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138]

ORIGINAL RESEARCH
Dental caries prevalence and treatment needs of Down
syndrome children in Chennai, India
Sharath Asokan, Muthu MS, Sivakumar N

Department of Pediatric
Dentistry, Meenakshi Ammal
Dental College, Chennai,
Tamil Nadu, India

Received
Review completed
Accepted
PubMed ID

:
:
:
:

ABSTRACT

02-08-07
27-12-07
28-12-07
18797099

Purpose: To assess the prevalence of caries and the treatment needs of Down syndrome children
in the Indian city of Chennai.
Materials and Methods: Among the130 Down syndrome children examined, only the children
aged 15 years were included in the study (n = 102). There were 57 male and 45 female children
in the total study sample. A specially prepared case record was used to record the findings for
each child. The dentition status and the treatment needs required were recorded. Comparisons
of the findings were done based on age and gender distribution.
Results: Twenty-nine per cent of the total sample of Down syndrome children was found to be
caries-free. Extraction (in 38 children) and one-surface filling (in 26 children) were the most
needed specific treatments for primary and permanent teeth, respectively. Oral prophylaxis
(99%) was the most required treatment in the overall treatment category.
Conclusions: Contrary to the findings of earlier studies, the percentage of caries-free Down
syndrome children was found to be lower in our study. However, their basic needs like oral
prophylaxis, restorations and extractions remain the same and can be easily fulfilled by an
efficient, community-based dental team.
Key words: Dental caries prevalence, Down syndrome, Trisomy 21

Down syndrome is a congenital autosomal anomaly

characterized by generalized growth and mental
deciency.[1-2] The risk for this chromosomal aberration
is one out of 600-1000 live births. Approximately 95%
of Down syndrome cases have the extra chromosome 21,
resulting in a chromosome count 47 instead of the normal
46. The other 5% of chromosomal abnormalities include
translocation (3%) and mosaicism or partial trisomy (2%).
Down syndrome has also been referred to by the terms
Trisomy 21, Trisomy G or Mongolism.[1]

Stabholz et al, showed that 84% of the Down syndrome

children examined were caries-free.[8] As no published data
is available on the prevalence of caries and treatment needs
of Down syndrome children in the South Indian city of
Chennai, this study was planned with the following aims
and objectives:
1. To assess the prevalence of dental caries and treatment
needs of children with Down syndrome.
2. To compare the age-wise and sex-wise distribution of
the above ndings.

Down syndrome children have characteristic orofacial

features. The most common oral ndings in these children
include mouth breathing, open bite, macroglossia, ssured
lips and tongue, angular cheilitis, delayed eruption of teeth,
missing and malformed teeth, microdontia, crowding,
malocclusion, bruxism, poor oral hygiene and a low level
of caries.[3-5]

MATERIALS AND METHODS

Brown and Cunningham showed that 44% of the

Down syndrome children they examined were caries-free.[6]
Johnson and Young reported a low incidence of dental
caries both in the primary and permanent dentition.[7]
Correspondence:
Dr. Sharath Asokan,
E-mail: asokansharath@yahoo.com
Indian J Dent Res, 19(3), 2008

A descriptive cross-sectional study was planned to assess

the status of dental caries in children with Down syndrome
in Chennai. A total of 130 Down syndrome children were
examined in this study. The children belonged to 15 special
schools in Chennai. All the children had been admitted
to the school after prior investigations to conrm the
syndrome. Consent was obtained both from the parents
and the concerned school authority to carry out the study.
Only children aged 15 years (n = 102) were included in
this study irrespective of their personal, medical and dental
history. A single examiner examined all the 102 children.
The children were assigned to three groups as mentioned
in Table 1.
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Asokan, et al.

225

11.4
133
29.0
320
9.1
74
49.8
109
16.9
59
34.0
192
0
0
19

5.9

88.6
1031
71.0
84
90.9
740
50.2
110
83.1
291
66.0
373
0
0

*Chi-square test was used to calculate the P value

Prevalence of dental caries: In group I (n = 13), 94.1% of all

Decayed teeth

RESULTS

94.1

Age-wise comparisons of the ndings were done among

the three different groups and within the same age group;
differences between the male and female samples were
assessed. A comparison of each nding between the total
male (n = 57) and female (n = 45) samples, irrespective of
their age group was also done. The proportions of different
ndings were estimated from the sample for each study
group. Proportions were compared by using either the
Chi-Square test or Chi-Square test with Yates continuity
correction, as explained in the footnotes below the tables.
In the present study, P < 0.05 was considered as the level
of signicance.

