5- mental disabilities- cerebral palsy & autism

When does an intellectual disability appear and what does it affect?

Before 18 yrs, below average IQ

Affects morbidity- effects daily life/adaptive behaviours

Can appear with physical impairments

Frequently has genetic base

What intellectual vs practical vs social functions are affected?

Reasoning, planning, problem solving

Concept acquisition, autonomous skills, social responsiveness

Social reciprocity, empathy, social skills generally

What are 4 prenatal causes of mental disability?

Genetic causes- downs, turner syndrome

Maternal drug abuse

Congenital hypothyroidism

Feeding problems during pregnancy

What are some perinatal causes of mental disability?

Extreme prematurities

Infections of newborn- severe meningitis, toxoplasmosis, lack of oxygenation during birth

What are 4 postnatal causes of mental disabilities?

Major seizures

Traumas

Heart failure

High fever

Percentages of origin of mental disabilities?

Genetic- 40%

Environmental- 15%

Prematurity- 10%

Multifactorial- 3-15%

Unknown- 20%

What are 5 adaptive skills?

Personal self care

Daily home life

Decision making

Social skills

Community interaction

Mild mental disability characteristics- IQ, life expectancy, rate, education?

50-70

50-59

89%

Yes

Medium mental disability characteristics- IQ, life expectancy, rate, education?

35-55

50-59

7%

Barely or with difficulty

Severe mental disability characteristics- IQ, life expectancy, rate, education?

20-40

40-49

3%

No

Deep mental disability characteristics- IQ, life expectancy, rate, education?

20-25

20 years

1%

No

Why do mentally disabled patients tend to have higher rates of oral pathology? (4)

Lack of understanding

Altered fine manual difficulty

Medication- (polymedicated)- neuroleptics or antipsychotics affect oral health

Lack of motivation

12 factors taken into account with disabled patient management?

Conduct

Magnitude of treatment

Physical and medical condition

Number of visits

Intelligence coefficient

Learning situation, mental age

Medical risks

Socio economic

Hygiene cooperation, communication

Impossible to carry out certain treatments

Displacement feasibility

Environment

What are 5 oral treatment objectives?

Instructing family members

Reporting drug effects

Avoid over medication

Carry out preventative, reparative, substitute treatments

Follow up

What are the 6 Mencius type behaviour?

1- patient cooperates, can be routinely treated

2- hesitant but cooperates after explanation

3- doesn’t cooperate, requires light physical restrainment, capable of eventual cooperation

4- physical restraint and premedication

5- requires treatment under general anesthesia

6- cannot cooperate and requires physical restraint even if treatment is minimal

What are 4 conditioning factors in dental treatments?

Adapted clinics

Sufficient, well trained staff

High number of densenitisation visits

Special additions or modifications

What are the 4 techniques used to manage a mentally disabled patient?

Behaviour modulation

Pharmacological control

Physical control- protective stabilisation

General anesthesia

How can you conduct behavioural modulation?(6)

Say-show-do

Positive reinforcement

Non verbal communication

Imitation

Distraction

Desensitisation

What are the 2 types of protective stabilisation and 3 objectives?

Passive- additions, active- professional

Eliminate unwanted movements, protect patient, appropriate treatment

What are 4 protective stabilisation indications?

Lack of maturity

Mental disability

Failure in behaviour management

Patient and professional risk

What are 3 examples of passive protective stabilisation additions?

Straps, belts

Sheets

Patented products- pedi-wrap, papoose board

What are 3 examples of active protective stabilisation additions?

Bite blocks

Mouth openers

Tongue depressors

(Technique- body arm support)

What are 5 objectives of pharmacological control?

Reducing anxiety

Reducing mobility

Improving communication

Allowing longer appointments

Increasing pain threshold

What are 2 indications of pharmacological intervention?

Prior technique failure

Reduce medical risk

What are 4 medications you can give to mentally disabled patients?

