DISABLED CHILD CONTENTS 1. Introduction 2. Classifications 3. Cerebral palsy 4. Seizure disorders 5. Deafness 6. Blindness 7. Mental retardation 8. Autism 9. Down‟s syndrome 10. Learning disabilities 11. Fragile X syndrome 12. Fetal alcohol syndrome 13. Preventive methods for disabled child 14. Positioning 15. Physical restraints 16. References 1 INTRODUCTION: According to the report of committee on child health (Court, 1976). A „defect‟ is some imperfection or disorder of the body. A „disability‟ is a defect, which does result in some malfunctioning, but which does not necessarily affect the individual‟s normal life. A „handicap‟ is a disability, which, for a substantial period or permanently, retards, distorts or otherwise adversely affects growth, development or adjustment to life. According to Harris (1971), “impairment is lacking part or all of a limb, or having a defective limb, organ or mechanism of the body; disablement is the disadvantage or restriction of activity caused by disability”. According to the developmental disabilities services and facilities construction act (Oct. 30, 1970), developmental disabilities are defined as: “A disability attributable to mental retardation, cerebral palsy, epilepsy, or other neurological handicapping conditions of an individual found to be closely related to mental retardation or to require treatment similar to that required by mentally retarded individuals, and a. Originates before the individual attains age 18. b. Has continued, or can be expected to continue indefinitely 2 c. Constitutes a substantial handicap to such individuals. In 1975, the definition was expanded to include “autism and any other conditions found to be closely related to mental retardation or to be attributable to dyslexia”. The WHO (1974) has defined a handicapped person as “one who over an appreciable period is prevented by physical or mental conditions from full participation in normal activities of their age groups including those of a social, recreational, educational and vocational nature”. According to the APHA A child who cannot within limits play, learn, work or do other things other children of his age can do; he is hindered in achieving his full physical, mental and social potentialities (Troutman, 1970). Holloway and Swallow (1982) “a patient is only handicapped as far as dentistry in concerned if he or she is unable to obtain treatment in the ordinary way”. According to the American academy of pediatric dentistry (1996), a person should be considered dentally handicapped if pain, infection or lack of functional dentition which affects the following: a. Restricts consumption of diet adequate to support growth and energy needs. b. Delays or otherwise alters growth and development. 3 c. Inhibits performance of any major life activity including work, learning, communication and recreation. Classification: A. Frank and Winter, (1974), have classified handicap as: Blind or partially sighted Deaf or partially deaf Educationally subnormal Epileptic maladjusted Physically handicapped Defective of speech Senile Agerholm (1975) classified handicapping conditions into: Intrinsic handicap Extrinsic handicap An intrinsic handicap is one from which the person cannot be separated, while an extrinsic handicap is one from which the person, the patient can be removed, for example, social deprivation. Nowak (1976) has classified handicapping conditions into nine categories as follows: Physically handicapped, e.g., poliomyelitis, scoliosis. Mentally handicapped, e.g., mental retardation. Congenital defects, e.g., cleft palate congenital heart disease. Convulsive disorder, e.g., epilepsy Communication disorder, e.g., deafness, blindness Systemic disorders, e.g., hypothyroidism hemophilia Metabolic disorders, e.g., juvenile diabetes Osseous disorders, e.g., rickets, osteopetrosis 4 Malignant disorders, e.g., leukemia. Considering the variations in the types of treatment modalities for handicapped children, for the convenience of management, they can be categorized into two: Developmentally disabled child Medically compromised patients CEREBRAL PALSY: Nelson et al. used the term cerebral palsy to describe a group of non-progressive disorders resulting from malfunction of the motor centers and pathways of the brain. These are characterized by paralysis, weakness, in coordination, or other aberrations of motor function that have their origin prenatally, during birth, or before the CNS has reached relative maturity (before age 5). Cerebral palsy encompasses the neuromotor manifestations of organic brain damage and may occur in conjunction with other manifestations (e.g., seizures, mental retardation, various sensory defects, and behavioral and emotional disorders). Cerebral palsy is a heterogeneous disorder that may result from congenital defects, mechanical and chemical injury, and infection. The condition is frequently subclassified according to clinical findings. The pathologic and clinical findings are varied. It is generally a nonfatal, noncurable condition that, in part, is amenable to education, therapy, and training. Patients with 5 cerebral palsy are frequently treated in neurology clinics in hospitals, and pediatric neurologists often request dental consultation for the many oral problems of these patients. Incidence: Estimates of the incidence and prevalence of cerebral palsy vary significantly among authorities. Capute(1974) reports that the incidence at birth varies from 0.6 to 5.9 per 1000 and estimates the prevalence in children of school age at 0.6 to 2.4 per 1000. Classification: Spastic type: 1. Occurs in more than 40% of the cases (possibly 60% to 70%). 2. Caused by a lesion in the cerebral cortex. 3. Tendency for the antigravity muscles to maintain a state of contraction and for the antagonists to lengthen, producing the characteristic flexion deformities, particularly in the large joints. 4. Spastic quadriplegia frequently associated with convulsions and mental retardation. Oro-dental manifestations: 1. Limited head movement 2. Hypertonicity of facial muscles 3. Slow jaw movements 4. Hypertonic orbicular muscles 5. Spastic tongue-thrust 6 6. Drooling 7. Constricted mandibular and maxillary arches 8. Class II, Division II, malocclusion (75%), usually with unilateral crossbite. 9. Mandibular shift. Athetosis: 1. Occurs in about 25% of the cases. 2. Caused by a lesion in the basal ganglion. 3. Distinguishing characteristic a slow, writhing, involuntary movement that occurs with volitional movement and interferes with normal muscle action. 4. Muscle normal, with no spasticity or weakness. 5. Involuntary movements either tremor or rotary. 6. Most often nor associated with convulsions or mental retardation. Oro-dental manifestations: 1. Excessive head movement or head drawn back with bull-type neck. 2. Quick jaw movements. 3. Hypotonic orbicular muscles. 4. Grimacing and drooling (85%). 5. Mouth breathing (continuous). 6. Tongue protruding between teeth and lips. 7. Bruxism. 8. High, narrow palatal vault. 9. Class II, Division I malocclusion may occur in 90% cases. 10. Anterior openbite. 11. Poor swallowing, sucking, etc., because of impaired function of muscles of deglutition. Ataxia: 7 1. Occurs in 10% of cerebral palsy patients. 2. Caused by a lesion of the cerebellum. 3. Distinguishing characteristic a disturbance in equilibrium. 4. No muscular involvement. Oro-dental manifestations: 1. Lack of positional sensation (balance). 2. Poor proprioceptive sensations. 3. Slow, tremorlike head movements. 4. Hypotonic orbicular muscles. 5. Ankyloglossia in some cases. 6. Tongue protrusion and open bite in some cases. 7. Grimacing and drooling. Rigidity: 1. Occurs in 5% of the cases. 2. Caused by a lesion of the basal ganglion. 3. Manifested by constant rigidity. 