[Downloaded free from http://www.jpbsonline.org on Tuesday, May 17, 2022, IP: 182.253.127.

131]

Original Article

Oral Health Status of Down’s Syndrome Patients in Aseer, Saudi Arabia

N. C. Sandeepa, Sara Ali Al Hagbani1, Fatmah Abdulrahman Alhammad1, Amal Saeed Al Shahrani1, Sara Eid Al Asmari1

Departments of Diagnostic Introduction: It was observed that compared to the general population, mentally

Abstract
Sciences and 1Oral Biology,
College of Dentistry, King
challenged subjects have higher rates of poor oral hygiene. Gingivitis is a common
Khalid University, Abha, finding with moderate or severe variety reported most commonly. Periodontal
Kingdom of Saudi Arabia disease is the most significant oral health problem, which can even lead to
mobility of tooth and tooth loss. It is essential to generate oral health precautionary
agendas and familiarize it with them. Materials and Methods: Four Centres of
rehabilitation in the Aseer region of Saudi Arabia were included and subjects
of 3–24  year age group was examined. Written informed consent was obtained
from directors of Centres. Caries, oral hygiene status, soft‑tissue and hard‑tissue
lesions were evaluated and statistically analyzed. Results: Higher Decayed,
Missing and Filled Teeth score was observed in the present study in contrast
to many other studies. Periodontal disease was seen in higher age group with
higher percentages. Poor oral hygiene was seen in 27.3% of males and 66.7% of
females. Tongue lesions comprised 85.7%, which accounted for the major part of
soft‑tissue abnormality. Various occlusal abnormalities  (75%) and developmental
tooth disturbances (53.6%) constitute the higher portion in hard‑tissue abnormality.
Conclusion: Dentists should be conscious of the range of oral anomalies that can
manifest in this group of the patients. The microbial or serological investigation
was not done which could have explained the etiology behind these lesions. In
spite of these confines, the survey result have provided information regarding the
oral health status of Down’s syndrome subjects and the necessity of focusing on
Submitted: 26‑Sep‑2020 oral health need.
Accepted: 27‑Nov‑2020
Published: 05-Jun-2021. Keywords: Caries, downs syndrome, oral hygiene, soft tissue abnormality

Introduction system deficiency, poor oral hygiene, delicate periodontal

D own syndrome  (DS) is considered to be the most
common neurodevelopmental disorder of genetic
origin. The incidence of DS is estimated to be between
1:750 and 1:1000 live births. DS arises due to an extra
copy of chromosome 21, which can lead to characteristic
abnormal facial morphology, large tongue, low muscle
tone, short stature, and intellectual incapacity.[1] Oral
health issues have a higher prevalence and is a major
problem for these individuals compared to the general
population. High rates of dental caries, periodontal
disease, missing teeth, prolonged retention of primary
teeth, supernumerary teeth, and malocclusion are all
pointers of reduced oral health and are common in this
population.[2] Periodontal disease is the utmost important
oral health problem which could be due to immune
tissue, early senescence, and poor masticatory function.[3]
There is a lack of enough information available on the
oral health of DS subjects. Thus, the objective of this
study was to determine the oral health condition of DS
patients who are residing in rehabilitation centers in the
Aseer region of Saudi Arabia.
Materials and Methods
Four centres of rehabilitation in the Aseer region were
included. Written informed consent was taken from
the Directors of Centres. A  total of 56 Participates of
Address for correspondence: Dr. N. C. Sandeepa,
College of Dentistry, King Khalid University, Abha,
Kingdom of Saudi Arabia.
E‑mail: drsandeepanc@gmail.com

This is an open access journal, and articles are distributed under the terms of the Creative
Access this article online Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
Quick Response Code: remix, tweak, and build upon the work non-commercially, as long as appropriate credit is
given and the new creations are licensed under the identical terms.
Website: www.jpbsonline.org
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Sandeepa NC, Al Hagbani SA, Alhammad FA,
DOI: 10.4103/jpbs.JPBS_593_20 Al Shahrani AS, Al Asmari SE. Oral health status of Down's syndrome
patients in Aseer, Saudi Arabia. J Pharm Bioall Sci 2021;13:S656-9.

