Integrating the Spina Bifida Patient
Into the General Dental Practice
JoAnn Campoli Scofield, RDH, BAAS
Patricia Regener Campbell, RDH, MS
Neural tube defects, including spina bifida, affect one out
of every 1,000 newborns each year. Due to advances in
medical technology, the life expectancy of these patients
is rising annually, and the dental community should be pre-
pared to treat them. This article discusses how, with proper
precautions and a little effort, patients with spina bifida can
be treated in the general dental practice.
Introduction
The term neural tube defect (NTD) refers to any one of a
group of malformations involving defects of the skull and/or
spinal cord that occur during embryonic development.1
Neural tube defects affect one out of every 1,000 American
newborns each year.1 Spina bifida (SB) is a type of NTD
in which the neural tube and posterior vertebrae do not
completely close during the first month in utero. Prior to
the advent of antibiotics and the advances in surgery in the
past several decades, the life expectancy for individuals
with SB was brief, but currently, 85% to 90% of children
born with the most severe form of SB survive into adult-
hood.2,3 In the US alone, there are an estimated 40,000
JoAnn Campoli Scofield, RDH, BAAS, is a graduate dental
hygiene student at the Caruth School of Dental Hygiene at
Baylor College of Dentistry, a member of the Texas A&M
University Health Science Center, Dallas, Texas. She is also Pro-
fessor of Dental Hygiene at Collin County Community College,
McKinney, Texas and has been a registered dental hygienist
for more than 25 years.
Patricia Regener Campbell, RDH, MS, is an Associate Professor
and Clinical Coordinator at the Caruth School of Dental
Hygiene at Baylor College of Dentistry, a member of the Texas
A&M University Health Science Center, Dallas, Texas. She has
been a practicing hygienist for more than 25 years and has pub-
lished several articles on patient assessment.
children and adults with SB.4 This article is intended to
educate the dental health professional to the special needs
of the SB patient, in order to integrate this population into
the general dental practice.
Types of Spina Bifida
Among SB patients, 1% of the vertebral defects occur in the
cervical region, 1% in the thoracic region, and 98% between
the lumbar and sacral vertebrae.5 There are also differences
in the severity of the condition (Figure 1). Spina bifida occulta
is a bony defect in which one or more of the vertebrae
fails to fully develop, but the skin is left intact. Detection
of this type of defect requires radiographic examination.2,6
Meningocele is a more severe type of defect, where
the meninges and cerebral spinal fluid protrude into the
opening of the spinal canal, forming an external sac filled
with cerebrospinal fluid. The sac is covered with skin, and
nerve tissue is not involved.2,6
The most severe form of SB, myelomeningocele (MSB),
is the one to which people most commonly refer. This
defect occurs when both the meninges and the spinal cord
protrude into an external sac (Figures 1 and 2). The sac con-
tains portions of the spinal cord, cord membranes, and spinal
fluid without benefit of skin coverage.2,5 Neuromuscular
function is affected below the level of the lesion, which is
indicated by a decrease or absence of sensation (eg, pain,
pressure, friction, temperature) in the lower body.5
The cause of SB is unknown, although environmen-
tal factors (eg, infections, drugs, repeated x-ray exposure)
and genetics have been implicated.7 Folic acid (0.4 mg per
day) and multivitamins taken by the mother before and
during pregnancy, as well as foods rich in foliates (eg, dark
green leafy vegetables, orange juice, dried peas, beans,
lentils) have been shown to reduce NTD.1-3,7,8 The Centers
for Disease Control and Prevention (CDC) estimate that
women taking the recommended dosage of folic acid
May/June 2001 27
The Spina Bifida Patient
Abnormal
Opening
in Bone
Normal Spine Spina Bifida Occulta
Figure 1. A comparison of a normal spine to the types of spina bifida (differing in severity).
