1.

Oral manifestation

What is Different About the Teeth of People With Down

Syndrome?
Delayed Eruption
The teeth of people with Down syndrome, both baby teeth and permanent teeth, may
come in late compared to children without Down syndrome. On average, babies with
Down syndrome get their first teeth at 12 to 14 months, but it may be as late as 24 months
of age. Babies without Down syndrome typically get their first teeth between 6-12
months. It is typical that a child with Down syndrome may not get all 20 baby teeth until
he or she is 4 to 5 years of age, rather than 2-3 years of age, which is typical for children
without Down syndrome. The front permanent teeth and permanent 6 year old molars
may not erupt until 8-9 years of age. It is also common for the teeth of children with
Down syndrome to erupt in a different order than in children without Down syndrome.

Small and Missing Teeth

Frequently, people with Down syndrome have smaller than average teeth and missing
teeth. It is also common for the teeth of people with Down syndrome to have roots that
are shorter than average.

Large Tongues
People with Down syndrome may have large tongues or they may have an average size
tongue and a small upper jaw that makes their tongue too large for their mouth. It is also
common for people with Down syndrome to have grooves and fissures on their tongues.

Problems with Bite

People with Down syndrome may have small teeth, which can cause spacing between the
teeth. They also tend to have a small upper jaw. This may cause crowding of the teeth
and may result in the permanent teeth being impacted because there is no room in the
mouth for them to come in. The small upper jaw may create a situation where the top
teeth do not go over the bottom teeth the way they are meant to; instead, the bottom teeth
may be out further than the top teeth in the back of the jaw, the front of the jaw, or both.
It is also common that the front teeth of people with Down syndrome do not touch.
Orthodontics (braces) may be able to improve some of these issues. Orthodontics require
a lot of cooperation and make the teeth even more difficult to keep clean, so it may not be
possible in all people. It may be a good idea to wait until a child is older and able to
tolerate it a bit better. Having orthodontic appliances in the mouth can also pose
challenges to speech. Children without Down syndrome typically adapt their speech
quickly; however, in a child with Down syndrome, where speech may already be an issue,
adapting to the appliances may be very difficult. Therefore, it may be a good idea to
delay orthodontic treatment until a child is older and his or her speech is further along.

Gum Disease
People with Down syndrome are at an increased risk for gum disease (periodontal
disease). Even when individuals with Down syndrome do not have a lot of plaque and
tartar (calculus), they get periodontal disease more frequently than others. This is because
people with Down syndrome have an impaired immune system and do not have some of
the natural protections against the disease that people without Down syndrome have. To
prevent gum disease brush twice daily, focusing the bristles along the gum line, floss
daily and be sure to visit the dentist regularly to have gum health monitored and to take
X-rays to monitor bone levels. If the gums bleed that means that they are inflamed.
Brushing and flossing should not be stopped because of this. In fact, brushing and
flossing will keep the gums clean and help to minimize the inflammation.

Cavities
Some research says that people with Down syndrome are at less of a risk for cavities;
however, much of that research was done when people with Down syndrome lived in
institutions and had very restricted diets. People with Down syndrome do get cavities, so
brushing with fluoride toothpaste, flossing between any teeth that touch, and limiting the
amount and frequency of sugar and refined carbohydrates eaten will help to prevent the
development of cavities.
See more at: http://www.ndss.org/Resources/Health-Care/Associated-Conditions/DentalIssues-Down-Syndrome/#sthash.HwnYofJp.dpuf
2. Treament for oral manifestations

Oral Health Problems in Down Syndrome and Strategies

for Care
People with Down syndrome have no unique oral health problems. However, some of the
problems they have tend to be frequent and severe. Early professional treatment and daily
care at home can mitigate their severity and allow people with Down syndrome to enjoy the
benefits of a healthy mouth.
PERIODONTAL DISEASE is the most significant oral health problem in people with
Down syndrome. Children experience rapid, destructive periodontal disease.
Consequently, large numbers of them lose their permanent anterior teeth in their early
teens. Contributing factors include poor oral hygiene, malocclusion, bruxism, conicalshaped tooth roots, and abnormal host response because of a compromised immune
system.
Some patients benefit from the daily use of an antimicrobial agent such as
chlorhexidine. Recommend an appropriate delivery method based on your
patient's abilities. Rinsing, for example, may not work for a person who has
swallowing difficulties or one who cannot expectorate. Chlorhexidine applied
using a spray bottle or toothbrush is equally efficacious.

