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Department Special Care in Dentistry, Faculty for health, School of Dentistry University of Witten/Herdecke,
Witten, Germany
Abstract
Introduction: Individuals with Down syndrome (DS) have an increased prevalence of periodontal disease compared with
otherwise normal, age-matched control groups and other intellectually disabled patients of similar age distribution. Caries
prevalence tends to be lower in this population.
Aim and objectives: To determine the long-term effect of periodic plaque control, on the progression of periodontal dis-
eases and tooth mortality in patients with DS.
Material and Methods: 25 adolescents and adults with DS (12 females/13 males, mean age 35.6 ± 8.6 years) were chosen
to participate in the study from all patients with a disability, who had been treated for dental problems in a private dental
practice in Borken, Germany. Standard indices to assess dental caries (DMFT), periodontal disease (PSR; bone loss; age
ratio; tooth loss) were applied. Routine dental care and preventive care were performed over at least ten years.
Results: Patient Group I consisted of 10 patients aged ≤ 15 years; Group II 15 patients aged ≥ 16 years, on first attend-
ance. The overall mean DMFT score of all surveyed patients with Down syndrome was 13.4. For Group I and Group II,
the mean DMFT scores were 8 and 17, respectively. Across all sites, 49.3% exhibited calculus and bleeding on probing.
Shallow pockets and deep pocketing could be identified in 37.5% and 13.2% of all sites, respectively; 58.3% of all patients
had slight bone loss in relation to age and 25% of all patients exhibited advanced bone loss. During the observation period
an average of 2.5 teeth were lost in all patients, 0.5 in Group I and 3.8 in Group II.
Conclusions: The results indicate that well-performed preventive procedures can prevent the progression of periodontal
destruction in patients with DS. Only a few sites exhibited signs of advanced attachment loss and only few teeth were lost
over the years of maintenance
Key words: Long-term effect, preventive programme, caries, periodontal disease, tooth mortality, Down syndrome
2002). The aetiology and pathogenesis of periodontal dis- the DMFT index was limited to the last examination.
eases in patients with DS are not fully understood. The
exaggerated immune-inflammatory response of the tissues Restorative Index (RI)
cannot be explained by poor oral hygiene alone and might The Restorative Index expresses the patient’s treatment
be the result of an impaired cell-mediated and humoral im- needs. It is calculated by the portion of decayed and filled
munity (Saxén and Aula, 1982; Izumi et al., 1989; Sohoel et teeth that have been treated restoratively (F/(D+F)x100).
al., 1992; Sohoel et al., 1995a; Sohoel et al., 1995b; Barr-
Agholme et al., 1998). Periodontal Screening and Recording (PSR)
Because of the altered inflammatory host response to bac- The mouth was divided into sextants and coded according
terial challenge and the patient’s inability to self-perform to the recommendations of the Periodontal Screening and
adequate oral hygiene, the prognosis for periodontal treat- Recording procedure (American Dental Association and
ment in patients with DS is questionable in the majority American Academy of Periodontology, 1992). The Peri-
of cases (Hanookai, 2000; Cichon et al., 2001). While the odontal Screening and Recording system is a modification
aim of periodontal therapy is to regain periodontal health, of the CPITN Index. It was officially introduced in 1993
the objective of preventive programmes is the preservation and recommended by the American Academy of Periodon-
of gingival and periodontal health. Although the benefit of tology (AAP) and the American Dental Association (ADA)
frequent preventive care in patients with DS has been dem- as a quick and reliable system for the early detection of peri-
onstrated (Sakellari et al., 2001; Yoshihara et al., 2005), no odontal disease.
programmes on the long-term effect of periodic plaque con- The WHO Periodontal Examination Probe was used
trol, on the progression of periodontal diseases and tooth throughout this study (World Health Organisation, 1978). It
mortality in patients with DS, have been reported. is a specially designed lightweight probe with a 0.5mm ball
The present study presents the caries prevalence, peri- tip and a black band between 3.5 and 5.5mm. The ball tip
odontal status and tooth loss in a group of children, ado- enhances detection of sub-gingival calculus or overhanging
lescents and young adults with DS after at least a decade of margins. The coloured band facilitates rapid interpretation
preventive and curative care. of probe depths. The Periodontal Screening and Recording
(PSR) codes are based on the following system:
Materials and methods
Code 0 - Coloured area of the probe remains completely
Subjects visible in the deepest crevice in the sextant. No calculus or
Twenty-five adolescents and adults with DS were chosen to defective margins are detected. Gingival tissues are healthy
participate in the study from all patients with a disability, with no bleeding after gentle probing.
who had been treated for dental problems in a private dental
practice in Borken, Germany. The criteria for inclusion were Code 1 - Coloured area of the probe remains completely
attending the practice for at least 10 years and preventive visible at the deepest probing depth in the sextant. No cal-
care regularly undertaken at least two to four times a year. culus or margins are detected. There is bleeding after gentle
probing.
