Saturday, July 5, 2014

Enamel Erosion and Severe Tooth Wear in PWS



Prader-Willi Syndrome Association of Wisconsin, Inc.
By Barbara Dorn R.N. and Dr. Kimberly Wachter, D.D.S.
The Gathered View ~ Prader-Willi Syndrome Association (USA) September-October 2013

For years, it has been noted that individuals with Prader-Willi syndrome (PWS) have problems with saliva production resulting in dental caries/cavities, loss of enamel and severe tooth wear. Recent studies on “Salivary Flow and Oral Abnormalities in Prader-Willi Syndrome” as well as the study on “Severe Tooth Wear in Prader-Willi Syndrome: A Case control Study” done by Saeves, Nordgarden, Espelid and Storhaug (2010 and 2012) from Oslo, Norway continue to support and validate these findings. The challenge now facing those with PWS is what to do to prevent and/or manage these problems. The following resource provides an overview of these dental problems
along with some possible approaches.


ENAMEL EROSION is the wearing down of the protective coating (enamel) of the teeth.
When enamel wears down, microscopic channels in the tooth open up and become exposed. Most people with this problem complain of discomfort and pain. However, since persons with PWS have an altered pain response, they may not experience this sensation.

Common Causes:

  •  Abnormal salivation
  •  Diet high in sugars and acid


EXAMPLES OF FOODS AND BEVERAGES WITH HIGH ACIDITY:
Soft drinks, sport drinks, fruit juices, lemonade, coffee, tomatoes, strawberries. (Citric acid, phosphoric acid, and ascorbic acid are a few ingredients to watch for in foods.)


  • Grinding of the surfaces of teeth
  • Health conditions including gastric reflux
  • Medications (aspirin, antihistamines and some vitamins)

Signs:

  • Translucency of the enamel
  • Darkening or discoloration of the teeth
  • Pain or cold sensitivity (may not always be reported in persons with PWS)


Prevention:


  • Drink water. Limit soft drinks, sport drinks, juices and coffee in moderation.  Dilute juices with water.
  • Swish your mouth out with water or brush your teeth after drinking or eating items high in acid.
  • Don’t sip on beverages for extended periods of time.
  • Do not drink or eat high acid beverages/food in the evening after supper.
  • Use a straw to keep acids away from teeth.
  • Brush with fluoride toothpaste. Minimize swallowing. (Too much fluoride can cause problems like enamel fluorosis.  This condition can occur in children and causes defects in the enamel of the teeth.  Ingesting large amounts of fluoride can be toxic and cause nausea, stomach pain and/or vomiting.  It may not be quickly detected in people with PWS.)
  • Get regular dental checkups and cleanings – at least every 6 months.
  • Talk to your dentist about daily fluoride mouthwash if there is a history of cavities (Use as a rinse; do not swallow.)  If needed, apply with a Q-tip or cotton bud.  

  • Ask the dentist if sealants may be helpful in preventing enamel erosion and tooth decay.

Treatment:
  • Once lost, enamel cannot be replaced. Treatment of tooth enamel loss depends on the underlying problem.
  • If a person with PWS is found to have a sudden loss of tooth enamel, testing should be done to determine if a medical condition is present. (May require special diet and medication intervention).

SEVERE TOOTH WEAR / GRINDING (also called bruxism)
Occurs most commonly at night. When teeth grinding occurs on a regular basis, teeth can be damaged and other oral complications can arise - often seen in both children and adults with PWS.
11
Causes:
  • Exact cause is unknown.
  • Often contributed to stress and/or abnormal bite
Treatment:

  • Mouth bite guard – best if individually fitted by a dentist. Used most commonly while the person sleeps. May require incentive program for compliance.
  • Avoid or cut back on foods and drinks that contain caffeine, such as colas, chocolate, and coffee.
  • (Avoid alcohol. Grinding tends to intensify after alcohol consumption.)
  • Discourage chewing on pencils or pens or anything that is not food. Minimize chewing gum. It allows jaw muscles to get used to clenching and makes it more likely to grind teeth.
  • Work with person with PWS to learn not to clench or grind his/her teeth. Have him/her practice relaxing jaw muscles.
  • Try holding a warm washcloth against the cheek in front of the earlobe.
  • Include plenty of water. Dehydration may be linked to teeth grinding.
EMPOWERING PARENTS

Tuesday, June 17, 2014

"Just Google it!"

In the distant past (ie pre internet days) very little was known about PWS, only that it was an 'eating disorder' and that a person who had it, would not live long and die from obesity-related illnesses.  (Life expectancy today is normal, providing good health management is undertaken.)  Information was hard to come by and was mostly written up as medical research. 

