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M.F. Mathias*, M.R.L. Simionato**, R.O. Guar***

*Discipline of Dentistry, Universidade Cruzeiro do Sul, So Paulo,
Brazil
2 **University of So Paulo, Brazil
***Discipline of Dentistry, Persons with Disabilities Division,
Universidade Cruzeiro do Sul,So Paulo, Brazil
e-mail: mariliafmathias@yahoo.com.br

Some factors associated

with dental caries
in the primary dentition
of children
with Down syndrome
ABSTRACT
Aim It is well reported in the scientific literature that there is
a high level of periodontal disease and lower caries
prevalence in Down Syndrome (DS) individuals, when
compared with age-matched non DS individuals. This study
was conducted to investigate the process of dental caries in
DS children.
Materials and method s In this study the following
parameters were considered: oral hygiene habits, levels of
Streptococcus mutans (SM) and Lactobacillus spp. (LB),
Modified Gingival Index (MGI), and Simplified Oral Hygiene
Index (OHI-S). A case group with DS children (n=69) and a
control group of non DS children (n=69) were formed to
perform this study. Dental caries severity was determined
using the DMFT index. Samples of non-stimulated saliva were
collected to determine the Lactobacillus spp levels. For SM
levels, MSB agar plates were used.
Results The findings revealed that the case group attended
dental check-ups more frequently, brushed their teeth more
times per day, flossed less, and also more frequently had SM
levels classified as high count. The MGI was higher and the
OHI-S was lower than the control group (p<0.001).
Conclusion No significant differences were found between
the DMFT indexes of children from the two groups (p=0.345).
The logistic regression analysis showed that in the case group,
age, MGI, and SM count were positively related to dental
caries (p<0.05).
Keywords: Paediatric dentistry; Down Syndrome; Dental
caries.

Introduction
Down syndrome is characterised by the presence of an
extra copy of chromosome 21 [Cutress, 1971] and its
prevalence is approximately 1:800 live births [Rogers et al.,
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1996]. There is a strong correlation between maternal age

and the risk of having a child with DS. At 30 years of age,
the risk ratio is 1:1000 and it increases to 9:1000 for
women over 40 years old [Jojnstone et al., 1999].
Approximately 80% of individuals with DS have an
intellectual quotient (IQ) ranging between 25 and 50.
Weight and height values at birth are below average and
there is a delay in growth as well as early aging [Pinazo
et al., 1998]. They are more susceptible to infections of
the gastrointestinal, respiratory, and urinary tracts due to
immune-system deficiencies (T lymphocytes) [Rogers et
al., 1996]. They have a greater risk of developing
leukemia (15 to 20 times greater than individuals
without
this
syndrome)
and
hypothyroidism
(approximately 8 times more frequent) [Pinazo et al.,
1998]. Approximately 40% to 60% of individuals with
DS present with congenital heart diseases, which can be
treated during early stages of life, resulting in a good
prognosis [Rogers et al., 1996; Desai and Faytetteville,
1997; Fiske and Shafik, 2001].
Several dental anomalies are also observed, such as:
hypodontia, olygodontia, conoid teeth, microdontia,
enamel hypocalcification, fusion and gemination [Allison
et al., 2000]. In general, there is a delay in both primary
and permanent tooth eruption in individuals with DS, and
the primary dentition is not fully completed before 4 or 5
years of age [Pinazo et al., 1998].
Individuals with DS are known to have a greater
predisposition to periodontal disease due to alterations in
their immune system [Desai and Faytetteville, 1997;
Reuland-Bosma et al., 1986]. There have also been reports
of low caries incidence in this population, which could be
related to a variety of factors including the buffer capacity
of their saliva, delayed eruption, generalised diastemas,
and a tendency towards bruxism that wears the occlusal
surfaces of teeth, making them flat and smooth [Jojnstone
et al., 1999; Shapira and Stabholz, 1996]. Other factors
that could be associated with this low caries prevalence
are: colonisation by S. mutans with a less cariogenic
profile, difference in the acidogenecity or acidoduricity of
strains [Cogulu et al., 2006a] and high levels of salivary
IgA [Cogulu et al., 2006b].
The aim of this study was to evaluate the clinical factors,
microbiological levels and oral hygiene habits in caries
disease in the primary dentition of DS children.

