**2. Oral hygiene**

the most common physical disability of childhood. Although some children might outgrow their CP symptoms due to the maturation of neurons, lesions within the central nervous system often compromise motor development severely through time. The classification of CP often differs according to the gestational age at birth, age, and the distribution of lesions. However, classifications are normally registered using two categories, extremity location and neurologic dysfunction. If extremities are involved, diagnosis is subjective to monoplegia, hemiplegia, diplegia, or quadriplegia. If neurologic dysfunctions are involved, it is subjective to spastic, hypotonic, dystonic, athetotic, or a combination [3]. While commonly diagnosed, it is often shown that CP affects many aspects of a child's health. Common health problems associated with CP are excessive drooling, respiratory issues, nutrition, sleep, and poor oral hygiene. With almost one-third of children with CP having difficulties with chewing and swallowing, it is important to note that oral health is a primitive underlying factor for the

Oral health in children with CP is impacted significantly by their neuromuscular and neurodevelopmental disabilities, leading them to have a higher risk of dental disease due to the greater difficulty for these individuals to perform or receive effective oral hygiene and oral care [4–6]. Specific attributions can be made to the high prevalence of orofacial motor dysfunction, which can lead to poor oral hygiene, and increase dental biofilm formation and retention [7]. Factors such as food consistency and snacking between meals have also been reported to contribute to the high incidence of dental diseases, like dental caries and periodontitis [8]. Nevertheless, dental caries is one of the most common chronic diseases in childhood. Dental caries are defined as one or more decayed, missing, or filled teeth for permanent teeth. Dental caries can also develop at any tooth site in the oral cavity. Hence, with the combined characteristics of poor oral hygiene and orofacial impairments, children with CP make seamless dental caries inhabitants. Several studies have examined caries rates in individuals who have CP [9–11]. However, most of those studies were conducted on highly selected children (e.g., children attending clinics or rehabilitation centers) and in high-income countries. A study from England did not find any significant differences in the levels of decayed, missing, and filled teeth between children who had CP and a control group of children without disabilities. They did find, however, that the children with CP had more untreated decay than children without a disability. Emphasizing the notion that oral health considerations were avoided or even worse, not accessible, which embarks the path of irreversible dental damage and further consequential health issues impacting overall quality of life. For this reason, society must change its outlook on the correlation between healthcare and oral health status for this

The concept of oral health-related quality of life (OHRQoL) is defined as the impact of oral health or disease on an individual's daily functioning and well-being. In the United States Surgeon General's report on oral health, they attribute OHRQoL as, "a multidimensional construct that reflects (among other things) people's comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction with respect to their oral health" [12]. Previous studies have in fact demonstrated that dental diseases and disorders have a negative impact on an individual's OHRQoL and the quality of life (QoL) of their parents or

majority of these complications.

80 Cerebral Palsy - Clinical and Therapeutic Aspects

population.

#### **2.1. Oral hygiene and CP**

Oral health pertains to the teeth, tongue, gums, and their supporting tissue, but also the upper and lower jaw, chewing muscles, throat, salivary glands, and lips that allow us to explore our five senses [12] through speech, facial expressions, food, smell, or touch. With these valuable assets being compromised under the CP population, it is very common for one to not understand or assume responsibility of a standard oral routine; but it is for this same reason that this specific population must be inspected more heavily. Thus, early oral health preventive care and routines must be explored in order for this population to subside in the category of prevalent dental caries.

Studies have shown that the prevalence of caries experience was higher in individuals who cleaned their teeth less than once a day than those whose teeth were cleaned at least once a day [13]. For this reason, tooth brushing twice a day can provide an effective maintenance of the oral cavity. Alongside with fluoride-containing toothpaste, it is shown to decrease the presence of plaque. Plaque being a microbial biomass is composed of resident bacteria from saliva. If a tooth surface is covered by dental plaque, the metabolic activity alters the chemical dissolution of the tooth surface [14]. Therefore, brushing is essential to disturb and remove plaque in efforts of decreasing the rate cariogenicity.

Tooth brushing and flossing also eliminates the quantity of food debris, which if not removed can lead acid erosion to breakdown enamel and dentin, leaving teeth sensitive and discolored. Being that these are the major factors that promote the increase of dental caries, there are no parts of a tooth that are necessarily, "more or less susceptible." However, the idea of susceptibility is one parent of children with CP must acknowledge that no matter the age, classification of CP, or dietary regime, lesion formation and progression of dental caries can be controlled.