It is staggering how much information is now "out there" on the net - you only have to google "Prader-Willi Syndrome" to have over 872,000 results at your fingertips.  Not all information can be helpful, however, and some is not very accurate.  However, there are some first-class resources you can tap into, in many different languages.  Our own IPWSO site endeavours to keep abreast of the information, but it is useful to know what's on other sites as well.  The PWSA (UK) has just updated 13 of their booklets including:
  • Characteristics of PWS
  • Diagnosis
  • Genetics of PWS
  • Endocrine Disorders in PWS
  • Growth Hormone for Children (UK Practice)
  • Health Care in PWS
  • Vision and Care of the Eyes
  • Weight Management in PWS
  • Behaviour Management in PWS
  • Educating the Child with PWS
  • Speech and Language in PWS
  • Ethical & Legal Issues
All of these can be found on their website 

Research on PWS has escalated hugely over the years - whereas once research concentrated mainly on genetics and then on growth hormone treatment, now all areas of PWS are being researched and results are coming through all the time.  A foundation for research (FPWR - Canada) was established in 2003 and has already committed over $3,000,000 in research grants.  The FPWR's generosity in grants for research is well-known and results are regularly written up on their research blog.

Further research from the American PWSA on medical topics and the latest 'red alerts' such as the vitally important signals for gastroparesis or slow emptying of the stomach which can cause severe constipation and complications.  This is also on our IPWSO website, along with a list of other research topics.

On-line Parent Support Groups: Just go to https://groups.google.com and google 'health' and then Prader-Willi Syndrome to find pages of support groups all over the world dedicated to discussing the syndrome and supporting families.  Just to know you are not alone, can be strength enough in the hard times to carry on.

Thank goodness for the internet!




Monday, June 2, 2014

Gratitude




I recently had a bad PWS appointment experience.  This was because when I arrived at the clinic, I was told by the occupational therapist whom I was due to see that she could only proceed with the appointment if my son's father was also present.  The rationale, quite simply, was that the advice she intended to impart was so important that we both needed to hear it.  I was flabbergasted.  It is true that for the first few months of my son's life both his father and I did attend every appointment.  This was until we realised how unsustainable this approach was.  I was tempted to point out that if my
husband and I had attended every appointment my son has had (over 600 by now) it would be impossible for either of us to hold down a job, which, of course, is necessary for all sorts of things, including paying for therapy sessions.  But, I think that my son needs OT support, and OTs are hard to find in my area, so I said nothing and politely walked away.  And inwardly fumed.

After I had stopped fuming I started to reflect on the many other PWS appointments and interactions that I have had since my son's diagnosis.  And the truth is that while some have been terrible, many more have been excellent  So, I decided to make a short list of some of the many anonymous people to whom I am grateful for making my family's PWS journey so much easier.

1. I am grateful to the community nurse, who came to my house every two weeks for 3 years after my son was born and taught me the rudiments of physiotherapy, speech therapy and occupational therapy, while all the time encouraging me to aim high for my son.

2. I am grateful to the physiotherapist who observing my infant son poking around at the workings of a toy casually noted that he may have a engineering career ahead of him.  She probably didn't realise the impact of her words, but they led to believe in possibilities for my son's life that others had written off as impossible.

3. I am grateful to the school principal who on my first visit to his school bashfully admitted that he hadn't thought about the potential dangers associating with having fruit trees at the school's perimeter and immediately offered to have them removed.  I told him not to remove them, but left his office happy that he would do whatever was necessary to keep my son safe.

4. I am grateful to the psychiatric consultant who didn't tell me that there was a 18-month waiting list for ASD assessments in my area and arranged to have my son assessed within 2 months.  I only learnt of the waiting lists much later.

5. I am grateful to the physiotherapist who with great patience and confidence made my son believe he could cycle a bike without stabilisers.  She was right!

6. I am grateful to the (overweight!) local doctor who every time I meet him has the good grace to sincerely and enthusiastically compliment both me and my son on my son's healthy weight.  

7. I am grateful to the special needs assistant who has been my son's shadow for the 5 years since he started school.  She has cheered him up, and calmed him down; she has kept him safe and kept me sane; she has helped him make friends and allowed him to learn;  she has boosted his confidence and expanded his horizons.  Most of all she been his friend.

8. Above all I am grateful to the obstetrician who, having cared for me during my pregnancy and after the birth of my son, refused to accept the considerable payment he was due for his services.  

