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Access to special care dentistry, IN BRIEF

Most dental treatment for adults with

part 8. Special care dentistry Downs syndrome should be possible in

PRACTICE
primary dental care.
Higher levels of oral disease can occur

services: seamless care for peo


among people with cerebral palsy.
It is important that the dental team are
aware of the common cardiac conditions
and their management.
ple in their middle years part 2 The dental team has a role to play in the
provision of oral health advice for patients
with respiratory disease.
D. Lewis,1 J. Fiske2 and A. Dougall3

VERIFIABLE CPD PAPER

This article about special care dentistry in the middle years considers people who have Downs syndrome and cerebral
palsy and those who have cardiac and respiratory disease. The increased life expectancy of people with Downs syndrome,
currently 50-60 years, is reected in the changing population prole and needs of these individuals. The preventive and
dental treatment of most people with Downs syndrome and cerebral palsy can be met in general dental practice. However,
those people with profound disability, anxiety or learning disability may require either a shared approach to care or referral
for specialist care. Cardiac and respiratory disease occur commonly in the general population both in middle and older age
groups and the dental team will meet increasing numbers of people with these conditions. The procedures and drugs used
in dentistry can aggravate heart disease and it is important that the dental team are aware of the common cardiac condi
tions and their management, as well as how to best manage the oral care of this group. Also, they have a role to play in
the provision of oral health advice, smoking cessation and dietary advice. This is particularly important as poor oral hygiene
has been linked to respiratory pathogen colonisation and dental plaque may act as a reservoir for aspiration pneumonia in
susceptible individuals.

ACCESS TO SPECIAL This second article on seamless care for biochemical factors have also been sug
CARE DENTISTRY people in their middle years considers two gested.1 Pre-natal risk factors include pre
conditions which have traditionally been eclampsia, irradiation, a maternal age of
1. Access
considered with childhood and young less than 20 or over 35, and infections such
2. Communication
adult conditions, and two conditions that as cytomegalovirus, rubella and syphilis.
3. Consent
have traditionally been associated with Peri-natal risk factors include trauma,
4. Education
older people. The rst two cerebral palsy breach birth or prolonged delivery.1,2
5. Safety
and Downs syndrome are included in Damage may also be caused post-natally
6. Special care dentistry services for
adolescents and young adults this article to reect the increasing life following infections such as encephali
7. Special care dentistry services for expectancy of people with these condi tis and meningitis during infancy. Other
middle-aged people. Part 1 tions and the subsequent change in their risk factors include cerebral ischaemia,
8. Special care dentistry services for population prole and needs. The latter haemorrhage and hypoxia secondary to
middle-aged people. Part 2
two conditions cardiac and respiratory trauma, respiratory distress, hypothermia
9. Special care dentistry services for
older people disease now occur commonly in middle or hypoglycaemia.1,2
age as well as in older age and the den Cerebral palsy is the most common
tal team will see increasing numbers of congenital cause of physical impair
people with these conditions. ment,1 with an incidence of approxi
1
Senior Dental Ofcer in Special Care Dentistry, Dorset mately 2-2.5 per 1,000 live births in
Healthcare NHS Foundation Trsut, Dental Department, 1. CEREBRAL PALSY developed countries.2 Primarily it is a
Canford Health Centre, Poole, Dorset, BH17 9DW;
2*
Chairperson of the Specialist Advisory Group in Special Cerebral palsy (CP) is an umbrella term disorder of voluntary moment, which
Care Dentistry/Senior Lecturer and Consultant in Special
Care Dentistry, Department of Sedation and Special
encompassing a group of non-progres results in a wide spectrum of disabil
Care Dentistry, Kings College London Dental Institute, sive neurological and physical disabilities ity ranging from virtually unnoticeable
Floor 26, Guys Tower, London, SE1 9RT; 3Lecturer and
Consultant for Medically Compromised Patients, Division
caused by damage or a lesion to a childs physical impairment. It may affect only
One/Special Care Dentistry, Dublin Dental School and brain early in the course of development, one limb (monoplegia), both lower limbs
Hospital, Lincoln Place, Dublin 2, Ireland
*Correspondence to: Dr Janice Fiske
either in utero, during birth or in the rst (paraplegia), one upper and one lower
Email: Janice.Fiske@gstt.nhs.uk few months of infancy.1 The damage to limb on the same side (hemiplegia) or all
DOI: 10.1038/sj.bdj.2008.850
the brain is caused mainly by hypoxia, four limbs equally (quadriplegia).1 There
British
Dental Journal 2008; 205: 359-371 trauma and infection but genetic and are four main types of CP (Table 1), the

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PRACTICE

features of which are governed by the


Table 1 The features of the four types of cerebral palsy (CP)
area of brain damage.2,3
Site of
Diagnosis Type Percentage of
cerebral Features
of CP all CP types
damage
Diagnosis is usually made from clinical
signs, such as weakness in one or more Increased muscle tone and contractions of affected limbs
limbs, abnormal gait with one foot or leg Complete/partial loss of control of muscle movement
Spastic 55% Cortex Difculties with head support
dragging, excessive drooling or difcul
Difculties with control and balance
ties in swallowing and poor control over
Falls easily
hand and arm movement. Other impair
Smooth writhing movements as muscle tone
ments which may accompany CP include uctuates from increased to decreased tone
visual, hearing and speech impairments, Constantly in motion
Athetoid/ Basal
epilepsy, drooling and learning disabil 20-25%
Dyskinetic ganglia High energy requirements
ity.4 Less than 50% of individuals with Movements exaggerated if anxious or an effort is made
CP have a learning disability and indeed to control them
many people are highly intelligent and Disordered short, jerky movements
well educated, though severely impaired Difculties with balance
speech due to dyspraxia or dysphasia Ataxic 10% Cerebellum Difculties with walking and sitting straight
and sensory impairments can mislead Requires time to execute changes in position
some unwary observers.1 Although CP Compromised co-ordination

