Cerebral palsy is a very diverse condition that affects each individual in different ways. Some people with cerebral palsy will be affected in ways that have implications for their dental care.

If you have cerebral palsy, and are concerned about your own dental care, or if you care for someone with cerebral palsy, then this may answer some of your questions and point you towards possible sources of support and advice.

Oral health concerns for people with cerebral palsy

Consideration should be give to how difficulties with dental care could impact upon someone with cerebral palsy such as:

• Being unable to clean teeth
• Having to eat soft food
• Difficulty in chewing or swallowing
• Not being able to communicate sensation in the mouth
• Fear of having the mouth examined
• Behavioural problems caused by not being able to communicate toothache or other sensations.

There are also indications that some concerns may be specific to particular types of cerebral palsy:

In some people with spastic cerebral palsy, the head may be tensely reclined, mouth open with restricted facial movements. The tongue is hypertonic (increased muscle tone) and cigar-shaped and there may be tongue thrusting during swallowing and speaking. These factors can make tooth brushing very difficult. If the upper lip is underdeveloped, it will not produce enough pressure on the front teeth to align them correctly. Poor alignment can lead to excessive wear.

In athetoid cerebral palsy, the tongue may produce spontaneous wave-like movements. There may also be abrupt and wide opening of the mouth, which can lead to jaw dislocation. There may be unco-ordinated movements of tongue, jaw, and face muscles and this makes achieving good dental hygiene very difficult.

In hypotonic (reduced muscle tone) cerebral palsy, the tongue may be large, flat, and protruding. Facial movements may be weak, and the upper lip inactive, which, again, may have implications for maintaining correct dental alignment.

In addition, it has also been found that:

• If orofacial difficulties are not addressed, they can often affect other aspects of a person's health, such as the ability to receive adequate nutrition.
• Poor oral hygiene increases the risk of gum disease which can lead to a build-up of harmful bacteria leading to bad breath. A build-up of bacteria may also affect general health.
• If there is any abnormal neuromuscular co-ordination of the tongue, lips, and cheeks, it can lead to poor dental alignment and associated gum and tissue problems.
• Injuries of the face and mouth occur much more frequently in children who have cerebral palsy.

Some people with cerebral palsy may demonstrate self-injurious behaviour, including tongue, cheek, and lip biting or finger, arm, and hand chewing. Protective oral appliances are sometimes used to reduce the effects of this behaviour, but thought should always be given to why a person is doing it, as it may indicate discomfort within the mouth, or some other problem.

Some people with cerebral palsy, particularly those who also have a cognitive disability or severe learning disability, demonstrate damaging oral habits. These include:

• Bruxism: clenching, grinding, and gnashing of teeth.
• Rumination: the re-chewing, regurgitation, and re-swallowing of previously ingested food. This causes the acidic contents of the stomach to travel up into the mouth, and bathe the teeth in acid which can lead to demineralization, and loss of tooth structure.
• Pouching: the placement of food or medicine between the cheek and teeth for long periods. This can cause decay.
• Pica: the compulsive eating of non-edible substances. Pica can lead to destruction of tooth structure and damage of soft tissue.

Some people with cerebral palsy frequently have gastro oesophageal reflux, as well as episodes of vomiting. Either problem can lead to dental erosion or loss of tooth structure.

The use of anti-seizure medications can lead to gum overgrowth.

Footnote: Information extracted from Paediatric Dental Health: Oral health for children with cerebral palsy. Article by Daniel Ravel DDS, FAAPD

What can be done to help?

By far the most important factor in achieving and maintaining oral health is good oral hygiene. For most people this will mean either brushing their teeth, or having their teeth brushed for them, at least twice a day and preferably after every meal. If their condition makes brushing difficult, a dentist may advise use of a special mouthwash.

Regular dental check-ups are very important. If possible register with a dentist who has experience of treating people with cerebral palsy. If it is impossible to find such a dentist locally, the Community Dental Service should be able to assist, as they have expertise in treating people with special needs. There are also specialist dental hospitals.

In some cases specialist dental appliances may be recommended to help correct the alignment of the person’s teeth or to protect from further damage.