Table 2(a): Dental caries prevalence - age-wise comparison

Radiographs and other investigations like pulp vitality tests

were not carried out because of the lack of facilities and all
the ndings recorded were based on clinical judgment. The
total numbers of sound and decayed primary and permanent
teeth in each group were counted and the percentages of
decayed and sound teeth calculated. The percentage of
caries-free children in each group was also calculated.

Total 11 to 15 years (40)

Primary
Permanent
(219)
(814)
n
%
n
%

The examination was carried out with the children sitting

on wooden or plastic chairs under an articial light. Each
participant was subjected to a clinical assessment using a at
dental mirror and an explorer. The ndings were recorded
in a specially prepared proforma prepared by the authors
from the Department of Pedodontics, Meenakshi Ammal
Dental College, Chennai. The status of the dentition and
the treatment needs were recorded using the WHO oral
assessment criteria (1997). Each tooth was examined and the
status was dened by numbers for permanent teeth and by
letters of the English alphabet for primary teeth. The teeth
were marked as sound, decayed, lled with decay, lled
with no decay, missing due to caries, missing due to other
reasons, ssure-sealed, unerupted, bridge abutment/crown/
veneer or traumatized, as recommended by the WHO.
Specic treatment needs included preventive caries arresting
care, ssure sealant, one-surface lling, two or more surface
llings, crowns, veneers/laminates, pulp care restoration and
extraction. These specic needs were marked in numbers
except for ssure sealant and preventive caries arresting
care, which were marked as F and P, respectively. The
overall treatment required was categorized in the last section
under the following headings: oral prophylaxis, uoride
therapy, restorative treatment, extractions, and orthodontic
correction.

301

Total (102)
Primary
Permanent
(1104)
(1164)
n
%
n
%

P*

Total
21
41
40
102

Total 6 to 10 years (41)

Primary
Permanent
(565)
(350)
n
%
n
%

Female
13
16
16
45

Total 0 to 5 years (21)

Primary
Permanent
(320)
(0)
n
%
n
%

Male
8
25
24
57

Particulars

Group I: 0 to 5 years
Group II: 6 to 10 years
Group III: 11 to 15 Years
Total

Sound teeth

Table 1: Total sample distribution

Primary
< 0.0001
Permanent
0.0002

Caries prevalence and treatment needs in down syndrome

Indian J Dent Res, 19(3), 2008

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Caries prevalence and treatment needs in down syndrome

Asokan, et al.

Table 2(b): Dental caries prevalence - age-wise comparison

Particulars

0 to 5 years (21)
n
%
13
61.9
8
38.1

Caries-free children
Children with caries

6 to 10 years (41)
n
%
6
14.6
35
85.4

11 to 15 years (40)
n
%
11
27.5
29
72.5

n
30
72

Total (102)
%
29.4
70.6

P*
0.0005

*Chi-square test was used to calculate the P value

Table 3(a): Dental caries prevalence - sex-wise comparison

Particulars

Sound
teeth
Decayed
teeth

Total male (57)

Primary
Permanent
(621)
(688)
n
%
n
%
438
70.5
626
91.0

Total female (45)

Primary
Permanent
(483)
(476)
n
%
n
%
346
71.6
405
85.1

Total (102)
Primary
Permanent
(1104)
(1164)
n
%
n
%
784
71.0
1031
88.6

Primary 0.74

183

137

320

Permanent 0.003

29.5

62

9.0

28.4

71

14.9

29.0

133

11.4

P*

*Chi-square test was used to calculate the P value

Table 3(b): Dental caries prevalence - sex-wise comparison

Particulars

Caries-free
children
Children with
caries

Total
male (57)
n
%
16
28.1

Total
female (45)
n
%
14
31.1

Total
(102)
n
%
30
29.4

41

31

72

71.9

68.9

70.6

P*

0.91

*Chi-square test was used to calculate the P value

primary teeth and 61.9% of the children were caries-free.

