Pagina 37

M.F. Mathias*, M.R.L. Simionato**, R.O. Guaré***
*Discipline of Dentistry, Universidade Cruzeiro do Sul, São Paulo,
2 **University of São Paulo, Brazil
***Discipline of Dentistry, Persons with Disabilities Division,
Universidade Cruzeiro do Sul,São Paulo, Brazil

Some factors associated
with dental caries
in the primary dentition
of children
with Down syndrome
Aim It is well reported in the scientific literature that there is
a high level of periodontal disease and lower caries
prevalence in Down Syndrome (DS) individuals, when
compared with age-matched non DS individuals. This study
was conducted to investigate the process of dental caries in
DS children.
Materials and method s In this study the following
parameters were considered: oral hygiene habits, levels of
Streptococcus mutans (SM) and Lactobacillus spp. (LB),
Modified Gingival Index (MGI), and Simplified Oral Hygiene
Index (OHI-S). A case group with DS children (n=69) and a
control group of non DS children (n=69) were formed to
perform this study. Dental caries severity was determined
using the DMFT index. Samples of non-stimulated saliva were
collected to determine the Lactobacillus spp levels. For SM
levels, MSB agar plates were used.
Results The findings revealed that the case group attended
dental check-ups more frequently, brushed their teeth more
times per day, flossed less, and also more frequently had SM
levels classified as “high count”. The MGI was higher and the
OHI-S was lower than the control group (p<0.001).
Conclusion No significant differences were found between
the DMFT indexes of children from the two groups (p=0.345).
The logistic regression analysis showed that in the case group,
age, MGI, and SM count were positively related to dental
caries (p<0.05).
Keywords: Paediatric dentistry; Down Syndrome; Dental

Down syndrome is characterised by the presence of an
extra copy of chromosome 21 [Cutress, 1971] and its
prevalence is approximately 1:800 live births [Rogers et al.,





1996]. There is a strong correlation between maternal age
and the risk of having a child with DS. At 30 years of age,
the risk ratio is 1:1000 and it increases to 9:1000 for
women over 40 years old [Jojnstone et al., 1999].
Approximately 80% of individuals with DS have an
intellectual quotient (IQ) ranging between 25 and 50.
Weight and height values at birth are below average and
there is a delay in growth as well as early aging [Pinazo
et al., 1998]. They are more susceptible to infections of
the gastrointestinal, respiratory, and urinary tracts due to
immune-system deficiencies (T lymphocytes) [Rogers et
al., 1996]. They have a greater risk of developing
leukemia (15 to 20 times greater than individuals
(approximately 8 times more frequent) [Pinazo et al.,
1998]. Approximately 40% to 60% of individuals with
DS present with congenital heart diseases, which can be
treated during early stages of life, resulting in a good
prognosis [Rogers et al., 1996; Desai and Faytetteville,
1997; Fiske and Shafik, 2001].
Several dental anomalies are also observed, such as:
hypodontia, olygodontia, conoid teeth, microdontia,
enamel hypocalcification, fusion and gemination [Allison
et al., 2000]. In general, there is a delay in both primary
and permanent tooth eruption in individuals with DS, and
the primary dentition is not fully completed before 4 or 5
years of age [Pinazo et al., 1998].
Individuals with DS are known to have a greater
predisposition to periodontal disease due to alterations in
their immune system [Desai and Faytetteville, 1997;
Reuland-Bosma et al., 1986]. There have also been reports
of low caries incidence in this population, which could be
related to a variety of factors including the buffer capacity
of their saliva, delayed eruption, generalised diastemas,
and a tendency towards bruxism that wears the occlusal
surfaces of teeth, making them flat and smooth [Jojnstone
et al., 1999; Shapira and Stabholz, 1996]. Other factors
that could be associated with this low caries prevalence
are: colonisation by S. mutans with a less cariogenic
profile, difference in the acidogenecity or acidoduricity of
strains [Cogulu et al., 2006a] and high levels of salivary
IgA [Cogulu et al., 2006b].
The aim of this study was to evaluate the clinical factors,
microbiological levels and oral hygiene habits in caries
disease in the primary dentition of DS children.

