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Special Dentistry Considerations
for Children and Adults with Down Syndrome

Children and adults with Down syndrome require regular, thorough dental care just as much as "typical" peers. Individuals with Down syndrome, however, may present to the dental care provider with a variety of associated oral and/or health conditions which the dentist should be aware of in order to adequately render care. The most frequently encountered associated conditions are briefly described below.

Orofacial Anomalies

Abnormalities in the development of the face and oral cavity are frequently seen in individuals with Down syndrome. Mid-face hypoplasia is typically present and refers to the underdevelopment of the midface with resulting prognathism (protrusion of the jaw). Malocclusion of the teeth/bite is common. Additionally, the tongue may appear to be too large; however, this is more often related to decreased size of the oral cavity than to actual macroglossia. Frontal and/or maxillary sinuses may be underdeveloped as well - or totally absent.

The high incidence of mouth breathing in individuals with Down syndrome is due to the typically small nasal airways. Chronic upper respiratory infections often exacerbate this effect. As a result, the patient's tongue may become dried out, and fissures and/or angular cheilitis (split skin at the corner of the mouth/lips) may develop over time. Chronic halitosis often results in such cases.

Alterations in Dentition

Individuals with Down syndrome frequently experience delayed eruption of both the primary and permanent teeth - this delay in eruption may be up to three years. Teeth often erupt in an unusual order. Some teeth may not be present at all - the most common of which are the lateral incisors. Delays in eruption in dentition may prevent an infant from moving on to solid foods at the usual time; problems with chewing may result and may necessitate dietary modifications in order to insure adequate nutrition. Malformations of the teeth themselves are also common, such as microdontia (small teeth). Roots are often smaller than normal and may complicate needed orthodontia. Some individuals may experience severe crowding of teeth due to the small oral cavity. In these cases, selective extractions may be helpful, if performed with an orthodontist's guidance.

Cardiac Concerns

The incidence of congenital heart defects in individuals with Down syndrome is approximately 50%. Most defects are surgically corrected before the age at which individuals typically present for dental care. However, the incidence of Mitral Valve Prolapse (MVP) in patients with Down syndrome is nearly 50%. The diagnosis of MVP must be confirmed by echocardiogram, as many cases are clinically silent, without auscultatory findings. Such individuals require antibiotic prophylaxis before dental treatment in order to prevent Subacute Bacterial Endocarditis from developing.

Intellectual Disability/Behavioral Concerns

Most individuals with Down syndrome experience some degree of intellectual disability, typically in the mild to moderate range of cognitive disability. Persons with Down syndrome are thus usually very easily accommodated within the "typical" dental office setting. Compliance issues should be dealt with in much the same way as for any other child presenting for dental treatment. The dental provider should demonstrate patience and respect for the individual when rendering care. All interventions should be explained to the child before beginning care. The child with Down syndrome may simply require a little more time and patience - especially during the first few visits. Sedation should only be used as a last resort, and only in extreme cases where care is vital and may not be performed in other way.

Communication Concerns

It is important for the dental provider to be aware of certain communication issues which are common to individuals with Down syndrome. As with various other disabilities, such as cerebral palsy, expressive language ability may not be an accurate depiction of receptive language skill in children/adults with Down syndrome. Individuals with Down syndrome usually understand language fairly well. The dental provider-patient interaction will benefit from the dentist's demonstrating an interest in understanding the patient's communicative ability. Communicating directly with the patient - even when more difficult - helps to build needed rapport and promote cooperation.

Musculoskeletal Considerations

Decreased muscle tone, or hypotonia, is common in persons with Down syndrome. Hypotonia plays a major role in the failure of the midface to develop properly in individuals with Down syndrome. Although the degree of tone tends to improve somewhat with age, some persons will experience rather significant ligamentous laxity, which results in instability of the joints. The dental provider should be aware of a specific condition which may occur in individuals with Down syndrome called atlantoaxial instability. This condition involves the atlas and axis (C1 and C2 vertebrae) of the neck. Twenty percent of children with Down syndrome experience this condition. It is important for the dental provider to use proper anatomical positioning, and provide ample head support, when rendering dental care to such individuals. Failure to do so may result in cervical cord injury.

Immunological Differences

Children/individuals with Down syndrome frequently experience abnormalities in their immune system. Decreases in certain types of white blood cells (specifically T-cells) may lead to an increased incidence of infections. This lowered T-cell count is also thought to play a role in the very high incidence of periodontal disease experienced by persons with Down syndrome. Childhood leukemia occurs more frequently in individuals with Down syndrome, with an estimated incidence of 20 times the rate in the non-Down syndrome population. The dental provider should closely examine the patient's oral cavity in order to detect any persistent lesions or bleeding gums which may indicate the presence of leukemia in undiagnosed individuals.

Peridontal Disease/Tooth Decay

Historically, individuals with Down syndrome were thought to experience a much lower rate of tooth decay (although higher incidence of gum disease) than the normal population. However, recent studies suggest that decay rates are more closely aligned with the non-Down syndrome population. Patients with Down syndrome frequently experience even severe periodontal disease as early as adolescence. This increased incidence of periodontal disease is thought to be related to both the decreased immunological response in persons with Down syndrome, and may be exacerbated by poor dental hygiene/care. Chlorhexedine mouth rinse and/or antibiotic therapy may be indicated in significant cases.

References

Pilcher, E.S.(1998). Dental care for the patient with Down syndrome. Down Syndrome Research and Practice, 5(3), 111-116.

NIDCR National Institute of Dental and Craniofacial Research (2005). Practical oral care for people with Down syndrome. Retrieved online 6/17/05 from http://www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/
DevelopmentalDisabilitiesAndOralHealth/PracticalOralCareforPeople
WithDownSyndrome.htm
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