Sensory impairment

Sensory impairment in children with medically compromised condition

Sensory impairment plays a very important role in determining the degree

of cooperation that can be attained by these children in the dental operatory.

The medically or developmentally compromised children’s adverse behaviour

could not just be related to the underlying condition or to their psychological

condition. At times we fail to determine the side effects of the medication that

may adversely affect their sensorium resulting in dizziness, vomiting, altered

hearing, tinnitus, muscular imbalances, malaise etc or the associated

conditions that may manifest with regard to the developmental disability such

as visual or hearing impairment, nerve palsies, hypersensitivity, etc. This

sensory impairment would be one of the essential factors that may result in

inadequate communication with the patient resulting in inability of the patient

to understand or perceive the treatment aspects on the contrary to the general

belief of mental retardation being the hindrance in instilling effective and

efficient treatment. Being advocates of oral health care it becomes crucial to

rule out the presence of these sensory impairments so as to completely

understand the psychological and physical disabilities of these children so as

to approach these patients in a more appropriate manner specifically tailored

according their individual needs. The various condition in which sensory

impairment is present and the type of impairment that may be observed is

explained below.

Sickle cell anemia : Repeated micro-infarction can destroy tissues having

microvascular beds that promote sickling. Occlusion of retinal vessels can

produce hemorrhage, neovascularization, and eventual detachments affecting

186 ABS/PD/08/L82
 Sensory impairment

the vision. The hand-foot syndrome is caused by painful infarcts of the digits

and dactylitis. Stroke is especially common in children; a small subset tend to

suffer from repeated episodes.

Thalassemia : Cranial nerve palsies have been described in thalassemia due

to the extramedullary hematopoiesis resulting in pressure on the nerves. This

could affect the optic and the auditory nerve affecting vision and hearing.

Anemias : Megaloblastic anemias due to deficiency of Vit. B12 may cause a

bilateral peripheral neuropathy or degeneration (demyelination) of the

posterior and pyramidal tracts of the spinal cord and, less frequently, optic

atrophy or cerebral symptoms. The patient presents with paresthesias, muscle

weakness, or difficulty in walking and sometimes dementia, psychotic

disturbances, or visual impairment. Long-term nutritional cobalamin

deficiency in infancy leads to poor brain development and impaired

intellectual development. In such patients, it is necessary to try to establish

whether or not there is significant cobalamin deficiency, e.g., by careful

examination of the blood film, cobalamin absorption studies, tests for

antibodies to IF or parietal cells, and serum methylmalonic acid (MMA)

measurement if available. A trial of cobalamin therapy for at least 3 months

will also usually be needed to determine whether the symptoms improve.

Leukemias : Leukemic Cells may infiltrate the central nervous system or

peripheral nerves, leading to cranial nerve palsy, paresthesia, anesthesia, and

paralysis. Retinal hemorrhages are detected in 15% of patients. About 25% of

patients present with significant bone pain and arthralgias caused by leukemic

infiltration of the perichondral bone or joint or by leukemic expansion of the

marrow cavity. Chemotherapeutic toxicity with high-dose cytarabine includes

187 ABS/PD/08/L82
 Sensory impairment

myelosuppression, pulmonary toxicity, and significant and occasionally

irreversible cerebellar toxicity.

Epilepsy : Partial seizures account for a large proportion of childhood

seizures, up to 40% in some series. Partial seizures may be classified as

simple or complex; consciousness is maintained with simple seizures and is

impaired in patients with complex seizures. Motor activity is the most

common symptom of simple partial seizure. The movements are characterized

by asynchronous clonic or tonic movements, and they tend to involve the

face, neck, and extremities. Unfortunately, children have difficulty in

describing aura and often refer to it as "feeling funny" or "something crawling

inside me." This could be an indication of the disturbance in the sensorium of

the child and an indication to the precipitation of the seizures. Simple partial

seizures may also manifest as changes in somatic sensation (e.g.,

paresthesias), vision (flashing lights or formed hallucinations), equilibrium

(sensation of falling or vertigo), or autonomic function (flushing, sweating,

piloerection). Simple partial seizures arising from the temporal or frontal

cortex may also cause alterations in hearing, olfaction, or higher cortical

function (psychic symptoms). This includes the sensation of unusual, intense

odors (e.g., burning rubber or kerosene) or sounds (crude or highly complex

sounds), or an epigastric sensation that rises from the stomach or chest to the

head. Some patients describe odd, internal feelings such as fear, a sense of

impending change, detachment, depersonalization, or illusions that objects are

growing smaller (micropsia) or larger (macropsia). When such symptoms

precede a complex partial or secondarily generalized seizure, these simple

partial seizures serve as a warning, or aura.

