As I'm writing this, I'm in agony. One of my back molars has caved in, there is an exposed nerve and I am waiting for an appointment with my dentist on Wednesday. It's horrifying and yucky all at the same time. I'm not happy with my teeth in general these days... Start with antibiotic discolouring, add vomiting every single day for 6 months when pregnant and then sucking back Cokes and sugary coffee in an effort to stay conscious (not to mention 'nurse food' like doughnuts and pizza and cookies and candies and all sorts of junk at 3 am)... Quel surprise! Things are a mess, I'm chewing on one side of my face and stealing the kid's Orajel.
I'm not the only one in dental hell either. If you are keeping tally with Team Logan's tooth parade, you'll know that someone is either losing or gaining teeth all the time right now. Quinn has lost his "grey" tooth (a incisor that he damaged when he was a toddler) and we are anxiously awaiting the appearance of the secondary tooth that is to replace it. Zoe has decided to skip her canines and premolars and go straight for molars, while Wyatt is finally deciding to give his two [razorlike!] teeth on the bottom some playmates on the top. Slooowly you can see them coming up; as of this writing one has cautiously poked through. I'm not the only grumpy one either; the twins both have red cheeks, copious amounts of drool, sore bums, loose-ish stools and are generally irritable as all get out. A few years ago when my oldest and our friends twins were teething, we had a catch phrase: "teeth suck". This was a direct result of those early desperate acetaminophen and gripe water soaked parenting years where we would have entertained just about any idea to get them all to feel better and stop crying. Wanna gnaw on my thumb for three solid hours? Please, go ahead, if it makes you happy! Now it's my turn with teething twins and my fridge is full of chewies of various sizes and descriptions, frozen washcloths and frozen waffles. I should have stock in Tylenol and diaper cream and both Sean and I could use an extra arm right about now. As far as we are concerned right now, teeth really suck!
Since we're all about les dents at the moment, I might as well prolong the agony and talk about Down syndrome and dentistry. I have had the same dentist since I've been 11 years old (when I actually go) and that hasn't been a problem, at least for me. However, is that practice the perfect choice for Wyatt? When should he start going to the dentist and what should I be looking for in a dentist? What kind of things do you have to deal with in Down syndrome that you may not have to deal with typically? Like just about everything else, there is a learning curve for me. Which means that there is one for many other people as well; it would only be fair to share my findings. I'll also switch to my "medical voice", which can be a bit dry and for that I'll apologise for now. To start, I thought I'd go over some of the more common problems.
Structural Issues:
To begin with, those with DS generally experience what is known as delayed eruption. With this, the teeth emerge late compared with typical children. All children are different, however it is not surprising to see "typical" children teething between 6-12 months, while children with Down syndrome generally start between 12-14 months and can possibly wait until 24 months. Typical children have all 20 of their deciduous or primary teeth by age two or three, while children with DS may not have all their teeth until they are 4 or 5. The permanent teeth are also delayed, with the front permanent teeth and permanent six year molars possibly not erupting until age 8 or 9. The teeth may also arrive in a different order than expected.
The teeth may also be smaller than usual (microdentia) or missing; in some cases malformed. Crowns are often smaller as are the roots (which can also be conical). Taurodentism is also common, as are 'peg teeth'.
The tongue is also an area of concern as it can be larger. It can also appear larger while being of average size as the upper jaw could be smaller. Grooves and fissures are common, especially with the high incidence of mouth breathing (due to smaller than average nasal passages). These can be severe at times, which would contribute greatly to halitosis. Mouth breathing can also lend to an overall decrease in saliva (xerostomia) which impacts on the ability of the mouth to clean itself.
Issues with bite can also occur. There may be gaps in the bite, due to spacing from smaller than average teeth. Malocclusions such as an "open bite" are common, as is Prognathism or "underbite", where the bottom jaw is moved forward and the top teeth rest behind the bottom. There also might be overcrowding of the teeth in those with a smaller than normal jaw which could lead to impaction of the secondary teeth. These are all completely treatable with orthodontics; however orthodontic appliances can interfere with speech development so that it is recommended by many sources to delay such treatment.
Tooth grinding or Bruxism is a common here and throughout the neuro-typical community as well. Children often grind their teeth and many stop as they grow older; if this does not cease, however, severe damage to the teeth can occur over time. If this is the case, a dentist may prescribe a mouth guard. DS, can affect ligaments around the teeth. As a side note, Atlantioaxial Instability can cause some positioning challenges whilst in the dentist's chair and possibly interfere with navigating throughout the office safely.