Material and methods

The case group was composed of 69 children with
Down syndrome between 13 and 85 months old. They
were examined at the Irmandade da Santa Casa de
Misericrdia de So Paulo, Darcy Vargas Childrens
Hospital, Associao de Pais e Amigos dos Excepcionais
(APAE) of the city of Barueri, Brazil.
The control group consisted of 69 children without
congenital anomalies, selected among students of the
Marly Teixeira de Almeida kindergarten, Barueri, So
Paulo, who were paired with children of the case group
considering gender, age and number of erupted teeth. As
the DS children present a delay in the dental eruption
process and this factor could influence their caries

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MATHIAS MF, SEMIONATO MRL AND GUAR RO

prevalence, an age compensation was necessary.
In the case group 26 children did not present complete
primary dentition. Based on their ages it was possible to
identify an average delay of 9 months for girls and 13
months for boys, when compared with the data from
tables proposed by Logan and Kronfield (1933) and
McCall and Shour (1941). This information was used for
pairing the children with complete primary dentition. As
this approach was not valid for the younger individuals (for
example 13 months old), a secondary criteria based on the
number of erupted teeth was adopted for pairing them.
Only children with DS in their primary dentition were
included in the study and the exclusion criteria were:
children with local oral factors (soft or hard tissue tumors,
stomatitis, recurrent canker sores or major oral
pathologies) and children who had participated in another
clinical study 30 days prior to the development of the
present study.
The clinical examination and data collection were
performed in the following steps: an interview with the
participants legal guardians during which all procedures
to be carried out were explained and a questionnaire
together with a consent form had to be filled out and
signed; saliva sample collection for microbiological
analysis; determination of GMI and OHI-S, tooth brushing
(after the saliva sample collection) and examination to
obtain the DTMF index. All exams were performed by a
calibrated examiner in a dental office under artifical
lighting. The calibration was done through repeated
exams during the course of the study (Kappa intraexaminer agreement was 0.89 for DTMF index, 0.83 for
OHI-S and 0.88 for GMI). Preparation of culture plates for
S. mutans and Lactobacillus spp. and the quantification of
colony-forming units of both bacteria were performed at
the Oral Microbiology lab of the Biomedical Scientific
Institute of the University of So Paulo.

Medical and dental history

General information regarding the medical and dental
history and oral hygiene habits of all children from the
case and control groups were obtained from the
participants legal guardians in a questionnaire. The
questions covered: presence of chronic disease, intake of
medications, access to dental care, tooth brushing
supervision (whether the child brushed its teeth alone,
with the fathers or mothers help, or the help of others),
brushing and flossing frequency (not brushing their teeth,
brushing 1 time per day, 2 times, three or more times).
Information regarding the mothers age and occupation
was also collected.

Salivary levels of Streptococcus mutans

The salivary levels of Streptococcus mutans were
determined using mitis-salivarius bacitracin (MSB) agar
plates, prepared as recommended by Gold et al. [1973].
The non-stimulated saliva samples were obtained using a
spatula, as described by Khler and Bratthal [1979]. The
plates were placed in plastic bags, in a microaerophilic
environment, which was obtained by vacuuming the air,
and were incubated at 37C for 48 hours in a portable
kiln. The Khler and Bratthals classification was used to
count the bacterial colony-forming units.

38

Salivary levels of Lactobacillus spp

Rogosa agar plates were used in this phase of the
experiment. Since participants with Down syndrome were
not able to cooperate, salivary samples were obtained
using an adapted device. A highly powerful vacuum and
two tubes were used, with one tube attached to the pump
and the other inserted in the childs oral cavity, and the
other end of both of tubes going through the BD
Vacutainer lid. The classification proposed by Klock and
Krasse (1977) was used, as follows: <104, 104-105, 105106, >106.

