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Home , Down syndrome, Microdontia

Practical Oral Care for People With Down

contents roviding oral care to people with requires Health Challenges IN down syndrome and adaptation of the skills you use every day. In fact, most people Strategies for Care with mild or moderate Down syndrome can be successfully 2 ...... Intellectual treatedP in the general practice setting. This booklet will help you make Behavior management 3 ...... a difference in the lives of people who need professional oral care. Medical conditions Cardiac disorders Down syndrome, a common , ranges in severity and is Compromised immune systems usually associated with medical and physical problems. For example, 4 ...... people with this may have cardiac disorders, infectious , hypotonia, and and deafness early professional Visual impairments hearing loss. Additionally, most Oral health treatment and problems IN down people with this disorder have mild or syndrome and daily oral care at strategies for care moderate , while a 5 ...... home can allow Periodontal small percentage are severely affected. Dental caries Developmental delays, such as in people with Down 6 ...... Orofacial features speech and language, are common. syndrome to enjoy anomalies the benefits of a 7 ...... Trauma and injury healthy mouth. Additional Readings

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES l National Institutes of Health l National Institute of Dental and Craniofacial Research a little extra time and attention to feel Health Challenges in down ­comfortable. Gaining the patient’s trust syndrome and strategies for Care is the key to successful treatment. Talk to the caregiver or physician People with Down syndrome may present about techniques they have found to with mental and physical challenges that be effective in managing the patient’s have implications for oral care. Before behavior. Share your ideas with them, the appointment, obtain and review the and find out what motivates the patient. patient’s medical history. Consultation It may be that a new toothbrush at the with physicians, family, and caregivers is end of each appointment is all it takes essential to assembling an accurate medical to ensure cooperation. history. Also, determine who can legally Schedule patients with Down syndrome provide informed ­consent for treatment. early in the day if possible. Early Intellectual disability. Although appointments can help ensure that the mental capability of people with Down everyone is alert and attentive and that syndrome varies widely, many have mild or waiting time is reduced. moderate intellectual disability that limits Set the stage for a successful visit by their ability to learn, communicate, and involving the entire dental team—from adapt to their environment. Language the receptionist’s friendly greeting to the development is often delayed or impaired caring attitude of the dental assistant in in people with Down syndrome; they the operatory. understand more than they can verbalize. Address your Provide oral care in an environment Also, ordinary activities of daily living and with few distractions. Try to reduce patient directly understanding the behavior of others as unnecessary sights, sounds, or other well as their own can present challenges. and with respect. stimuli that might make it difficult for Listen actively, since speaking may your patient to cooperate. Many people be difficult for people with Down with Down syndrome, however, enjoy syndrome. Show your patient whether music and may be comforted by hearing you understand. it in the dental office during treatment. Talk with the parent or caregiver to Plan a step-by-step evaluation, starting determine your patient’s intellectual with seating the patient in the dental and functional abilities, then explain chair. If this is successful, perform each procedure at a level the patient an oral examination using only your can understand. Allow extra time to fingers. If this, too, goes well, begin explain oral health issues or instructions using dental instruments. Prophylaxis and demonstrate the instruments is the next step, followed by dental you will use. radio­graphs. Several visits may be Use simple, concrete instructions, and needed to accomplish these tasks. repeat them often to compensate for Try to be consistent in all aspects of any short-term memory problems. ­providing oral health care. Use the same staff, dental operatory, appointment Behavior management is not times, and other details to help sustain ­usually a problem in people with Down familiarity. The more consistency you syndrome because they tend to be warm provide for your patients, the more likely and well behaved. Some can be stubborn that they will be cooperative. or uncooperative, but most just need