S656 © 2021 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.jpbsonline.org on Tuesday, May 17, 2022, IP: 182.253.127.131]
Sandeepa, et al.: Oral changes in Down’s syndrome
age 3–24  years of diagnosed DS from the four centers
were examined. Clinical examination was done by two
dentists under artificial light. Caries was measured using
the Decayed, Missing, and Filled Teeth  (DMFT) index
according to the WHO criteria. The plaque index was
measured using Sillness and Loe index. It was interpreted
as poor oral hygiene, moderate oral hygiene, fair oral
hygiene, and good oral hygiene based on the score.
Periodontal pockets were evaluated using William’s
periodontal probe. All the mucosa was carefully
observed for any ulcer or red and white lesions. The
tongue was observed for macroglossia or fissuring or
other lesions. Frenum was checked gingiva specifically
for inflammation, enlargement, and ulcers. Abnormalities
of teeth, including developmental defects affecting size,
eruption, shape, number, structure, and color of the tooth
were noted. Occlusion abnormalities such as crossbite,
openbite, rotation, and crowding were also observed.
Any acquired abnormalities affecting tooth was also
given consideration during the examination. The palate
was observed for any defects such as high palate or cleft
palate.
Statistical analysis
Chi  square test, Independent t‑test, and one‑way
ANOVA  (test of significance) were applied at 95%
confidence interval. Data analysis was performed
using version  21 of Statistical Package for the Social
Sciences (SPSS; IBM, and Chicago, IL, USA).
Results
Study population included a total of 56 DS patients. It
included 11  males  (19.6%) and 45  females  (80.4%).
Group I included subjects with 0–6  years of age.
Group II subjects were of 7–12  years of age and
Group III included 13–18  years of age. The age group
of 19–24  years was included under Group IV. Sample
percentage under each group from I to IV were 12.7%,
34.5%, 28.6%, and 25.5%, respectively. Poor oral
hygiene was observed in 28.6% of Group I, 47.4% of
Group II, 75% of Group III, and 71.4% of Group IV
subjects. Periodontal disease was seen in 14.3% of
Group I, 15.8% of Group II, 56.3% of Group III, and
71.4% of Group IV. The age group of 19–24  years
showed statistically significant  (P  <  0.01) higher
number of periodontal cases  (71.4%) when compared
to other age groups. In the case of DMFT, there was
no correlation observed between the age group and
the DMFT score. With respect to oral hygiene, female
showed statistically significant (P < 0.05) higher number
of cases of poor oral hygiene (66.7%) when compared to
males  (27.3%). With respect to periodontal disease, the
female showed statistically significant  (P  <  0.01) higher
Journal of Pharmacy and Bioallied Sciences  ¦  Volume 13  ¦  Supplement 1  ¦  June 2021
number of cases (48.9%) in comparison to male (9.1%).
DMFT score was 11.64  ±  6.289 for females and
8.55  ±  5.067 for males  [Table  1]. Tongue lesions were
observed, which included a large tongue and fissured
tongue. Gingival enlargement or other abnormality was
grouped under gingival diseases. Narrow, high palate, or
cleft palate was categorized under palatal abnormality.
Tongue lesions were detected in 48 individuals (85.7%).
Ulcers were seen in 18  (32.1%) and fungal infection
in  (1.8%) one subject. Frenum abnormalities were
seen in 9  (28.6%) and 9  (16.1%) individuals presented
with gingival lesions. Females showed a statistically
significant (P < 0.05) higher number of cases of frenum
abnormalities  (35.6%) when compared to males  (0%).
Fungal infection was seen in 1  (2.2%) of females while
none of the male subjects had features of the same.
Gingival enlargement or any other lesions was observed
in 9  (20%) of female subjects and male patients did not
present with this feature. Palate abnormality was seen in
13 (28.9%) of females and 4 (36.4%) of males [Table 2].
Among the age group, 19–24  years showed statistically
significant (P < 0.01) higher number of cases of gingival
diseases  (42.9%). Hard tissue abnormalities were
categorized and grouped as developmental disturbances,
attrition, enamel hypoplasia, and malocclusion.
Developmental disturbances affecting tooth included
anomalies affecting tooth number, size, shape, and
eruption. All patients had class III skeletal relation.
Malocclusion was seen in 42  (75%) and abnormality
in the shape, number, or eruption was observed in
30  (53.6%) of subjects. Hypoplasia  (19.6%) and
attrition  (17.9%) was observed. In the case of attrition,
male patients showed statistically significant  (P  <  0.05)
higher number of cases  (36.4%) when compared to
female (13.3%) [Table 2].
Discussion
In this study, DS specifically was selected to investigate
as there is a relatively high incidence of DS. Advanced
maternal age was found to be a risk factor toward
an increased incidence of DS.[4] Moreover, the life
expectancy of these patients is greater than before
compared to the past few years.[5] Advanced medical
care and facilities have decreased mortality rate in DS
patients. Oral health of DS patients is an important
focus of care and can play a significant role in the
overall quality of life of patients. Caries: A  majority
of published studies have reported that people with
DS have lower caries rates than people without DS.
Several other studies found that DS individuals and the
general population have the same caries rates, though
some reported higher caries rates in DS individuals.[6,7]
Decrease in dental caries in DS individuals compared
S657
[Downloaded free from http://www.jpbsonline.org on Tuesday, May 17, 2022, IP: 182.253.127.131]