Simplified Oral Hygiene Index

The patients oral hygiene was evaluated according to
the criteria used in the Simplified Oral Hygiene index (OHIS) proposed by Greene & Vermillion [1964]. With the tip of
a cotton bud, a plaque disclosing agent was applied on
the buccal surfaces of the primary maxillary right central
incisor, the mandibular left central incisor and the maxillary
second molars, bilaterally, as well as on the lingual
surfaces of the mandibular second molars. These surfaces
were examined and given a score from 0 to 3.

Modified Gingival Index

To evaluate periodontal disease, the index proposed by
Le & Silness [1963] and modified by Lobene et al. [1986]
was used, and this technique does not include the
application of pressure with a probe to determine the
presence or absence of gingival bleeding.
The primary teeth evaluated (gingival margins and
papillae) in each oral quadrant were: maxillary right
second molar, maxillary right lateral incisor, maxillary left
primary molar, mandibular left second molar, mandibular
left lateral incisor, and mandibular right primary molar. The
MGI consists of visual examination only, using scores from
0 to 4.

DMFT Index
After brushing the childrens teeth, the dental surfaces
were dried with sterile gauze. Intraoral examination was
systematically carried out, quadrant by quadrant, using a
dental mirror and a dental probe with a blunt tip. The
index chosen for carious lesion diagnosis was the DMFT
[Grubell, 1944], and the diagnostic criteria were those
recommended by the World Health Organization (WHO) in
1987.

Statistical method
For statistical analysis the Chi-square test, Fishers Exact
test or t-tests for two independent samples were used.
The Chi-square test was used for groups comparison with
regard to the qualitative variables. When it was not
possible to apply the Chi-square test, the Fisher Exact test
was used. The numerical variables (mothers age and
DMFT) were compared by the t-test for independent
samples. Statistical difference that is, the statistical
difference level considered significant between the groups
was set at p < 0.05.
A univariate logistic regression analysis was also
performed to determine which parameters (childs age,
total number of surfaces, OHI-S, GMI, SM count,
Lactobacillus spp. count and cardiopathy) could be
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FACTORS ASSOCIATED TO CARIES IN DOWN SYNDROME CHILDREN

Characteristics

Case N (%)

% having regular dental visits

Yes
38 (55.1)
Oral hygiene orientation
Yes
40 (58.0)
Who brushes the childs teeth?
Does not brush
6 (8.7)
Mother
55 (79.7)
Father
1 (1.5)
Others
1 (1.5)
By himself/herself
2 (2.9)
Mother and Father
4 (5.8)
Daily frequency of toothbrushing
Does not brush
6 (8.7)
Once
2 (2.9)
Twice
38 (55.1)
3 times
23 (33.3)
Instrument used for brushing
Does not brush
6 (8.7)
Wet cloth
4 (5.8)
Toothbrush
58 (84.1)
Finger brush
1 (1.5)
% children flossing (once a day)
Yes
4 (5.8)
% mothers working outside the house
Yes
21 (30.9)

Control N (%)

0.010*
23 (33.3)
0.729*
<0.001*
6 (8.7)
35 (50.7)
1 (1.5)
3 (4.4)
9 (13.0)
15 (21.7)
0.016*
6 (8.7)
14 (20.3)
31 (44.9)
18 (26.1)
0.813*
6 (8.7)
3 (4.4)
59 (85.1)
1 (1.5)
< 0.001*
21 (30.4)
0.001*
40 (58.0)

Results
Oral hygiene habits, age and mothers
occupation
Comparison of the frequency of dental follow-up was
statistically significant, indicating that DS children visit the
dentist more regularly than non DS ones (Table 1). There
was no statistically significant difference between the
groups with regard to receiving oral hygiene guidance, as
the majority was given professional guidance.
In the case of DS children, tooth brushing was
performed by the mother in the majority of cases, and also
in the control group tooth brushing was largely performed
by the mothers, though in an important portion tooth
brushing was performed by the child itself and by the
mother and father, with statistically significant difference
between the groups (p<0.001).
In general, the DS children brushed their teeth more
times per day than the children without the syndrome,
and the comparison was statistically significant. The mean
number of times that the children brushed their teeth per
day was 2.13 in the case group and 1.88 in the control
group (Table 1).
There was no statistically significant difference between
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TABLE 1 - Frequency of
regular visits to the dentist
and oral hygiene habits of
children with DS and children
without the syndrome.

