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Periodontal Disease in Down Syndrome Patients

Myah Young and Jacob DeWerd

MCC Dental Hygiene Program

DHE 219: Practice Management

Mrs. Zitek, RDH, MAEd

January 30, 2024

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Abstract

In patients with Down syndrome, there are many etiologic risk factors associated with the

development of periodontal disease. In undergoing research and a meta-analysis of several peer

reviewed research articles discussing the predisposing factors for periodontal disease in Down

syndrome patients, a thorough summary of these findings was created in order to provide dental

hygienists with the knowledge needed to provide the best quality of care for these patients. By

being able to implement modifications and specialized oral hygiene instructions in each dental

visit for these patients, dental hygienists are given the opportunity to decrease the progression of

periodontal disease in individuals with Down syndrome.

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Periodontal Disease in Down Syndrome Patients

Considered the most common chromosomal anomaly, Down syndrome is a genetic

condition resulting from the trisomy of chromosome 21 and is linked to stunted growth,

developmental delay, typical facial characteristics, and relevant intellectual impairment. Health

impairments include alterations of the nervous system and the immune system as well as

cardiovascular, hematopoietic, and musculoskeletal anomalies (Scalioni et al., 2018, p.382). Due

to these health complications, dental hygienists should be made aware that these impairments can

greatly affect the oral health of these individuals. There are many risk factors for periodontal

disease that are linked to this autosomal genetic disorder, thus individuals diagnosed with Down

syndrome are predisposed to early onset and rapidly progressing periodontal disease. This

includes gingivitis, generalized juvenile periodontitis, and chronic periodontitis (Contaldo et al.,

2021, p.2). By evaluating these risk factors, dental hygienists will be able to detect early signs

and symptoms of periodontal disease and provide a timely diagnosis and appropriate dental

treatment before the disease worsens.

Down syndrome weakens the immune response in these individuals, including defective

neutrophil and monocyte chemotaxis and phagocytosis, T system immune-deficiencies, and

premature immune system senescence. Due to the predisposition to a chronic proinflammatory

status, individuals with Down syndrome have a higher susceptibility to oral infection (Contaldo

et al., 2021, p. 2). Not only does a decreased host immune response make these patients more

susceptible to acquiring periodontal disease to begin with, but it also favors an increased immune

response leading to rapid destruction. Because Down syndrome is associated with an increased

pro-inflammatory cytokine production, this can worsen both the onset and progression of

periodontitis in these individuals (Contaldo et al., 2021, p. 5). Thus, it is extremely important that
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periodontal disease is caught at its earliest signs because the disease destruction will be rapid and

severe. A study focusing on the metabolic parameters of patients with Down syndrome focused

on the role of anthropometric variables and metabolic serum parameters in both the high

prevalence of periodontitis, and its severity and extent. Because these aspects can also influence

the systemic condition and act as risk factors for cardiovascular disease, atherosclerosis, and

dementia, it is even more crucial that preventive and early multiprofessional care is given to

Down syndrome patients (Mouchrek et al., 2022, p. 911).

A systematic review article that was used in this meta-analysis focused on the difference

of oral microbiota features in those with Down syndrome as compared to individuals without

Down syndrome and even those with other disorders causing decreased motor function and poor

oral hygiene. After assessing extensive research studies, it was found that due to their systemic

compromised immunological conditions, the early subgingival colonization and growth of

periodontal pathogen bacteria is favored (Contaldo et al., 2021, p. 5). With this, comes an

increase in the microbiota composition in terms of periodontopathogenic bacteria such as T.

forsythia and A. naeslundi being significantly more prevalent at any age, P. gingivalis, A.

actinomycetemcomitans, C. rectus, P. intermedia, and C. sputigena being more prevalent in

adolescents and young adults, and E. corrodens, P. nigrescens and P. micros peculiarly

significantly higher in DS young adults (Contaldo et al., 2021, p. 21).

