Indonesian Journal of Dental Medicine

Volume 1 Issue 1 2018; 1-4

Case Report

General anaesthesia in the dental management of a child with cerebral

palsy and autism: A Case Report
Seno Pradopo, Firli Cahaya Khairani, Wahyudi Sudarsono, Masyithah, Udijanto Tedjosasongko
Department of Pediatric Dentistry,
Faculty of Dental Medicine, Universitas Airlangga,
Surabaya – Indonesia

ABSTRACT

Background: Cerebral palsy described as a spectrum of movement and posture disorders which result from
pathological injury to the developing fetal or infant brain. Many conditions associated with cerebral palsy
require surgery. Purpose: This article presents case report of a 15-year old, autistic male patient with cerebral
palsy who required urgent management of multiple gangren radix, multiple pulpitis and gingivitis. Case
Management: General anaesthesia was chosen for the purpose of behaviour management. The dental
procedure were restoration with flow able composite of 7 teeth, extraction of 15 gangren radix, scaling of
maxilla and mandibular region, also preventive treatment with topical aplication of fluoride. Discussion:
Principles to the care of a such patient including early recognition, parental support, multi-disciplinary
planning of procedure requiring general anesthesia, continuity of anesthesia care, and clear guidelines about
the perioperative management of uncooperative children. Dental surgery under general anaesthesia was done,
the patient was received restoration with flow able composite of 7 teeth, extraction of 15 gangren radix, scaling
calculus at maxilla and mandibular region, also preventive treatment with topical aplication of fluoride.
Conclusion: The case report showed that dental treatment should be done in patient with cerebral palsy and
autism comprehensively.

Keywords: Cerebral Palsy, Autism, General Anaesthesia, child, dental treatment

Correspondence: Seno Pradopo, Departement of Pediatric Dentistry Faculty of Dental Medicine, Universitas
Airlangga, Jl. Prof. Dr. Moestopo 47 Surabaya 60132 – Indonesia. Phone: +62315030255 Email: seno-
[email protected]

neurological disorders characterized by

INTRODUCTION varying degrees of motor, sensory, and
intellectual impairmentt. The National Institute
Special needs are terminology used in
of Neurological Disorders and Stroke
clinical diagnostic and functional development
published a perinatal study which suggested
to describe individuals who require assistance
that complicated deliveries could only account
for disabilities that may be medical, mental, or
for 10% of all CP cases. The life expectancy of
psychologicall. As medical care providers, we
many patients with CP now extends into
should individualize our treatment and service
adulthood and they frequently present to both
and ensure delivery of optimal medical
specialized and general hospitals for
resources for individuals with special needs.1
anesthesia and surgery.2
There is a higher incidence of dental caries in
Autism spectrum disorder (ASD) refers to a
patients with CP because of inadequate plaque
group of disorders of brain development,
removal due to motor, sensory, or intellectual
which are variably characterized by social
disabilities in these patients. Oral health
interaction and communication difficulty,
education and the interventions of sedation and
restricted interests, and repetitive behaviors.
general anesthesia should be instituted for
Common behavior-related barriers to dental
management of dental health conditions.1
care include the fact that children with ASD
Cerebral palsy (CP) is a collective term
are prone to agitation, self-injury, and
used to describe a diverse group of
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Volume 1 Issue 1 2018; 1-4

emotional dysregulation. Hypersensitivity to hygiene status, and that performing dental

sensory input can also interfere with dental procedures on multiple teeth using local
and oral care. These features make it difficult anesthesia would be difficult due to the
for parents to care for their children’s teeth and patient’s lack of ability to cooperate. As a
for dental professionals to position, examine, result, general anesthesia was chosen for the
and treat children with ASD.3 This article purpose of behavior management. His mother
presents case report of a 15-year old, autistic and grandmother were well informed about the
male patient with cerebral palsy who required method, process, and side effects of the dental
urgent management of multiple gangren radix, procedure. Then, a consent form was signed
multiple pulpitis and gingivitis. prior to inpatient general anesthesia procedure.

CASE

A 15-year old, (weight: 37 kg) male

patient with cerebral palsy and autism
accompanied by his mother and grandmother
to the Pediatric Dentistry Clinic, Universitas
Airlangga Dental Hospital with a major
complaint of recurrent painful and abscessed
in mandibula molar permanent. Extra oral
examination showed simetris face (Fig.1),
intra oral examination showed multiple
Fig 2. Preoperative intra oral photo
gangren radix, multiple pulpitis and gingivitis.
A preoperative complete blood examination
was performed and consultation was requested
of his private pediatrics. The test results
showed no risk factors associated with
performing general anesthesia on the patient.
At this time, the patient was not taking any
medications. Monitoring devices
(electrocardiogram [ECG] monitor, pulse
oximeter, sphygmomanometer, thermometer,
and end-tidal CO2 monitor) were attached to
the patient. Antibiotic cefazolin 2 gr as a
prophylaxis, drip in NaCL 0.9% 100 ml one
hour before procedure for 15 minutes. No
movement or spontaneous respiration by the
patient was observed during the procedure. No
Fig 1. Extra oral photo additional muscle relaxants were administered.
Due to his lack of ability to communicate The dental procedure were restoration with
and cooperate with others, Pedi-wrap and oral flow able composite of 7 teeth, extraction of
opening devices were used. Treatment was 15 gangren radix (Fig.3) , scaling of maxilla
performed step-by-step while the patient was and mandibular region, also preventive
under physical restraint. During a regular oral treatment with topical aplication of fluoride.
examination, a number of dental caries and Socket were sutured with absorbable string.
gangren radix were identified on the maxillary The treatment was take 2 hours long and the
and mandibular tooth (Fig.2), and accordingly, anesthetic procedure lasted for 2,5 hours. The
exctraction and restorative treatment was patient showed no signs of complications after
planned. the treatment and was moved back to his
house, one day after dental surgery.