188 ABS/PD/08/L82
 Sensory impairment

Diabetes : The signs and symptoms of diabetes involving the sensorium is

changes in vision, weakness, malaise, irritability and nausea. Diabetes is a

group of microvascular and macrovascular complications affecting multiple

organ systems. People with diabetes have a greatly increased risk for sensory

impairment such as blindness and stroke. AGE-modified arterial collagen

immobilizes circulating LDL, contributing to atheroma formation.

Accumulation of AGEs causes increased basement membrane thickness in the

microvasculature of the retina and around the nerves.

Respiratory disease : The upper respiratory tract infections include

symptoms such as rhinorrhea, nasal congestion and oropharyngeal irritation.

Other symptoms that may be present include cough, fever, malaise, fatigue,

headache, and myalgia. Allergic rhinoconjunctivitis may also be an hindrance

in providing care. Transient impairments of eustachian tube function are seen

in conditions that cause nasopharyngeal mucosal edema and obstruction of the

eustachian tube orifice, such as allergic rhinitis and viral upper respiratory

infections.

Renal disease : The most common metabolic disorders that may lead to CRF

include diabetes mellitus (DM), amyloidosis, gout, and primary

hyperparathyroidism. This may result in sensory impairment such as

retinopathy, restricted and painful movements of the extremeties or fingers.

The early signs and symptoms of CRF are related to changes in the neurologic

system. Both central and peripheral nervous systems are involved, with

diverse consequences. The degree of cerebral disturbance roughly parallels

the degree of azotemia. As the disease progresses, asterixis and myoclonic

jerks may become evident; central nervous system irritability and eventual

189 ABS/PD/08/L82
 Sensory impairment

seizures may occur. Seizures also can occur secondary to hypertensive

encephalopathy and electrolyte disturbances such as hyponatremia. Along

with neurologic hyper irritability, peripheral neuropathy is commonly present

as a result of a disturbance of the conduction mechanism rather than a

quantitative loss of nerve fiber. The clinical picture is dominated by sensory

symptoms and signs. Impairment of vibratory sense and loss of deep tendon

reflexes are the earliest, most frequent, and most constant findings. The

predominant patient complaint is paresthesia or burning feet that may

progress to eventual muscle weakness, atrophy, and finally, paralysis; there is

a tendency toward increasing incidence with decreasing renal function. This

predominantly affects the lower extremities but can affect the upper

extremities as well. Rarely, facial, oral, and paraoral regions also can be

affected. Renal replacement therapy may halt the progress of peripheral

neuropathy, but once these changes occur, sensory changes are poorly

reversible while motor changes are considered irreversible.

Down’s syndrome : People with down syndrome have an increased risk of

visual and hearing impairment compared to the individuals with typical

development or intellectual disabilities due to other etiologies. Early diagnosis

and treatment of illnesses, e.g. middle ear infections, causing hearing

impairment in children with down syndrome provides significantly improved

hearing levels compared to delayed diagnosis and treatment. These children

have increased incidence of congenital heart defects, thyroid disease, diabetes,

depression and Alzheimer’s disease. Other risks to cognitive abilities include

central nervous system infections and stroke. Hypotonicity of tongue and

perioral musculature is also observed.

190 ABS/PD/08/L82
 Sensory impairment

Cerebral palsy : Motor disability the primary limitation in these children.

Loss of control of the body posture is one of the common manifestations.

Epilepsy may be present in association with cerebral palsy. Hypotonicity of

the musculature is also present. Hypersensitivity to touch and exaggerated gag

reflex are the complications encountered in the dental operatory. Vision,

hearing and inability to communicate due to lack of proper speech is a

presenting feature. Based on the type of cerebral palsy, the findings may vary

from, head being tensely reclined, facial movements being tense, and the

tongue is hypertonic. Spontaneous wave like movements of tongue can be

observed with uncoordinated movements of tongue, jaw and facial muscles.

Autism : Repetitive movements of the body and extremity is present.

Hypotonicity of lips and hypersensitivity and oral defensiveness is commonly

observed in these children. Verbal and nonverbal communication skills are

delayed or are absent. Among those people who do speak (approximately 50

percent), however, there often is a low rate of spontaneous initiation of

communication, one-sided talk rather than back-and forth conversation, and

an inability to integrate words with gaze, facial expression and gestures.

Behavioural symptoms of autism, particularly in young children, include

temper tantrums and, as they get older, impulsivity, agitation, anger,

aggressivity and self-injury sets in. Various nonspecific neurological

symptoms or signs may be noted (for example, motor incoordination, delayed

development of hand dominance). Seizures (often grand mal) also are

common, with more than 30 percent of adolescents having had two or more

epileptic seizures. Motor stereotypes often referred to as “self-stimulatory”

behaviors include finger flicking, hand flapping, body rocking, self spinning

191 ABS/PD/08/L82
 Sensory impairment

and running in circles. Stress, excitement or certain stimuli (such as noise)

may trigger these repetitive actions.

192 ABS/PD/08/L82