REVISÃO

Dental Assistance for Children with Cerebral Palsy and Tecnological Perspectives for Rehabilitation

Assistência Odontológica em Crianças com Paralisia Cerebral e Perspectivas Tecnológicas de Reabilitação

Maria Júlia Pereira Coelho Ferraz^*, Mónica Fernandes Gomes^**, Miriam Yumi Matsui^*

 

^*São Paulo State University, UNESP e São José dos Campos Dental School, Brazil;

^**Department of Biosciences and Oral Diagnosis, São Paulo State University, UNESP, São José dos Campos Dental School, Biosciences Center for Special Health Care Needs (CEBAPE) e Special Health Care Needs Association (ASPE), Brazil.

 

Correspondência

 

ABSTRACT

The improvement of oral health and quality of life is closely related to transdisciplinary dialogue, technological development and social responsibility. In patients with cerebral palsy, the lesion of motor areas of the brain compromises the development and function of the craniofacial complex. Considering all the ethiopathogenic conditions, the treatment of such patients involves great difficulties. The dentist and other professionals related to their rehabilitation need to deal with difficulty in chewing, respiration, phonation, besides the poor oral hygiene resulted from abnormal involuntary movements of facial and masticatory musculature, tongue, and upper limb. It is also relevant the lack of understanding about the importance of oral health care due to mental deficits of these individuals. This study aims to review some aspects of oral health in patients with cerebral palsy proposing rehabilitation associated to technology. Few studies concerned about the effectiveness of therapies for oral rehabilitation in patients with cerebral palsy. Laser therapy, electromyography, electrostimulation and LED therapy should be analyzed as options for treatment of patients with cerebral palsy. Following research projects should focus more attention on the dynamic and oral function of these patients to achieve positive repercussions in their overall health.

Key-words: cerebral palsy; electric stimulation; electromyography; laser therapy; oral health; phototherapy

 

RESUMO

A melhoria da saúde bucal e qualidade de vida está intimamente ligada ao diálogo transdisciplinar, desenvolvimento tecnológico e responsabilidade social. Em pacientes com paralisia cerebral, a lesão de áreas motoras do cérebro compromete o desenvolvimento e função do complexo craniofacial. Considerando todas as condições etiopatogênicas, o tratamento odontológicos destes pacientes envolve grandes dificuldades como lidar com a dificuldade de respiração, mastigação, fonação, além da má higiene oral devido aos movimentos involuntários anormais da musculatura facial e da mastigação, da língua e dos membros superiores. Também é relevante a falta de compreensão sobre a importância da saúde bucal, devido ao déficit mental destes indivíduos. Este estudo tem como objetivo revisar alguns aspectos da saúde bucal em pacientes com paralisia cerebral propondo reabilitação associados à tecnologia. Poucos estudos preocupados com a eficácia das terapias de reabilitação oral em pacientes com paralisia cerebral foram encontrados. A terapia com laser, a eletromiografia de eletroestimulação e terapia LED deve ser analisada como opções para o tratamento de pacientes com paralisia cerebral. Sugere-se que há necessidade de implementar projetos de pesquisa que focalizem a dinâmica e a função oral com repercussões positivas na saúde geral do paciente com PC.

Palavras-chave: paralisia cerebral; saúde bucal; eletromiografia; estimulação elétrica; fototerapia

 

Introduction

In the contemporaneous world, the implementation of a transdisciplinary approach, technological improvement and social responsibility are indispensable for the professional who aims to promote health. Promoting health involves the dentist’s choice to defend life in a pluralist and tolerant conjecture.

The oral cavity is responsible for vital physiological functions for the maintenance of overall health, since it is involved with nutrients absorption, which is essential to physical and mental development; with defense from pathogenic microorganisms due to enzyme and antibodies from saliva; and also with feeling expression. Besides, the mouth is an important structure for social life and relationship, affecting the judgment of appearance and functioning as a connection instrument between people.