 Why does this stand out for me more than the others?  Because it was the first experience I had of a random stranger standing by me in recognition of the challenges posed by PWS.  The solidarity he showed to me when I least expected it gave me hope that the community in which I live would continue to support my son and my family.  I am grateful for all that support.  I also believe that my son's positive experiences  of support will lead to him being able and willing to support others when the opportunity arises.  I fully expect that someday random strangers will also be grateful to him.

Monday, May 19, 2014

Dear Mum ...

Somehow, a hand-made card beats the bought variety any day of the week.  Every year on my birthday, or Mother's Day, I get one from my daughter.  It's generally the same style with lots of cut-outs and hearts and so on and not much has changed over the many years I've collected them.

They also nearly always say the same thing about how much she loves me and what a great mother I am and my apparent amazing attributes are freely listed.  What this does is put my own life into perspective.  It doesn't matter that most of my friends have 'normal' kids, it doesn't matter that I might have missed out on various outings, or feasts, or had to stay home and deal with stuff that wasn't expected.  It doesn't matter that the word 'dysfunctional' may have been used to describe my family - words, after all, are just words.  What does matter is that my daughter can see past her own disability and see her life as "fantastic".

I don't know what it is with our kids, but they seem to have their own amazing attributes that can often be overlooked in the greater scheme of things.  What I wish, more than anything, is that those people in 'power' who control education, health programmes, or benefits, and who actually control the lives of others, could understand what they are doing to those who can't fight the system for themselves - who rely on their parents and families, or the goodness of caregivers to make their lives as "fantastic" as possible.  Whenever there are cuts in governmental budgets, they filter down to our kids and all the others in the world who rely on benefits or grants in whatever form that may be.  It pains me to think of the struggles that we face as parents, whether fighting for a fair and equitable education system, or battling the health system for a simple piece of equipment needed to improve health, or trying to prove to authorities that medical help is desperately needed - it seems that more and more, we have to fight for the right to life.

On the other hand, when things go right, when systems work and medicines help, then all our lives can be equally 'fantastic'!



Sunday, May 4, 2014

My Baby is not Perfect

(I write this blog in the hope that on May 6th you will support the 2014 Giving Challenge so that parents of newborn children with PWS do not have to go through the same agony as I did.  And I live in a Western country that prides itself on its good health system.

All you have to do on May 6 at noon till May 7th 11:59:59 am (est) is go to: www.givingpartnerchallenge.org  search Prader-Willi Syndrome Association.  Click the button.  There is $440,000 worth of matching dollars out there. The Patterson Foundation will match all our gifts, dollar for dollar, minimum $25 up to $1000 per individual, as long as the funds are still available. 

Please donate early before the matching funds run out!  Let's take this great opportunity to get some matching dollars.  Your click, your donation will help IPWSO continue its work in the world.)


When I was pregnant with my third child I wondered, very briefly, whether my baby would be born perfect.  My other two had, so I put the thought out of my mind and concentrated on eating well, exercising, and looking forward to the new arrival.  I noticed that my baby didn’t move so much in the womb and that there was none of the violent kicking that made my gasp and feel faintly queasy, but, in a way, this was a relief.  Her movements were gentle, like a fluttering, or a slight wobble.    My pregnancy on the whole had been calm, apart from a scare in the third month when there was slight bleeding.  I wondered if I might miscarry; it disappeared for a few weeks but then reappeared to an extent that I rang Emergency and they told me to come into hospital.  There, they made me wait and drink copious quantities of water before taking me in for a scan.  It was incredibly difficult to retain all that water, and retain my dignity.  The scan was normal.  The bleeding stopped, and the pregnancy progressed.

On my due date, I started Braxton-Hick’s contractions, the false labour that can send you into a panic.  They were irregular, just a tightening across the belly as the muscles contracted and relaxed.  Although I wasn’t unduly worried, it seemed prudent to check with the hospital.  They said to come in anyway.  So I arrived at the hospital doors awaiting admittance.  The contractions faded soon after, and in the morning I was sent home.  There was not much longer to wait, though, and that night I was admitted again, this time in labour.

It was a struggle and, because my previous pregnancy had been a caesarean section, the doctor decided forceps delivery was going to be better, so, after a few hours of labour, she was born.  The rush of oxytocin, endorphin and adrenaline hormones made me feel elated and excited.  But there was no cry, no waving of tiny arms, just silence.  I remember the nurse holding her, naked, limp, like a rag doll, arms and legs totally relaxed.  The nurse quickly took her away to a waiting crib and wrapped her in muslin.  Still no cry.  No movement.  To begin with, I did not notice, and was waiting for them to bring her back to me.  The nurse turned to me and said they would just run a couple of quick tests.  I imagined these to be the usual muscle reflex.

