**Author details**

Rahena Akhter<sup>1</sup> \*, Nur Mohmmad Monsur Hassan<sup>2</sup> , Mangala Nadkarni<sup>1</sup> , Elizabeth F. Martin<sup>1</sup> and Gulam Khandaker<sup>3</sup>

\*Address all correspondence to: rahena.akhter@sydney.edu.au

1 Faculty of Dentistry, The University of Sydney, NSW, Australia

2 School of Dentistry and Health Sciences, Charles Sturt University, NSW, Australia

3 The Children's Hospital at Westmead Clinical School, University of Sydney, NSW, Australia

#### **References**

care, as it must be accessible to all families. Ignorance to this measure would thus extend the gap of hosting an equal opportunity for quality oral and general health for children and

In summary, efforts should be made to develop oral health initiatives for children with CP. The rudimentary neurological and muscular impairments default this population to be highly susceptible candidates for oral health diseases like dental caries. Children with more severe functional motor impairment might have a higher risk of experiencing dental caries, which could be attributed to difficulties in performing adequate oral hygiene. Therefore, the role of oral hygiene must be emphasized in the household of these families in order to treat the prevalent risk factors. To reduce dental caries susceptibility, improvements such as minimal snacking and carbohydrate intake must be made to mend OHRQoL and frequent dental pain. Prioritization should be given by oral health rehabilitation programs to abide the relationship between the physician, caregiver, and the child with the disability to recuperate family dynamics and subsequently improve their overall quality of health. By pinpointing these improvements, a prospective outlook can be set on the impact training and reorganization of preventative and restorative dental care can provide for this challenged population.

We would like to acknowledge Penelope Subervi, Biomedical Engineering from the University of Rochester for drafting the manuscript as a part of her internship program at the School of

, Mangala Nadkarni<sup>1</sup>

, Elizabeth F. Martin<sup>1</sup>

families with CP.

90 Cerebral Palsy - Clinical and Therapeutic Aspects

**7. Conclusion**

**Acknowledgements**

**Conflict of interest**

**Author details**

Rahena Akhter<sup>1</sup>

Australia

and Gulam Khandaker<sup>3</sup>

Dentistry, The University of Sydney.

None of the authors reported any conflict of interest.

\*, Nur Mohmmad Monsur Hassan<sup>2</sup>

\*Address all correspondence to: rahena.akhter@sydney.edu.au

1 Faculty of Dentistry, The University of Sydney, NSW, Australia

2 School of Dentistry and Health Sciences, Charles Sturt University, NSW, Australia 3 The Children's Hospital at Westmead Clinical School, University of Sydney, NSW,


[15] Rodrigues dos Santos MT, Masiero D, Novo NF, Simionato MR. Oral conditions in children with cerebral palsy. Journal of Dentistry for Children (Chicago, Ill.). 2003;**70**(1):40-46 **Section 4**

**Therapeutic Aspects of Cerebral Palsy**


**Therapeutic Aspects of Cerebral Palsy**

[15] Rodrigues dos Santos MT, Masiero D, Novo NF, Simionato MR. Oral conditions in children with cerebral palsy. Journal of Dentistry for Children (Chicago, Ill.). 2003;**70**(1):40-46

[16] Ohmori I, Awaya S, Ishikawa F. Dental care for severely handicapped children. Inter-

[17] Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy.

[18] Dourado MR, Andrade PM, Ramos-Jorge ML, Moreira RN, Oliveira-Ferreira F. Association between executive/attentional functions and caries in children with cerebral

[19] Lamkin MS, Oppenheim FG. Structural features of salivary function. Critical Reviews in

[20] Oredugba FA. Comparative oral health of children and adolescents with cerebral palsy

[21] Sheetal A, Hiremath VK, Patil AG, Sajjansetty S, Kumar SR. Malnutrition and its oral outcome—A review. Journal of Clinical and Diagnostic Research. 2013;**7**(1):178-180 [22] Siqueira WL, Santos MT, Elangovan S, Simoes A, Nicolau J. The influence of valproic acid on salivry pH in children with cerebral palsy. Special Care in Dentistry. 2007;**27**(2):64-66

[23] Arvidson Bufano UB, Holm AK. Dental health in urban and rural areas of central and

[24] Dougherty NJ. A review of cerebral palsy for the oral health professional. Dental Clinics

[25] Center for Scientific Information, ADA Science Institute. Caries Risk Assessment and Management. ADA; 2017. https://www.ada.org/en/member-center/oral-health-topics/

[26] Fakir MM, Ul Alam KM, Al-Mamun F, Sarker N. A survey on oral health condition in

[27] Nowak J.Dental disease in handicapped persons. Special Care in Dentistry. 1984;**4**(2):66-69 [28] Abanto J, Shitsuka C, Murakami C, Ciamponi AL, Raggio DP, Bonecker M. Associated factors to erosive tooth wear and its impact on quality of life in children with cerebral