42 (60.9)

associated with dental disease, defined as DMFT?1. This

analysis was performed separately for the DS and non DS
groups, in order to verify whether the parameters
associated with caries were the same in the two groups.
It was also investigated whether the caries risk could be
associated with the individuals condition using a
contingency table.

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the groups as regards the resource used for tooth

brushing, as the large majority in both cases used a tooth
brush (Table 1). However, DS children tended to use dental
floss less frequently than non DS children, and this
comparison was statistically significant (Table 1).
The larger part of mothers of DS children did not work
outside the home, while in the non DS childrens group,
the opposite occurred, and the majority of mothers were
employed. In this case, the deceased mothers or those
who had disappeared were not taken into account. In
Table 1, mothers who were retired, unemployed,
laid off work or housewives were inserted in the
category do not work outside of the home.
Comparison between the age of the childrens mothers
presented statistical significance, indicating that the
mothers of children with DS were a little older than the
mothers of the group of non DS children (Table 1).

Frequency of CFUs of Streptococcus mutans

and Lactobacillus spp.
Significant difference was identified in the SM count, as
the mean count (105 to 106 CFUs of S.Mutans/ml saliva)
was more frequent in the control group and the high
count (over 106 CFUs of S.Mutans/ml saliva) was more
frequent in the DS group. There was no significant
difference as regards low SM count (Table 2).
Table 2 shows no statistical difference between the
groups as regards the LB count. In all the children with
counts considered below 104 CFU/ml, in reality in 9 cases
(3 DS and 6 non DS) this count was so low that it was not
detected. Moreover, in 7 cases (all DS) it was not possible
to collect a saliva sample due to the very low salivary flow
and little cooperation from the child.

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MATHIAS MF, SEMIONATO MRL AND GUAR RO

Characteristics
S. Mutans CFUs/ ml saliva
5
Low (< 10 )
5
6
Medium (10 10 )
6
High (> 10 )
Lactobacillus count (CFUs)
4
< 10
4
5
10 10
5
> 10

Case N (%)

Control N (%)

20 (29.0)
15 (21.7)
34 (49.3)

12 (17.4)
37 (53.6)
20 (29.0)

55 (88.7)
5 (8.1)
2 (3.2)

66 (95.7)
1 ( 1.5)
2 ( 2.9)

TABLE 2 - S. mutans and

Lactobacillus spp. count of
the case group and control
group.

P
0.001*

0.190**

N
Mothers age (years): p<0.001
Case
69
Control
69
MGI: p<0.001
Case
69
Control
69
OHI-S: p=0.017
Case
69
Control
69
DMFT: p=0.345
Case
69
Control
69

Average

SD

Minimum

Median

Maximum

34.1
26.1

8.5
5.5

14
16

37
25

47
41

2.64
0.31

2.45
0.40

0
0

2.00
0.17

8.33
1.50

1.11
1.37

0.58
0.66

0
0

1.17
1.50

2.33
2.67

2.2
3.4

6.3
8.1

0
0

0
0

33
46

TABLE 3 - Mothers age, dental caries index, MGI and IHO-S values of the case group and control group.

MGI, OHI-S and DMFT Index

Table 3 shows that there was a statistically significant
difference between groups as regards MGI, as children
with DS presented a higher MGI than children without the
syndrome.
As regards OHI-S, there was also a statistically significant
difference between the groups, as children with DS
presented a lower OHI-S than children of the non DS
group (Table 3).
The difference in the DMFT index between the groups
(Table 3) was found to be not statistically significant.