In group II (n = 6), 66% of all primary teeth, 83.1% of all
permanent teeth and 14.6% of the children were caries-free.
There was a signicant difference in the prevalence of caries
in primary teeth between the male and female samples in
group II (P = 0.04). In group III (n = 11), 50.2% of all primary
teeth, 90.9% of all permanent teeth and 27.5% of the
children were caries free. There was a signicant difference
in the prevalence of caries in permanent teeth between the
male and female categories in group III (P = 0.003).
An age-wise comparison showed a signicant difference
in the prevalence of caries in primary (P < 0.0001) and
permanent teeth (P = 0.0002) between the different age
groups [Table 2a]. A signicant difference in the percentage
of caries-free children was also evident among the three
groups (P = 0.0005) [Table 2b]. In the total sample, 71%
of primary teeth (n = 784), 88.6% of permanent teeth
(n = 1031) and 29.4% of the thirty children in this sample,
were caries-free. There was a signicant difference in the
prevalence of caries in the permanent teeth of the male
and female categories of the total sample (P = 0.003) as
seen in Table 3a. There was no signicant difference in the
prevalence of decay in primary teeth and in the percentage
of caries-free children between the male and female subsets
of the total sample [Table 3b].
Specific treatment needs: In group I, 23.8 and 4.8% of the
children needed one-surface and two-surfaces fillings,
respectively for their primary teeth. In the same group, 9.5%
of the children needed crown and preventive restorations for
their primary teeth and 4.8% needed pulp care. Extraction
Indian J Dent Res, 19(3), 2008

and ssure sealants were not needed by any of the children

belonging to this group.
In group II, one-surface llings were required for primary
and permanent teeth in 43.9 and 26.8% of the children,
respectively. In the same group, two-surfaces llings were
needed for primary and permanent teeth in 24.4 and 4.9%
of the children, respectively. Pulp care therapy and crowns
were required in the primary teeth of 14.6% of the children.
Extractions were required in the primary and permanent
teeth of 48.8 and 2.4% of the children respectively, and
ssure sealants by 14.6% of the children on their permanent
teeth. Primary and permanent teeth required preventive
restoration in 36.6 and 26.8% of children, respectively.
In group III, 25 and 37.5% of the children needed one-surface
llings for their primary and permanent teeth, respectively.
Much lower percentages were seen (17.5 and 5%) for twosurface llings in primary and permanent teeth, respectively.
Crowns and pulp care were needed for primary teeth in
5 and 10% of the children, respectively. More children
(40%) needed primary teeth extraction than permanent
teeth extraction (2.5%). Fissure sealants were needed on
permanent teeth in 17.5% of the children. Preventive
restorations were needed for primary and permanent teeth
in 7.5 and 27% of the children, respectively.
There was no signicant difference in the specic treatment
required for both primary and permanent teeth between
the male and female categories of groups I, II and III. An
age-wise comparison of treatment needs showed signicant
differences in the specic treatment required for primary
teeth in different age groups [Table 4]. Extraction of teeth
was required more in group II and III than in group I children
(P = 0.0004). Preventive restorations were needed more by
the children in group II than the other two groups (P = 0.002).
Treatment for permanent teeth did not show any signicant
difference among the children of different age groups. There
was no signicant difference in the specic treatment required
for both primary and permanent teeth between the male and
female categories of the total sample [Table 5].
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0.43
1
1
0.86
0.96
0.12
0.16
0.004
0.48
0.0004
0.002
-

In group II, oral prophylaxis and uoride therapy were

needed in 100 (n = 41) and 85.4% (n = 35) of the children,
respectively. Restorative treatment and orthodontic
corrections were required in 70.8 (n = 32) and 53.7% (n = 22)
of the children, respectively. Unlike group I, 48.8% of the
children (n = 20) required extraction.

