After reading this course, the participant should
be able to:
1. Define the different types of spina bifida.
2. Describe the guidelines for antibiotic prophylaxis.
3. Discuss the need for latex allergy precautions in the dental office.
4. List appropriate dental care modifications for patients with spina bifida.
Spina bifida is a neural tube defect that impedes
the complete development of the brain, spinal
cord, and/or their protective coverings. It is
caused by the failure of the fetus's spine to close properly
during the first month of pregnancy (Figure 1).1
The most common birth defect affecting the central
nervous system, approximately eight babies are
born each day in the United States with some form of
spina bifida.2 The causes of this birth defect are
unknown, but its risk can be reduced by 70%
through adequate supplemental intake of folic
acid. All women capable of becoming pregnant
should take 0.4 mg of folic acid every day. For
mothers who have had previous infants with neural tube defects, a prescription of 4 mg folic
acid per day beginning 1 month before
conception and continuing through the
first trimester of pregnancy is recommended.3
Spina bifida affects people in different
ways. Common side effects include hydrocephalus
(fluid on the brain), full or partial
paralysis, bladder and bowel control problems,
learning disorders, depression, latex
allergy, and social/sexual difficulties.4 With
more than 160,000 people currently living
with spina bifida in the US, dental professionals
need to be knowledgeable about the special
needs created by this birth defect so they
can effectively provide oral health care services
to this population.4 With advances in
treatment, more than 90% of children with
spina bifida today will live beyond the third
decade of life, and with supportive, comprehensive
health care, they can live normal, productive
Myelomeningocele Spina Bifida
There are four types of spina bifida: occulta,
closed neural tube defects, meningocele,
and myelomeningocele (Table 1). Myelomeningocele is the most common type and
is commonly associated with Chiari II malformation
(Figure 2), which consists of the
downward displacement of the cerebellar
vermis through the foramen magnum;
changes in the fourth ventricle; downward
displacement of the brainstem with potential
for altered pressures on the lower cranial
nerves; a smaller, tighter posterior fossa;
and a somewhat larger foramen magnum.1,6
Chiari II malformation presents in one out
of three children with myelo menin go cele
The development of symptoms
vary in complexity and
may be related to the individual's
age at presentation and
the severity of the malformation.
These symptoms include
difficulty swallowing that leads
to poor feeding, weak and
poor cry, inspiratory stridor
(noise on breathing in) frequently
exacerbated by crying,
arching of the head, and
possible facial weakness in
newborns and young infants.
The child and adolescent may
develop stiffness or spasticity of
the arms or hands, which may
lead to loss of sensation in the involved extremities. In the younger child,
balance control and coordination of movement
may be hindered.7
Approximately 70% to 90% of children
with myelomeningocele also have hydrocephalus,8 which requires the permanent
insertion of a shunt to drain excess fluid from
the head to another place where the body
can remove it naturally.9 Pediatric neurosurgeons
disagree on which shunt is preferred,
but the most commonly used is the ventriculoperitoneal
(VP) shunt. Table 2 summarizes the
various shunt options.9
Updated Guidelines on Antibiotic Prophylaxis
Patients at risk of bacteremia (blood infection),
may require antibiotic prophylaxis
(AP) before dental treatment. Patients with
spina bifida who have ventriculoatrial, ventriculocardiac,
or ventriculovenus shunts for
hydrocephalus are at risk of bacteremia due
to their vascular access. In contrast, VP
shunts do not involve any vascular structures
and do not require AP.