Logistic Regression
Study group: Table 4 shows that the childs age and MGI
are associated with dental caries. It also shows that
children with a high level of SM CFU count (>106) have
more propensity to risk of caries than those with a count
considered low or medium (106).
The variables: LB count, OHI-S and cardiopathy were not
shown to be associated with dental caries (Table 4).
Control group: Table 5 reveals that only the variables
childs age and MGI are associated with dental caries.

Discussion
The literature has reported the high incidence of
periodontal disease in individuals with DS and that the
presence of dental biofilm was not related to the severity
of periodontal disease, indicating that the main
aetiological factor would be an alteration in their immune
mechanism. Other studies, such as that of Shapiro et al.
[1969], found a positive correlation between deficient oral
hygiene and severity of bone loss in young individuals with

40

the syndrome. The fact that drew attention in the present

study was that despite the majority of children with DS
presented lower OHI-S values, these children obtained
higher MGI values, indicating that the presence of the
dental biofilm was not related with the gingivitis found in
these individuals.
Although factors such as lack of access to professional
care [Allison et al., 2000; Lpez-Perez, 2002], low efficacy
of care at home, and limited manual dexterity are
mentioned in the literature as being responsible for the
severity of the gingivitis observed since the stage of
infancy of DS individuals, in the present study it could be
observed that the children with the syndrome had regular
dental check-ups, statistically more frequently than those
in the control group. In So Paulo city and its suburbs,
where this study was conducted, there are several public
hospitals, such as the Darcy Vargas Hospital, as well as
charity institutions such as the APAE, Basic Health Units
and dentistry schools in Barueri, which offer dental
treatment and periodic preventive and educational followups for children with DS. However, in many
underprivileged regions of Brazil, access to dental
treatment for patients with special needs is still not a
tangible reality.
It is necessary to emphasize that, in most cases, children
with DS had their teeth brushed by their mothers. It was
also observed that the mothers of the case group children
did not work outside their homes, perhaps due to the fact
that these children need full time care. Nevertheless,
perhaps due to DS children having difficulty with
understanding and cooperating, the use of dental floss
was more common among children from the control
group.
A variety of studies have reported a lower caries
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FACTORS ASSOCIATED TO CARIES IN DOWN SYNDROME CHILDREN

Parameter

Class

Total N

DMFT >1
N (%)

OR

95% CI

Age (months)

69

17 (24.6)

1.04

0.013

1.01 1.07

OHI-S

69

17 (24.6)

1.09

0.864

0.42 2.82

MGI

69

17 (24.6)

1.40

0.006

1.10 1.78

SM Count

Low + medium
High

35
34

5 (14.3)
12 (35.3)

1.00
3.27

0.049

1.01 10.64

< 104
? 104

55
7

12 (21.8)
4 (57.1)

1.00
4.78

0.060

0.94 24.34

no
yes

49
20

12 (24.5)
5 (25.0)

1.00
1.03

0.964

0.31 3.42

LB count

Heart Disease

TABLE 4 - Variables related to dental caries in children with DS: univariate logistic regression analysis.

Parameter

Class

Total N

DMFT >1
N (%)

OR

95% CI

Age (months)

69

22 (31.9)

1.08

<0.001

1.04 1.12

OHI-S

69

22 (31.9)

1.78

0.182

0.76 4.12

MGI

69

22 (31.9)

5.52

0.012

1.47 20.8

SM count

Low + medium
High

49
20

15 (30.6)
7 (35.0)

1.00
1.22

0.723

0.41 3.67

< 104
> 104

66
3

21 (31.8)
1 (33.3)

1.00
1.07

0.956

0.09 12.5

LB count

TABLE 4 - Variables related to dental caries in children with DS: univariate logistic regression analysis.