Sandeepa, et al.: Oral changes in Down’s syndrome

Table 1: Descriptive and inferential analysis of variable related to oral hygiene status being compared between age
groups and gender
Variable Responses Study group P Gender P
Group I Group II Group III Group IV Male Female
Plaque index Fair oral hygiene 3 (42.9) 1 (5.3) 1 (6.3) 1 (7.1) 0.039 4 (36.4) 2 (4.4) 0.004
Moderate oral hygiene 2 (28.6) 9 (47.4) 3 (18.8) 3 (21.4) 4 (36.4) 13 (28.9)
Poor oral hygiene 2 (28.6) 9 (47.4) 12 (75) 10 (71.4) 3 (27.3) 30 (66.7)
Periodontal pocket Absent/cannot be assessed 6 (85.7) 16 (84.2) 7 (43.8) 4 (28.6) 0.003 10 (90.9) 23 (51.1) 0.016
Present 1 (14.3) 3 (15.8) 9 (56.3) 10 (71.4) 1 (9.1) 22 (48.9)
DMFT (mean±SD) 7.57±5.094 9.42±3.892 12.56±6.582 13.21±7.678 0.096 8.55±5.067 11.64±6.289 0.136
DMFT: Decayed, Missing and Filled Teeth, SD: Standard deviation

Table 2: Descriptive and inferential analysis of variable related to hard tissue and soft tissue finding being compared
between age groups and gender
Variable Responses Study group P Gender P
Group I Group II Group III Group IV Male Female
Soft Tongue lesions 6 (85.7) 15 (78.9) 15 (93.8) 12 (85.7) 0.670 9 (81.8) 39 (86.7) 0.680
tissue Ulcers 2 (28.6) 3 (15.8) 5 (31.3) 8 (57.1) 0.094 2 (18.2) 16 (35.6) 0.269
Fungal infection 0 1 (5.3) 0 0 0.576 0 1 (2.2) 0.618
Frenum abnormalities 0 4 (21.1) 7 (43.8) 5 (35.7) 0.140 0 16 (35.6) 0.019
Gingival diseases 0 0 3 (18.8) 6 (42.9) 0.006 0 9 (20) 0.105
No abnormality 0 2 (10.5) 1 (6.3) 1 (7.1) 0.829 1 (9.1) 3 (6.7) 0.780
Hard Palate abnormalities 3 (42.9) 6 (31.6) 7 (43.8) 1 (7.1) 0.141 4 (36.4) 13 (28.9) 0.629
tissue Developmental tooth disturbances 3 (42.9) 8 (42.1) 10 (62.5) 9 (64.3) 0.478 4 (36.4) 26 (57.8) 0.202
Malocclusions 5 (71.4) 13 (68.4) 10 (62.5) 14 (100) 0.090 7 (63.6) 35 (77.8) 0.332
Hypoplasia 2 (28.6) 6 (31.6) 3 (18.8) 0 0.139 4 (36.4) 7 (15.6) 0.119
Attrition 3 (42.9) 4 (21.1) 3 (13.3) 0 0.104 4 (36.4) 6 (13.3) 0.074
No abnormality 1 (14.3) 1 (5.3) 0 0 0.308 2 (18.2) 0 0.004

