Periodontal health in Down syndrome: Contributions of mental disability, personal, and professional dental care

Comparing the Effectiveness of Octenidine Hydrochloride and Chlorhexidine Gluconate Mouthrinses in Reducing Plaque and Oxidative Stress in Institutionalized Children with Down Syndrome

Background and objectives

Due to decreased manual dexterity, a lack of motivation, and difficulty on the part of the caregiver conducting efficient oral hygiene measures at home, patients with Down syndrome (DS) are badly affected. The objective of this study is to compare the efficacy of 0.1% octenidine (OCT) hydrochloride and 0.12% chlorhexidine (CHX) gluconate on plaque control and oxidative stress in institutionalized children with DS.

Materials and methods

In 20 children, salivary samples were collected for analysis of the inflammatory marker high-sensitive C-reactive protein (hsCRP) and oxidative stress markers, specifically malondialdehyde (MDA). Plaque index (PlI) and gingival index (GI) were scored. After oral prophylaxis, the participants were randomly assigned to two groups, each consisting of 10 individuals (octenidol and CHX). Salivary oxidative stress marker assays were carried out using a modified version of Yagi's (1984) method, and absorbance was measured at 540 nm using an ultraviolet-visible spectrophotometer at 535 nm. hsCRP assays were conducted via latex turbidimetric immunoassay.

Results

On comparison between the two groups, the OCT group showed a statistically significant reduction in GI, PlI, and MDA values (p < 0.05).

Conclusion

It was seen that the use of 0.1% OCT hydrochloride could facilitate the maintenance of good oral hygiene and periodontal status, especially in patients with motor difficulties.

Clinical trial registration

PMS/IEC/2016/02.

How to cite this article

Raj AS, George S, S A, et al. Comparing the Effectiveness of Octenidine Hydrochloride and Chlorhexidine Gluconate Mouthrinses in Reducing Plaque and Oxidative Stress in Institutionalized Children with Down Syndrome. Int J Clin Pediatr Dent 2024;17(4):437-441.

A Comparative Evaluation of Physical Parameters of Saliva and Correlation with Periodontal Condition in Down Syndrome Children and Healthy Controls

AIM

The aim of this study was to assess the significance and role of physical parameters of saliva on periodontal health in children with Down syndrome (DS).

MATERIALS AND METHODS

A comparative evaluation of physical parameters of saliva such as flow rate, viscosity, pH, quantity and buffering capacity, and buffer capacity was carried out using GC Saliva-Check Buffer kit and correlated with periodontal condition examined using community periodontal index of treatment needs (CPITN) in 40 DS subjects (group I) and 40 healthy controls (group II) aged 8-15 years.

RESULTS

Down syndrome subjects had a low resting salivary flow rate, moderately acidic saliva, very low quantity of stimulated saliva, and low buffering capacity. On correlating salivary parameters with the periodontal condition, DS subjects with CPITN code 1 had low resting salivary flow rate, normal viscosity, moderately acidic pH, very low quantity of stimulated saliva, and low buffering capacity. Down syndrome subjects with CPITN code 2 had low resting flow rate, increased viscosity, very low quantity of stimulated saliva, low buffering capacity, and moderately acidic pH. Healthy controls with CPITN code 0 had normal resting flow rate, viscosity of saliva, quantity of stimulated saliva, buffering capacity, and moderately acidic pH.

CONCLUSION

Compared to healthy controls, DS subjects showed decreased values for resting flow rate, pH, quantity of stimulated saliva, and buffering capacity. A statistically significant correlation was observed between the physical parameters of saliva and periodontal condition in DS subjects (p < 0.05).

CLINICAL SIGNIFICANCE

Periodontal diseases start at a very early age and periodontal health deteriorates at a faster rate in DS children for which saliva also plays its part. Prime importance should be given to frequent oral hygiene and preventive measures in DS children thus preventing accumulation of debris and plaque.

Cross-sectional study of the factors associated with the number of teeth in middle-aged and older persons with intellectual disabilities

BACKGROUND

We investigated the number of teeth in middle-aged and older individuals with intellectual disability and evaluated the related factors.

METHODS

A questionnaire survey on oral health was administered to 604 persons over 40 years old with intellectual disabilities in Aichi Prefecture, Japan. The questionnaire designed for this study included items on diagnosis of disability, severity of intellectual disability and type of residence. As oral-health-related factors, the proxy-reported number of teeth, family dentist, regular dental check-ups, problems during dental treatment and tooth-brushing frequency were evaluated. A multinomial logistic regression analysis was performed using the proxy-reported number of teeth (≥20, 10-19 or 0-9) as the dependent variable, and the odds ratios (ORs) and 95% confidence intervals (CIs) of independent variables were calculated. In addition, linear regression analysis was performed using the proxy-reported number of teeth as the dependent variable.

RESULTS

In the multivariate multinomial logistic regression analysis, age, diagnosis of disability and type of residence were significantly associated with having 10-19 versus ≥20 teeth. Participants with autism spectrum disorder had a significantly lower OR for 10-19 teeth compared with those with intellectual disability [OR (95% CI): 0.49 (0.22-1.08)]. Age, diagnosis of disability, regular dental check-ups and tooth-brushing frequency were significantly associated with having 0-9 versus ≥20teeth. Participants with Down syndrome had a significantly higher OR for 0-9 teeth compared with those with intellectual disability [OR (95% CI): 3.17 (1.09-9.23)]. The ORs for 0-9 teeth of participants who did not attend regular dental check-ups and who brushed their teeth 1 time/day compared with ≥3 times/day were significantly high, and the OR (95% CI) was 2.37 (1.06-5.30) and 4.76 (1.09-20.77), respectively. [Corrections made on 22 August 2022, after first online publication: in the previous sentence, "who attend" has been changed to "who did not attend".] In the multivariate linear regression analysis, age, diagnosis of disability and regular dental check-ups were significantly associated with the proxy-reported number of teeth. The proxy-reported number of teeth was -0.42 less with each 1-year increase in age. With autism spectrum disorder, the proxy-reported number of teeth was 0.74 more compared with intellectual disability. In Down syndrome, the proxy-reported number of teeth was -0.93 less compared with intellectual disability. The proxy-reported number of teeth was -2.12 less for those who did not have regular dental check-ups.

