Year : 2008 | Volume
: 19 | Issue : 3 | Page : 224--229
Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India
Sharath Asokan, MS Muthu, N Sivakumar
Department of Pediatric Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
Department of Pediatric Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu
Purpose: To assess the prevalence of caries and the treatment needs of Down syndrome children in the Indian city of Chennai.
Materials and Methods: Among the130 Down syndrome children examined, only the children aged £15 years were included in the study ( n = 102). There were 57 male and 45 female children in the total study sample. A specially prepared case record was used to record the findings for each child. The dentition status and the treatment needs required were recorded. Comparisons of the findings were done based on age and gender distribution.
Results: Twenty-nine per cent of the total sample of Down syndrome children was found to be caries-free. Extraction (in 38 children) and one-surface filling (in 26 children) were the most needed specific treatments for primary and permanent teeth, respectively. Oral prophylaxis (99%) was the most required treatment in the overall treatment category.
Conclusions: Contrary to the findings of earlier studies, the percentage of caries-free Down syndrome children was found to be lower in our study. However, their basic needs like oral prophylaxis, restorations and extractions remain the same and can be easily fulfilled by an efficient, community-based dental team.
|How to cite this article:|
Asokan S, Muthu M S, Sivakumar N. Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India.Indian J Dent Res 2008;19:224-229
|How to cite this URL:|
Asokan S, Muthu M S, Sivakumar N. Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India. Indian J Dent Res [serial online] 2008 [cited 2021 Oct 27 ];19:224-229
Available from: https://www.ijdr.in/text.asp?2008/19/3/224/42955
Down syndrome is a congenital autosomal anomaly characterized by generalized growth and mental deficiency. , The risk for this chromosomal aberration is one out of 600-1000 live births. Approximately 95% of Down syndrome cases have the extra chromosome 21, resulting in a chromosome count 47 instead of the normal 46. The other 5% of chromosomal abnormalities include translocation (3%) and mosaicism or partial trisomy (2%). Down syndrome has also been referred to by the terms Trisomy 21, Trisomy G or Mongolism. 
Down syndrome children have characteristic orofacial features. The most common oral findings in these children include mouth breathing, open bite, macroglossia, fissured lips and tongue, angular cheilitis, delayed eruption of teeth, missing and malformed teeth, microdontia, crowding, malocclusion, bruxism, poor oral hygiene and a low level of caries. ,,
Brown and Cunningham showed that 44% of the Down syndrome children they examined were caries-free.  Johnson and Young reported a low incidence of dental caries both in the primary and permanent dentition.  Stabholz et al, showed that 84% of the Down syndrome children examined were caries-free.  As no published data is available on the prevalence of caries and treatment needs of Down syndrome children in the South Indian city of Chennai, this study was planned with the following aims and objectives:
To assess the prevalence of dental caries and treatment needs of children with Down syndrome.To compare the age-wise and sex-wise distribution of the above findings.
Materials and Methods
A descriptive cross-sectional study was planned to assess the status of dental caries in children with Down syndrome in Chennai. A total of 130 Down syndrome children were examined in this study. The children belonged to 15 special schools in Chennai. All the children had been admitted to the school after prior investigations to confirm the syndrome. Consent was obtained both from the parents and the concerned school authority to carry out the study. Only children aged ≤15 years (n = 102) were included in this study irrespective of their personal, medical and dental history. A single examiner examined all the 102 children. The children were assigned to three groups as mentioned in [Table 1].
The examination was carried out with the children sitting on wooden or plastic chairs under an artificial light. Each participant was subjected to a clinical assessment using a flat dental mirror and an explorer. The findings were recorded in a specially prepared proforma prepared by the authors from the Department of Pedodontics, Meenakshi Ammal Dental College, Chennai. The status of the dentition and the treatment needs were recorded using the WHO oral assessment criteria (1997). Each tooth was examined and the status was defined by numbers for permanent teeth and by letters of the English alphabet for primary teeth. The teeth were marked as sound, decayed, filled with decay, filled with no decay, missing due to caries, missing due to other reasons, fissure-sealed, unerupted, bridge abutment/crown/veneer or traumatized, as recommended by the WHO. Specific treatment needs included preventive caries arresting care, fissure sealant, one-surface filling, two or more surface fillings, crowns, veneers/laminates, pulp care restoration and extraction. These specific needs were marked in numbers except for fissure sealant and preventive caries arresting care, which were marked as 'F' and 'P', respectively. The overall treatment required was categorized in the last section under the following headings: oral prophylaxis, fluoride therapy, restorative treatment, extractions, and orthodontic correction.
Radiographs and other investigations like pulp vitality tests were not carried out because of the lack of facilities and all the findings recorded were based on clinical judgment. The total numbers of sound and decayed primary and permanent teeth in each group were counted and the percentages of decayed and sound teeth calculated. The percentage of caries-free children in each group was also calculated.