is a non-progressive disorder, other sec Some or all of the above


ondary complications may occur and can Some or Tremor of all or part of the body
include respiratory complications, sec Mixed 10-15% all of the Hypotonia of muscles
above Inability to stand
ondary digestive system problems (reux
Inability to raise the head
and constipation), bladder infections and
kidney infections, skin problems on pres
sure areas and peri-orally from drooling, presents. Bobath therapy is very popu Splints, orthopaedic surgery and medica
and musculo-skeletal problems such as lar and is a trans-disciplinary approach tions such as muscle relaxants are used
arthritis, dislocations and deformities.5 using specialised handling and posture to relieve muscle stiffness and to reduce
techniques to encourage more controlled pain and contortions.1 Between 25-30%
Treatment patterns of movement. Combined with of people with CP have epilepsy and take
While there is no cure, therapy can help physiotherapy, occupational therapy related drug therapy.1 Dietary advice is
children, adults and their families man and speech and language therapy it can required where nutrition or swallowing is
age the problems that cerebral palsy change the clinical presentation of CP.5 compromised.4 Life expectancy in CP has

Fig. 1 Wheelchair designed to provide


maximum support and independence for a
woman with cerebral palsy Fig. 2 The personal assistive devices near to hand for a woman with cerebral palsy

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PRACTICE

increased signicantly in the last dec- affects their upper limbs and manual
ades, however respiratory infections are dexterity. Pre-disposing factors to peri-
common and aspiration pneumonia is a odontal disease in this group include
major cause of death.1 Wheelchair design mouth breathing, gingival hyperplasia
and assistive devices can help to provide secondary to the use of phenytoin for
a degree of independence (Figs 1 and 2). the treatment of epilepsy7 and increased
food retention which is exacerbated by
Oral and dental features difculties in oral self-care and plaque
People with CP will encounter the same removal.3,4 The increasing use of peg
oral and dental disease as the rest of the (percutaneous endoscopic gastronomy)
population, however there are additional feeding has helped improve the nutri
factors such as access to dental care tional status of patients with swallowing
and support in carrying out daily liv difculties, but the need for regular and
ing activities, which can result in higher meticulous oral hygiene has not been
levels of untreated disease and tooth addressed4 even though Dicks et al.8 have
loss.4 Scope, the national voluntary and shown that calculus formation is signi
political body for CP, works actively cantly more rapid in tube-fed patients.8
on campaigns to get equal and make This is important as poor oral health in
rights a reality. At the time of writing it patients with dysphagia has frequently
was running an online campaign seek been associated with the development Fig. 3 A woman with cerebral palsy using a
mouth-held device to aid independence
ing out disablism, which it describes as of aspiration pneumonia.9 There is good
discriminatory, oppressive or abusive evidence that improved oral hygiene and
behaviour arising from the belief that frequent professional oral healthcare palsy12,13 and although the incidence is
disabled persons are inferior to others.2 reduces the occurrence or progression of lower in adults, for many individuals it
It will only be a matter of time before respiratory diseases.10 is severe enough to interfere with daily
their active and ongoing research high Caries the risk of caries is increased social and practical functions.13,14 It is
lights the inequality in oral health and by a number of factors related to CP not caused by hyper-salivation, but is
acts accordingly. and its treatment, for example reduced due to impaired swallow and poor con
There are many potential causes of chewing and swallowing ability, the trol of the orofacial musculature15,16 and
increased risk of dental disease in CP. tendency for food to be retained in the can be exacerbated by malocclusion,
They include: mouth,4 malocclusion and mechanical postural problems, dental caries and an
Developmental abnormalities the and physical difculties in removing inability to recognise salivary spill.17
maxillary arch is frequently tapered plaque. In the absence of effective oral Lip trauma is a condition associated
or ovoid and the upper incisors may be hygiene procedures, individuals with with individuals who have a profound
labially inclined, making oral hygiene feeding difculties who use dietary sup neurodisability18,19 and has been reported
difcult.1 The incidence of malocclu plements and laxatives with a high sugar in people with cerebral palsy.20,21 The
sion is high and delayed eruption, poor content can develop extensive levels of bite reex occurs pathologically in this
oromuscular co-ordination, lack of ade caries rapidly.4 group and is often a result of facial
quate lip seal and oral habits of tongue Fractured teeth the increased like hypersensitivity, anxiety and poor
thrust contribute to this.1,3,4 lihood of falls3 and seizures1 amongst head position.19,22
Uncontrolled movement characteris people with CP means that fractured
tic symptoms of the movement disorder teeth are more likely than in the general Seamless care
may be observed in the orofacial and population. The management of oral health needs
cervical muscles,6 including spasticity Xerostomia dry mouth secondary to be embedded into the general care
of the temporomandibular joint (TMJ) to the use of medication to control sei plan of every individual with CP. While
musculature.3 Facial grimacing, dys zures is undoubtedly a causative factor at times the dental team may be on the
phagia and swallowing difculties are of oral disease.7 However, studies have periphery of the multidisciplinary team,
common 3 and jaw dislocation due to shown that even when not taking such at others they are integral and can play
spontaneous subluxation may occur.1,4 medication, people with CP have a lower a signicant role in improving the qual
Bruxism and tooth wear these are than normal salivary ow rate, lower pH ity of life for people with CP. Some of the
common in CP, especially in those indi and reduced buffering capacity, further ways they contribute to this include:
viduals with athetoid CP.3 Loss of tooth increasing their risk of oral disease.11 The maintenance of independence.
tissue may be exacerbated by erosion Exacerbated by mouth breathing, crust If an individual relies on mouth-held
due to gastro-oesophageal reux, which ing mucous deposits are commonly seen devices to carry out certain activities or
is also common.1,4 on the palate and soft tissues.4 to assist communication, maintaining
Periodontal disease is reported in a Drooling problem drooling affects good oral health is critical to retaining
high proportion of people with CP which up to 58% of children with cerebral independence (Fig. 3).