CONCLUSIONS

The number of teeth in middle-aged and older individuals with intellectual disability was related to age and the type of disability. Regular dental visits may be effective at preventing tooth loss in middle-aged and older persons with intellectual disability.

Identifying metabolic parameters related to severity and extent of periodontitis in down syndrome patients

BACKGROUND AND OBJECTIVE

Systemic metabolic status and periodontitis can be related in patients with Down syndrome (DS). The objective of this study was to identify metabolic indicators (anthropometric measurements, blood pressure, and serum markers) related to severity and extent of periodontitis in DS patients.

METHODS

A cross-sectional study was conducted with 49 patients with DS. Periodontal evaluation included the periodontal probing depth (PPD), clinical attachment level (CAL), gingival bleeding index (GBI), and visible plaque index (VPI). Periodontitis severity was classified by the stages system. The extent of periodontitis was assessed as the percentage of sites with CAL ≥3 mm, CAL ≥4 mm, PPD ≥4 mm, and PPD ≥5 mm. The metabolic condition of the participants was determined by analyzing anthropometric parameters, blood pressure, and serum markers. Data were analyzed using the Mann-Whitney test, Spearman's correlation coefficient, and multivariate regression analysis.

RESULTS

Periodontitis stage 3/4 was detected in 32.7% of patients, with high values of VPI (54.6 ± 35.8) and GBI (42.4 ± 33.3). The severity of periodontitis was related to higher mean corpuscular hemoglobin (β = .291, p = .028) and mean corpuscular volume values (β = .293, p = .046). Arm circumference measurements were inversely related to CAL ≥3 mm (β = -.408, p = .023), PPD ≥4 mm (β = -.475, p = .006), and PPD ≥5 mm (β = -.443, p = .010).

CONCLUSIONS

The findings suggest that the severity and extent of periodontitis may be related to some metabolic parameters in DS patients.

Immune Dysregulation and the Increased Risk of Complications and Mortality Following Respiratory Tract Infections in Adults With Down Syndrome

The risk of severe outcomes following respiratory tract infections is significantly increased in individuals over 60 years, especially in those with chronic medical conditions, i.e., hypertension, diabetes, cardiovascular disease, dementia, chronic respiratory disease, and cancer. Down Syndrome (DS), the most prevalent intellectual disability, is caused by trisomy-21 in ~1:750 live births worldwide. Over the past few decades, a substantial body of evidence has accumulated, pointing at the occurrence of alterations, impairments, and subsequently dysfunction of the various components of the immune system in individuals with DS. This associates with increased vulnerability to respiratory tract infections in this population, such as the influenza virus, respiratory syncytial virus, SARS-CoV-2 (COVID-19), and bacterial pneumonias. To emphasize this link, here we comprehensively review the immunobiology of DS and its contribution to higher susceptibility to severe illness and mortality from respiratory tract infections.

Oral health needs of athletes with intellectual disability in Southern Europe: Greece, Italy and Spain

AIMS

The population with intellectual disabilities (ID) has been reported to be a vulnerable population in terms of oral health. The aims of this study were to evaluate the oral condition and treatment needs of Special Olympics (SO) athletes from Greece, Italy and Spain.

METHODS AND RESULTS

A cross-sectional study was performed with data collected in annual SO events held in Greece, Italy and Spain, between 2010 and 2012. The recorded parameters were the presence/absence of edentulism, untreated decay, filled or missing teeth, sealants, tooth injury and signs of gingival disease. Among the main findings, the prevalence of untreated decay was 57.0% in Greece, 48.8% in Italy and 41.7% of the Spanish athletes. The prevalence of signs of gingival disease was 61.1% in Greece, 60.6% in Italy and 66.1% in Spain. While the majority of the athletes were in need of dental treatment.

CONCLUSIONS

Oral disease is an unresolved problem among athletes with ID in these Mediterranean countries. Therefore efforts should be directed to meet their treatment needs and to prevent oral disease.

Comparison of salivary cytokines levels among individuals with Down syndrome, cerebral palsy and normoactive

Background

Individuals with Down syndrome (DS) present increased susceptibility to infections and high prevalence of periodontal disease. The objective of this study is to evaluate the salivary concentrations of IL-1β, IL-6, IL-8, IL-10, TNFα and IL-12p70 of DS individuals and compare to cerebral palsy (CP) and normoactive patients (all with gingivitis).

Material and Methods

Twenty-two individuals with DS, 24 with CP and 22 normoactive participated in this cross-sectional study. Salivary flow rate, osmolality rate, Oral Hygiene Index, Gingival Index (GI) and salivary inflammatory markers IL-1β, IL-6, IL-8, IL-10, TNFα and IL-12p70 were evaluated. Shapiro-Wilks, Chi-square, ANOVA One-Way and Kruskal Wallis tests were applied with significance level at 5%.

Results

The groups were homogenous for gender, age, and IL12p70 cytokine (p>0.05). GI was significantly higher in DS compared to CP and healthy (p<0.05). CP presented reduced salivary flow and increased osmolality rate. CP showed significantly higher values for TNFα, IL10, and IL6 compared to DS and normoactive (p<0.05). DS and CP presented significantly higher values of IL-1β and IL8 compared to normoactive (p<0.05).

Conclusions

Individuals with CP have higher risk to develop periodontal disease due to reduced salivary flow rate, increased salivary osmolality rate and elevated TNFα, IL-10, IL-6 compared to DS.

Key words:Cytokines, biomarkers, gingivitis, periodontal diseases, Down syndrome, cerebral palsy, saliva.

Oral health of adults with intellectual disabilities: a systematic review

BACKGROUND

There have been several past reports that adults with intellectual disabilities experience poor oral health (tooth loss, periodontal health and untreated dental caries). Loss of a functional dentition has serious consequences, including problems with chewing, swallowing, nutrition, speech, temporomandibular joint osteoarthritis and pain and systemic health conditions. Poor oral health is largely preventable through proactive oral care support. In recent years, social care provision for adults has changed, with deinstitutionalisation and home-based personalised care now being the typical provision in high income countries. Hence, oral health inequalities might be reducing. However, there is limited recent evidence-synthesis on the topic. We aimed to address this.