prevalence in patients with DS, nevertheless, Cutress

[1971] and Fung and Allison [2005] reported that when
compensation was made for hypodontia and delayed
eruption, the caries indexes were the same between
individuals with and without DS. In this study, after
adjusting the factor delayed eruption, a slightly lower
DMFT was found in the group of children with DS than in
the control group, although this difference was not
statistically significant.
In the DS group a high S. mutans CFU count was also
observed, which could be justified by the reduced salivary
flow rate frequently found in these children, causing a
greater concentration of CFU per milliliter of saliva.
However, in the logistic regression, it was verified that
children with DS with a high S. mutans CFU count (>106)
presented a greater risk of developing dental caries than
children with a medium or low count.
In the present study it was not possible to identify an
association between Lactobacillus spp. count and dental
caries, although this variable was almost significant in the
DS group. In both groups the majority of children
presented a low CFU count for this type of bacteria
(<104). Of the total sample in this study, consisting of 138
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children, only 36 individuals (18 from the case group and

18 from the control group) presented untreated cavitated
lesions. This could explain the low Lactobacillus spp. count
observed.
The variable childs age showed to be positively
associated with dental caries in both groups. These results
are in agreement with those of Walter et al. [1997], who
pointed out an increase in caries prevalence with age, with
a maximum prevalence between 13 and 24 months of age
due to: a greater number of dental surfaces to be
colonized, the introduction of sweetened food into the
childs diet and socialization through contact with other
people who offer sweets.
The MGI presented an association with dental caries in
both groups. In a study SantAnna et al. [2001] stated that
swelling or bleeding of the papillae was associated with
carious lesions in the cervical third, especially proximal
lesions. However, Beighton et al. [1996] studied a sample
of 328 twelve-year-old British schoolchildren and
concluded that dental caries experience was not
influenced by the GI.
The aim of the OHI-S is to identify personal oral hygiene
habits and both in the case and control groups this index

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MATHIAS MF, SEMIONATO MRL AND GUAR RO

was not associated with dental caries. This is in agreement
with Mayer and Lorenzo [2004] whose reports indicated
that the relationship between plaque index and caries risk
is very weak because there are various types of plaque,
with particular metabolic activities and microbiological
constitutions and it is impossible to clinically differentiate
between cariogenic and non-cariogenic plaque.
Fiske and Shafik [2001] reported that 40% to 60% of
children with DS present with congenital heart defects
(CHD). In this study, 20 DS individuals with uncorrected
CHDs were seen and none of the individuals in the control
group had CHDs. Thus, the variable heart disease was only
investigated in the experimental group. Results showed
that CHDs were not associated with the occurrence of
dental caries in these children.
Analysing the results obtained, in which children with
DS presented high levels of S.mutans, dental caries and
gingivitis, it is necessary to establish a treatment program
based on the prevention of oral diseases. The treatment
protocol should include a detailed medical and dental
history and reduction in dental biofilm formation through
mechanical control, the use of chemical agents, and
microbiological salivary analysis whenever possible.
Moreover, it should be emphasised that education is still
the most effective form of prevention. Therefore, as a part
of the routine treatment, the childrens' parents and carers
should be provided with guidance on oral health care, in a
multidisciplinary context, providing a holistic view of the
child as an individual.

Conclusion
The case group and control group presented a similar
caries index, whereas gingivitis was shown to be present
from early childhood in children with Down syndrome.

References
Allison PJ, Hennequin M, Faulks D. Dental care access among individuals
with Down syndrome in France. Spec Care Dent 2000;20(1):28-34.
Beighton D, Adamson A, Rugg-Gunn A. Associations between dietary intake,
dental caries experience and salivary bacterial levels in 12-year-old
english schoolchildren. Arch Oral Biol 1996;3(33):271-80.
Cogulu D, Sabah E, Uzel A, Ozkinay F. Genotyping of Streptococcus mutans
by using arbitrarily primed polymerase chain reaction in children with
Down syndrome. Arch Oral Biol 2006a;51:177-82.
Cogulu D, Sabah E, Kutukaeler N, Ozkinay F. Evaluation of the relationship
between caries indices and salivary secretory IgA, salivary pH, buffing
capacity and flow rate in children with Downs syndrome. Arch Oral Biol
2006b;51(1):23-8.
Cutress TW. Dental caries in trisomy 21. Arch Oral Biol 1971;16:132944.