Study design
The entire group (n=25) was divided into two patient co- Code 2 - Coloured area of the probe remains completely
horts according to the age when the patients attended for visible at the deepest probing depth in the sextant. Supra- or
the first time in the practice for dental care. Patient Group I sub-gingival calculus and/or defective margins are detected.
consisted of 10 patients aged ≤ 15 years and patient Group
II consisted of 15 patients who were aged ≥ 16 years when Code 3 - Coloured area of the probe remains partly visible at
they first attended the preventive programme. the deepest probing depth in the sextant.
radiographic bone loss was defined as the distance from the On average, 48 % (n=12) of the patients appeared twice,
cemento-enamel junction (CEJ) to the alveolar crest (AC) 40% (n=10) 3 times and 12% (n=3) 4 times a year to the
exceeding 2mm (Aass et al., 1994; Bishop et al., 1995). follow-up sessions (Figure 1).
The percentage of bone loss was calculated by transforming
the alveolar bone loss in relation to the radiographic tooth Statistical analysis
length. The bone loss/age ratio (BL/age) was determined by A frequency distribution for the DMFT, PSR, maximum
dividing the percentage of bone loss by the age of the pa- PSR and BL/Age scores was calculated for the last clinical
tient. The risk categories for further attachment loss were and radiographic examinations.
subdivided into six intervals from 0.25 to ≥ 1.5. The thresh- The median value, mean value with standard deviation, the
old for the moderate risk category was 0.5 and for the high minimum, maximum and quartiles 1 and 3 for lost teeth
risk category 1 (Lang and Tonetti, 2003). during the observation period were determined for both age
groups. Tooth mortality between the two age groups was
Number of lost teeth compared using the Mann-Whitney U- test.
The mean number and annual rates for those teeth which
had been extracted during the entire period of observation
were calculated.
Figure 1a- e. A 2- year-old patient with DS who at-
Treatment
tended for preventive care regularly from the time of
Following the baseline examination, all carious lesions were
eruption of the first primary tooth
treated and faulty restorations adjusted. Teeth with a ques-
tionable prognosis or those which could not be successfully a b
treated were extracted.
Preventive programme
In addition to clinical examinations, the preventive sessions
included an instruction in proper personal oral hygiene, pro-
fessional tooth cleaning and dental treatment, whenever it
was indicated.
Subsequent to the initial examination, patients with a dis-
ability, their relatives and/or guardians received detailed in-
formation about the role of dental plaque and nutrition in the
aetiology of dental caries and periodontitis, on an individual c d
basis. They were instructed how to perform oral hygiene
correctly. A method of tooth cleaning was recommended for
each individual patient which could be carried out by the
patient or their relatives and/or their caregiver. The patient’s
oral hygiene technique was checked and, if necessary, cor-
rected. Following motivation and instruction, a professional
tooth cleaning programme was carried out (Axelsson, 1994).
e
The teeth were carefully scaled, plaque and dental calculus
were removed and all teeth were polished at baseline in one
session. The vestibular and lingual surfaces of all teeth were
cleaned with the aid of a rotating rubber cup. A rotating,
pointed bristle brush was used to clean the occlusal fissures.
In addition, a 0.2% chlorhexidine solution was adminis-
tered in a spray form (Chlorhexamed® Forte 0.2 % Spray,
GlaxoSmithKline, Germany) twice a day for one week after Results
professional tooth cleaning (Francetti et al., 2000) in some
patients with compromised oral hygiene, due to the impos- Of the 25 subjects selected, 12 were females and 13 males,
sibility of performing adequate mechanical oral hygiene with a mean age ± SD, 35.6 ± 8.6 years. For the two groups,
measures. Subsequent to the termination of the baseline those < 15 years at first presentation in the practice (Group
examination, prevention and treatment period, all patients I) and those ≥ 16 years at first presentation (Group II), the
were recalled four times per year for evaluation of their oral mean age (± SD) of the patients in Group I was 7 ± 3.9 years
health and hygiene status, reinstruction in tooth cleaning and 24.5 ± 5.3 years in Group II, respectively at the initial
and for dental therapy, whenever it was necessary. visit (Table 1 and Figure 2).
