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CHAPTER 9
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• Poor oral hygiene
• Malocclusion
Problem List
• High caries risk due to special needs status, high
intake of sugared beverages, and poor oral hygiene
• Lack of a dental home
• Increased risk for periodontal disease due to poor oral
hygiene and compromised immunity
• Increased risk for ectopic eruption or impaction of teeth,
especially in maxillary arch (due to maxillary hypoplasia)
FUNDAMENTAL POINT 3
Trisomy 21 andOral Health
• Caries risk: use the American Academy of
Pediatric Dentistry Caries Assessment Tool in
assigning a patient’s risk category
• Periodontal disease: onset of periodontal
disease in individuals with trisomy 21 is
frequently seen by the late teen years. Incidence
in some adult populations has been reported to
be over 90%. This is probably due to the
reduced immune response in these people.
Early, aggressive therapy, including frequent
cleanings and possible systemic antibiotic
therapy, should be considered
• Malocclusion, ectopic eruption, impactions:
The class III malocclusion seen in trisomy 21
involves midface hypoplasia, and would, in
most cases, require extensive surgical
procedures to correct
Patients should be monitored for dental
crowding, ectopia, and impactions. These
problems may be correctable with orthodontic
and minor oral surgical treatment
(Pilcher 1998; Hennequin et al. 1999; American
Academy of Pediatric Dentistry [AAPD] 2018–2019)
Re‐evaluate patient’s ability to cooperate for
radiographic exam. If cooperative, take radiographs
to evaluate for interproximal caries and
development of permanent dentition
M. Prognosis andDiscussion
• This patient’s high intake of sugary beverages and poor
oral hygiene increases his risk for caries. Dietary
modifications and increased recall visits including topical
fluoride treatments should reduce this patient’s caries risk
• This patient is at high risk for development of periodontal
disease due to a combination of compromised immune
response and poor oral hygiene. Improved oral hygiene
and increased recall visits, including prophylaxis and
monitoring for periodontal problems, may help improve
this patient’s periodontal prognosis
• Behavioral capabilities, both in the dental setting and at
home, are always a consideration when treating
children with intellectual disabilities. There is a wide
range of behaviors in children with trisomy 21, and
many of them are treatable for routine dental care with
little or no modifications in care necessary. Diagnostic
exams for this particular patient were compromised by
the fact that he has, up to now, been uncooperative for
radiographs. An oral examination, prophylaxis, and
fluoride varnish treatment were made possible with the
mother’s assistance, holding her child in the dental
chair. Tell‐show‐do was used with limited effectiveness.
As per the mother’s report, the child’s behavior also
makes it difficult for her to accomplish adequate oral
hygiene at home. An attempt was made to keep the
dental visit as atraumatic as possible, and it is possible
that, in the future, the child may become more
cooperative. Children with trisomy 21 are at an
increased risk for complications related to sedation and
general anesthesia, and careful consideration must be
made for each individual as to whether or not an
anesthetic procedure is warranted for routine diagnostic
and dental procedures (see Fundamental Point 4).
Comprehensive Treatment Plan
L.
• Establish a dental home
• Dental prophylaxis and topical fluoride
• Encourage parent to reduce sugared beverage intake
• Encourage improved oral hygiene (in this case, with
parent), focusing on brushing and flossing
• Three‐month recall
Re‐evaluate caries risk
Re‐evaluate oral hygiene status
Monitor eruption of permanent dentition
356 Clinical Cases inPediatric Dentistry
Complications andAlternative
N.
TreatmentPlan
• If this patient had clinically detectable caries, would
the behavior management techniques previously used
be adequate to accomplish needed treatment?
• If this child had cervical spine (atlanto‐axial) instability,
how might the practitioner need to modify the way in
which dental care was delivered?
• Would there be any differences in this child’s
orthodontic care at this age if his behavior was
cooperative?
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FUNDAMENTAL POINT 4
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PATiEnTs wiTHDisAbiliTiEs
Sedation Considerations
• Individuals with trisomy 21 show an increased
incidence of the following anatomic variations/
medical conditions, which may place them at an
increased risk for complications associated with
sedation and general anesthesia:
Congenital heart defects
Small nasopharyngeal complex
Increased incidence of airway anomalies, including
laryngomalacia, tracheomalacia, bronchomalacia
Self‐Study Questions
1. What are some systemic ndings in children with
trisomy 21 that could signicantly impact longevity
and/or quality of life?
