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Salar Amer Ibragim
V course, group 15
Oral status among Down syndrome patients
Master’s Thesis Supervisor Dr. Sandra Žemgulytė Kaunas, 20172
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC FOR PREVENTIVE AND PAEDIATRIC DENTISTRY
Oral status among Down syndrome patients
Master’s Thesis
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7 TABLE OF CONTENTS SUMMARY……….8 INTRODUCTION………..9 REVIEW OF LITERATURE……….11-16 MATERIAL AND METHODS………..16
1. Sample selection………..16-19 RESULTS………...20-28 DISCUSSION……….28-30 ACKNOWLEDGEMENT………..30 CONFLICT OF INTERESTS………30 CONCLUSION………..31 PRACTICAL RECOMMENDATIONS………....31 ETHICAL STATEMENT………..31
REFERENCES………...32-388
Oral status among Down syndrome patients.
SUMMARYAim: To evaluate oral health status and applied treatment methods in Down′s syndrome patients attended Clinic for preventive and paediatric dentistry of LUHS Kaunas.
Materials and methods: 35 children with Down Syndrome and 35 healthy children were included in
the study. Clinical records of patients with Down syndrome patients’were selected from patients records in Clinic for preventive and Paediatric dentistry (LUHS Kaunas Clinics). If patients had been referred for treatment under general anaesthesia to Department of maxillofacial surgery (LUHS Kaunas Clinics), the following clinical patients’ histories were taken from Department of archive. The clinical findings (oral hygiene status, DMFT/dmft index, accomplished dental treatment) were analized and compared between both groups.
Results: Conclusion:
Individuals with Down syndrome in Clinic for preventive and paediatric dentistry of LUHS Kaunas
have poorer oral health and more treatment needs than controls ones. They would benefit from frequent oral health assessment.
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Introduction
Down syndrome also known as trisomy 21, is a genetic disorder caused by the presence of all, or part of a third copy of chromosome 21 to simplify it-an extra chromosome [1]. The parents of the affected individual are typically genetically normal [2].The extra chromosome occurs by chance without any known behavioral activity or environmental factor that could change the possibilityof having a DS child [3]. However, the increase of mothers age is related to higher possibility for this genetic
disorder from less than 0.1% in 20-year-old mothers to 3% in those age 45 [4].The Down Syndrome can be diagnosed during pregnancy or right after birth [5].
Globally, as of 2010, Down syndrome occurs in about 1:1000 births [6]. More children are born with Down syndrome in countries where abortion is not allowed and in countries where pregnancy more commonly occurs at a later age [6,7]
In Lithuania however, abortions are legal until first trimester of pregnancy, after this period special authorisation is required for an abortion [8]. Lithuanian authors states that the frequency of this disease among newborns is 1:650-1000, and that approximately 30 000 babies are born in Lithuania, thus, every year approximately 40 newborns, who have the disease, should be born in Lithuania according to Utkus [9,10].
There are numerous oral abnormalities and the oral status of these individuals have been well
reported. There are factors such as dental anomalies,malocclusions and motor disorders
(coordination skills) which can make it difficult for a Down Syndrome person to maintain a good oral hygiene independently, but more complex pathologies such as cardiac diseases, suppressed immunity, respiratory and hematologicalproblems may also aggravate a dental treatment [11,12].
Its very important to not only construct a treatment with optimal results, its just as important to make the patient feel that the visit to the dentist is not horrifying, and this can be a challenge especially among Down Syndrome patients since they have their characteristic features which can be
challenging during a treatment-its always good to be prepared in order to perform a smooth treatment with a short chair-time as possible and minimal compromises. Other circumstances of most highly importance are neurological problems (visual and hearing) and dismorphology ( underdeveloped maxilla/ macroglossia atlantoaxial instability,obstructive sleep apnea) which might also interfere with the verbal and visual communication as well as the cooperation between the dentist and DS patient [12,13,14, 15,16,17,18].
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Patients with Down Syndrome need special care during treatment because of intellectual disability (most of the time). The average IQ of a young adult with Down syndrome is 50, equivalent to the mental age of an 8- or 9-year-old child, but this can vary widely [11]. It is also common that these individuals develop early dementia,therefore the paediatric dentist should be aware to welcome the patient with Down Syndrome as a child if so necessary [12]. There is no cure for Down syndrome[
and regular checkups of health problems common in Down syndrome is recommended throughout the person's life [19].
As future dentists we know how important it is to have a good oral status in order to live a life of high quality, education and proper care of these individuals will improve their quality of life.
Hypothesis: Poor oral hygiene and high levels of periodontal diseases and oral diseases among children with Down Syndrome compared to the control group, which should show that preventive treatment procedures and dental treatment in clinic is significantly less appropriate among DS patients.