Material and methods
The case group was composed of 69 children with
Down syndrome between 13 and 85 months old. They
were examined at the Irmandade da Santa Casa de
Misericórdia de São Paulo, Darcy Vargas Children’s
Hospital, Associação de Pais e Amigos dos Excepcionais
(APAE) of the city of Barueri, Brazil.
The control group consisted of 69 children without
congenital anomalies, selected among students of the
Marly Teixeira de Almeida kindergarten, Barueri, São
Paulo, who were paired with children of the case group
considering gender, age and number of erupted teeth. As
the DS children present a delay in the dental eruption
process and this factor could influence their caries


Preparation of culture plates for S. tooth brushing (after the saliva sample collection) and examination to obtain the DTMF index. using a dental mirror and a dental probe with a blunt tip. count and cardiopathy) could be EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL. DMFT Index After brushing the children’s teeth. 12/1-2011 . GMI. A highly powerful vacuum and two tubes were used. 38 Salivary levels of Lactobacillus spp Rogosa agar plates were used in this phase of the experiment. with one tube attached to the pump and the other inserted in the child’s oral cavity. in a microaerophilic environment. and were incubated at 37°C for 48 hours in a portable kiln. maxillary right lateral incisor. an age compensation was necessary.art_semionato 15-03-2011 11:09 Pagina 38 MATHIAS MF. The classification proposed by Klock and Krasse (1977) was used. SM count. as well as on the lingual surfaces of the mandibular second molars. and mandibular right primary molar. three or more times). The non-stimulated saliva samples were obtained using a spatula. mandibular left second molar. When it was not possible to apply the Chi-square test. Lactobacillus spp. All exams were performed by a calibrated examiner in a dental office under artifical lighting. Fisher’s Exact test or t-tests for two independent samples were used. mutans and Lactobacillus spp. OHI-S. Statistical difference – that is. as follows: <104. Only children with DS in their primary dentition were included in the study and the exclusion criteria were: children with local oral factors (soft or hard tissue tumors. 2 times.89 for DTMF index. 1944]. access to dental care. mandibular left lateral incisor. With the tip of a cotton bud. Modified Gingival Index To evaluate periodontal disease.83 for OHI-S and 0. using scores from 0 to 4. Information regarding the mother’s age and occupation was also collected. [1986] was used. The index chosen for carious lesion diagnosis was the DMFT [Grubell. 0. The calibration was done through repeated exams during the course of the study (Kappa intraexaminer agreement was 0. Intraoral examination was systematically carried out. which was obtained by vacuuming the air. and the quantification of colony-forming units of both bacteria were performed at the Oral Microbiology lab of the Biomedical Scientific Institute of the University of São Paulo. [1973]. A univariate logistic regression analysis was also performed to determine which parameters (child’s age. prepared as recommended by Gold et al. The numerical variables (mother’s age and DMFT) were compared by the t-test for independent samples. the dental surfaces were dried with sterile gauze. In the case group 26 children did not present complete primary dentition. SEMIONATO MRL AND GUARÉ RO prevalence. quadrant by quadrant. intake of medications.05. Medical and dental history General information regarding the medical and dental history and oral hygiene habits of all children from the case and control groups were obtained from the participants’ legal guardians in a questionnaire. determination of GMI and OHI-S. As this approach was not valid for the younger individuals (for example 13 months old). This information was used for pairing the children with complete primary dentition. the Fisher Exact test was used. The primary teeth evaluated (gingival margins and papillae) in each oral quadrant were: maxillary right second molar. and the diagnostic criteria were those recommended by the World Health Organization (WHO) in 1987. brushing 1 time per day. the mandibular left central incisor and the maxillary second molars. >106. stomatitis. bilaterally. a plaque disclosing agent was applied on the buccal surfaces of the primary maxillary right central incisor. 104-105. Statistical method For statistical analysis the Chi-square test. Since participants with Down syndrome were not able to cooperate. or the help of others). These surfaces were examined and given a score from 0 to 3. and the other end of both of tubes going through the BD Vacutainer® lid. salivary samples were obtained using an adapted device. Simplified Oral Hygiene Index The patient’s oral hygiene was evaluated according to the criteria used in the Simplified Oral Hygiene index (OHIS) proposed by Greene & Vermillion [1964]. as described by Köhler and Bratthal [1979]. The plates were placed in plastic bags. and this technique does not include the application of pressure with a probe to determine the presence or absence of gingival bleeding. Salivary levels of Streptococcus mutans The salivary levels of Streptococcus mutans were determined using mitis-salivarius bacitracin (MSB) agar plates. The clinical examination and data collection were performed in the following steps: an interview with the participants’ legal guardians during which all procedures to be carried out were explained and a questionnaire together with a consent form had to be filled out and signed. when compared with the data from tables proposed by Logan and Kronfield (1933) and McCall and Shour (1941). saliva sample collection for microbiological analysis. brushing and flossing frequency (not brushing their teeth. total number of surfaces.88 for GMI). The questions covered: presence of chronic disease. with the father’s or mother’s help. the statistical difference level considered significant between the groups – was set at p < 0. 