2. List four characteristic craniofacial features of
individuals with trisomy 21
Increased incidence of cervical spine instability
Obesity
Hypotonia
Obstructive apnea
• A careful risk/benet analysis should be conducted
for each child with trisomy 21 who is being
considered for treatment under sedation or general
anesthesia
(Lewanda et al. 2016)
5. What is the probable explanation for the
increased incidence of early, aggressive periodontal
disease in many individuals with trisomy 21?
6. Name four health conditions frequently seen in
individuals with trisomy 21
3. Name common intraoral ndings in individuals
with trisomy 21
4. List features of trisomy 21 that make these
patients poor candidates for outpatient sedation
procedures
7. If a patient presents with an unclear cardiac
history, what questions would you ask the patient’s
cardiologist?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 357
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CHAPTER 9
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Self‐Study Answers
1. Congenital heart defects, cognitive impairment,
compromised immune response, thyroid disorders,
cervical spine instability, increased risk for
development of leukemia, increased incidence of
early development of senile dementia
2. Hypoplastic midface, mild microcephaly,
upslanted palpebral fissures, short neck
3. Hypodontia, microdontia, delayed dental
eruption, ectopic dental eruption, dental impactions,
crowding of maxillary dentition,relative
macroglossia, class III malocclusion
4.
Increased incidence of airway anomalies, small
nasopharyngeal complex, hypotonia, obesity,
increased incidence of congenital heart defects,
increased incidence of spinal deformities and instability
Bibliography
American Academy of Pediatric Dentistry. 2018–2019. Caries‐risk
assessment and management for infants, children, and adolescents. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:205–12. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
caries‐risk‐assessment‐and‐management‐for‐infants‐
children‐and‐adolescents
American Academy of Pediatrics. 2011. Clinical report ‐ health
supervision for children with Down syndrome. Pediatrics
128(2):393–406.
Freeman SB, etal. 1998. Population‐based study of congenital
heart defects in Down syndrome. Am J Med Genet
80(3):213–17.
Individuals with trisomy 21 have a compromised
5.
immune response, which places them at increased
susceptibility for chronic infectious processes. This is
the probable explanation for their relatively high
incidence of periodontal disease
6. Congenital heart disease, hypotonia,
hypothyroidism, and compromised immune
function are a few of many associated
healthconditions associated with Down syndrome
(see Background Information 1 for a complete list)
7.
History of cardiac problems, associated
symptoms, surgeries, medications, and any
restrictions on activities
Hennequin M, etal. 1999. Significance of oral health in persons
with Down syndrome: a literature review. Dev Med Child
Neurol 41(4):275–83.
Jones KL, Jones MC, del Campo M. 2013. Recognizable
patterns of malformation. In: Smith’s Recognizable Patterns
of Human Malformation, 7th Edition. Philadelphia: Elsevier.
Lewanda AF, et al. 2016. Preoperative evaluation and compre-
hensive risk assessment for children with Down syndrome.
Paediatr Anaesth 26(4):356–62.
Mitchell RB, Call E, Kelly J. 2003. Ear, nose and throat disor-
ders in children with Down syndrome. Laryngoscope
113(2):259–63.
Pilcher ES. 1998. Dental care for the patient with Down
syndrome. Down Syndrome Res Pract 5(3):111–16.
358 Clinical Cases inPediatric Dentistry
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Case 2
Cerebral Palsy, Bronchopulmonary Dysplasia
D.
Medical History
• Premature birth (child was born at 26 weeks
gestational age, birth weight = 978 g) (see
Fundamental Point 1)
• Cerebral palsy, mixed type (spastic and dyskinetic)
(see Background Information 1)
• Status post bronchopulmonary dysplasia secondary to
long neonatal course of positive pressure ventilation
• Hospitalization for aspiration pneumonia at age two
• Mild/moderate asthma, currently managed with
Flovent (fluticasone) and albuterol inhalers used on a
daily basis
• Mild intellectual disability
Figure 9.2.1 Facial photograph.
A.