Aim: To evaluate oral health status and applied treatment methods in Down′s syndrome patients attended Clinic for preventive and paediatric dentistry of LUHS Kaunas.
Objectives:
1. To collect data from patients’ clinical records. 2. To assess the oral health status by clinical data.
3. To analyse which treatment methods were used for Down syndrome patients and control group
4. To compare oral health status between healthy and Down syndrome children.
5. To analyse literature related to chosen topic and to compare results with accomplished study.
Abbreviations:
DS- child with Down Syndrome
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dmft- number of decayed, missing due to caries and filled teeth in the primary dentition.
Review of literature
Delayed Eruption and Delayed Exfoliation of primary teethThe teeth of individuals with Down syndrome, both deciduous teeth and permanent teeth, may erupt late compared to children without Down syndrome [20, 21]. The causes of delayed eruption in Down’s children are unknown, due to lack of information on the factors intervening in the process of normal eruption. There is suggestive evidence that eruption is influenced by the vascularity of the periapical connective tissue, the poor peripheral circulation in Down’s syndrome could be a factor leading to delayed eruption [21, 22]. The bone resorption occurs during eruption in normal children; this process may be depressed in Down’s children which might also be a reason of the postponed eruption of the primaries [21,22].
Babies without Down syndrome usually get their first teeth between 6-12 months and have complete primary dentition around 2-3 years of age compared to babies with DS whom get their first teeth at around 12 months, but it may be as late as 24 months of age [20, 23, 24]. However, individuals with Downs syndrome typically have all the primary teeth erupted around 4-5 years of age, which is around 2 years of delay compared to normal development [23,24]. Primary dentition in DS individuals usually developed late and later on delay the eruption, especially upper and lower anterior teeth and first molars are commonly affected [23,24].
In a study from 1997 made By Ondarza et alit was reported that the central and lateral incisors and canines’ eruption were delayed significantly among Chilean Down syndrome individuals compared to the normal population [25]. Like normally, central incisors erupted first, and 2nd molars usually last, but in between there was some variations in the sequence of eruption [23,24].
Eruption of the permanent dentition
As the eruption and exfoliation of primary dentition is delayed in DS individuals, there is a setback in the eruption of permanent teeth as well. The lower front permanent teeth and permanent first molars
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may not erupt until 8-9 years of age[23,24]. In a study from 1993 by Jara et al showed a altered eruption sequence among 240 DS individuals in Chile compared to children without Down syndrome which can lead to future malocclusion and consultation with an orthodontist [25, 26].
However, a nationwide survey was made in New Zealand by Cutress, found that both the
chronologic sequence of eruption and symmetry among Down Syndrome individuals was similar to the normal population [27,28]. Comparing these studies we can see that the eruption sequence does not have to be delayed but it exists and needs to be taken into consideration when examining paediatric patients.
Microdontia , hypodontia and taurodontism
Many authors, through the years have investigated (by evaluating panoramic x-rays ) the presence of dental anomalies in (both the primary and permanent) DS individuals [29, 30, 31, 32, 33, 34].
The most common observed anomalies were hypodontia, supernumerary teeth, taurodontism, but also a high prevalence of microdontia have been reported-Peg-shaped upper lateral incisors [ 24, 32, 35].
It is also common for the teeth of people with Down syndrome to have crown and root lengths that are shorter than average except for mandibular first premolar [24, 35]. Conical short teeth, retained teeth, impaction, root dilaceration, fusion, and delayed tooth formation and eruption are other abnormalities found. The reduced permanent crown size have been to reported to be associated with a reduction in both enamel (enamel hypoplasia) and dentine thickness (dentine dysplasia) where enamel was significantly more reduced than dentine; the same authors reported the severity of tooth wear including attrition and erosion and the study displayed a big difference between DS and non-DS children [29, 36, 37, 38, 39, 40].
Taurodontism is a another frequent finding reported among DS persons. Taurodontism together with abnormally short root anatomyis reducing the extent of periodontal attachment and result in tooth mobility which is commonly seen in this population [41,42].
Malocclusion and Malalignment.
People with Down syndrome may have small teeth, which can cause spacing ,but more often, due to a small upper jaw, crowding can be seen because of the teeth and may result in the permanent teeth being “impacted” because there is no room for them in order to erupt.
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Due to the smaller upper jaw it may often create a narrow palate with crowded teeth, class III malocclusion with posterior crossbite. It is also common that the front teeth of people with Down syndrome do not touch due to mouth breathing which can create an anterior open bite [24, 43, 44]. Ondarza et al. examined 136 DS individuals and compared them with mentally impaired individuals and normal Chilean individuals [45]. They showed a higher frequency of malalignments in both the primary and permanent dentition compared with the other groups. The most frequently involved teeth were central incisors, lateral incisors and canines. Anterior and posterior crowding can also often be seen in DS individuals [46].