105106. a secondary criteria based on the number of erupted teeth was adopted for pairing them. recurrent canker sores or major oral pathologies) and children who had participated in another clinical study 30 days prior to the development of the present study. Based on their ages it was possible to identify an average delay of 9 months for girls and 13 months for boys. The Chi-square test was used for groups comparison with regard to the qualitative variables. the index proposed by Löe & Silness [1963] and modified by Lobene et al. tooth brushing supervision (whether the child brushed its teeth alone. The MGI consists of visual examination only. The Köhler and Bratthal’s classification was used to count the bacterial colony-forming units. maxillary left primary molar.

001* 21 (30.9) 18 (26. in order to verify whether the parameters associated with caries were the same in the two groups.7) Father 1 (1. In this case. “laid off work” or “housewives” were inserted in the category “do not work outside of the home”. 39 . There was no significant difference as regards low SM count (Table 2). in reality in 9 cases (3 DS and 6 non DS) this count was so low that it was not detected. and the comparison was statistically significant. though in an important portion tooth brushing was performed by the child itself and by the mother and father.7) 0. as the majority was given professional guidance.1) 0. age and mother’s occupation Comparison of the frequency of dental follow-up was statistically significant. It was also investigated whether the caries risk could be associated with the individual’s condition using a contingency table.1) Oral hygiene orientation Yes 40 (58.1) 3 times 23 (33. the deceased mothers or those who had disappeared were not taken into account.4) 59 (85. In Table 1.5) % children flossing (once a day) Yes 4 (5.5) 3 (4. mothers who were “retired”.729* <0.Mutans/ml saliva) was more frequent in the control group and the high count (over 106 CFUs of S.1) Finger brush 1 (1.88 in the control group (Table 1).7) 14 (20.001). There was no statistically significant difference between the groups with regard to receiving oral hygiene guidance. as the mean count (105 to 106 CFUs of S.001* 6 (8. 42 (60.7) Once 2 (2.art_semionato 15-03-2011 11:09 Pagina 39 FACTORS ASSOCIATED TO CARIES IN DOWN SYNDROME CHILDREN Characteristics Case N (%) % having regular dental visits Yes 38 (55.813* 6 (8. “unemployed”. DS children tended to use dental floss less frequently than non DS children.13 in the case group and 1.4) 9 (13.010* 23 (33. tooth brushing was performed by the mother in the majority of cases.4) 0.9) Mother and Father 4 (5.3) 0. Frequency of CFUs of Streptococcus mutans and Lactobacillus spp.7) Mother 55 (79. In general. Table 2 shows no statistical difference between the groups as regards the LB count.001* 40 (58. EUROPEAN JOURNAL P the groups as regards the resource used for tooth brushing. the opposite occurred.8) Toothbrush 58 (84.1) 1 (1. Moreover. There was no statistically significant difference between OF PAEDIATRIC DENTISTRY • VOL.5) Others 1 (1. in 7 cases (all DS) it was not possible to collect a saliva sample due to the very low salivary flow and little cooperation from the child. with statistically significant difference between the groups (p<0.016* 6 (8.5) By himself/herself 2 (2.8) % mothers working outside the house Yes 21 (30.5) < 0.9) associated with dental disease.8) Daily frequency of toothbrushing Does not brush 6 (8. and the majority of mothers were employed. while in the non DS children’s group. defined as DMFT?1. 12/1-2011 TABLE 1 . Significant difference was identified in the SM count.7) 3 (4. The larger part of mothers of DS children did not work outside the home. and also in the control group tooth brushing was largely performed by the mothers. However. indicating that the mothers of children with DS were a little older than the mothers of the group of non DS children (Table 1). the DS children brushed their teeth more times per day than the children without the syndrome.Frequency of regular visits to the dentist and oral hygiene habits of children with DS and children without the syndrome. The mean number of times that the children brushed their teeth per day was 2. Comparison between the age of the children’s mothers presented statistical significance.9) Control N (%) 0.7) Wet cloth 4 (5.0) Results Oral hygiene habits.Mutans/ml saliva) was more frequent in the DS group. and this comparison was statistically significant (Table 1).9) Twice 38 (55. In all the children with counts considered below 104 CFU/ml.3) 31 (44. as the large majority in both cases used a tooth brush (Table 1).0) 15 (21. indicating that DS children visit the dentist more regularly than non DS ones (Table 1).7) 1 (1.7) 35 (50. In the case of DS children.0) Who brushes the child’s teeth? Does not brush 6 (8.3) Instrument used for brushing Does not brush 6 (8. This analysis was performed separately for the DS and non DS groups.