METHOD

PROSPERO registration number: CRD42018089880. We conducted a preferred reporting items for systematic reviews and meta-analyses systematic review of publications since 2008. Four databases were searched with a clear search strategy, strict inclusion criteria for selection of papers, double scoring (two raters), systematic data extraction and quality appraisal of included papers.

RESULTS

A total of 33/3958 retrieved articles were included, of which 14 were drawn from dental service users and 10 from Special Olympic athletes, therefore not necessarily being representative of the wider population with intellectual disabilities. Despite this limitation, adults with intellectual disabilities were still shown to experience poor oral health. High levels of poor oral hygiene and gingivitis were found, with many also affected by periodontitis and untreated dental decay. There is clear unmet need relating to both periodontal (gum) and tooth health, leading to tooth loss.

CONCLUSIONS

Despite reports in the past of poor oral health amongst adults with intellectual disabilities, and despite it being preventable, there remains a high burden of poor oral health. This highlights the need to raise awareness, and for polices on effective daily oral care, and appropriate service provision. The importance of oral health and its possible negative sequelae needs to be elevated amongst carers and professionals.

Periodontal status of individuals with Down syndrome: sociodemographic, behavioural and family perception influence

BACKGROUND

The aim of the present study was to assess the periodontal condition of individuals with Down syndrome and the association with sociodemographic and behavioural characteristics and family perception of oral health.

METHODS

This cross-sectional observational study was performed at a referral centre for dental assistance to disabled persons in Araçatuba, Brazil. Parents of the individuals were interviewed, and the visible plaque index, bleeding on probing, probing pocket depth and clinical attachment level were recorded by one periodontist in six sites per tooth of all teeth. The individual was the unit of analysis. The significance level was set at 5%.

RESULTS

Sixty-four subjects (23.8 ± 8.3 years old) were included. Eighteen (28.1%) were diagnosed with gingivitis and 46 (71.9%) with periodontitis. In the multiple logistic regression final model, age and self-reported oral hygiene practices were associated with the occurrence of periodontitis. The chance of having periodontitis was 4.7 times higher among individuals older than 20 years and approximately 4 times higher in patients whose oral hygiene was performed by themselves and their parents, compared with those who performed oral hygiene alone. Sex, follow-up time in the centre, education, degree of participants' dependence, flossing and family history of periodontal disease were not associated with the occurrence of periodontitis. Higher levels of plaque and bleeding were observed for participants with parents reporting bad gingival health (76.2% and 46.9%) and deficient oral hygiene (79.5% and 47.3%). The perception of parents regarding gingival bleeding was correlated with higher bleeding detected clinically (P = 0.01; 50.1%).

CONCLUSIONS

The prevalence of periodontitis in individuals with Down syndrome is high and increases with age, even in the face of the parents' perception about their children's oral condition.

Oral Health Status among Children with Down Syndrome in Dubai, United Arab Emirates

Objectives:

The purpose of this study was to assess the oral health status in Down syndrome (DS) children in Dubai, United Arab Emirates.

Materials and Methods:

A total of 106 DS children (mean age = 9.3 ± 2.8) and 125 healthy children (mean age = 11.7 ± 4.4) were recruited from both special needs centers and private/public schools in Dubai. A dental examination for decayed-missing-filled teeth (DMFT) in deciduous dentition/DMFT in permanent dentition indices, simplified oral hygiene index, calculus index (CI), were carried out. In addition, occlusal, dentofacial, soft-tissue abnormalities, and erosion were assessed. Statistical analysis was conducted using SPSS for Windows, version 20.0 (SPSS Inc., Chicago, IL, USA).

Results:

The mean number of DMFT in DS children was significantly higher than that in healthy children. DS children in the primary dentition group had higher restorative index and Met Need Index scores than the control group. On the other hand, CI was found to be significantly higher among children with DS compared to healthy controls (P < 0.004). DS children had a significantly higher proportion of open bite and other occlusal problems. Class III molar angle malocclusion was significantly higher in DS (66%) compared to controls (11.2%). Erosion was significantly higher among DS children compared to healthy control (34% vs. 15.3%).

Conclusions:

DS children in Dubai had higher caries rate compared to healthy children. DS group received more restorations and dental treatment compared to the control group. More to add, DS children had significantly more calculus, erosion, and malocclusion problems.

Symmetry of dental agenesis in Down Syndrome children

Background/purpose

Down syndrome (DS) may affect the mouth, influencing its function, feeding and hence overall health status. We aim at investigating the frequency and type of dental agenesis in a school-age DS sample, evaluating gender, laterality, upper or lower side, and mono- or bi-laterality.

Materials and methods

Oral clinical and radiological exams were performed. Forty-six (20 female and 26 male) panoramic radiographs, done when DS patients were 8-12 years old, were examined, from patients between 3 and 25 years old at the first visit.

Results

The percentage of missing teeth was compared with chi-squared test: 65% of patients presented agenesis of one or more teeth. The most frequently missing teeth were the upper left lateral incisor, the lower second premolars and the upper right lateral incisor. Usually, the absence was bilateral. There was no difference between sexes, between mandible and maxilla, either in the left or in the right side.

Conclusion

A high occurrence of dental agenesis was observed in DS patients: some teeth were mostly affected and bilateral agenesis was frequent. Due to the high prevalence of teeth agenesis in DS patients, special care is devised for correct development of oral functions and for avoidance of oral pathologies.

Oral health status of the disabled compared with that of the non-disabled in Korea: A propensity score matching analysis

Background

There are many types of disabilities, and each type has a variety related to socioeconomic factors. Such factors affect to many health problems of the disabled. However, surveys of the oral health status of the disabled in Korea are rare.

Objective

The purpose of this study was to estimate oral health disparity through comparing oral health status of the disabled to the non-disabled, adjusted for the net effect of the disability on oral health status.