Large tongue
People with Down syndrome are usually associated with having a large tongue( macroglossia) but to clear this out investigations have shown that they may have a normal sized tongue but a
underdeveloped maxillary jaw that makes their tongue too large for their mouth in combination with constant protruding tongue due to poor control it can be difficult to treat these individuals [24]. Geographic and fissured tongue is frequently seen in DS individuals its an asymptomatic condition caused habitual behaviours such as tongue thrusting, tongue sucking, it may cause food impaction and later on halitosis[47, 48].
Persistent mouth opening due to the relatively large tongue in a small sized oral cavity may be the reason to mouth breathing. Drooling is also a cause due to persistent open mouth and not increased salivary flow rate as it is easy to assume, this can cause a thin mucosal lining in oral cavity [49,50]. Chapped lower lip, and angular cheilitis or infectious lesion at the corner of the mouth are other common features found [14].
Periodontal diseases
Periodontal disease is a serious and morbid oral condition among Down-syndrome individuals [51].
Periodontal diseases are inflammatory diseases of the supporting structures of the teeth and are multifactorial with complex pathogenesis [52, 53, 54]. People with Down syndrome have an
impaired immune system and do not have some of the natural protection functions against the disease as people without the syndrome have [56, 57, 58]. Normally, neutrophils migrate from within the gingival tissues towards the gingival sulcus and build a barrier wall against the bacteria [52, 54]. Within the gingival connective tissue, the gingival macrophages and fibroblasts produce
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inflammatory cytokines that activate collagenases and other degrading enzymes which destroys the gingival collagen and lymphocytes are recruited to the gingival lesion to initiate an adaptive immune response and help with restricting the infection [52, 54]. Increased inflammatory activity disrupts the normal balance of bone formation/resorption and results in alveolar bone loss [52, 53].
It is well known that periodontal diseases develop due to poor oral hygiene status, the Down
syndrome population however are at an increased risk for periodontal disease even when they do not have a lot of plaque and calculus [51, 56]. When the bacteria has the opportunity to advance
subgingivally it can no longer be removed by simple toothbrushing and the inflammation can advance further to the membrane around the tooth and bone, and further progression of periodontal disease will eventually lead to tooth and bone loss [52, 53, 55].
Periodontal disease is an important cause of tooth loss among DS individuals and it is necessary to have a continuous professional preventive care on regular basis [59].
Dental caries
There are different results of various studies. Some researches claim, that patient with Down syndrome have lower DMFT, whereas other studies report that there is no significant difference among healthy people compared with Down Syndrome ones, respectively.
Bradley and McAlister reported a higher prevalence of caries free children among Irish children with DS, compared with children of similar mental status. There are many reasons claimed to be related with a low caries prevalence for instance; delayed eruption- which reduces the time of exposure to a cariogenic environment, hypodontia-less teeth, higher salivary pH and bicarbonate levels- a more alkaline environment, microdontia- spaced dentition and shallow fissures of the teeth- easier to clean [24, 43, 60]. DS individuals who were caries free had also a significantly lower Streptococcus mutans counts [61].
But a more recent experimental study showed that salivary concentration of F, Ca, and Pi was similar between children with and without DSand that the level of Streptococcus mutans was also similar [62].But the dental biofilm of children with DS ,however, showed higher Pi and EPS concentration levels compared to the children without the syndrome.This type of biofilm posses a higher
cariogenic potential and the reason is that EPS is synthesized from sucrose by oral bacteria, and plays an important role in microbial adhesion, and contributes to increased thickness and porosity of the
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biofilm, which increases the concentration of acid at the tooth-biofilm interface [62]. Therefore, bacteria that synthesize higher quantities of EPS tend to be more cariogenic,and despite the
similarity in Streptococcus mutans level and sucrose intake between DS and children without DS-the concentration of EPS was higher in DS individuals compared to those without the syndrome [62]. A caries free state is also dependent on many external factors such as the socioeconomic status and education of patients and their parents [63, 64, 65].
Chairtime
An important factor to consider when treating patients, is to decrease the chairtime and the treatment has to be as atraumatic as possible, this will require true professional skill and knowledge by the operator. Applied treatment method should also be chosen to be the best for patients comfort [66].
There are interesting studies that have evaluated physiological changes related to dental anxiety, such as heart rate. The authors claimed that the heart rate increased among DS patients most probably due to increased treatment time when the non-mechanical method was used [67]. Meanwhile, Poiset et
al., Brand and Shriks et Van Amerongen reported an increase when a high-speed handpiece was used
[68, 69, 70].