Total 11 to 15 years (40)

Primary
Permanent
n
%
n
%
10
25.0
15
37.5
7
17.5
2
5.0
2
5.0
0
0.0
4
10.0
0
0.0
18
45.0
1
2.5
3
7.5
11
27.5
0
0.0
7
17.5

Similar to group II, oral prophylaxis and uoride therapy

were needed in 100 (n = 40) and 85% (n = 34), respectively,
of the children in group III. Restorative treatment and
orthodontic corrections were required in 72.5 (n = 29)
and 53.7% (n = 33) of the children, respectively. Similar to
group II, 50% of the children (n = 20) required extraction.
There was no signicant difference in treatment needs
between the male and female categories of groups I, II and
III. An age-wise comparison of the treatments required
in different age groups however, showed a signicant
difference [Table 6]. Fluoride therapy ( P < 0.0001),
restorations ( P = 0.001), extractions ( P = 0.0002) and
orthodontic treatment (P = 0.0004) were needed more
by the older children (groups II and III) than the
younger children (group I). Orthodontic treatment was
comparatively more necessary in group III than in group
II children. There was no signicant difference in the
treatment needs between the male and female categories
of the total sample [Table 7].

Total 6 to 10 years (41)

Primary
Permanent
n
%
n
%
18
43.9
11
26.8
10
24.4
2
4.9
6
14.6
0
0.0
6
14.6
0
0.0
20
48.8
1
2.4
15
36.6
11
26.8
0
0.0
6
14.6

DISCUSSION

*Chi-square test was used to calculate the P value

One-surface filling
Two-surfaces filling
Crown
Pulp care
Extraction
Preventive restoration
Fissure sealant

Total 0 to 5 years (21)

Primary
Permanent
n
%
n
%
5
23.8
0
0
1
4.8
0
0
2
9.5
0
0
1
4.8
0
0
0
0.0
0
0
2
9.5
0
0
0
0.0
0
0
Particulars

Table 4: Specific treatment needs - age-wise comparison

227

Asokan, et al.

Overall treatment required: In group I, oral prophylaxis and

uoride therapy were needed in 95.2 (n = 20) and 28.6%
(n = 6) of the children, respectively. Restorative treatment
and orthodontic corrections were each required in 33.3%
(n = 7) of the children. No child in this group however,
needed extraction.

Total (102)
Primary
Permanent
n
%
n
%
33
32.4
26
25.5
18
17.6
4
3.9
10
9.8
0
0.0
11
10.8
0
0.0
38
37.3
2
2.0
20
19.6
22
21.6
0
0.0
13
12.7

Primary

P*
Permanent

Caries prevalence and treatment needs in down syndrome

Brown and Cunningham (1961) examined 80 institutionalized

Down syndrome individuals (1-39 years) and found that 44%
of the sample was caries-free. Stabholz et al, examined the
prevalence of dental caries in 32 Down syndrome children,
aged 8-13 years and found 84% of them to be caries-free.
Barnett et al, compared the prevalence rates of periodontitis
and dental caries in 30 Down syndrome patients and 30
matched, mentally handicapped controls. The results
revealed a greater prevalence of periodontitis and a lower
prevalence of dental caries in Down syndrome patients
compared to the mentally retarded controls.[9] Morinushi
et al, conducted a study in 1995 to evaluate the incidence
of dental caries in 75 Down syndrome children in the age
group of 2-18 years. They found 46.1% of these children
with 61.4% of children below the age of ve years to be
caries-free.[10]
The ndings of our study however, differ from those of
the above studies. Our results showed a lower percentage
Indian J Dent Res, 19(3), 2008

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Caries prevalence and treatment needs in down syndrome

Asokan, et al.

