U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES l National Institutes of Health l National Institute of Dental and Craniofacial Research

P

roviding oral care to people with cerebral palsy requires adaptation 

of the skills you use every day. In fact, most people with mild or 

moderate forms of cerebral palsy can be treated successfully in the 

general practice setting. This booklet will help you make a difference in the 

lives of people who need professional oral care.

Cerebral palsy is a complex group of motor abnormalities and functional 

impairments that affect muscle coordination. This developmental 

disability may be associated with uncontrolled body movements, seizure 

disorders, balance-related abnormalities, sensory dysfunction, and mental 

retardation. For some,

the disorder is mild, causing 

movements to appear merely 

clumsy or awkward. These patients 

may need little or no day-to-day 

supervision. Others, however, 

experience such severe forms of 

cerebral palsy that they require a 

wheelchair and a lifetime of personal 

care.

Practical Oral Care 

for People With Cerebral Palsy

contents

Health Challenges IN

cerebral palsy and 

Strategies for Care

2 . . . . . . . . . . . . . . . . . . . . . 

Types of cerebral palsy

3 . . . . . . . . . . . . . . . . . . . . . 

Uncontrolled body 

movements

Primitive reflexes

Mental capabilities

4 . . . . . . . . . . . . . . . . . . . . . 

Seizures

Visual impairments

Hearing loss and deafness

5 . . . . . . . . . . . . . . . . . . . . . 

Dysarthria

Gastroesophageal reflux

Oral Health Problems 

in cerebral palsy 

and strategies for 

care

Periodontal disease

6 . . . . . . . . . . . . . . . . . . . . . 

Dental caries

Malocclusion

Dysphagia

7 . . . . . . . . . . . . . . . . . . . . . 

Drooling

Bruxism

Hyperactive bite and gag 

reflexes

Trauma and injury

Additional Readings

Cerebral palsy itself does 

not cause any unique oral 

abnormalities. However, 

several conditions are 

more common or more 

severe in people with 

cerebral palsy than in the 

general population.
People with cerebral palsy may present 

with physical and mental challenges that 

have implications for oral care. Before 

the appointment, obtain and review the 

patient’s medical history. Consultation 

with physicians, family, and caregivers is 

essential to assembling an accurate medical history. Also, determine who can legally 

provide informed consent for treatment.

The different types of cerebral

palsy are classified according to associated motor impairments:

Spastic palsy presents with stiff or rigid 

muscles on one side of the body or in 

all four limbs, sometimes including the 

mouth, tongue, and pharynx. People with 

this form of cerebral palsy may have legs 

that turn inward and scissor as they walk, 

or arms that are flexed and positioned 

against their bodies. Many also have 

mental retardation, seizures, and dysarthria 

(difficulty speaking).

Dyskinetic or athetoid palsy is characterized by hypotonia and slow, uncontrolled 

writhing movements. People with this 

type of cerebral palsy experience frequent 

changes in muscle tone in all areas of their 

bodies; muscles may be rigid during waking 

hours and normal during sleep. Dysarthria 

is also associated with this type.

Ataxic palsy is marked by problems with 

balance and depth perception, as well as an 

unsteady, wide-based gait. Hypotonia and 

tremors sometimes occur in people with 

this rare type of cerebral palsy.

Combined palsy reflects a combination of 

these types.

Everyone who has cerebral palsy has 

problems with movement and posture. 

Observe each patient, then tailor your care 

accordingly.

Maintain clear paths for movement 

throughout the treatment setting. Keep 

instruments and equipment out of the 

patient’s way.

Some patients cannot be moved into the 

dental chair but instead must be treated 

in their wheelchairs. Some wheelchairs 

recline or are specially molded to fit 

people’s bodies. Lock the wheels, then 

slip a sliding board (also called a transfer 

board) behind the patient’s back to support the head and neck. 

If you need to transfer your patient 

from a wheelchair to the dental chair, 

ask about special preferences such as 

padding, pillows, or other things you 

can provide to ease the transition. The 

patient or caregiver can often explain 

how to make a smooth transfer. (See 

Wheelchair Transfer: A Health Care 

Provider’s Guide, also part of this series.)



