All of these red flags are also potential areas for collaboration and/or mutual promotion of anticipatory guidance with a PNP. Review each area of concern and see some things that could be addressed for each.

Abuse/Neglect

Children with developmental disabilities are at increased risk for child abuse and neglect. Signs of physical abuse often manifest in oral trauma. Key signs in Justin’s case that should raise a suspicion of child abuse include:

• Inconsistent medical/dental care and frequent change in providers
• Loosened/fractured teeth
• Frenulum injury/laceration

Findings of oral trauma such as these may indicate that Justin is being maltreated. Accidental injuries of the mouth are common. Differentiating accidental injuries from abuse requires a careful health history from the child’s caregiver to determine whether the injuries are consistent history provided and the child’s physical and developmental abilities. Reporting of suspected child abuse or neglect is mandatory when a health care provider has concern a child is being victimized. In cases where there is uncertainty of abuse or no immediate concern, consultation with Justin’s pediatric nurse practitioner would be appropriate. All findings/explanations should be carefully documented in the patient’s health record.

Diet

Children with cerebral palsy are at increased risk for dental caries and have an increased risk of enamel hypoplasia. Limit Justin’s use of sugary snacks. Encourage fruits and vegetables with dips to facilitate swallowing. Suggestions include peanut butter, mild salsa, yogurt-based dips, fruit and yogurt, homemade bean dip, and dressings. Referral to a nutritionist for dietary assessment and recommendations may be indicated.

Chewing course foods assists in cleaning teeth and stimulating gum tissue. Soft diets may promote development of caries. Encourage Justin to brush his teeth twice daily with a soft toothbrush and toothpaste with fluoride. Referral to a nutritionist for dietary assessment and recommendations may be indicated.

Physical Therapy

There is nothing in the patient’s history or evaluation that warrants discussion of physical therapy at this time.

Medications

Muscle relaxants and anticonvulsants can cause xerostomia. Encourage sugar-free gum, if Justin can tolerate, to stimulate saliva flow and restore moisture. Caries-preventive measures (sealants, fluoride supplements and antimicrobial mouthwashes) should be implemented.

Mobility

Since Justin is at risk for falls, he is susceptible to dental trauma. The recommended protocol to follow with Justin should be reviewed with his parents and his pediatric nurse practitioner.

Cognition

Consulting with the PNP may be helpful in discovering which examination strategies have been successful in the past. Try to keep staff consistent at each visit to promote trust. Explain all procedures and follow-up instructions at levels appropriate for the child’s intellectual and developmental level.

Bruxism/Tongue Thrust

Justin’s tongue thrust may cause malocclusion and impair swallowing of food. Referral to an orthodontist for evaluation may be indicated. Referral to a speech-language pathologist for retraining of muscles associated with swallowing may be indicated. Bruxism can result in fracturing, loosening, and/or loss of teeth. Mouth guards, if tolerated, can decrease the adverse effects of bruxism.

Immunizations

The PNP would recommend discussing the benefits of immunizations versus the risks from disease. Immunizations are an efficacious and cost-effective way to improve the overall health of children.

Oral Hygiene

Modifications to the routine dental exam may be indicated, including not forcing limbs into unnatural positions in the dental chair; using gentle but firm pressure to calm spasticity of limbs; treating children in their wheelchair if applicable; and minimizing use of bright lights and sudden movements that may stimulate reflexive movements and spasticity. Again, collaborative discussion with the PNP may help in indicated which treatment style works best for Justin.