It was at that stage that all my unbidden fears, all the things I had pushed to the back of my mind, flooded in quickly taking away the adrenaline and leaving me feeling as limp as my baby looked.  What was the matter?  Where were they taking her?  What was wrong?

My baby is not perfect.  The only thing they could offer was that she had been exhausted by the birth and was hypotonic, limp, no muscle tone.  They wheeled me back to the ward without my baby.  I lay there motionless, waiting for someone to bring her to me, or to tell me what was happening.  Nothing.  I waited.  Hours went by, and a nurse popped her head around my curtains and said – ‘oh, you’re the one with the baby who’s got the speckled head-rash!’  What was she talking about?  I asked her: she said straight away, ‘oh that usually means mental retardation.’

My world collapsed, spinning out of control.  I was icy calm, trying to marshal my thoughts.  What now?  Who can tell me what is going to happen?  I spent the night alone in the ward, separated by a flimsy white curtain from other mothers and their perfect babies.  In the morning the specialist asked to see us.  He said a whole lot of things that simply would not fix themselves in my head.  They entered, then flew away.  I kept asking if he would repeat himself, tell me again what did it mean?  Words jumbled around in my mind.  I could not tell you anything he said.  I felt calm, as though I was not really participating in this discussion, more as though I was hovering above us all just watching. 

They brought me my little red-faced, long-limbed, silent baby to feed.  She would not suck.  I thought she was tired, but she had no power to suckle.  They gave me a bottle with an extra long teat.  ‘Squeeze the teat into her mouth’, they advised.

They let me bath her, and she lay there in the water, limbs outstretched, unable to move, barely able to open her eyes.  Every few hours they brought her back to be fed, and I pretended it was fine.  The nurses volunteered their own information, a cousin whose baby was ‘just like this’ and went on to regain her strength in a matter of weeks.  A son who never walked ‘til he was 3, but was just fine; she’s just like many babies who are born tired but soon recover. 

But the speckled rash was still there, and the words from outspoken nurse who’d frozen my heart, were still tight in my chest.

It was no good, she was losing weight, not crying, not moving; just sleeping.  So they tube fed her and I watched, feeling desperately useless, and wondering what was wrong.  No one could tell me.  Failure to thrive, was the best I could get.  I was terrified, but the terror was now iced in and would not thaw for many months yet.  I expressed milk, sitting in a corner of the nursery, listening to other babies crying, feeling so alone, so sad. 

I was allowed home after – how many days?  I don’t remember, they blurred into one long day, one long night.  And once home the feeding became the only challenge of the day.  She slept endlessly, not waking, not crying, not moving.  I squeezed the bottle’s teat into her mouth and massaged her throat, willing her to swallow.  It took an hour to feed 15 mls.  She became weaker and weaker and went back to hospital where they tube fed her, then left her to sleep.  I would drive to the hospital and sit with her for hours begging her to pull through, to be normal, to come alive.  She lay motionless and pale.  Sometimes when I held her she would open her eyes and engage mine.  That was when I would pray, to what, to whom, I did not know.  They were just words repeated over and over, “let her live, let her be alright”.

She wasn’t, of course.  She did live, but there was something fundamentally wrong; she remained in hospital and the doctors continued to look for an answer.  I came in day after day, asking whether they had found out anything more.  One day there was a plaster on the calf muscle of her tiny leg.  They’d taken a muscle biopsy to see whether she could have Werdnig Hoffman’s Disease.  Spinal muscular atrophy.  A wasting disease that has a child living 18 months or less, then wasting to death.  But they didn’t tell me that.  It was years and years later when Google came into being that I found the answer.  I could then see why they tested for it.  Many of the symptoms and characteristics were there.

After she had gained some weight, I was allowed to take her back home.  I tried to encourage her to stay awake for longer by not putting her to bed, but setting her up in her bouncinette so she could watch the other children, hear household noises, listen to music, watch the dogs.  Slowly, very, very slowly, she started to become more alert, she smiled, she watched our world from her own.  But there was no answer to her medical condition; she still had the label of Benign Hypotonia.

At three and a half years old, when she was finally walking albeit unsteadily, finally talking albeit a language of her own, and we had accepted her as she was, a friend showed me an article in an Australian women’s magazine about a child who was 10 years old and who had started life in the same way as our child had.  This child had a deletion in the 15th chromosome which caused all sorts of things including hypophagia.  An inability to know when to stop eating.  ‘Obesity and early death usually in their teens, followed.’