Lastly, in comparing DS subjects and non-DS with mental retardation, both affected by

periodontitis, it was found that DS reported worst periodontal indices and a significant increase

in periodontopathogenic bacteria of the orange and yellow complexes higher in DS than in MR

(Contaldo et al., 2021, p. 21-22). Take note, that the bacteria in the orange complex are

associated with periodontal disease. These studies showed that even in individuals that have the
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same motor and cognitive disabilities and thus similar poor oral hygiene and plaque control, the

oral microbiota in Down syndrome is more severe. Thus, it can be concluded that poor motor

skills and oral hygiene habits are not the only reason responsible for the early and aggressive

onset and prevalence of periodontitis, but that the microbial composition in those with Down

syndrome plays a role as well (Contaldo et al., 2021, p. 22).

Many studies show that as compared to individuals with other disabilities, such as

cerebral palsy and intellectual disability, those with Down syndrome have shown a higher

prevalence and greater severity of periodontal disease. This further highlights the hypothesis that

factors such as manual dexterity and poor oral hygiene are not enough to explain this higher

prevalence (Mouchrek et al., 2022, p. 905). Still, it is very important that dental hygienists

recognize the need to provide more effective and specific oral hygiene instructions to both their

Down syndrome patients and their parents/caregivers by demonstrating proper brushing and

flossing techniques. Especially given the findings of the previously mentioned study that

described an increase in oral bacteria in these individuals, as well as the fact that these patients

are at an increased risk of periodontal disease. Increased risk factors for periodontitis associated

with their genetic periodontium makeup include having short roots, low volume of the alveolar

process, agenesis of neighboring elements, and a shorter frenulum of the lower lip (van de Wiel

et al., 2018, p. 299).

Because those with Down syndrome have decreased manual dexterity and intellectual

disability that can make it hard for them to have meticulous oral hygiene, dental hygienists

should always make a point to take the time to provide effective and specific instructions to both

the patient and parent/caregiver as well as helpful oral hygiene aids such as a toothbrush with an

easier hand grip. The accumulation of plaque on those with Down syndrome can be associated
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with inappropriate tooth-brushing and flossing, thus these individuals usually need to be

supervised and aided by their parents/caregivers in order to prevent gingival bleeding and worse.

Even with meticulous oral hygiene help from their parents or caregivers, dental hygienists must

remember that immunodeficiency and early/high colonization by periodontopathogenic bacteria

is also a culprit in the progression of inflammation and disease (Scalioni et al., 2018, p. 388).

Thus, having these patients come in more frequently for dental visits can help in maintaining

these risk factors and preventing the progression of periodontal disease.

It is important as dental hygienists to invest time and education in studying the Down

syndrome disorder as it is starting to become more integrated with our career. Due to advances in

medicine many individuals who have down syndrome are seen to be living longer and healthier

lives (Gehrig et al., 2019, p. 323). This means it is becoming abundantly common to see patients

with Down syndromes seeking dental care. Furthermore, the type of oral manifestations and

systemic diseases that come along with down syndrome are now being seen and treated; for

example, there are underdeveloped midfacial regions making the maxilla, bridge of the nose, and

bones smaller than normal. This causes issues such as prognathic presentations of occlusal bites,

mouth breathing due to small nasal passageways, stronger gag reflexes due to the position of the

tongue, and high vaulted palates (Gehrig et al., 2019, p. 323). Hygienists must take into

consideration these anatomical anomalies in order to properly care for their patients with Down

syndrome such as spending more time with radiographs to avoid gagging, referring to dentists or

specialists such as myofunctional therapists or orthodontists to help readjust bites and issues with

the tongue.

Not only should dental hygienists watch for anomalies, but how these anomalies also

increase the chances of the individual developing periodontal disease. As shown with other
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individuals with malocclusion, the mispositioning of teeth has an increased chance of periodontal

diseases (Gehrig et al., 2019, p. 323). Additionally, proper oral health care education not only to

the patient but also to their caregivers is important since there is an increased risk. A study done

on periodontal disease in Down syndrome patients states, “People with intellectual disabilities

show reduced cooperation with self-care, such as teeth brushing, but also with dental treatment.

