Prevention and Periodontal Treatment in Down Syndrome Patients: A Systematic Review

Cytokine levels in the gingival crevicular fluid and their association with periodontal status of down syndrome patients: a cross-sectional study

OBJECTIVE

To evaluate cytokine levels of interleukin (IL)-1β, IL-4, IL-6, IL-17a, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ in the gingival crevicular fluid (GCF) of periodontal sites in individuals with Down syndrome (DS) and analyze their relationship with clinical periodontal parameters.

MATERIALS AND METHODS

A cross-sectional study was conducted with 49 DS patients and 32 individuals without DS (non-DS group). Periodontal probing depth (PPD), clinical attachment level (CAL), bleeding on probing (BoP), and visible plaque index (VPI) were evaluated. The periodontal sites were classified as shallow, moderate, and deep. GCF was collected in all shallow sites and, when present, in moderate and deep sites for the analysis of cytokine levels. The cytokines, IL-1β, IL-4, IL-6, IL-17a, TNF-α, and IFN-γ, were quantified using the Luminex® automatic analyzer system.

RESULTS

The DS group presented greater severity of periodontitis compared to the non-DS group (P = 0.005). The DS group showed a significant direct correlation of IL-1β and an inverse correlation of IFN-γ and IL-14 with all periodontal variables. In the analysis stratified by periodontal pocket depth, we observed a higher level of IFN-γ, IL-17a, IL-1β, and IL-6 in the shallow sites, and IL-17a, IL-1β, and IL-6 in deep pockets of DS group individuals. Multivariate models showed that higher levels of IL-1β, IL-4, IL-6, and IL-17a were associated with Down syndrome even after adjusting for periodontal status, sex, and age.

CONCLUSION

The findings suggest that people with DS have greater periodontal impairment and higher levels of cytokines in GCF, even in sites having clinical periodontal parameters similar to those of individuals without DS. These data reiterate the concept of an altered and less effective immune response in the population with DS in the face of a periodontal microbial challenge.

CLINICAL RELEVANCE

Elevated periodontal inflammation burden can be observed with higher cytokine levels in the gingival crevicular fluid of people with Down syndrome, especially IL-1, IL-4, IL-6, and IL-17, regardless of the stage of periodontitis.

Factors associated with halitosis reported by parents/caregivers in individuals with Down syndrome

AIMS

Data on halitosis among individuals with Down syndrome (DS) are scarce. The aim was to evaluate factors associated with the occurrence of halitosis reported by parents/caregivers (P/Cs) in individuals with DS.

METHODS AND RESULTS

A cross-sectional study was conducted in non-governmental assistance institutions in the State of Minas Gerais-Brazil. P/Cs have answered an electronic questionnaire with sociodemographic, behavioral and oral health data. Factors associated with halitosis were evaluated by multivariate logistic regression. The sample comprised 227 P/Cs (age 48.8 ± 13.2 years; 82.9% mothers) of individuals with DS (age 20.8 ± 13.5 years). The prevalence of halitosis in the total sample was 34.4% (n = 78) and its occurrence was associated: 1) in individuals with DS ≤18 years old (26.2%; n = 27)-negative perception of oral health (OR = 3.91); 2) in individuals with DS > 18 years (41.1%; n = 51)-gingival bleeding (OR = 4.53), absence of tongue brushing (OR = 4.50), negative perception of oral health (OR = 2.72).

CONCLUSIONS

The occurrence of halitosis in individuals with DS reported by P/Cs was relevant and associated with dental factors, having a negative impact on the perception of oral health. Oral hygiene practices, especially tongue brushing, should be reinforced to prevent and control halitosis.

Periodontal disease in down syndrome: Predisposing factors and potential non-surgical therapeutic approaches

BACKGROUND

Periodontal diseases (PDs) have been documented to be significantly more prevalent and severe in patients with Down syndrome (DS). Different immunological and microbiological factors contributed to predisposing these patients to progressive and recurrent PDs.

AIM

The aim of this review was to investigate the altered immunological responses and oral microbiota disorders as well as focus on adjunctive non-surgical methods for the treatment of PDs and its applicability in patients with DS.