 If use of particular medications has led to gingival hyperplasia, emphasize the

importance of daily oral hygiene and frequent professional cleanings.
Encourage independence in daily oral hygiene. Ask patients to show you how they
brush, and follow up with specific recommendations on brushing methods or
toothbrush adaptations. Involve patients in hands-on demonstrations of brushing
and flossing.
Some people with Down syndrome can brush and floss independently, but many
need help. Talk to their caregivers about daily oral hygiene. Do not assume that all
caregivers know the basics; demonstrate proper brushing and flossing techniques.
A power toothbrush or a floss holder can simplify oral care. Also, use your
experiences with each patient to demonstrate sitting or standing positions for the
caregiver. Emphasize that a consistent approach to oral hygiene is importantcaregivers should try to use the same location, timing, and positioning.
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DENTAL CARIES. Children and young adults who have Down syndrome have fewer
caries than people without this developmental disability. Several associated oral
conditions may contribute to this fact: delayed eruption of primary and permanent teeth;
missing permanent teeth; and small-sized teeth with wider spaces between them, which
make it easier to remove plaque. Additionally, the diets of many children with Down
syndrome are closely supervised to prevent obesity; this helps reduce consumption of
cariogenic foods and beverages.
By contrast, some adults with Down syndrome are at an increased risk of caries due to
xerostomia and cariogenic food choices. Also, hypotonia contributes to chewing problems
and inefficient natural cleansing action, which allow food to remain on the teeth after
eating.
Advise patients taking medicines that cause xerostomia to drink water often.
Suggest taking sugar-free medicines if available and rinsing with water after
dosing.
Recommend preventive measures such as topical fluoride and sealants. Suggest
fluoride toothpaste, gel, or rinse, depending on your patient's needs and abilities.
Emphasize noncariogenic foods and beverages as snacks. Advise caregivers to
avoid using sweets as incentives or rewards.
Tips for caregivers are available in the booklet Dental Care Every Day: A Caregiver's
Guide, also part of this series.
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Several OROFACIAL FEATURES are characteristic of people with Down syndrome.
The midfacial region may be underdeveloped, affecting the appearance of the lips,
tongue, and palate.

The maxilla, the bridge of the nose, and the bones of the
midface region are smaller than in the general population,
creating a prognathic occlusal relationship. Mouth
breathing may occur because of smaller nasal passages,
and the tongue may protrude because of a smaller midface
region. People with Down syndrome often have a strong
gag reflex due to placement of the tongue, as well as
anxiety associated with any oral stimulation.
The palate, although normal sized, may appear highly
vaulted and narrow. This deceiving appearance is due to
the unusual thickness of the sides of the hard palate. This
thickness restricts the amount of space the tongue can
occupy in the mouth and affects the ability to speak and chew.
The lips may grow large and thick. Fissured lips may result from chronic mouth
breathing. Additionally, hypotonia may cause the mouth to droop and the lower lip to
protrude. Increased drooling, compounded by a chronically open mouth, contributes to
angular cheilitis.
The tongue also develops cracks and fissures with age; this condition can contribute to
halitosis.
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MALOCCLUSION is found in most people with Down syndrome because of the
delayed eruption of permanent teeth and the underdevelopment of the maxilla. A smaller
maxilla contributes to an open bite, leading to poor positioning of teeth and increasing the
likelihood of periodontal disease and dental caries.
Orthodontia should be carefully considered in people with Down syndrome. Some
may benefit, while others may not.
In and of itself, Down syndrome is not a barrier to orthodontic care. The ability of
the patient or caregiver to maintain good daily oral hygiene is critical to the
feasibility and success of treatment.
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TOOTH ANOMALIES are common in Down syndrome.
Congenitally missing teeth occur more often in people with Down syndrome than in the
general population. Third molars, laterals, and mandibular second bicuspids are the most
common missing teeth.
Delayed eruption of teeth, often following an abnormal sequence, affects some children
with Down syndrome. Primary teeth may not appear until age 2, with complete dentition
delayed until age 4 or 5. Primary teeth are then retained in some children until they are 14
or 15.