Presenting Patient
• Eight‐year‐, two‐month‐old Caucasian male
(Figure9.2.1)
Diagnosed with cerebral palsy, bronchopulmonary
•
dysplasia, asthma, and mild intellectual disability
B. Chief Complaint
• Patient presenting for recall appointment; last dental
visit was 18 months ago
C. Social History
• Patient attends school, and is in a class for children
with special educational needs
• Child lives at home with mother, father, and three
older siblings
• Father works full time; mother is a full‐time caregiver
• Socioeconomic status is lower-middle class
FUNDAMENTAL POINT 1
Low Birth Weight andAssociated Disorders
• Children who are born at extremely low birth
weights (<1000 g) are at risk for a number of
medical and developmental conditions that can
persist past the neonatal period and result in
health care issues throughout life. These include:
Cerebral palsy
Bronchopulmonary dysplasia (with subsequent
higher rates of asthma than children born at
full gestational age)
Patent ductus arteriosus
Intellectual disability
Visual impairment (retinopathy of prematurity)
Hearing impairment
(Hack et al. 2005)
Medical Consult
E.
• Consulted with primary care physician to ascertain
patient’s current respiratory status, which is stable
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BACKGROUND INFORMATION 1
Cerebral Palsy
• Cerebral palsy can be described as “a group of
disorders of the development of movement and
posture causing activity limitations that are
attributed to nonprogressive disturbances that
occurred in the developing fetal or infant brain.
The motor disturbances of cerebral palsy are
often accompanied by disturbances of
sensation, cognition, communication,
perception, and/or behavior and/or a seizure
disorder” (Bax etal. 2005)
• Bronchopulmonary dysplasia (BPD) is a
common complication of preterm birth. It is
seen most frequently in infants born prior to 30
weeks gestational age and weighing <1200 g at
birth. Itis related to the need for positive‐
pressure ventilation (PPV) in neonates with
poorly developed pulmonary systems. PPV can
result in injury to the pulmonary
microvasculature and alveolar structures.
Neonates with BPD are at increased risk for
abnormalpulmonary function into late
childhood and possibly adulthood (Blayney etal.
1991; Jobe and Bancalari 2001)
F. Dental History
• Has been managed at the same dental clinic from
three years of age
• Attendance at clinic has been sporadic (last visit 18
months ago)
• Positive behavior for brief procedures, but very active
in dental chair: try to keep appointments short
• Does not snack frequently, eats mostly at meal times
• Optimal water fluoridation levels
• Brushes without supervision (once or twice per day)
G. Extraoral Exam (Figure9.2.1)
• No significant findings
H. Intraoral Exam (Figure9.2.2a-c)
• Early mixed dentition (slightly delayed for age)
A B
C
Figure 9.2.2 (A–C) Intraoral photographs showing generalized
marginal gingivitis and mandibular crowding.
Poor Oral Hygiene
•
Generalized marginal gingivitis
• Clinical exam suggests caries‐free dentition
I. Diagnostic Tools
• Radiographic imaging (bitewings and a panoramic
film) were attempted, but were of poor diagnostic
quality due to patient’s difficulty staying still
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Cerebral palsy
• Cognitive impairment (mild)
• Status post bronchopulmonary dysplasia with current
mild/moderate asthma
Problem List
Irregular use of a dental home
•
• Gingival inflammation due to poor oral hygiene
• High caries risk due to poor oral hygiene and asthma
medications
• Unknown caries status of interproximal surfaces
• Large overjet increases risk of traumatic dental injury
• Moderate mandibular crowding
Occlusion
• Overjet 9 mm, anterior open bite
• Moderate crowding of the lower arch
• Mesial step primary molars, class I canines
360 Clinical Cases inPediatric Dentistry
L. Comprehensive Treatment Plan
(Fundamental Point 2)
• Dental prophylaxis (sedation may be necessary)
• Fluoride treatment
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PATiEnTs wiTHDisAbiliTiEs
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• Review of oral hygiene and diet (with parent
andchild)
• Orthodontic consultation:
Space analysis to evaluate arch length
Evaluate patient’s behavior regarding his ability to
cooperate for orthodontic treatment (if treatment is
indicated at this time)
• Three‐month recall:
Re‐evaluate caries risk
Re‐evaluate oral hygiene and soft tissue status
M. Intraoral andPostoperative Images
• Not applicable
N. Prognosis andDiscussion
• Although the patient is in a high‐risk category for
dental caries due to poor oral hygiene, he has never
had a carious lesion. The prognosis for continued
periodontal pathology is high due to poor hygiene,
butcould improve with better daily oral hygiene.
