Periodontal disease and Down syndrome patients
What dental professionals can expect
Susan P. Burzynski, RDH, MSEd, FAADH
I began my day as I have every workday, checking my schedule, only to see some of my favorite patients were coming in. Joe and Jude like to repeat the same statements: “Suzy, are you married?” “I love you!” “I’m happy!” Cynthia loves to tell me jokes during her entire appointment time. Caroline hates coming to the office and refuses to talk to anyone. Mark just wants to hug me and hold my hand.
What do Joe, Jude, Cynthia, Caroline, and Mark have in common? They all have various levels of Down syndrome (DS). The other common trait for these adults is periodontal disease. Jude, Caroline, and Mark’s foster mothers are diligent in their dental care. They not only bring them in for a professional prophylaxis every three months, they also supervise their homecare, keep after the staff to supervise their brushing and flossing, and have taken on the system so these individuals receive good dental care. Joe’s caregiver has become proactive in his oral care by supervising his use of disclosing tablets, fluoride rinse, and a power brush. Cynthia’s parents are also diligent in seeing that she performs good oral health care.
My patients’ lack of improvement in their oral health led me to do some investigating as to why, with the involvement of their caregivers, their conditions continue to deteriorate.
Down syndrome is a set of mental and physical symptoms that are the result of an extra copy of chromosome 21 (also called Trisomy 21, where there are three copies of chromosomes instead of two), which changes the body and brain’s normal development. DS is the most common genetic birth defect and affects 1 to 800 babies a year in the United States. According to the National Down Syndrome Society, there are more than 400,000 individuals with DS in the United States.
The following are manifestations of DS listed on the Center for Pediatric Dentistry’s website:
• Clinical — Increased risk of abnormalities in almost every organ system, including intellectual disability and delayed growth; vision and hearing problems; cardiac defects (VSD,ASD, PDA, Tetralogy of Fallot); characteristic physical features such as brachycephalic skull, prominent epicanthic skin folds, small low-set ears, reduced muscle tone, pelvic dysplasia, transverse palmar crease, broad hands and feet, short fingers, and lenticular opacities.
• Oral — Early onset severe periodontal disease (most significant oral health problem); lower prevalence of dental caries; delayed eruption of permanent teeth, malocclusion; congenitally missing and malformed teeth are common; hypoplasia of mid-facial region; hypodontia, microdontia; macroglossia, fissured and protruding tongue; and tongue thrust, bruxium, clenching, and mouth breathing.
• Other potential disorders/concerns — Epilepsy, cardiac defects, atlantoaxial instability (fagility of cervical vertebrae/spinal cord), compromised immune system, sleep apnea, increased risk of leukemia, hearing loss, vision problems, and hypothyroidism.
The immune alterations described in DS are related to leukocyte function, which is responsible for the defensive mechanisms in periodontal tissues. It is also characterized by aggressive and generalized periodontitis.
Patients with DS often lose their teeth in their early teens due to periodontal disease as well as other contributing factors:
- Immune deficiency
- Inadequate control of bacterial plaque
- Deficient masticatory function
- Early aging
- Alterations in dental anatomy (short roots)
In a study conducted with 26 DS patients and 16 healthy volunteers, the saliva of these people was tested. The LL-37 (cleaved antimicrobial peptide) and hCAP18 (human cathelicidin antimicrobial protein) was found to be higher in individuals with DS than in those without DS. A Brazilian study found patients with DS had a higher incidence of periodontal disease than dental caries. This prevalence seems to be due to the impaired host response rather than to specific periodontal pathogens. Prevalence of low caries rates seems due to immune protection caused by the elevated salivary S. mutans-specific IgA concentrations.
The caregivers of Joe, Jude, Cynthia, Caroline, and Mark are making a difference in their lives. It is a slow process, but they are determined to be the best for them. Verbalization for patients with DS is difficult when they try to express any discomfort. Mark routinely tells me his teeth are loose. We have done a prophylaxis, probed, charted, and X-rayed his entire mouth and have not found a tooth that is loose. However, we continue to advise his foster mother to supervise his oral homecare.
Research needs to continue for these individuals, as does advocating by their caregivers on their behalf. Additionally, as professionals, we need to slow down and listen when they try to tell us what their problems are — to them their problems are very real.
In looking ahead to my work schedule for the week, I see that Joe is coming in. I know this is going to be a good week. He will be sure to ask me if I am married. He has added a new question as well. “Suzy, how old are you?” My response is, “A lady never tells.”
Susan P. Burzynski, RDH, MSEd, FAADH, has practiced clinical dental hygiene since 1971. An active member of the American Dental Hygienists’ Association, Susan is vice-president of the Buffalo Dental Hygienists’ Association, as well as delegate and director for the component for the Dental Hygiene Association for New York State (DHASNY). In 2007, Susan became a member of the American Academy of Dental Hygiene. She is a 2010 recipient of the Sunstar/RDH Award of Distinction. She can be reached at KleenTeeth@verizon.net
- Bachrach B, Chaushu G, Zigmond M, et al, “Salivary LL-37 Secretion in Individuals with Down Syndrome is Normal.” Journal of Dental Research (2006): 933-936.
- Eunice Kennedy Shriver National Institute of Child Health & Human Development. 23 Feb. 2011. 25 April 2011 <http://www.nichd.nih.gov/health/topics/down_syndrome.cfm
- March of Dimes. 14 Sept. 2011 <http://www.marchofdimes.com
- de Moraes MEL, de Moraes LC, Dotto GN, et al. “Dental Anomalies in Patients with Down Syndrome.” Brazilian Dental Journal (2007): 346-350.
- Oral Health Fact Sheet for Dental Professionals Children with Down Syndrom (Trisomy 21). 14 Sept. 2011 <http://www.thecenterforpediatricdentistry.com>;.
- Grollmus ZCN, Chavez MCM, Donat FJS. “Periodontal Disease Associated to Systemic Genetic Disorders.” Medincina Oral, Patologia Oral (2007): E211-5.
As dental professionals, there is much we can do for both DS patients and their caregivers. Primarily, we can treat individuals with DS with respect. In the pamphlet, “Practical Oral Care for People With Mental Retardation” from the National Institute of Dental and Craniofacial Research, the following suggestions for professionals were made:
- Encourage the patient to perform oral care independently, if possible.
- Engage the caregiver or parent to supervise the patient’s homecare routine.
- Suggest the use of disclosing tablets to highlight missed areas, making it easier for these patients to see where they need to brush.
- Ask patients to demonstrate their brushing technique to you. Follow up with hand-over-hand specific directions on either brushing technique or adaptations. Demonstrate not only to patients, but also to their caregivers.
- Use your experience in patient positioning to assist the caregiver in assisting the DS patient. (In the case of Jude and Mark’s foster mothers, they stood them in front of the kitchen sink to not only watch, but also assist in brushing.)
- Use of a power brush may encourage DS patients to be more independent in their oral health care.
- Use of an antimicrobial mouthwash may help these patients. (Some patients find it difficult to expectorate. In this instance, the toothbrush can be dipped in the mouthwash and applied to the patient’s teeth.)
- Should particular medications be required due to gingival hyperplasia, stress their importance as well as regularly scheduled hygiene appointments.