[29] Goursand D, Paiva SM, Zarzar PM, Pordeus IA, Allison PJ. Family impact scale (FIS): Psychometric properties of the Brazilian Portuguese language version. European Journal

[30] Versloot J, Hall-Scullin E, Veerkamp JS, Freeman R. Dental discomfort questionnaire: its use with children with a learning disability. Special Care in Dentistry. 2008;**28**(4):140-144

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western Bangladesh. Odonto-Stomatologie Tropicale. 1990;**13**(3):81-86

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**Chapter 6**

**Provisional chapter**

**Use of Botulinum Toxin A in Cerebral Palsy**

**Use of Botulinum Toxin A in Cerebral Palsy**

effect particularly with multilevel therapy are still not clear.

**Keywords:** cerebral palsy, botulinum toxin, spasticity, muscle function, children

DOI: 10.5772/intechopen.79551

Botulinum toxin A (BTX-A) is widely used worldwide to overcome the significant problem in spastic cerebral palsy (CP). In the past three decades, botulinum toxin serotype A (BTX-A) has been introduced as a selective treatment option for spasticity in children with cerebral palsy. BTX-A is an acetylcholine-blocking agent that causes presynaptic neuromuscular blocking when injected into the muscle. Its action of decreasing or normalization of tone prevent the development of contractures and deformities and avoid or postponed surgical intervention particularly when combined with other treatment modalities such as physiotherapy, casting, orthosis, etc. Equinus deformity, scissoring and crouch gait in the lower limbs, and different spastic deformities like pronation of forearm, elbow flexion, wrist flexion, fisting, or abnormal dystonic posture of upper limb deformities were the main indications wherein botulinum toxin injection is needed in spastic cerebral palsy; moreover, its benefit of relieving pain that are associated with muscular hypertonia and palpation of the muscle, particularly the large one, remains the cornerstone for injection of BTX in CP patient for most experts worldwide, but it needs a well of knowledge in anatomy and its landmark. Invasive procedure like electromyography (EMG) is more difficult to be applied successfully in children than in adults. Spasticity is considered a positive phase of muscle function. Therefore, when relaxing the muscle, the patient's condition might get worse functionally in some instance. So, the first question clinician put in his account before injecting BTX is whether hypertonia is impeding or improving function; therefore, injection is tailored individually by an expert physician. Generally, the adverse side effects of BTX-A are seldom to occur providing that the physician strictly adheres to the dose ranges and reinjection period. The interinjection period must be at least 12 weeks to avoid antibodies ands. So far, BTX-A is considered to be safe to some extent if used professionally; however, long-term adverse

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79551

Adel A. Kareem

Adel A. Kareem

**Abstract**

#### **Use of Botulinum Toxin A in Cerebral Palsy Use of Botulinum Toxin A in Cerebral Palsy**

DOI: 10.5772/intechopen.79551

#### Adel A. Kareem Adel A. Kareem

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.79551

#### **Abstract**

Botulinum toxin A (BTX-A) is widely used worldwide to overcome the significant problem in spastic cerebral palsy (CP). In the past three decades, botulinum toxin serotype A (BTX-A) has been introduced as a selective treatment option for spasticity in children with cerebral palsy. BTX-A is an acetylcholine-blocking agent that causes presynaptic neuromuscular blocking when injected into the muscle. Its action of decreasing or normalization of tone prevent the development of contractures and deformities and avoid or postponed surgical intervention particularly when combined with other treatment modalities such as physiotherapy, casting, orthosis, etc. Equinus deformity, scissoring and crouch gait in the lower limbs, and different spastic deformities like pronation of forearm, elbow flexion, wrist flexion, fisting, or abnormal dystonic posture of upper limb deformities were the main indications wherein botulinum toxin injection is needed in spastic cerebral palsy; moreover, its benefit of relieving pain that are associated with muscular hypertonia and palpation of the muscle, particularly the large one, remains the cornerstone for injection of BTX in CP patient for most experts worldwide, but it needs a well of knowledge in anatomy and its landmark. Invasive procedure like electromyography (EMG) is more difficult to be applied successfully in children than in adults. Spasticity is considered a positive phase of muscle function. Therefore, when relaxing the muscle, the patient's condition might get worse functionally in some instance. So, the first question clinician put in his account before injecting BTX is whether hypertonia is impeding or improving function; therefore, injection is tailored individually by an expert physician. Generally, the adverse side effects of BTX-A are seldom to occur providing that the physician strictly adheres to the dose ranges and reinjection period. The interinjection period must be at least 12 weeks to avoid antibodies ands. So far, BTX-A is considered to be safe to some extent if used professionally; however, long-term adverse effect particularly with multilevel therapy are still not clear.

**Keywords:** cerebral palsy, botulinum toxin, spasticity, muscle function, children

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
