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

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

A R T I C L E

A B S T R A C TThe aim of this study was to investigate

caries experience in individuals with

cerebral palsy (CP) who have oromotor

dysfunction and relate it to age and

dietary consistency. Noninstitutionalized

individuals with CP (n � 108) aged 4–

19 years (mean: 10 years, 1 month � SD

4 years, 5 months) were recruited for

this study. Subjects who were severely

impaired (35.2%) had orofacial motor

dysfunction most frequently, followed by

those who were slightly affected

(27.7%), moderately affected (20.4%),

and very slightly affected (16.7%). Age

was a statistically significant factor for

oromotor dysfunction (p � 0.007), with

the youngest individuals having the

most severe oromotor problems. Dietary

consistency and oromotor function were

statistically significant influence on the

DMF index (p � 0.0352). The highest

total DMF values were measured for

individuals who were severely impaired

and also the youngest, as well as for

those receiving liquid diets. Early reha-

bilitation, intervention, and prevention

are important for these individuals.

Caries experience in individuals withcerebral palsy in relation to oromotordysfunction and dietary consistency

Maria Teresa Botti Rodrigues Santos, DDS, PhD;1* Renata Oliveira Guare,

DDS, PhD;1 Paula Celiberti, DDS, Dr. Med. Dent, PhD student;2 Walter Luiz

Siqueira, DDS, PhD3

1Post-Graduate Professor, Discipline of Dentistry, Persons with Disabilities Division, Universidade

Cruzeiro do Sul, São Paulo, Brazil; 2Department of Orthodontics and Pediatric Dentistry, School of

Dentistry, University of São Paulo (USP), São Paulo; 3Schulich Dentistry, Schulich School of Medicine

and Dentistry, The University of Western Ontario, London, Ontario, Canada.

*Corresponding author e-mail: [email protected]

Spec Care Dentist 29(5): 198-203, 2009

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

should be included in the patient’sassessment.8

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

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

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

KEY WORDS: cerebral palsy, caries,

oral motricity, orofacial motor function

assessment scale (OFMFAS), diet consis-

tency

©2009 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2009.00092.x

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incidence of caries and periodontal disease found in persons with CP.10-14

However, oromotor impairment in indi-viduals with CP as a risk factor in cariesexperience has yet to be elucidated.

Thus, the aim of this study was toevaluate the inter-relationship betweencaries experience, oromotor dysfunction,age, and dietary consistency in individu-als with CP.

Mate r i a l and me thodsSelection and inclusion criteriaIndividuals seeking dental treatment atthe outpatient dentistry service of theRehabilitation Center Lar Escola SãoFrancisco (LESF), São 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 individuals’parents or guardians so that they couldparticipate in the study.

This study was approved by theEthics in Human Research Committee ofthe Federal University of São PauloSchool of Medicine, Brazil, under proto-col number 0425/03.

After approval, 108 individuals withCP (50 females and 58 males) aged 4–19 years (mean age 10 years 1 month � SD4 years 5 months), living in São Paulo,Brazil (0.7 mg/L F� in water supply),were enrolled in the study.

Assessment of orofacial motorfunctionThe assessment of an individual’s 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

forward, with abduction of the scapulae,and the cervical spine was elongated.

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

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 subject’sfinal 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).

1. Jaw mobility Subtotal:

a) voluntary jaw opening

yes = 2 no = 0 unable to determine = 0

b) jaw opening

midline = 2 right / left deviation = 1 inconsistent = 0

c) opening against resistance

normal / adequate = 2 weak = 1 unable to determine = 0

d) closing against resistance

normal / adequate = 2 weak = 1 unable to determine = 0

2. Voluntary jaw protrusion Subtotal:

a) yes = 2 no = 0 unable to determine = 0

b) midline = 2 right / left deviation = 1 inconsistent = 0

3. Voluntary lateral jaw movements Subtotal:

a) right


b) left


c) presence of involuntary jaw movements during jaw lateral movements

yes = 0 no = 2

4. Rapid coordinated jaw movements Subtotal:

a) tooth tap

present = 2 slow/slows with time/irregular/erratic = 1 unable P/D = 0

b) lateral jaw excursion


5. Voluntary facial movements Subtotal:

a) show teeth

symmetrical = 2 right / left weakness = 1 unable P/D = 0

b) pucker lips


Figure 1. Orofacial Motor Function Assessment Scale (OFMFAS).