Evenperforming a thorough prophylaxis may be
difficult and sedation may be considered (see
Fundamental Point 3)
• The prognosis for malocclusion is poor. Although the
patient is fairly cooperative for oral examinations and
prophylaxis, it is not clear what his level of
cooperation would be for lengthier or more
complicated treatments. This must be evaluated and
taken into consideration before a decision is made to
begin orthodontic treatment
O. Complications andAlternative
TreatmentPlan
• If the patient had dental caries present, would the
behavior management techniques previously used be
adequate to accomplish the needed treatment?
• Is this child an appropriate candidate for in‐office
sedation, or would he be better managed in a hospital
operating room setting, if treatment needs dictated?
• Would there be any difference in this child’s
orthodontic treatment at this age, if behavior was not
a consideration?
FUNDAMENTAL POINT 2
Oral Health withCerebral Palsy
• Caries risk: use the American Academy of Pediatric
Dentistry (AAPD) Caries Assessment Tool in
assigning a patient’s risk category (AAPD
2018–2019a)
• Provide dietary counseling to the parent (AAPD
2018–2019a,b)
• Hypotonia of the tongue and perioral musculature
can result in anterior open bites and a constricted
palate. (This particular patient does not have a
constricted palate)
Immature swallow pattern, with characteristic
•
tongue thrust, can also contribute to anterior open
bite
• A poor swallow reex, seen in some patients with
cerebral palsy, can result in persistent drooling,
which can irritate skin in the perioral region (Ortega
etal. 2007)
•
Increased risk of candidiasis with the use of an
inhaler
• Gingival inammation:
Stress to parent the importance of daily oral
home care. Instruct the parent to help with
child’s oral hygiene
Schedule recall visits at more regular intervals to
assess home care, perform prophylaxis, and
monitor gingival inflammation (AAPD 2018–2019c)
Malocclusion:
•
Conduct orthodontic evaluation in early mixed
dentition
Assess tooth size, shape, position
Conduct space analysis (AAPD 2018–2019d)
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FUNDAMENTAL POINT 3
Sedation Considerations
• This patient’s history of bronchopulmonary
dysplasia, aspiration pneumonia, and mild/
moderate asthma puts him at risk for respiratory
complications during sedation
• According to the American Society of
Anesthesiologists (ASA) physical status
classification system, the patient would be ASA
class II (mild systemic disease)
• If the patient required dental procedures that could
not be completed without sedation and/or general
anesthesia, his respiratory history should be taken
into consideration when deciding the most
appropriate setting (i.e.outpatient clinic or hospital
operating room) and type of anesthesia (AAPD
2018–2019e)
362 Clinical Cases inPediatric Dentistry
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Self‐Study Questions
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PATiEnTs wiTHDisAbiliTiEs
1. What are some common complications of
extreme low birth weight that can have
long‐term sequelae?
2. Name three oral/perioral complications, and
theiretiology, sometimes seen in patients with
cerebral palsy
3. True or false: cerebral palsy is a progressive
neurologic disorder
4. In what category of neonates does
bronchopulmonary dysplasia most frequently
develop?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 363
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CHAPTER 9
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Self‐Study Answers
1. Cerebral palsy, respiratory disorders, intellectual
disability, visual impairment, hearing impairment,
congenital heart defects
2. Anterior open bite, narrow palate and persistent
drooling can all be a result of hypotonia (low muscle
tone) of the perioral musculature
3. False. Cerebral palsy is sometimes termed a
“static encephalopathy.” The original lesion in the
Bibliography
American Academy of Pediatric Dentistry. 2018–2019a. Caries‐
risk assessment and management for infants, children, and
adolescents. In: Clinical Practice Guidelines and Best
Practices (Reference Manual). Pediatr Dent 40:205–12.
https://www.aapd.org/research/oral‐health‐policies‐‐
recommendations/caries‐risk‐assessment‐and‐management‐
for‐infants‐children‐and‐adolescents
American Academy of Pediatric Dentistry. 2018–2019b. Policy
on dietary recommendations for infants, children and adolescents. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:65–7. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
dietary‐recommendations‐for‐infants‐children‐and‐
adolescents
American Academy of Pediatric Dentistry. 2018–2019c.
Periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants,
children and adolescents. In: Clinical Practice Guidelines
and Best Practices (Reference Manual). Pediatr Dent
40:194–204. https://www.aapd.org/research/oral‐health‐policies‐‐
recommendations/periodicity‐of‐examination‐preventive‐dental‐
services‐anticipatory‐guidance‐counseling‐and‐oral‐
treatment‐for‐infants‐children‐and‐adolescents
American Academy of Pediatric Dentistry. 2018–2019d.
