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Journal of Disability and Oral Health (2011) 12/2 68-80

The long-term effect of a preventive programme on


caries, periodontal disease and tooth mortality in
individuals with Down syndrome
Prof. Dr. Habil Peter Cichon

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

Introduction susceptible to infections because of genetic abnormalities in


their immune system
Down syndrome (DS) is an autosomal chromosomal anom- Individuals with DS have an increased prevalence of
aly and the most commonly known single cause of men- periodontal disease compared with otherwise normal, age-
tal retardation (Hennequin et al., 1999). It occurs approxi- matched control groups and other intellectually disabled
mately once in 600-1,000 births (Desai, 1997). Genetically, patients of similar age distribution (Barnett et al., 1986;
Down syndrome is a gene dosage disease with an over-ex- Reuland-Bosma and van Dijk, 1986; Modéer et al., 1990;
pression of genes located on the distal half of the long arm Ulseth et al., 1991; Barr-Agholme et al., 1998). Reuland-
of chromosome 21, known as band 21q22 (Neibuhr, 1974; Bosma and van Dijk (1986) have reported that the same
Hennequin et al., 1999; Fiske and Shafik 2001). amount of plaque accumulation gives rise to earlier, more
The phenotype of the syndrome is characterised by men- rapid and more extensive gingival inflammation in DS
tal retardation, weak muscle tone, and typical orofacial fea- children compared to non-disabled, children.
tures with epicanthic folds at the eyelids, a broad bridge of Signs of alveolar bone loss can be detected in a high per-
the nose, an underdeveloped mid-part of the face in relation centage of younger patients with DS. A previous study was
to an oversized mandible with protrusive dentition, an open able to verify a distinct increase in the level of periodontal
mouth and an oversized, fissured tongue. DS patients are disease in the age group of 25-29 year-old subjects (Franz,
Cichon: Prevention in individuals with Down syndrome 69

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.

Clinical examinations Code 4 - Coloured area of the probe completely disappears,


The following variables were recorded on all available teeth indicating that the probing depth is greater than 5.5mm.
with the exception of third molars:
Bone loss/ age ratio (BL/Age)
Caries detection and DMFT For patients characterised as cooperative, a panoramic ra-
Clinical, radiographic and recurrent caries lesions were iden- diograph was exposed, and for partly cooperative patients,
tified according to criteria from the World Health Organisa- intraoral radiographs were taken with the parallel technique,
tion (1997). Each tooth was recorded as healthy, decayed or under general anaesthesia.
filled (DF) or missing (M) in order to estimate the DMFT Alveolar bone loss was assessed in the posterior tooth re-
index (Klein and Palmer, 1940). Because of the young age gion at the site with the most advanced periodontal attach-
of patients at the beginning of treatment, the calculation of ment loss using a calliper. In adolescents and young adults,
70 Journal of Disability and Oral Health (2011) 12/2

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

Table 1 Age of subjects at the initial visit

Age ≤ 15 years at the Age ≥16 years at the


initial visit to practice initial visit to practice
(n = 10) (n = 15) Entire Group (n = 25)

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

Table 2 Age of subjects at the time of the last observation

Age at the initial visit to Age at the initial visit to


practice ≤ 15 years practice ≥16 years
(n = 10) (n = 15) Entire Group (n = 25)

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

Figure 3 Frequency distribution of PSR codes at the last examination

Table 3 Period of observation

Age ≤ 15 years at the Age ≥16 years at the


initial visit to practice initial visit to practice
(n = 10) (n = 15) Entire Group (n = 25)