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PRACTICE

The management of xerostomia and


erosion. Strategies for management of
xerostomia will be discussed in more
detail in the next paper in the series.
Characteristic problems such as mucus
or crusting deposits on the tongue, in the
palate or on the teeth may be prevented
by the use aqueous lubricating gel both
peri- and intraorally. Deposits may be
removed by gentle brushing with a soft
toothbrush or swab dipped in mucolytic
solvent, for example Bisolvon 2 ml/mg
(bromhexin).23 Erosion and hypersen
sitivity may be addressed with topical
uoride application as outlined in arti
cle 4,24 with the use of gel, varnishes or
mousse preparations being more appro
priate than mouthwash in those patients
with dysphagia.4,23
Management of bruxism. Bruxism
reects a multi-factorial interaction of
anatomical, physiological and psycho Fig. 4 Transfer from wheelchair to dental chair by hoist for a patient with cerebral palsy
logical factors and, not surprisingly, is
more common in patients with movement
disorders and learning disability.1 Goals
of treatment are reduction of clench
ing, reduction of any associated pain
and prevention of further tooth damage.
Traditional treatment options includ
ing use of occlusal adjustment maybe of
limited success,1 and rst-line manage
ment for people with CP is to ensure that
trigger factors (such as caries and sharp
teeth, pain, poor posture and stress) are
reduced.22 Appliance therapy, even if the
individual can tolerate it, may be com
promised by the difculty in obtaining
impressions and the risk of compromised
swallowing and airway protection.
Rather than using alginate, Milwood et Fig. 5 Man using a mouth-held device to operate his computer, which is used for
communication
al.19 advocate the use of silicone putty
impression material (with removal from
the mouth before nal set to avoid motor therapy, appliance therapy and rassing and detrimental to peer bond
locking into undercuts and interdental behaviour modication in childhood;14 or ing.15,17 Overall it seems that surgical and
spaces) and props to aid opening19 during radiotherapy, drug therapy and surgery pharmacological approaches are entirely
impression taking. Other reported suc for adults.16 Treatment should progress empirical and there is no evidence to sug
cessful management strategies include from the least invasive modality to the gest a more successful outcome for any
relaxation of facial and TMJ muscles by most invasive. Behavioural modications particular approach.14 Reversible options
massage techniques,4 cryotherapy25 and coupled with oromotor therapy seems include scopolamine patches1 and botu
the use of medications such as gabap to be the treatment of choice for chil linum toxin injections into the salivary
entin1 and botulinum toxin26 which are dren with CP.27 However, where drool glands.26 The disadvantage of botulinum
best managed by a specialist multidisci ing persists into adulthood, it can have toxin is its short duration of action (two
plinary team. a signicant impact on quality of life17 to six months) which means repeated
Management of drooling. Drooling as it impairs masticatory function and injections are required. This is a dilemma
management is a complex clinical prob speech and increases the likelihood of if patients who are unable to co-operate
lem that involves a multidisciplinary maceration and peri-oral infections.15,17 need repeated general anaesthesia (GA)
team approach.16 Strategies include oro Furthermore, drooling can be embar for this purpose. Also, the highest safe