In patients with cerebral palsy (CP), the involvement of motor areas of the brain determinates a delay in motor development of audio-phonological and articulatory organs (1). In these patients, the presence of reflex is frequent while patients of the same age, but without this disorder, do not present any reflex. Therefore, the pathological persistence of these reflex compromises the perfect functional efficiency of masticatory organs and development of refined muscle activities.

The increasing advancement of science permitted new technologies to be used to assist diagnosis and rehabilitation of patients that suffer from neurological damage. The interdisciplinarity has contributed to the improvement of quality of life, promoting more functional independence of people that were completely considered as dependents.

Surface electromyography has been indicated for the comprehension of the biomechanics of the jaws. The use of neuromuscular electrostimulation has proved to be very useful in the rehabilitation of patients with neurological problems. International protocols recommend high frequency sessions per week, or even twice a day (2). Another instrument used for the recuperation of nerve function, is phototherapy, which is based on its property of acceleration of healing process and tissue repair.

In this context, this study aims to review some aspects of oral health in patients with cerebral palsy, suggesting their rehabilitation in agreement with technological development.

 

Cerebral palsy

Cerebral palsy (CP), also defined as chronic non-progressive encephalopathy of childhood, results from primary brain injury, often induced by lack of oxygenation of brain cells during the pre-, peri- or postnatal period, affecting the central nervous system in phase of structural and functional maturation (3-5). This non progressive disturbance refers to a group of disorders related to movement and posture, causing activity limitation (6).

The motor disorders are permanent and mutable, causing secondary musculoskeletal changes and limitations of physical and mental activities (7). These disorders of motor development are often accompanied by disturbances of sensation, perception, cognition, communication and behavior, epilepsy, and secondarily, musculoskeletal problems (8). It is estimated that in the general population the prevalence is 2/1000 (9).

The sequels vary in intensity and location, depending on the cerebral area that was affected, as well as the extension of the lesion. There are not identical cases of people with cerebral palsy. In certain situations, the residual sequel is minimal, representing just few motor problems, such as mild claudication and stereotyped posture during physical effort. It must be emphasized however, that even in mild cases, the motor involvement, though minimal, affects these people psychologically, resulting in anxiety and even in the reinforcement of stereotyped posture pattern (2).

The classification of CP is based on the part of the brain that was damaged and on the pattern of movement alteration. In relation to muscle tonus, the spastic type (lesion of the motor cortex and incidence of 75%) is the most frequent, with increase of muscle tone. The extra-pyramidal is the second most common type, and is characterized by the lesion of the basal ganglia, leading to slow involuntary movements, defined as athetoid movements. The ataxic CPis infrequent and difficult to diagnose, occurring due to cerebellar lesion, and consequently, resulting in the inability to finely coordinate movements. The mixed type cerebral palsy represents the combination of two or more types of CP, usually involving spastic with athetoid (10,11). According to the affected area, CP can also be topographically classified: hemiparetic, diparetic and quadriparetic (12,13).

 

Cerebral palsy and oral health promotion

The most frequent general and oral complication in people with CP are pulmonary and upper airway infection, swallowing difficulties, saliva drooling, dysphagia and oral persistence of primitive reflexes (14).

In relation to the oropharyngeal dynamism, the oral phase is affected and characterized by the inability to control the food in the mouth. This can occur due to lip incompetence, loss of oral reflexes and movement of anterior and dorsal parts of the tongue (15).

Concerning the motor disorders, the postural alterations can interfere in the craniofacial development, leading to a poor performance in chewing, swallowing, breathing and phono-articulatory functions (15-17). Besides the inference in development of such functions, orofacial myofunctional disorders are also common in people with CP and thus it is important to expand the knowledge in this area for an appropriate prognosis and treatment of these abnormalities (18).

 

The importance of electromyography in diagnosis of masticatory disorders

The alterations in posture and movement of patients with CP manifest as various motor dysfunctions. The disequilibrium of masticatory muscles is intimately related to the disequilibrium of the postural system. The mandible movements are connected to the cervical movements and these, through compensatory postural synergies, are associated, in turn, with the rest of the body (19).

The dynamics of the mandible and related organs can be evaluated through surface electromyography, which studies the kinesiology (kinesio= movement; logy = study) of groups of striated muscles.