4. Voluntary movement that is slow and stiff. 5. Patients resistant to flexor and extensor movements with contraction of agonists and antogonists. Tremors: 1. Present in about 5% of the cases. 2. Caused by a lesion of the basal ganglion. 3. Distinguishing characteristic a repetitive, rhythmic, involuntary contraction of flexor and extensor muscles. Any of these characteristic disorders can affect the following areas : 1. Monoplegia, one extremity affected. 2. Diplegia, affecting like parts on both sides of body. 8 3. Paraplegia, legs and lower part of body. 4. Hemiplegia, half of body affected. 5. Quadriplegia, all four limbs affected. Prognosis and associated defects: The mortality rate is about 15% in the first 5 years of life. Of these at least 45% are severely mentally defective. Abount 30% are educable. Some 35% can be classified as normal. About 25% are severely physically disabled, another 50% moderately disabled, and the other 25% minimally involved. General disabilities associated with cerebral palsy occur at the following rates : Speech defects 50% to 75% Mental retardation (severe) 45% Visual defects 20% to 50% Seizures (convulsions) 35% to 60% Deafness 10% to 30% Communication: An important aspect in the management of the patient with cerebral palsy in the dental office is communication. It has been noted that 45% may have severe retardation, 25% have hearing loss, and 50% to 75% have associated speech defects. Even with these obvious handicaps, both verbal and non-verbal communication is possible and necessary. Because significant personality differences exist in each type of cerebral palsy, 9 understanding the characteristics of each can more easily attain communication with the patient. The spastic patient has been described as shut in and introverted. Fearfulness is prominent and spastic episodes may be induced by any outside stimulus (e.g., loud noises, sudden jars, new situations, or meeting strangers). Consequently the spastic patients prefers an environment devoid of excitment and stimulation. He is even afraid of demonstrations of affection because of their effect on him. The spastic patient is slow to show anger and quick to recover. He needs preparation before he is introduced to a new situation and requires patience and understanding in every phase of handling. The rigid patient resembles the spastic individual in personality. Fear generally is not so pronounced, but it may be prominent. The individual with athetosis is typically without excessive fear. He is readily provoked to outbursts of anger, but his annoyance is quickly forgotten. He craves attention and affection and enjoys the company of people. Striking features are his lack of insight into his shortcomings and his drive to succeed. Despite his difficulties in expressing himself, he likes to engage in conversation. 10 The personality of the ataxic individual resembles that of the athetoid patient. He has little fear. Anger is readily provoked by his inability to direct a movement. When asked to make repeated efforts, he appreciates firm quiet handling. He craves affection and is demonstrative and outgoing. He likes people and makes friends easily with both normal persons and other handicapped individuals. Affection and approval are necessary when working with him. Dental considerations: No specific oral disease is related to cerebral palsy; however, there are some specific characteristics that depend on the musculature affected and the degree of mental or developmental retardation present. The usual dental problems of caries and periodontal disease are often exaggerated by neglect. Hence the primary problems for dentists are patient management and preventive care. There is no significant difference in the eruption time of primary and permanent teeth. The caries pattern is similar to that of healthy individuals but may be exaggerated because of poor diet, faulty nutrition, poor hygiene, and prolonged retention of food on the teeth. Dental management: Routine dental procedures can normally be accomplished effectively with these patients. Generally the patient with cerebral 11 palsy will understand and cooperate when the dentist takes the time to show and explain before starting a procedure. These patients typically want to cooperate, but their lack of muscular control makes it difficult for them. One can also assist the patient by using a rubber mouth prop to hold the mouth open. Care must be taken not to force the mouth open but just to help keep it open. The dentist should at all times support or cradle the patient‟s head as he works, to control involuntary movements, and should be especially concerned with the patient‟s positioning since most individuals with cerebral palsy have a preferred comfortable postural state. Spastic patients, in particular, have a definite postural preference since the affected limbs tend to normally remain in a flexed position. This may sometimes necessitate the dentist‟s working in an uncomfortable position. Restraints or supports frequently help in immobilizing a patient with excessive involuntary movements. The purpose and function of the restraints should be explained to the patient and the family before the procedure, with emphasis that they are not a form of punishment but a protection for the patient. Restraints that are too tight may increase involuntary movements. Premedication is a useful modality in the management of patients with cerebral palsy who have difficulty controlling 12 movements or have excessive fear and apprehension. The dentist should be thoroughly familiar with premedicant drugs and should understand their interactions and effects before using them. Some older patients are too large for restraints, and pre - medication is contraindicated in the large doses often required. General anesthesia may be needed for these patients and others extremely difficult to manage. Seizure disorders: Nelson et al. described five main types of seizure disorders in children divided into two etiologic groups, idiopathic and symptomatic. Seizures in the idiopathic group cannot be attributed to a demonstrable structural lesion of the brain and are frequently of genetic origin. Those in the symptomatic group are associated with developmental anomalies, injury, or disease of the brain. Chronic or recurrent convulsions are the problem the dentist will most often encounter in these patients. The dentist should be able to recognize and manage the seizure if it occurs. Five different types of seizures, which vary in severity, repetitiveness, length, and cause, are examined here. Classification of seizures: Grand mal seizures: - These are preceded by a momentary aura in approximately a third of the patients. 13 - Characterized by generalized seizures, usually occurring with tonic and clonic phases of muscular spasm with rapid onset. - The patient looses consciousness and becomes pale. - Dilatation of pupils upward rolling of eyeballs, facial distortion and rapid contraction of jaw muscles. - Micturition and defecation may occur. - Patient may experience cyanosis during the tonic phase, which generally lasts for 20-40 seconds. This is followed by the clonic phase, which may last for variable periods of time, usually for a few minutes. - Patients who awaken from the seizure generally have severe headache and are in a state of confusion. Petit mal seizures: - They appear generally between 3 years of age and puberty . - They occur in more commonly in girls than in boys. - Characterized by transient loss of consciousness, frequency may vary from once or twice a month to several times a day. - The seizure generally lasts for about 30 seconds. - Other manifestations like rolling of eyes, moving of eyelids, rhythmic movement of the head and quivering of trunk and limb muscles may occur. - Many times these seizures go unnoticed. 