Methods

A cross-sectional study was conducted among the disabled in urban and suburban areas in Korea from June to September 2016. People with physical, mental, and multiple disabilities took part in this survey. The clinical examinations were carried out by trained dentists. Statistical analysis was performed to quantify the association between oral health and socioeconomic status after restricting the analysis using a propensity score matching method.

Results

The disabled had more DMFT, DT, and MT, fewer FT, and fewer teeth than the non-disabled based on entire groups (P<0.01). No difference in the ratio of periodontitis was observed. The subjects with mental disabilities (MD) scored 3.09 (95% CI, 1.07–8.97), and those with multiple disabilities scored 4.37 (95% CI, 1.16–16.37) for edentulous status. The MD had an odds ratio of 1.34 (95% CI, 1.03–1.74), and those with multiple disabilities had an odds ratio of 1.75 (95% CI, 1.11–2.76) for the DMFT index.

Conclusions

These results represent poor oral health status of the disabled compared to the non-disabled. Consequentially, we can verify that not only the existence of disability but also the type of disability has a decisive effect on oral health condition. This comparison is necessary to widen our approach to evaluate the actual status condition of the disabled.

Periodontal disease in Down's syndrome patients. A retrospective study

AIM

The purpose of this study was to assess the periodontal condition of people with Down syndrome (DS). Furthermore, risk factors were identified for the development of periodontitis.

METHODS AND RESULTS

Data were collected at the Centre for Special Care Dentistry (CBT) Rijnmond from the records of all 183 registered patients with DS who were 18 years of age on 31 December 2013. Patients were divided into two groups on the basis of their periodontal status: healthy or periodontally compromised. A total of 36.6% of the DS patients had actually incurred damage by periodontitis. The risk factors were: high age at the time of intake, large number of treatment sessions, and impossibility for the "Dutch Periodontal Screening Index" to be measured. In conclusion, the early introduction and continuous attendance of DS patients in a CBT can contributed to better results for a healthy periodontal condition.

Periodontal disease in patients with Down syndrome: A systematic review

BACKGROUND

The authors systematically reviewed the scientific evidence of an association between periodontal disease and Down syndrome (DS).

TYPES OF STUDIES REVIEWED

In this systematic review, the authors included observational studies in which the investigators assessed the prevalence, incidence, or experience of periodontal disease in patients with DS compared with that in healthy patients. The authors used the Population, Exposure, Comparison, Outcome structure. The population was patients of any age, the exposure was the presence of DS, the comparison was the absence of DS, and the outcome was the presence of periodontal disease. The authors conducted an electronic search in 5 databases through March 2017. Two independent reviewers assessed the risk of bias by using the Fowkes and Fulton scale. The authors performed a meta-analysis to compare periodontal disease among patients with DS and those without DS. The authors calculated a summary effect measure-standard mean difference-when evaluating the means of the oral hygiene index. The authors assessed the strength of evidence from the selected studies by using a modified Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The authors included 23 case-control studies in the systematic review and submitted 3 to meta-analysis. In the qualitative analysis, results from most studies showed that the prevalence of some periodontal parameters was higher among patients with DS than among those without DS. Evaluations of the Fowkes and Fulton scale point to many methodological problems in the studies evaluated. Results of the meta-analysis revealed no differences between groups with regard to the oral hygiene index (standard mean difference, 0.05; 95% confidence interval, -0.55 to 0.65; I² = 0.0%).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Further research is required, in particular well-designed studies that avoid the deficiencies identified in the studies in this review.

The Dental Needs and Treatment of Patients with Down Syndrome

Down syndrome is a common disorder with many oral conditions and systemic manifestations. Dentists need to take a holistic approach including behavioral, oral, and systemic issues. This review of the literature focuses on oral anomalies, systemic interaction, management, and recommendations.

Preventative therapies and periodontal interventions for Down syndrome patients

Data sourcesMedline, Embase, Cochrane CENTRAL and OpenGREY databases without language restriction until March 2016 plus manual searching of four specific journals and consideration of reference lists.Study selectionStudies evaluating different methods of periodontal treatment in Down syndrome patients measuring at least two periodontal parameters at different periods of assessment. Titles, abstracts and full texts were considered by two independent reviewers and a third where discussion did not reach consensus. Randomised controlled trials were evaluated using the Cochrane risk of bias tool. The observational studies were evaluated using an adapted version of the Newcastle-Ottawa Scale.Data extraction and synthesisData extraction was carried out independently by two reviewers and organised into evidence tables. No meta-analysis was undertaken, however a narrative synthesis was presented.ResultsNine studies met the inclusion criteria; four longitudinal studies, one prospective case series and four clinical trials which included two cross-over studies and a controlled trial. The studies showed marked heterogeneity in terms of methodology, intervention and outcome measures. All studies, however, included assessment of different plaque and gingival indices.Three studies investigated outcomes after scaling and root planing, one of which compared surgical and non-surgical approaches. Periodontal pockets of 1-3 mm were statistically significantly improved with non-surgical treatment in comparison with pockets greater than 4 mm which showed greater reduction with surgical treatment. Six studies investigated different forms and uses of chlorhexidine, three of which investigated its use as an adjuvant to mechanical debridement and one which also included plaque disclosing as an intervention. Chlorhexidine was shown to be most effective when used daily as a 1% gel for toothbrushing. The use of a plaque disclosing tablet and fluoridated tooth paste, however, showed further improved outcomes with regards to plaque control.ConclusionsEight of the nine studies included showed improvement in the primary outcomes of improved plaque and gingival bleeding indices. Professional intervention and periodontal maintenance significantly reduced plaque and gingival indices, irrespective of the treatment performed. Increased frequency of interventions was associated with better outcomes, especially in younger age groups.

Global oral health status of athletes with intellectual disabilities

Background

The aim of this study is to identify the oral health status and treatment needs of Special Olympics athletes with intellectual disabilities from 181 countries by the assessment of oral health parameters and differences between world regions.