Midazolam- oral, IV

Lorazepam- sublingual

Ketamine- oral, I.m, I.v

Other common oral- diazepam, hydroxyzine

Inhalation- nitrous oxide 50-60% for cooperative patients, sevoflurane before IV analgesia

5 Advantages vs 4 disadvantages of oral medication

Easily administered, no equipment, inexpensive, longer working time, no training

Needs cooperation, absorption unpredictable, can cause respiratory depression if have respiratory infection, variable duration

Advantages vs disadvantages of inhalation anaesthesia

Useful for somewhat cooperative patient, patient remains conscious, cheap, can give at dental clinic

Not for uncooperative or respiratory deficit patients, only superficial sedation, need equipment, requires training (14hrs includes cpr)

Advantages vs disadvantages of IV sedation

Achieve total cooperation, allows wide field of vision and adequate work time

High risk, need special equip and trained staff and anaesthesiologist

What are the 5 risks of IV sedation?

respiratory depression

airway obstruction

vomiting, aspiration

allergies

vascular lesions (i.v.)

most used medication: midazolam

What are 4 indications of general anesthesia?

For patients whose treatment while conscious has a risk due to previous pathologies

Uncooperative patients

For a magnitude of extensive treatments

For complex displacement

What are the 4 phases of general anesthesia?

Analgesic period- loss of sensory function

Period of excitation or delirium

Period of surgical anesthesia- skeletal-muscle relaxation

Period of IV or bulbar paralysis

What is cerebral palsy? Accompanied by? When?

Non-progressive central motor dysfunction- causes changes in muscle tone

Can be accompanied by mental deficiency and other disorders like epilepsy, visual + hearing + speech impairment and progressive orthopaedic deformities

Established before age 5 (ICP- infantile cerebral palsy)

6 causes of cerebral palsy

Cerebral hemorrhages

Infections (meningitis, toxoplasmosis)

Cranial trauma

Maternal infections (rubeola)

Perinatal anoxia

5% of cerebral palsy cases are from unknown causes

Characteristics of cerebral palsy

60-70% have speech difficulties

33% have learning difficulties

All physically handicapped

Can have normal IQ with no alterations at cognitive level

5 most common types of cerebral palsy

Spastic (hypertonia)- in 50-70%, affects upper motor neuron, hyperreflexia in hands, abnormal postures

Athestosic- 15-20%, fluctuates contract- relax, uncontrolled movements, abnormal postures, extra pyramidal base lesion

Ataxic- 5-10%, altered balance, coordination, hard to reach objects, abnormalities in cerebellum

Hypotonic- fatal in pure form

Mixed- spastic upper limbs, dystonia in lower limbs and head

What do all forms of cerebral palsy have in common? (Symptoms- 13)

Muscular disorders (dysphagia)

Abnormal gait

Joint contracture

Muscular weakness

Visual disorders squinting

Auditory disorders hearing impairment

Dysarthria

Epilepsy

Difficulty chewing and swallowing

Early puberty onset

Learning disabilities

Respiratory difficulty

Psychopathic reactions tics, autism, negativism, agressiveness

What are 9 oral characteristics of cerebral palsy?

Hypoplasias

Dental trauma

Gingival hyperplasia due to hydantoins (anticonvulsants)

Caries- soft/liquid diet, sugary meds, swallowing difficulties, rewarded with sweets

Excessive saliva

Mouth respiration

Malocclusion- due to muscular disturbances or head position

Periodontal disturbances

Abnormal habits- couching, rumination, self harm, bruxism

What are 2 special treatments of cerebral palsy?

Excessive salivation (difficulty swallowing)- oral additions to help or Botox

Self harm- adapted oral protectors

5 types of autism

Classic

Rett syndrome- mainly women

Asperger syndrome

Childhood disintegrative disorder

Atypical autism

Etiology of autism

Genetically susceptible after exposed to irritant- mercury positioning, infections

Abnormality in neural connections, usually due to genetic mutations

Characteristics of autism? 4 possible manifestations?

4:1 freq in men

Highly genetic

High concordance in homozygous twins

Can effect personal relationships, communication difficulties, patterns of obsessive conduct, high IQ

11 symptoms of autism

Social interaction deficiency

Isolation

Stereotypes- uncontrolled movements

Language difficulties

Impulsivity, ADHD, behaviour problems

Stimulus hypersensitivity- sound, light

Resistance to change

Associated sometimes with mental illness

Emotional disturbed

Other- digestive, ophthalmic disorder

Disturbed sleep pattern

Oral manifestations of autism?

Not linked to ASD but more pathology due to limited physical, motor and behavioural difficulties

5 ways to management dental treatment in autistic patients?

Assess behaviour relationship capacity

Techniques- modulate conduct, pharma control, protective stabilisation, GA

Find out how they communicate

Desensitise

Don’t upset or alter routine