14 Psychomotor seizures: - Most difficult to diagnose and control. - Usually a slight aura manifests itself in a young child as a shrill cry or an attempt to run for health. - After an attack of seizure the child generally become drowsy. - Characterized by loss of postural tone, 1-5 minute‟s unconsciousness. - Generally there are no tonic and clonic phases present. Focal seizures (Jacksonian seizures): - These are produced by injury to some part of the brain, which may be due to trauma or toxic agents. - Manifestations are related to the part of the brain affected. - The seizures are sensory or motor and are of clonic in nature. - The muscles commonly involved are the voluntary ones required for movements of hand, face and tongue. Self induced seizures: - Some children induce petit mal or grand mal seizures by over breathing, by watching a blinking light or by performing some form of learned behaviour. - These should be distinguish from other types because drug treatment alone may not be satisfactory in managing these children. 15 - It is generally an attempt to draw attention, indicating some kind of behavioural, psychiatric and/or family problems. Dental management: Most convulsive disorders are controlled through mediation and pose few problems in dental treatment. The dentist or hygienist should ask the following questions during history taking of all seizure patients: 1. What was the age of the patient at the time of onset of the seizure disorder? 2. How many seizure types do the patients have? 3. What is the frequency of the seizures? 4. Is the attack preceded by an aura? If so, what is the nature of the aura? 5. Does the patient tend to injure himself during the attack? 6. Do the seizures occur at any particular time of day? 7. How does the patient act immediately preceding the seizure and after the seizure is over? 8. What types of medication is the patient taking and when is the medication taken? During actual dental or dental hygiene appointments, adequate preparation must be made prior to the insertion of instruments or tooth-anchored devices (rubber dam, clamps) into the oral cavity. Since anxiety is a frequent precipitating factor of 16 seizure activity, premedication with minor tranquilizers can be considered. The particular anticonvulsant drug regimen of the patient must be carefully evaluated, however, prior to the administration of such sedative drugs. These patients often arrive at the office in a slightly sedated state due to the CNS-depressed activity of anticonvulsant medications. It must be stressed that the patient should never alter the daily medication routine in either time of administration or dosage on the day of dental treatment. The prescribing of antianxiety premedications can also enhance the postictal depression of major motor seizures if a seizure does occur in the office. The use of a mouth prop is mandatory during actual treatment. Once a seizure begins, it is usually impossible to insert any device to prevent intraoral injury due to the strength of masseter contractions. The mouth prop is the best preventive measure against trauma during a seizure episode. Dental units that employ “over the patient” delivery systems for handpieces and air-water syringes should be pushed away from the working field in case the patient lurches forward during the tonic phase of a seizure. This reduces the possibility of hitting dental devices, which could cause facial lacerations. The major consideration for the dentist and auxiliaries during a seizure is to ensure that the patient does not suffer any physical 17 harm. Merely use stabilizing techniques to assure that the patient does not fall out of the chair. Maintain the mouth prop in place. Loosen the patient‟s clothing. Once the postictal phase begins, turn the patient‟s head to the side, pulling the rubber dam material on the Young‟s frame away from the face to evacuate any accumulated oral secretions. Constantly and produce a calming effec t. If treatment has not yet actually begun, be sure that all tissues are without damage. Discontinue dental therapy. If restorative procedures have already been started, either temporize or complete the final restoration. Although the patient will be in a sedated form of consciousness, this does not contraindicate completion of a restoration unless some injury has occurred or systemic parameters are not within normal range. If appliances are indicated for tooth movement or tooth replacement purposes, the fixed type is preferred because there is less chance of dislodgement. If fixed appliances are used for replacing avulsed anterior teeth, however, the possibility of fracturing prosthetic tooth material always remains a factor. It is always best to sacrifice some esthetic qualities for safety precautions be ensuring that no lateral or protrusive contacts are present. Appointments should occur just after the patient has taken daily medications. Confirmation that the medication has been 18 taken should always be made before the dentist institutes any form of treatment. Dilantin hyperplasia, an overgrowth of the gingival tissue resulting from phenytoin (Dilantin) medication, can occur in, patients with convulsive disorders. Baired and Bhaskar report that 10% to 30% of patients who receive phenytoin for control of epilepsy have a generalized enlargement of the gingiva, with the labial gingiva of the maxillary and mandibular teeth the most frequently involved. A distinction should be made between the excessive fibrous tissue that occurs because of the phenytoin and the unhealthy inflamed tissue that is superimposed on the hyperplasia. The hyperplastic tissue that becomes unhealthy and inflamed because of poor oral hygiene may be a focus of infection and cause pain, which can in turn precipitate a convulsion. DEAFNESS: Deafness is a handicap that is often overlooked because it is not obvious. Total deafness is not common, but a dentist is likely to treat hearing impaired children who have varying degrees of deafness. Almost inevitably, speech is affected. If an impairment is severe enough that dentist and child cannot communicate verbally, the dentist must use slight, taste, and touch to communicate and to allow the child to learn about dental experiences. 19 ISO Handicap Speech comprehension Psychologic problems in (db) children 0 Insignificant Little or no difficult None >25 Slight Difficulty with faint speech; May show a slight verbal language and speech deficit development within normal limits >40 Mild- Frequent difficulty with Psychological problems can moderate normal speech at 1 m; be recognized language skills are mildly affected >55 Marked Frequent difficulty with loud Child is likely to be speech at 1 m; difficulty educationally retarded, with understanding with hearing more pronounced emotional aid in school situation and social problems than in children with normal hearing >70 Severe Might understand only The prelingually deaf show shouts or amplified speech pronounced educational at 1 foot from ear retardation and evident emotional and social problems >90 Extreme Usually no understanding of The prelingually deaf usually speech even when amplified; show severe educational child does not rely on retardation and emotional hearing for communication underdevelopment Many times, mild hearing losses are not diagnosed, leading to management problems because of misunderstanding of instructions, whereas children with more severe hearing losses already possess psychological and social disturbances that make dental behavior management more complex. No abnormal dental findings are associated with deafness. 