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200 Spec Care Dent is t 29(5 ) 2009 Oromotor dys funct ion and car ies in cerebra l pa lsy


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.

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.

In order to evaluate intraexaminerreproducibility, 10 random subjects wereexamined at a 7-day interval; the exam-iner had no access to or knowledge ofthe subject’s previous oral health status.No radiographic examinations weremade. The Kappa statistic was measuredat 0.89.

Assessment of dietary consistencySubjects enrolled in this study periodi-cally consulted an audiologist (LarEscola São Francisco). These profession-als prescribed the dietary consistency foreach subject after assessing the subject’sfeeding difficulties, in order to avoidchoking and food aspiration. Dietaryconsistency was divided into threegroups.

• Solid food: This food consistency isnormally offered to individuals withno oromotor dysfunction and con-sists of food pieces that need to bechewed.

• Semisolid food: Food with a paste-likeconsistency, but with pieces ofcrushed, kneaded or triturated foods.Figure 1. Continued.

6. Lip muscle strength: puff out cheeks/maintain pressure Subtotal:

present and strong = 2 present and weak = 1 unable P/D = 0

7. Rapid coordinated lip movements Subtotal:

a) protrusion/retraction of lips


b) pa-pa-pa-pa-pa-pa


8. Glossopharyngeal and vagal motor activity Subtotal:

ah!


9. Rapid coordinated palatal movements Subtotal:

mm-bah, mm-bah

adequate = 2 poor = 1 unable P/D = 0

10. Hypoglossal motor: voluntary tongue movements Subtotal:

tongue protrusion

a) yes = 2 no = 0 unable to determine = 0

b) midline = 2 right/left deviation = 1 inconsistent = 0

11. Voluntary elevation and lateralization of tongue Subtotal:

a) back incisors = ttt


b) back soft palate = ing


c) right corner of the mouth


d) left corner of the mouth


12. Rapid coordinated movements of tongue Subtotal:

a) t-t-t-t-t

present = 2 rhythm slows with time/erratic = 1 unable P/D = 0

b) k-k-k-k-k

present = 2 rhythm slows with time/erratic = 1 unable P/D = 0

13. Oral abnormal reflexes Subtotal:

a) sucking

present = 0 absent = 2

a) tonic biting


a) gagging


a) rooting


TOTAL:* P/D = perform or determine

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Cereals, vegetables, cookies, or breadcrushed into milk and triturated, orfinely pulled meat are examples ofsemisolid food.

• 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.

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.

Statistical analysisOne-factor analysis of variance was usedto analyze the equality hypothesis amongthe four OFMFAS classifications, withmultiple comparisons, using theBonferroni test. The Kruskall–Wallis 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.

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%).

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).

One-factor analysis of varianceshowed a statistically significant differ-ence (p � 0.007) among the four

classifications of OFMFAS (scores �19;20–31; 32–41; 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).

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 OFMFAS. Anincrease in total DMF was found forsubjects who were severely and moder-ately impaired when compared tosubjects who were slightly and very

slightly impaired; however, these differ-ences were not statistically significant (p � 0.063).

Subjects were grouped according totheir age as well as their dentition, whichwere defined as primary, mixed, or per-manent. Of the 108 subjects, 31 (28.7%)had a primary dentition only and wereaged 4–7 years (mean 5.1 � 1.1 years),45 (41.7%) had a mixed dentition andwere aged 8–12 years (mean 9.5 �1.5 years), while 32 (29.6%) had perma-nent dentition and were aged 12–19 years (mean 15.7 � 2.9 years).

No statistically significant differenceswere observed between the three-denti-tion types for total DMF values amongthe four OFMFAS classifications (p �0.05; Table 3). When subjects who wereseverely impaired were analyzed, thosewith a mixed dentition had an increase

Table 1. Distribution of subjects according to OFMFAS by ageand gender.

OFMFAS scores Age Female Male Total

(mean ± SD) n % n % n %

Severe 8.2 ± 3.8* 19 38 19 32.7 38 35.2

Moderate 12.3 ± 5.3 11 22 11 19.0 22 20.4

Slight 10.5 ± 4.4 13 26 17 29.3 30 27.8

Very slight 10.7 ± 4.9 7 14 11 19.0 18 16.6

Total 10.1 ± 4.8 50 46.3 58 53.7 108 100

The data was compared by the Bonferroni test, *p < 0.05.