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PRACTICE

dosage and the long-term complications


are still unknown.15,16,28 Surgery, although
non-reversible, has a high success rate15,16
with preference given to more conserva
tive procedures, such as sub-mandibular
duct relocation.15,16
Treatment of drooling, whether phar
malogical or surgical, results in reduced
salivary ow and the patient will always
be more susceptible to dental car
ies.16 Regular dental examination and
extra preventive measures, as detailed
in article 4 of this series, are therefore
mandatory for patients undergoing this
type of therapy.24
Management of lip trauma. Vari
ous oral appliances have been used in
an effort to prevent trauma and pro
mote healing of lesions.18,20,21,29,30 The
drastic solutions of extracting teeth
and orthognathic surgery to create an Fig. 6 Use of gentle restraint of legs with wide Velcro strap to control ataxic or jerky leg
movements
anterior open bite have been used in
isolated cases.31 The removal of teeth
does not usually solve the problem as pain, should be minimised where possible for individuals who have dysphagia and
trauma is relocated to a different site and Bobath techniques have been shown poor oromuscular co-ordination.34
once the lip support is reduced following to be effective.19,22 Communication may be compromised
extractions.19 A dentist-led multidisci by speech impairment and sensory de
plinary team acknowledged that current Dental treatment cits and require the use of communication
clinical management options are limited, The provision of dental treatment can strategies such as the use of hearing loops,
often ineffective, and require further present its own set of challenges. How computer assisted technology and AAC
development.22 Numerous factors affect ever, with knowledge and understanding aids (Fig. 5).3,32,35 Article 2 in this series
the choice of treatment, with patient of CP, an empathic approach and careful considers communication in detail.35
co-operation, access to the oral cavity planning, they can mainly be overcome. Operative procedures require care
and wishes of the individual and family They include: ful consideration of physical posture
being the most limiting factors.22 Consent this should be assessed on and positioning of the subject, through
Systemic desensitisation through touch, an individual basis and it is essential appropriate support with cushions, etc,
using techniques common amongst speech that assumptions about capacity are during treatment.22 Together with use
and language therapists, has been shown not made on the basis of appearance of high volume suction and/or the use
to be useful in the prevention of bites and or speech, which can be misleading.1 of rubber dam, it will aid prevention of
to facilitate impression-taking for fab Article 3 in this series provides further choking or silent aspiration during treat
rication of hard acrylic bite guards, lip information on this topic.33 ment due to swallowing difculties and
bumpers or soft vacuum moulds.22 Open Access some individuals with CP are poor protective airway reexes.4 Sud
ing of the mouth may require assistance wheelchair users and may require assist den movements may require the use of
or use of one of the aids or props outlined ance or transfer aids, such as a hoist physical intervention, with the patients
in article 1 of this series.32 Similarly, the (Fig. 4) to access the practice or the den consent, such as the gentle restraining
use of botulinum toxin26 and muscle tal chair. This has been covered in detail of a limb36 (Fig. 6), or the use of a mouth
relaxants such as midazolam have been in article 1 of this series.32 prop or nger guard to prevent sudden
used to this end where there is spasticity Preventive dentistry counselling closing due to muscle spasm or the bite
and hypertonia of the TMJ muscles.22 The about diet, oral hygiene and the use of reex.1 Restoration of fractured anterior
greatest challenge is where none of these uorides is important for this group of teeth is important to prevent discomfort
treatment options provide a solution. In people.1 Suitable toothbrush adaptations and, more so, to restore self-esteem and
these cases use of antimicrobial gel and/ (as outlined in article 4 of the series) may social acceptability. For the latter two
or aqueous lubricating agents, peri- and be crucial to achieve optimal self-care reasons, it can be argued that aesthet
intraorally, provide some relief and aid and liaison with carers will be required ics is of greater importance to the person
prevention of infection.22 Predisposing where they are responsible for providing with disability than it is for the individ
factors such as posture and positioning, oral care.24 The use of sprays and gels in ual with no disability,37 and a full range
patient comfort, illness or presence of place of mouth-rinses is more appropriate of restorative treatment should be made

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PRACTICE

available to them. There are no contra


indications to the use of local analgesic
agents for restorative care or surgery,
although access to sites of some injec
tions maybe limited (Fig. 7).1
Anxiety and movement management
anxiety may worsen the usual athetoid
movements or spasticity, and anxiolyt
ics or muscle relaxants may be useful as
a pre-medication.1 Oral sedation may be
effective but its effectiveness is unpre
dictable in patients who are taking other
neuroepileptic drugs.37 Article 5 of this
series provides further information.38
Inhalation sedation is an excellent option,
however the requirements of continuous
nasal breathing may be difcult for indi
viduals with some physical disabilities or Fig. 7 Use of head support to control possible movement during administration of a local
anaesthetic
intellectual disability.37 Manley demon
strated that the use of conscious sedation
provides a valuable solution to providing
a good standard of care in patients with
CP. It enables repeated treatment ses
sions, often in primary care, and thereby
opens a full range of treatment options.37
He advocates the technique of titration of
intravenous midazolam against patient
response, with the suggested use of 0.25
ml of 40 mg/ml intra-nasal midazolam
initially if required to overcome difcul
ties with cannulation due to movement
disorder, patient co-operation, and/or
compromised cognition. For people with
profound disabilities or movement disor
ders, some care may need to be completed
under GA due to poor co-operation or to
ensure airway protection. This treatment
modality can limit treatment provision Fig. 8 The characteristic facial features associated with Downs syndrome
if they are lengthy procedures or require
repeat appointments.37 Nor is it without
risks in this group, due to the propen
sity for gastro-oesophageal reux, poor
pharyngeal reexes, liability to aspirate
material into the lungs and increased
risk of hypothermia.1,7
The preventive and dental needs of
most people with cerebral palsy can be
met in general dental practice. However,
some people, mainly those with profound
neuro-disability, anxiety or learning dis
ability, require either a shared approach
to care or referral for specialist care.

2. DOWNS SYNDROME
Downs syndrome (DS) is a genetic con
dition caused by a chromosomal abnor
Fig. 9 The characteristic dental features associated with Downs syndrome
mality (usually trisomy of chromosome

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PRACTICE

21) that results in a characteristic The former explanation is generally Table 2 Differential diagnosis of
appearance, learning disability (which favoured, and it is thought that the age behavioural and functional change in
ranges from mild to severe) and a vari ing process starts sooner or is speeded up. later life in people with Downs syndrome
ety of physical and medical features.39 Subtle memory losses, physical tiredness Depression
The characteristic appearance in DS and general frailty, as well as specic
Hypothyroidism
is that of short stature, relatively short illnesses, may be present when a person
arms and legs, broad hands and short with DS is in his/her thirties rather than Sensory impairments, visual and/or hearing
ngers, attened face and occiput, his/her sixties. However, Alzheimers Dementia, usually Alzheimers disease
slanting eyes with prominent epican disease (AD) is the only condition associ
thic folds and underdevelopment of the ated with decreased life expectancy that Impact of major life events, eg bereavement