to other individuals was explained by features such as a
different composition of saliva as seen in salivary IgA,
salivary pH, flow rate, buffering capacity, oligodontia,
delayed eruption, or a difference in eruption times. In
children with DS, teeth often erupts 1–2 years later than
that of the normal subject.[8] Our study showed a DMFT
score of 7.57  ±  5.094 in the younger age group and
varied up to 13.21  ±  7.678 as observed in Group IV. It
was unlike other studies that showed that DS individuals
have lower values of the DMFT index.[8,9] Values of
the DMFT index obtained in our study correlate with
the values obtained in the survey conducted in certain
countries.[10,11] High rate of caries could be due to muscle
weakness and inadequate muscle coordination, which can
affect oral hygiene measures. Periodontal disease: As the
age increases, the severity of gingivitis and periodontal
disease also increase. In DS adolescent subjects,
prevalence of periodontal disease reaches up to 30% to
40%. The incidence of periodontal disease rises up to
nearly 100% by the age of thirties.[12] Poorer oral hygiene
and periodontal status were reported in DS patients
compared to the general population.[13,14] In this study,
71.4% of individuals of the age group of 19–24  years
showed statistically significant (P < 0.01) higher number
of periodontal disease. Female showed statistically
significant  (P  <  0.05) higher frequency of periodontal
pocket  (48.9%) in comparison to male  (9.1%).
Soft‑tissue lesions: The most common dentofacial
anomaly reported were tongue changes, which included
fissured tongue followed by macroglossia.[13.15]  Gingival
hyperplasia and generalized gingivitis were also
dominant in DS subjects. Poor oral hygiene, together
with systemic and local factors, is the likely reason for
the greater frequency of gingival diseases among the
DS population.[16,17] Sasaki et al., in their study, reported
42% DS individuals with gingivitis.[18] Gingivitis
was observed in 30% of individuals and 16.1% of
had gingival enlargement in our study. Hard‑tissue
abnormalities: high arch palate and cleft palate were the
palatal abnormality observed in our study  (30.4%). In
another study, high arched palate was seen in 84.4% of
DS subjects.[19] Angle Class III malocclusion was seen
in 97% incidence in a study.[19] When compared, it was
found in 93% of DS individuals, while malocclusion
was observed only in 20%–36% of the general
population.[20] It was seen in 100% of individuals in our
study. Crossbite, crowding, and open bite altogether was
seen in 75% of individuals. These findings are consistent
with other studies.[21] Developmental tooth disturbances
affecting tooth affecting number, eruption, shape was