This is a useful diagnosis tool for dentists, physiotherapists, speech therapists, occupational therapists, neurologists, otolaryngologists, orthopedists and professionals of related areas that need objective parameters for clinical evaluation of muscular activity, as well as to evaluate the therapeutic results.

The electromyography also investigates the general muscular alterations and determinates the beginning of muscular activation and the coordination or disequilibrium of different muscles evolved in kinesiology of muscles.

In patients with temporomandibular disorders, surface electrodes are used in electromyography in order to determinate the electrical activity of position in mandible at rest and the hyper or hypoactivity of such muscles, and also to examine the equilibrium of muscles during chewing function, clenching teeth and parafunctional activity (20,21). Since orofacial disorders are common in individuals presenting CP, research in this area is fundamental for appropriate prognosis and treatment.

Though there exists a lot of factors that can influence the contraction pattern of masticatory muscles, the stability of masticatory muscles can be analyzed by means of the symmetric evaluation activity of homologous muscular activity (19, 22,23). Thus, the orofacial electromyography evaluation can provide an objective measurement ofquality of movement in children with CP (18), contributing to treatment planning and oral rehabilitation.

 

Oral rehabilitation in cerebral palsy

The dental managementof patients with CP,considered their ethiopatogenic conditions, evolves great difficulties, since the dentist faces impasses that result in poor oral hygiene, due to the abnormal involuntary movements of facial and masticatory musculature, tongue, and also upper limb.

These extrinsic factors interfere in teeth brushing, resulting in the accumulation of bacterial plaque (24). It must be also considered the difficulties in understanding of the importance of oral health due to the patients` mental impairment.

A high prevalence of not treated oral diseases is characteristic in children and adults with CP (25-27) presenting malocclusion, anterior open bite, increase of superior, narrow and high palate, oral breathing pattern, bruxism and presence of residual food, conditioned by the aggravating factor of muscular dysfunction (27-29).

Few studies concerning the quality of oral movements and the rehabilitation in individuals who have CP are found in literature.

According to antique concepts, when the incapacity of neuronal division was accepted, an efficient functional recuperation was impossible, justifying the inertia of the treatment, which was based on nature or time for the spontaneous recuperation of damaged functions. The discovery of neuronal plasticity ended with this therapeutic passivity, resulting in the study and origin of innumerable protocols of rehabilitation, based on chemical and electrical transmissions. Thus, several therapeutic procedures can result from the same neurotransmission (30).

The surface neuromuscular electrostimulation is based on the application of a controlled electric current externTeh in the skin surface, through specific electrodes, aiming to reach a muscle or group of muscles and / or their nerve terminals, producing a muscular contraction (2). Advices that produce electrical pluses excites the peripheral nerves and, subsequently, muscular tissue. The electric pulses penetrate the corporal tissues through the surface electrodes. Nowadays, a lot of different types of electric stimulators are available in the market. The main difference between them is the electrical output, that can determinate a constant current or a constant tension (31).

Research on animals and human beings confirm that the modification of skeletal muscles properties by means of the prolonged electric stimulation is possible. The functional and structures alterations correlate to the molecular changes, confirming the muscular plasticity.

The Nobel Price of 1986 contemplated a discover made in part in Brazil from the laboratory of Institute of Biophysics from Universidade Federal do Rio de Janeiro. The Italian scientist Rita Levy-Montalcini showed the existence of the Nerve Grown Factor- NGF, a fluid produced by the own organism that, in contact to the nervous cells, has the property of making them grow. By using resources of Genetic Engineer to produce the NGF, a promissory field started for treatment of series of degenerative diseases of nervous system and thus, with applicability for CP. According to the researcher, in animals, the NGF is capable of regenerating nervous cells, but they still need concrete evidences that it also happens in human beings. According to Aloe (32), this discover was one of the most notable for neurobiology development in the last 60 years.