Several factors should be considered
before AP is recommended. In consultation
with the American Heart Association, the
American Academy of Pediatric Dentistry (AAPD) recommends the conservative and
judicious use of AP in order to minimize the
risk of resistant organism development.10 Table 3 summarizes the AAPD's statement on
AP for dental procedures.10 When treating a
patient with a vascular shunt, consulting his
or her physician is prudent.10
AP is typically recommended for all dental
procedures that involve manipulation of gingival
tissue, the periapical region of teeth, or
perforation of the oral mucosa. Procedures,
such as routine anesthetic injections through
noninfected tissue, dental radiographs,
placement of removable prosthodontics or
orthodontic appliances, adjustment of orthodontic
appliances, placement of orthodontic
brackets, shedding of deciduous teeth, and
bleeding from trauma to the lips or oral
mucosa, no longer require AP.10
Risk Management for Latex Allergy
Children with spina bifida are at increased
risk of latex allergy, with more than 70%
exhibiting symptoms of this potentially dangerous
allergy. Why people with spina bifida are predisposed to latex allergy is unknown,
although, it is surmised that the more contact
a person has with latex, the greater the risk
of allergy, as is the case with health care
personnel. It may be that because patients
with spina bifida often have shunts, other
allergies, and need frequent health care, they
are at greater risk. Additionally, children with
a strong or confirmed allergy to bananas are
most likely allergic to latex as well.11
The dental office contains many sources
of latex, such as gloves, rubber dams, suction
tips, air or water syringes, impression
materials, mixing bowls, blood pressure
cuffs, gutta-percha, orthodontic rubber
bands, and nitrous oxide reservoirs.12 When
treating patients with spina bifida in the
dental office, a latex-free environment must
be maintained. If latex-safe rooms are not
available, elective patients should be scheduled
for treatment in the morning in order
to minimize exposure to airborne latex.11 The use of latex-free equipment and all precautionary
measures taken during patient
contact should be documented. Signs of an
allergic reaction may include: irritated eyes,
sneezing and coughing, rash, wheezing,
difficulty breathing, and drop in blood pressure.
Latex allergy can be fatal so injectable
epinephrine should be available and the
practice should be well prepared for an
Oral Care Considerations
Treating children with spina bifida can be
challenging, but through modifications in
care, dental professionals can provide adequate,
efficient, and effective care to this
patient population. Prior to the appointment,
if the parent or guardian of the patient is concerned
about dental anxiety, an antianxiety
agent, such as diazepam or lorazepam, can
be prescribed. These medications can help
the child remain calm during the dental
During the appointment, a soft beanbag
can be placed on the dental chair to help
prevent pressure wounds as well as redistribute
the pressure on the sensitive vertebrae
and areas of insensate skin. Performing an
extraoral/intraoral exam can help assess the
integrity of the patient's skin. The six most common risk factors for skin breakdown
include reduced mobility, nutritional status,
fecal and urinary incontinence, medications
that cause a change in sensation or mobility,
decreased tissue oxygenation or reduced
oxygenated blood, and age.13 Children with
spina bifida are at higher risk of wound development
and, therefore, should be assessed
for skin breakdown at each appointment with
results documented in the patient record.
Patients with spina bifida who have gastrointestinal
and/or tracheostomy tubes
need special consideration in order to maintain
the airway. They should be placed as
upright as possible in the dental chair, and
the use of water should be minimized
because people with spina bifida often have
dysphagia, in addition to a highly sensitive
gag reflex. Also, when working with children,
regardless of the presence of special needs,
a positive atmosphere should be maintained
in the clinic and child-friendly language
should be used.
The dental treatment of children with spina
bifida involves a team-based multidisciplinary approach to help them achieve optimal
health. Due to the complexity of this birth
defect, children may hesitate to become
more autonomous in daily tasks as they
grow and mature. In 2009, Friedman et al
found that children with spina bifida tended
to be more passive, more dependent on
adults for guidance, less likely to make independent
decisions, and displayed less intrinsic
motivation in school.14 This dependency can
be tough on family members who may feel
overwhelmed by frequent physician visits
and hospitalizations. As a result, oral health
care may become less important in relationship
to the other health problems exhibited.
Oral health professionals must emphasize
the importance of performing adequate selfcare
and receiving consistent professional
dental care, as well as providing support and
encouragement to families.
The authors would like to thank Elaine
Ekmark, RN, MS, spina bifida nurse practitioner
at Texas Scottish Rite Hospital for
Children, for her assistance with this manuscript.
Publications, Inc., designates this activity for 2 continuing education
credits. This course is released April 2012 and expires April 2015.
