• tongue biting
• cheek biting
• lip biting
• finger chewing
• arm chewing
• hand chewing.

Protective oral appliances (which will be described below) may be useful in combating self-injurious behavior.

Children with Cerebral Palsy frequently have episodes of vomiting as well as a condition in which the valve between the stomach and the esophagus lets stomach acid leak from the stomach back up into the esophagus (gastroesophageal reflux). Either problem can lead to dental erosion, or loss of tooth structure.

Gingivitis, an inflammation of the gums, characterized by redness and swelling can also be a frequent problem in children with cerebral palsy. It can be caused by the overgrowth of bacteria in the mouth due to seizure medications. It can also stem from the disorganized swallowing pattern. 

Children with Cerebral Palsy who are also affected by cognitive disability or mental retardation often practice damaging oral habits, including: bruxism, rumination, pouching, and pica.

• Bruxism: This is clenching, grinding, and gnashing of teeth. It is a frequent finding in children with cerebral palsy. The treatment for bruxism may include the use of a soft or hard mouth guard – if the child can tolerate it.
• Rumination: This is the re-chewing, regurgitation, and re-swallowing of previously ingested food. This habit causes the acidic contents of the stomach to travel up into the mouth, and bathe the teeth in acid. Rumination can lead to demineralization, and loss of tooth structure.
• Pouching: This is the placement of food or medicine between the cheek and teeth for a long period of time. This habit can cause dental decay.
• Pica: This is the compulsive eating of non-edible substances, including: sand, dirt, and paint chips. Pica can lead to destruction of tooth structure and damage of oral soft tissue. 

Each type of Cerebral Palsy has certain patterns of orofacial findings.

• Spastic Cerebral Palsy: The head is tensely reclined. The mouth is open, and facial movements are tense. The tongue is hypertonic and cigar-shaped. There is tongue thrust during swallowing and speaking. Since the upper lip is underdeveloped, it does not produce enough pressure on the front teeth to align them correctly.
• Athetotic Cerebral Palsy: The tongue shows spontaneous wave-like movements. There may be an abrupt and wide opening of the mouth, which can lead to jaw dislocation. There is an uncoordinated movement of tongue, jaw, and face muscles.
• Hypotonic Cerebral Palsy: The tongue is large, flat, and protruded. Facial movements are weak, and the upper lip is inactive.

Dental Care At Home For Children With Cerebral Palsy
Children with CP may be more susceptible to tooth decay than their non-disabled peers. This is because the natural, self-cleaning which is facilitated by saliva (especially at night) may be disrupted. In addition, debris which usually gets moved away by the motion of the tongue may not be cleared as effectively if a child’s tongue is less mobile.

Start oral hygiene in the first year even before the child has teeth. Pick a well-lit location in your home so that you can look into your child's mouth. No matter what position you are using for brushing your child's teeth, remember to always support the head. If the child has spasms, make sure they are positioned to minimize their spasms. When you start your program of oral hygiene with your infant, they may show some anxiety. Give lots of praise and encouragement while brushing your child's teeth. Begin by just wiping the inside of the child’s mouth with a moist cloth – this will get him used to having his mouth cleaned.

Regular brushing of teeth is vital. You should start to clean your baby’s teeth as soon as they appear in the mouth and can be started with soft small brushes.If a baby’s rubber toothbrush is available, many young children will enjoy munching on this. This may also provide a good practice for developing chewing skills. If the child finds it too difficult to tolerate a toothbrush, then it is preferable to continue tooth-cleaning with a finger or moist cloth, and with the possible introduction of a small amount of toothpaste. Many parents do not know that up to the age of three, parents should only use baby tooth cleanser – to avoid fluorosis (discoloration of the adult teeth.) When brushing your child’s teeth try to develop a technique which is three teeth at a time in a circular or ‘mini-scrub’ motion. Pay particular attention to the inner surfaces and the small, difficult-to-clean spaces between the teeth and the biting surfaces of the teeth at the back of the mouth. Brushing should include the gums and tongue as well as the teeth. Using a battery operated toothbrush might help to make teeth cleaning easier. In addition to cleaning the outer surfaces of your child’s teeth by brushing, it is also important to clean the surfaces between the teeth with dental floss. Many parents find flossing easier if they use a floss holder.

Children should have their first oral/dental health evaluation by the age of 12 months, or within 6 months of the eruption of the first tooth.