One of the effects of the using prolonged electrostimulation are changes in muscular function, as well as improvement in overall condition of surrounding soft tissue (33). Kerr et al. (34), in his review article, described two theories about strengthening mechanisms: first, the muscle would strengthen by the principle of overcharge, which would increase the cross-sectional area of the muscle; the second would be by the selective recruitment of type II fibers (fast-twitch fibers, relatively larger in diameter), causing an increase of synaptic efficiency in the muscle. Jensen & Sinkjær (35) evaluated the effects of electrostimulation in the afferent innervation of anesthetized rats and observed that the sensorial information stands preserved in the afferent enervation of muscles submitted to electrostimulation.

Kraft apud Lianza (36) compared groups of acute and chronic hemiplegic patients submitted to electrostimulation. The chronically hemiplegic individuals reached and maintained functional improvement. It was demonstrated that functional electrostimulation in chronic hemiplegic superior members was efficient in reconditioning of motor activity associated to perception, favoring voluntary movement, adjusting muscular tonus and reducing abnormal postural and motor patterns.

It should be worthwhile, then, to adequate this methodology for patients with CP aiming to improve their masticatory performance.

Nunes et al (2) evaluated the effects of neuro-muscular electrical stimulation in strength, movement amplitude and gross motor function of the toe, during walking, running and jumping in spastic hemiparetic children. It was demonstrated that it was efficient in all groups and suggested that it is useful even in low frequencies, such as once a week.

This reinforces that the neuro-muscular electrical stimulation is therapeutically useful for the reestablishment of stomatognathic system in children with CP.

The laser irradiation has also been used as surgical and biomodulator agent for therapy both in medical and dentistry specialties (37).

Clinical and experimental studies evidence the property of the laser to increase nerve function (38), prevent scar formation (39), accelerate the metabolism of neurons and also the capacity of myelin production. Since the laser photodynamic therapy is not invasive, it presents the advantage of radiating damaged nerves without surgical interventions.

Low-level laser therapy is effective for treatment of orofacial pain, since it presents analgesic effect, reducing pain from diverse etiologies, including trigger points in myofascial pain (40,41). Besides, it has anti-inflammatory properties that reduce edema and hyperemia, presents antibacterial action and biostimulator effect on cellular tropism, accelerating the process of tissue repair (42,43).

The effectiveness of low-level laser in dentistry has been demonstrated in several studies, showing rapid recovery and pain relief in cases of recurrent aphthous stomatitis , traumatic ulcers, herpetic lesions, pericoronitis, gingivitis, primary herpetic gingivostomatitis , recurrent herpes simplex, dentin hypersensitivity, angular cheilitis, periodontitis / periocementitis, burning mouth syndrome, alveolitis, temporomandibular disorder and mucositis (44-47).

Another photoactivated instrument for rehabilitation is LED (light-emitting diode), a semiconductor device composed by several layers of semiconductors that emit light when a tension is applied between the layers. It is indicated for diverse purposes such as low intensity radiation therapy, CD and DVD players, barcode readers, among others.

In the later 90´s, Shuji Nakamura developed the blue LED, composed by gallium nitrate. This LED, which is narrowband light (higher selectivity than common light), present minimal heat release, is cheaper and economic, in relation to the electrical energy consumption (43).

Whelan et al (48) reported that LED is a secure, efficient, easy to carry and less expensive option for wound healing. It presents a lot of advantages when compared to laser for clinical use. Differently from the laser, the LED allows the treatment three-dimensionally and of a wider surface. Besides, the dissipation of heat is low, not offering risk to tissue and then been accepted for application in human beings.

In 2003, Vinck et al (49)investigated the increasing of the fibroblastic proliferation induced by both LED and laser irradiation. The authors concluded that both stimulated proliferation in vitro and suggested that with adequate parameters they could possibly present bio stimulatory effects for healing in vivo.

 

Discussion

The current and constant transformations undergone by the area of health in relation to diagnosis and rehabilitation resulted in the modern concept of expanded health, which integrates the environment, social and psychological factors. This represents a great advance, since until the 80s of the twentieth century the focus was, above all, the disease (50).

According to the World Health Organization (2001)¹, 10% of the world’s population consists of individuals with special needs, 50% of them presenting mental retardation, 20% physical disabilities, 15% hearing impairment, 5% visual impairment and 10% multiple alterations. Most of these individuals live in underdeveloped countries or developing countries and only 2% receive appropriate treatment according to their needs.

