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Paeds L1: Neuro impairment
Intro
Dental importance
Special…
Paeds L1: Neuro impairment
- Intro
- Dental importance
- Special considerations
- Examples
- Etiquette: Respect person + Level of impairment
Impairments
Physical
- Brain injury (CP, epilepsy)
- Spinal cord injury (tetra/paraplgeia)
- Anterior horn cell
- Nerve
- MSK
- Sensory
Developmental/Behavioural
Mixed
- Global developmental delay (Both cog & phys)
- Multiple disabilities
Genetic syndromes
- Down syndrome (most common)
- Dysmorphic (varying physical/intellectual)
- Not all are neurologically impaired
Special needs
- Individual who requires assistance for disabilities (physical/developmental)
Barriers to OH
- Dento-facial anomalies
- Dependence on others
- Diet
- Medication
- Relatively high cost
Importance of OH
- Pain/sleep
- Function (Eat, speech)
- Infection
Special considerations
Sedation risk
- Light sedation (Low dose chloral 30mg/kg/dose)
- 1. Risks Airway: Narrow airway, midface hypoplasia, assessment mallapati score (1 best 4 worst)
- 2. Risks muscle: Poor lung capacity, cough, failure under GA, maliganent hyperthermia
-
Physical
Epilepsy:
- Prevalence: 15-60% in children with neurological impairment
- Definition: Recurrent unprovoked seizures, discharges from brain
- S/Sx Loss of consciousness, tonic/clonic (stiffening/jerking) limbs :red_cross: with respiratory arrest
- Mx: Know seizure type, Anti-epileptic drugs and side effects valproate may cause thrombocytopenia, phenytoin may cause gum hypertrophy :red_cross:
- Post-seizure: Fever, infection, sleep deprivation, stress, acute withdrawal :red_cross:
- Acute Mx: Recovery flat surface, removing harmful objects / FB in airway, provide oxygen and suction, note nature / onset duration. Rectal diazepam if seizure does not cease aft 5mins :red_cross: 1 tube (5mg) <20kg, 2 tube (10mg) >20kg, hold buttocks together so diazepam will not leak out. Look out for respiratory depression. Onset 5-10mins
C1/C2 subluxation (Atlanto-axial)
- Association: 20% Downs, Marfans, NF-1 :red_cross:
- Risk for spinal cord injury during hyperextension during dental procedure
- Need orthopedic/neuro assessement before sedation/GA, eg. flexion and extension films
Ab Prophy
- Conditions: Prosthetic valves, Heart transplant with valve regurgitation, Unrepaired or residual cyanotic congenital heart disease, previous IE
- Cyanotic congenital heart disease might trigger hypercyanotic attack if patient is in pain
Specific examples
CP
- Definition: Damage to developing brain, results in disorder of movement and posture that is permanent
- Associations: Intellectual disability, Non-ambulant, Epilepsy, Beahaviour disorder, non-oral feeding
- Types: Regional vs Global, R-Spastic, G-Dyskinetic, G-Ataxia (lack of voluntary contraction)
- Most common type of Neuro kids who will see dentist
- Difficulty: Transport, random movements (Dystonia: Spastic /Dyskinesia: Abnormal or impaired), gag reflex (before breakfast), hearing or visual impairment
- Moderate to high sedation risk - airway, muscular weakness
Downs (Genetic syndrome)
- Prevalence: 1/1000 births :red_cross:
- Definition: Dysmorphic features, physical delays, intellectual disability
- Dental: Conial tooth roots, poor immunity, fewer dental caries due to delayed erruption, missing lots of teeth :red_cross:
- Health poor immunity C1/C2 subluxation, cardiac disorders (MVP 50%), Hypotonia floppy baby, Malignancy risk leukemia, poor immunity
- Small midface, open bite (Airway difficulties), large tongue, gag reflex
- Behavoiur not a problem
- Tell show do works
ASD
- Definition: Persistent deficient in social communication and interaction, repetitive patterns of interest Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
- Difficulties: Malnutrition, epilepsy, behavioural - hypersensitivity to surroundings, tell-show-do, desnsitize,
- moderate sedation risk