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

Figure 4 Frequency distribution of BL/Age categories at the clinical examination


Cichon: Prevention in individuals with Down syndrome 73

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

Mean ± SD 0.5 ± 1.3 7.1 ± 6 5.7 ± 6.1 13.3 ± 9.7

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

Mean ± SD 0.9 ± 1.9 3.4 ± 2 3.6 ± 5 8 ± 7.3

Median 0 4 0.5 4.5

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

Mean ± SD 0.3 ± 0.7 9.5 ± 8.2 7.1 ± 6.4 17 ± 9.6

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

Caries (DMFT) Periodontal Screening and Recording (PSR) – maximal


The mean DMFT scores and the single D, M and F com- codes
ponents at the last examination are presented in Tables The frequency distribution of the maximal PSR codes is
4-6 and Figure 5. The overall mean DMFT score of all presented in Table 8. It shows that no patient examined
surveyed patients with Down syndrome was 13.4. For the was disease-free. In this study, 29.2% of all subjects with
age Group I and Group II, the mean DMFT scores were DS exhibited calculus and bleeding, 50% had shallow
8 and 17, respectively. In Group I, the filling component and 20.8% deep pockets. In the first patient group 70%
(FT: 3.6) dominated the scores whereas in the second of the subjects with DS exhibited calculus and gingivitis
group the missing teeth (MT: 9.6) represented the highest and 30% shallow pockets. In the second age group 64%
scores. of the patients had shallow pockets and 36% deep pock-
ets.
Remaining teeth at the last observation
Table 7 and Figure 6 present the number of remaining Bone loss/age ratio (BL/Age)
teeth in the two age groups at the last examination. The The bar chart in Figure 8 illustrates the distribution of
average number of teeth present at the last observation sites with the most advanced periodontal bone loss in
was 20.8 for all patients and 24.5 and 18.4 for the Groups relation to the patient’s age at the last examination. It
I and II, respectively. shows that 58.3% of all patients had slight bone loss in
relation to the age (BL/Age: 0.25) and 25% of all pa-
Restorative Index (RI) tients exhibited advanced bone loss (BL/Age: 1.25 and
The mean restorative index was 91.9% for all patients BL/Age: ≥ 1.5).
combined. In the first age group the RI was 80% and in In the first age group, 90% of patients exhibited the
the second group the RI amounted to 95.9%. lowest risk category (BL/Age: 0.25) and 10% of DS sub-
jects of this age group showed the highest risk category
Periodontal Screening and Recording (PSR) (BL/Age: ≥ 1.5) for further attachment loss. In the second
The frequency distribution of the PSR codes for the group, 35.7% of the patients had low bone loss (BL/Age:
two age groups are presented in Figure 7; 49.3% of all 0.25), 28.6% had moderate bone loss (BL/Age: 0.75) in
sites exhibited calculus and bleeding on probing. Shal- relation to the age and 25% were at high risk for further
low pockets and deep pocketing could be identified in attachment loss with a BL/Age relation of 1.25 and ≥1.5.
37.5% and 13.2% of all sites, respectively. In age Group
I, 88.3% of the sites had gingivitis and calculus (code 2) Number of lost teeth
and 11.7% of the sites had shallow pockets (code 3). In During the observation period an average number of 2.5
the second age group, calculus and gingivitis could be teeth were lost in all patients, 0.5 in Group I and 3.8 in
detected in 18.4% of sites. In the second group, 57.9% Group II (Table 9 and Figure 9). Twenty incisors, 10
of sites had shallow pockets and 23.7% of sites exhibited canines, 13 premolars and 14 molars were lost to caries
deep pockets (code 4). (16) and advanced periodontal disease (36).
The calculated annual rates of tooth loss/patient for the
entire observation period were 0.14 teeth for all DS sub-
jects, 0.02 teeth in age Group I and 0.24 teeth in the sec-
ond age group. Because of the small number of lost teeth,
statistically significant differences between the two inde-
pendent age groups could not be determined.

Table 7 Number of remaining teeth at the last examination

Age ≤ 15 years at the Age ≥16 years at the


initial visit to practice initial visit to practice
(n = 10) (n = 15) Entire Group (n = 25)

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

Figure 6 Remaining teeth at the last examination

Figure 7 Frequency distribution of PSR codes at the last examination

Table 8 Frequency distribution of maximum PSR codes

Code 0 Code 1 Code 2 Code 3 Code 4

Entire Group (n = 25) 0 0 29.2 50 20.8

Age at the initial visit to 0 0 70 30 0


practice

Age at the initial visit to 0 0 0 64 36


practice
76 Journal of Disability and Oral Health (2011) 12/2

Figure 8 Frequency distribution of BL/Age catagories at the clinical examination

Table 9 Number of lost teeth

Age ≤ 15 years at the Age ≥16 years at the


initial visit to practice initial visit to practice
(n = 10) (n = 15) Entire Group (n = 25)

