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Joseph O. Adenubi, BDS, MSc, MPH*, Faris H. Saleem, FRCP (Edin), DCH**

Josielyn N. Martirez, DMD***


Sixty-six disabled children, 3 to 14 years old, attending the Disabled Children’s Rehabilitation Center (DCRC)
in Riyadh between March 1993 and July 1994 were evaluated before and after treatment. The types of dental
problems found in the disabled child, the causes of the handicap, the pattern of dental treatment carried out
and the management techniques used in providing care are reported. Personal, medical and dental data were
recorded and analyzed. Main etiologic factors for disabilities were congenital or due to perinatal events and
78.8% of the children had cerebral palsy. The oral problems included dental caries 79%, poor oral hygiene
37.8%, bruxism 24% and malocclusion 15%. The treatment modalities carried out were prophylaxis in 15%,
restorations including pulp therapy in 81.8%, exodontia in 19.7% and interceptive orthodontics in 3%. All
types of treatment were achieved under local anesthesia [LA] with or without restraint. Premedica-tion such as
Vallergan 3.5 mg/kg or Phenergan 1 mg/kg body weight was used for proper management of the patients. An
aggressive prevention program is recommended along with other proven methods in the dental care of
disabled children. The experiment of making dental treatment readily available to the disabled children in
Riyadh appears to be succeeding.

Dental management of the handicapped child has

received scant attention in the literature compared with the

normal child. Until recent years, the management of the

handicapped child was not even mentioned in the

undergraduate curriculum of most dental schools in

different parts of the world. This partly explains why the

handicapped child has not received its fair share of dental

management in the community.
The Department of Health, Education and Welfare of the

United States, in its Rehabilitation Act of 1973’ defined a

Received 09/10/96; revised & accepted 20/11/96
* Professor of Pediatric dentistry, College of Dentistry, King

Saud University, P.O.Box 60169, Riyadh 11545, Saudi

** Medical Director and consultant Pediatrician, Disabled
Children’s Rehabilitation Center, Riyadh.

*** Dental Hygienist, Disabled children’s Rehabilitation center,
Riyadh address reprint request to : Prof. J.O. Adenubi.

handicapped person as one who has a physical or mental

impairment which substantially limits one or more major

life activities such as caring for one’s self, performing

manual tasks, walking, seeing, hearing, speaking,

breathing, learning and working. In addition, a handicapped

person has a record of such impairment (has a history of or

has been classified as having a condition that limits major

life activities); and is regarded as having such an

Nowadays, the term "disability" is preferred to the

"handicapped". The term disability refers to any

impairment that restricts or limits daily activity in some

The disability may be developmental in origin or

acquired.’’ Developmental disabilities are handicapping

conditions identified in early childhood and usually persist

throughout an individual’s life. Etiologic factors of

developmental disabilities are medically broad based and

are due to a variety of conditions which include cerebral

palsy, Down’s syndrome, mental retardation, autism,

The Saudi Dental Journal, Volume 9 Number 1, January - April 1997.

Page 2


seizure disorders, hearing and visual impairments,

congenital defects, and even social or intellectual

deprivation.3 The acquired disabilities are caused by a

disability factor later in life and include neuromuscular

disorders, traumatic injuries, and psychiatric disorders

producing various forms of physical and mental disabilities

in the individual.3
In 1979, the Journal of Dental Education


guidelines for predoctoral dental training in the care of the

handicapped. In 1985, curriculum guidelines for dental

students managing patients with minor disabilities
and a

curriculum for general practice residents in care of the

developmentally disabled child were published.

events marked the beginning of closer attention to the dental

health of the disabled. In 1990, the Journal of Education

published an updated Curriculum Guidelines for training

General Practice residents to treat a person with a handicap

as approved by the American Association of Dental

A survey of the availability of dental services to the

developmentally disabled residing in a community in north

central Florida, USA, showed that dentists were reluctant to

provide services for a variety of reasons including : patient

is too uncooperative, inadequate knowledge and

preparation, lack of proper equipment necessary to treat this

group of special patients, and financial disincentives.