Communication problems
The communication is perhaps the most important aspect of the profession and dentists needs to cope with the situation when a DS patient is coming for treatment. Its not very easy since visual, auditory and language problems are common in these individualsand the dental environment with; strong light, sound of hand piece, suction, water, air syringe and the strange taste/ texture of gloves, dental material and instruments plus movement of chair does not make it easier [71, 72].
General anaesthesia
Children with DS may often require a general anaesthetic even for dental procedures, the anatomical abnormalities together with a anxiety and uncooperative behaviour ,which might be reinforced when
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separated from parents and placed in unfamiliar situations,can make it difficult for the dental team to manage the treatment in a safe way [24, 73, 74].
Complications of general anaesthesia can occur among all type group of patients, but especially those with Down syndrome. To start with, delivery of anaesthesia and pain medications IV can be
complicated due to dry thickened skin. Sedation depress some of the natural reflexes that help keep the airways open like coughing, swallowing and to prevent aspiration. Due to Obstructive sleep apnea among downs syndrome, their airway tissues are already prone to collapse during natural sleep, the loss of these reflexes under sedation and the obstructed airways can be deadly due to lack of oxygen reaching the lungs. Depression of these reflexes also implicate that there is no protection of the airways from stomach acid and contents that may reflux into the esophagus. Those contents can reach into the lungs (aspiration) where irritation, inflammation and even infection can result [74].
Atlantoaxial instability a condition common in DS patients, where the joint between the top two vertebrae (C1 and C2) of the neck is unstable and there is a risk for spinal cord injury-the head should stay in relaxed position during dental treatment and unnecessary head extensions should be avoided in these patients [75]. However, studies have been reported that postoperative health have been positively achieved after GA by both parents and surgeons [75, 76].
Even with all possible complications GA needs to be used in some cases in order to prevent future health problems.
Materials and Methods:
Sample Selection
35 children with Down Syndrome and 35 healthy children were included in the study.
Down syndrome patients’ clinical recordings were selected from Clinic for preventive and Paediatric dentistry (LUHS Kaunas Clinics). All patients’ clinical records were screened, subsequently child with Down Syndrome was included to survey if the diagnosis (M.Dauni or Q 90 regarding to ICD) was found in patient’s card or referral.
The subjects of control group were selected randomly from clinic’s records, the first healthy child of the same gender and age, attended Clinic for preventive and paediatric clinic for consultation
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If patients had been sent for treatment under general anaesthesia in Department of maxillofacial surgery (LUHS Kaunas Clinics), the following clinical patients’ histories were taken from Kaunas Clinics archive department.
Age of patients was used as a data when patient was referred for the first consultation to the Clinic for preventive and paediatric clinic. DMFT/dmft index and OHI index were calculated from the first recordings as well.
After having received approval from LSMU Medical Faculty Ethics Committee (Ethics committee protocol code)
Data’s results findings of both groups will be compared.
Caries experience index (dmft, DMFT or DMFT+DMFt) and oral hygiene status and applied treatment methods for each child were evaluated. Patient’s clinical records and were analysed.
DMFT index
WHO Oral Health Surveys Basic Methods (The 5th edition of "Oral Health Surveys - Basic methods) has been used and the recommendations been followed as a guideline to asses the oral health status among DS individuals.
Dental caries experience was counted according to the DMFT and dmft indexes. This index was
presented by Klein et al. in 1938.
DMFT index is a number of decayed (D), Missing (M) and Filled (F) teeth (T) in permanent dentition, whereas dmft index is a number of decayed (d), missing (m) and filled (f) teeth (t) in primary dentition. The mean DMFT or dmft values show caries experience in group and is calculated by adding individual values of all subjects and divided by a number of subjects.
The criteria for diagnosing a tooth status and the coding are as follows:
0- Sound tooth, when there is no evidence of treated or untreated clinical caries.
1- Decayed tooth, when carious lesion is present in following occlusal surface, smooth tooth surface, a tooth with a temporary filling, sealed tooth but also decayed .
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2 - Filled crown, with caries, when one or more permanent restorations and one or more areas that are decayed or no distinction between primary and secondary caries and the same code applies regardless of whether the carious lesions are in contact with the restoration(s).
3- Filled tooth, with no caries, when one or more permanent restorations are present and there is no caries anywhere on the crown; tooth that has been crowned because of previous decay is recorded in this category,;a tooth that has been crowned for reasons other than caries by means of a fixed dental prosthesis abutment is coded 7.