S658 Journal of Pharmacy and Bioallied Sciences  ¦  Volume 13  ¦  Supplement 1  ¦  June 2021
[Downloaded free from http://www.jpbsonline.org on Tuesday, May 17, 2022, IP: 182.253.127.131]
Sandeepa, et al.: Oral changes in Down’s syndrome
observed in 30  (53.6%) of subjects. Missing teeth,
delayed eruption, and microdontia altogether were seen
in half of the subjects. These findings were also seen in
other studies.[19,21]
Conclusion
The current study explores the prevalence of various
dental anomalies and oral health status in DS that may
require further consultation and intervention. Intervention
programs should be focused to special needs schools.
Counseling of parents and guardians plays a significant
zone which can help in the implementation of health
programs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Karmiloff‑Smith A, Al‑Janabi T, D’Souza H, Groet J, Massand E,
Mok  K, et al. The importance of understanding individual
differences in Down syndrome. F1000Res 2016;5:389.
2. Altun C, Guven G, Akgun OM, Akkurt MD, Basak F, Akbulut E.
Oral health status of disabled individuals attending special
schools. Eur J Dent 2010;4:361‑6.
3. Atsuo A, Jumpei M, Shigehisa A, Morisaki I. Etiologic factors of
earlyonset in Down syndrome. Jpn Dent Sci Rev 2008;44:118‑27.
4. Niazi  MA, al‑Mazyad  AS, al‑Husain  MA, al‑Mofada  SM,
al‑Zamil  FA, Khashoggi  TY, et al. Down’s syndrome in Saudi
Arabia: Incidence and cytogenetics. Hum Hered 1995;45:65‑9.
5. Horbelt CV. Down syndrome: A review of common physical and
oral characteristics. Gen Dent 2007;55:399‑402.
6. Areias  C, Sampaio‑Maia  B, Pereira Mde  L, Azevedo A, Melo  P,
Andrade  C, et al. Reduced salivary flow and colonization
by mutans streptococci in children with Down syndrome.
Clinics (Sao Paulo) 2012;67:1007‑11.
7. Areias CM, Sampaio‑Maia B, Guimaraes H, Melo P, Andrade D.
Caries in Portuguese children with Down syndrome. Clinics (Sao
Paulo) 2011;66:1183‑6.
8. Singh  V, Arora  R, Bhayya  D, Singh  D, Sarvaiya  B, Mehta  D.
Journal of Pharmacy and Bioallied Sciences  ¦  Volume 13  ¦  Supplement 1  ¦  June 2021
Comparison of relationship between salivary electrolyte levels
and dental caries in children with Down syndrome. J  Nat Sci
Biol Med 2015;6:144‑8.
9. Asokan  S, Muthu  MS, Sivakumar  N. Dental caries prevalence
and treatment needs of Down syndrome children Chennai, India.
Indian J Dent Res 2008;19:224‑9.
10. Jain  M, Mathur  A, Sawla  L, Choudhary  G, Kabra  K,
Duraiswamy  P, et al. Oral health status of mentally disabled
subjects in India. J Oral Sci 2009;51:333‑40.
11. Porovic  S, Zukanovic  A, Juric  H, Dinarevic  SM. Oral health
of down syndrome children in bosnia and herzegovinA. Mater
Sociomed 2016;28:370‑2.
12. Cichon  P, Crawford  L, Grimm  WD. Early‑onset periodontitis
associated with Down’s syndrome  –  Clinical interventional
study. Ann Periodontol 1998;3:370‑80.
13. Bhowate R, Dubey A. Dentofacial changes and oral health status
in mentally challenged children. J  Indian Soc Pedod Prev Dent
2005;23:71‑3.
14. Fisher WL Jr. Quantitative and qualitative characteristics of the
face in Down’s syndrome. J Mich Dent Assoc 1983;65:105‑7.
15. Cohen  MM, Winer  RA. Dental and facial characteristics
in Down’s syndrome  (Mongolism). J  Dent Res
1965;44(Suppl):197‑208.
16. Al‑Sufyani  GA, Al‑Maweri  SA, Al‑Ghashm  AA,
Al‑Soneidar  WA. Oral hygiene and gingival health status of
children with Down syndrome in Yemen: A cross‑sectional study.
J Int Soc Prev Community Dent 2014;4:82‑6.
17. Al Habashneh  R, Al‑Jundi  S, Khader  Y, Nofel  N. Oral health
status and reasons for not attending dental care among 12‑  to
16‑year‑old children with Down syndrome in special needs
centres in Jordan. Int J Dent Hyg 2012;10:259‑64.
18. Sasaki Y, Sumi Y, Miyazaki Y, Hamachi T, Nakata M. Periodontal
management of an adolescent with Down’s syndrome  –  A case
report. Int J Paediatr Dent 2004;14:127‑35.
19. Shukla  D, Bablani  D, Chowdhry  A, Thapar  R, Gupta  P,
Mishra  S. Dentofacial and cranial changes in Down syndrome.
Osong Public Health Res Perspect 2014;5:339‑44.
20. Shivakumar  KM, Chandu  GN, Subba Reddy  VV, Shafiulla  MD.
Prevalence of malocclusion and orthodontic treatment needs
among middle and high school children of Davangere city, India
by using Dental Aesthetic Index. J  Indian Soc Pedod Prev Dent
2009;27:211‑8.
21. Pueschel  SM, Rynders  JE. Downs Syndrome Advances in
Biomedicine and the Behavioural Sciences. New  York: Ware
Press; 1982.
S659