Oral conditions in children with special needs

# Oral Development

## Tooth eruption
Tooth eruption may be delayed, accelerated, or inconsistent in children with growth disturbances. Gums may appear red or bluish-purple before erupting teeth break through into the mouth. Eruption depends on genetics, growth of the jaw, muscular action, and other factors. Children with Down syndrome may show delays of up to 2 years.
Offer information about the variability in tooth eruption patterns and refer to an oral health care provider for additional questions.

## Malocclusion
Malocclusion, a poor fit between the upper and lower teeth, and crowding of teeth occur frequently in people with developmental disabilities. Nearly 25 percent of the more than 80 craniofacial anomalies that can affect oral development are associated with intellectual disability. Muscle dysfunction contributes to malocclusion, particularly in people with cerebral palsy. Teeth that are crowded or out of alignment are more difficult to keep clean, contributing to periodontal disease and dental caries.
Refer to an orthodontist or pediatric dentist for evaluation and specialized instruction in daily oral hygiene.

## Tooth anomalies
Tooth anomalies are variations in the number, size, and shape of teeth. People with Down syndrome, oral clefts, ectodermal dysplasia, or other conditions may experience congenitally missing, extra, or malformed teeth.
Consult an oral health care provider for dental treatment planning during a child's growing years.

## Developmental defects
Developmental defects appear as pits, lines, or discoloration in the teeth. Very high fever or certain medications can disturb tooth formation and defects may result. Many teeth with defects are prone to dental caries, are difficult to keep clean, and may compromise appearance.
Refer to an oral health care provider for evaluation of treatment options and advice on keeping teeth clean.

# Oral Trauma

## Trauma
Trauma to the face and mouth occur more frequently in people who have intellectual disability, seizures, abnormal protective reflexes, or muscle incoordination. People receiving restorative dental care should be observed closely to prevent chewing on anesthetized areas. If a tooth is avulsed or broken;
Take the patient and the tooth to a dentist immediately & Counsel the parent/caregiver on ways to prevent trauma and what to do when it occurs.

# Bruxism
Bruxism, the habitual grinding of teeth, is a common occurrence in people with cerebral palsy or severe intellectual disability. In extreme cases, bruxism leads to tooth abrasion and flat biting surfaces.
Refer to a dentist for evaluation; behavioral techniques or a bite guard may be recommended.

# Oral Infections

## Dental caries
Dental caries, or tooth decay, may be linked to frequent vomiting or gastroesophageal reflux, less than normal amounts of saliva, medications containing sugar, or special diets that require prolonged bottle feeding or snacking. When oral hygiene is poor, the teeth are at increased risk for caries.
Counsel the parent/caregiver on daily oral hygiene to include frequent rinsing with plain water and use of a fluoride-containing toothpaste or mouth rinse. Explain the need for supervising children to avoid swallowing fluoride.
Refer to an oral health care provider and/or gastroenterologist for prevention and treatment. Prescribe sugarless medications when available.

## Early, severe periodontal (gum) disease
Early, severe periodontal (gum) disease can occur in children with impaired immune systems or connective tissue disorders and inadequate oral hygiene. Simple gingivitis results from an accumulation of bacterial plaque and presents as red, swollen gums that bleed easily. Periodontitis is more severe and leads to tooth loss if not treated. Professional cleaning by an oral health care provider, systemic antibiotics, and instructions on home care may be needed to stop the infection.
Explain that the parent/caregiver may need to help with daily toothbrushing and flossing and that frequent appointments with an oral health care provider may be necessary.

## Viral infections
Viral infections are usually due to the herpes simplex virus. Children rarely get herpetic gingivostomatitis or herpes labialis before 6 months of age. Herpetic gingivostomatitis is most common in young children, but may occur in adolescents and young adults. Viral infections can be painful and are usually accompanied by a fever.
Counsel the parent/caregiver about the infectious nature of the lesions, the need for frequent fluids to prevent dehydration, and methods of symptomatic treatment.

# Gingival Overgrowth
Gingival overgrowth may be a side effect from medications such as calcium channel blockers, phenytoin sodium, and cyclosporine. Poor oral hygiene aggravates the condition and can lead to superimposed infections. Severe overgrowth can impair tooth eruption, chewing, and appearance.
Refer to an oral health care provider for prevention and treatment. A preventive regimen of antimicrobial rinses and frequent appointments may be needed. Consider alternative medications if possible.

# Source
National Institute of Dental and Craniofacial Research

# Additional Resources
- Section III: Developmental Disabilities.  In Batshaw ML, Pellegrino L, Roizen NJ (eds.).  Children With Disabilities (6th ed.).  Baltimore, MD: Paul H. Brookes Publishing Co., 2007.
- Fenton, SJ, Perlman S, Turner H (eds.), Oral Health Care for People With Special Needs:  Guidelines for Comprehensive Care. River Edge, NJ: Exceptional Parent, Psy-Ed Corp., 2003.
- Weddell, JA, Sanders BJ, Jones JE.  Dental problems of children with disabilities.  In McDonald RE, Avery DR, Dean JA.  Dentistry for the Child and Adolescent (8th ed.).  St. Louis, MO:  Mosby, 2004.  pp. 524-556.