Cichon: Prevention in individuals with Down syndrome 71
At the time of the last observation, the mean age (± SD) sons with an intellectual impairment. With regard to the
of the patients in Group I was 27.3 ± 6 years and 41.1 ± level of cooperation, in order to accept the clinical and
4.9 years in Group II, respectively (Table 2 and Figure radiographic examinations as well as the preventive care
3). The mean duration (± SD) of the observation period programme, 15 patients were identified as sufficiently co-
was 17.8 ± 4.7 years for the entire group, 20.4 ± 3.6 years operative for their clinical examinations and professional
for Group I and 16 ± 4.5 years for Group II (Table 3 and tooth cleaning to be carried out in the conscious state.
Figure 4). Ten patients were partly cooperative: radiographs of their
Twelve patients were living at home, 13 were in insti- teeth could be exposed but only under general anaesthe-
tutions or communities that provide for the needs of per- sia.
Figure 2 Mean DMFT, decayed teeth (DT), missing teeth (MT), filled teeth (FT) scores at the last observa-
tion
Age (years)
Mean age ± SD 7 ± 4.2 24.5 ± 5.4 17.5 ± 10
Median 8 24 20
Min - Max 1-13 17-34 1-34
Age (years)
Mean age ± SD 27.3 ± 6.3 41.1 ± 5 35.6 ± 8.8
Median 28 41 37
Min - Max 15-35 32-54 15-54
72 Journal of Disability and Oral Health (2011) 12/2
Mean age ± SD
20.4 ± 3.8 16 ± 4.7 17.8 ± 4.8
Median 22 17 20
Min - Max 12 – 24 10 - 21 10 - 24
Table 4 Mean DMFT, decayed teeth (DT), missing teeth (MT), filled teeth (FT) scores for the total patient
group at the last observation (n = 25)
DT MT FT DMFT
Median 0 5 3 14
Min-Max 0 – 6 0 - 28 0 - 18 1 – 28
Table 5 Mean DMFT , decayed teeth (DT), missing teeth (MT), filled teeth (FT) scores for the age group ≤
15 years at the last observation (n = 10)
DT MT FT DMFT
Min-Max 0 – 6 0 - 6 0 - 12 1 – 12
Table 6 Mean DMFT , decayed teeth (DT), missing teeth (MT), filled teeth (FT) scores for the age group
≥16 years at the last observation (n = 15)
DT MT FT DMFT
Median 0 8 4 16
Min-Max 0 – 2 0 - 28 0 - 18 1 – 28
Figure 5 Mean DMFT scores and single components at the last observation
74 Journal of Disability and Oral Health (2011) 12/2
Mean age ± SD
24.5 ± 2 18.4 ± 8.5 20.8 ± 7.3
Median 24 20 23
Min - Max 22 – 28 1 - 28 1 - 28
Cichon: Prevention in individuals with Down syndrome 75
Number 5 57* 62
Mean age ± SD 0.5 ± 1.5 3.8 ± 3.9 2.5 ± 3.7
Median 0 3 1
Min - Max 0-4 0-13 0-13
Table 10 DMFT scores in age matched subjects with and without disabilities in Germany
DT MT FT DMFT RI
Disabilities (2004)
4.3 6.9 5 16.2 53.8%
German Oral
Health Study 0.5 2.4 11.7 14.5 95.9%
Min-Max 0 – 2 0 - 28 0 - 18 1 – 28
detected more frequently than has been indicated in this and gingival inflammation. Although in some studies the
study. effectiveness of surgical and non-surgical periodontal
treatment in DS subjects could be demonstrated (Sakel-
Tooth mortality lari et al., 2001; Zaldivar-Chiapa et al., 2005; Cheng et
The tooth mortality during the period of observation, with al., 2008) it has to be noted that the results of these stud-
a mean value of 2.5 teeth for all patients and an average ies were obtained under clinical trials conditions. The pa-
of 0.5 teeth for the first age group of this study, is lower tients were seen for professional tooth cleaning at least
than the findings of other studies in intellectually impa- every 4-6 weeks. The entire observation period was lim-
ried adults (Gabre et al., 1999, 2000). Only the loss of a ited to a maximum of one year.