Sleep apnea should also be assessed when positioning and seriously assessed when considering sedation and sleep dentistry.
Disease-Related Issues
Peridontal disease, or issues with the gums is very common in those individuals with Trisomy 21. This is due largely to a predisposition based on an diminished immune defense (see below). Also, there is an overall increased amount of plaque. Onset is rapid and often results in the loss of adult teeth by the teenage years. Frequent brushing (targeting the gum line) and flossing are very important to prevent problems in this area. Regular dental check ups and X-rays are also important to monitor such potential problems such as bone loss. Using specialized antimicrobial mouth rinses such as chlorhexidine might also be helpful. I'm not the only one in dental hell either. If you are keeping tally with Team Logan's tooth parade, you'll know that someone is either losing or gaining teeth all the time right now. Quinn has lost his "grey" tooth (a incisor that he damaged when he was a toddler) and we are anxiously awaiting the appearance of the secondary tooth that is to replace it. Zoe has decided to skip her canines and premolars and go straight for molars, while Wyatt is finally deciding to give his two [razorlike!] teeth on the bottom some playmates on the top. Slooowly you can see them coming up; as of this writing one has cautiously poked through. I'm not the only grumpy one either; the twins both have red cheeks, copious amounts of drool, sore bums, loose-ish stools and are generally irritable as all get out. A few years ago when my oldest and our friends twins were teething, we had a catch phrase: "teeth suck". This was a direct result of those early desperate acetaminophen and gripe water soaked parenting years where we would have entertained just about any idea to get them all to feel better and stop crying. Wanna gnaw on my thumb for three solid hours? Please, go ahead, if it makes you happy! Now it's my turn with teething twins and my fridge is full of chewies of various sizes and descriptions, frozen washcloths and frozen waffles. I should have stock in Tylenol and diaper cream and both Sean and I could use an extra arm right about now. As far as we are concerned right now, teeth really suck!
Since we're all about les dents at the moment, I might as well prolong the agony and talk about Down syndrome and dentistry. I have had the same dentist since I've been 11 years old (when I actually go) and that hasn't been a problem, at least for me. However, is that practice the perfect choice for Wyatt? When should he start going to the dentist and what should I be looking for in a dentist? What kind of things do you have to deal with in Down syndrome that you may not have to deal with typically? Like just about everything else, there is a learning curve for me. Which means that there is one for many other people as well; it would only be fair to share my findings. I'll also switch to my "medical voice", which can be a bit dry and for that I'll apologise for now. To start, I thought I'd go over some of the more common problems.
Structural Issues:
To begin with, those with DS generally experience what is known as delayed eruption. With this, the teeth emerge late compared with typical children. All children are different, however it is not surprising to see "typical" children teething between 6-12 months, while children with Down syndrome generally start between 12-14 months and can possibly wait until 24 months. Typical children have all 20 of their deciduous or primary teeth by age two or three, while children with DS may not have all their teeth until they are 4 or 5. The permanent teeth are also delayed, with the front permanent teeth and permanent six year molars possibly not erupting until age 8 or 9. The teeth may also arrive in a different order than expected.
The teeth may also be smaller than usual (microdentia) or missing; in some cases malformed. Crowns are often smaller as are the roots (which can also be conical). Taurodentism is also common, as are 'peg teeth'.
The tongue is also an area of concern as it can be larger. It can also appear larger while being of average size as the upper jaw could be smaller. Grooves and fissures are common, especially with the high incidence of mouth breathing (due to smaller than average nasal passages). These can be severe at times, which would contribute greatly to halitosis. Mouth breathing can also lend to an overall decrease in saliva (xerostomia) which impacts on the ability of the mouth to clean itself.
Issues with bite can also occur. There may be gaps in the bite, due to spacing from smaller than average teeth. Malocclusions such as an "open bite" are common, as is Prognathism or "underbite", where the bottom jaw is moved forward and the top teeth rest behind the bottom. There also might be overcrowding of the teeth in those with a smaller than normal jaw which could lead to impaction of the secondary teeth. These are all completely treatable with orthodontics; however orthodontic appliances can interfere with speech development so that it is recommended by many sources to delay such treatment.
Tooth grinding or Bruxism is a common here and throughout the neuro-typical community as well. Children often grind their teeth and many stop as they grow older; if this does not cease, however, severe damage to the teeth can occur over time. If this is the case, a dentist may prescribe a mouth guard. DS, can affect ligaments around the teeth. As a side note, Atlantioaxial Instability can cause some positioning challenges whilst in the dentist's chair and possibly interfere with navigating throughout the office safely.
