cerebral palsy ( cp ) is a severe childhood disability , characterized by a nonprogressive motor disorder of posture and movement due to a lesion in the developing brain .
the   prevalence of this clinical condition among children aged 310 years has been reported to be 2.4 in every 1000 live - borns , being significantly higher in males and black people .
the most common disorders associated with cp are mental retardation , sensory limitations , epilepsy , speech disorders and hearing loss .
the more common oral conditions in individuals with cp include higher mean decayed , missing and filled surfaces index , higher plaque index , tendency for delayed eruption of permanent molars , malocclusion , as well as high rates of bruxism .  
this rhythmic grinding can cause masseter hypertrophy , headaches , temporomandibular joint destruction , and tooth wear .
the incidence of bruxism in the general population has been reported to be as high as 21% , but its incidence in pc is still unknown .
many factors may be involved in the etiology of this parafunctional activity such as spasticity ; unbalanced oral myofunctional disturbance[3 , 5 ] , backbone dysfunction with the head projected forward , which changes the contact between the teeth and predisposes hyperactivity of the main masticatory muscles ( temporal and masseteric ) , lack of control of the mandibular posture which can worsen in periods of emotional stress ; sleep disorders ; use of neuroleptics   and malocclusion .
the mastigatory musculature spasticity of cp can interfere with daily activities such as tooth brushing , cleaning of the oral cavity and eating .
the treatment for this parafunctional activity includes restorative treatment , occlusal adjustment , the use of oral splints , pharmacological treatments and dental extraction .
the most severe cases require a multidisciplinary input , including pediatricians , psychiatrists , paediatric dentists , and/or oral surgeons .   
the following paper reports a severe case of bruxism in a child with cerebral palsy and discusses the treatment given .
a seven - year - old boy with spastic cerebral palsy ( type quadriplegia , the severest cp ) was brought to the pediatric dentistry department of the federal university of rio de janeiro , brazil because his parents complained of the repeated grinding which was damaging his teeth and gums .
the parents reported during anamnesis that the pregnancy and parturition were normal and he was born in 40th week of gestation .
when he was 5 days old he spent 11 days in the neonatal intensive care unit because of icterus with moderate bilirubin levels and he needed a blood transfusion .    
the child was under medical treatment during his first year of life because of convulsive crises .
the child has been followed up by a multidisciplinary team including pediatrician , physiotherapist , psychologist and neurologist .
the enamel had been worn away on large areas of anterior cusps and mastigatory primary molar surfaces .
because of the poor participation of the patient , the size of movements could not be measured .
he had no salivary drooling and had an adequate swallow in spite of evidence of facial and hypoglossal nerve dysfunction .
his parents reported he used to eat ordinary food , but in the last six months they had noticed he appeared in pain while eating so he was only able to eat pured food .     
as the molars had extensive teeth surface losses , stainless steel crowns were the proposed treatment for the primary molars under local anesthesia and nitrous oxide - induced sedation ( n2o ) .
at the first appointment , the treatment of the right molars was carried out and four stainless steel crowns were cemented on the primary molars .
a week later a protective oral appliance was designed for covering all the maxillary molars , in order to reduce the bruxism and prevent injuries to the soft tissues .
impressions were made with a silicone material to obtain a working model ( figure 1 ) and two acrylic resin appliances were made ( figures 2 and 3 ) under n2o sedation . at the following appointment ,
the protective appliance was fixed on both sides of the mandibular teeth by means of ionomer cement .
the parents were educated on the proper oral hygiene measures to be adopted and the need for regular dental visits in the future . after a period of two weeks , grinding behavior had decreased significantly and no further damage to the dentition were seen .
his parents reported that the child had received the appliance well and he no longer ground his teeth ( the bruxism had been controlled with concomitant alleviation of symptoms ) ; feeding had improved , because he was able to consume solid foods instead of the semisolid diet that he had before treatment .
the patient was periodically followed up in order to remove and clean the appliances , apply topical fluoride and instruct the parents on oral hygiene .