42

Desai SS, Faytetteville NY, Down syndrome: a review of the literature. Oral
surg Oral Med Oral Pathol Oral Radiol Endond 1997;84:279-85.
Fiske J, Shafik HH. Downs syndrome and oral care. Dent Update
2001;28:148-156.
Fung K, Allison PJ. A comparison of caries rates in non-institutionalized
individuals with and without Down syndrome. Spec Care Dent
2005;25(6):302-10.
Gold OG, Jordan HV, van Houte J. A selective medium for Streptococcus
mutans. Arch Oral Biol 1973;18:1357-64.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc
1964; 68:7-13.
Johnstone SC, Barnard KM, Harrison VE. Recognizing and caring for the
medically compromised child: 4. Children with other chronic medical
conditions. Dent Update 1999;26:21-6.
Khler B, Bratthall D. Practical method to facilitate estimation of
Streptococcus mutans levels in saliva. J Clin Microbiol 1979;9:584-8.
Klock B, Krasse B. Microbial and salivary conditions in 9- to 12- year-old
children. Scand J Dent Res 1977:85:56-63.
Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker L. A modified
gingival index for use in clinical trials. Clin Prev Dent 1986;8(1):3-6.
Logan WMC, Kronfield R. Development of the human jaws and surroceding
structures from buth to the age of fifteen years. J Amer Assoc
1933;20(3):374-427.
Lpez-Prez R, Borges-Yes SA, Jimnez-Garca G, Maupom G. Oral
hygiene, gingivitis, and periodontitis in persons with Down syndrome.
Spec Care Dent 2002 22(6):214-20.
Mac Call M, Shour I. Studies in tooth development theorias of eruption.
Amer j Orthod 1941;27(10):552-76.
Mayer MPA, de Lorenzo JL. Avaliao do risco de crie dental. In: Lorenzo JL.
Microbiologia para o estudante de Odontologia. So Paulo: Atheneu;
2004:117-28.
Pinazo JDC, Vianna MIP, Lopes FL. Crie dentria e placa bacteriana em
crianas de 07 a 14 anos portadoras da sndrome de Down, matriculadas
em instituies pblicas e privadas do municpio de Salvador Bahia.
Rev Fac Odontol da UFBA 1998;17:15-24.
Reuland-Bosma W, van Dijik LJ, van der Weele L. Experimental gingivitis
around deciduous teeth in children with Downs syndrome. J Clin
Periodontol 1986;13:294-300.
Rogers PT, Roizen NJ, Capone GT. Down Syndrome. In: Capute AJ, Accardo
PJ. Developmental disabilities in infancy and childhood. 2nd ed.
Baltimore: Paul H Brookes; 1996.p. 221-43.
SantAnna GR. Cariologia: Diagnstico, Controle e Tratamento. In: SantAnna
GR, Bnecker MJS, Duarte DA, Suga SS. Caderno de Odontopediatria.
So Paulo: ed Santos; 2001.p. 82.
Shapira J, Stabholz A. A comprehensive 30-month preventive dental health
program in a pre-adolescent population with Dows syndrome: A
longitudinal study. Spec Care Dent 1996;16(1):33-37.
Shapiro S, Gedalia A, Hofman A, Miller M. Periodontal disease and blood
citrate levels in patients with trisomy 21. J Dent Res 1969;48:1231-3.
Walter LRF, Ferelle A. Issao M. Crie dentria. In: Walter LRF, Ferelle A. Issao
M. Odontologia para o beb Odontopediatria do nascimento aos 3
anos. So Paulo: Artes Mdicas; 1997. p.95-106.
World Health Organization. Oral health surveys: basic methods. 3th ed.
Geneva: WHO; 1987.p.53.

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