Appropriate care should mean access to treatment of dysphagia, upper and lower airway dysfunction, xerostomy, oral breathing pattern, bruxism and gastroesophageal reflux which are the most frequent alterations, that interfere directly or indirectly, in a greater or lesser extent, in form, function and esthetics of stomatognathic system.

These abnormalities represent risk for both oral and overall health of these people, who are also venerable because of their low socioeconomic level, dependence on the quality of care offered by another person and the limitation of public and private specialized health services (15-17).

Though the oral diseases that affects people with CP do not differ from that suffered from the general population (tooth decay, periodontal disease, malocclusion, bruxism, masticatory disorders and enamel hypoplasia), they often occur more frequently in patients with CP due to poor oral hygiene, food type and consistency, use of medication, facial muscle tonus, lack information and access to dental services (24,51-55).

The rehabilitation of these patients means dealing with all physiological, anatomical and environmental restrictions, in order to improve their independence, and as a consequence, the quality of life of their entire family (56).

Under the perspective of holistic oral health, the rehabilitation of the stomatognahtic system must not only improve the masticatory function, but also stimulate the comprehension that the mouth performs delicate physiological and vital functions that reflects in overall health.

Considering all the physiological,behavioral and social impacts that can be achieved by means of adequate and modern treatment, knowledge in this area is essential to improve prognosis and treatment of people with cerebral palsy.

Though some literature reviews focused on the improvement of dynamics of the stomatognathic system of patients with special needs, it still cannot be found studies or reviews concerning neuromuscular electrostimulation associated or not to laser or LED therapy in their rehabilitation.

The present review presents some effective alternatives of treatment and shows that this research area is a promissory field for the improvement of quality of life of people with special needs.

Among the methods of treatment for the recuperation of neuromuscular function, electrical stimulation is used with the objective of minimizing nerve degeneration and muscle weakness during the period of regeneration (57-58).

Though the molecular basis is still unclear, phototherapy with low-level laser is another instrument for its property of increasing nerve regeneration (59). When Karu (60) irradiated isolated mitochondria, it was observed that the laser irradiation induced positive changes on the cellular homeostasis. This suggested that some components of the respiratory chain (cytochromes, flavins and dhydrogenase) are capable of absorbing light and that results in the increase of ATP synthesis, affecting the levels of cellular hydrogen and activating ionic gradient (sodium, potassium and calcium).

 

Conclusions

This review evidences the role of phototherapy in the promotion of recovery of muscle morphophysiology, in the reduction of inflammatory responses and in pain relief, as well as the role of electrostimulation in the modulation of hypo or hyper stimulation of muscle fibers, adjusting them to normal physiological pattern of contraction and relaxation.

Biomedical engineering represents a promissory field for development of neural stimuli applicable to home healthcare, after establishment of protocols and professional training. Scientific research may provide bioelectronic sensors that can capture brain waves emitting electrical stimuli to the masticatory muscles for rehabilitation of people with cerebral palsy.

This study confirms the importance of oral rehabilitation in patients with cerebral palsy and its impact on overall health and therefore, on their quality of life.

 

Agradecimentos

Os autores agradecem a Coordenação de Aperfeiçoamento de Pessoal de Nível Superior(CAPES) pelo apoio no desenvolvimento desta linha de pesquisa.

 

References

1 -Tabith JR A. Foniatria: disfonias, fissuras labiopalatais, paralisia cerebral. São Paulo: Cortez Editora; 1989.         [ Links ]

2 -Nunes CBG, Quevedo AAF, Magdalon EC. Effects of neuromuscular electrical stimulation on tibialis anterior muscle of spastic hemiparetic children. Rev Bras Fisioter 2008;12:317-23.         [ Links ]

3 -Castro CC, Batistela F, Martini G, Fonseca J, Montesanti L, Oliveira MC. Correlação da função motora e o desempenho funcional nas atividades de auto-cuidado em grupo de crianças portadoras de paralisia cerebral. Med Reabil 2006;25:7-11.         [ Links ]