six months later , the eruption of permanent central incisors of both jaws could be noted and at the one year ( figure 4 ) review the crowns of these teeth were more exposed .
individuals with cp tend to develop accentuated involuntary muscle tonus in orofacial muscles and other muscles and often show various types of stereotypy , especially when they lack any other occupation , as in this case , where the child occupied himself by grinding his teeth for a large part of the day .
lindqvist and heijbel   observed that abnormal dental wear is closely related to a low level of mental development   and severe dental wear indicates that cp children have more pronounced bruxism than normal children [ 8 , 9 ] .   in this case ,
clinical signs as lip biting or small ulcers were not found , even though they have been reported as clinical signs of bruxism [ 6 , 18].on the other hand , the patient presented limited mouth opening or trismus , an inherent characteristic of bruxism .  
there is contradictory information in the literature regarding the incidence of oral diseases in patients with cp . according to brown and schodel   ,
these controversies are due to the failure of the criteria used to choose the population to be studied as well as the absence of control groups .
however , no carious lesions were diagnosed in the patient described in the present case . this
may be explained because the parents had received oral hygiene and diet instructions in a pediatric clinic when the child was very young and they have always been very careful with the child 's oral hygiene .
they are often treated under general anesthetic or deep sedation , which has many disadvantages .yoshida et al .  
presented a study pointing out the beneficial properties of nitrous oxide-(n2o- ) induced sedation performed during dental treatment on cp patients .
the authors decided to carry out the dental procedures on the patient using n2o sedation considering the procedure was of short duration , the difficulties involved in local hospital admission and the safety of the technique . in studies of bruxism in mentally retarded children in the literature , the term  abnormal abrasion  has varying implications ; so treatment for the oral injuries caused by this parafunctional activity may include restorative techniques , dental extractions , and the use of oral protective appliances .
the first choice was to restore the primary molars with stainless steel crowns because of their high degree of dental wear .
this procedure was not sufficiently effective , since the patient continued to grind his teeth with great force .
although the appliance was cemented , the parents were instructed to verify the stability of the appliance in order to avoid the risk of aspiration .
although the appliance was cemented , before choosing this treatment option , the authors discussed the risk of aspiration with the child 's parents .
they were instructed to verify the stability of the appliance and to keep it cleaned .
although there are few studies concerning the use of oral devices directly with children , an oral appliance applied to prevent the self - mutilation of the lower lip in a mentally handicapped patient with moebius syndrome , has been described , with positive results [ 15 , 23 ] .
the bruxism was reduced and the parents related that activities like eating and sucking became easier for the patient .
it probably occurred because the resin appliance increased vertical dimension and the occlusal parameters had been established , so the patient was able to have a better functional occlusal activity .   in a later followup ,
the eruption of permanent first molars and incisors was observed , indicating the success of the treatment .
as the child gets older , the appliance can be extended to other teeth if necessary , as his future neurological condition can not be predicted .
early diagnosis and interventions of parafunctional habits in individuals with cp is important to reduce invasive treatment and worse complications for the patient .
this paper also highlights that oral protective appliances can be clinically viable and effective for the prevention of bruxism .
furthermore , this case illustrates the importance of the treatment by a dental team in patients with cerebral palsy .
 cerebral palsy ( cp ) is one of the most severe childhood disabilities due to a lesion in the developing brain . 
 oral conditions often observed in this pathogenic are a tendency for the delayed eruption of permanent molars , higher percentages of malocclusion and parafunctional habits , including bruxism . 
 the significance of oral conditions observed in cp patients demonstrates the need for intensive home and professional care for these individuals . this paper presents a 7-year - old boy , with cerebral palsy , severe mental retardation , who had high abrasion wear of the primary teeth related to bruxism . 
 dental care was carried out under oxide - induced sedation , and management of the bruxism was achieved after the use of a resin acrylic protective appliance fixed on both sides of the mandibula . 
 the treatment performed offered efficiency advantages , was clinically viable , and should be a valuable option to practitioners considering appliance therapy to control parafunctional behavior . 
1. Introduction
2. Case Report
3. Discussion