4- Missing tooth, due to caries. This code is used for permanent or primary teeth that have been extracted because of caries. For missing primary teeth, this score should be used only if the subject is at an age when normal exfoliation would not be a sufficient explanation for absence.
5- Permanent tooth missing due to any other reason coded when Permanent teeth deemed to be absent due to congenitally, extracted for orthodontic reasons, periodontal disease, trauma, etc.
6- Fissure sealant. When a fissure sealant has been placed on the occlusal surface, pits or for teeth in which the occlusal fissure has been enlarged with a rounded or “flame-shaped” bur, and a composite material placed.
7- Fixed dental prosthesis abutment, special crown or veneer. When a tooth forms part of a fixed bridge abutment. This code can also be used for crowns placed for reasons other than caries and for veneers or laminates covering the labial surface of a tooth, on which there is no evidence of caries or a restoration.
8- Unerupted tooth. It is used only for a tooth space with an unerupted permanent tooth but no primary tooth.
9- Not recorded. This code is used for an erupted permanent tooth that cannot be examined for any reason such as orthodontic bands, severe hypoplasia, etc.
For the typical indicator age groups of children (12 years) and adults (35–44 years), the following population levels of DMFT may be considered for summarizing the degree of caries experience:
Children 12 years of age (DMFT); Very low <1.2, Low 1.2–2.6; Moderate 2.7–4.4; High 4.5–6.5; Very high >6.5.
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Oral hygiene assessment
Oral hygiene was evaluated by Silness-Loe plaque index (PI) (plaque accumulation and the gingival index) (Löe H. Silness J. 1963), which determines the amount and location of dental plaque. A plaque disclosing agent was not used during examination. An examination of plaque was performed using probe and visually.
The scale of oral hygiene assessment:
0 – an excellent;
0.1- 0.9 – good;
1.0- 1.9 – fair;
2.0- 3.0 – poor.
All the records were coded and statistical analysis was performed using SPSS 19 version.
Consequently, Pearson Chi Square test was used to calculate p-value for parametric variables and Mann-Whitney U test was used for non-parametric variables, respectively. The level of significance was set at P<0.05. Confidence interval = 95%.
RESULTS
In total 70 paediatric patients were included as the participants in this retrospective survey. The distribution of both groups was the following 35 children with Down Syndrome and 35 children of control group.
Age
Age mean of both groups was 7.3(3.24) year old children, while age mean among patients with Down Syndrome was 7.34(3.3) and 6.97(3.21) years in control group, respectively (p=0.607). The age of patients in both groups ranged from 2 year to 13 years old.The most prevalent age of patients was 5 year old in both groups.
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Gender
Considering by gender, more boys than girls were included to the study in both groups, 54.3% in control group and 51.4% in DS group, respectively. While no statistically significant difference was noticed among distribution by gender (p=0.811).
Reason for dental appointment in Clinic for preventive and paediatric dentistry
The most common reason for dental visit was dental caries or complications due to dental caries (95.7%), whereas 2 patients (1 child with Down Syndrome and 1 child from control group) suffered from apthtous stomatitis and 1 child with Down Syndrome had chickenpox.
Number of consultations in Clinic for preventive and paediatric dentistry
Results showed that mean of consultations was 1.67(1.56) among all participants in LUHS Clinic for preventive and paediatric dentistry, whereas this mean was 1.26(0.1) in control group and 2.09(0.35) among children with Down syndrome, respectively. Moreover, a statistically significant difference was found among both groups (p=0.031) (Table 1).
Majority of patients (71.4%) had one consultation, while 14.3% had two consultations, 8.6% had 3 consultations and 5,6% had 5 to 9 consultations, respectively.
DMFT/dmft index
Mean DMFT/dmft score among both groups was 6.3. Meanwhile, mean DMFT/dmft score was 6.08 among children with Down Syndrome and 6.6 in control group, respectively.
Moreover, 10 % of data about DMFT index was missed because it was impossible to find filled teeth formula or already counted DMFT index in patients’ clinical records.
Oral hygiene status
Surprisingly, approximately three quarters (74.3%) of data about oral hygiene status were not found in patient’s clinical records. Furthermore, only 2.9% had excellent oral hygiene status, while 14.3% had good or moderate oral hygiene status and remaining subjects (8.6%) had poor oral status, respectively. There was no statistically significant difference between both groups (p=0.946). No any records about periodontal status were found in patients clinical records.
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Treatment procedures performed for all patients
Various treatment procedures were done for both groups patients regarding to oral status, current complains. Figures 1 and 2 present the main features of accomplished dental treatment procedures for control and subjects’ groups.
Fig.1. Distribution of various treatment procedures for control group patients.