#### **2.2. Fluoride and antimicrobial products and CP**

The presence of fluoride within a child's oral practice is essential in the prevalence and severity of dental caries. Fluoride's attraction to calcium inhibits and even reverses the potential of dental caries to form by disrupting demineralization and enhancing remineralization of teeth. Remineralization of teeth increases the acid resistance of the enamel surface structure, thus preventing the change in pH levels, which are primarily responsible for tooth erosion and the creation of new lesions. Fluoride can be integrated in three main functions, community water fluoridation, pastes, and mouthwashes. Frequent consumption of water containing fluoride can permit a consistent barrier for dental caries to occur among the CP population, with minimal dietary efforts needed. Daily toothpaste use alongside with tooth brushing can provide a direct dosage of fluoride for the enamel to combat acid erosion. Studies relating dental caries risk factors attributed difficulty in the application of fluoride to the oral reflexes, such as biting and vomiting and intraoral sensitivity [7, 15]. As a result, it is advised that parents aide their children in the process of tooth brushing, by altering the child's orofacial position to decrease the probability of these refluxes, thereby promoting the ability to apply the daily dosage of fluoride on all teeth. Antimicrobial products although not noted as often can also be utilized in low concentrations to diminish the role of bacteria within the oral region. With minimal bacterial growth, oral cavities will be less prone to metabolize fermentable carbohydrates. Counteracting the microbial environment will thus set additional inhibitors that these dental caries agents will try and override. Finally, mouthwashes containing low concentrations of fluoride (0.05% neutral sodium fluoride or 0.1% stannous fluoride) and antimicrobial agents can provide an effective mean in increasing salivary production, which will allow a continuous aqueous flow to protect the oral cavity throughout the day.

**3. Motor and orofacial impairment**

**3.1. CP type and motor impairment**

Children with CP experience varying degrees of motor impairment as quantified by the gross motor function classification system (GMFCS), which classifies children with CP based on functional abilities and limitations [17]. GMFCS is a classification system intended to enhance communication between families and professionals when describing a child's gross motor function and can be useful when setting goals and making management decisions. The GMFCS levels range from level I of "Walks without limitations" to level V of "Transported in a manual wheelchair." Motor impairment results in difficulty in performing and receiving oral hygiene, which among other factors, such as feeding problems and reduced access to oral health care, increases caries risk. The GMFCS has not traditionally been used to inform dental professionals in their evaluation of dental caries risk and management decisions for children with CP; however, it has recently been identified that children with CP with severe motor impairment are at high risk for dental caries. As a result, this section will focus on motor

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Motor impairment in children with CP can be communicated in a variety of ways making it difficult to gather information from the literature on the impact of motor impairment. It is commonly described by some combination of location, type, and severity and falls along a continuum with the most severe presentation being of the "quadriplegic spastic type characterized by stiff hypertonic muscles and motor deficits in all four limbs." Location is often described as tetraparesis/tetraplegia/quadriplegia, triplegia, diparesis/diplegia, monoplegia, or hemiparesis/hemiplegia and type is often described as spastic, athetoid, ataxic, hypotonia, or mixed. Recent studies in Brazil found a relationship between increased motor impairment and increased caries experience in children with CP. It has been found that "individuals with mild to moderate mobility disability (GMFCS levels I, II and III) had a 4.2-fold greater chance of having teeth with cavities and those with severe motor impairment (GMFCS levels IV and V) had an eightfold greater chance of having cavities in comparison to individuals without motor impairment" [18]. As a result, attributed difficulty in providing oral hygiene to children with CP can be claimed by the "differences in intraoral sensibility, presence of involuntary physical movements and/or oral pathological reflexes and spasticity in masticatory muscles" [15]. For these reasons, attention must be paid forward in the act of involving primary caregivers in the instrumental role of oral hygiene practices, as they are the main source to provide

impairment and its association with worse OHRQoL of children with CP.

consistent care and additional oral health care for these children with CP.

The OHRQoL instrument has been used in several studies to obtain data from primary caregivers or parents, to reference the effect of their child's current oral health on their daily lives, (i.e., "how often have you had mouth sores because of your teeth/mouth?"). These data points also include the parents' concerns about their child's oral health in regards to being upset, having disrupted sleep, or taken time off work. Studies using this paradigm concluded that compared to children with GMFCS I-III, the group of children with increased motor impairment of GMFCS IV-V had worse outcomes for having difficulty saying words, having trouble

**3.2. GMFCS and oral health-related quality of life in CP**

#### **2.3. Frequent dental visits and CP**

Disease preventative measures can be performed within one's home; however, it can also be supported by seeking a professional opinion, at least once a year. Seeking an oral health professional that is an approved medical practitioner in one's estate can provide the family and child with CP, a clear, understandable, and personalized protocol to be followed if the oral health evaluation is not up to par. Oral health practitioners can provide insight on the severity of the dental caries present, and the following steps to be considered if a stronger optical concentrated treatment is needed. Specifically, in low-income and middle-income countries (LMIC), parents and physicians must work together in reassuring the child of an oral evaluation as governmental and service providers are limited in their capacity to quantify current and future resources of this population. This phenomenon has been evaluated by studies in Brazil, Bangladesh, and Japan. Determinations were made on the effects of oral health care access and dental caries progression in LMIC [3, 13, 16]. Results displayed that progression of dental caries was reduced once handicapped children participated in the funded rehabilitative programs of oral health professionals [16]. Practitioners should be specifically trained and equipped to handle CP-related orofacial impairments in order to provide the patient the least amount of discomfort and pain as possible.

The role of oral hygiene in the prevention and decrement of dental caries within the CP population can be reviewed by three major provisions, daily tooth brushing, use of fluoridecontaining products, and scheduled dental visits. The combination of tooth brushing and fluoride toothpaste can provide an effective barrier to the ubiquitous degradation of plaque and cariogenic bacteria. Scheduled dental visits can provide a professional review of the child's current oral health status and can deliver an incentive to change oral health behavior if dental examinations are abnormal. Overall, efforts should be emphasized that the role of oral hygiene plays a significant role in the prevalence of dental caries, and caregivers should focus on providing a primal example of daily oral health routines to combat this notion.