mean of 3.8 teeth in the second age group concurs with The removal of supragingival plaque alone leads to
the findings of these studies in which an average loss of reduced subgingival bacterial counts (Loos et al., 1988;
3.7 teeth over a period of 10 years has been reported. McNabb et al.1992; Hellstrom et al., 1996; Westfelt et
The low value for the mean tooth mortality/subject in al., 1998; Ximenez-Fyvie et al, 2000; Haffajee et al.,
the first age group (0.5 teeth/subject) during the observa- 2001; Petersilka et al., 2002; Teles et al., 2006) espe-
tion period is in agreement with the findings of long-term cially at sites with shallow pocket depths (McNabb et
studies on the oral health status of individuals without al., 1992; Westfelt et al., 1998). In previous studies, the
disabilities. Over a 12-year interval, a mean of 0.4 teeth/ authors of the current study, were able to demonstrate
subject (Wennström et al., 1993) and, over a 30-year pe- that a single, supragingival plaque removal visit had no
riod, means of 0.4, 0.7 and 1.8 teeth/subject were lost in beneficial effect on the accumulation of supragingival
different age cohorts (Axelsson et al., 2004). The annual plaque and gingivitis in DS subjects but led to a signifi-
tooth loss of 0.14 teeth/subject corresponds to the results cant decrease in the total number of microorganisms in
of long-term studies (McFall, 1982; Goldman 1986) in the subgingival plaque, for a period of 3 months (Cichon
well maintained patients, in which a mean annual loss of et al., 1998; Cichon et al., 2001). The results of the cur-
0.14 teeth/subject and 0.16 teeth/subject, respectively has rent study indicate that well-performed preventive proce-
been reported. dures can prevent the progression of periodontal destruc-
The distribution of tooth mortality amongst individual tion in patients with DS. Only a few sites exhibited signs
patients showed a cumulative tooth loss in a small group of advanced attachment loss and only a few teeth were
of patients. In five patients, 69% (n = 43) of teeth had lost over the years of maintenance.
to be extracted, while in 12 patients no teeth were lost. The progression of periodontal diseases in people with
According to the definition by Hirschfeld & Wasserman Down syndrome seems to be age-related (Izumi et al.,
(1978), 17 patients were classified as ‘well maintained’ 1989; Franz, 2002). The clinical benefit of plaque control
(loss of 0 – 3 teeth) seven belonged to the ‘down hill’ measures in DS subjects depends on the period of life
group (loss of 4-9 teeth), and one was assigned to the when it is initiated. The earlier in childhood that dental
‘extreme downhill’ group (loss of 10 or more teeth). care commences, the better is the periodontal status in
adulthood.
Conclusions Patients with DS who had been introduced to the pre-
ventive programme at ≤ 15 years of age had sites with
The caries experience with a low mean DMFT values calculus and bleeding on probing only, at the final clinical
and DT scores, as well as the high level of the restor- observation and only a few sites with probing depths and
ative index compared with age-matched patients with advanced bone loss. Two patients in this age group lost
and without disabilities in Germany demonstrates that a total of five teeth. Most patients with DS in the second
caries is not a specific problem in DS patients. On the age group, who attended the preventive care programme
basis of regularly performed preventive care, including for the first time at an age of ≥ 16 years, had more sites
professional tooth cleaning with instruction in oral hy- with pockets and a markedly higher number of lost teeth
giene procedures and the early detection and treatment than the patients in the younger age group.
of carious lesions, destruction of the dentition by caries This does not imply that the introduction of preventive
could be prevented. programmes is of no benefit in older patients with Down
The combination of impaired host-response mecha- syndrome. The low number of sites with deep pockets
nisms and inadequate oral hygiene has an unfavourable and bone loss and the relative low tooth mortality in the
impact on the progression and treatment of gingivitis and present study show that severe periodontal destruction
periodontitis in DS subjects. The high percentage of pa- could also be prevented in older patients with DS.
tients and sites with calculus and gingival inflammation The results of the current and former studies demon-
in the present study shows that professional tooth clean- strate that the accumulation of bacterial plaque and gingi-
ing without careful supportive home oral care had only vitis seem to be unavoidable in subjects with DS and that
a minor effect on the accumulation of bacterial plaque periodontal diseases in DS subjects can largely be kept
Cichon: Prevention in individuals with Down syndrome 79
under control by preventive programmes, when initiated Goldmann MJ, Ross IF, Goteinert D: Effect of periodontal therapy on
Patients maintained for 15 years or longer. A retrospective study.
early on.
J Periodontol 1986; 57: 347-353.
Haffajee A D, Smith C, Torresyap G, Thompson M, Guerrero D,
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