there was also a statistically significant difference between the groups. The fact that drew attention in the present study was that despite the majority of children with DS presented lower OHI-S values. found a positive correlation between deficient oral hygiene and severity of bone loss in young individuals with 40 the syndrome. It also shows that children with a high level of SM CFU count (>106) have more propensity to risk of caries than those with a count considered low or medium (106). OHI-S and cardiopathy were not shown to be associated with dental caries (Table 4).001* 0.001 Case 69 Control 69 OHI-S: p=0.66 0 0 1. The difference in the DMFT index between the groups (Table 3) was found to be not statistically significant. these children obtained higher MGI values. Although factors such as lack of access to professional care [Allison et al.001 Case 69 Control 69 MGI: p<0.1 0 0 0 0 33 46 TABLE 3 .1) 2 (3.7) 1 ( 1. there are several public hospitals. low efficacy of care at home.3 8. as children with DS presented a lower OHI-S than children of the non DS group (Table 3).7) 5 (8.5 5.3) 12 (17.345 Case 69 Control 69 Average SD Minimum Median Maximum 34. Nevertheless. OHI-S and DMFT Index Table 3 shows that there was a statistically significant difference between groups as regards MGI. mutans and Lactobacillus spp. as well as charity institutions such as the APAE. Basic Health Units and dentistry schools in Barueri. such as that of Shapiro et al.. 2000. Discussion The literature has reported the high incidence of periodontal disease in individuals with DS and that the presence of dental biofilm was not related to the severity of periodontal disease.50 1.Mother’s age. where this study was conducted. P 0.art_semionato 15-03-2011 11:09 Pagina 40 MATHIAS MF. and limited manual dexterity are mentioned in the literature as being responsible for the severity of the gingivitis observed since the stage of infancy of DS individuals. It was also observed that the mothers of the case group children did not work outside their homes.7) 34 (49.11 1.1 8. access to dental treatment for patients with special needs is still not a tangible reality. in the present study it could be observed that the children with the syndrome had regular dental check-ups. statistically more frequently than those in the control group. indicating that the presence of the dental biofilm was not related with the gingivitis found in these individuals.58 0. such as the Darcy Vargas Hospital.17 8. perhaps due to the fact that these children need full time care. children with DS had their teeth brushed by their mothers.33 2. Logistic Regression Study group: Table 4 shows that the child’s age and MGI are associated with dental caries. MGI. indicating that the main aetiological factor would be an alteration in their immune mechanism.31 2. [1969]. 12/1-2011 .6) 20 (29. Mutans CFUs/ ml saliva 5 Low (< 10 ) 5 6 Medium (10 – 10 ) 6 High (> 10 ) Lactobacillus count (CFUs) 4 < 10 4 5 10 – 10 5 > 10 Case N (%) Control N (%) 20 (29. However.2) 66 (95.5 14 16 37 25 47 41 2.17 1. In São Paulo city and its suburbs. Control group: Table 5 reveals that only the variables child’s age and MGI are associated with dental caries. in many underprivileged regions of Brazil.45 0. López-Perez. which offer dental treatment and periodic preventive and educational followups for children with DS. Other studies.50 2.190** N Mother’s age (years): p<0.67 2.2 3.017 Case 69 Control 69 DMFT: p=0.0) 15 (21. perhaps due to DS children having difficulty with understanding and cooperating.4 6.0) 55 (88.40 0 0 2. The variables: LB count. A variety of studies have reported a lower caries EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL.1 26.9) TABLE 2 . the use of dental floss was more common among children from the control group. dental caries index. 2002]. as children with DS presented a higher MGI than children without the syndrome.37 0.64 0. count of the case group and control group. in most cases. As regards OHI-S. MGI and IHO-S values of the case group and control group. It is necessary to emphasize that.S. SEMIONATO MRL AND GUARÉ RO Characteristics S.5) 2 ( 2.00 0.4) 37 (53.33 1.