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Treatment procedures performed in Clinic for preventive and paediatric clinic
A total 67.1% of subjects did not have any dental treatment in Clinic for preventive and paediatric clinic. Results showed that less children with Down syndrome had dental treatment than patients of control group (14.3% vs. 51.4%), but no statistically significant difference was found (p=0.084). Number of procedures for patients who had a dental treatment varied from 1 appointment to 13 ones in control group and from 1 to 5 visits, respectively.
Overall the mean of treatment procedures in clinic value was 1.14(2.41), while 0.37(0.18) among children with Down Syndrome and 1.91(0.52) in control group, respectively. Furthermore, a
statistically significant difference was found comparing mean of treatment procedures in clinic value among both groups (p=0.001) (Table 1).
Types of treatment procedures performed in clinic
Figure 3 presents the main dental treatment procedures performed for all patients in Clinic for preventive and paediatric dentistry.
Non operative caries treatment methods such as instructions of oral hygiene were applied for majority of patients. Subsequently, removal of plaque and fluoride applications were performed rarer.
The most common dental treatment procedures were the following uncomplicated caries lesions treatment and pulpotomy, whereas extractions were not common. Meanwhile, only few sealants were applied.
Overall, treatment of primary teeth was not done for 85.7% of patients. Results showed that more children in control group than patients with Down Syndrome had caries treatment in primary dentition (20% vs. 8.6%), but it did not differ significantly (p=0.384).
Number of treated primary teeth ranged from 0 to 7 in control group and from 0 to 3 among children with Down Syndrome, respectively.
Meanwhile, mean of treated primary teeth value was 0.43(1.22) among all participants and it was higher in control group than among children with Down Syndrome (0.69(0.27) vs. 0.17(0.10)), respectively. Furthermore, a statistically significant difference was found among both groups (p=0.005).
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(84.3%) did not have permanent teeth treatment in clinic.
Comparing both groups, a significantly higher number of control group children (28.6%)had permanent teeth treatment than children with Down Syndrome (2.9%), respectively. Furthermore, a statistically significant difference was found among both groups prevalence (p=0.03).
Number of treated permanent teeth ranged from 1 to 4 in control group and only 1 tooth was treated in other group, respectively.
Overall mean of treated permanent teeth value was 0.24(0.67) among both groups, while it was significantly higher in control group than among children with Down Syndrome (p=0.003) (Table 1). Consequently, results showed that mean of treated teeth in both type of dentitions value was
0.67(1.56) and this mean value was significantly higher in control group than in subject one (p=0.005) (Table 1).
Majority of patients (98.6%) did not have tooth extraction in clinic, while only one primary tooth was extracted for a child from control group. A total mean of extracted teeth value was 0.01(0.12) and it did not differ significantly among both groups (p=0.317).
Results showed, that sealants were placed for 5.7% of patients among both groups, while no any sealant was applied for children with Down Syndrome and up to 4 sealants was places for 4 patient in control group, respectively.
The mean of placed sealants in clinic value was 0.19(0.82) and a statistically significant difference was noticed among both groups (p=0.041) (Table 1).
24
Fig.3. Distribution of treatment procedures performed for both groups in clinic.
Treatment procedures performed in Department of maxillofacial surgery under general anaesthesia
A total 40% of both groups patients had dental treatment procedures in Department of maxillofacial surgery (LUHS Kaunas Clinics). While statistically significant difference was found between more patients with Down Syndrome and children of control group (68.6% vs. 11.4%) (p<0.001).
Moreover, some patients were hospitalised more than once, distribution of treatment’s procedures number in hospital was the following 1 time (37.1%), 2 times (20.0%), 3 times (8.6%) and 4 times (2.9%) among children with Down Syndrome; and 1 time (8.6%) and 2 times (2.9%) in control group, respectively.
25
The overall mean of hospitalized patients value was 0.64(0.94) among both groups. Furthermore, a statistically significant difference of mean of hospitalised patients value among both groups was noticed (p<0.001) (Table 1).
Types of treatment procedures performed in hospital
Figure 4 shows the distribution of dental treatment procedures for all patients performed in hospital. The most common performed procedure for patients was teeth extractions in hospital.
Total mean of extracted teeth for patient value was 2.3(4.44) in hospital; and a statistically significant difference was noticed among both groups (p=<0.001)(Table 1).
Firstly, 51.4% of patients with Down Syndrome had primary teeth extractions. Meanwhile, a number of extracted primary teeth for patient varied from 1 to 20. Subsequently, only 11.4% of control group patients had the same procedure and a number of extracted primary teeth ranged from 2 to 6,
respectively. Although, no statistically significant difference was found (p=0.155).
