Rama Univ J Dent Sci 2015 Dec;2(4):6-10 Dental care in Down’s syndrome

Case Report
Dental Care of Infants and Young Children with Down Syndrome: A
Review
Kohli A, Katiyar A, Gupta K, Singh G, Katyayan R, Dwivedi A
ABSTRACT: Down's syndrome is caused by a chromosomal abnormality and is characterized by
certain physical, mental and medical features with specific oral manifestations. A number of these
features, such as learning disability, cardiac anomalies and an altered immune system and oral
manifestations like early onset of severe periodontal disease (most significant oral health problem),
lower prevalence of dental caries, delayed eruption of permanent teeth, malocclusion, congenitally
missing and malformed teeth, hypoplasia of mid-facial region, hypodontia, microdontia,
macroglossia, fissured and protruding tongue, tongue thrust, bruxism, clenching, mouth breathing
can have a profound effect on oral health and the delivery of oral care. In turn, this can affect social
acceptability and quality of life. The optimum potential of the person with Down's syndrome is
achieved via a multidisciplinary approach that involves the pediatric dentist from an early stage.

Keywords: Down syndrome; Trisomy; 21st chromosome; Hypoplasia; Microdontia; Macroglossia.

INTRODUCTION abnormality, most receive surgical correction

within the first few years of life. There is
Down syndrome is one of the most common however, an abnormally large percentage that
genetic syndromes, occurring in one of 800 to develop mitral valve prolapsed (MVP) by
1,000 live births.1 Down syndrome is a adulthood. The incidence of MVP in the
chromosomal disorder associated with an extra normal population is between 5-15%.
chromosome (Trisomy 21) resulting in Approximately 50% of adults with Down
intellectual disability and specific physical syndrome have mitral valve prolapse requiring
features. The teeth of people with Down subacute bacterial endocarditis (SBE)
syndrome, both baby teeth and permanent prophylaxis for dental treatment.3 One third of
teeth, may come in late compared to children these adults with MVP do not have
without Down syndrome. On average, babies auscultatory findings, requiring diagnosis of
with Down syndrome get their first teeth at 12 the MVP by echocardiogram. Patients with
to 14 months, but it may be as late as 24 Down syndrome or their caregivers may not
months of age. Babies without Down be aware of the need for diagnostic
syndrome typically get their first teeth echocardiology in adulthood.
between 6-12 months. It is typical that a child
with Down syndrome may not get all 20 baby A compromised immune system with a
teeth until he or she is 4 to 5 years of age, corresponding decrease in number of T cells is
rather than 2-3 years of age, which is typical characteristic of most individuals with Down
for children without Down syndrome. The syndrome; this contributes to a higher rate of
front permanent teeth and permanent 6 year infections and is also a contributing factor in
old molars may not erupt until 8-9 years of the extremely high incidence of periodontal
age. It is also common for the teeth of disease. Children with Down syndrome often
children with Down syndrome to erupt in a have chronic upper respiratory infections
different order than in children without Down (URIs). These contribute to mouth breathing
syndrome.2 with its associated effects of xerostomia (dry
mouth) and fissuring of the tongue and lips.
Systemic factors influencing dental care There is also a greater incidence of apthous
Although 40 to 50% of babies with Down ulcers, oral candida infections and ANUG.4
syndrome are born with some type of cardiac A reduced degree of muscle tone (hypotonia)
is generally found in Down syndrome. This