Irregularities in tooth formation, such as microdontia and malformed teeth, are also
seen in people with Down syndrome. Crowns tend to be smaller, and roots are often small
and conical, which can lead to tooth loss from periodontal disease. Severe illness or
prolonged fevers can lead to hypoplasia and hypocalcification.
Examine a child by his or her first birthday and regularly thereafter to help
identify unusual tooth formation and patterns of eruption.
Consider using a panoramic radiograph to determine whether teeth are
congenitally missing. Patients often find this technique less threatening
than individual films.
Maintain primary teeth as long as possible. Consider placing space
maintainers where teeth are missing.
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TRAUMA and INJURY to the mouth from falls or accidents occur in people with Down
syndrome. Suggest a tooth-saving kit for group homes. Emphasize to caregivers that
traumas require immediate professional attention and explain the procedures to follow if a
permanent tooth is knocked out. Also, instruct caregivers to locate any missing pieces of a
fractured tooth, and explain that radiographs of the patient's chest may be necessary to
determine whether any fragments have been aspirated.
Physical abuse often presents as oral trauma. Abuse is reported more frequently in people
with developmental disabilities than in the general population. If you suspect that a child
is being abused or neglected, State laws require that you call your Child Protective
Services agency. Assistance is also available from the Childhelp National Child Abuse
Hotline at (800) 422-4453 or the Child Welfare Information Gateway
(http://www.childwelfare.gov/).
3. Preventif

What Can I Do to Prevent Cavities and Gum Disease?

Brush teeth twice daily with a soft toothbrush and fluoride toothpaste. Children less
than 2 years should get a thin smear of fluoride toothpaste, and children 2 to 5 years
should get a small pea-sized amount.

Limit the frequency of sugar and cracker/bread based snacks.

The first dental visit should be within 6 months of the first tooth erupting or by 1 year
of age.

Visit the dentist regularly; it is typically recommended that you go every 6 months,
but some people may need to go more often.

- See more at: http://www.ndss.org/Resources/Health-Care/Associated-Conditions/DentalIssues-Down-Syndrome/#sthash.HwnYofJp.dpuf

Dental Management
An aggressive preventive dental program is recommended for patients with Down
syndrome. The program should include:

Three to four month recalls: Consistent preventive care can help reduce
periodontal disease

Dietary counseling and encouragement of good oral hygiene: Practical advice to

minimize consumption of cariogenic foods and the effects of such foods on tooth
structure

Topical fluoride application: For caries prevention and/or reduction of dentinal

hypersensitivity

Chlorexidine gluconate 0.12% rinse: For reduction of bacteria that cause

periodontal disease

4. Cooperatif

What If I Do Not Think My Child Can Cooperate for

Dental Care?
Pediatric dentists are experienced in working with children of all ages and children who
have different abilities to cooperate. Pediatric dentists have many skills to help children
have a successful dental visit. Some children who need dental treatment may need some
form of sedation. Your dentist will be able to discuss this with you depending on your
childs dental needs and medical conditions.
- See more at: http://www.ndss.org/Resources/Health-Care/AssociatedConditions/Dental-Issues-Down-Syndrome/#sthash.HwnYofJp.dpuf
Treatment Options
Many people with Down syndrome can cooperate for dental care in the traditional office
setting
In office sedation may not be appropriate for some people with Down syndrome due to:
Small airway, Low muscle tone causing airway collapse, Large tongue
General anesthesia may be needed to complete dental treatment
5. Caries, gingivitis, and enlargement gingiva
Early Childhood Caries

 Enlargment gingiva
Gingival (Gum) enlargement, also known as gingival hyperplasia or hypertrophy, is
an abnormal overgrowth of gingival tissues.
There are several causes of gingival enlargement and they can be grouped into four
categories: 1) inflammatory gingival enlargement, 2) medication-induced gingival
enlargement, 3) hereditary gingival fibromatosis, and 4) systemic causes of gingival
enlargement.
Gingivitis
Specific causes of gingivitis include:

Poor dental hygiene resulting in bacterial plaque, gingivitis and periodontitis

Smoking, mouth breathing and overcrowded teeth

Systemic diseases especially diabetes, HIV infection

Non-inflamed gingival enlargement tends to be a darker red or purple. It may be soft,
which bleeds easily, or firm and fibrous. It is also more likely to occur in those with
poor dental hygiene. Causes include:

Hormonal states: pregnancy, puberty;

Nutritional deficiency: scurvy (vitamin C deficiency);

Medications, most often ciclosporin, phenytoin and other anticonvulsants, calcium

channel blockers. Uncommonly, it may be due to antibiotics, antidepressants and other
medications.