middle third of face resulting in relative occurs earlier in DS.51 It increases from Other rare illnesses
prognathism (Fig. 8). about the age of 30, and by their fties
Source: reference 48
Oral and dental characteristics include around 50% of people with DS show
delayed development and eruption of signs of AD. It increases with age at a
both dentitions, hypodontia, microdon similar rate as in the general population, found a lower caries rate in the DS group
tia, short roots, hypocalcication and but 30 or 40 years sooner. Its onset can than the matched control group. The
hypoplastic defects, occlusal problems, be difcult to detect as in people with adults with DS had signicantly fewer
and a high incidence of severe early DS it may affect personality or behav lled teeth, fewer decayed teeth, more
onset periodontal disease (Fig. 9).40 Phys iour before the classical early features of peg-shaped maxillary lateral incisors,
ical and medical features include cardiac memory loss become apparent.48 Demen and more retained deciduous teeth.58
anomalies (40%),41 visual impairment tia will be explained in more detail in The low caries prevalence in children
(50%),42 hearing impairment (mild to the next article in this series. Diagnosis with DS has been linked to immune pro
moderate in 50%),43 atlantoaxial insta is based on the exclusion of other con tection from elevated salivary Strep
bility or subluxation (20%),44 compro ditions that might present with similar tococcus mutans IgA concentrations.59
mised immune system,41 hypothyroidism symptoms (Table 2). However, a study among 39 people with
(15%),45 increased risk of epilepsy (2-10% People with DS experience the same DS aged from 11 to 69 years demon
depending on age),46 increased risk of conditions as the general population as strated a lower rate of salivary secretion
diabetes Type 1 (2%) 47and earlier onset they age but experience them at an ear in people with DS than in a non-DS con
of Alzheimers disease.48 All of these lier age. However, they may be misinter trol group. It was attributed to decreased
conditions need to be considered when preted and where, for example, hearing stimulated parotid salivary ow and,
providing dental treatment.49 or visual impairments lead to a decline although not statistically signicant,
in communication or living skills, they decreased with increasing age. Thus it
Living longer can be misdiagnosed as depression.48 is possible that caries may become more
There are currently more than 26,000 Depression itself is one of the most fre of a problem as people with DS age,
people with DS in the UK and an inci quently diagnosed psychiatric disorders although as yet there is no evidence to
dence of 1 in 1,000 births, both male and in the DS population, but is probably support this hypothesis.
female.46 The life expectancy of people under-reported as people with DS may The severity, prevalence and extent of
with DS has improved dramatically from nd it difcult to express how they are periodontal disease are all signicantly
an average of nine years in 1900 to an feeling, complicating its diagnosis. greater in the DS population than in the
average of 50-60 years currently. As the general population.60 Prevalence has
prevalence of DS is set to rise, ageing in Oral health been reported from 58-96% for people
DS is only beginning to be researched Despite an ageing DS population, most with DS under the age of 35 years,60 with
and addressed.50 Although many people of the literature about oral health and lower incisors and upper rst molars
with DS are able to live healthy adult DS relates to children and adolescents.52 most commonly affected.61 This situa
55
lives without concerns related to seri These studies generally indicate a tion is not attributed solely to poor oral
ous illness or additional disability, it is lower caries rate than in the child popu hygiene and there has been a focus on
reported that the health needs of older lation as a whole. However, Davila et al. an altered immune response due to the
people with DS are not yet being met found 53% of their study population had underlying genetic disorder of DS.60
and some people with DS are dying from caries56 and a study of 20-40 year old Findings regarding the management of
manageable and treatable conditions.51 adults with learning disability living periodontal disease in people with DS
Although life expectancy has in an institution found a signicantly are mixed. Zigmond et al.61 reported that
increased, it is still lower than for the lower DMFT in people with DS compared a preventive programme had no effect
general population. Possible explana with those with cerebral palsy or idi on reducing the progression of either
tions are that people with DS age pre opathic developmental delay.57 A Hong generalised or localised periodontal
maturely and thus life expectancy is Kong survey looking at the oral health disease, indicating that impaired oral
reduced; and that DS is associated with status of 65 community dwelling adults hygiene plays a relatively minor role in
an increased risk of illness and mortality. with DS aged between 17 and 42 years its pathogenesis. This is at odds with