Secondly, 28.6% of DS patients had permanent teeth extractions in hospital and no any permanent teeth were extracted for control group children, furthermore a statistically significant difference of permanent teeth extraction between both groups was found (p=0.042).
Overall mean of extracted permanent teeth in hospital value was 0.48(1.43) and a statistically significant difference of this mean between both groups was noticed (p=0.001)(Table 1). Caries treatment or pulpal therapy were performed for 34.3% of all patients under general anaesthesia. More children with Down Syndrome (37.1%) had restorative treatment than control group children (2.9%), whereas no statistically significant difference was found between these groups (p=0.084).
More children with Down Syndrome had primary teeth restorative treatment (14.3%) than healthy children (2.9%), but it did not differ significantly (p=0.310). Number of treated primary teeth varied from 1 to 6 teeth and mean values were the following 0.6(0.28) among children with Down
Syndrome and 0.11(0.11) in control group, respectively. There were no statistically significant difference between both groups (p=0.088).
Consequently, only children with Down Syndrome (25.7%) had permanent teeth restorative dental treatment under general anaesthesia. Number of treated permanent teeth varied from 1 to 11 and mean value was 1.17(0.43) among children with Down Syndrome (p=0.001).
26
Fig.4. Distribution of treatment procedures performed for both groups in hospital.
27
Table 1. Mean values of items among children with Down Syndrome and control group.
Means of items Children with
DS
Control group
Total P-value
Number of consultations in clinic 2.08(0.35) 1.26(0.10) 1.67(1.56) 0.031
Number of treatment procedures in clinic.
0.37(0.18) 1.91(0.52) 1.14(2.41) 0.001
Number of treatment procedures in hospital.
1.14(0.18) 0.14(0.07) 0.64(0.94) <0.001
Number of extracted primary teeth in hospital. 3.2(0.86) 0.43(0.22) 1.81(3.95) <0.001
Number of extracted permanent teeth in hospital.
0.97(0.32) 0.00(0.00) 0.48(1.43) 0,001
Number of extracted teeth (primary and permanent) in hospital
4.17(0.94) 0.43(0.22) 2.3(4.4) 0.001
Number of treated primary teeth in hospital
0.6(0.28) 0.11(0.11) 0.35(1.27) 0.088
Number of treated permanent teeth in hospital
1.17(0.43) 0.00(0.00) 0.58(1.88) 0.001
Number of treated teeth (primary and permanent) in hospital.
1.77(0.47) 0.11(0.11) 0.94(2.19) <0.001
Number of treated primary teeth in clinic
0.17(0.10) 0.69(0.27) 0.43(1.22) 0.005
Number of treated permanent teeth in clinic.
28
Discussion
There are many factors which can aggravate a dental procedure when treating children and especially
those with DS. However, common characteristics such as being quiet, passive, natural spontaneity,
genuine warmth, loving music, gentleness, tolerance and honesty can make a treatment approach possible without sedation [24, 77].Despite the adequacy of low IQ and delayed mental development, DS individuals have different characters as well as different levels of inabilities, where it has been shown that moderate to mild mental retarded individuals are mobile, functional and can perform well and are highly motivated during workshops [78].
A total two thirds of patients did not have restorative treatment in the clinic for preventive
paediatrics. The results of this study showed that significantly less children with Down syndrome had dental treatment in comparison to patients of control group in clinic.
Patients with DS have difficulties to communicate with other people and the unknown environments, but its the dentist job to win trust from patients, a way is to ask the guardian about the patient’s level of intellectual and functional abilities. Tell- show- do is very practically since visual-spatial
processing and perception are generally viewed as strengths in individuals with DS- short, clear instructions given together with pictures and models are recommended when dealing with this group of patients [77].
The majority of all patients (71.4%) had only one consultation and the same situation was also observed with the majority of patients with Down syndrome group. These findings might indicate that patients with DS were not/or less cooperative than children from control group and were referred Number of treated teeth (primary and
permanent) in clinic.
0.20(0.10) 1.14(0.34) 0.67(1.56) 0.005
Sealants placed in clinic. 0,00(0.00) 0.37(0.19) 0.19(0.82) 0.041
Sealants placed in hospital. 0.23(0.14) 0.00(0.00) 0.11(0.58) 0.079
DMFT/dmft index 6.08 6.6 6.3(5.2) 0.823
29
for treatment under general anaesthesia in hospital. Moreover, a relatively high percentage of control group children were referred to Department of maxillofacial surgery as well due to
uncooperativeness in the Clinic for preventive and paediatric dentistry, but as searching of data showed that a quite low number of these children had dental treatment in the hospital. The main reasons could be, that parents went to other clinic or some codes were missed in patient’s clinical record and it was impossible to find patients history from Department of Archive.