during the childbearing years and early in pregnancy can
prevent up to 3,000 serious birth defects annually.8
Medical Complications
Children born with MSB have a 90% chance of also hav-
ing hydrocephalus, which is characterized by an accumu-
lation of cerebrospinal fluid in the head that puts increased
pressure on the brain. Causes may include developmen-
tal anomalies, infection, trauma, or brain tumors.9 Surgical
placement of a shunt helps to relieve the pressure by redi-
recting the fluid buildup to the abdominal area.2,5,7 The
shunt is inserted subcutaneously behind the ear, runs down
the side of the neck, and ends in the abdomen, where the
excess spinal fluid is reabsorbed. In many instances, the
shunt needs to be revised or replaced as the child matures.5
There has been some disagreement about adverse
effects associated with shunts. According to Jansen et al,
there is a correlation between hydrocephalus patients with
shunts and poor hand function.10 In contrast, a study by
Muen et al reports that poor fine motor skills may be a
result of cerebellum abnormalities, and the lack of strength
in the small muscles of the hand may be due to cervical
cord abnormalities.11
While most children with MSB are not mentally
retarded, complications such as hydrocephalus or infections
can lead to delays in learning.2,7 Dysfunctions, for example,
28 The Journal of Practical Hygiene
With Meningocele With Myelomeningocele
short attention span, visual perception problems, sensory
processing difficulties, decreased arm and hand function,
poor eye-hand coordination, and memory deficits, are asso-
ciated with MSB and are complicated by hydrocephalus.
A condition common to all children with MSB is
Arnold-Chiari malformation, a congenital structural defect
where the brainstem is pushed into the cervical spine due
to pressure from increased cerebrospinal fluid in the fourth
ventricle. Common symptoms include headache, scoliosis,
difficulty with balance and coordination, low muscle tone,
voice alteration, decreased gag reflex, and respiratory diffi-
culties.5,12 Other complications include neurogenic bladder,
neurogenic bowel, and kyphosis (hunchback).2,7,13 Only
9% to 21% of those affected will need treatment for this
condition,7,12 which involves the reduction of the pressure
against the brainstem and spinal cord through surgical
decompression, involving removal of small portions of bone.13
Nutrition and Growth Complications
A combination of poor self-esteem, dependence on family
for care, and fears of maturity and independence put adoles-
cent MSB patients at risk for eating disorders (eg, anorexia).14
Eating disorders may also be precipitated by caretakers
who urge the patient to lose weight.2,14 In addition, 50%
to 60% of children with MSB exhibit a disturbed growth
pattern that may be a result of growth hormone deficiency.15

Figure 2. Patient placed in an oxygen tent at birth to
address respiratory problems. The presence of myelo-
meningocele is evident.
Figure 3. Back view of the patient.
Table
Common Items Containing
Natural Rubber Latex
Latex gloves
Elastic bandages
Face mask with
elastic band
Medication stopper
Anesthetic carpule
with rubber plunger
Disposable rubber cup
prophylaxis angles
Blood pressure
cuff tubing
Stethoscope tubing
Adhesive
Rubber bands
Scofield
Dermatological Disorders
It has been reported that children with SB are 500 times
more likely to have a reaction to latex than the general
population.15 Other studies indicate 28% to 60% are affected
to varying degrees.16,17 Symptoms may include urticaria
(hives), conjunctivitis, and anaphylaxis.16 While some stud-
ies indicate that early and repeated exposure to latex from
multiple surgeries can cause sensitivity,2,8,17-20 others indi-
cate that the number of surgeries may not be the primary
cause. A high association between latex sensitivity and
foods such as avocados, bananas, and chestnuts has been
reported,16,20 indicating that various foods are risk factors
to SB patients.16,20 A study by Szépfalusi et al suggests the
propensity for latex sensitization by the SB population may
be caused by genetics.19
Body positioning and assistive devices (eg, wheel-
chairs and leg braces) may create pressure and cause irri-
tation to the skin. Due to the lack of sensation in the lower
body, blisters and bedsores may go unnoticed by the
patient. Skin infections also pose a potential danger to the
spinal cord, particularly in the MSB patient,2,7 therefore,
strict infection-control procedures are crucial. Bacteria do
not have to travel far to infiltrate the nerves of the spinal
column and cause irreparable harm. Efforts should be made
to reduce the potential of irritation to the gibbus (ie, hump)
when seating a SB patient in the dental chair (Figures 3
and 4). Pillows, a styrofoam ring (ie, donut), a mattress
pad, or a body-size beanbag can be used to protect the
gibbus and provide comfort for the patient. The patient
should be allowed to shift his or her weight every 20 min-
utes to maintain circulation and prevent pressure sores.