Similar reports abound.
" The clinical management of

special patients may require additional staff members, extra

time, various behavior modification techniques including

physical restraint, and or sedation for which the dentist may

not be reimbursed.
These factors account for why the

disabled child has difficulty in obtaining dental treatment in

most of the world.
In 1988. in Riyadh, the capital of the Kingdom of Saudi

Arabia, the Welfare Association for Handicapped Children

now known as the Saudi Benevolent Association for

Handicapped Children, - as a charity foundation, -

established a Handicapped Children’s House [HCH] which

is now called the Disabled Children’s Rehabilitation Center

[DCRC]. The primary objective of the center is to render a

comprehensive care for disabled children from birth to the

age of 12 years. The center functions both as a medical

center and as a school in addition to rehabilitation of the

children. It also serves to assist the families of the children

to accept the facts of retardation. The state of the art

medical facilities in the center include a pediatric dental

clinic where this study was carried out.
The purposes of this study were to describe the types of

dental problems found in the disabled child in the Disabled

Children’s Rehabilitation Center [DCRC], collate the causes

of handicapped children, determine the pattern of dental

treatment carried out on the disabled children- both curative

and preventive and to catalogue the management techniques

used in providing dental care.

Materials and Methods
In a prospective study, all the handicapped children who

attended the Pediatric Dental Clinic at the DCRC in Riyadh

between March 1993 and July 1994 were evaluated from

their first visit till treatment was completed by the pediatric

dentist. The following information on each child was

* Age, sex, medical diagnosis of the handicap, the cause,

type of disability, and extra-oral findings.

* Intra-oral findings included state of oral hygiene,
periodontal disease, dental caries, trauma to anterior

teeth, malocclusion, bruxism, supernumerary teeth or

missing teeth, and tooth discolorations.

* Types of dental treatments carried out.
* Behavioral management technique.

Details on the medical history of each child were

obtained from the hospital file and at regular meetings with

the physician, surgeon and pediatrician when necessary.

The pediatric dentist recorded all the data relevant to

clinical dentistry as management progressed to completion.

These data were later analyzed.

The clinical findings and treatment carried out by the

pediatric dentist are presented in Tables 1-6. There were 39

boys and 27 girls who attended for treatment during the

period of the study for a total of 66. Nearly half [30] were

between the age of 3 and 5 years and two of the children

were 14 years old though the center normally looks after

children from birth to age 12 years (Table 1).
Medical diagnosis (Table 2) showed that 52 (78.8%) of

the children treated had cerebral palsy, two were epileptic,

one with Spina Bifida while others (II) constitute 16.7%.

Table 1. Distribution of the children treated in the
pediatric dental clinic at DCRC Riyadh by age and sex.

Age G r o u p Sex

3-5 yrs 6-10 yrs 11-14 yrs Total

Male 19 15 5 39
Female 11 14 2 27

Total 30 29 7 66

Table 2. Medical diagnosis of the disabled children at
DCRC, Riyadh.

Diagnosis No. of Children %
Cerebral Palsy 52 78.8

Epilepsy 2 3
Spina Bifida 1 1.5
Other 11 16.7

Total 29 66

The Saudi Dental Journal, Volume 9 Number I, January - April 1997.

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Table 3 presents the etiology of the disability and

medical diagnosis of the 66 children, 34 of which are

congenital or unknown while prematurity, birth asphyxia

and forceps delivery accounted for 39%.
Table 4 shows that 25 children or 37.8% had poor oral

hygiene. As many as 15% had good oral hygiene while

39.4% were ranked fair. Overall, calculus was present in

3 males and 1 female with the age-group 9 years and


Table 3. Etiology of the handicap by number and


Diagnosis No. of Children %
Prematurity 8 12

Birth Asphyxia 16 24
Forceps Delivery 2 3
Viral Infections 3 4.5
RTA 3 4.5
Unknown/congenital 34 52

Total 66 100

Table 4. Oral hygiene status of the handicapped children.

