Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 26

 Physical therapy and occasionally orthopaedic surgeryTable 1.1.1 Considerations for dental management.Risk assessmentInvoluntary movements and contractions – these can increase further with stress and local stimuliAbnormal gag/bite reflexAbnormal swallowing and cough reflexAspiration riskEpilepsyCriteria for referralReferral to a specialised clinic or hospital centre is determined by:Factors related to the severity of the patient's general condition (e.g. respiratory distress, uncontrolled seizures)Factors that significantly limit access for dental procedures (e.g. pathological reflexes and uncontrolled movements)Access/positionPatients who present in wheelchairs may have treatment provided without transfer, particularly if there is a wheelchair platform available (Figure 1.1.4)If they are transferred to the dental chair, the patients will need to be stabilised with pillowsConsider safe immobilisation of the head using vacuum cushions/supports with consentCommunicationFrequent difficulties in verbal communicationNon‐verbal language might sometimes need to be interpretedThe level of comprehension can be normalConcentration may be poorConsent/capacityCapacity may be intactDo not make assumptions due to the physical signs/symptoms or impaired verbal communicationClinical holding may be required (e.g. to reduce involuntary arm movements) – this must be appropriately risk assessed, undertaken by trained staff, consented and documentedRegular medication may be sedative and hence impair capacityAnaesthesia/sedationLocal anaesthesiaNot contraindicated, although involuntary movements may make delivery challengingSedationConscious sedation can help control anxiety, nausea and lingual dystoniaMedical consultation is recommended if the patient takes neuroleptics, is already taking benzodiazepines or has respiratory difficultiesGeneral anaesthesiaMay be indicated if the movements are uncontrollable or there is a lack of co‐operation (the risk/benefit should be assessed)Dental treatmentBeforeThe need for conscious sedation should be anticipated and consent for any intervention undertaken prior to thisOrthodontic treatment planning should consider the impact of increased muscle toneDuringConsider the use of atraumatic mouth openers, protective thimbles and stainless steel/plastic mirrors (involuntary contractions)Fixed prostheses are generally preferable over removable prostheses (due to difficulties inserting the prosthesis, involuntary movements and the risk of fracture in patients with epilepsy)AfterClose follow‐up after completion of orthodontic therapy as relapse is more frequentDrug prescriptionConsider the associated systemic complications and concurrent medicationsCaution with the use of benzodiazepines if the patient is already taking sedation medicationEducation/preventionInvolve the relatives and caregivers where possibleAn electric or adapted manual toothbrush should be consideredRegular oral prophylaxis/calculus removalFluoride treatmentDietary counsellingTable 1.1.2 Classification and characteristics of cerebral palsy.Type (lesion location)FrequencyClinical presentationSubtype/area involvedSpastic (upper motor neuron) 70–80%Muscle hypertonia Contracture HyperreflexiaMonoplegic: one extremityParaplegic: legsHemiplegic: one arm and one ipsilateral legDouble hemiplegic: all extremities but more in the armsDiplegic: all extremities but more in the legsTetraplegic: all extremitiesAthetoid (basal ganglia) 15%Vermiform movements Muscle hypertoniaChorea (restless, fidgety, dancing movement): face, chest and extremitiesAthetosis (slow, writhing movement): hands and feetChoreoathetosis: generalisedAtaxic (cerebellum) 10%Abnormal equilibrium and gait

 Drug treatment for tone/movement disorders, including baclofen, trihexyphenidyl, gabapentin, diazepam, clonidine and botulinum toxin

 Neurosurgical interventions, including selective rhizotomy and electrode implantation in the basal ganglia

 Epilepsy control, speech therapy and hearing and vision support

 Special education and occupational therapy