Patient Management
All female patients of childbearing age can benefit from
Shoes nutritional counseling regarding the use of multivitamins.
Dental rubber dam Neural tube defects occur soon after conception, usually
Dental bite block before a woman realizes she is pregnant, so the nutritional
Fingercot status of a woman at the time of conception is critical. As
Penrose drain reported by Butterworth and Bendich, 60% of women who
Orthodontic elastics took multivitamins for three months prior to conception and
Wheelchair tires three months after conception were less likely to have
Elastic ligature thread infants with NTDs than those women who did not take a
Induction mask supplement during the same time period.1
Window insulation Problems with obesity and eating disorders among
Underwear elastic SB patients make nutritional counseling a necessity.14 The
Stamps dental hygienist can deliver such information in a non-
threatening manner, which can serve as reinforcement for
existing knowledge.
May/June 2001 29
The Spina Bifida Patient
Since patients with SB are considered at high risk for
latex allergy, they should all be treated in a latex-free
environment (Table). Powdered latex gloves have been
reported to increase the latex aeroallergen level by as much
as 115 times in areas where latex gloves are used, causing
a reaction in sensitive patients.16 Nelson et al reported a case
of anaphylactic shock by a dental patient, possibly caused
by radiograph packets contaminated with powder from
latex gloves.21
Radiation Exposure
As diagnostic radiographs of the spine, neck, and head are
important tools in long-term management, SB patients are
exposed to high amounts of radiation over time. Gaskill
and Marlin reported that excessive radiation exposure may
be the reason patients with SB are at increased risk to
develop bladder and rectal carcinomas.4 Definitive conclu-
sions, however, regarding cumulative, long-term radiation
exposure cannot be drawn at this time for the SB popula-
tion. As additional SB patients grow into adulthood, more
precise conclusions may be determined. Based on current
knowledge, radiographs should be taken only if they will
improve the ability of medical/dental professionals to care
for the patient.4
Case Report
Patient History
A seven-year-old white male patient presented for a rou-
tine oral prophylaxis. His medical history included myelo-
meningocele affecting the spine at T8, with kyphosis,
hydrocephalus, and Arnold-Chiari malformation. The patient
was born by cesarean section and had accompanying res-
piratory complications. Spina bifida correction surgery was
performed at the age of one week and again at two weeks.
A ventriculoperitoneal shunt was placed to reduce the pres-
sure caused by the hydrocephalus. The shunt was exam-
ined annually by a neurosurgeon and had not been replaced
or presented complications. Although both hips are dis-
located, the parents and physician have decided not to
correct this condition since the patient will never be ambu-
latory. Decompression surgery was performed at the age
of two for the Arnold-Chiari malformation. Although the
patient exhibits a neurogenic bladder and bowel, the child’s
mother reported a history of only two urinary tract infec-
tions. The patient appeared to have difficulties with visual
perception despite corrective lenses. When reading, he
tilted his head to one side to see properly. The patient
took 2 mL per day of senna, an over-the-counter peristaltic
agent to prevent constipation.
30 The Journal of Practical Hygiene
Figure 4. Side view of the patient. Note the gibbus,
for which accommodation must be made so the patient
will be comfortable.