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the ndings of Zaldivar-Chiapa et al., once co-operation is established, local The dental team are important mem
who reported that while there is partial analgesia is the rst line of treatment bers of the DS multidisciplinary care
impairment of immunological functions for most dental procedures for most team, as a healthy mouth can reduce the
in people with DS, this did not seem to people.69 The choice of technique must problems associated with DS and help to
affect the clinical response to surgical always take account of any systemic dis maintain the individuals self-esteem,
or non-surgical periodontal therapy in a ease, such as congenital heart and neu quality of life and social acceptability.
group of 14 people with DS aged 14 to rological conditions. Shared care with
30 years.62 This is supported by the work specialist support can be put in place if 3. CARDIOVASCULAR DISEASE
of Yoshihara et al., whose results sug conscious sedation or general anaesthe Cardiovascular disease (CVD) is the
gest that periodic preventive care (at one sia is required. most common cause of adult death in the
to three month intervals) is effective in Access to dental care is essential for developed world. Dental procedures and
suppressing the progression of periodon adults with DS in order that a rigorous drugs used in dentistry can aggravate
tal disease in young adults with DS aged preventive regime that will hopefully heart disease and it is important that the
15 to 26 years.63 Positive ndings are control periodontal disease and reduce dental team are aware of the common
also reported by Cheng, Leung and Cor the risk of tooth loss can be provided. cardiac conditions and their manage
bett,58 who achieved satisfactory healing The literature suggests that this should ment, as well as how to best manage the
responses following non-surgical peri include daily adjunctive chlorhexidine oral care of this group. The risk factors
odontal therapy with the adjunctive use and professional input on a monthly for CVD are shown in Table 3. Although
of chlorhexidine and monthly recalls in basis. Tooth replacement is not straight precise mechanisms of interaction
21 adults with DS aged 20 to 30 years.58 forward for this group of people. Den remain unclear, sufcient evidence
While the balance seems to be in favour tures are difcult, although not always exists to conclude that periodontitis
of preventive programmes improving impossible, for people with learning places certain patients at increased risk
the periodontal situation for people with disability to manage. Attention needs of developing CVD.72-74 Dentists need to
DS, the programmes require a degree of to be given to denture design mak take a careful medical history to ascer
intensity and/or monthly review.58,63,64 ing it as simple as possible, avoiding tain the patient at risk of CVD.
The short roots of teeth in DS com gingival margin coverage and provid
bined with increased periodontal dis ing as good retention as is possible. a) Hypertension
ease make it probable that tooth loss Patience is required on the part of the Hypertension is a persistently raised
from periodontal disease is more likely. dentist and the individual with DS. The blood pressure >140/90 mm Hg. Ninety
There would seem to be no evidence in use of adhesive bridges can be compro percent of cases are essential, with no
the literature to support or refute this mised by small crown size and/or spac obvious cause, although smoking, diet
supposition. The limited information ing between teeth. While the literature and lifestyle are recognised causes.
relating to tooth wear is in the child related to the use of dental implants for Pharmacological intervention should
population only and the ndings are people with DS is sparse, the two papers be offered to patients with persistently
mixed. Bell et al. report it as signi available suggest that implant dentistry high blood pressure of over 160/100
cantly more common than in the general is a viable treatment option70,71 provided mm Hg, with the aim of maintaining
population (59% and 8% respectively),65 there is support from carers for the pro it at or below 140/90 mm Hg to reduce
with an aetiology of attrition and ero vision of good oral hygiene.71 the risk of cardiovascular disease and
sion, while more recently, bruxism has In dealing with adults with DS in their death.75 Antihypertensive drug manage
been reported as no more common in forties and fties, it must be remembered ment includes the use of diuretics, beta
children with DS than in those without that some of them will have elderly par blockers, calcium channel blockers, ACE
it.66,67 There appears to be no literature ents who may nd it increasingly dif inhibitors, sympatholytics and vasodi
indicating whether tooth wear is a prob cult to support them in their oral hygiene lators.76 A signicant number of people
lem in adults with DS. needs. They will need information, advice are in receipt of anti-hypertensive ther
and support to maintain their motiva apy, with up to 5% and 13% of patients
Seamless care tion. Many of the issues associated with attending general dental practice and
The majority of dental treatment for seamless care for middle-aged people dental hospitals, respectively, reported
most people with DS should be possi with DS have been explored in greater to take anti-hypertensive drugs.77 Stress,
ble in the primary dental care service. depth earlier in this series of articles, for including that associated with den
Achieving patient co-operation is based example issues related to physical access tal treatment, may further increase an
on building trust and rapport through to the surgery in article 1,32 communi already raised blood pressure, leading to
the use of behavioural management cation in article 2,35 capacity and con a risk of stroke or cardiac arrest.78
techniques such as acclimatisation and sent (including physical intervention) in The National Institute for Health and
tell-show-do. The degree to which this article 333 and provision of information Clinical Excellence (NICE) recommends
is successful in people with a learning and materials related to oral hygiene in patient-centred care for management of
disability may depend on the sever article 4.24 The reader is referred to them hypertension, taking account of individ
ity of the learning disability. However, for further information. ual needs and preferences and providing

366 BRITISH DENTAL JOURNAL VOLUME 205 NO. 7 OCT 11 2008


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PRACTICE

Table 3 The risk factors for


cardiovascular disease
Risk factors for cardiovascular
disease include:

Smoking

Excess alcohol

Diabetes mellitus

Hypercholesterolaemia

Family history of cardiovascular disease

Sedentary lifestyle

Obesity

Source: reference 78

evidence-based information to allow


patients to reach informed decisions
about their care. Fig. 10 Localised lingual caries associated with prolonged use of GTN tablets