Material and methods

Data were collected through interview and oral examinations within the Healthy Athletes Screening. These data were analysed with descriptive statistics of oral health parameters of athletes from Africa, Asia Pacific, East Asia, Europe/Eurasia, Latin America, Middle East North Africa (MENA) and North America. Mean differences of untreated visible dental caries, gingival signs and missing teeth were tested between regions by one-way ANOVA test and between age groups (8–11, 12–18, 19–39 and 40+) by chi-square tests for multiple comparisons with Hochberg-adjusted p value. The level of significance for all tests was set at a p value < 0.05.

Results

A total of 149,272 athletes with intellectual disabilities were screened. More than 80% of the athletes reported that they cleaned their mouths at least once a day. Athletes in Europe/Eurasia, Latin America, and MENA presented higher rates of signs of gingival disease than other regions. The prevalence of untreated dental caries was significantly higher in Latin America and the group of 8–11-year-olds from Latin America, Europe/Eurasia and Asia Pacific.

Conclusions

The data provided by this study demonstrate that continuous efforts for preventive and restorative oral health care are needed for the oral health of these athletes with ID especially in Latin America, MENA and Europe/Eurasia regions.

Oral Rehabilitation with Implant-Retained Overdenture in a Patient with Down Syndrome

Down syndrome, known as trisomy 21, is the most common chromosomal disorder. The disorder affects mental and systemic development as well as oral structure, including dental anomalies, high susceptibility of periodontal disease, and poor quality of alveolar bone. This report presents a case of dental rehabilitation by means of dental implants of a patient with Down syndrome. Two titanium dental implants were placed in the maxilla, and three titanium dental implants were installed in the mandible. One implant was lost during the osseointegration period. The prosthetic rehabilitation was performed with implant-retained maxillary and mandibular overdentures with the Locator attachment system. After a 2-year follow-up period, the patient was doing well, and all implants were clinically stable with no signs of bone loss or inflammation. The present study emphasizes that implant-retained overdentures with Locator attachment system could be a therapeutic option even for patients with Down syndrome. This therapy prevents crestal bone loss around the implants, improves functional and esthetic outcomes, and provides optimum oral hygiene for patients with mild mental impairment. Careful patient selection and education of patients and caregivers are essential considerations for a successful and safe treatment with dental implants in Down syndrome patients.

Periodontal disease's contribution to Alzheimer's disease progression in Down syndrome

People with Down syndrome (DS) are at an increased risk for Alzheimer's disease (AD). After 60 years of age, >50% of DS subjects acquire dementia. Nevertheless, the age of onset is highly variable possibly because of both genetic and environmental factors. Genetics cannot be modified, but environmental risk factors present a potentially relevant intervention for DS persons at risk for AD. Among them, inflammation, important in AD of DS type, is potential target. Consistent with this hypothesis, chronic peripheral inflammation and infections may contribute to AD pathogenesis in DS. People with DS have an aggressive form of periodontitis characterized by rapid progression, significant bacterial and inflammatory burden, and an onset as early as 6 years of age. This review offers a hypothetical mechanistic link between periodontitis and AD in the DS population. Because periodontitis is a treatable condition, it may be a readily modifiable risk factor for AD.

Treatment needs and impact of oral health screening of athletes with intellectual disability in Belgium

BACKGROUND

Special Olympics Special Smiles (SOSS) is an initiative created for oral health data collection and education in oral hygiene for athletes with an intellectual disability. The aims of this study were to evaluate treatment needs of participants of Special Olympics in Belgium 2013 in comparison with those from 2008 and to assess the impact of screening and referral within the SOSS in a group of athletes who participated in two consecutive events, 2012 and 2013.

METHODS

Data were collected following a standardized protocol developed by the U.S. Centres for Disease Control and Prevention, Division of Oral Health. Oral hygiene habits, treatment urgency and reports of oral pain, gingival signs, sealants, untreated caries, missing and filled teeth were recorded. Data analysis of data from 2013 consisted in descriptive statistics followed by the analysis of the data by univariable and multivariable logistic regression. This data was compared with data from 2008 published by Leroy et al., 2012 using Chi square tests. Data from athletes who participated in both Special Olympics events (2012 and 2013) were compared using Exact McNemar's test and Chi-square test for homogeneity of proportions. The level of significance for all tests was set at a p-value < 0.05.

RESULTS

A total of 627 athletes with intellectual disability participated to the SOSS program in 2013, while 132 athletes met the inclusion criteria of being a participant at both SO Belgium 2012 and 2013. The prevalence of gingival signs was 44.3 % in 2013, slightly higher than in 2008 (42.4 %). The burden of untreated decay affected 27.1 % of the population showing a net increase in comparison to 2008 (20.9 %). McNemar's test and Chi-square test revealed that there were no statistically significant differences in the proportions of all compared parameters between 2012 and 2013.

CONCLUSION

Special Olympics results from 2013 indicate a considerable unmet treatment need among Belgian Special Olympics Athletes, persistent from 2008 to 2013. Moreover, SO intervention had no impact in the oral health of athletes who participated in 2012 and 2013 events. Continuous efforts for preventive and restorative oral health care are needed for this population.

Effect on plaque control in children patients with Down syndrome using Digital Brush with or without chlorhexidine: a randomized clinical trial

OBJECTIVES

The aim of this study was to evaluate efficacy in children affected by Down syndrome of "Digital Brush" in terms of Plaque Index reduction added to the daily oral hygiene procedures.

METHODS

A total of 56 patients with Down syndrome were recruited and randomly assigned in two groups: both control and test groups underwent standard hygiene procedures of tooth brushing twice a day followed by the intervention of Digital Brush, TNT gauze impregnated with chlorhexidine 0.12%, for the test group and by sterile gauze soaked in water for the control group. Initial plaque index was measured for all patients (T0), subsequently were instructed to use either Digital Brush or gauze soaked with water for 2 weeks. At last, patients were reevaluated (T1) and the plaque index measured.

RESULTS

Plaque index improvement from T0 to T1 in control group was 11.7%, while in test group was 24.1%. The mean differences between test and control group was statistically significant (p < 0.001).

CONCLUSIONS

This study demonstrates how the Digital Brush, added to the daily oral hygiene procedures, obtains significant improvements in supragingival plaque control in children with Down syndrome.