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affects the musculature of the head and oral conditions. Alzheimer's disease and Down
cavity as well as the large skeletal muscles. syndrome appear to have a strong connection
The reduced muscle tone in the lips and to one another. The importance of a thorough
cheeks contribute to an imbalance of forces on medical history including a work-up by a
the teeth with the force of the tongue being a physician cannot be over emphasized
greater influence. This contributes to the open
bite often seen in Down syndrome.
Oral Manifestations:
1. Small and missing teeth: Frequently,
Additionally, reduced muscle tone causes less people with Down syndrome have smaller
efficient chewing and natural cleansing of the than average teeth and missing teeth. It is also
teeth. More food may remain on the teeth after common for the teeth of people with Down
eating due to this inefficient chewing. syndrome to have roots that are shorter than
Associated with the low muscle tone seen in average.
Down syndrome is a ligamentous laxity seen 2. Large tongue: People with Down
throughout the body. This causes syndrome may have large tongues or they may
hyperflexibility of the joints and it is theorised have an average size tongue and a small upper
that the ligaments around teeth may be jaw that makes their tongue too large for their
influenced as well.5 A condition related to mouth. It is also common for people with
ligamentous laxity is that of Atlanto Axial Down syndrome to have grooves and fissures
Instability. The diagnosis and significance of on their tongues.5
this condition is controversial but is described 3. Problems with bite: People with
as an increase in mobility between the C1 and Down syndrome may have small teeth, which
C2 cervical vertebrae and may be seen in 10- can cause spacing between the teeth. They
20% of individuals with Down syndrome. If a also tend to have a small upper jaw. This may
patient has this instability, careful positioning cause crowding of the teeth and may result in
in the dental chair is required to avoid any the permanent teeth being “impacted” because
potential harm to the spinal cord. there is no room in the mouth for them to
come in. The small upper jaw may create a
Persons with Down syndrome vary widely as situation where the top teeth do not go over
to their degree of intellectual impairment. the bottom teeth the way they are meant to;
Most have IQs in the mild to moderate range instead, the bottom teeth may be out further
and are able to be treated in a normal setting. than the top teeth in the back of the jaw, the
There is often a relatively severe delay in front of the jaw, or both. It is also common
language development. The patient with Down that the front teeth of people with Down
syndrome will probably understand more than syndrome do not touch. Orthodontics (braces)
their apparent level of verbal skills. The may be able to improve some of these issues.
assistance of the patient's family or caregiver Orthodontics require a lot of cooperation and
will be necessary in conveying to the dentist make the teeth even more difficult to keep
and staff what level of communication should clean, so it may not be possible in all people.
be used with the patient. It may take a little It may be a good idea to wait until a child is
extra appointment time to explain procedures older and able to tolerate it a bit better.
to the patient with Down syndrome, but once a Having orthodontic appliances in the mouth
level of trust is achieved they are likely to be can also pose challenges to speech. Children
very co-operative patients. without Down syndrome typically adapt their
speech quickly; however, in a child with
Down syndrome, where speech may already
Down syndrome is frequently seen in be an issue, adapting to the appliances may be
conjunction with other medical problems. very difficult. Therefore, it may be a good
There is a higher incidence of epilepsy, idea to delay orthodontic treatment until a
diabetes, leukemia, hypothyroidism and other

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Rama Univ J Dent Sci 2015 Dec;2(4):6-10 Dental care in Down’s syndrome