4 -Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet 2004;363:1619-31.         [ Links ]

5 -Mancini MC, Alves ACM, Schaper C, et al. Gravidade da paralisia cerebral e desempenho funcional. Rev Bras Fisioter 2004;8:253-60.         [ Links ]

6 -Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol 2005;47:571-6.         [ Links ]

7 -Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy. Dev Med Child Neurol Suppl 2007;49:480.         [ Links ]

8 -Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil 2006;28:183-91.         [ Links ]

9 -Mayston MJ. Physiotherapy management in cerebral palsy:an update on treatment approaches. In: Scrutton D, Damiano DL, Mayston M, editors. Management of the motor disorders of children with cerebral palsy. 2^nd ed. Cambridge: Cambridge University Press; 2004. p.147-60.         [ Links ]

10 -Diament A. Encefalopatia crônica da infância In: Diament A, Cypel S. Neurologia infantil. 3 ed. São Paulo: Atheneu; 1996. p.781-98.         [ Links ]

11 -Souza AMC. Prognóstico funcional da paralisia cerebral. In: Souza AMC, Ferrareto I. Paralisia cerebral: aspectos práticos. São Paulo: Memnon; 1998. p. 33-37.         [ Links ]

12 -Dabney KW, Lipton GE, Miller F. Cerebral Palsy. Curr Opin Pediatr 1997;9:81-8.         [ Links ]

13 -Piovesana AMS. Paralisia cerebral: contribuição do estudo por imagem. In: Souza, AMC, Ferrareto I. Paralisia cerebral: aspectos práticos. São Paulo: Memnon; 1998. p.8-32.         [ Links ]

14 -Troughton KEV, Hill AE. Relation between objectively measured feeding competence and nutrition in children with cerebral palsy. Dev Med Child Neurol 2001;43:183-90.         [ Links ]

15 -Furkim AM, Behlau MS, Weckx LLM. Avaliação clínica e videofluoroscópica da deglutição em crianças com paralisia cerebral tetraparética espástica. Arq Neuro-Psiquiatr 2003;61:611-6.         [ Links ]

16 -Cesa CC, Ecco CT, Bersch R, Chiappetta ALML. Funções do sistema estomatognático e reflexos motores orais em crianças com encefalopatia crônica infantil do tipo quadriparesia espástica. Rev CEFAC 2004;62:158-63.         [ Links ]

17 -Seacero LF, Guedez ZCF.Avaliação dos órgãos fonoarticulatórios e aspectos odontológicos em crianças portadoras de paralisia cerebral com espasticidade e quadriplegia. In: Marchesan I, Zorzi J. Anuário CEFAC de fonoaudiologia 1999/2000. Rio de Janeiro: Revinter; 2000. p.251-7.         [ Links ]

18 -Ray J. Functional outcomes of orofacial myofunctional therapy in children with cerebral palsy. Int J Orofacial Myology 2001;27:5-17.         [ Links ]

19 -Ries LGK, Bérzin F. Asymmetric activation of temporalis, masseter, and sternocleidomastoid muscles in temporomandibular disorder patients. Cranio 2008;26:59-64.         [ Links ]

20 -Bérzin F. Surface eletromiography in the diagnosis of syndromes of the cranio-cervical pain. Braz J Oral Sci 2004;3:484-91.         [ Links ]

21 -Pedroni CR, Borini CB, Bérzin F. Electromyographic examination in temporamandibular disorders - evaluation protocol. Braz J Oral Sci 2004;3:526-9.         [ Links ]

22 -VisserA,McCarroll RS,Naeije M.Masticatorymuscle activity in different jaw relations during submaximal clenching efforts. J Dent Res 1992;71:372-9.         [ Links ]

23 -Coelho Ferraz MJP, Bérzin F, Amorim C, Queluz DP. Electromyographic Evaluation of Mandibular Biomechanic. Int J Morphol 2009;27:485-90.         [ Links ]

24 -Santos MT, Nogueira ML Infantile reflexes and their effects on dental caries and oral hygiene in cerebral palsy individuals. J Oral Rehabil 2005;32:880-5.         [ Links ]