20 The following are known causes of hearing loss; Prenatal factors: Viral infections, such as rubella and influenza Ototoxic drugs Congenital syphilis Heredity (for example, Waardenburg syndrome) Perinatal factors: Toxemia late in pregnancy Prematurity Birth injury Anoxia Erythroblastosis fetalis Postnatal factors: Viral infections, such as mumps, measles, chickenpox, influenza, poliomyelitis, miningitis Injuries Ototoxic drugs, such as aspirin, streptomycin, neomycin, kanamycin. The following should be considered when treating a hearing - impaired patient; 1. Prepare the patient and the parent before the first visit, with a “welcome” letter than states what is to be done. 2. Through the parent, determine during the initial appointment how the patient desires to communicate, which will go far in decreasing the child‟s fears. 3. Assess speech and language ability and degree of impairment by taking a complete medical history. 21 4. Face the patient and speak at a natural pace and directly to the patient without shouting. Exaggerated facial expressions and the use of slang make lip-reading difficult. Even the best lip-readers comprehend only 30% to 40% of what is said. 5. Watch the patient‟s expression. Make sure the patient understands what the dental equipment is, what is going to happen, and how it will feel. 6. Reassure the patient with physical contact; hold the patient‟s hand initially, or place a hand reassuringly on the patient‟s shoulder. 7. Employ the tell-show-do approach. Allow the patient to see the instruments, and demonstrate how they work – for example, vibrations of the handpiece, scratching of the explorer, scooping of the excavator, and texture of the rubber dam. 8. Use smiles and reassuring gestures to build up confidence and reduce anxiety. 9. Avoid blocking the patient‟s visual field. 10. Adjust the hearing aid (if the patient has one) while the handpiece is in operation, since a hearing aid will amplify all sounds. Many times the patient will prefer to have it turned off. 22 BLINDNESS: Blindness affects over 15 million people today and will affect an estimated 30 million people by the year 2000. The list that follows gives some of the known causes of blindness; however, in over 35% of those affected the cause is either unknown or unerupted. Blindness is not an all-or-none phenomenon; a person is considered to be affected by blindness if the visual acuity does not exceed 20/200 in the better eye, with correcting lenses, or if the acuity is greater than 20/200 but accompanied by a visual field of no greater than 20 degrees. Prenatal causes: Optic atrophy Microphthalmus Cataracts Colobomas Dermoid and other tumors Toxoplasmosis Cytomegalic inclusion disease Syphilis Rubella Tuberculous meningitis Developmental abnormalities of the orbit Postnatal causes: Trauma Retrolental fibroplasia Hypertension Premature birth 23 Polycythemia vera Hemorrhagic disorders Leukemia Diabetes mellitus Glaucoma Blindness may be only one aspect of a child‟s disability. For example, a patient with congenital rubella may be afflicted with deafness, mental retardation, congenital heart disease, and dental defects, as well as blindness resulting from congenital cataracts. Blindness is one disorder that may result in frequent hospitalizations, separation from family, and slow social development. Since a blind child‟s capabilities are difficult to assess, many times such a child may be considered developmentally delayed. Consideration must be given to every developmental aspect of a blind child. Many times, early in development the parents experience guilt and either overprotect or reject the child, resulting in a lack of development of self-help skills and delayed development in general, which is often misinterpreted as mental retardation. Assessment of parental attitudes is of primary importance in behavioral management. In addition, blind children may exhibit self-stimulating activities such as eye pressing, finger flicking, rocking, and head banging. Therefore assessment of the child‟s socialization is useful in the management of dental behavior. 24 A distinction should be made between children who at one time had sight and those who have never seen and thus do not form visual concepts. More explanation is needed for children in the latter category to help them perceive the dental environment. Dentists should realize that congenitally blind children need a greater display of affection and love early in life and that they differ intellectually from children who are not congenitally blind. Although explanation is accomplished through touching and hearing, reinforcement takes place through smelling and tasting. The modalities of listening, touching, tasting and smelling are extremely important for blind children, in that they help these children to learn coping behavior. Once speech is developed, reports indicate that the other senses assume heightened importance and that other development can occur that is comparable to what takes place in children with sight. Reports also reveal that motor activity affects the development of language and perception. Blind children tend to have more accidents than other children do during the early years while they are acquiring motor skills. Hypoplastic teeth and trauma to the anterior teeth have been reported with greater than average frequency in blind children. Such children are also more likely to have gingival inflammation because of their inability to see and remove plaque. Other dental 25 abnormalities occur with the same frequency as in the normal population. Before initiating dental treatment for a blind child, the dentist should keep the following points in mind; 1. Determine the degree of visual impairment. For example, can the patient tell light from dark? 2. If a companion accompanies the patient, find out if the companion is an interpreter. If he or she is not, address the patient. 3. Avoid expressions of pity or references to blindness as an affliction. 4. In maneuvering the patient to the operatory, ask if the pat ient desires assistance. Do not grab, move, or stop the patient without verbal warning. 5. Describe the office setting. Always give the patient adequate descriptions before performing treatment procedures. 6. When making physical contact, do so reassuringly. 7. Introduce other office personnel very informally. 8. Allow the patient to ask questions about the course of treatment and answer them, keeping in mind that the patient is highly individual, sensitive and responsive. 9. Allow a patient who wears eyeglasses to keep them on for protection and security. 26 10. Avoid sight references. 11. Rather than using the tell-show-do approach, invite the patients to touch, taste, or smell, recognizing that these senses are acute. 12. Describe in detail instruments and objects to be placed in the patient‟s mouth. 13. Demonstrate a rubber cup on the patient‟s fingernail. 14. Holding the patient‟s hand often promotes relaxation. 15. Since strong tastes may be rejected, use smaller quantities of dental materials with such characteristics. 16. Explain the procedures of oral hygiene and then place the patient‟s hand over yours as you slowly but deliberately guide the toothbrush. 17. Use audiocassette tapes and “braille” dental pamphlets explaining specific dental procedures to supplement information and decrease chair time. 18. Announce exits from and entrances to the dental operatory cheerfully. Keep them minimal, and avoid unexpected loud noises. 19. Limit the patient‟s dental care to one dentist. 