Medical problems associated with Down syndrome that can affect dental treatment are discussed. Also, social and emotional factors involved in dental treatment are covered, including techniques to help children with Down syndrome become cooperative dental patients. Information on how to choose the right dentist for your child and how to communicate effectively with the dental staff is given. Finally, information on proper home care and prevention of dental disease is covered, including information on the most recent dental products.
A compromised immune system with a corresponding decrease in number of T cells is characteristic of most individuals with Down syndrome. This contributes to a higher rate of infections and is also a contributing factor in the extremely high incidence of periodontal disease. Children with Down syndrome often have chronic upper respiratory infections. These contribute to mouth breathing with its associated effects of dry mouth (xerostomia) and fissuring of the tongue and lips. There is also a greater incidence of aphthous ulcers, oral candida infections and acute necrotizing ulcerative gingivitis.
A reduced degree of muscle tone is generally found in Down syndrome. This affects the musculature of the head and oral cavity as well as the large skeletal muscles. The reduced muscle tone in the lips and cheeks contribute to an imbalance of forces on the teeth with the force of the tongue being a greater influence. This contributes to the open bite often seen in Down syndrome. Additionally, reduced muscle tone causes less efficient chewing and natural cleansing of the teeth. More food may remain on the teeth after eating due to this inefficient chewing. Associated with the low muscle tone is a ligamentous laxity seen throughout the body. This causes hyperflexibility of the joints and is theorized that the ligaments around teeth may be influenced as well (Southern Assoc. of Institutional Dentists, p.4, 1994). A condition related to ligamentous laxity is that of Atlanto-axial Instability. The diagnosis and significance of this condition is controversial but is described as an increase in mobility between the C1 and C2 cervical vertebrae and may be seen in 10 - 20% of individuals with Down syndrome. If a patient has this instability, careful positioning in the dental chair is required to avoid any potential harm to the spinal cord.
Persons with Down syndrome vary widely as to their degree of intellectual impairment. Most have IQ's in the mild to moderate range and are able to be treated in a normal setting. There is often a relatively severe delay in language development. The patient with Down syndrome will probably understand more than their apparent level of verbal skills. The assistance of the patient's family or caregiver will be necessary in conveying to the dentist and staff what level of communication should be used with the patient. It may take a little extra appointment time to explain procedures to the patient with Down syndrome, but once a level of trust is achieved they are likely to be very cooperative patients.
Down syndrome is frequently seen in conjunction with other medical problems. There is a higher incidence of epilepsy, diabetes, leukemia, hypothyroidism and other conditions. Alzheimer's disease and Down syndrome appear to have a strong connection to one another. The importance of a thorough medical history including a work-up by a physician cannot be over emphasized.
Historically the incidence of dental decay in persons with Down syndrome has been reported to be extremely low. Recent studies, however, have shown that while the incidence is lower, it is not as rare as once thought and it certainly shouldn't be taken for granted that "these patients won't get decay" (Barnett, 1986). Older studies of caries in persons with Down syndrome used institutionalized populations whose diets were controlled. These groups may not have had the exposure to cariogenic foods at the rate of today's children with Down syndrome who are growing up at home. The incidence is lower, however, and it is theorized that this may be due to delayed eruption of the teeth, increased spacing between teeth or possible differences in the chemical content of the saliva (Morinushi et al, 1995).
Today, children with Down syndrome should be educated in proper oral hygiene, and receive the benefits of topical and systemic fluoride. Occlusal sealants are also recommended. Decay in the primary dentition should be properly treated. With the delay of the permanent teeth and the high number of missing teeth, it is critical to maintain the primary dentition as long as possible.
Obviously, good home care is essential in the management of periodontal disease of this type. This may be difficult to achieve with the intellectual impairment and decreased manual dexterity seen in Down syndrome. Flossing may be very hard for these patients and instruction in the use of a floss holder may be helpful. New mechanical tooth brushing and flossing aids on the market may also be of help. It is important to be sure that the patient's family or caregiver is educated in proper home care as well. Parents need to realize the importance of proper daily home care because the child with Down syndrome may be resistant to tooth brushing. Additionally, the age at which a child with Down syndrome can be expected to take care of his/her own teeth may be much later than that of normal children.
Treatment objectives for any population with developmental disabilities should be the same as that of normal patients. Treatment plans may need to be adapted as necessary due to each individual's condition, but the overall goal should be to provide as comprehensive treatment as possible. Areas of dental care such as cosmetic dentistry, orthodontics, prosthodontics, and reconstructive oral surgery should not be ruled out simply because the patient has Down syndrome. With the numbers of persons with Down syndrome working and living out in the community, there may be many who desire and can handle some of the more extensive treatment options available today.
Good behavior in the dental office is learned. In a population with delayed learning, this can be a challenge for the dentist and staff. Dental treatment for children with Down syndrome may not be sought out at an early age. There may be more pressing medical problems, financial considerations or parents may want to wait until the child seems mature enough to handle a visit to the dentist. Unfortunately this makes it more difficult to teach proper home care and to develop a relationship with the child that will result in cooperative behavior during dental treatment.
Scheduling appointments early in the day is beneficial as both patient and operator are more rested. First appointments should be for orientation only, and subsequent appointments may require a little more time than what is usually allowed. The patient's medical history should be obtained prior to the first appointment. This allows for medical consultation if necessary before any treatment begins.
Determining the level of communication is very important in developing a cooperative relationship with your patient with Down syndrome. The level of receptive vs. expressive language may not be the same. The patient's family or caregiver will be able to guide the dental staff as to what level of communication is appropriate. It is important that the dentist communicate directly with the patient whenever possible in order to build a level of trust. It may be advantageous to have a parent in the operatory during some early childhood visits. Finding out what motivates the child with Down syndrome is also important. Something as simple as receiving a mask at the end of the appointment may be all it takes to ensure cooperation. With more difficult patients requiring more extensive treatment, premedication and/or restraint may be necessary. However, most patients with Down syndrome can handle routine dental care with just a little more time and attention given during the appointment.