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Comfort people who resist oral care Compromised immune systems and reward cooperative behavior with lead to more frequent oral and systemic compliments throughout the appointment. infections and a high incidence of Use immobilization techniques only perio­dontal disease in people with Down when absolutely necessary to protect syndrome. Aphthous ulcers, oral Candida the patient and staff during dental infections, and acute necrotizing ulcerative treatment—not as a convenience. are common. Chronic respiratory There are no universal guidelines infections contribute to , on immobilization that apply to all xerostomia, and fissured and tongue. treatment settings. Before employing Treat acute necrotizing any kind of immobilization, it may ulcerative gingivitis and other help to consult available guidelines infections aggressively. on federally funded care, your State Talk to patients and their caregivers department of mental health/, about preventing oral infections with and your State Dental Practice Act. regular dental appointments and daily More than half Guidelines on behavior management oral care. of all adults with published by the American Academy of Pediatric (http://www.aapd.org) Stress the importance of using Down syndrome may also be useful. Obtain consent fluoride to prevent dental caries experience mitral from your patient’s legal guardian and associated with xerostomia. choose the least restrictive technique Use balm during treatment to ease valve prolapse. that will allow you to provide care the strain on your patient’s lips. safely. Immobilization should not cause ­physical injury or undue discomfort. Hypotonia affects the muscles in ­various areas of the body, including the Medical conditions. Though their mouth and large skeletal muscles. When it average life expectancy has risen to the involves the mouth, it leads to an imbalance mid-50s, people with Down syndrome are of forces on the teeth and contributes to an still at risk for problems in nearly every open bite. If the muscles controlling facial system in the body. Some problems are expression and mastication are affected, manifested in the mouth. For example, oral problems with chewing, swallowing, findings such as persistent gingival lesions, , and speaking can result. A prolonged wound healing, or spontaneous related problem is atlantoaxial instability, a gingival hemorrhaging may suggest an spinal defect that increases the mobility of underlying medical condition and warrant the cervical vertebrae and often leads to an consultation with the patient’s physician. unsteady gait and neck pain. Cardiac disorders are common Maintain a clear path for movement in Down syndrome. In fact, mitral valve throughout the treatment setting. prolapse occurs in more than half of all Determine the best position for your adults with this developmental disability. patient in the dental chair and the safest Many others are at risk of developing way to move his or her body, especially valve dysfunction that leads to congestive the head and neck. Talk with the heart failure, even if they have no known physician or caregiver about ways to cardiac disease. Consult the patient’s protect the spinal cord. Use pillows to physician if you have questions about the stabilize your patient and make him or medical history and the need for antibiotic her more comfortable. prophylaxis (http://www.heart.org).

3 Seizures sometimes occur in this appointment. Speak with this person popu­lation, especially among infants, in advance to discuss dental terms and but can usually be controlled with your patient’s needs. anticonvulsant medications. The mouth Visual feedback is helpful. Maintain is always at risk during a : Patients eye contact with your patient. Before may chip teeth or bite the tongue or cheeks. talking, eliminate background noise People with controlled seizure disorders can (turn off the radio and the suction). easily be treated in the general dental office. Sometimes people with a hearing loss Consult your patient’s physician. simply need you to speak clearly in Record information in the chart a slightly louder voice than normal. about the frequency of seizures and Remember to remove your facemask the medications used to control them. first or wear a clear face shield. Determine before the appointment Visual impairments whether medications have been taken such as as directed. Know and avoid any factors (crossed or misaligned eyes), that trigger your patient’s seizures. , and can affect people with Down syndrome. Be prepared to manage a seizure. If one occurs during oral care, remove Determine the level of assistance your any instruments from the mouth patient requires to move safely through and clear the area around the dental the dental office. chair. Attaching dental floss to rubber Use your patients’ other senses to dam clamps and mouth props when connect with them, establish trust, and treatment begins can help you remove make treatment a better experience. them quickly. Do not attempt to insert Tactile feedback, such as a warm any objects between the teeth during ­handshake, can make your patients a seizure. feel comfortable. Stay with your patient, turn him or her Face your patients when you speak and to one side, and monitor the airway to keep them apprised of each upcoming reduce the risk of aspiration. step, especially when water will be used. Rely on clear, descriptive language to Hearing loss and deafness may explain procedures and demonstrate further complicate poor communication how equipment might feel and sound. skills, but these, too, can be accommodated Provide written instructions in large with planning. Patients with a hearing print (16 point or larger). problem may appear to be stubborn because of their seeming lack of response to a request. Record in the patient’s chart Patients may want to adjust their strategies that were successful in ­hearing aids or turn them off, since the providing care. Note your patient’s sound of some instruments may cause auditory discomfort. preferences and other unique If your patient reads lips, speak in a details that will facilitate treatment, normal cadence and tone. If your such as music, comfort items, and patient uses a form of , flavor choices. ask the interpreter to come to the