20. Maintain a relaxed atmosphere. An in-depth understanding of the patient‟s background facilitates the provision of dental care to a blind child. A team 27 approach by all health professionals involved in the care of the child is ideal. Disease prevention and continuity of care are of utmost importance. MENTAL RETARDATION: Mental retardation is a general term used when an individual‟s intellectual development is significantly lower than average and whose ability to adapt to their environment is consequently limited. According to the AAMD, as reported by Holmes et al. (1972) “Mental retardation is subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior”. Capute (1974) described the following criteria for a patient with mental retardation. 1. IQ less than 70 and represents ≥ 2 standard deviations from a mean of 100. 2. Impairment of adaptive behavior. Etiology of mental retardation: Pre-natal Natal Post-natal Genetic diseases Birth injuries Cerebral infections Infections Infection Cerebral trauma Kernicterus Cerebral trauma Poisoning Cretinism Hemorrhage Cerebral vascular accidents Fetal alcohol syndrome Hypoxia Encephalopathy Hypoglycemia Malnutrition 28 Classification: The AAMD as classified mental retardation as follows; IQ Mental retardation 69-55 Mildly or educably retarded 54-40 Tranably retarded 39-25 Severely retarded <25 Profoundly retarded Degree of Special requirements for mental SB-IV WISC-III Communication dental care retardation Treat the child as normal, Able to communicate well Mild 67-52 69-55 sedation or N2O analgesia enough may be beneficial Language skills such that Sedation may be beneficial, Moderate 51-36 54-40 the child can communicate restrains and GA may be at basic level indicated in severe cases Sedation may be beneficial, Severe or 35 & 39 & Little or no communication restrains and GA may be profound below below skills indicated in severe cases Mental retardation has been identified in approximately 3% of the population. For many years the potential abilities of people with intellectual disabilities were poorly understood. They were described with the terms „idiot‟ (IQ below 25), „imbecile‟ (IQ 25-50) and „moron‟ (IQ 50-70). Although a child who scores two standard deviations below the mean of the Stanford-Binet test or the WISC may have some degree of retardation, a diagnosis of mental retardation is not based on IQ along. A person who demonstrates both inadequate 29 adaptive functioning and intellectual deficiency is considered to have mental retardation. A child with mental retardation because of low intelligence requires special care in the school. Educational programs for mild to moderate mentally handicapped children generally focus on simplified versions of school programs and attainment of daily living skills. The classrooms are designed in the way similar to home and the curriculum includes dressing, grooming, cooking etc. A child with severe mental retardation may present a significant challenge. Such a child can achieve success with self-help, leisure, and some vocational skills given sufficient training and support. Dental management: Providing dental treatment for a person with mental retardation requires adjusting to social, intellectual, and emotional delays. A short attention span, restlessness, hyperactivity, and erratic emotional behavior may characterize patients with mental retardation undergoing dental care. The dentist should assess the degree of mental retardation by consulting the patient‟s physician or other caregiver if the patient does not live with the parents. The following procedures have proved beneficial in establishing dentist-patient rapport and reducing the patient‟s anxiety about dental care. 30 1. Familiarization of the patient with the personnel and faculty in the dental office will help to reduce the patient‟s fear of the unknown. 2. Repetitive slow speaking in simple terms is essential. Make sure that the patient understands explanations. Alternative communication methods such as a picture board or electronic devices may also be used. 3. One instruction at a time followed by rewards with compliments after successful completion of each procedure is beneficial. 4. Be attentive towards the patient, as these patients could be sensitive to gestures and verbal requests. 5. The parent may be allowed in the operatory to aid in communication. 6. Short appointments and gradual progression towards more complex operative procedures will help in good management. 7. Appointment should be early in the day when the dentist and the staff also are fresh enough and the patient will be less fatigue. By thoroughly understanding the patients degree of mental retardation and abilities and by exercising patience and understanding, the dentist should not have any significant problems in managing the mentally retarded child. 31 Autism: Autism was first described by Leo Kanner in 1943. Klien and Nowak (1998) have given an excellent article on autistic disorder in 1998. Autism is recognized as an organic disorder characterized by abnormalities in the brain, especially the limbic system and cerebellum. It is associated with abnormal emotional, social and linguistic behavior. It is characterized by qualitative impairment of social interaction, deviant behavior patterns and activities. Etiology: Organically based neurodevelopmental disorder. Decreased number of purkinje fibers in the postero-inferior sections of the cerebellar hemispheres. Truncation in the dendritic redevelopment of the limbic system. Hypoplasia of cerebellar lobules VI and VII. Hashimoto et al. (1995) suggested that it could be due to disturbances in early pre or perinatal life. Pre-natal causes include chromosomal abnormalities, intrauterine viral infections and metabolic disorders. Autistic disorder is more common in males as compared to females, the ratio being 4:1. Because of this a x-linked mode of inheritance has been suggested. 32 Autistic disorder has also been associated with fragile x- syndrome, tuberous sclerosis and phenylketonuria. The incidence of autism is about 2-10 per 10000 births. Clinical features: Kamen and Skier (1985) reported a higher pain threshold in patients with AD. AD patient dislike change in environment. Hyperactive knee jerk, poor muscle tone and poor coordination. Drooling saliva, reduced masticatory abilities, tendency to pouch food instead of swallowing. Kopel (!977) reported high degree of lateral vision. Self injurious behaviors like self-pinching, scratching, head banging to attract attention may be seen. Johansson et al. (1996) reported gingival cleft on canine due to self-infected behaviour. The medications commonly used in patients with autism are methyl phenindate, diphenhydramine, phenytoin, carbamazetine and fluoxetine. Prognosis: Development of speech by 5 years of age is considered as a good prognostic indicator. Autstic disorder is a lifelong disorder without regression, but symptom patterns do change. The IQ is less 33 than 50 in 60% of AD patients, between 50-7- in 20% of the patients and more than 70 in 20% of the patients (Klien and Nowak, 1998). Oral health status: The oral health status of AD patients has been described by Shapira et al. (1999). Lowe and Lindemann (1985) found that the dmf of children with AD was greater than normal children. However, no differences were found in the DMF values. Kamen and Saier (1985) reported low incidence of caries in patients with AD. Management: Braff and Nealon (1979) reported that high concentration of nitrous oxide is required in these patients for sedation. High flexibility is required on behalf of dentist. Short clear commands should be given. Touch pressure may give the patient a sense of warmth and may be helpful in behavioral management. Generally restrains may have to be used. Parental presence should be avoided. DOWN’S SYNDROME: It is one of the most common recognizable malformation syndromes. It may occur due to trisomy of chromosome 21(95% cases). It may also occur because of translocation (3% cases) or due to mosaicism (2% cases). 