It is very important that good oral health is seen as an integral element of general health care. Professionals, such as occupational therapists and speech and language therapists, can also play an important role in advising on equipment, positioning and therapeutic techniques that will assist with good oral hygiene. If the person with cerebral palsy has complex support needs concerns or requires sedation in order to receive dental treatment, it may be necessary for the dentist to liaise with the GP.

Frequently asked questions

I find it difficult to brush my teeth. Is there anything that could help?

Controlling hand/arm movements can be a problem for some people, making effective cleaning difficult. It is important to reach all areas of the mouth. A small to medium headed toothbrush with soft to medium bristles is usually recommended. There are special handgrips and other adaptations which can be fitted to ordinary toothbrushes to make them easier to hold.

In some cases, electric toothbrushes are recommended for people with manual problems. They are also helpful for those with learning difficulties as they may be viewed as a novelty and therefore encourage tooth brushing. The dentist or dental team will be able to offer advice and practical help on tooth brushing and general mouth care.

My child has cerebral palsy, how can I ensure they have good oral health right from the start?

Even before your child’s first teeth have come through, try to get your child used to you looking in their mouth and touching their gums. Once teeth have emerged, brush them daily and ideally, after every meal. Children taking medication in the form of syrups should, preferably, have their teeth cleaned after each dose as such medicines contain a lot of sugar which can lead to decay. Give lots of praise while brushing your child’s teeth to reinforce it as a positive experience.

When brushing your child’s teeth ensure s/he is well positioned so that you are both comfortable and their head is well supported. Choose a well-lit location so that you can look into your child’s mouth. If possible sit them in front of a mirror to clean their teeth, as this will help them to learn what needs to be done. Let them watch other family members cleaning their teeth as again this will help your child to learn about dental hygiene. Up to the age of three, parents should only use baby tooth paste or gel, as this helps to avoid the discoloration caused by fluoride in adult toothpaste.

View the care of your child’s teeth as an integral part of their overall health care needs. Encourage a healthy, well balanced diet, as this helps build and maintain strong teeth. Avoid too many sugary snacks, fruit juice, sweetened and fizzy drinks. Also drinking from a bottle or feeding cup can prolong exposure of teeth to harmful sugars.

Children should have their first oral/dental health evaluation by the age of 12 months, or within six months of the eruption of the first tooth.

I am not registered with a dentist. How can I find the right one for me?

You will find dentists listed in the Yellow Pages telephone directory under “Dental Practitioners”. Dentists usually work privately or under contract to the NHS, but some do a combination of both. Dental care is free for certain groups of people, see point below “What will dental treatment cost?”

Not all dental surgeries will be fully accessible and some dentists will lack the specialist knowledge or experience necessary to work with disabled people. Finding the right dentist can be difficult but NHS Direct can assist you to find an NHS dentist.

What does the dentist need to know?

Ensuring that the dentist has information in advance of your visit will better equip him or her for working with you. The dentist will need to know:

• Medical history, including how you or your child is affected by cerebral palsy, any medication being taken, recent medical procedures and any allergies.
• Details of the GP and, if relevant, details of hospital consultant, speech and language therapist or other professionals involved.
• Any specific concerns or anxieties about your or your child’s dental care.
• Any other special needs, such as an interpreter or translator, mobility or access issues, both to the building and the treatment chair.

How often should I go to the dentist?

It is important to visit the dentist regularly. Normally it will be every six months. The dentist may also recommend appointments with a dental hygienist who, like the dentist, can clean your teeth and offer advice to you or your carers, on how to brush effectively and maintain good oral hygiene.

Aim for short, but regular appointments rather than infrequent long ones. This is especially important for those that are very anxious or have a learning disability, as it helps them develop trust in the dental team.

If you are registered with the dentist as a NHS patient you will need to attend six monthly or yearly checkups or risk being de-registered.

What will dental treatment cost?

Treatment is available either under the National Health Service or privately, depending on the dental practice you register with. NHS treatment is free to those under 18 years of age, pregnant women and for treatment taken within a year of giving birth. Generally speaking, NHS treatment is also free to anyone receiving means-tested benefits.