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recommendations on brushing methods Oral Health Problems in Down or toothbrush adaptations. Involve Syndrome and Strategies for Care patients in hands-on demonstrations of brushing and flossing. People with Down syndrome have no Some people with Down syndrome unique oral health problems. However, can brush and floss independently, but some of the problems they have tend to many need help. Talk to their be frequent and severe. Early professional caregivers about daily . treatment and daily care at home can Do not assume that all caregivers know ­mitigate their severity and allow people the basics; demonstrate proper brushing with Down syndrome to enjoy the benefits and flossing ­techniques. A power of a healthy mouth. toothbrush or a floss holder can simplify oral care. Also, use your experiences is the with each patient to demonstrate sitting most ­significant oral health problem in or standing positions for the caregiver. people with Down syndrome. Children Emphasize that a consistent approach experience rapid, destructive periodontal to oral hygiene is important—caregivers disease. Consequently, large numbers of should try to use the same location, them lose their permanent anterior teeth ­timing, and positioning. in their early teens. Contributing factors include poor oral hygiene, malocclusion, Dental caries. Children and young , conical-shaped tooth roots, adults who have Down syndrome have and abnormal host response because of fewer caries than people without this a compromised . developmental disability. Several associated Some patients benefit from the daily oral conditions may contribute to this fact: use of an antimicrobial agent such delayed eruption of primary and permanent as chlorhexidine. Recommend an teeth; missing permanent teeth; and small- appropriate delivery method based on sized teeth with wider spaces between your patient’s abilities. Rinsing, for them, which make it easier to remove example, may not work for a person plaque. Additionally, the diets of many who has swallowing difficulties or one children with Down syndrome are closely who ­cannot expectorate. Chlorhexidine supervised to prevent ; this helps applied using a spray bottle or reduce consumption of cariogenic foods toothbrush is equally efficacious. and beverages. If use of particular medications has led By contrast, some adults with Down to gingival hyperplasia, emphasize the syndrome are at an increased risk of caries importance of daily oral hygiene and due to xerostomia and cariogenic food frequent professional cleanings. choices. Also, hypotonia contributes to chewing problems and inefficient natural Encourage independence in daily oral cleansing action, which allow food to hygiene. Ask patients to show you how remain on the teeth after eating. they brush, and follow up with specific

Tips for caregivers are available in the booklet Dental Care Every Day: A Caregiver’s Guide, also part of this series.

5 Advise patients taking medicines that unusual thickness of the sides of the cause xerostomia to drink water often. hard . This thickness restricts the Suggest taking sugar-free medicines amount of space the tongue can occupy if available and rinsing with water in the mouth and affects the ability to after dosing. speak and chew. Recommend preventive measures such The lips may grow large and thick. as topical fluoride and sealants. Suggest Fissured lips may result from chronic fluoride toothpaste, gel, or rinse, mouth breathing. Additionally, depending on your patient’s needs hypo­tonia may cause the mouth to and abilities. droop and the lower lip to protrude. Increased drooling, compounded by Emphasize noncariogenic foods and a chronically open mouth, contributes ­beverages as snacks. Advise caregivers to angular . to avoid using sweets as incentives or rewards. The tongue also develops cracks and ­fissures with age; this condition can Several orofacial features are ­contribute to halitosis. characteristic of people with Down syndrome. The midfacial region may be Malocclusion is found in most underdeveloped, affecting the appearance people with Down syndrome because of of the lips, tongue, and palate. the delayed eruption of permanent teeth and the underdevelopment of the maxilla. The maxilla, the bridge of the nose, A smaller maxilla contributes to an open and the bones of the midface region are bite, leading to poor positioning of teeth smaller than in the general and increasing the likelihood of periodontal population, creating a ­disease and dental caries. prognathic occlusal relationship. Mouth Orthodontia should be carefully breathing may occur ­considered in people with Down because of smaller ­syndrome. Some may benefit, while nasal passages, and others may not. the tongue may In and of itself, Down syndrome is not a protrude because barrier to orthodontic care. The ability of a smaller of the patient or caregiver to maintain ­midface region. good daily oral hygiene is critical to the People with feasibility and success of treatment. Down syndrome often have a strong TOOth anomalies are common in gag reflex due to Down syndrome. placement of the tongue, as well as Congenitally missing teeth occur associated with more often in people with Down any oral stimulation. syndrome than in the general population. Third molars, laterals, The palate, although normal sized, and mandibular second bicuspids may appear highly vaulted and narrow. are the most common missing teeth. This deceiving appearance is due to the