25 -Nunn JH, Murray JJ. The dental health of handicapped children in Newcastle and Northumberland. Br Dent J 1987;162:9-14.         [ Links ]

26 -Pope J, Curzon ME. The dental status of cerebral palsied children. Ped Dent 1991;13:156-62.         [ Links ]

27 -Dos Santos MT, de Oliveira LM. Use of cryotherapy to enhance mouth opening in patients with cerebral palsy. Spec Care Dentist 2004;24:232-4.         [ Links ]

28 - Rodrigo dos Santos MT, Masiero D, Novo NF, Simionato MR . Oral conditions in children with cerebral palsy. J Dent Child (Chic) 2003;70:40-6.         [ Links ]

29-Manzano FS, Granero LM, Masiero D, Dos Maria TB. Treatment of muscle spasticity in patients with cerebral palsy using BTX-A: a pilot study. Spec Care Dentist 2004; 24:235-9.         [ Links ]

30 -Unphred DA. Fisioterapia Neurológica. 2ed. São Paulo: Manole;1994.         [ Links ]

31 -Howe T. Correntes de Baixa Freqüência: Introdução. In: Kitchen S, Bazin S. Eletroterapia de Clayton. 10 ed. São Paulo: Editora Manole; 1998. p.261-5.         [ Links ]

32 -Aloe L. Rita Levi-Montalcini: the discovery of nerve growth factor and modern neurobiology. Trends Cell Biol 2004; 14:395-9.         [ Links ]

33 - Daly JJ , Marsolais EB , Mendell LM, et al. Therapeutic Neural Effects of Electrical Stimulation. IEEE Trans Rehabil Eng 1996;4:218-30.         [ Links ]

34 -Kerr C, McDowel B, McDonough S. Electrical stimulation in cerebral,palsy: a review of effects on strengh and motor function. Developmental Medicine & Child Neurology 2004;46: 05-13.         [ Links ]

35 -Jensen W.; Sinjær T. Effect of agonist-antagonist electrical stimulation on muscle afferent recordings in anesthetized rabbits. Neuromodulation 2001;4:127-37.         [ Links ]

36 -Lianza, S. Medicina de Reabilitação. 4ed. Rio de Janeiro: Guanabara Koogan; 2007.         [ Links ]

37 -Sutter R, Grossenbacher R. Ressection of palatal tumours with the CO2 laser. J Laryngol Otolog 1990;104:20-3.         [ Links ]

38 -Bagis S, Comelekoglu U, Sahin G, Buyukakilli B, Erdogan C, Kanik A. Acute electrophysiologic effect of pulsed gallium-arsenide low energy laser irradiation on configuration of compound nerve action potential and nerve excitability. Lasers Surg Med 2002;30:376-80.         [ Links ]

39 -Carvalho PTC, Mazzer N, dos Reis FA, Belchior ACG, Silva IS. Analysis of the influence of low-power HeNe laser on the healing of skin wounds in diabetic and non-diabetic rats. Acta Cir Bras 2006;21:177-83.         [ Links ]

40 -Chow RT, Barnsley L. Systematic Review of the Literature of Low-Level Laser Therapy (LLLT) in the Management of Neck Pain. Lasers in Surgery and Medicine 2005;37:46-52.         [ Links ]

41 -Kato MT, Kogawa EM, Santos CN, Conti PCR. Tens and low-level laser therapy in the management of temporomandibular disorders. J Appl Oral Sci 2006;14:130-5.         [ Links ]

42 -Lizarelli RFZ, Bagnato VS. Laser de baixa intensidade vermelho (660nm) para tratamento de hipersensibilidade dentinária cervical. J Bras Clín Odontol Integr 2001;5:433-7.         [ Links ]

43 -Lizarelli RFZ, Miguel FAC,Villa GEP, Filho EC, Pelino JEP, Bagnato VS. Clinical Effects of Low-intensity Laser vs Light-emitting Diode Therapy on Dentin Hypersensitivity. J Oral Laser Applications 2007;7:167-74.         [ Links ]