Oral Hygiene No. of Children
Male & Female


Good 10 15.2
Fair 26 39.4
Poor 25 37.8
Not recorded 5 7.6

Total 66 100

Fifty five or 83.3% of the children examined and treated

had no gingivitis while 10 (15.2%) had. It was only in one

child that gingivitis had advanced to periodontal disease.
Fifty two (79%) of the children had dental caries with 35

(53%) in the posterior teeth only, while 13 (20%) had caries

in both anterior and posterior teeth. Four children (6%) had

caries in the anterior teeth only and all the caries were in the

upper jaw.
Malocclusion was present in 10 (15%) of the children

with anterior open bite being the most common form of

malocclusion (Table 5). Excessive overbite and overjet in

the anterior teeth as well as unilateral crossbite in the

posterior teeth also occurred. One child had both excessive

overjet and protrusion of the upper anterior teeth.
Three out of 39 boys (7.7%) and one out of 27 girls

(3.7%) or 4 out of 66 children [6%] had traumatized

anterior teeth. Bruxism was present in nearly one out of four

(24.2%) of the disabled children. One 11-year-old child had

Table 5. Type of malocclusion present and percentage of

total malocclusions.

Type of Malocclusion Number %

Excessive overbite 2 20

Excessive overjet 1 10

Anterior open bite 4 40

Protrusion upper

anterior teeth

2 20

Anterior crossbite


1 10

Posterior crossbite


1 10

a mesiodens, another had teeth #83 and 84 missing while a

third child had two fused teeth, #72 and 73 as well as #82

and 83.
Often, the child is mentally retarded and presents the

problems of behavioral management. A typical child,
generally, does not sit back in the dental chair and would

frequently move forward or even attempt to get out of the

chair. The child also may not respond to requests to open

his or her mouth and when the mouth is opened, the child

may close it on any instrument or the handpiece applied to

the mouth.
It was therefore necessary to use restraint with the

cooperation of the parents and the dental assistant. In most

cases, this was inadequate and the use of premedication

together with "Pedi Wrap" and mandatory use of local

anesthesia were necessary. Vallergan at the dose of 3.5

mg/kg body weight or Phenergan (1 mg/kg body weight)

were the drugs used as intraoral premedication one hour

before treatment to ensure that each child was well prepared

to allow adequate dental treatment.
Table 6 shows the types of treatment carried out on all

the children seen at the pediatric dental clinic of the center.

Fifty-four (81.8%) of the children had their teeth restored

while 13 [19.7%] had their teeth extracted. Interceptive

orthodontics occurred only in 2 children. The restorations

carried were mostly amalgam and glass ionomer cements

and, to a lesser extent, composites and stainless steel

crowns. Pulp treatment consisted of 8 pulpotomies in

primary molars and 3 pulpotomies in anterior primary teeth.

Table 6. Treatment carried out by type and percentage.

Type of Treatment No. of Children %
Prophylaxis only 10 15.2
Restorations 54 81.8
Extractions 13 19.7
Interceptive orthodontics 2 3.0

The Saudi Dental Journal, Volume 9 Number 1, January - April 1997.

Page 4


Nearly 80% of the children treated have cerebral palsy

with most of them presenting as being both mentally

retarded and physically disabled. Therefore, they all

presented problems in behavioral management. The etiology

of these mishaps as earlier reported in a review by Tesini

and Felton3 are due to congenital, natal and perinatal causes.
It is typical of disabled children to have poor oral hygiene

and periodontal disease particularly in the mentally retarded

due to lack of proper oral hygiene.