Oral health needs of athletes with intellectual disability in Eastern Europe: Poland, Romania and Slovenia

OBJECTIVES

The aims of this study were to evaluate the oral condition and treatment needs of Special Olympics (SO) athletes from Poland, Romania and Slovenia.

METHODS

A cross-sectional study was performed with data collected through standardised oral screening of athletes who participated in the annual SO events held in Poland, Romania and Slovenia, between 2011 and 2012. The data were compiled and transferred to an SPSS data file for analysis using descriptive statistics.

RESULTS

A total of 3,545 athletes participated in the study. Among the main findings, the prevalence of untreated decay was 41% in Poland and 61% in Slovenia, whilst 70% of the Romanian athletes had signs of gingival disease and only 3.8% presented molar fissure sealants. In addition, 47% of Polish athletes were in need of urgent treatment.

CONCLUSIONS

Analysis of the results obtained following screening showed comparable oral health needs of athletes with intellectual disability among countries. Exploration of the oral health systems of the countries revealed similar significant co-payments and lack of incentive for dentists to treat patients with special needs. The results from Romania, Poland and Slovenia demonstrated the need for a structured system in which a special population is a target for oral-health-related education programmes and system-included preventive, restorative and maintenance interventions.

Oral cleanliness and gingival health among Special Olympics athletes in Europe and Eurasia

Background

Special Olympics athletes, as well as the general population of people with intellectual disabilities, are expected to have poorer gingival health. The aim of the study is to explore the prevalence of gingival signs of inflammation and its relationship to oral cleanliness and age among Special Olympics athletes from Europe and Eurasia.

Material and Methods

A retrospective longitudinal study was performed with data collected through standardized oral from 15.941 athletes from annual Special Olympics events held in 49 countries, from Europe and Eurasia between 2007 and 2012. The data was analysed descriptively, with One-Way ANOVA test and Chi-Square test.

Results

The level of significance was predetermined at a p value < 0.05. A total of 7,754 athletes presented with gingival signs (48.64%). There were no significant differences (p= 0,095) in mean gingival signs between age groups, however the association between mouth cleaning and age, was statistically significant.

Conclusions

The data suggests that there is a high prevalence of gingival signs among individuals with special needs; over 50% in more than 20 countries. Therefore, there is a serious need for education and preventive programs for the patients, their parents and caregivers.

Key words:Gingivitis, prevalence, hygiene, disability, Special Olympics.

Association between Dental Caries and Down Syndrome: A Systematic Review and Meta-Analysis

Scientific evidence of susceptibility to dental caries in the population with Down Syndrome (DS) is limited and conflicting, making it difficult to establish firm conclusions. The aim of this systematic review and meta-analysis was to obtain scientific evidence of the possible association between dental caries and individuals with DS, compared to individuals without DS (control). An electronic search of five databases was performed, with no language or publication date restrictions. The studies were selected by two independent reviewers (Kappa = 0.83). The systematic review included 13 studies, while eight studies were included in the meta-analysis. The studies are presumably all at risk of bias given their observational character. Two of these evaluated the presence or absence of caries in permanent and deciduous teeth, and six evaluated the mean DMFT index in permanent teeth. Combined odds ratios (OR), standard difference, standard error and a 95% confidence interval (CI) were obtained. The vast majority of the studies found that individuals from control groups had more carious lesions or caries experience than those with DS. The results were statistically significant in seven studies (p<0.05). Meta-analysis of two studies revealed that individuals with DS had a lower dental caries than those in the control group (OR = 0.36; 95% CI = 0.22-0.57). In six studies, individuals with DS had a significantly lower mean DMFT index than individuals from the control group (Sd = -0.18; SE = 0.09; 95% CI = -0.35--0.02). The quality of the studies varied and in general had a high risk of bias. Scientific evidence suggests that individuals with DS have fewer dental caries than individuals without DS.

Special needs dentistry: perception, attitudes and educational experience of Malaysian dental students

A compromised oral health condition amongst patients with special health care needs (SHCN) has been associated with the reluctance and shortage of skills of dental professionals in managing such patients. Lack of training and experience at the undergraduate level are reported barriers to the provision of care for this patient cohort. Undergraduate education therefore, plays an important role in producing professionals with the knowledge, skills and positive attitude in treating patients with SHCN. This study aims to determine the level of knowledge, comfort and attitudes of Malaysian undergraduate dental students towards caring for patients with SHCN, as well as their perception on education in this field. A self-administered questionnaire was administered in the classroom style to final year undergraduate dental students in Malaysian public dental schools. Most students were aware of Special Needs Dentistry (SND) as a specialty after being informed by academic staff. The majority of the students demonstrated poor knowledge in defining SND and felt uncomfortable providing care for such patients. They perceived their undergraduate training in SND as inadequate with most students agreeing that they should receive didactic and clinical training at undergraduate level. A high percentage of students also expressed interest in pursuing postgraduate education in this area of dentistry despite the lack of educational exposure during undergraduate years. The study supports a need for educational reform to formulate a curriculum that is more patient-centred, with earlier clinical exposure in various clinical settings for students to treat patients with special health care needs, applying the concept of holistic care in a variable clinical condition.

Effects of declared levels of physical activity on quality of life of individuals with intellectual disabilities

Routine physical fitness improves health and psychosocial well-being of individuals with intellectual and developmental disabilities. The current study investigated impact of physical fitness on quality of life by comparing individuals who maintain a physically active lifestyle with those who do not report exercising. We assessed several indicators of quality of life, including inclusion and community participation; satisfaction with professional services, home life, and day activities; dignity, rights, and respect received from others; fear; choice and control; and family satisfaction. Our data suggested that individuals who regularly exercise reported having more frequent outings into the community than did their peers who reported exercising infrequently; regular exercisers were also more likely to live in intermediate care facilities (ICF) as opposed to living independently or with family members. We discuss possible reasons for this as well as ideas for future research needed to expand on this area.

Oral hygiene and gingival health status of children with Down syndrome in Yemen: A cross-sectional study

Purpose:

The objective of the present study was to assess the oral hygiene and gingival health status among Yemeni children with Down syndrome.