MATERIAL AND METHODS

A literature review was conducted addressing the following topics: (1) the altered immunological responses, (2) orofacial disorders related to DS patients, (3) oral microbiota changing, and (4) adjunctive non-surgical treatment and its efficacy in patients with DS.

RESULTS

Due to the early onset of PDs in children with DS, the need for prompt and effective treatment in these patients is essential.

DISCUSSION AND CONCLUSION

So, investigating underlying factors may open a new window to better understand the pathology of PDs in DS people and thus, find better strategies for treatment in such group. Although non-surgical treatments such as photodynamic therapy and probiotic consumption represented acceptable outcomes in different examined patients without DS, data about the application of these convenience and no need for local anesthesia methods in patients with DS is limited.

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

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.

Rodent Modeling of Alzheimer's Disease in Down Syndrome: In vivo and ex vivo Approaches

There are an estimated 6 million people with Down syndrome (DS) worldwide. In developed countries, the vast majority of these individuals will develop Alzheimer's disease neuropathology characterized by the accumulation of amyloid-β (Aβ) plaques and tau neurofibrillary tangles within the brain, which leads to the early onset of dementia (AD-DS) and reduced life-expectancy. The mean age of onset of clinical dementia is ~55 years and by the age of 80, approaching 100% of individuals with DS will have a dementia diagnosis. DS is caused by trisomy of chromosome 21 (Hsa21) thus an additional copy of a gene(s) on the chromosome must cause the development of AD neuropathology and dementia. Indeed, triplication of the gene APP which encodes the amyloid precursor protein is sufficient and necessary for early onset AD (EOAD), both in people who have and do not have DS. However, triplication of other genes on Hsa21 leads to profound differences in neurodevelopment resulting in intellectual disability, elevated incidence of epilepsy and perturbations to the immune system. This different biology may impact on how AD neuropathology and dementia develops in people who have DS. Indeed, genes on Hsa21 other than APP when in three-copies can modulate AD-pathogenesis in mouse preclinical models. Understanding this biology better is critical to inform drug selection for AD prevention and therapy trials for people who have DS. Here we will review rodent preclinical models of AD-DS and how these can be used for both in vivo and ex vivo (cultured cells and organotypic slice cultures) studies to understand the mechanisms that contribute to the early development of AD in people who have DS and test the utility of treatments to prevent or delay the development of disease.

Melatonin as an immunomodulator in children with Down syndrome

BACKGROUND

Down syndrome (DS) is a disorder characterised by marked immune dysfunction, increased mortality from sepsis, chronic inflammation, increased oxidative stress, sleep disturbance and possibly abnormal endogenous melatonin levels. Melatonin has a myriad of immune functions, and we hypothesised that this therapeutic agent could modulate the innate immune system in this cohort.

METHODS

We investigated neutrophil and monocyte function (CD11b, TLR4 expression by flow cytometry), genes involved in TLR signalling (MyD88, IRAK4, TRIF), the inflammasome (NLRP3, IL-1β), and circadian rhythm (BMAL, CLOCK, CRY) by qPCR, and inflammatory cytokines (IL-2, IL-6, IL-8, IL-18, IL-1β, TNF-α, IFN-γ, IL-10, IL-1ra, VEGF, Epo, GM-CSF) by enzyme-linked immunosorbent assay (ELISA) following immunomodulation with LPS endotoxin and melatonin. 47 children with DS and 23 age- and sex-matched controls were recruited.

RESULTS

We demonstrated that melatonin has several significant effects by reducing CD11b and TLR4 expression, attenuating TLR signalling, genes involved in the inflammasome and has the potential to reduce LPS-induced inflammatory responses.

CONCLUSIONS

Immunomodulatory effects of melatonin were found in both paediatric cohorts with more marked effects in the children with DS. Melatonin mediates immune response through a wide array of mechanisms and this immunomodulator may buffer the inflammatory response by regulating pro and anti-inflammatory signalling.