The darkness that descended was, again, indescribable.  Our daughter now wore a different label, that of Prader-Willi syndrome.  Again, we were still pre-Google, pre-internet, and pre-information.  This time, the block of ice that had served me so well in the beginning, had melted and what was left in its place was a well-forged, intensely heated rod of iron.  The fight was on, let the battle commence.  I fought for knowledge.  I asked questions.  I was no longer afraid of medical professionals spouting coded messages.  I would not leave their rooms until I had the answers I needed.  It was a long wait and usually ended with one step forward, two back.  The geneticist took down a large medical dictionary, opened the page at “P” and left the room.  Why did he do that?   I still have no idea.  Did he expect me to turn the book around and read the section on Prader-Willi Syndrome (as, of course, I did)?  What then?  Did he think I would understand?  He returned eventually, but threw no new light other than this was a genetic disorder.  The paediatric psychologist did all sorts of puzzle tests with her; finally walking us to the door and saying, ‘Oh look, there’s a young lass with PWS, do you really think your daughter has that?’ 

How the hell did she not see it when I could, so clearly?

It was an ongoing battle.  Friends who knew me well stood by me.  Family worried about me.  No one else mattered.  I had become fanatical about this wretched syndrome, but I kept it to myself knowing how quickly others become bored with fanatics.  Slowly, bit by bit I recalculated my life.  It was a completely new rebuild; I discarded things that no longer held true; fanciful, dreams that would never come true, people I couldn’t be bothered with, certain principles were abandoned in favour of new.  There was a fire sale – a big one – and I closed down the old burnt-out me.  I reopened some months later, just a few doors at a time, just a peep now and again until the paintwork was reapplied, the garden weeded, the fences restored; a completely new façade gave no hint to its terrified interior.


The child grew up, did not die, was loved, educated, and though there were some dramatically bad times, we all got through them.  The façade of the new me still held good.  However, the interior always needs re-strengthening, redecorating, reviving, and old things cast out for new, It has worked; most of the time it has worked.  Nearly 30 years later, life is different, but it is still good and the interior decorating still goes on.  Nothing is perfect.

Tuesday, April 29, 2014

Danish Group Homes for PWS


Contributed by Dorica Dan,  Romania

 EURORDIS, the European Organisation for Rare Diseases, has visited several Danish Group Homes for PWS last October. The visit occurred in the scope of the Joint-Action for Rare Diseases from the European Union Committee of Experts on Rare Diseases (EUCERD), where EU­RORDIS leads a work package on Specialised Social Services and Social Policies.

Dorica Dan, work package leader and President of the Romanian PWS Association, and Raquel Castro, Social Policies Manager at EURORDIS tell us what they thought of our group homes:
“We have had the chance to visit such different structures as Bofæl­lesskab Myrholmsvej (Aarhus), Grankolen (AllingÃ¥bro), Solvang and Marienlund (Fejø) and Orionvej 60 (Næstved). None of these services is exactly using the same model, yet all of them seem to be very successfully integrating their residents and helping them to be more autonomous.

We’ve realised that these houses had residents with different spec­trums of the disease and each housing facility adapted its struc­ture and activities to their residents. We’ve seen residents riding horses and we’ve seen others sitting quietly at home making puzzles and all of them looked rather satisfied.

In all houses there was an important connection with the staff, which is permanently there helping residents with their daily routine and activi­ties, making them feel supported and safe.
We’ve been told that several of these residents have tried to live on their own and have been unsuccessful in keeping their health and be­haviour at their best levels. Supporting staff has shown to be key for these residents to be able to be more autonomous while staying healthy. 
The purpose of the visits is to get to know certain Specialised Social Services for Rare Diseases in different European Countries in order to compile case study documents which can be used as advocacy tools and sources of inspiration. We consider that other countries might gain a lot from learning with the experience of the Danish PWS Group Homes and will be broadly sharing the information we’ve collected in Denmark.”

«As any parent in the world, I would like to have an independent daughter, even if she has PWS. I can say that she is well integrated into community but, until there will be a treatment to manage the food driven symp­toms caused by PWS, she may not live safely really independent. She learned and achieved things that looked impossible for anybody but the problem of the food control is extremely difficult for all of us.

Throughout our visit in Denmark, I couldn’t stop thinking which of these living arrangements would be the best for my daughter, which type could be organised in other countries (including Romania) and of course, I realized once again that the transition to independent living is solved just in a few coun­tries in Europe.

We have to learn and understand that supervision from social workers in these homes has to be accepted as a supportive reality and as part of the independent living. The “arrangements” for this change in our children’s lives will depend always on our child’s individual needs and abilities, the needs of the others living in the same home, resources avail­able in the community, our child’s dreams and hopes, etc. There is a need of sharing the experience of parents with the services providers and between the social workers, involved in this field. We have also to think that options and wishes may change over time, too.»

Dorica Dan, mother of Oana