Materials and Methods:

The study sample comprised 101 children with Down syndrome attending special needs schools in Sana’a, Yemen. The calculus index (CI), plaque index (PI), and the gingival index (GI) were used to assess oral hygiene and gingival health status.

Results:

All subjects had gingivitis; the mean CI, PI, and GI scores were 0.58 ± 0.61, 1.45 ± 0.57, and 1.54 ± 0.64, respectively, with no significant difference found across gender. Stepwise linear regression analysis revealed that the best predictors in the descending order for CI were age and mother's education, and the best predictors for PI were IQ level, age, and father's education. Having severe mental retardation, older age, less educated parents were the most important predictors for poor gingival health status.

Conclusions:

These findings show that children with Down syndrome have poor oral hygiene and high levels of periodontal diseases. Hence, appropriate oral health education should be tailored to the needs of these children with the support of their teachers and parents.

Evaluation of Oral Hygiene Status and Periodontal Health in Mentally Retarded Subjects with or without Down's Syndrome in Comparison with Normal Healthy Individuals

AIM

The aim of the study was to assess the oral hygiene status and periodontal status of Mentally Retarded, Down's syndrome and normal subjects.

MATERIAL AND METHODS

The study was undertaken at OPPORTUNITY SCHOOL at Vepery, Chennai, India. 150 subjects were selected. Among them 100 were Mentally Retarted, 50 were Down's Syndrome subjects. 50 healthy normal subjects were selected (Students from Madha School, Chennai, India) for comparison. All were screened for oral hygiene and periodontal status by OHI-S and CPITN index. Statistical analyasis was done by Pearsson correlation coefficient.

RESULTS AND CONCLUSION

The results showed that the Mentally Retarded and Down's Syndrome subjects had decreased prevalence rate of periodontitis.

Oxidative burst intensity of peripheral phagocytic cells and periodontitis in Down syndrome

BACKGROUND

This study investigated the oxidative burst function of peripheral phagocytic cells (granulocytes and monocytes) and assessed the relation between oxidative burst and periodontal status in adult individuals with Down syndrome (DS) vs. other groups.

METHODS

Of 55 DS individuals (18-56 years old), 74 individuals with mental retardation (MR) and 88 medically healthy controls (HC) participated in the study. The MR and HC groups were age, race and gender matched with the DS group. Gingival index, plaque index, probing depth, attachment level and bleeding on probing were recorded for each subject. Whole blood was collected for granulocyte/monocyte oxidative burst tests. Oxidative burst was determined by flow cytometry in terms of percentage of cells actively involved in oxidative burst, and oxidative intensity (magnitude of ROIs per cell).

RESULTS

The basal oxidative burst intensity of DS granulocytes was higher than that of HC and MR granulocytes (p = 0.05). The Escherichia coli stimulated oxidative burst intensity of DS monocytes was higher than that of HC and MR monocytes (p = 0.05). Regression analysis controlling for age, sex, race and plaque levels showed a significant association between monocyte oxidative burst intensity and loss of periodontal attachment in DS subjects (p < 0.01). Regression analysis also showed a significant association between granulocyte oxidative burst intensity and bleeding on probing in all subjects (p < 0.05).

CONCLUSIONS

Oxidative burst activity of peripheral monocytes and granulocytes is elevated in DS affected individuals and may contribute to periodontal tissue inflammation and loss of periodontal attachment in this susceptible group.

The value of education in special care dentistry as a means of reducing inequalities in oral health

People with disability are subject to inequality in oral health both in terms of prevalence of disease and unmet healthcare needs. Over 18% of the global population is living with moderate to severe functional problems related to disability, and a large proportion of these persons will require Special Care Dentistry at some point in their lifetime. It is estimated that 90% of people requiring Special Care Dentistry should be able to access treatment in a local, primary care setting. Provision of such primary care is only possible through the education and training of dentists. The literature suggests that it is vital for the dental team to develop the necessary skills and gain experience treating people with special needs in order to ensure access to the provision of oral health care. Education in Special Care Dentistry worldwide might be improved by the development of a recognised academic and clinical discipline and by providing international curricula guidelines based on the International Classification of Functioning, Disability and Health (ICF, WHO). This article aims to discuss the role and value of promoting and harmonising education in Special Care Dentistry as a means of reducing inequalities in oral health.

Is There Anything to Smile about? A Review of Oral Care for Individuals with Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (I/DD) are at risk for dental disease and face substantial challenges in accessing both routine and preventive dental services. In terms of unmet needs it ranks third, following residential services and employment opportunities for this particular group of people. Poorer oral health status negatively impacts overall health and one's quality of life. Factors contributing to this problem include significantly higher rates of dental caries, periodontal disease, poor oral hygiene, low expectations, fear of treatment, and lack of awareness among individuals and carers. Additional factors include problems accessing dental care or denial of services because of inadequate education and clinical training, inappropriate bias, or inadequate levels of compensation to providers. Strategies to improve service delivery include individualized and coordinated care services, education of individuals, carers, and providers, including both classroom and clinical experiences with special needs patients in dental programs.

Subgingival microbiota in adult Down syndrome periodontitis

BACKGROUND AND OBJECTIVE

The subgingival microbiota in Down syndrome and non-Down syndrome adults receiving periodic dental care was examined for 40 bacterial species using checkerboard DNA-DNA hybridization and the results were related to clinical periodontal attachment loss.

MATERIAL AND METHODS

A total of 44 Down syndrome, 66 non-Down syndrome mentally retarded and 83 mentally normal adults were clinically evaluated. This involved, for each subject, the removal of subgingival specimens from three interproximal sites on different teeth; all subgingival samples per subject were then pooled and assessed for the presence and levels of 40 bacterial species using species-specific whole-genomic DNA probes and checkerboard DNA-DNA hybridization. Significant group differences in species proportions averaged across subjects were evaluated using the Kruskal-Wallis test, and associations between subgingival species and mean subject attachment loss within Down syndrome and non-Down syndrome subject groups were quantified using Pearson correlation and multiple linear regression analysis.