child is older and his or her speech is further and can handle some of the more extensive
along. dental treatment options available today.
4. Gum disease: People with Down
syndrome are at an increased risk for gum
Behaviour Management
disease (periodontal disease). Even when
individuals with Down syndrome do not have Good behavior in the dental office is learned.
a lot of plaque and tartar (calculus), they get In a population with delayed learning, this can
periodontal disease more frequently than be a challenge for the dentist and staff. Dental
others. This is because people with Down treatment for children with Down syndrome
syndrome have an impaired immune system may not be sought out at an early age. There
and do not have some of the natural may be more pressing medical problems,
protections against the disease that people financial considerations or parents may want
without Down syndrome have. To prevent to wait until the child seems mature enough to
gum disease brush twice daily, focusing the handle a visit to the dentist. Unfortunately this
bristles along the gum line, floss daily and be makes it more difficult to teach proper home
sure to visit the dentist regularly to have gum care and to develop a relationship with the
health monitored and to take X-rays to child that will result in co-operative behaviour
monitor bone levels. If the gums bleed that during dental treatment.7
means that they are inflamed. Brushing and
flossing should not be stopped because of Many children with Down syndrome can
this. In fact, brushing and flossing will keep successfully be treated in the dental office.
the gums clean and help to minimize the
inflammation. Guidance
5. Cavities: Some research says that • Plan a pre-appointment (in person/
people with Down syndrome are at less of a phone) to discuss patient special needs
risk for cavities; however, much of that prior to the first visit. Discuss this with
research was done when people with Down the parent or care provider-they know
syndrome lived in institutions and had very the child best.
restricted diets. People with Down syndrome • Schedule appointments early in the
do get cavities, so brushing with fluoride morning or best time of day for patient.
toothpaste, flossing between any teeth that • Talk with the parent or caregiver to
touch, and limiting the amount and frequency determine the patient’s level of
of sugar and refined carbohydrates eaten will intellectual and functional abilities and
help to prevent the development of cavities.6 explain each procedure at a level the
patient can understand.
Treatment Objectives • Use short, clear instructions and speak
directly to the patient.
Treatment objectives for any population with
developmental disabilities should be the same • Minimize distractions, such as sights
as that of normal patients. Treatment plans and sounds, which may make it difficult
for the patient to cooperate.
may need to be adapted as necessary due to
each individual's condition, but the overall • Start the oral examination slowly, using
goal should be to provide as comprehensive only fingers at first. If this is successful,
treatment as possible. Areas of dental care begin using dental instruments.
such as Pedodontics, cosmetic dentistry, • Use the Tell-Show-Do approach when
orthodontics, prosthodontics, and introducing new instruments or
reconstructive oral surgery should not be ruled procedures.
• Reward cooperative behavior with
out simply because the patient has Down
syndrome. With the numbers of persons with positive verbal reinforcement.
Down syndrome working and living out in the • Develop trust and consistency between
the dental staff and the patient. Use the
community, there may be many who desire
same staff, dental operatory, and

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appointment time each visit if • Seizure management during treatment:

appropriate.8 Remove all dental instruments from the
mouth. Clear the area around the dental
Dental Treatment And Prevention: chair. Stay with the child and turn child
• Consider patient’s cardiac status and to one side. Monitor airway to reduce
need for premedication-medical consult risk of aspiration. Note time seizure
may be indicated begins: if seizure continues >3 min call
• It is not uncommon to encounter EMS – Danger of Status Epilepticus
patients who are tube-fed among the (potentially life threatening).
population of Children with Special • Carefully move patients with
Healthcare Needs. Patients fed by tube atlantoaxial instability into the dental
typically have low caries, rapid chair, giving special attention to the
accumulation of calculus, GERD spine and neck. Use pillows to stabilize
(Gastro-esophageal Reflux Disease), the patient and increase comfort, as
oral hypersensitivity, and are at high directed by the caregiver.10
risk for aspiration in the dental chair.
No antibiotic premedication is needed CONCLUSION: Life tables published in 1989
for Gastric or Nasogastric tubes. showed that more than 50 percent of infants
Position the patient in as upright a with Down syndrome could be expected to
position as possible and utilize low live more than 50 years.11 As mortality rates
amounts of water and high volume for the operative repair of congenital heart
suction to minimize aspiration. defects continue to decrease, survival may
• Examine patients by the first birthday; increase considerably.12 Since the trend toward
monitor tooth eruption patterns and deinstitutionalization began in the 1970s, it
malformations. has become apparent that the maintenance of
• Monitor periodontal disease. Treat as optimal health is a major factor in the lifelong
needed and consider specialty referral if functioning of persons with Down syndrome.
indicated. Primary health care has become essential to
• Powered toothbrushes may be too helping these persons have longer, more
stimulating for some children and productive lives. Dental care for the patient
should be recommended only after with Down syndrome can be achieved in the
determining if the child will tolerate general practitioner's office in most instances
one. with minor adaptations. Although this
• Consider prescribing Chlorhexidine or population has some unique dental care needs,
other antimicrobial agents for daily use. few patients require special facilities in order
• Some patients are good candidates for to receive dental treatment. Adequate dental
full orthodontic treatment. Maintain health care for persons with developmental
primary teeth as long as possible and disabilities is a major unmet health need. It is
consider space maintenance and hoped that the information contained in this
orthodontic consultation for missing review will encourage general practitioners to
teeth.9 be willing to provide comprehensive dental
care to their patients with Down syndrome.
Considerations due to Associated Medical Author affiliation: 1. Dr. Anil Kohli, MDS, Proff.
Conditions: & HOD, 2. Dr. Aahish Katiyar , MDS, Reader, 3.
• Increased gag reflex during oral Dr. Kirtija Gupta, MDS, Reader, 4. Dr. Garima
examination. Singh, MDS, Reader, 5. Dr. Rahul Katyayan, PG
• Chronic respiratory infections and open Student, 6. Dr. Amit Dwivedi, PG Student, Dept.
mouth posture → frequent mouth Of Pedodontics & Preventive Dentistry Rama
breathing → xerostomia. Dental College, Hospital & Research Centre
Kanpur, U.P, India.