The data was compared by the Kruskal–Wallis test, *p < 0.05.

Table 2. DMF, D, M, and F values (mean ± SD) for the four clas-sifications of OFMFAS.

DMF ± SD D ± SD M ± SD F ± SD

OFMFAS scores

Severe 6.03 ± 4.41 3.71 ± 3.71 1.08 ± 2.25 1.26 ± 1.83

Moderate 6.32 ± 4.55 1.41 ± 1.84 1.73 ± 2.53 3.18 ± 3.86

Slight 4.53 ± 3.25 2.63 ± 2.87 0.83 ± 1.23 1.07 ± 1.81

Very slight 4.56 ± 4.33 2.17 ± 3.15 0.44 ± 0.92 1.94 ± 2.21

Total 5.43 ± 4.17 2.69 ± 3.16 1.04 ± 1.93 1.71 ± 2.53

Dietary consistency

Solid 5.02 ± 4.02 2.27 ± 2.76 0.83 ± 1.30 1.92 ± 2.86

Semisolid 4.81 ± 4.08 1.81 ± 2.88 1.15 ± 2.21 1.89 ± 2.26

Liquid 7.60 ± 4.26 5.10 ± 3.63 1.55 ± 2.91 0.95 ± 1.54

Total 5.43 ± 4.17 2.69 ± 3.16 1.04 ± 1.93 1.71 ± 2.53



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202 Spec Care Dent is t 29(5 ) 2009 Oromotor dys funct ion and car ies in cerebra l pa lsy


of 28.5% for total DMF when comparedto those with a primary dentition.Overall, subjects with a permanent denti-tion were found to have an increase ofaround 17% for total DMF when com-pared to those with a mixed dentition.

The distribution of subjects accord-ing to OFMFAS by dietary consistency isshown in Figure 2. Fisher’s exact test(two-tail) showed a statistically signifi-cant difference regarding dietaryconsistency among the four classifica-tions of OFMFAS (p � 0.001). Subjectswho were severely compromised weremore likely to be given a higher liquiddiet, while subjects who were moder-ately, slightly, and very slightly impairedtogether were more likely to be pre-scribed a solid diet.

Using the Kruskal–Wallis test, a sta-tistically significant difference was foundfor total DMF values (p � 0.0352) and D teeth when assessed separately (p �0.002), with regard to dietary consis-tency (Table 2). The Dunn test verifiedthat subjects on a liquid diet had a statis-tically significantly higher DMF and D

values (p � 0.05) compared to those onsemisolid and solid diets. The M and Fvalues when assessed separately werefound to have no statistically significantdifferences with regard to dietary consis-tency (p � 0.999, p � 0.245,respectively).

Evaluating the dental treatment car-ried out, preventive measures, such asdental prophylaxis, sealants, and fluorideapplication were completed on 53 sub-jects (49%). Restorative procedures wererequired by 29 (26.6%) while 26 (24.4%)required oral surgery.

Di scus s i onUnderstanding the impact of oromotordysfunction on oral health status may behelpful in identifying individuals at highrisk of developing dental caries so thatmore extensive preventive strategies anddental treatment can be planned for theseindividuals.

The results of this study suggest thatindividuals with severe orofacial motorimpairments were significantly youngerthan those who were moderatelyimpaired. This finding agrees with theproposed definition and classification ofCP,1 which states that the clinical pictureof CP evolves with time, development,learning, training, and therapy.

When subjects with no neurologicaldisorders were assessed using theOFMFAS, scores between 57 and 60 wererecorded (mean � SD; 59.4 � 0.73),which showed that all oromotor skillscould be carried out without difficulty atthis age.15

A detailed diary of food intake fornoninstitutionalized subjects was notrecorded, due to caregivers’ low commit-ment to this request. In general, thesubjects were presented with three mainmeals and two snacks per day.