Age-wise comparisons of the findings were done among the three different groups and within the same age group; differences between the male and female samples were assessed. A comparison of each finding between the total male (n = 57) and female (n = 45) samples, irrespective of their age group was also done. The proportions of different findings were estimated from the sample for each study group. Proportions were compared by using either the Chi-Square test or Chi-Square test with Yates continuity correction, as explained in the footnotes below the tables. In the present study, P Prevalence of dental caries: In group I (n = 13), 94.1% of all primary teeth and 61.9% of the children were caries-free. In group II (n = 6), 66% of all primary teeth, 83.1% of all permanent teeth and 14.6% of the children were caries-free. There was a significant difference in the prevalence of caries in primary teeth between the male and female samples in group II (P = 0.04). In group III (n = 11), 50.2% of all primary teeth, 90.9% of all permanent teeth and 27.5% of the children were caries free. There was a significant difference in the prevalence of caries in permanent teeth between the male and female categories in group III (P = 0.003).
An age-wise comparison showed a significant difference in the prevalence of caries in primary (P P = 0.0002) between the different age groups [Table 2a]. A significant difference in the percentage of caries-free children was also evident among the three groups (P = 0.0005) [Table 2b]. In the total sample, 71% of primary teeth (n = 784), 88.6% of permanent teeth (n = 1031) and 29.4% of the thirty children in this sample, were caries-free. There was a significant difference in the prevalence of caries in the permanent teeth of the male and female categories of the total sample (P = 0.003) as seen in [Table 3a]. There was no significant difference in the prevalence of decay in primary teeth and in the percentage of caries-free children between the male and female subsets of the total sample [Table 3b].
Specific treatment needs: In group I, 23.8 and 4.8% of the children needed one-surface and two-surfaces fillings, respectively for their primary teeth. In the same group, 9.5% of the children needed crown and preventive restorations for their primary teeth and 4.8% needed pulp care. Extraction and fissure sealants were not needed by any of the children belonging to this group.
In group II, one-surface fillings were required for primary and permanent teeth in 43.9 and 26.8% of the children, respectively. In the same group, two-surfaces fillings were needed for primary and permanent teeth in 24.4 and 4.9% of the children, respectively. Pulp care therapy and crowns were required in the primary teeth of 14.6% of the children. Extractions were required in the primary and permanent teeth of 48.8 and 2.4% of the children respectively, and fissure sealants by 14.6% of the children on their permanent teeth. Primary and permanent teeth required preventive restoration in 36.6 and 26.8% of children, respectively.
In group III, 25 and 37.5% of the children needed one-surface fillings for their primary and permanent teeth, respectively. Much lower percentages were seen (17.5 and 5%) for two-surface fillings in primary and permanent teeth, respectively. Crowns and pulp care were needed for primary teeth in 5 and 10% of the children, respectively. More children (40%) needed primary teeth extraction than permanent teeth extraction (2.5%). Fissure sealants were needed on permanent teeth in 17.5% of the children. Preventive restorations were needed for primary and permanent teeth in 7.5 and 27% of the children, respectively.
There was no significant difference in the specific treatment required for both primary and permanent teeth between the male and female categories of groups I, II and III. An age-wise comparison of treatment needs showed significant differences in the specific treatment required for primary teeth in different age groups [Table 4]. Extraction of teeth was required more in group II and III than in group I children (P = 0.0004). Preventive restorations were needed more by the children in group II than the other two groups (P = 0.002). Treatment for permanent teeth did not show any significant difference among the children of different age groups. There was no significant difference in the specific treatment required for both primary and permanent teeth between the male and female categories of the total sample [Table 5].
Overall treatment required: In group I, oral prophylaxis and fluoride therapy were needed in 95.2 (n = 20) and 28.6% (n = 6) of the children, respectively. Restorative treatment and orthodontic corrections were each required in 33.3% (n = 7) of the children. No child in this group however, needed extraction.
In group II, oral prophylaxis and fluoride therapy were needed in 100 (n = 41) and 85.4% (n = 35) of the children, respectively. Restorative treatment and orthodontic corrections were required in 70.8 (n = 32) and 53.7% (n = 22) of the children, respectively. Unlike group I, 48.8% of the children (n = 20) required extraction.
Similar to group II, oral prophylaxis and fluoride therapy were needed in 100 (n = 40) and 85% (n = 34), respectively, of the children in group III. Restorative treatment and orthodontic corrections were required in 72.5 (n = 29) and 53.7% (n = 33) of the children, respectively. Similar to group II, 50% of the children (n = 20) required extraction.
There was no significant difference in treatment needs between the male and female categories of groups I, II and III. An age-wise comparison of the treatments required in different age groups however, showed a significant difference [Table 6]. Fluoride therapy (P P = 0.001), extractions (P = 0.0002) and orthodontic treatment (P = 0.0004) were needed more by the older children (groups II and III) than the younger children (group I). Orthodontic treatment was comparatively more necessary in group III than in group II children. There was no significant difference in the treatment needs between the male and female categories of the total sample [Table 7].