Preventive and prophylactic dentistry as in maintaining good oral hygiene and control subgingival plaque is of high importance for children and young people especially with Down syndrome and should be emphasised since it has been shown that non-surgical periodontal therapy suppresses the development of periodontal diseases in this population [79, 80, 81, 82, 83]. However, removal of plaque and fluoride applications were performed for many patients, but only few sealants were applied in both groups. This finding could be due to that patients were referred (from their doctors) mainly for consultation and placement of sealants was perhaps done elsewhere.
A follow up study of children with DS, being treated with Castillo-Morales plate with a mean age of 1,1 yrs for 19 months, showed improved orofacial appearance and function that remain stable after 13 years, which can tell us that these appliances can be beneficial to improve the motor awareness of these children, which might be of help when trying to keep a good oral hygiene without professional help [84].
Mean DMFT/dmft score among both groups was 6.3 and it was higher in control group than among children with Down Syndrome (6.6 vs 6.08), respectively. It might be that children in control group allowed to be examined thoroughly and doctors could record dental formula more precisely.
The level of function in all medical and psychological aspects among these individuals seems to play a huge role in weather a dental treatment without sedation is possible or not. Since general
anaesthesia also has increased recently among healthy children, we can assume that anxiety and inability to convince paediatric patients into treatment without sedation is a problem in all groups of paediatric patients and not only among DS [85, 86].
By having a dental care system where clinics send out mandatory invitations for a consultation in the paediatric clinic will most probably increase the amount of visits by patients to the clinic, and the preventive measures will be detected earlier, the sooner a treatment will take place-the better the dental rehabilitation will be and might as well prevent future complications [78].Another advantage of having frequent recalls/ periodic preventive care with professional help, is that the patient will be
30
familiar with the dental office and its staff, also having professional oral hygiene instead of a invasive treatment might feel more pleasant for the patient and less chance of developing dental anxiety and the patient will come for next recall. Periodic preventive care has been proven to be effective for suppressing the progression of periodontal disease in young adults with DS [54, 79]. It has also been reported that non-surgical mechanical periodontal therapy with the adjunctive use of chlorhexidine gel (for toothbrushing) and chlorhexidine (moutwash) followed by monthly recalls can show good healing response on DS patients [81].
As we know there are difficulties with these patients and a comprehensive medical anamnesis and safety precautions can not be underestimated when planning a treatment for DS subjects.
Acknowledgement
I submit my heartiest gratitude to my respected teacher Dr. Sandra Žemgulytė for her sincere guidance and help for completing this study…
Conflict of interest
31
Conclusion
Children with Down syndrome had more extensive treatment than children from control group in this study. Also our results regarding treating children under GA may reveal the importance of using behaviour management techniques when treating children with special needs. Since dentists have obligations to prevent oral diseases-guidelines and techniques should be included in dental education program in order to be able to treat these patients in the most safe way. Frequent recalls with a dental hygienist have been reported to help down syndrome patients to control their oral conditions however , the clinical records needs to be documented in order to have precise followups of these patients. Without any records it will be almost impossible to notify improvements and design a proper treatment plan. Another essential factor is to educate and motivate parents about the importance of the oral health when it comes to their children.
Practical recommendations
In certain situation it is almost impossible to accomplish comprehensive oral examination for patient, but some data were not analysed due to not fully done clinical records by doctors. Therefore, it is very important for doctors to fill clinical records properly.
Ethical statement
32
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Annex No.10
EVALUATION FORM OF THE MASTER’S THESIS FOR THE MEMBER OF DEFENCE COMMITTEE
Graduate student
___________________________________________________________________, of the year ______, and the group _____ of the integrated study programme of Odontology
Master’s Thesis title: ………...……….………...…………
………...….………...……...
No. MT evaluation aspects
Evaluatio n
Yes Partially No
1 Has the student’s presentation lasted for more than 10 minutes?
2 Has the student presented the main problem of the Master’s thesis, its aim and tasks?
3 Has the student provided information on research methodology and main research instruments?
4 Has the student presented the received results comprehensively?
5 Have the visual aids been informative and easy to understand?
6 Has the logical sequence of report been observed?
7 Have the conclusions been presented? Are they resulting from the results?
8 Have the practical recommendations been presented?
9 Have the questions of the reviewer and commission’s members been answered correctly and thoroughly?
10 Is the Master’s thesis in compliance with the essence of the selected study programme?
40
Remarks of the member of evaluation committee of Master’s Thesis
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Evaluation of the Master’s Thesis
_____________________________________________________________________________
Member of the MT evaluation committee:
________________ ___________________________ _____________________
(scientific degree) (name and surname) (signature
41
