83 (76.9%) were diagnosed asspastic CP, 17 (15.7%) as dystonic CPwith athetosis, and 8 (7.4%) were a com-bination of these disorders. There were34 (31.5%) subjects who had quadriple-gic CP, while diplegia was found in 37(34.3%), and hemiplegia in 12 (11.1%).</p><p>The distribution of subjects accord-ing to the OFMFAS by age and gender isshown in Table 1. There were no differ-ences by sample size with regard togender (p 0.701).</p><p>One-factor analysis of varianceshowed a statistically significant differ-ence (p 0.007) among the four</p><p>classifications of OFMFAS (scores 19;2031; 3241; and 42) with age. TheBonferroni test showed that individualswho were the most severely compro-mised were statistically significantlyyounger than subjects who were moder-ately compromised (p 0.05).</p><p>Table 2 summarizes the data regard-ing total DMF mean values (SD); D,M, and F teeth are separately comparedto the four classifications of OFMFAS inindividuals with CP. No statistically sig-nificant differences were found in totalDMF index or separate D, M, and Fvalues (p 0.311, 0.097, 0.292, and0.090, respectively) with regard to thefour classifications of...</p></li></ul>