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REFERENCES 7. Reuland-Bosma W., Van Dijk J.

Periodontal disease in Down’s syndrome:
1. E. S. Pilcher, “Dental care for the patient
A review. J. Clin. Periodontol. 1986;
with Down Syndrome,” Down Syndrome
13(1): 64-73.
Research and Practice, vol. 5, no. 3, pp.
8. Fiske, J., Shafik, H.H. Down's syndrome
111–116, 1998.
and oral care. Dent Update. 2001;28:148–
2. Barnett, M.L., Friedman D., & Kastner T.
156.
(1988). The prevalence of mitral valve
9. Morgan, J. (2007) Why is periodontal
prolapse in patients with Down syndrome:
disease more prevalent and more severe in
Implications for dental management. Oral
people with Down syndrome? Special
Surgery Oral Medicine Oral Pathology,
Care Dentist, 27(5):196-201.
66, 445-7
10. Dyment H, Casas M. Dental care for
3. National Institute for Dental and
children fed by tube. Spec Care Dentist
Craniofacial Research, National Institutes
1999; 19: 220–224.
of Health, Oral Health: Special Needs. 25
11. Baird PA, Sadovnick AD. Life tables for
March 2011. Web. 1 Nov. 2011.
Down syndrome. Hum Genet
4. Southern Association of Institutional
1989;82:291-2.
Dentist. Down Syndrome: a review for
12. Laks H, Pearl J. Surgical intervention and
dental professional. In Self-Study Course
postoperative results in patients with
Module 3, 1994: 1-9.
congenital heart disease and Down
5. Sterling E. Oral and dental considerations syndrome. In: Marino B, Pueschel S, eds.
in Down syndrome. In: Lott IT, McCoy Heart disease in persons with Down
EE, eds. Down syndrome: advances in syndrome. Baltimore: Paul H. Brookes,
medical care. New York: Wiley-Liss, 1996:161-74
1992:135-46
6. Barnett, M.L., Press, K.P., Friedman, D., Corresponding Author:
& Sonnenburg E.M. (1986). The Dr. Amit Kumar Dwivedi,
prevalence of periodontitis and dental PG Student
caries in a Down's syndrome Dept. Of Pedodontics & Preventive Dentistry,
population. Journal of Periodontology, 57, Rama Dental College, Hospital & Research
288-93. Centre, Kanpur, U.P, India
Contact number : 09795197161
Email id : cooldramit47@gmail.com

How to cite this article: Kohli A, Katiyar A, Gupta K, Singh G, Katyayan R, Dwivedi A.
Dental Care of Infants and Young Children with Down Syndrome: A Review. Rama Univ J
Dent Sci 2015 Dec;2(4):6-10.

Sources of support: Nil Conflict of Interest: None declared

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