Belmont Publications, Inc., presents Dimensions CE. Belmont
Publications, Inc., is an ADA-CERP recognized provider. The current term
of acceptance extends from May 2011 through June 2014.
ADA CERP is a service of the American Dental Association to assist
dental professionals in identifying quality providers of continuing
dental education. ADA CERP does not approve or endorse
individual courses or instructors, nor does it imply acceptance of
credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed to the
provider or to ADA CERP at www.ada.org/cerp.
Faizan Kabani, RDH, BSDH,
is currently pursuing a master of science in health care administration
degree at the University of Texas at Arlington. He is also the staff
dental hygienist in the pediatric special-needs dental clinic at Texas
Scottish Rite Hospital for Children in Dallas. Kabani is a member of the
American Dental Hygienists' Association (ADHA) and the American College
of Healthcare Executives.
Maria Anderson, RDH, BSDH, MS,
is the dental clinic manager at Texas Scottish Rite Hospital for
Children. She is also assistant professor in the Department of Pediatric
Dentistry at Baylor College of Dentistry, Texas A&M Health Science
Center, in Dallas. Anderson is a member of the ADHA, Texas Dental
Hygienists' Association, and Special Care in Dentistry Association.
The author has nothing to disclose.
1. National Institute of Neurological Disorders and Stroke. What is spina bifida? Available at: www.ninds.nih.gov/disorders/spina_bifida/spina_bifida.htm. Accessed March 16, 2012.
2. Fletcher JM, Brei TJ. Introduction: Spina bifida--a multidisciplinary perspective. Dev Disabil Res Rev. 2010;16:1–5.
3. Folic acid for the prevention of neural tube defects. American Academy of Pediatrics. Committee on Genetics. Pediatrics. 1999;104:325–327.
4. Spina Bifida Association. About spina bifida. Available at: www.spinabifidaassociation.org/site/c.liKWL7PLLrF/b.2642323/k.8E10/Spina_Bifida.htm. Accessed March 22, 2012.
5. SpinaBifidaInfo.com. Spina bifida life expectancy. Available at: http://spinabifidainfo.com/life-expectancy. Accessed March 22, 2012.
6. Adams RC. Spina bifida: life span management. In: Orthopedic Intervenentions for Pediatric Patients. La Crosse, Wis: American Physical Therapy Association Orthopedic Section; 2000.
7. Spina bifida Association. Folic acid. Available at: www.spinabifidaassociation.org/site/c.liKWL7PLLrF/b.2642343/k.8D2D/Fact_Sheets.htm. Accessed March 16, 2012.
8. Liptak GS. Spotlight on spina bifida. Available at: www.spinabifidaassociation.org/site/c.liKWL7PLLrF/b.2642343/k.8D2D/Fact_Sheets.htm. Accessed March 16, 2012.
9. Dias MS. Hydrocephalus and shunts in the person with spina bifida. Available at: www.spinabifidaassociation.org/site/c.liKWL7PLLrF/b.2642343/k.8D2D/Fact_Sheets.htm. Accessed March 16, 2012.
10. American Academy of Pediatric Dentistry. Guideline on antibiotic
prophylaxis for dental patients at risk for infection. Available at: www.aapd.org/media/Policies_Guidelines/G_AntibioticProphylaxis.pdf. Accessed March 16, 2012.
11. American Latex Allergy Association. AANA latex protocol. Available at: www.latexallergyresources.org/articles-and-brochures. Accessed March 16, 2012.
12. Kean T, McNally M. Latex hypersensitivity: A closer look at considerations for dentistry. J Can Dent Assoc. 2009;75:279–282.
13. Ekmark EM. Risky business: preventing skin breakdown in children with spina bifida. J Pediatr Rehabil Med. 2009;2:37–50.
14. Friedman D, Holmbeck GN, DeLucia C, Jandasek B, Zebracki K.
Trajectories of autonomy development across the adolescent transition in
children with spina bifida. Rehabil Psychol. 2009;54:16–27.
From Dimensions of Dental Hygiene. April 2012; 10(4): 52, 55-57.