34 It is also called as Mongolism. Schreiner (1992) found that this term was inappropriate and may be insulting to the affected families. Etiology: Down‟s syndrome occurs very early in embryonic development, possibly during first cell divisions. Incidence: It is found in one of every 600 new borns. Predisposing factors include advanced maternal age, uterine and placental abnormalities and chromosomal aberrations. Benda (1960) reported the frequency of Down‟s syndrome to be approximately 1.5 per 1000 births of mothers in 18-29-year-old age group. The frequency increases after the maternal age of 30 years, reaching 29 per 1000 in the 40 year old and older age group and a high risk of 91 per 1000 in the 44-year-old age group. General manifestations: Skull: Brachycephalic skull, flattened face and occiput. Presence of third frontanelle just anterior to the posterior frontanelle. Flat nasal bridges, small maxilla. Eyes: Oblique palpable fissures, prominent epicanthic folds Brushfield‟s spots appear on the iris in a ring concentric with pupil. 35 Scanty eyelashes. Cataracts, squints and nystagmus are common. Ears: Dysplastic ears with abnormal pinna. Neck: Short and broad with excess skin posteriorly Hands: Broad and short (clinodactyly) with a single transverse palmar crease (simian crease). Short incurved little finger. Multiple loops on finger tips. Muscles and joints: Hypotonicity and hyper extensibility. IQ: Often severely retarded with an IQ of 25-50. Associated congenital abnormalities: a. Congenital heart lesions are found in upto 50% (atrial septal defect, atrioventricular canal and VSD). b. Duodenal atresia. c. Atlanto axial instability. d. Umbilical hernia. e. Multiple immunological defects affecting the skin, GIT and respiratory tracts. f. Acute lymphoblastic leukemia 20 times more common in these children. g. Hypothyroidism and Alzheimer‟s disease. 36 Oral manifestations: Mouth: Small drooping mouth Open mouth posture Tongue: Protrusive, fissured (scortal) tongue. Circumvallate papillae may be enlarged but filiform papillae may be absent. Macroglossia. Lips: Thick, dry, fissured. Occlusion: Anterior open bite and crossbite, class III tendency. Small maxilla. Palate: Often appears high with horizontal palatal shelves (omega palate). Bifid uvula, cleft lip and palate. Landau (1966) made a cephalometric comparison in childre n with Down‟s syndrome with their normal siblings. They found that there was a retardation in the growth of both maxilla and mandible. Upper facial height was significantly smaller, midface was smaller in both horizontal and vertical dimensions. They concluded that because of this factor there was tendency towards crowding and the tongue also tended to be larger than normal. 37 Eruption of teeth: Retarded Early shedding of deciduous teeth. Ondarza et al. (1997) conducted a study of 127 males and 128 females with Down‟s syndrome and found, on average, that 6 primary teeth were delayed in eruption in boys and 11 in girls. Jara et al. (1993) in a similar study of 116 males and 124 females showed delayed eruption of 13 permanent teeth in boys and 8 permanent teeth in girls. Teeth: Hypodontia especially third molars and maxillary lateral incisors. Microdontia. Hypocalcification and hypoplastic defects. Low incidence of caries. Johnson et al. (1961) found that dental caries prevalence in both primary and permanent dentition in Down‟s syndrome patients was low. Brown and Cunningham (1961) in a study found that 44% Down‟s syndrome children were caries free. Periodontium: Severe, early onset periodontal disease due to local factors like poor hygiene, tooth morphology and malocclusion and systemic factors like decreased humoral response, reduced chemotaxis, impaired phagocytosis, poor circulation etc. 38 Tannenbaum (1975) observed that prevalence and severity of periodontal disease in children with Down syndrome is much higher than the normal. Cichon et al. (1998) concluded that individual with Down‟s syndrome as compared to the normal groups and exaggerated immunoinflammatory responses, which could not be explained only by poor oral hygiene and indicated that there may be some abnormality in cell mediated or humoral immunities. Morinushi et al. (1997) obtained blood samples of 75 subjects with Down‟s syndrome. They found that the extent of gingival inflammation and anti-body titers was high and suggested that colonization of certain pathogenic organisms for periodontal disease occurred before 5 years of age. Carlstedt et al. (1992) demonstrated significantly higher colonization of candida albicans in Down‟s syndrome children as compared to control group. They believed that abnormalities in immune response in Down‟s syndromes children are responsible for making them more susceptible to oral diseases. Dental treatment: These children (10%) are mentally retarded (moderate t severe) and require appropriate treatment. Incidence of cardiac disease associated with Down syndrome is 40% and will require adequate prophylaxis. 39 Increased incidence of leukemia and acute and chronic infections of the upper respiratory tract can also alter treatment. Children are generally affectionate and cooperative and present no special problems during management. Nitrous oxide analgesia or TSD in mildly apprehensive patients can be used: general anesthesia in severe resistance to dental treatment. Preventive procedures along with chlorhexidine mouth wash may be beneficial. Pulp treatment in deciduous teeth are contraindicated in patients with cardiac problems because of the risk of bacteremia whereas in permanent teeth it can be considered if an adequate apical seal can be obtained. Learning disabilities: - The term learning disabilities is applied to the children who exhibit a disorder in one or more of the basic psychological processes involved in understanding or using spoken or written language. - Affects 3 to 15% of the population - Four times more common in boys, as compared to girls. - May be manifested in disorders of listening, thinking, talking, and reading, writing, spelling or erythematic. 40 - Includes conditions that have been referred to as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. - Learning disabilities do not include problems caused by hearing, visual and motor handicaps, mental retardation and emotional or environmental disturbances. - Physiological factors such as brain injury or damaged to the CNS have been implicated. - Genetic factors have been also implicated. - Emotional disturbances can also develop as a result of learning disabilities. - Most children accept dental care and usually do not pose problems for the dentist although some cases may require pharmacologic management. Fragile x-syndrome: - It is a common inherited form of mental retardation and autism. - It accounts for 30-50% cases of x-linked mental retardation. - It is due to abnormal gene in the terminal portion of the lon g arm of chromosome X. - Males are more vulnerable than females because of only one X chromosome. 41 - Patient present with history of developmental delay, hyperactivity. - Physical features include prominent ears, long face, and prominent jaw, high arched palate, flattened nasal bridge, hyperextensible joints, flat feet, and simian crease of palms and nacroorchidism. - Behavioral features include hand slapping, hand biting and poor eye contact. - May also concurrently have Down‟s syndrome or cerebral palsy. - Treatment is multidisciplinary – requiring speech, language, and occupational therapy. Mental intervention can be useful in decreasing hyperactivity and increase in attention span. - Prognosis is better in females than in males. - Severe cases may have to be treated under general anesthesia. Fetal alcohol syndrome: - The consumption of 1-3 drinks daily during first 2 months of pregnancy may result in significant damage to developing baby. - Alcohol consumption can cause multiple problems, which include neurologic abnormalities, cardiac defects, growth retardation and cognitive defects. 