Most of the subjects who wereseverely impaired (65%) and had primarydentition were fed a liquid diet and67.4% of the subjects aged 4–7 were fedeither liquid or semisolid foods. A liquiddiet may be harmful especially whenconsumed at an early age when growth isoccurring. If nutritional disturbancesexist, there needs to be rehabilitation ofthe dentition and this should be pro-vided for these children.4,9,18 Foodcariogenicity is associated with the pres-ence of fermentable carbohydrates andsugars. Liquid food has a higher cario-genic potential, due to the addition ofsugar-based nutritional supplements.Frequency of exposure differs with eachdiet; for instance, a liquid diet is digestedquicker and so is provided more fre-quently.9

A liquid diet is comprised of foodsranging from watery to creamy consis-tency and can be offered with differentfeeding techniques, such as a spoon, acup, a syringe, or a modified baby bottle.(This modification is made by cutting offthe tip of the nipple, thus forming a largehole.) The modified baby bottle nippleand syringe were used to pour the liquidfood into the child’s mouth. Once thefood is in the mouth, we hypothesizethat oral-motor problems, rather than thefeeding technique itself, may exert aninfluence on oral clearance time and,consequently, on caries experience.

A high caries rate in individualswith CP has been previously reported in the literature.10-14 In our study, theyoungest individuals, due to their oromotor dysfunctions, were fed aliquid diet and had a significantlyhigher total DMF score than those fedsemisolid and solid diets.

Some of the problems that have beendescribed in the literature4,7,9,18-22 arefood consistency, the amount of carbohy-drate exposure per day,4,9,18 thedifficulties that occur during mastication,inadequate oral hygiene due to the biting

The data was compared by the Kruskal–Wallis test, *p < 0.05.

Table 3. Total DMF values (mean ± SD) according to OFMFAS inprimary, mixed, and permanent dentition.

OFMFAS DMF ± SD

Scores Primary Mixed Permanent

Severe 4.76 ± 4.25 6.66 ± 4.22 8.00 ± 5.33

Moderate 6.50 ± 5.20 6.50 ± 3.01 6.16 ± 5.28

Slight 6.00 ± 2.12 4.47 ± 3.62 3.75 ± 2.96

Very slight 2.60 ± 3.05 6.14 ± 5.53 4.33 ± 3.26

Total 4.84 ± 3.95 5.73 ± 4.10 5.56 ± 4.54

0

5

10

15

20

25

30

² 19 20-31 32-41 ³ 42

OFMFAS

Liquid

Semisolid

Solid

Figure 2. Distribution of subjects (n) accord-ing to the OFMFAS classification and dietaryconsistency.

scd_092.qxd 8/29/09 7:11 AM Page 202

reflex,7 reduced salivary flow,19 long-termuse of liquid medication,20 high dentaltreatment needs,21 and problems relatedto dental management.22 However, theinfluence of oromotor impairment onindividuals with CP as a factor in cariesrisk had not yet been elucidated.

In this study, the decay componentwe found was similar to other stud-ies11,21,23-25 which have reported that thecaries component was high in this popu-lation. In the permanent dentition, wefound a DMF of 5.56, which is in agree-ment with other reported studies.7,13,21,23

However, subjects in the oldest agegroup (over 16 years of age) had thehighest total DMF (8.92) and the highestfilled component (6.07). RodríguezVázquez et al.13 also observed that totalDMF increased with age, although intheir study the filled component waslower.

Only five children (16.1%) with a pri-mary dentition in our study were cariesfree, versus 35% and 41.2% found in pre-vious studies.14,23 These studies14,23 didnot report the severity of the oromotordysfunction or the dietary consistency intheir population. Because caries experi-ence and the number of carious teethwere significantly higher in individualsfed a liquid diet, it is likely that the otherstudies had lower numbers of individualson liquid diets. Also, previous studies didnot report the severity of the oromotordysfunction with the use of liquid diets.The difference could also be due to thefact that our study was carried out in amultidisciplinary rehabilitation center,where dental treatment was provided atthe caregivers’ request and expense.Therefore, preventive or restorative measures may not achieve the proposedoral health objectives.

Caries in deciduous teeth mayexpose an individual to a higher cariesrisk for their permanent teeth,26 there-fore, early preventive care isfundamental in this population. A pre-ventive program should include properinstruction, training, and motivation ofthe caregivers with regard to an adequatelevel of daily oral hygiene, plaque con-trol, dental floss use, and fluoride

therapy, as well as choosing an appropri-ate dietary consistency.

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