Genetic conditions, often present at birth (all rare conditions): hereditary fibromatosis,
I-cell disease, mucopolysaccharidoses, fucosidosis, aspartyl glycosaminuria, Pfeiffer's
syndrome, infantile systemic hyalinosis and primary amyloidosis. Localised gingival
enlargement may be seen in Fabry's syndrome, Cowden's syndrome, tuberous
sclerosis, Sturge-Weber angiomatosis and gingival granular cell tumour.

Blood conditions such as acute leukaemia, lymphoma or aplastic anaemia;

Systemic diseases most often Wegener granulomatosis, sarcoidosis, Crohn disease,

Type 1 neurofibromatosis, primary amyloidosis, Kaposi sarcoma and acromegaly.

6. Etiology Down Syndrome

The genetic basis of Down syndrome

In humans, the egg cells and sperm cells have 23 chromosomes. The rest of your cells
normally contain 23 pairs of chromosomes (a total of 46 chromosomes) one set from
your father and one set from your mother. Children with Down syndrome usually have
three copies of chromosome 21 called trisomy 21 instead of two copies (a total of
47 chromosomes).
Down syndrome results when abnormal cell division involving chromosome 21 occurs. These
cell division abnormalities result in extra genetic material from chromosome 21, which is
responsible for the characteristic features and developmental problems of Down syndrome.
Any one of three genetic variations can cause Down syndrome:

Trisomy 21. About 95 percent of the time, Down syndrome is caused by trisomy 21
the child has three copies of chromosome 21 (instead of the usual two copies) in all
cells. This is caused by abnormal cell division during the development of the sperm
cell or the egg cell.

Mosaic Down syndrome. In this rare form of Down syndrome, children have some
cells with an extra copy of chromosome 21. This mosaic of normal and abnormal cells
is caused by abnormal cell division after fertilization.

Translocation Down syndrome. Down syndrome can also occur when part of
chromosome 21 becomes attached (translocated) onto another chromosome, before or
at conception. These children have the usual two copies of chromosome 21, but they
also have additional material from chromosome 21 attached to the translocated
chromosome.

There are no known behavioral or environmental factors that cause Down syndrome.

Is it inherited?
Most of the time, Down syndrome isn't inherited. It's caused by a mistake in cell division
during the development of the egg, sperm or embryo.
Translocation Down syndrome is the only form of the disorder that can be passed from parent
to child. However, only about 4 percent of children with Down syndrome have translocation.
And only about one-third of these children inherited it from one of their parents.
When translocations are inherited, the mother or father has some rearranged genetic material,
but no extra genetic material this means he or she is a balanced carrier. A balanced carrier
has no signs or symptoms of Down syndrome, but he or she can pass the translocation on to
children, causing extra genetic material from chromosome 21.
The chance of passing on the translocation depends on the sex of the parent who carries the
rearranged chromosome 21:

If the father is the carrier, the risk is about 3 percent.

If the mother is the carrier, the risk is between 10 and 15 percent.

7. The kinds of pulp disease

Types of Pulp Diseases
There are several different pulp diseases, including:

Reversible pulpitis, or mild inflammation of the pulp. Symptoms typically include

pain upon eating or drinking something very sweet, hot, or cold. Without treatment,
the inflammation can progress to a dental abscess, a collection of bacteria and pus.
Good oral health habits can help offset reversible pulpitis, but in many cases, a filling
is eventually needed. Pulpitis can also occur if you crack or break a tooth.

Irreversible pulpitis, or severe inflammation of the pulp that can't be cured.

Symptoms include sudden intense pain. Left untreated, it can result in a widespread
gum and connective tissue infection. Irreversible pulpitis is generally treated with a
root canal procedure. If that doesn't work, your dentist may have to remove the tooth.

Dental pulp calcification (also known as dental pulp stones). This is a condition in
which hardening, or calcification, of pulp tissue results in hypersensitivity and
extreme pain because the dental nerves become compressed. A root canal is usually
necessary to clear away hardened tissue.

Dental pulp exposure. This condition comes on when damage to the external
covering of a tooth, such as a cavity or crack in the tooth, exposes the normally
protected pulp to bacteria and irritating food particles. Pain is the most frequent
symptom and without proper dental care, a mild infection can progress into a serious
abscess. Depending on the degree of pulp exposure, a filling, root-canal procedure, or
even tooth extraction may be required.