nevertheless. a slightly lower DMFT was found in the group of children with DS than in the control group.09 – 12.12 MGI - 69 22 (31. in the logistic regression.09 0.00 4. although this difference was not statistically significant. the caries indexes were the same between individuals with and without DS. [1997].34 no yes 49 20 12 (24. These results are in agreement with those of Walter et al. In both groups the majority of children presented a low CFU count for this type of bacteria (<104).82 MGI - 69 17 (24.40 0. prevalence in patients with DS.31 – 3. mutans CFU count was also observed. Of the total sample in this study.41 – 3. the introduction of sweetened food into the child’s diet and socialization through contact with other people who offer sweets. only 36 individuals (18 from the case group and 18 from the control group) presented untreated cavitated lesions.52 0.9) 5. with a maximum prevalence between 13 and 24 months of age due to: a greater number of dental surfaces to be colonized. especially proximal lesions. The MGI presented an association with dental caries in both groups.723 0.012 1.001 1.42 – 2.08 <0.04 – 1.07 0. In this study.27 0.07 OHI-S - 69 17 (24.3) 1.Variables related to dental caries in children with DS: univariate logistic regression analysis. However.01 – 1. In a study Sant’Anna et al. In the DS group a high S.42 LB count Heart Disease TABLE 4 . which could be justified by the reduced salivary flow rate frequently found in these children.3) 1. although this variable was almost significant in the DS group.0) 1. This could explain the low Lactobacillus spp.6) 7 (35. [2001] stated that swelling or bleeding of the papillae was associated with carious lesions in the cervical third. consisting of 138 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL.8 SM count Low + medium High 49 20 15 (30. it was verified that children with DS with a high S. [1996] studied a sample of 328 twelve-year-old British schoolchildren and concluded that dental caries experience was not influenced by the GI. Cutress [1971] and Fung and Allison [2005] reported that when compensation was made for hypodontia and delayed eruption.8) 1 (33. mutans CFU count (>106) presented a greater risk of developing dental caries than children with a medium or low count. Parameter Class Total N DMFT >1 N (%) OR P 95% CI Age (months) - 69 22 (31.3) 12 (35.013 1.864 0.6) 1.9) 1.76 – 4. after adjusting the factor delayed eruption.00 1.78 SM Count Low + medium High 35 34 5 (14. The variable child’s age showed to be positively associated with dental caries in both groups.006 1.78 0.03 0.47 – 20.22 0. causing a greater concentration of CFU per milliliter of saliva. 12/1-2011 children.060 0.8) 4 (57. The aim of the OHI-S is to identify personal oral hygiene habits and both in the case and control groups this index 41 .5) 5 (25.956 0.9) 1.0) 1.94 – 24. who pointed out an increase in caries prevalence with age.182 0.964 0.64 < 104 ? 104 55 7 12 (21.78 0.6) 1.6) 1.1) 1.12 OHI-S - 69 22 (31.10 – 1. However. count and dental caries.00 1.00 3.04 0.00 1. count observed.Variables related to dental caries in children with DS: univariate logistic regression analysis. Beighton et al. In the present study it was not possible to identify an association between Lactobacillus spp.art_semionato 15-03-2011 11:09 Pagina 41 FACTORS ASSOCIATED TO CARIES IN DOWN SYNDROME CHILDREN Parameter Class Total N DMFT >1 N (%) OR P 95% CI Age (months) - 69 17 (24.049 1.5 LB count TABLE 4 .67 < 104 > 104 66 3 21 (31.01 – 10.