Health Challenges in Cerebral Palsy 

and Strategies for Care

Positioning for treating a patient in a wheelchair. Note the 

support a sliding board can provide. Sliding or transfer boards 

are available from home health care companies.
cerebral palsy

Uncontrolled body movements are common in people with 

cerebral palsy. Their limbs move often, so 

providing oral care can be difficult. When 

patients with cerebral palsy attempt to 

move in order to help, their muscles often 

tense, increasing uncontrolled movements.

Make the treatment environment calm 

and supportive. Try to help your patient 

relax. Relaxation will not stop uncontrolled body movements, but it may 

reduce their frequency or intensity.

Place and maintain your patient in the 

center of the dental chair. Do not force 

arms and legs into unnatural positions, 

but allow the patient to settle into a 

position that is comfortable and will not 

interfere with dental treatment.

Observe your patient’s movements and 

look for patterns to help you anticipate 

direction and intensity. Trying to stop 

these movements may only intensify 

the involuntary response. Try instead 

to anticipate the movements, blending your movements with those of your 

patient or working around them.

Softly cradle your patient’s head during 

treatment. Be gentle and slow if you 

need to turn the patient’s head.

Exert gentle but firm pressure on your 

patient’s arm or leg if it begins to shake.

Try to keep appointments short, take 

frequent breaks, or consider prescribing 

muscle relaxants when long procedures 

are needed. People with cerebral palsy 

may need sedation, general anesthesia, 

or hospitalization if extensive dental 

treatment is required.

Primitive reflexes are common 

in many people with cerebral palsy and 

may complicate oral care. These reflexes 

often occur when the head is moved or 

the patient is startled, and efforts to control them may make them more intense. 

Three types of reflexes are most commonly 

observed during oral care.

Asymmetric tonic neck reflex: When a 

patient’s head is turned, the arm and leg on 

that side stiffen and extend. The arm and 

leg on the opposite side flex.

Tonic labyrinthine reflex: If the neck is 

extended while a patient is lying on his or 

her back, the legs and arms also extend, and 

the back and neck arch.

Startle reflex: Any surprising stimuli, such 

as noises, lights, or a sudden movement on 

your part, can trigger uncontrolled, often 

forceful movements involving the whole 

body.

Be empathic about your patient’s concerns and frustrations.

Minimize the number of distractions 

in the treatment setting. Movements, 

lights, sounds, or other stimuli can make 

it difficult for your patient to cooperate. 

Tell him or her about any such stimulus before it appears. For example, tell 

the patient before you move the dental 

chair.

Mental capabilities vary. Many people with cerebral palsy have mild or moderate mental retardation, but only 25 percent 

have a severe form. Some have normal 

intelligence.

Talk with the parent or caregiver to 

determine your patient’s intellectual 

and functional abilities, then explain 

each procedure at a level the patient 

can understand. Allow extra time to 

explain oral health issues, instructions, 

or procedures.

Use simple, concrete instructions and 

repeat them often to compensate for any 

short-term memory problems. Speak 



Observe 

your patient’s 

movements.

Try to blend your 

movements with 

those of your 

patient.
slowly and give only one direction at a 

time.

Demonstrations can make patients more 

cooperative. For example, turn on the 

saliva ejector so the patient can hear it 

and feel it at the corner of the mouth. 

Then slowly introduce it inside the 

mouth, being careful not to trigger a gag 

reflex.

Be consistent in all aspects of oral care. 

Use the same staff and dental operatory each time to help sustain familiarity. Consistency leads to improved 

cooperation.

Listen actively, since communicating 

clearly is difficult for some—show your 

patient whether you understand. Be 

sensitive to the methods he or she uses 

to communicate, including gestures and 

verbal or nonverbal requests.

Seizures may accompany cerebral palsy, 

but can usually be controlled with anticonvulsant medications. The mouth is always 

at risk during a seizure: Patients may chip 

teeth or bite the tongue or cheeks. Patients 

with controlled seizure disorders can easily 

be treated in the general dental office.