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

Mann-Whitney U- test.: *P > 0.05

Figure 9 Lost teeth during the period of observation


Cichon: Prevention in individuals with Down syndrome 77

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

Discussion drome have more congenitally missing teeth than people


in the general population (Steinbicker et al., 1972; Acerbi
The present study presents the long term outcome of a et al., 2001).
regularly performed preventive dental treatment in a
group of subjects with Down syndrome over a period of Restorative Index (RI)
≥ 10 years. In order to compare the results with the find- The provision of dental restorations in DS subjects in this
ings of other studies it should be noted that all dental ex- study is slightly lower in comparison with the mean RI
aminations, preventive and treatment efforts were carried value in the 35-44 year age group of the Fourth German
out in one private dental practice during normal office Oral Health Study (Micheelis and Schiffner, 2006) but
hours. markedly higher than the level of restorations in age-
matched patients with disabilities in Germany (Cichon
Caries (DMFT) and Donay, 2004) (Table 10).
At the final clinical observation, the caries experience
in the patients’ groups exhibited an overall mean DMFT Periodontal Screening and Recording (PSR)
score of 13.4 with a mean DT score of 0.5; 80% (n = 20) The frequency distribution of the PSR codes in the two
of all patients had no carious lesions. The caries experi- age groups shows that all sites were in need of vary-
ence in DS patients in this study demonstrated a lower ing amounts of periodontal therapy (codes 2, 3 and 4).
mean DMFT value and a lower mean DT score than In 86.8% of all sites there was evidence of calculus and
those of age-matched patients with and without disabili- bleeding on probing or shallow pockets (code 2 and 3).
ties in Germany (Cichon and Donay, 2004; Micheelis and Deep pockets could only be detected in 13.2% of sites.
Schiffner, 2006) (Table 10). These findings are consistent While gingivitis could be detected in 88.3% of all sites in
with findings of most studies on the oral health status of the first age group, 81.6% of the sites in the second age
patients with Down syndrome, which show similar caries group had shallow or deep pockets (code 3 and 4).
experience compared to population groups without dis- The distribution of the maximal PSR codes in the cur-
abilities (Bradley and McAlister, 2004; Lee et al., 2004; rent study shows a higher portion of DS patients with cal-
Cheng et al., 2007). The low rate of caries in the cur- culus and bleeding than in the population without disabil-
rent study, especially in the first age group, cannot be ex- ities, whereas the percentage of shallow and deep pockets
plained solely by the generally low caries rates in patients was in accordance with the results of the Fourth German
with DS but may be as a consequence of the regularly Oral Health Study of 2006 (Micheelis and Schiffner,
performed preventive care with professional tooth clean- 2006).
ing, repeated oral hygiene demonstrations as well as ear-
ly detection and consequent treatment of carious lesions Bone loss/age ratio (BL/Age)
as well as the daily use of a fluoridated dentifrice. With regard to the distribution of all DS patients with
moderate (58.3%) and severe bone loss (25%), these
Remaining teeth at the last observation findings are in contrast to the results of a former study
The mean number of 20.8 remaining teeth for all patients on the prevalence and severity of periodontal diseases in
at the final observation visit is in accordance with the re- adults without disabilities (Hugoson and Laurell, 2000).
sults of a previous study on the dental status of patients Although these authors established that about 80% of the
with disabilities (Cichon and Donay, 2004). In the latter population had one or more sites with bone loss of 10%,
study, the authors found an average number of 21.1 teeth only very few individuals, about 5%, exhibited a mean
present in age-matched patients groups. Comparing the bone loss of 2mm or more.
low mean number of remaining teeth in the second age On the other hand, Saxen et al. (1977), Barr-Agholme
group with the number of remaining teeth in the non-dis- et al. (1992) and Scott (1998) reported that advanced
abled population, it may be that subjects with Down syn- bone loss in patients with Down syndrome could be
78 Journal of Disability and Oral Health (2011) 12/2

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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Address for correspondence:


Peter Cichon
Department of Special Care in Dentistry
School of Dental Medicine
University of Witten/Herdecke
Alfred-Herrhausen-Str. 50
58455 Witten
Germany
Email: pcichon@t-online.de

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