The oral hygiene and

periodontal disease findings in this study are not typical of

the literature. This is due to the special preventive program

at the DCRC in Riyadh. This program includes a weekly

demonstration of oral hygiene instructions to the children

and the aids or teachers who directly supervise to help carry

out the oral hygiene procedures on the children. This study

supports the reports of Nicolai and Tesini
that the oral

hygiene of institutionalized mentally retarded individuals

can be improved through the training of direct care staff.

Calculus was found in only 4 children- 3 boys and one girl,

all aged 9 years and above.

Dental Caries & Malocclusion
The findings that 79% of the children had caries while

15% had malocclusion reflect the other major problems of

the disabled child in addition to poor oral hygiene and

periodontal disease.




The phenomenon of bruxism, which is defined as

non-functional contact of the teeth and includes clenching,

quashing, grinding and tapping of the teeth,
occurred in

24.2% of the children. This is in agreement with studies that

reported bruxism to be practiced with much greater

frequency in children and adults with developmental

disabilities30 compared with approximately 15% of normal

school-aged children.

Treatment Carried Out
Due to the major problem of dental caries, 81.8% of the

children needed and had restorations in their teeth. Only

19.7% had extractions. The typical situation in different

parts of the world is that of neglect of the disabled child

such that most of the caries is untreated with very poor oral



In this study, all the children had their

restoration needs met and more than half of them have good

or fair oral hygiene. This appears to be an indication of

proper oral health care by the parents, the supervising staff

at the center and the dental team of dental hygienist and

pediatric dentist who are all responsible for an aggressive

prevention program for the children. Appliance therapy in

interceptive orthodontics was reduced to minimum and was

often avoided to prevent any complications that may arise

from the use of an orthodontic appliance.

Preventive Program for Children at the DCRC
After the medical diagnosis of the disabled child, members

of the dental staff confer with the physician, surgeon,

pediatrician, speech therapist, psychologist, dietician,

physical therapist, and occupational therapist. The primary

objective is to combine their efforts to diagnose, treat, and

assess the problems of treatment of each child admitted into

the center. This is followed by regular meetings to

continually assess the progress and treatment needs of each

child. The pediatric dentist effects all operative treatment

needed by each child using various behavior modification

techniques of restraint and conscious sedation. Since most

of the children with mental retardation cannot perform the

oral hygiene procedures themselves but always require the

assistance of a supervisor or aid in the school, and

parent/guardian at home, the dental hygienist carries out a

Special Preventive Program as follows.

A. In the classrooms of children admitted to the center :
� Weekly Oral Health Education [OHE] to supervising staff

[i.e. aids or direct care staff] and to the few children in

each class who may be able to help themselves.

� Weekly individualized hygiene instructions.
� Step by step demonstration of oral hygiene procedures to

small groups of children and direct care staff who are

called aids in DCRC. This procedure includes teaching of

preventive techniques such as positioning of the child,

toothbrushing, and flossing where appropriate.

� Use of disclosing solution to highlight areas of poor oral
hygiene on the teeth.

� Dietary counselling to supervising staff.
� Providing continual Oral Health Instructions [OHI] to aids

and teachers. This is sometimes complimented by the use

of audio-visual material.

B. In the dental clinic of the center :
� Initial prophylaxis.
� Monthly application of topical fluoride.
� Periodic scaling and prophylaxis.
� Continuous motivation of children who can cope with

special toothbrushes.

� Continuous motivation of the accompanying aid [direct
care staff].

� Motivation of the parents when the children are discharged
and attend the clinic from home.

This report on the disabled children at the DCRC in

Riyadh suggests that the objectives of the center are

being achieved and that the experiment of Special

Prevention Programs for the children is succeeding. The

regimen of an aggressive prevention program as

practiced in this center is recommended along with other

proven methods in the dental care of disabled children.

As reported in earlier studies particularly from

Scandinavia, the major thrust in the management of the

oral health of the disabled child should be


The center’s existing prevention

The Saudi Dental Journal, Volume 9 Number I, January - April 1997.

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