Prior to that first trip to the dentist, parents can work at making the child's teeth more decay resistant by using an ADA-approved children's toothpaste. Place only a pea-sized drop of toothpaste on the toothbrush. Parents can also decrease the risks of decay by not letting their children drink fruit juice or sweetened drinks from a bottle or "tippy" cup, since this prolongs the exposure of teeth to harmful sugar. It is also recommended that you never put a child to bed with a bottle.

Parents should provide healthy, balanced meals for children. Plenty of healthy snacks should be available for children. They should limit the amount of sugar-laden foods and snacks in the diet. Cheese products actually fight dental caries.

The Role Of The Dentist
The dentist should ask parents to schedule appointments for children with Cerebral Palsy early in the day or at a time of day when the child is usually in the best mood. The dentist should also obtain the child’s medical history before the first appointment so that any necessary medical consultations can be arranged and take place before the first appointment.

It is important for the dentist to try to develop a good rapport with the child. They may try to gain the cooperation of the cerebral palsied child by using behavior management techniques such as: tell-show-do, positive reinforcement, and voice control.

Children with other disabilities as a result of Cerebral Palsy will need additional strategies to make the dental visits more successful for all. For instance:

a child who has a really hard time understanding may require repetition of commands and requests, which will enhance comprehension; a child with severe visual impairment needs a verbal description of the planned dental procedures, this will help prevent fear and anxiety; communication can also be accomplished using nonverbal techniques, especially for children with hearing impairment.

The dentist may need to use sedation techniques to calm a child – if the child’s medical situation permits. Some children can only be treated under general anesthesia, however.

Children with cerebral palsy may have a severe gag reflex – making it difficult to take dental xrays.

It is important to remember that children and adults with Cerebral Palsy are just as aware of their physical appearance as other individuals. It is an added stigma for those who already have impairments to go into public with gaps in their mouths caused by missing teeth. Care should to taken to have a plan for a satisfactory visual appearance before teeth are removed. When the teeth at the back of th mouth have large cavities and too much of the tooth has been destroyed, stainless steel crowns are often used. Fixed bridgework is usually not done for patients with cerebral palsy because of the increased risk of falling and dental injury Fixed bridgework for patients with frequent seizures is not recommended because of the possibility of damage to the supporting teeth or bone during a seizure-related fall.

The dentist should discuss the option of myofunctional therapy for young children who have orofacial and tongue hypotonia. Myofunctional therapy is a retraining effort to correct tongue thrusting and an improper swallow. It is often prescribed to individuals who have an abnormal swallow usually caused by tongue placement resulting in a mis alignment of the teeth. This therapy can also help with tongue thrusting which is the abnormal habit of placing the tongue between the teeth before and during the act of swallowing. Myofunctional therapy may increase the muscle tone of the lips, as well as keep the tongue inside of the mouth.

It is part of the dentist's job to counsel parents about growth and development of the teeth and orofacial (mouth and face) structures. Regular dental appointments are highly recommended in order to supervise and evaluate a patient’s oral hygiene. Regular dental appointments also allow the dentist to monitor any gingival overgrowth which may be caused by anti-seizure medications.

What is Orofacial Regulation Therapy and Does It Help?
The orofacial regulation therapy concept includes: functional diagnostics of oral sensorimotor dysfunctions; a special manual stimulation and facilitation program, which helps to control and improve head and body posture; and the use of removable activating palatal plates, and other orthodontic appliances.

Treatment using these activating orthodontic appliances should only be done in conjunction with a special physiotherapy program. The type of appliance will vary with the form of Cerebral Palsy.

Description of the myofunctional appliance for spasticity:
Includes a stimulating palatal plate, which helps to reduce tongue thrust.

A removable appliance is worn every day, about one hour at a time, for a total of four hours each day. This "palatal button" appliance is not worn during sleep or feeding, however. The appliance may be modified, later on, to include upper lip stimulators.

Description of the myofunctional appliance for hypotonia:
Acts by stimulating the facial "motor points." The upper lip may be stimulated with "bumpers" which are attached to a "vestibular wire."

Care of the teeth is one part of the overall care of individuals with CP. The dentist will be one part of the team. Speech therapists can also be of assistance with swallowing and other area where the lack of coordination of the muscles of the face, mouth, tongue, jaws and neck create difficulties for the child.