Table 5: Specific treatment needs - sex-wise comparison

Particulars

One-surface filling
Tw-surfaces filling
Crown
Pulp care
Extraction
Preventive
restoration
Fissure sealant

Male (57)
Primary
Permanent
n
%
n
%
18
31.6
14
24.6
10
17.5
2
3.5
6
10.5
0
0.0
5
8.8
0
0.0
20
35.1
1
1.8
11
19.3
12
21.1

Female (45)
Primary
Permanent
n
%
n
%
15
33.3
12
26.7
8
17.8
2
4.4
4
8.9
0
0.0
6
13.3
0
0.0
18
40.0
1
2.2
9
20.0
10
22.2

Total (102)
Primary
Permanent
n
%
n
%
33
32.4
26
25.5
18
17.6
4
3.9
10
9.8
0
0.0
11
10.8
0
0.0
38
37.3
2
2.0
20
19.6
22
21.6

0.0

14.0

0.0

11.1

0.0

13

12.7

Primary

P*
Permanent

0.98
0.82
1
0.53
0.76
0.87

0.99
1
1
0.92

0.89

*Chi-square test was used to calculate the P value

Table 6: Treatment required - age-wise comparison

Particulars
Oral prophylaxis
Fluoride therapy
Restoration
Extraction
Orthodontic treatment

Total (102)
n
%
101
99.0
75
73.5
68
66.7
40
39.2
62
60.8

0-5 years (21)

n
%
20
95.2
6
28.6
7
33.3
0
0.0
7
33.3

6-10 years (41)

n
%
41
100.0
35
85.4
32
78.0
20
48.8
22
53.7

11-15 years (40)

n
%
40
100.0
34
85.0
29
72.5
20
50.0
33
82.5

P*
0.14
<0.0001
0.001
0.0002
0.0004

*Chi-square test was used to calculate the P value

Table 7: Treatment required - sex-wise comparison

Particulars
Oral prophylaxis
Fluoride therapy
Restoration
Extraction
Orthodontic
treatment

Total (102)
n
%
101 99.0
75
73.5
68
66.7
40
39.2
62
60.8

Male (57)
n
%
57 100.0
45
78.9
39
68.4
20
35.1
31
54.4

Female (45)
n
%
44
97.8
30
66.7
29
64.4
20
44.4
31
68.9

P*
0.44
0.24
0.83
0.45
0.2

*Chi-square test was used to calculate the P value

(n = 30, 29.4%) of the Down syndrome children studied to

be caries-free. This higher incidence of caries could be due
to the lack of awareness about dental visits, irregular dietary
habits, inadequate oral hygiene measures, lack of uoridated
water, easy availability of high sucrose-containing cheap
food stuffs, parental neglect and lack of initiative towards
prevention.
Cornejo et al, studied the oral health conditions of children
aged 3-19 years and compared them with control groups. In
every age group, the decayed missing lled-tooth (dmf-t)
and decayed missing lled-surface (dmf-s) indices were
higher in Down syndrome children than in the control
population. From the age of ten years onwards, the DMF T
and DMF-S of the control population were higher than
those of the Down syndrome individuals.[11] Although
DMFT/S and dmft/s were not calculated in the present
study, the percentage of children with dental caries was
found to be higher. Oredugba showed that individuals with
Down syndrome had a higher prevalence of dental caries
than the controls.[12] It was reported that children with
Down syndrome are more likely than typically developing
children to be weaned off bottled milk at an older age
or given syrup-based medicines for repeated infections
because of swallowing problems.[13] The results of the
studies of Cornejo et al and Oredugba were in accordance
with the results of the present study.
Indian J Dent Res, 19(3), 2008

In the specic treatment category, the children in this study

commonly required restorative treatments like one-surface
llings and preventive restorations. The overall treatments
required by these children were more of the preventive
type such as oral prophylaxis and fluoride treatment
followed by restorative treatments. As children with Down
syndrome exhibit poor oral hygiene, malocclusion and
decient immune systems, dentists have an obligation to
prevent oral diseases through appropriate activities and
programs that take the special needs of their patients into
account. Preventive oral hygiene and subgingival plaque
control has been emphasized and considered of particular
importance for children and young people with Down
syndrome.[14]

SUMMARY AND CONCLUSIONS

This study is one of the few studies that has involved and
examined more than 100 Down syndrome children. We
have offered to treat all the children examined, free of cost in
our dental college. The following conclusions were derived
from the results of this study:
1. Contrary to earlier ndings, 29.4% of the children were
caries-free.
2. Extraction was the most frequently encountered (37.3%)
specic treatment need in primary teeth. In permanent
teeth, one-surface llings were the most needed specic
treatment (n = 26, 25.5%).
3. In the overall treatment category, oral prophylaxis was
the most required treatment (n = 101; 99%).

