Introduction

Handicap is the loss or limitation of opportunities to take part in the normal life of the community on an equal level with others due to physical and social barriers.¹  According to the data from the 1988 National Interview Survey there are nearly 11 million children, aged 17 and under, with developmental, learning, or emotional disorders.  The most common major handicaps are disorders of the central nervous system, the cardiovascular system, and the mind.²  Cerebral palsy is one of these neuromuscularly handicaps, which has specific motor skill problems, delay in developmental milestones, as well as physical findings that might include abnormal muscle tonus, reflexes, and persistent infantile reflexes.^3,4

In disabled individuals the process of developing gingival/periodontal diseases does not differ from non-disabled individuals.  There are no differences in prevention of the diseases and the treatment modalities between these groups.  The main factor related to gingival/periodontal problems in disabled individuals is the inadequacy of the plaque removal from the teeth.  Motor coordination problems and muscular limitation in neuromuscularly disabled individuals along with the difficulty in understanding the importance of oral hygiene in mentally disabled individuals have resulted in the progression of inflammatory diseases.^5,6,7

The mechanical control of dental plaque in disabled individuals generally causes some difficulties, is found to be time-consuming, and sometimes ineffective.^8,9  Advances in manual (M) and electrically powered (E) toothbrushes have increased their ability to remove plaque.  Haffajee et al.¹⁰  compared the efficacy of M and E toothbrushes on clinical parameters.  They stated the E toothbrushes significantly reduced the mean Gingival Index (GI) and probing attachment level in a 6 month time interval.  Their results are in concordance with numerous studies^11-19 which suggested that E toothbrushes deliver superior plaque removal compared to M toothbrushes.

However, the effectiveness of M and E toothbrushes is limited by the manual dexterity and skill of the user.²⁰  As a result, chemical plaque control has been recommended as an alternative and adjunctive to mechanical plaque control in these special patient groups.^21,22  It has been suggested chlorhexidine gluconate (CHX) may be the only possible answer to the oral hygiene problem of the disabled patients.²³ The effectiveness and the effect mechanisms of CHX have widely been investigated in various patient populations, including the disabled, and the results have led CHX to be defined as the “gold standard.”^24-28  The CHX mouthwash technique caused many problems when used in a disabled population.  Previous investigators estimated only 22% of institutionalized disabled patients were able to rinse effectively.²⁹  In spastic cerebral palsy patients, the CHX spray application exhibited ease of use, effective plaque control, reduced adverse effects, and swallowing problems.^3,30

The combination of mechanical and chemical plaque control seemed to be even more beneficial than only using a mouthwash.^31,32  When the main volume of the dental plaque is removed by mechanical actions, the oral chemopreventive agents only have to combat sparse biofilm remnants.³³  Consequently, mouthrinses are recommended as adjuncts to mechanical oral hygiene.^34-38

The aim of this study was to investigate the effect of various oral hygiene strategies on the symptoms of gingival inflammation, define the optimum hygiene method, and to examine combined oral hygiene strategies (CHX as adjunct to M and E toothbrushes) to determine the efficacy for removing dental plaque in neuromuscularly disabled individuals.

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Citation Number: Vol. 5, No. 4, Page 024