42 - Physical findings include microcephaly, bilateral ptosis, a short and depressed midface, flat nasal bridge, a short philtrum, thin upper lip, cleft palate, micrognathic mandible and prognathic jaws. - As children grow older, these children become less cooperative and are less difficult to treat. Management of the disabled patient: A thorough knowledge of the patient‟s personal and social background is valuable in enabling the practitioner to become familiar with the disabled person‟s home environment. Cooperation of the parents or the primary care taker is essential for complete and planned treatment. Family involvement: The clinician should make a careful study of the family, their strengths and weaknesses and the stresses and strains of each member of the family. The dentist can play a significant role in reducing the burden and many times in assisting in making the child more manageable, thereby facilitating for a more healthy life of the child and entire family. Before evaluating the situation it is essential to sit down and make the parents to evaluate the intelligence, IQ, understanding the child‟s problem and their reasons for seeking dental care. 43 When talking to the parents the dentists and the auxilliaries must try to understand the anxious times these parent have had and are having and will continue to have in raising a child with handicapping condition. Very commonly, the parents get involved with the child‟s social and medical problems to such an extent that the childs dental problems are neglected. For considerable number of these children, diet consists of a large amount of soft foods with considerable refined sugar. Lack of dental care further complicates the problem of dental caries. Parents‟ attitude towards the handicap child dictates the approach of the dentist towards the child. The behavior of the parents may be hostile, uncertain, fearful, ashamed and frequently frustrated. The fearful parents are often afraid the child may be unnecessarily hurt. The over protective parents may be ashamed of their child and neglect the problems of their child. The ashamed parents feel humiliated when they appear with their child in the public. If these parents are kept waiting in the reception room for a long period of time, this certainly will have a negative effect on their opinion about the dentist and his ways of handling the child. Preventive methods for the disabled child: Expectations and motivation: The dentist, owing to his professional background may conceive of patient education as primarily transmission of facts 44 about dental health. Patients have been educated about oral health and oral hygiene only when they have been given information in such a way so that they can apply it in everyday life. This requires methods of presentation relevant to the needs of the child. The values and interest of the disabled child may be varied and complex. For many children oral health is a relatively low priority and these patients are unlikely to share the dentist high priority for oral health. The goals for these children‟s should be attainable. When an objective is set at an unrealistic level, failure to achieve the target may frustrate the child and may abandon the task. For example, total elimination of carbohydrates may be unacceptable. Instructions to modify the diet may be more realistic. The objectives set should be meaningful and attractive to the patients. For purposes of teaching oral hygiene to handicapped persons, 3 groups have been described by Bensberg et al. (1969): 1. Self care group 2. Partial care group 3. Total care group 1. Self care group: The individuals are easiest to work with Most of them are ambulatory and are able to stand in the lavatory. 45 Modifications are necessary for patients with rheumatoid arthritis or chronic damage to joints. Some patients may find advantageous to have a heavier toothbrush handle. They can usually brush their teeth without much help and may even learned to floss. Although persons in this group are most capable, it is necessary to see that they have a daily set routine for oral care whether in school or at home. It is the duty of the dentist and more so of the parents to see that the daily routine is properly maintained. 2. Partial care group: Individuals in this group are moderately disabled and often retarded. They require close supervision and direct assistance to perform the routine task of daily requirements. They may not be able to foresee long term benefits of proper tooth brushing. They may not understand that brushing now will be important to them 5 years from now. These children have to be taught tooth brushing on the premise that it makes them look more handsome or beautiful. 46 Rapid learning cannot expected in these patients the task of each step has to be repeated several times in order to achieve results. For Example it may be taught as following: - Hold the toothbrush with help. - Put the brush in the mouth with help - Make the brush strokes in the mouth with help - Make the brush strokes by self - Brush the teeth from beginning to completion by self on being told to do so. The individual should have mastered the previous step in order to move to the next step. The teaching has to be in a pleasant manner. Compliment the individual on any effort he makes to brush. These children can be motivated a making fancy calendar and placing stars on the dates that they brushed or by providing tokens for accomplishments. Total care group: This group consists of children who are severely disabled. Many children may be confined to wheelchairs or may be bed ridden. These children need individual instructions and help. 47 The proper training, these children may or may not able to achieve the responsibility. Many of these children may not able to use the routine toothbrush. Smith and Blankinship (1964) found electric toothbrushes to be superior to the conventional toothbrushes. Electric toothbrushes also make it easier for the parent to master brushing the individuals teeth. This group is more difficult to manage than the previous two groups. Positioning: For self-care and partial care groups, most important aspect is development of an effective preventive program and communication is very important. But for the total care group the important aspect is positioning. Positioning should be in such a way that it should provide the caretaker with a clear field of vision of the oral cavity. Thereby making oral health care easier. The health care professionals, teachers, parents and caretakers must know the common techniques used. Standing: With a larger child or an adult the person doing the brushing or flossing may stand behind the patient and cradle the patients head in one arm, holding the lower jaw open with 48 the same hand and brushing and flossing with a other han d. Mouth props or padded tongue blades may be useful in extremely uncooperative children. Sofa: Many mothers feel more comfortable sitting on a sofa and having the child to lie down with his head in the caretakers lap to accomplish oral hygiene procedures. Lap: The todler or small child may be handled with a caretaker sitting on a chair without arms or on the toilet seats in the bathroom. The child is draped across the parents lap with the head hanging down over one leg slightly to assist in the opening the mouth. Sitting one the floor: For difficult to control patients, the parents can easily restrain the child and get a clear view of the mouth, still maintaining a comfortable position, by having the child sit on the