44 -Colvard M, Kuo P. Managing apthous ulcers: laser treatment applied. J Am Dent Assoc 1991;122:51-3.         [ Links ]

45 -Convissar RA, Massoumi-Sourney M. Recurrent aphtousulcers: Ethiology and laser ablation.Gen Dent1992;12:512-5.         [ Links ]

46 -Silva NMM, Cecchini RCM, Eduardo CP. Aplicações clínicas do soft laser em Odontologia. Rev Paul Odont. 14: In: Harvey A & Wigdor JDB. 1992;4:30-2.         [ Links ]

47 -Azevedo LR, Magalhães AC, Dias A. O uso do Laser no tratamento de lesões Bucais. JBC 2003;7:496-8.         [ Links ]

48 - Whelan HT , Connelly JF, Hodgson BD, et al. NASA light- emitting diodes for the prevention of oral mucositis in pediatric bone marrow transplant patients. J Clin Laser Med Surg 2002;20:319-24.         [ Links ]

49 -Vinck EM, Cagnie BJ, Cornelissen MJ, Declercq HA, Cambier DC. Increased fibroblast proliferation induced by light emitting diode and low power laser irradiation. Lasers Med Sci 2003;18:95-9.         [ Links ]

50 -Brasileiro IC, Moreira TMM, Jorge MSB, Queiroz, MVO, Mont’Alverne DGB. Activities and participation of children with Cerebral Palsy according to the International Classification of Functioning, Disability, and Health. Rev bras enferm 2009;62:503-11.         [ Links ]

51 -Prat MJG, Jiménez JL, Quesada JRB. Estúdio epidemiológico de las caries en um grupo de niños com parálisis cerebral. Méd Oral 2003;8:45-50.         [ Links ]

52 -Desai M, Messer LB, Calache H. A study of the dental treatment needs of children with disabilities in Melbourne Australia. Aust Dent J 2001;46:41-50.         [ Links ]

53 -Bhowate R, Dubey A. Dentofacial changes and oral health status in mentally challenged children. J Indian Soc Pedod Prev Dent 2005;23:71-3.         [ Links ]

54 -Guare RO, Ciampioni AL. Dental caries prevalence in primary dentition of cerebral-palsied children. J Clin Pediatr Dent 2003;27:287-92.         [ Links ]

55 -Mansano MAP, Salazar CR, Manzano FMA. Patologia bucal prevalente en niños excepcionales. Acta Odontol. Venez 1999;37:1-11.         [ Links ]

56 -Olney SJ, Wright MJ. Cerebral palsy. In: Campbell SK, Vander Linden DW, Palisano RJ, editors. Physical therapy for children. 2^nd ed. Philadelphia: W. B. Saunders; 2000.         [ Links ]

57 -Lehto M, Alanen A. Healing of a muscle trauma. Correlation of sonographical and histological findings in a experimental study in rats. J Ultrasound Med 1987;6:425-9.         [ Links ]

58 -Eberstein A, Eberstein S. Electrical stimulation of denervated muscle: is it worthwhile? Med Sci in Sports Exerc 1996;28:1463-9.         [ Links ]

59 -Reis FA, Belchior ACG, Nicolau RA, Fonseca TS, Carvalho PTC. Efeito da terapia com laser de arsenieto de gálio e alumínio (660Nm) sobre a recuperação do nervo ciático de ratos após lesão por neurotmese seguida de anastomose epineural: análise funcional. Rev Bras Fisioter 2008;12: 215-21.         [ Links ]

60 -Karu TI. Molecular mechanisms of the therapeutic effect of low-intensity laser irradiation. Lasers Life Sci 1988; 2: 53-74.         [ Links ]

 

Correspondencia:

Dr. Maria Júlia Pereira Coelho Ferraz

Departamento de Biociência e Diagnóstico Bucal da Faculdade de Odontologia de São José dos Campos/UNESP Avenida Eng. Francisco José Longo, 777 CEP:12245-000 São José dos Campos São Paulo Brazil. E-mail: mjcoelhoferraz@hotmail.com

 

Notes

¹Available in URL: http://www.who.int/whr/