The patient used a specially designed wheelchair with
support straps and steadied himself with his left hand on
a stable surface when not strapped in the wheelchair or
otherwise secured. To avoid pressure sores on the skin, the
back of the chair had a cushion with an opening to allow
for the gibbus. The child’s mother reported that ulcerations
occurred on the gibbus approximately three to four times
per year.
The patient brushed his teeth once or twice daily with
a soft-bristled toothbrush utilizing fluoridated toothpaste.
No other oral hygiene products were employed. His mother
reported that she occasionally brushed his teeth as a follow-
up. The patient did not report any oral complications
(eg, dry mouth, aphthous ulcers, sensitivity).
Treatment
One hour before the scheduled procedure, the patient
took 12 ccs of 250 mg/5 mL oral suspension amoxicillin
trihydrate. A beanbag pillow was placed on the dental chair
for the comfort of the patient (Figure 5), and he was trans-
ferred from his wheelchair by his mother.
A resident pediatric dentist performed an oral exam-
ination, and a dental assistant recorded the findings. The
oral examination revealed a Class I amalgam restoration
on T. A carious lesion was discovered on J. The patient
exhibited a Class I occlusal relationship on the right side
and a Class II occlusal relationship on the left side. The
mother reported that she had a similar occlusal relation-
ship. There was a lack of interproximal spacing in the pri-
mary dentition. Due to the slow growth rate of the patient,
there was a possibility of crowding of the permanent den-
tition. The maxillary left buccal mucosa appeared slightly

Figure 5. A beanbag pillow, covered with a clean white
sheet, is placed under the patient during treatment.
erythematous. The mother mentioned that the patient
had a tendency to hold food in the left side of his mouth
before swallowing.
As scaling was not required, the teeth were polished
with a soft-bristled toothbrush and fluoridated toothpaste.
Following rinsing the mouth with the water syringe, the
dentition was dried thoroughly with compressed air.
Acidulated phosphate fluoride foam was then applied to
the teeth with a toothbrush, and the excess was removed
with a 2"! 2" gauze. The dental assistant attempted to take
a bitewing radiograph on the left side, but the patient had
severe gag reflex; the attending dentist decided to forego
the radiograph at that time.
Discussion
Annual tests to detect latex sensitivity have had negative
results. Respiratory infections have been minimal, occuring
only two or three times over the patient’s lifetime. There
have been no complications related to the shunt; nonethe-
less, future replacement of the shunt may be indicated as
growth occurs. No treatment has been necessary for the
Arnold-Chiari malformation. Since the patient appears to
be small for his age, the parents plan to have him tested
in the near future for a growth hormone deficiency, which
is common in 50% to 60% of persons with SB.15
Conclusion
The life expectancy of patients with NTDs is rising annu-
ally.2,3 As there are an estimated 40,000 children and adults
in the US with SB, the dental community needs to make
provisions to treat this population. With some minor
modifications, there should be little difficulty treating the
Scofield
SB patient in any general dental practice. Latex-avoidance
precautions, wheelchair access, limited radiation exposure,
and accommodations for comfort in the dental chair are
further examples of ways to integrate SB patients with safety
and comfort. Placing a beanbag pillow or an egg crate
mattress pad will provide additional comfort for patients
with back problems as well as the SB patient. Placing a
hand on the shoulder of the SB patient as the dental chair
is reclining will give the patient a feeling of stability. An alter-
native is to leave the patient in the wheelchair during the
procedure. Verbal as well as written self-care instructions
are also extremely beneficial, due to the patient’s visual and
perceptual difficulties. These simple procedures can easily
be adapted within the dental practice and can provide com-
fortable accommodations for physically challenged patients.
Acknowledgment
The authors would like to thank Michael Webb, DDS, Chil-
dren’s Medical Center, Dallas, TX, for his review of this article.
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