It was deemed that the caries would

develop rapidly due to patient’s poor oral

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Volume 1 Issue 1 2018; 1-4

aspiration pneumonia. Their oral hygiene

status is also the burden of the caregivers.
Patients with cerebral palsy usually have
additional disability attributable to central
nervous system damage, such as cognitive
impairment, visual or hearing problems,
seizures, and communication and behavioral
disturbances, as well as the chronic systemic
problems resulting from their disease. Severity
of cerebral palsy is often associated with
postoperative complications. Airway
maintenance during anesthetic induction may
Fig 3. Extracted gangren radix photo
be complicated by excessive secretions.
One week follow up showed poor oral Tracheal intubation should be performed if this
hygiene status from the intra oral examination is a concern or if there is a history of
(Fig.4). His mother and grandmother were gastroesophageal reflux. Tracheal tube size
instructed how to perform dental hygiene selection should be based on the patients’ age.
procedure by daily cleaning of the teeth with Careful positioning is of paramount
sterile gauze. The patient was scheduled for importance in the child with spastic cerebral
follow up in the next 3 months. palsy to forestall nerve or muscle damage.
Fixed contractures may add difficulty to
positioning.
The responses to anesthetic agents may also
differ. They may be resistance to non-
depolarizing muscle relaxants. They appear to
be a close correlation between severity of
preoperative cerebral palsy and postoperative
complications. The risk of perioperative
adverse events was 63.1%, mostly of
hypothermia and hypotension. Factors
associated with increased risk included
Fig 4. Intra oral photo a week postoperatif American Society of Anesthesiologists (ASA)
physical status score of 2 or higher, history of
DISCUSSION seizures, upper airway hypotonic, general
surgery procedures, and adulthood.1
Appropriate general anesthesia could ease Autism is a developmental disorder that is
the process of dental treatment in patients who usually diagnosed before age 3 years. Children
are unable to cooperate during the dental visit. with autism have characteristic symptoms such
Motor dysfunction includes Parkinson, as impaired social interactions, verbal and
cerebral palsy, and other diseases that cause nonverbal communication deficiencies, limited
uncontrolled tremor. General anesthesia is activities and disinterest, repetitive behaviors,
sometimes required so that these patients can and difficult responses to changes in routine.
keep their mouth open for the treatment. Some of them have other behavioral
Cerebral palsy comprises a group of no disturbances such as self-mutilation,
progressive motor conditions manifested by aggression, and psychiatric symptoms. Some
physical disabilities in development due to autistic patients take medications for behavior
brain injuries during the antenatal, perinatal, or control to help them integrate effectively in the
postnatal period. The prevalence is educational and rehabilitative process. Early
approximately two per 1000 live births. communication with the patient’s families,
Patients with cerebral palsy tend to have flexibility to individualize the anesthetic plan,
complicated dental problems due to lack of lip and awareness of possible interaction of
seal, higher malocclusion rate, behavior medications and
temporomandibular disorder, difficulty
swallowing, and associated malnutrition and

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Volume 1 Issue 1 2018; 1-4

anaesthetics are important in management Informed consent is an important factor of

of these patients.1 a patient’s autonomous decision-making, and
Increasing numbers of dental procedures it prevents medico legal issues related to
that involve anesthesia as a means to manage various complications. Most children have
patient behavior are being performed today, immature cognitive abilities, and cannot make
and common anesthetics are used in outpatient legal decisions on their own; therefore,
clinics during general anesthesia due to their informed consent must be given by their legal
rapid onset of action and good reversibility representatives. To prevent any legal issues
upon ceasing the administration.5 In the from arising later on, several factors should be
hospital this study focused on, it was also considered, such as determining the person to
common for general anesthesia to be give informed consent and the level at which
performed on intellectually disabled patients, the surgical and anesthetic procedures should
who are unlikely to cooperate during dental be explained to intellectually disabled patients.
procedures in an outpatient operation room.4 The case report showed that dental treatment
However, in cases of outpatient general should be done in patient with cerebral palsy
anesthesia, it is difficult to check a patient’s and autism comprehensively.
comorbidities unlike in inpatient general
anesthesia, and the cooperation of the patient’s
is necessary for the proper preparation of REFERENCES
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