Management of the developing dentition and occlusion in
pediatric dentistry. In: Clinical Practice Guidelines and Best
Practices (Reference Manual). Pediatr Dent 40:352–65.
https://www.aapd.org/research/oral‐health‐policies‐‐
recommendations/management‐of‐the‐developing‐dentition‐
occlusion‐in‐pediatric‐dentistry
brain does not progress or result in further
deterioration to the central nervous system.
Beaware, however, that the clinical presentation of
cerebral palsy, especially muscle function, can
change as an individual matures and ages
4. Bronchopulmonary dysplasia develops most
frequently in infants born with extremely low birth
weights (<1000 grams) and/or prior to 30 weeks
gestation
American Academy of Pediatric Dentistry. 2018–2019e.
Monitoring and management of pediatric patients before,
during and after sedation for diagnostic and therapeutic procedures. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:287–316. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
monitoring‐and‐management‐of‐pediatric‐patients‐before‐
during‐and‐after‐sedation‐for‐diagnostic‐and‐therapeutic‐
procedures‐update‐2016
Bax M, Goldstein M, Rosenbaum P etal. 2005. Proposed defi-
nition and classification of cerebral palsy. Dev Med Child
Neurol 47(8):571–6.
Blayney M, Kerem E, Whyte H, O’Brodovich H. 1991.
Bronchopulmonary dysplasia: improvement in lung function
between 7 and 10 years of age. J Pediatrics 118(2):201–6.
Hack M, Taylor HG, Drotar D etal. 2005. Chronic conditions,
functional limitations, and special health care needs of
school‐aged children born with extremely low‐birth‐weight
in the 1990s. JAMA 294(3):318–25.
Jobe AH, Bancalari D. 2001. Bronchoplmonary dysplasia. Am J
Respir Crit Care Med 163(7):1723–9.
Ortega AOL, Guimaraes SS, Ciamponi ALL, Mari SKN. 2007.
Frequency of parafunctional oral habits in patients with
cerebral palsy. J Oral Rehab 34;323–8.
364 Clinical Cases inPediatric Dentistry
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Case 3
Attention Deficit Hyperactivity Disorder
BA
Figure 9.3.1 (A, B) Facial photographs.
A. Presenting Patient
• Nine‐year‐, six‐month‐old female (Figure9.3.1)
• New patient visit
B. Chief Complaint andHistory of
PresentIllness
• Routine examination and evaluation for possible
orthodontic treatment
C. Social History
• Patient lives at home with both parents and one
brother
•
Both parents work full‐time
• All family members are healthy
D. Medical History
• Patient received diagnosis of attention deficit
hyperactivity disorder (ADHD) when she was seven
years old. According to mother, patient’s ADHD is
primarily inattentive type. She is forgetful and has
trouble concentrating, but has never had behavioral
issues at school or in other settings (see Background
Information 1 and Fundamental Point 1)
• Mild asthma, exacerbated by upper respiratory
infections
• Mild eczema
• Patient is followed by a developmental pediatrician;
routine visits every six months. Primary care
pediatrician for asthma and eczema
• Current medications:
Concerta: 27 mg once a day, to manage ADHD (See
Fundamental Point 2)
Albuterol inhaler as needed for asthma (patient last
used inhaler three months ago)
Betamethasone cream applied topically to
eczema as needed
E. Medical Consult
• Primary care pediatrician confirmed patient’s status of
mild asthma
• Requested that family bring inhaler to dental visits
F. Dental History
• Patient had been to previous dentist; had dental
cleanings and fluoride treatment. No behavior
problems, according to parent (family recently
moved, and therefore seeking treatment with new
dentist)
• Before moving to the area, lived in an area without
water fluoridation. Now, optimal water fluoridation
levels
• Healthy, relatively low cariogenic diet, moderate
snacking noted
• Brushes without supervision twice a day. Mother
knows that child does not brush thoroughly (note food
debris on maxillary right permanent first molar in
Figure9.3.2.b). However, child is resistant to receiving
help with brushing
G. Extraoral Exam
• Patient has an underdeveloped midface region, with
relative prognathism of the jaw (see Figure9.3.1b)
Clinical Cases inPediatric Dentistry 365
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