IMPACT

We highlight that melatonin mediates its immune response through a wide array of mechanisms, its effects appear to be dose dependant and children with Down syndrome may be more receptive to treatment with it. Immunomodulatory effects of melatonin were demonstrated with marked effects in the children with Down syndrome with a reduction of MyD88, IL-1ß and NLRP3 expression in whole-blood samples. Melatonin is a proposed anti-inflammatory agent with a well-established safety profile, that has the potential for mitigation of pro- and anti-inflammatory cytokines in paediatric Down syndrome cohorts, though further clinical trials are warranted.

Genetic Susceptibility to Periodontal Disease in Down Syndrome: A Case-Control Study

Severe periodontitis is prevalent in Down syndrome (DS). This study aimed to identify genetic variations associated with periodontitis in individuals with DS. The study group was distributed into DS patients with periodontitis (n = 50) and DS patients with healthy periodontium (n = 36). All samples were genotyped with the “Axiom Spanish Biobank” array, which contains 757,836 markers. An association analysis at the individual marker level using logistic regression, as well as at the gene level applying the sequence kernel association test (SKAT) was performed. The most significant genes were included in a pathway analysis using the free DAVID software. C12orf74 (rs4315121, p = 9.85 × 10⁻⁵, OR = 8.84), LOC101930064 (rs4814890, p = 9.61 × 10⁻⁵, OR = 0.13), KBTBD12 (rs1549874, p = 8.27 × 10⁻⁵, OR = 0.08), PIWIL1 (rs11060842, p = 7.82 × 10⁻⁵, OR = 9.05) and C16orf82 (rs62030877, p = 8.92 × 10⁻⁵, OR = 0.14) showed a higher probability in the individual analysis. The analysis at the gene level highlighted PIWIL, MIR9-2, LHCGR, TPR and BCR. At the signaling pathway level, PI3K-Akt, long-term depression and FoxO achieved nominal significance (p = 1.3 × 10⁻², p = 5.1 × 10⁻³, p = 1.2 × 10⁻², respectively). In summary, various metabolic pathways are involved in the pathogenesis of periodontitis in DS, including PI3K-Akt, which regulates cell proliferation and inflammatory response.

Oral Care Experiences and Challenges for Children with Down Syndrome: Reports From Caregivers

Purpose: The purpose of this study was to investigate the oral care experiences and challenges encountered by children with Down syndrome. Methods: Participants were 372 parents of five- to 14-year-olds with Down syndrome. Parents completed a 48-item questionnaire designed by the authors to elicit information about oral care in the home and dental office. Descriptive statistics were used to examine oral care variables. Results: Parents reported difficulty across almost all oral care variables, including oral care in the home, oral care at the dentist, and access to oral care. Approximately one-third of parent respondents reported that toothbrushing was difficult and brushing occurred four or fewer days a week. Over half of the respondents reported that it was difficult to have a dental professional clean their child's teeth, uncooperative behaviors and sensory sensitivities increased in the office, and those behaviors and sensitivities made care challenging. Most respondents reported having a dental home for their child, that it was difficult locating their dentist, and that finances limited visits. Conclusions: Children with Down syndrome experience difficulties and barriers to care in both the home and dental office settings.

Oral health in older adults

The UK population is rapidly ageing, and this is set to continue for many more years. Consequently, this projects a number of health problems and challenges that need to be addressed. Functional impairment and age-related diseases have a significant impact on oral health, leading to a poor quality of life. Dental diseases become more prevalent in older adults, partly as a result of their poor general health, medication side effects and, in some instances, due to limited access to good dental care. Healthcare staff should be aware of these problems and ensure that individuals are given the correct advice, care and treatment. This article outlines what is known about oral health among older adults and highlights some of the common health conditions that affect oral health status in this population. Community nurses are well placed to educate and empower older adults in maintaining good oral health.

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.