b) Angina at diagnosis to avoid the need for dental angina during treatment.81 GTN should
Angina is severe, crushing chest pain. care later on. If feasible, dental treat also be easily to hand throughout dental
Stable angina is typically precipitated ment is best carried out using local treatment and should relieve chest pain
by effort and relieved by rest within ten analgesia, with or without conscious in angina within ve minutes. Prolonged
minutes. The usual cause is coronary sedation. Anxiolytic agents and use of use of GTN tablets has been found to
atherosclerosis resulting in insufcient sedation are valuable tools for reducing cause caries localised to the area where
blood ow to and oxygenation of the the effects of stress while maintaining the tablet is retained (Fig. 10).82 This can
heart muscle.78 The pain typically occurs oxygenation and obviating the need be avoided by using a GTN spray.
behind the sternum, radiating to the left for general anaesthesia. Side-effects of It is commonly recommended that
upper arm and occasionally to the left beta blockers can include xerostomia patients do not receive dental care for
mandible, and rarely to the teeth, tongue and appropriate management of dry at least six months after experiencing
or palate. Unstable angina is that occur mouth needs to be instigated.24 Also, an MI.83,84 However, Meechan suggests
ring at rest, on minimal exertion or with calcium channel blockers, particularly that ideally, elective treatment should be
rapidly increasing severity. Both forms nifedipine, have been associated with postponed for a year as there is a high
are relieved by sublingual glyceryl trin gingival overgrowth which is best man chance of a further infarct during this
itrate (GTN) spray or tablets. Unstable aged through good oral hygiene but may period.78 Until this time, acute dental
angina carries a signicant risk of myo require surgery.76,79 needs should be managed in consulta
cardial infarct and elective dental treat Both beta blockers and non-potas tion with the patients physician. All
ment should not be carried out. Surgical sium sparing diuretics can exacerbate patients with CVD should be managed
treatment using either stents or coro the effects of epinephrine in dental using a stress-reduction protocol that
nary artery bypass grafts has a good local anaesthetic agents and it is recom includes short appointments, preferably
survival rate. mended that patients with mild to mod in the morning when patients are well
erate CVD receive the smallest amount rested; use of effective local anaesthetic
c) Myocardial infarction of local anaesthetic needed to provide to minimise discomfort; use of conscious
Signs and symptoms of myocardial inf effective analgesia, using an aspiration sedation to reduce stress; and provision
arction (MI) are similar to angina but technique to prevent intravascular injec of excellent post-operative analgesia.
are more severe, of longer duration and tion.80 Many patients with CVD may be
are not relieved by GTN. The dental team taking anticoagulants such as aspirin or d) Congenital cardiac conditions
should be aware that some myocardial warfarin and the management of these
and acquired cardiac disease
infarctions are silent and occur with individuals is described in article 5 of Infective endocarditis (IE), although
out any recognised symptoms or signs this series.38 uncommon, may affect damaged heart
at the time. Effective analgesia, short appointments valves, prosthetic heart valves, a coar
and availability of both oxygen and GTN tated aorta, patent ductus arteiosus or
Seamless care are all important in treatment regimens. ventricular septal defect. As Strepto
For patients with hypertension, preven Prophylactic GTN prior to dental treat coccus viridans is the most commonly
tive advice and information on access ment has been shown to be effective in isolated bacteria in IE,78 until recently
to oral healthcare should be instituted the prevention of both hypertension and prophylactic use of antibiotics was

BRITISH DENTAL JOURNAL VOLUME 205 NO. 7 OCT 11 2008 367


2008 Macmillan Publishers Limited. All rights reserved.
PRACTICE

recommended for dental treatment in


Table 4 Indications of infective endocarditis
patients with acquired valvular heart
disease with stenosis or regurgitation, Low grade fever and generalised malaise develops and persists
valve replacement, structural congenital Weakness
heart disease, previous IE and cardiac Systemic signs Arthralgia
myopathy. Although these groups are Loss of weight
still considered to be at risk of developing Sepsis of unknown origin
endocarditis, after reviewing the litera Pallor (anaemia)
Skin
ture, recent NICE guidance has removed Light pigmentation (caf au lait)
the need for antibiotic cover for dental Purpura of skin and mucous membranes
treatment as no evidence could be found Splinter haemorrhages under ngernails
that this regime prevents infective endo Janeway lesions (small painless erythematous or haemorragic stigmata in the
carditis.85 Patients who have received Embolic phenomena palms of hands or the soles of feet
antibiotic cover for dental treatment for Oslers nodes (tender vasculitic raised lesions in the skin, usually on the digits)
Haematuria
many years will require careful counsel
Stroke or transient ischaemic attack
ling to help them understand the situa
tion and to avoid confusion and distress. Changing or evolving cardiac murmurs
Cardiac
Loss of peripheral pulse
Seamless care
Source: reference 100
NICE recognises the pivotal role that both
the individual and the dental profes
sional play in maintaining oral health.86 lung diseases including chronic bronchi developing central cyanosis, cor pul
It is paramount that this group of patients tis, emphysema and chronic obstructive monale and oedema.91 Cor pulmonale or
have ready access to oral care and they airways disease, all of which can occur pulmonary hypertension relates to the
have every opportunity to achieve and together. These diseases have different heart being affected adversely as a result
maintain good oral health in the primary aetiologies but may have overlapping of raised blood pressure in the lungs and
dental care setting. The responsibility of signs and symptoms. may occur as a direct result of COPD.
the dental team is to educate the patient COPD is the most common chronic There is no single diagnostic test for
about, and to alert them to, the signs condition in the UK, varying in sever COPD and diagnosis relies on clini
of infective endocarditis (Table 4) and ity from mild through to disabling and cal judgement based on a combination
when to seek expert advice; and to instil severe disease with respiratory fail of history, physical examination and
in them the importance of good oral ure.88 Most commonly it affects people conrmation of the presence of airow
hygiene and regular reviews and dental over the age of 40 and it is thought that obstruction using spirometry.90 The
treatment as appropriate. around 900,000 people in England and treatment of the disease is tailored to the
Wales have been diagnosed with COPD, severity of the symptoms and the cor
e) Inherited and acquired although the true number may be around nerstones are smoking cessation, inhaled
bleeding disorders 1.5 million.89 It is predominantly caused bronchodilators and inhaled corticos
This subject has been dealt with in article by smoking and is almost entirely pre teroids. Patients with severe COPD may
5 of this series and the reader is referred ventable.90 It is characterised by airow need nebulised oxygen at home for up to
to it for information.38 limitation that is not fully reversible, is 15 hours a day. This can improve short
Given the high mortality rate of CVD usually progressive, although it does not ness of breath but limits activities and
and the relatively minor morbidity of change markedly over several months, may mean they are conned to home.
periodontal therapy, maintenance of and is due to a combination of airway The impact of COPD on the quality of life
periodontal health should be among the and parenchymal damage resulting from of individuals and carers can be consid
routine recommendations for prevention chronic inammation. Other factors, erable92 and they are also prone to anxi
of heart disease.87 particularly occupational exposures, ety and depression.
may also contribute to the development
4. RESPIRATORY DISEASE of COPD. Seamless care
This section covers only the respiratory Many dentists will remember learning Patients with COPD should have access
diseases most likely to be encountered in about pink puffers and blue bloaters. to the wide range of skills available from
dental practice, namely chronic obstruc The former are patients with emphy a multidisciplinary team (MDT). Profes
tive pulmonary disease and asthma. sema who maintain normal blood gases sionals involved in their care may include
by hyperventilation and are breathless a respiratory nurse specialist, specialist
a) Chronic obstructive pulmonary but not cyanosed, while the latter are physiotherapist, occupational therapist
disease (COPD) patients with chronic bronchitis who to assist with managing daily living
Chronic obstructive pulmonary disease fail to maintain adequate ventilation, activities and, for people with end stage
(COPD) is the name for a collection of becoming hypercapnic and hypoxic and disease, the palliative care team. The