Sleep apnea should also be assessed when positioning and seriously assessed when considering sedation and sleep dentistry.
Disease-Related Issues
Dental caries or 'cavities' as they are more commonly known, are also common. In years past, it was assumed that individuals with DS had a natural resistance to caries as they had a lower incidence. Sadly, this research was done in an era where most people with learning disabilities were institutionalized and therefore, had a restricted diet. In this more forward thinking time, everyone is exposed to the same abundance of carbohydrates and therefore, the same risk of forming cavities. Reducing carbohydrate intake, frequent flossing and brushing (with a fluoridated toothpaste) will significantly reduce the formation of caries.
There is a distinct link between oral disease and heart disease. People who have heart conditions are usually recommended to take antibiotics before any invasive dental procedure, including cleaning or scaling (tartar removal). Due to the high incidence of heart problems associated with Down syndrome (specifically, mitral valve prolapse), it is not surprising that many individuals with DS are prescribed antibiotics before a trip to the dentist to prevent bacterial endocarditis.
As mentioned previously, those with Down syndrome often have a decreased immune response due to a decreased number of T cells, a specialized white blood cell that fights infection. As a result, there is an overall increase in oral infections including periodontal disease, acute necrotizing ulcerating gingivitis (ANUG), candida (yeast), and ulcers. Wound healing times may also be prolonged, especially if the individual also has diabetes. Frequent upper respiratory infections often lead to mouth breathing, xerostomia and fissures of the lips and tongue.
Seizures are common in the DS community. Providing your dentist with a complete medical history and list of medications will be important, as will a list of triggers, etc. This way, the staff can be more prepared if a seizure were to occur in the office or in the chair during a procedure.
It is recommended that oral hygiene be stressed and any problems with the primary teeth to be addressed quickly. Due to the generally late appearance of the secondary teeth it is advisable to encourage the primary teeth to stay around as long as possible.
Other Considerations
When looking for a dentist for your child, it may be worth considering a pediatric dentist who specializes in treating children. This is especially ideal if there are sensory issues with your child or if your child is often fearful. Speech, vision and hearing difficulties could easily hinder communication. Due to the cognitive diversity found within Down syndrome, there could possibly be interpretation issues as well, which could hinder treatment. At the very least, having a dental team with experience with special needs is probably a wise decision.
Behaviour management can also be a consideration. Suggestions to improve the overall experience include:
- Scheduling the appointment early in the day so that all parties are well rested.
- Active listening to ensure ideas and instructions are communicated and understood clearly.
- Simple, concrete speech to facilitate short-term memory.
- Whole team involvement/introductions to help acclimatise and reduce any anxiety.
- Limiting distractions
- Consistency of care
- Reward co-operative behaviour and comfort those who require it
- Avoid immobilization techniques
- Use a collaborative approach; sharing information, positive techniques and previous experience between staff and caregivers can improve any clinical experience.
As with any child, it is recommended that professional dental care begin with the eruption of the first teeth; this has been stressed in much of the literature concerning Down syndrome as well. This will not only acclimatise the child to the environment, but also ensure that they have exceptional care from the very start.
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That's a lot to think about.
However, it is in our best interest. Many, if not all of these conditions are present in the 'typical' population and are by no means exclusive to those with Trisomy 21. I won't know if my dentist is the best for Wyatt until I get there and start asking questions. If not, I will move on. However, for now, I will encourage this process by offering up the best example that I can to the kids. That starts Wednesday when I face the drill of my DDS.
Writing this article in spots, if you forgive the analogy, was like pulling teeth. Hopefully the information provided here will help promote oral health for your child (and you)... and keep that very thing from happening.
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Debord, Dr. Jessica, DDS, Dental Issues and Down syndrome, National Down Syndrome Society (NDSS), ©2012.
Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India, Indian Journal of Dental Research, 2008; 19(3); 224-229
Frydman A, Nowzari H., Down syndrome-associated periodontitis: a critical review of the literature, Compendium of Continuing Education in Dentistry, 2012; 33(5): 356-361.
Pilcher ES. Dental Care for the Patient with Down Syndrome, Down Syndrome Research and Practice. 1998; 5(3); 111-116.
Practical Oral Care for People With Down Syndrome, National Institute of Dental and Craniofacial Research, National Institute of Health, #09-5193