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Delayed eruption of teeth, often following general population. If you ­suspect that a an abnormal sequence, affects some child is being abused or ­neglected, State laws children with Down syndrome. Primary require that you call your Child Protective teeth may not appear until age 2, with Services agency. Assistance is also available complete dentition delayed until age 4 or 5. from the Childhelp® National Child Abuse Primary teeth are then retained in Hotline at (800) 422–4453 or the Child some children until they are 14 or 15. Welfare Information Gateway (www.childwelfare.gov). Irregularities in tooth formation, such as and malformed teeth, are Making a difference in the oral health also seen in people with Down syndrome. of a person with Down syndrome may Crowns tend to be smaller, and roots are go slowly at first, but determination can often small and conical, which can lead to bring positive results—and invaluable from periodontal disease. Severe rewards. By adopting the strategies illness or prolonged fevers can lead to ­discussed in this booklet, you can have hypoplasia and hypocalcification. a significant impact not only on your • Examine a child by his or her first patients’ oral health, but on their ­birthday and regularly thereafter to as well. help identify unusual tooth formation and patterns of eruption. additional readings • Consider using a panoramic radio­ Fenton SJ, Perlman S, Turner H (eds.). Oral graph to determine whether teeth are Health for People with : Guidelines congenitally missing. Patients often for Comprehensive Care. River Edge, NJ: find this technique less threatening Exceptional Parent, Psy-Ed Corp., 2003. than individual films. • Maintain primary teeth as long as Roizen NJ. Down Syndrome. In Batshaw ML, possible. Consider placing space Pellegrino L, Roizen NJ (eds.). Children With maintainers where teeth are missing. Disabilities (6th ed.). Baltimore, MD: Paul H. Brookes Publishing Co., 2007. TRAUMA and INJURY to the mouth Weddell JA, Sanders BJ, Jones JE. Dental from falls or accidents occur in people with problems of children with disabilities. In Down syndrome. Suggest a tooth-saving kit McDonald RE, Avery DR, Dean JA. Dentistry for group homes. Emphasize to ­caregivers for the Child and Adolescent (8th ed.). St. that traumas require immediate ­professional Louis, MO: Mosby, 2004. pp. 524–556. ­attention and explain the procedures to follow if a permanent tooth is knocked out. Also, For more information about Down syndrome, contact instruct caregivers to locate any missing pieces of a fractured tooth, and explain that National Institute of Child Health and Human radiographs of the patient’s chest may be Development Information Resource Center necessary to determine whether any fragments P.O. Box 3006 have been aspirated. Rockville, MD 20847 (800) 370–2943 Physical abuse often presents as oral trauma. http://www.nichd.nih.gov Abuse is reported more frequently in people [email protected] with developmental disabilities than in the

7 This booklet is one in a series on providing oral care for people with mild or moderate developmental disabilities. The issues and care strategies listed are intended to provide general guidance on how to manage various oral health challenges common in people National Institute of Dental with Down syndrome. and Craniofacial Research Other booklets in this series: Continuing Education: Practical Oral Care for People With Developmental Disabilities Practical Oral Care for People With Practical Oral Care for People With Cerebral Palsy Practical Oral Care for People With Intellectual Disability Wheelchair Transfer: A Health Care Provider’s Guide Centers for Disease Control Dental Care Every Day: A Caregiver’s Guide and Prevention

SAFER • HEALTHIER • PEOPLETM

Special Care Dentistry Association ACkNOWLEDgMENTS

The National Institute of Dental and Craniofacial Research thanks the oral health professionals and caregivers who ­contributed their time and expertise to reviewing and pretesting the Practical Oral Care series. For additional copies of this booklet, contact Expert Review Panel National Institute of Dental and Craniofacial Research • Mae Chin, RDH, University of Washington, Seattle, WA National Oral Health Information Clearinghouse 1 NOHIC Way • Sanford J. Fenton, DDS, University of Texas, Houston, TX Bethesda, MD 20892–3500 1–866–232–4528 • Ray Lyons, DDS, New Mexico Department of Health, http://www.nidcr.nih.gov Albuquerque, NM • Christine Miller, RDH, University of the Pacific, San Francisco, CA This publication is not copyrighted. Make as many photocopies as you need. • Steven P. Perlman, DDS, Special Smiles, Lynn, MA NIH Publication No. 09–5193 Reprinted July 2009 • David Tesini, DMD, Natick, MA