A comparison of caries rates in non-institutionalized individuals with and without Down syndrome. Arch Oral Biol 1996. Shapira J. Roizen NJ. Fung K. Shafik HH.48:1231-3. Bönecker MJS. Rev Fac Odontol da UFBA 1998. 68:7-13. van Houte J. Cogulu D.art_semionato 15-03-2011 11:09 Pagina 42 MATHIAS MF. 1987. Vermillion JR. Jiménez-García G. Arch Oral Biol 1973. Uzel A. it should be emphasised that education is still the most effective form of prevention. gingivitis. 2nd ed. Walter LRF. whereas gingivitis was shown to be present from early childhood in children with Down syndrome. Cogulu D. with particular metabolic activities and microbiological constitutions and it is impossible to clinically differentiate between cariogenic and non-cariogenic plaque. Cárie dentária e placa bacteriana em crianças de 07 a 14 anos portadoras da síndrome de Down. Amer j Orthod 1941. providing a holistic view of the child as an individual. Scand J Dent Res 1977:85:56-63. López-Pérez R.17:15-24. Moreover. Rugg-Gunn A. A selective medium for Streptococcus mutans. Oral hygiene. dental caries experience and salivary bacterial levels in 12-year-old english schoolchildren. São Paulo: ed Santos. Arch Oral Biol 2006a. SEMIONATO MRL AND GUARÉ RO was not associated with dental caries.53. Barnard KM. In: Sant’Anna GR. Results showed that CHDs were not associated with the occurrence of dental caries in these children. Arch Oral Biol 1971.51:177-82. Cárie dentária.51(1):23-8. Pinazo JDC.25(6):302-10. Microbial and salivary conditions in 9. Clin Prev Dent 1986. São Paulo: Artes Médicas. 2001. Genotyping of Streptococcus mutans by using arbitrarily primed polymerase chain reaction in children with Down syndrome. The simplified oral hygiene index. van Dijik LJ. World Health Organization. Cutress TW.3(33):271-80. Kutukaeler N. Weatherford T. Faytetteville NY. Fiske J. Developmental disabilities in infancy and childhood. Studies in tooth development – theorias of eruption.p. J Am Dent Assoc 1964. 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This is in agreement with Mayer and Lorenzo [2004] whose reports indicated that the relationship between plaque index and caries risk is very weak because there are various types of plaque. 3th ed.mutans. Menaker L. van der Weele L. Allison PJ. Experimental gingivitis around deciduous teeth in children with Down´s syndrome. EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL. the childrens' parents and carers should be provided with guidance on oral health care. Gedalia A. J Clin Microbiol 1979.p. Microbiologia para o estudante de Odontologia. dental caries and gingivitis. Spec Care Dent 1996. Rogers PT. Suga SS. Greene JC.26:21-6. Harrison VE. Hennequin M. Oral surg Oral Med Oral Pathol Oral Radiol Endond 1997. Practical method to facilitate estimation of Streptococcus mutans levels in saliva. Ferelle A. Odontologia para o bebê – Odontopediatria do nascimento aos 3 anos.year-old children. Hofman A. Reuland-Bosma W. Maupomé G. J Dent Res 1969. as a part of the routine treatment. 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Down Syndrome. 82. In: Walter LRF. Controle e Tratamento. Johnstone SC. Faulks D. In: Capute 12. Associations between dietary intake. Miller M. Lopes FL. References Allison PJ. Klock B. Stabholz A.p. Down’s syndrome and oral care.27(10):552-76. Dent Update 1999. the use of chemical agents. Lamm RA.28:148-156. Periodontal disease and blood citrate levels in patients with trisomy 21. Oral health surveys: basic methods. Spec Care Dent 2005. Sant’Anna GR. the variable heart disease was only investigated in the experimental group. Development of the human jaws and surroceding structures from buth to the age of fifteen years. A modified gingival index for use in clinical trials. Lobene RR. Krasse B. 221-43.18:1357-64.95-106. Therefore. in which children with DS presented high levels of S. Dental caries in trisomy 21. Down syndrome: a review of the literature. Shapiro S. de Lorenzo JL. in a multidisciplinary context.