If you are on a particularly low income, but do not claim any benefits, you may still be able to get help with dental charges. You can claim this help by filling in a form HC1. People who have to pay NHS charges may be able to get help under the NHS Low Income Scheme. The amount of help is based on a comparison between a person’s income and requirements at the time that a claim is made or a charge was paid.

How do I make a low income claim?

You need to complete form HC1 - this form cannot be downloaded from the Internet. You must obtain a hard copy. Ring the DH Publications Order line on 0300 123 1002, Minicom 0300 123 1003, to get an HC1 and pre-paid return envelope. Job centre Plus offices and NHS hospitals should also have HC1s available. Some GPs, dentists, opticians may also have them.

If you think you will be paying for your treatment, it is important to ask for a treatment plan and estimate of charges at the time of the check up, to avoid any confusion over payment.

What happens if I need more specialist treatment or facilities than my own local dentist can provide?

If physical access to the dental surgery is difficult it is possible that your dentist will make some other arrangement, such as visiting you at home or treating you at a local health centre.

Some people may need to be referred to their local Community Dental Service, who specialise in treating people with special needs. There are also hospitals that take people needing specialist care, and they may be able to offer other treatments such as sedation or a general anaesthetic.

If you need specialist care your usual dentist or GP should refer you to the service that best suits your needs. Some Community Dental Services allow patients to refer themselves but this is rare. Normally, the person referring you will write a referral letter and send it together with any hospital letters and x-rays, to give the Community Dental Officer a full picture of your dental history.

I feel very anxious about visiting the dentist as I am worried it may be painful. Is there anything that can help?

Some people find it helpful to arrange to visit the dental practice and meet the staff prior to attending for treatment. The dental team should be able to reassure you that modern dentistry aims to be as pain free as possible. Very nervous people may be offered an intravenous injection to sedate them. Such drugs will relax and calm the patient so that treatment can be carried out, while still allowing the dentist and patient to communicate. However this treatment is not suitable for everyone.

You may have heard of a treatment called Relative Analgesia (RA) which involves breathing nitrous oxide and oxygen gases through a nosepiece. This is an effective treatment for many people but is not normally suitable for people with cerebral palsy, multiple sclerosis or learning disabilities.

Should women have any special concerns?

Yes. Specific hormonal changes in adolescence, during pregnancy and the menopause, can increase sensitivity to oral health problems.

It is very important during pregnancy to have regular dental checks.

This information sheet is for information purposes only and is not intended to be a recommendation.

Further information and resources

NHS Direct
Tel: 0845 4647
Website: www.nhsdirect.nhs.uk

Help with health costs
Tel: 0845 850 1166
Website: www.nhs.uk/nhsengland/Healthcosts/

In some parts of the country, there may be a dental access centre where a client who is unable to access dental care by other means may receive both routine and emergency treatment. In England and Wales, a client can find out whether there is a dental access centre in her/his area by contacting NHS Direct. In Scotland, a client should contact her/his local Health Board.

British Dental Health Foundation
Tel: 0845 0631188
Website: www.dentalhealth.org.uk 
Charity offering independent advice on all aspects of dental health including information on fear management, treatment options and preventative care.

Frequently asked questions about the standard of care a person with special needs can expect from their dentist.

Guy’s Dental Hospital
Special Care Dentistry, Floor 26, Guy’s Tower, St Thomas’ Street, London SE1 9RT.
Tel: 020 7188 7188
Web: www.guysandstthomas.nhs.uk/services/dental/dental.aspx 
Provides dental care and oral health advice for people who need specialist care because of disability or illness.

British Society of Medical and Dental Hypnosis
Incorporated into The British Society of Clinical and Academic Hypnosis
Tel: 0844 884 3116
Website: www.bsmdh.org
Can supply a list of dentists qualified in hypnosis.

British Society for disability and oral health
www.bsdh.org.uk/guidelines/physical.pdf 
These guidelines highlight some of the barriers to good oral health care for disabled people and provide guidance to facilitate equitable access to services which are sensitive to individual needs.

For more information on Scope

Contact Scope Response for information, advice and support on cerebral palsy and disability issues.

This information was last reviewed April 2010.

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