As the treatability is reduced, the relative strain caused by the same periodontal therapy

increases. Also, early introduction of periodontal care, participation of parents/caregivers, and

frequency of attendance seem to improve periodontal outcomes in preventive of periodontal

treatment of DS patients” (van de Wiel et al., 2018, p. 300). It is highly important as the role of

the dental hygienist to stress home care aids and techniques as the treatment for periodontal

diseases is affected immensely by how Down syndrome individuals along with their caretakers

maintain the health of their teeth at home. This study also stated that, “it becomes clear that

patients with DS, visiting a special care dentist regularly, showing good cooperation during

dental treatment and performing adequate dental selfcare (with help), have less chance of

developing periodontitis” (van de Wiel et al., 2018, p. 305). Because patients with Down

syndrome may be apprehensive to dental hygiene treatment, it is crucial that these patients be

seen regularly at an early age because the more familiar they are with treatment, the more

effective treatment will become an as such, further prevention of periodontal disease ((van de

Wiel et al., 2018, p. 305). With the help of early interventions, dental hygienists can help to slow,

prevent, or maintain periodontal diseases with meticulous home care and regular dental visits.

Dental hygienists can also recommend electric toothbrushes and water flossers to help

ease any issues caretakers or Down syndrome individuals may have with coordination due to

more simple actions than regular flossing or manual brushing. Additionally, due to Down
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syndrome individuals having abnormal PMN function it may also be important to implement

chlorhexidine gluconate rinse in adjunct to treatment and self-care. Chlorhexidine has shown to

reduce the severity of oral mucosal inflammation and decrease plaque scores (Gehrig et al.,

2019, p. 322). This allows for a better balance against pathogenic bacteria and overall has a

better chance in keeping these individuals stable.

Overall, as dental hygienists, it is imperative that we fully understand not only the risk

factors associated with periodontal disease in Down syndrome patients, but also the steps needed

to be taken in their dental hygiene visits in order to prevent periodontal disease and maintain

their oral health. This includes seeing them for routine and more frequent dental visits, providing

specific oral hygiene instructions to both the patient and the caregiver, and taking all the extra

steps and precautions to help them fight and prevent disease. Because these individuals are

already susceptible to periodontal disease, dental hygienists always need to be one step ahead!
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References

Contaldo, M., Lucchese, A., Romano, A., Della Vella, F., Di Stasio, D., Serpico, R., &

Petruzzi, M. (2021). Oral Microbiota Features in Subjects with Down

Syndrome and Periodontal Diseases: A Systematic Review. International

Journal of Molecular Sciences, 22(17), 9251.

https://doi.org/10.3390/ijms22179251

Gehrig, J. S., Shin, D. E., & Willmann, D. E. (2019). Foundations of periodontics for the dental

hygienist (5th ed.). Jones and Bartlett Learning.

Mouchrek, M. M. M., Franco, M. M., da Silva, L. A., Martins, K. A. C., Conceição, S. I.

O. da, Rodrigues, V. P., & Benatti, B. B. (2022). Identifying metabolic

parameters related to severity and extent of periodontitis in down syndrome

patients. Journal of Periodontal Research, 57(4), 904–913.

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Scalioni, F., Carrada, C. F., Abreu, L., Paiva, S. M., & Ribeiro, R. A. (2018). Perception

of parents/caregivers on the oral health of children/adolescents with Down

syndrome. Special Care in Dentistry, 38(6), 382–390.

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van de Wiel, B., van Loon, M., Reuland, W., & Bruers, J. (2018). Periodontal disease in

Down’s syndrome patients. A retrospective study. Special Care in Dentistry,

38(5), 299–306.

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