Consult your patient’s physician. 

Record information in the chart about 

the frequency of seizures and the 

medications used to control them. 

Determine before the appointment 

whether medications have been taken as 

directed. Know and avoid any factors 

that trigger your patient’s seizures.

Be prepared to manage a seizure. If 

one occurs during oral care, remove 

any instruments from the mouth and 

clear the area around the dental chair. 

Attaching dental floss to rubber dam 

clamps and mouth props when treatment begins can help you remove them 

quickly. Do not attempt to insert any 

objects between the teeth during a seizure.

Stay with your patient, turn him or her 

to one side, and monitor the airway to 

reduce the risk of aspiration.

Visual impairments affect a large 

number of people with cerebral palsy. 

The most common of these defects is 

strabismus, a condition in which the eyes 

are crossed or misaligned. People with 

cerebral palsy may develop visual motor 

skills, such as hand-eye coordination, later 

than other people.

Determine the level of assistance your 

patient requires to move safely through 

the dental office.

Use your patients’ other senses to 

connect with them, establish trust, 

and make treatment a good experience. Tactile feedback, such as a warm 

handshake, can make your patients feel 

comfortable.

Face your patients when you speak and 

keep them apprised of each upcoming 

step, especially when water will be used. 

Rely on clear, descriptive language to 

explain procedures and demonstrate 

how equipment might feel and sound. 

Provide written instructions in large 

print (16 point or larger).

Hearing loss and deafness can 

be accommodated with careful planning. 

Patients with a hearing problem may 

appear to be stubborn because of their 

seeming lack of response to a request.

Patients may want to adjust their 

hearing aids or turn them off, since the 

sound of some instruments may cause 

auditory discomfort.



Be sensitive to

the methods 

your patient uses 

to communicate, 

including gestures 

and verbal 

or nonverbal 

requests.
cerebral palsy

If your patient reads lips, speak in a 

normal cadence and tone. If your 

patient uses a form of sign language, 

ask the interpreter to come to the 

appointment. Speak with this person 

in advance to discuss dental terms and 

your patient’s needs.

Visual feedback is helpful. Maintain 

eye contact with your patient. Before 

talking, eliminate background noise 

(turn off the radio and the suction). 

Sometimes people with a hearing loss 

simply need you to speak clearly in 

a slightly louder voice than normal. 

Remember to remove your facemask 

first or wear a clear face shield.

Dysarthria is common in people with 

cerebral palsy, due to problems involving the muscles that control speech and 

mastication.

Be patient. Allow time for your patient 

to express himself or herself. Remember 

that many people with dysarthria have 

normal intelligence.

Consult with the caregiver if you have 

difficulty understanding your patient’s 

speech.

Gastroesophageal reflux sometimes affects people with cerebral palsy, 

including those who are tube-fed. Teeth 

may be sensitive or display signs of erosion. 

Consult your patient’s physician about the 

management of reflux.

Place patients in a slightly upright 

position for treatment.

Talk with patients and caregivers about 

rinsing with plain water or a water and 

baking soda solution. Doing so at least 

four times a day can help mitigate the 

effects of gastric acid. Stress that using 

a fluoride gel, rinse, or toothpaste every 

day is essential.



Record in the 

patient’s chart 

strategies that 

were successful 

in providing care. 

Note your patient’s 

preferences and 

other unique 

details that 

will facilitate 

treatment, such 

as music, comfort 

items, and flavor 

choices.

Oral Health Problems in Cerebral 

Palsy and Strategies for Care

Cerebral palsy itself does not cause any 

unique oral abnormalities. However, 

several conditions are more common or 

more severe in people with cerebral palsy 

than in the general population.

Periodontal disease is common 

in people with cerebral palsy due to poor 

oral hygiene and complications of oral 

habits, physical abilities, and malocclusion. 

Another factor is the gingival hyperplasia 

caused by medications.

Encourage independence in daily oral 

hygiene. Ask patients to show you how 

they brush, and follow up with specific 

recommendations on brushing methods 

or toothbrush adaptations. Involve your 

patients in hands-on demonstrations of 

brushing and flossing.