Altered Toll-Like Receptor Signalling in Children with Down Syndrome

Toll-like receptors (TLRs) are the key in initiating innate immune responses. TLR2 is crucial in recognising lipopeptides from gram-positive bacteria and is implicated in chronic inflammation. Children with Down syndrome (DS) are prone to infections from these pathogens and have an increased risk of autoimmunity. Sparstolonin B (SsnB) is a TLR antagonist which attenuates cytokine production and improves outcomes in sepsis. We hypothesised that TLR signalling may be abnormal in children with DS and contribute to their clinical phenotype. We evaluated TLR pathways in 3 ways: determining the expression of TLR2 on the surface of neutrophils and monocytes by flow cytometry, examining the gene expression of key regulatory proteins involved in TLR signal propagation, MyD88, IRAK4, and TRIF, by quantitative PCR, and lastly determining the cytokine production by ELISA following immunomodulation with proinflammatory stimuli (lipopolysaccharide (LPS), Pam3Csk4) and the anti-inflammatory agent SsnB. We report TLR2 expression being significantly increased on neutrophils, total monocytes, and intermediate and nonclassical monocytes in children with DS (n = 20, mean age 8.8 ± SD 5.3 years, female n = 11) compared to controls (n = 15, mean age 6.2 ± 4.2 years, female n = 5). At baseline, the expression of MyD88 was significantly lower, and TRIF significantly raised in children with DS. The TLR antagonist SsnB was effective in reducing TLR2 and CD11b expression and abrogating cytokine production in both cohorts. We conclude that TLR signalling and the TLR2 pathway are dysregulated in DS, and this disparate innate immunity may contribute to chronic inflammation in DS. SsnB attenuates proinflammatory mediators and may be of therapeutic benefit.

Rare Diseases with Periodontal Manifestations

Background: The object of this paper was to provide an overview of rare diseases (RDs) with periodontal manifestations and allocate them to relevant categories. Methods: In ROMSE, a database for “Rare Diseases with Orofacial Involvement”, all 541 entities were analyzed with respect to manifestations of periodontal relevance. Inclusion criteria were periodontally relevant changes to the oral cavity, in accordance with the 2018 version of the Classification of Periodontal and Peri-Implant Diseases and Conditions. Rare diseases were recorded, using the methodology described, and subsequently compared with the Orphanet Classification of Rare Diseases. Results: A total of 76 RDs with periodontal involvement were recorded and allocated in accordance with the Classification of Periodontal and Peri-Implant Diseases and Conditions. Of the 541 RDs analyzed as having known orofacial manifestations, almost 14 percent indicated a periodontally compromised dentition. Conclusions: Around 14 percent of RDs with an orofacial involvement showed periodontally relevant manifestations, which present not only as a result of gingivitis and periodontitis, but also gingival hyperplasia in connection with an underlying disease. Thus, dentists play an important role in therapy and early diagnoses of underlying diseases based on periodontally relevant manifestations.

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.

Social Inclusion of Children With Down Syndrome: Jewish and Muslim Mothers' Knowledge, Attitudes, Beliefs, and Behavioral Intentions

PURPOSE

The current study examined mothers' knowledge, beliefs, attitudes, and intention to socially integrate children with Down syndrome (DS) in the family, with children without disabilities and school system.

DESIGN AND METHODS

A questionnaire based on a descriptive, cross-sectional design was administered to Jewish and Muslim mothers. The questionnaire included demographics, knowledge, beliefs, attitudes, and intention to integrate children with DS. Analysis included a regression test of intention to integrate children with DS and a one-way ANOVA for differences between Jewish and Muslim mothers.

RESULTS

Nearly all the Jewish mothers (93.7%) and about half the Muslim mothers (52.8%) had performed screening tests for DS during their pregnancy. All mothers displayed low knowledge level about DS. Being Jewish (t=2.89; p=0.005) and holding more positive beliefs (t=3.39; p=0.001) were associated with a higher intention to socially integrate children with DS. Significant positive correlations were found between beliefs and attitudes (r=0.65; p<0.001) and between attitudes and intention to socially integrate children with DS (r=0.39; p<0.001).

CONCLUSIONS

This study shows that Jewish and Muslim mothers' beliefs and attitudes towards social inclusion of children with DS are quite positive and the intention to integrate children with DS in the family, with children without disabilities, and in the mainstream school system is high. However, their level of knowledge about DS is low.

PRACTICE IMPLICATIONS

Nurses, as a critical source of information about DS, should develop an ethno-cultural sensitivity to diverse populations in order to influence attitudes and beliefs regarding the social integration of children with DS.