floor. Wheel chair patients: These patient present a special problem for persons who provide oral hygiene care. The same type of approach can be used as in standing. But with the design of some types of chairs, it may be more difficult. Bedridden patients: The approach for bedridden patient is somewhat a reversal of positions previously described. The patient is approached from the front rather than the back. 49 Transferring the patient from the wheel chair to the dental chair is often a difficult problem several aids are used for this purpose. A useful aid is the transfer or sliding board, which allows the wheel chair patients to be moved without lifting. One side of the wheel chair, which should be beveled at its narrower edges, is pushed beneath the patient‟s buttocks. The other end is resting on the dental chair. The patient with assistance slides across the board into the dental chair. A second aid that is useful is the turntable, having non -slip ribbed rubber surfaces on both top and bottom so that it will not move on a highly polished surface. The wheel chair is moved to the side of the dental chair and turntable is placed beneath the patient‟s feet. The patient is then assisted to stand. After rotating him/her through the required angle, the patient is allowed to sit on the dental chair. Another transportable device is the Hatrick recliner, which allows the wheel chair to be reversed into its framework so that the occupant‟s head rests against a support. Another simple way is having a two-person lift. Physical restraints: The physical restrains are mainly used for immobilization during treatment. 50 Indications for immobilization: Patient who requires diagnosis or treatment and cannot cooperate because of lack of maturity. Patient who requires diagnosis or treatment and cannot cooperate because of mental or physical disabilities. Patients who require diagnosis or treatment and do not cooperate after other behavior management techniques have failed. When safety of the patient would be at risk without the protective use of immobilization. Contraindications: Cooperative patients Patients who cannot be safely immobilized Underlying medical or systemic conditions As a punishment As a convenience to staff Without informed consent The commonly used immobilization aids are those for the body, extremities and the head: Body Extremities Head Papoose board Posey straps Forearm-body support Triangular sheet Velcro straps Head positioner Pedi-wrap Towel and tape Plastic bowl Beanbag dental chair insert Extra assistant Extra assistant Safety belt Extra assistant 51 Papoose board: Simple to store and use Available in both large and small sizes It has attached head stabilizers Reusable Does not always fit contour of dental chair. Sometimes a pillow may be required. Because it covers the patient‟s diaphragm, a pretrachial stethoscope is necessary to monitor respiration. Extremely resistant patient may develop hyperthermia Triangular sheet: Mink (1966) described it as bed-sheet technique. Allows patient to sit upright during radiographic examination. Disadvantages include frequent need for straps and difficulty to use small patients, and possibility of airway obstruction if patient slips downwards unnoticed. Hyperthermia may be another problem. Constant need for supervision. Pedi-wrap: Comes in various sizes and allows for some movement but does not have a head stabilizer. Its mesh fabric permits better ventilation. Thereby lessening hyperthermia. Straps are required and constant supervision is necessary. 52 Bean bag dental chair insert: Comfortably accommodates severely spastic children. Reusable and rewashable, available in several sizes. If movement of extremities is the only problem having the dental assistant to restrain the child is helpful. Posey straps fasten the arms to the dental chair and allow limited movement. A towel wrapped around the patient‟s arms is often useful in athetoid – type of cerebral palsy. Patient‟s head can be usually maintained successfully by use of forearm of dentists although other equipments may also be used. For keeping the patients mouth open, a mouthprop can be used by identifying it as a tooth chair. Rubber bite blocks may also be used which are available in various sizes to stabilize the mouth in open an position. A padded tongue blade may also be used. Oral appliances used in disabled children: Mouth stick appliances are devices, which are of benefit to patients whose head and neck remains the only neurologically intact part of the body. Patients who may benefit include those with cerebral palsy, poliomyelitis or quadriplegia. Palatal training aids are appliances used by patients with acquired or congenital defects of neuromuscular control of the velopharynx as described by Selley (1977). Patients with velopharyngeal insufficiency suffer from nasal escape of air 53 with an associated lack of intraoral pressure leading to hypernasal speech patterns, abnormal articulation and fewer words articulated with each breath. Anti-chewing devices may also be used in comatose patients who may develop powerful chewing movements, which can lead to self-inflicted trauma. ISMAR (Innsbruck Sensorimotor Acticator and Regulator), this appliance is a combination of the activator and the Frankle appliance. Hoppenbrauer (1989) described it. Recently Gisel (2001) gave a review article describing the use of this appliance. This appliance is especially useful for training proper chewing methods in-patients with neuromuscular abnormalities like cerebral palsy. 54 REFERENCES: Agarholm, M. (1975): “Handicaps and the handicapped – A nomenclature and classification of intrinsic handicap”. J.R. Soc. Health.; 1: 113. Braff, M.H. and L. Nealon (1979): “Sedation of the autistic patient for dental procedures”. J. Dent. Child.; 46: 404-407. Capute, A. (1974): “Developmental disabilities - An overview”. Dent. Clin. North Am.; 18(3): 559. Court, S.D.M. (1976): “Fit for future. Report of the committee on child health in London”. Franks, A.S. and G.B. Winter (1974): “The management of the handicapped and chronic sick patient in dental practice”. Br. Dent. J.; 136: 20. Gisel E.G. et al. (1999): “The innsbruck sensorimotor activator and regulator (ISMAR) : Construction of an intraoral appliance to facilitate ingestive functions”. J. Dent. Child: 180-187. Harris, A.I. (1971): “Handicapped or impaired in great Britain. Part- I”. London. Hashimoto, T. et al. (1995): “Development of the brainstem and cerebelium in autistic patients”. J. Autism Dev. Disord.; 25: 1-18. Holloway, P.J. and J.N. Swallow: “Child dental health”. 3 rd Ed., Bristol john Wright, 1982: 155. 55 Johnson, C.D. et al. (1996): “Preventing factitious gingival injury in an autistic patient”. J. Am. Dent. Assoc.; 127: 244-247. Johnson, R. and D.C. Baldwin (1961): “Maternal anxiety and child behaviour”. J. Dent. Child.; 36: 87. Kamen, S. and I. Skier (1985): “Dental management of the autistic child”. Spec. Care. Dentist.; 5: 20-23. Kopel, H.M. (1977): “The autistic child in dental practice”. J. Dent. Child.; 44: 302-309. Mink, J.R.: “Dental care for the handicapped child”. In Goldman, H.M. et al. (Ed) Current therapy in dentistry. Vol. 2, St. Louis, Mosby, 1966. Nowak, A.J.: “Dentistry for handicapped patient”. 1 st Ed., St. Louis, Mosby, 1976. Selley, W.G. (1977): “Dental health for the stroke patients”. Br. Dent. J.; 143: 409. Shapira, J. et al. (1989): “Oral health status and dental needs of an autistic population of children and young adult”. Spec. Care Dent.; 9: 38-41. Tannenbaum, K.A. and J.W. Miller (1960): “Oral conditions of mentally retarded patients”. J. Dent. Child.; 27: 277. WHO (1952): “Joint expert committee on the physically handicapped child”. Report series No. 58, Geneva. 56
"Disabled child final"