Some patients cannot brush and floss 

independently because of impaired 

physical coordination or cognitive 

skills. Talk to caregivers about daily 

oral hygiene. Do not assume that all 

caregivers know the basics; demonstrate 

proper brushing and flossing techniques. 

A power toothbrush or a floss holder 

can simplify oral care. Also, use 

your experiences with each patient 

to demonstrate sitting or standing 

positions for the caregiver. Emphasize 

that a consistent approach to oral 
hygiene is important—caregivers should 

try to use the same location, timing, and 

positioning.

Explain that some patients benefit from 

the daily use of an antimicrobial agent 

such as chlorhexidine. Recommend 

an appropriate de­livery method based 

on your patient’s abilities. Rinsing, for 

example, may not work for a patient 

with swallowing difficulties or one who 

cannot expectorate. Chlorhexidine 

applied using a spray bottle or toothbrush is equally efficacious.

If use of particular medications has led 

to gingival hyperplasia, monitor for possible delayed tooth eruption and emphasize the importance of daily oral hygiene 

and frequent professional cleanings.

Dental caries is prevalent among people with cerebral palsy, primarily because 

of inadequate oral hygiene. Other risk factors include mouth breathing, the effects of 

medication, enamel hypoplasia, and food 

pouching.

Caution patients or their caregivers 

about medicines that reduce saliva or 

contain sugar. Suggest that patients 

drink water often, take sugar-free 

medicines when available, and rinse 

with water after taking any medicine.

Advise caregivers to offer alternatives to 

cariogenic foods and beverages as incentives or rewards.

For people who pouch food, talk to 

caregivers about inspecting the mouth 

after each meal or dose of medicine. 

Remove food or medicine from the 

mouth by rinsing with water, sweeping the mouth with a finger wrapped in 

gauze, or using a disposable foam applicator swab.

Recommend preventive measures such 

as fluorides and sealants.

Malocclusion in people with cerebral 

palsy usually involves more than just misaligned teeth—it is also a musculoskeletal 

problem. An open bite with protruding 

anterior teeth is common and is typically 

associated with tongue thrusting. The 

inability to close the lips because of an open 

bite also contributes to excessive drooling.

Unfortunately, correcting malocclusion is 

almost impossible in people with moderate or severe cerebral palsy. Orthodontic 

treatment may not be an option because of 

the risk of caries and enamel hypoplasia. 

However, a developmental disability in and 

of itself should not be perceived as a barrier 

to orthodontic treatment.

The ability of the patient or the caregiver to maintain good daily oral 

hygiene is critical to the feasibility and 

success of orthodontic treatment.

Inform caregivers of emergency 

procedures for accidents involving oral 

trauma, since protruding anterior teeth 

are more likely to be displaced, fractured, or avulsed.

Dysphagia, difficulty with swallowing, 

is often a problem in people with cerebral 

palsy. Food may stay in the mouth longer 

than usual, increasing the risk for caries. 

Additionally, the semi-soft foods caregivers 

may prepare for people with this problem 

tend to adhere to the teeth. Coughing, 

gagging, choking, and aspiration are other 

related concerns.

Keep the breathing passages open by 

placing your patient in a slightly upright 

position with the head turned to one 

side during oral care.

Use suction frequently or as tolerated 

by the patient. Use a rubber dam 

when indicated, but make sure you 

introduce it slowly, perhaps over a few 

appointments.


cerebral palsy

Advise the caregiver to inspect the 

patient’s mouth after eating and remove 

any residual food.

Drooling affects daily oral care as 

well as social interaction. Hypotonia 

contributes to drooling, as does an open 

bite and the inability to close the lips.

Bruxism is common in people with cerebral palsy, especially those with severe forms 

of the disorder. Bruxism can be intense 

and persistent and cause the teeth to wear 

prematurely. Before recommending mouth 

guards or bite splints, consider that gagging 

or swallowing problems may make them 

uncomfortable or unwearable.

Hyperactive bite and gag 

reflexes call for introducing instruments gently into the mouth. Consider 

using a mouth prop. A patient with a gagging problem benefits from an early morning appointment, before eating or drinking. 