REFERENCES
1.

Desai SS, Fayatteville NY. Down syndrome: A review of the literature.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:279-85.
228

[Downloaded free from http://www.ijdr.in on Wednesday, October 05, 2016, IP: 114.143.242.138]

Caries prevalence and treatment needs in down syndrome

2.
3.
4.
5.
6.
7.
8.

9.
10.

Surabian SR. Developmental disabilities and understanding the needs

of patients with mental retardation and Down syndrome. J Calif Dent
Assoc 2001;29:415-23.
Borea G, Magi M, Mingarelli, Zamboni C. The oral cavity in Down
syndrome. J Pedod 1990;14:139-40.
Cohen MM, Winer RA. Dental and facial characteristics in Downs
syndrome. J Dent Res 1965;44:197-209.
Gullikson JS. Oral findings in children with Downs syndrome. J Dent
Child 1973;40:293-7.
Brown RH and Cunningham WM. Some dental manifestations of
mongolism. Oral Surg Oral Med Oral Pathol 1961;14:664-76.
Johnson NP, Young MA. Periodontal disease in Mongols. J Periodontol
1963;34:41-7.
Stabholz A, Mann J, Sela M, Schurr D, Steinberg D, Shapira.
Caries experience, periodontal treatment needs, salivary pH and
Streptococcus mutans counts in a preadolescent Down syndrome
population. Spec Care Dentist 1991;11:203-8.
Barnett ML, Press KP, Friedman D, Sonnenberg EM. The prevalence
of periodontitis and Dental caries in a Down syndrome population.
J Periodontol 1986;57:288-93.
Morinushi T, Lopatn DE, Poparin N. The relationship between dental
caries in the primary dentition and anti S.mutans serum antibodies in

Asokan, et al.

11.

12.
13.
14.

children with Down syndrome. J Clin Pediatr Dent 1995;10:379-84.

Cornejo LS, Zak GA, Dorronsoro de Cattoni ST, Calamari SE, Azcurra AI,
Battellino LJ. Mucodental health condition in patients with Down
syndrome of Cordoba City, Argentina. Acta Odontol Latinoam
1996;9:65-79.
Oredugba FA. Oral health condition and treatment needs of a group
of Nigerian individuals with Down syndrome. Downs Syndr Res Pract
2007;12:72-6.
Randell DM, Harth S, Seow WK. Preventive dental health practices of
non-institutionalized Down syndrome children: A controlled study.
J Clin Pediatr Dent 1992;16:225-8.
Sasaki Y, Sumi Y, Mitazaki Y, Hamachi T, Nakata M. Periodontal
management of an adolescent with Down syndrome: A case report.
Int J Paediatr Dent 2004;14:127-35.

How to cite this article: Asokan S, Muthu MS, Sivakumar N. Dental caries
prevalence and treatment needs of Down syndrome children in Chennai, India.
Indian J Dent Res 2008;19:224-9
Source of Support: Nil, Conflict of Interest: None declared.

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4)

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First Page File:

Prepare the title page, covering letter, acknowledgement, etc., using a word processor program. All information which can reveal your
identity should be here. Use text/rtf/doc/pdf files. Do not zip the files.
Article file:
The main text of the article, beginning from Abstract till References (including tables) should be in this file. Do not include any information
(such as acknowledgement, your names in page headers, etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size to
400 kb. Do not incorporate images in the file. If file size is large, graphs can be submitted as images separately without incorporating them
in the article file to reduce the size of the file.
Images:
Submit good quality color images. Each image should be less than 1024 kb (1 MB) in size. Size of the image can be reduced by decreasing
the actual height and width of the images (keep up to about 6 inches and up to about 1200 pixels) or by reducing the quality of image. JPEG
is the most suitable file format. The image quality should be good enough to judge the scientific value of the image.
Always retain a good quality, high resolution image for print purpose. This high resolution image should be sent to the editorial office at the
time of sending a revised article.
Legends:
Legends for the figures/images should be included at the end of the article file.

Indian J Dent Res, 19(3), 2008