RESULTS

Down syndrome subjects exhibited greater attachment loss than non-Down syndrome subjects (p=0.05). Most microbial species were present in Down syndrome subjects at levels similar to non-Down syndrome subjects, except for higher proportions of Selenomonas noxia, Propionibacterium acnes, Streptococcus gordonii, Streptococcus mitis and Streptococcus oralis in Down syndrome subjects compared with non-Down syndrome study subjects, higher proportions of Treponema socranskii in Down syndrome subjects compared with non-Down syndrome mentally retarded subjects, and higher proportions of Streptococcus constellatus in Down syndrome subjects compared with mentally normal subjects. Down syndrome adults classified with periodontitis revealed higher subgingival levels of T. socranskii than Down syndrome subjects with no periodontitis (p=0.02). Higher subgingival proportions of S. constellatus, Fusobacterium nucleatum ssp. nucleatum, S. noxia and Prevotella nigrescens showed significant positive correlations (r=0.35-0.42) and higher proportions of Actinomyces naeslundii II and Actinomyces odontolyticus showed negative correlations (r=-0.36 to -0.40), with increasing mean subject attachment loss in Down syndrome adults.

CONCLUSION

Individuals with Down syndrome show higher levels of some subgingival bacterial species and specific associations between certain subgingival bacterial species and loss of periodontal attachment. These findings are consistent with the notion that certain subgingival bacteria may contribute to the increased level of periodontal disease seen in Down syndrome individuals and raise the question as to the reason for increased colonization in Down syndrome.

Phagocytic cell activity and periodontitis in Down syndrome

BACKGROUND

This study investigated the phagocytic function of peripheral granulocytes and monocytes from adult individuals with Down syndrome (DS) and assessed the relation between phagocytic function and periodontal status.

METHODS

Fifty-five DS individuals (18-56 years old), 74 mentally retarded individuals, and 88 medically healthy controls (HC) participated in the study. Gingival inflammation index, plaque index, probing depth, periodontal attachment level (AL), and bleeding on probing were taken for each subject. Whole blood was collected for granulocyte/monocyte phagocytosis tests. Phagocytic function was determined by flow cytometry in terms of percentage of cells actively involved in phagocytosis, and phagocytic intensity (magnitude of the bacterial staining per cell).

RESULTS

Phagocytic intensity of both granulocytes and monocytes was comparable in HC and DS subjects. While AL was directly related to phagocytic intensity of both granulocytes (r = 0.14, P = 0.03) and monocytes (r = 0.2, P = 0.003) in all subjects, this relationship was stronger in DS than in other subjects, even after controlling for known risk factors for periodontitis (P < 0.05). Monocyte phagocytic intensity was the only necessary predictor of AL (P = 0.003), indicating a similar relationship between AL and phagocytic activity in either cell type.

CONCLUSIONS

While granulocyte and monocyte phagocytic intensities are similar in Down and non-DS individuals, phagocytic intensity was associated with more AL in DS than non-DS individuals.

Association of interleukin-1 polymorphisms with periodontitis in Down syndrome

This study examined the association of IL1 genetic polymorphisms (IL-1A +4845, IL-1B +3954 & IL-1RN +2018) with periodontal disease status of Down syndrome (DS) individuals. Fifty-four DS patients (18-56 yr, 48.15% male, 77.78% Caucasians) were recruited from the Georgia Regional Hospital (GRH) health care system. Two comparable groups (71 mentally retarded patients and 87 control subjects) were also recruited. All subjects were nonsmokers. Periodontal evaluations (plaque index, gingival index, bleeding-on probing and clinical attachment levels (AL)), personal and professional dental care habits were recorded. Blood was collected by a venipuncture. The IL-1A +4845, IL-1B +3954 & IL-1RN +2018 loci were genotyped by the TaqMan assay. No statistically significant differences were noted in the distribution of IL-1 gene polymorphisms between the three groups. The IL-1 variant genotypes varied by race; for both IL-1A and IL-1RN, the variant gene was significantly more prevalent among whites than non-whites (ps > 0.1). ANCOVA, which also adjusted for age, showed a 3-way interaction among dental visits, gene variation and Down status [(F(1, 179) = 3.96, P = 0.048 in White subjects and F(1, 241) = 2.96, P = 0.087 in all subjects). Post-hoc t-tests confirmed lower levels of AL in IL-1RN-variant Down subjects receiving more frequent dental visits (P < 0.05). ANCOVA, which also adjusted for age, showed an interaction between IL-1A/B gene variation and Down status (F(1, 174) = 3.04, P = 0.083 in White subjects and F(1, 235) = 3.72, P = 0.055 in all subjects). Post-hoc t-tests confirmed lower levels of AL in IL-1A/B-variant Down subjects (P < 0.05). The distribution of variant IL-1 genes in DS subjects was not different from the general population. However the association between the carriage of the IL-1 rare alleles and periodontitis differed between the Down and non-Down subjects. The carriage of the IL-1 rare alleles in the Down subjects tended to confer a protective effect against loss of periodontal attachment.

Ill-health and intellectual disabilities

PURPOSE OF REVIEW

Adults with intellectual disabilities are recognized globally as a group of individuals with poorer access to appropriate healthcare and have worse health outcomes than the general population, including significantly reduced life expectancy. This article reviews the evidence base published over the past 12-24 months, highlighting how public health policy is influencing the literature on the health needs of people with intellectual disabilities.

RECENT FINDINGS

Recent studies looking at information from death certificates found people with intellectual disabilities died 15 years younger than people without intellectual disabilities. Using standardized mortality rates, the overall mortality for people with intellectual disabilities is three times higher than for the general population. People with intellectual disabilities have higher rates of asthma and oral disease, but similar rates of hypertension. There is limited high-quality evidence on drugs used to treat epilepsy in this population, despite epilepsy being one of the leading causes of premature deaths.

SUMMARY

Recent evidence continues to show that people with intellectual disabilities have poorer health outcomes than the general population. However, the quality of evidence available on the wider health needs remains limited, but, with the move to a public health approach through health surveillance, this may increase the quality of evidence available, so influencing health outcomes for people with intellectual disabilities.