Help minimize the gag reflex by placing 

your patient’s chin in a neutral or downward position.

TRAUMA and INJURY to the mouth 

from falls or accidents occur in people with 

cerebral palsy. Suggest a tooth-saving kit 

for group homes. Emphasize to caregivers 

that traumas require immediate professional attention and explain the procedures 

to follow if a permanent tooth is knocked 

out. Also, instruct caregivers to locate any 

missing pieces of a fractured tooth, and 

explain that radiographs of the patient’s 

chest may be necessary to determine 

whether any fragments have been aspirated.

Physical abuse often presents as oral 

trauma. Abuse is reported more frequently in people with developmental 

disabilities than in the general population. If you suspect that a child is being 

abused or neglected, State laws require that 

you call your Child Protective Services 

agency. Assistance is also available from the 

Childhelp® USA National Child Abuse 

Hotline at (800) 422–4453 or the National 

Clearinghouse on Child Abuse and Neglect 

Information (http://nccanch.acf.hhs.gov).

Making a difference in the oral health 

of a person with cerebral palsy may go 

slowly at first, but determination can 

bring positive results—and invaluable 

rewards. By adopting the strategies 

discussed in this booklet, you can have 

a significant impact not only on your 

patients’ oral health, but on their quality of life as well.

Additional Readings

Pellegrino L. Cerebral palsy. In Batshaw 

ML. Children With Disabilities (5th 

ed.). Baltimore, MD: Paul H. Brookes 

Publishing Co., 2002. pp. 443–466.

Weddell JA, Sanders BJ, Jones JE. Dental 

problems of children with disabilities. In 

McDonald RE, Avery DR. Dentistry for the 

Child and Adolescent (7th ed.). St. Louis, 

MO: Mosby, 2000. pp. 566–599.



For more information about cerebral 

palsy, contact

National Institute of Neurological 

Disorders and Stroke

NIH Neurological Institute

P.O. Box 5801

Bethesda, MD 20824

(800) 352–9424

www.ninds.nih.gov 

braininfo@ninds.nih.gov

Tips for caregivers are available in the booklet

Dental Care Every Day: A Caregiver’s Guide, also part of this series.
This booklet is one in a series on providing oral care for people 

with mild or moderate developmental disabilities. The issues and 

care strategies listed are intended to provide general guidance on 

how to manage various oral health challenges common in people 

with cerebral palsy.

Other booklets in this series: 

Continuing Education: Practical Oral Care for People

 With Developmental Disabilities

Practical Oral Care for People With Autism

Practical Oral Care for People With Down Syndrome

Practical Oral Care for People With Mental Retardation

Wheelchair Transfer: A Health Care Provider’s Guide

Dental Care Every Day: A Caregiver’s Guide

For additional copies of this booklet, contact

National Institute of Dental and Craniofacial Research

National Oral Health Information Clearinghouse

1 NOHIC Way

Bethesda, MD 20892–3500

(301) 402–7364

www.nidcr.nih.gov

This publication is not copyrighted. 

Make as many photocopies as you need.

NIH Publication No. 06–5192

Reprinted May 2006

Acknowledgments

The National Institute of Dental and Craniofacial Research 

thanks the oral health professionals and caregivers who 

contributed their time and expertise to reviewing and 

pretesting the Practical Oral Care series.

Expert Review Panel

• Mae Chin, RDH, University of Washington, Seattle, WA

• Sanford J. Fenton, DDS, University of Tennessee, Memphis, TN

• Ray Lyons, DDS, New Mexico Department of Health, 

Los Lunas, NM

• Christine Miller, RDH, University of the Pacific, 

San Francisco, CA

• Steven P. Perlman, DDS, Special Olympics Special Smiles, 

Lynn, MA

• David Tesini, DMD, Natick, MA

NATIONAL INSTITUTE OF

DENTAL AND CRANIOFACIAL

RESEARCH

National Institute of Dental 

and Craniofacial Research

Centers for Disease Control 

and Prevention

National Institute of Child Health 

and Human Development

Special Care Dentistry