368 BRITISH DENTAL JOURNAL VOLUME 205 NO. 7 OCT 11 2008


2008 Macmillan Publishers Limited. All rights reserved.
PRACTICE

dietician may also be involved, as about UK deaths were attributable to asthma. Additionally, efforts should be made to
one third of people with COPD have sig- It is described as a generalised airway allay anxiety as far as is possible. Pref
nicant malnutrition related to dimin obstruction which, in the early stages, is erably, treatment should be carried out
ished appetite and the increased energy paroxysmal and reversible. The obstruc with local analgesia.95 If conscious seda
expenditure required for breathing. tion is due to bronchial muscle contrac tion is required, relative analgesia is the
The dental professional can be a valu tion, mucosal swelling and increased technique of choice as in the event of an
able member of the MDT as there are a mucous production and leads to cough asthma attack, it can be more rapidly
number of oral health risk factors. The ing, wheezing, and/or shortness of controlled than intravenous sedation.95
frequency and severity of periodon breath.96 Common triggers include house Aspirin is not recommended for anal
tal disease is increased in people with dust mites, animal fur, pollen, tobacco gesia as many people with asthma are
COPD.93 The oral health risk can be exac smoke, cold air, chest infections and allergic to it.95 Also, use of non-steroi
erbated if the individual is a smoker, or stress, and adult asthma can develop dal anti-inammatory drugs (NSAIDs)
if they are on oxygen therapy, which after a viral infection. There is no cure may precipitate an asthma attack
is associated with xerostomia. Addi for asthma and treatment and manage and it is safer to recommend the use
tionally, patients may be advised to eat ment include the use of preventer and of paracetamol.
small, nutrient and calorie-rich meals reliever inhalers. If this proves insuf If an asthma attack occurs on the
frequently. The dental team have a role cient, inhaled steroids are used and dental premises, the individual should
to play in the provision of oral health in severe cases systemic steroids may use their reliever inhaler immediately,
advice, smoking cessation and dietary be prescribed. sit but not lie down, and loosen any
advice. This is particularly important, tight clothing. If there is no immediate
as poor oral hygiene has been linked to Seamless care improvement, they should continue to
respiratory pathogen colonisation and Anti-asthmatic medication, such as use their reliever inhaler at the rate of
dental plaque may act as a reservoir salbutamol inhaler or tablets and bec one puff every minute for ve minutes
for acquired pneumonia in older peo lamethasone inhaler, can lead to both or until symptoms improve. If symp
ple, particularly residents of long-term increased dental caries and periodontal toms do not improve in ve minutes the
care facilities.94 disease. In order to control any possi emergency services should be called and
Most people with COPD can receive ble exacerbation of dental disease, peo the reliever inhaler use continued every
dental treatment safely, with only minor ple with asthma should be advised by minute until help arrives.96
adjustments to procedures, in general their doctor, pharmacist or dentist that Although a large proportion of peo
dental practice. For comfort of breath they need to adopt more precautionary ple with respiratory disease are able
ing, they may need to have their dental oral hygiene practices and have regu to receive routine dental treatment in
treatment in an upright or semi-reclined lar dental reviews.97 Salbutamol is a 2 general dental practice, those with sig
position. People on oxygen therapy will adrenergic agonist and can produce nicant respiratory problems are best
need ambulance transport for dental dry mouth, taste alteration and discol treated in a hospital setting.
appointments and an adequate supply ouration of teeth. People using corti The illustrative material used in Figures 1, 2, 3
of oxygen during the visit, or provision costeroid inhalers are also predisposed and 5 is credited to www.JohnBirdsall.co.uk. The
authors would like to thank the Downs Syndrome
of domiciliary oral healthcare. Patients to developing candidosis.98,99 To help Association for providing them with the illustra
with severe COPD are at particular risk prevent these side-effects, people are tive material used in Figure 8.

when given intravenous sedatives, opi advised to rinse and gargle with water 1. Scully C, Dios P D, Kumar N. Special care in
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Edinburgh: Churchill Livingstone, 2007.
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