Brown and Cunningham (1961) examined 80 institutionalized Down syndrome individuals (1-39 years) and found that 44% of the sample was caries-free. Stabholz et al, examined the prevalence of dental caries in 32 Down syndrome children, aged 8-13 years and found 84% of them to be caries-free. Barnett et al, compared the prevalence rates of periodontitis and dental caries in 30 Down syndrome patients and 30 matched, mentally handicapped controls. The results revealed a greater prevalence of periodontitis and a lower prevalence of dental caries in Down syndrome patients compared to the mentally retarded controls.  Morinushi et al, conducted a study in 1995 to evaluate the incidence of dental caries in 75 Down syndrome children in the age group of 2-18 years. They found 46.1% of these children with 61.4% of children below the age of five years to be caries-free. 
The findings of our study however, differ from those of the above studies. Our results showed a lower percentage (n = 30, 29.4%) of the Down syndrome children studied to be caries-free. This higher incidence of caries could be due to the lack of awareness about dental visits, irregular dietary habits, inadequate oral hygiene measures, lack of fluoridated water, easy availability of high sucrose-containing cheap food stuffs, parental neglect and lack of initiative towards prevention.
Cornejo et al, studied the oral health conditions of children aged 3-19 years and compared them with control groups. In every age group, the decayed missing filled-tooth (dmf-t) and decayed missing filled-surface (dmf-s) indices were higher in Down syndrome children than in the control population. From the age of ten years onwards, the DMF T and DMF-S of the control population were higher than those of the Down syndrome individuals.  Although DMFT/S and dmft/s were not calculated in the present study, the percentage of children with dental caries was found to be higher. Oredugba showed that individuals with Down syndrome had a higher prevalence of dental caries than the controls.  It was reported that children with Down syndrome are more likely than typically developing children to be weaned off bottled milk at an older age or given syrup-based medicines for repeated infections because of swallowing problems.  The results of the studies of Cornejo et al and Oredugba were in accordance with the results of the present study.
In the specific treatment category, the children in this study commonly required restorative treatments like one-surface fillings and preventive restorations. The overall treatments required by these children were more of the preventive type such as oral prophylaxis and fluoride treatment followed by restorative treatments. As children with Down syndrome exhibit poor oral hygiene, malocclusion and deficient immune systems, dentists have an obligation to prevent oral diseases through appropriate activities and programs that take the special needs of their patients into account. Preventive oral hygiene and subgingival plaque control has been emphasized and considered of particular importance for children and young people with Down syndrome. 
Summary and Conclusions
This study is one of the few studies that has involved and examined more than 100 Down syndrome children. We have offered to treat all the children examined, free of cost in our dental college. The following conclusions were derived from the results of this study:
Contrary to earlier findings, 29.4% of the children were caries-free.Extraction was the most frequently encountered (37.3%) specific treatment need in primary teeth. In permanent teeth, one-surface fillings were the most needed specific treatment (n = 26, 25.5%).In the overall treatment category, oral prophylaxis was the most required treatment (n = 101; 99%).
|1||Desai SS, Fayatteville NY. Down syndrome: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:279-85.|
|2||Surabian SR. Developmental disabilities and understanding the needs of patients with mental retardation and Down syndrome. J Calif Dent Assoc 2001;29:415-23.|
|3||Borea G, Magi M, Mingarelli, Zamboni C. The oral cavity in Down syndrome. J Pedod 1990;14:139-40.|
|4||Cohen MM, Winer RA. Dental and facial characteristics in Down's syndrome. J Dent Res 1965;44:197-209.|
|5||Gullikson JS. Oral findings in children with Down's syndrome. J Dent Child 1973;40:293-7.|
|6||Brown RH and Cunningham WM. Some dental manifestations of mongolism. Oral Surg Oral Med Oral Pathol 1961;14:664-76.|
|7||Johnson NP, Young MA. Periodontal disease in Mongols. J Periodontol 1963;34:41-7.|
|8||Stabholz A, Mann J, Sela M, Schurr D, Steinberg D, Shapira. Caries experience, periodontal treatment needs, salivary pH and Streptococcus mutans counts in a preadolescent Down syndrome population. Spec Care Dentist 1991;11:203-8.|
|9||Barnett ML, Press KP, Friedman D, Sonnenberg EM. The prevalence of periodontitis and Dental caries in a Down syndrome population. J Periodontol 1986;57:288-93.|
|10||Morinushi T, Lopatn DE, Poparin N. The relationship between dental caries in the primary dentition and anti S.mutans serum antibodies in children with Down syndrome. J Clin Pediatr Dent 1995;10:379-84.|
|11||Cornejo LS, Zak GA, Dorronsoro de Cattoni ST, Calamari SE, Azcurra AI, Battellino LJ. Mucodental health condition in patients with Down syndrome of Cordoba City, Argentina. Acta Odontol Latinoam 1996;9:65-79.|
|12||Oredugba FA. Oral health condition and treatment needs of a group of Nigerian individuals with Down syndrome. Downs Syndr Res Pract 2007;12:72-6.|
|13||Randell DM, Harth S, Seow WK. Preventive dental health practices of non-institutionalized Down syndrome children: A controlled study. J Clin Pediatr Dent 1992;16:225-8.|
|14||Sasaki Y, Sumi Y, Mitazaki Y, Hamachi T, Nakata M. Periodontal management of an adolescent with Down syndrome: A case report. Int J Paediatr Dent 2004;14:127-35.|