Thesis abstract:

Cerebral palsy (CP) describes a group of permanent but not unchanging disorders of movement and posture resulting from injury or insult to the developing brain.1 CP is the most common physical disability of childhood occuring in two of every 2 1000 live births in developed countries and is a lifelong condition.2 The causal pathways to CP are complex and not yet completely understood. However, there are recognized risk factors such as male sex, multiple birth, low birthweight and preterm birth.2 In addition to the functional movement limitations Assoicated with CP, people with CP frequently experience co-morbidities including but not limited to: epilepsy, communication disorders, intellectual impairment, hearing and vision loss.2 These co-morbidities can impact participation in daily activities and general health and well-being.3

An additional and commonly overlooked condition associated with CP is poor oral health. Oral health is essential to general health and quality of life and poor oral health is a known cause of disability.4 Conversely general health problems may cause or worsen oral health conditions.4 The World Health Organization (WHO) 2003 states that “Oral health is a key indicator of overall health, wellbeing and quality of life”. 5 [para 1.], Oral health is defined as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.”6 Currently in the general population 50% of five-year old children and nearly 65% of nine-year old children are reported to have decayed, missing or filled deciduous teeth. Poor oral health affects many individuals with approximately 16% of those aged between 15 and 64 having experienced toothache in the previous 12 months, over a quarter of the same range being dissatisfied with the appearance of their teeth, and approximately one third of the population avoiding certain types of food due to tooth related problems.7

At present, there are no documented systematic reviews reporting on oral health outcomes for people of all ages with CP. Subsequently, there are no clear guidelines, frameworks or detailed oral health recommendations for people with CP in Australia or globally. Considering the importance of oral health on general well-being and quality of life, it is important that oral health is not overlooked when focusing on patient-centered care for people with CP. This project aims to fill these gaps along with targeted research to better understand the oral health concerns for all ages of this at-risk population, with the end goal of improving oral health outcomes and wellbeing for people with CP.

There is a paucity of literature considering oral health outcomes of people with CP. However from the limited available literature it would appear that the burden of dental disease is more prevalent in individuals with disabilities including CP8, as evidenced by an increased risk for dental caries, increased number of dental anomalies and a fourfold increase in dental trauma compared to that of children without disabilities. Furthermore, a recent study conducted in children in a low resource setting reported decay rates of approximately 70% for children with CP aged between seven and 11 years.9 Individuals with CP may be more susceptible to oral health issues due to the reported dental implications associated with pre-term birth, a known risk factor for CP.2 These include, but are not limited to, delayed tooth eruption, developmental enamel defects, enamel trauma. These dental problems coupled with the neuromuscular effects of CP have been shown to cause canages to the oro-facial structures, negatively impacting nourishment, oral hygiene and resulting in parafunctional habits of the mouth, jaw and tongue. This negatively affect self-esteem and self-confidence, particularly in social situations.10-11 There is emerging evidence to suggest that children with CP are at increased risk of developing sleep apnea and increased risk of dental-related conditions such as drooling, bruxism (grinding or jaw clenching) and pain12.

Preliminary search of databases including Scopus, MEDLINE, JBI Database of Systematic Reviews and Implementation Reports, and Cochrane Oral Health that was conducted in September 2018 revealed a paucity of quality research regarding oral health of people with CP, particularly in the adult population. Currently, there is one systematic review that reports on oral health in children with CP8; however, this study did not consider reported dental problems for people with CP such as dental

pain, tooth diseases, bruxism or saliva-related factors.

A traditional systematic review to begin this process is impractical, because the term ‘‘oral health’’ is a broad multi-faceted term that encompasses a range of conditions. It has been determined by the authors that a scoping review is the most practical way to gain an overall picture of oral health needs of people with CP. Scoping reviews are increasingly utilized in the literature, not only to assess the quality of existing research but also to map ideas, clarify definitions, provide an overview of a broader topic and provide future direction for systematic reviews. The combination of these projects will inform future research in the forms of mixed methods and a Delphi Best/Worst study, with the aims of providing targeted and specific oral health recommendations, informing policy, and improving the general health of people with CP.