Down’s syndrome

CF: midface hypoplasia, upslanting palpebral fissures, flat nasal bridge

pallor in palmar creases of hands
Check for signs of cyanosis eg finger clubbing
( dry skin, thin hair, weight gain- signs of hypothyroidism)
I/O: Relative macroglossia d/t tonsillar hypertrophy and reduced oral cavity volume due to
low palatal vault
Fissuring of tongue or smooth depapillated tongue and angular cheilitis
More apthous ulcers
Decreased crown:root ratio
Decreased tooth size
Hypodontia/ partial anodontia
Delayed eruption
Reduced OVD
AOB: due to tongue thrust and hypotonicity of tongue
If persistent bleeding from gums-consider leukemia

Medical problems: CHD ( mitral valve prolapse-Approximately 50% of adults with Down
syndrome have mitral valve prolapse requiring subacute bacterial endoconditis (SBE)
prophylaxis for dental treatment, ASD or VSD,TOF ), leukemia (AML more likely than ALL ),
prone to seizures
Hypothyroidism; impaired cognition, decreased growth parameters, dry skin, dental
abnormalities, altered mood, snoring and reduced exercise capacity

 If patient has had valve replacement, might be on anticoagulants/NOACs

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Dental considerations
1) Poor communication – hearing loss/deafness, visual impairment
2) Risk of tmj dislocation
3) Atlantoaxial instability : careful positioning in the dental chair is required to
avoid any potential harm to the spinal cord.
4) Dentures- poor muscle tonicity, cant control tongue. High gag reflex, small
and narrow mouth opening, aspirate easily due to poor muscle tone.
Improve breathing in Down Syndrome

OSA in children with Down syndrome

midfacial and mandibular hypoplasia, glossoptosis, adenoid and tonsillar enlargement, the
presence of enlarged lingual tonsils, airway malacia, obesity and generalised muscle
hypotonia which may be associated with collapse of the pharyngeal muscles during
inspiration.
Removal of enlarged tonsils and adenoids is the first line surgical treatment.
lingual tonsillectomy, uvulopalatopharyngoplasty, midline posterior glossectomy,
genioglossus advancement, hyoid advancement and craniofacial surgery, including
mandibular and midface advancements.
intranasal corticosteroids, orthodontic treatment, weight loss programmes and palatal
plate that contained a stimulation knob that shifted the base of the tongue forward ;
myofunctional therapy (MT)
MT- Padovan method ;Exercises are performed both passively and actively,
with the active parts increasing across sessions, and begin with physical exercises that aim
to strengthen overall muscle tone and improve posture. oral exercises, which are targeted
to airflow control, lip activity, tongue movements to increase its strength, activation of the
buccinator and masseter muscles, and proprioception through chewing exercises. The oral
exercises aim at strengthening the orofacial complex and to improve ingestion, articulation
and the development of the facial and jawbones.
Alternate protocol- a series of exercises for myofunctional rehabilitation divided according
to the functional goals to be pursued. Each of these goals included a series of about 5
exercises.the child had to repeat each exercise at least 3 times a day, so that every day the
child performed at least 30 min of myofunctional therapy.
Goals : awareness of the nose’s functionality (learn to blow nose),
Promote nasal breathing: Children must keep their mouths closed and inhale and exhale,
keeping a tongue depressor between their lip
Establish tongue rest position: The tip of the tongue will rest on the retroincisal papilla with
the remaining portion of the tongue resting on the palate- restore lip seal
Restoring lip seal : exercises to facilitate a correct swallowing pattern as well as promoting
nasal breathing and a physiological postural position of the mandible
Improving fx of buccinator and masseter- improve chewing and swallowing
Strengthening soft palate: gargling and energetic pronunciation of vowel phonemes and
single vowels
Repatterning correct swallowing
A specific protocol of myo-functional therapy in children with Down syndrome. A pilot study
S. Saccomanno*, C. Martini**, L. D’Alatri***, S. Farina****, C. Grippaudo* Fondazione
Policlinico Universitario A. Gemelli IRCCS, Rome Università Cattolica del Sacro Cuore *
Dental Institute, Head and Neck Department, Università Cattolica del Sacro Cuore ** Dental
Institute, Università Cattolica del Sacro Cuore *** ENT, Head and Neck Department -
Università Cattolica del Sacro Cuore **** ENT, Head and Neck Department email:
sabinasaccomanno@hotmail.it DOI: 10.23804/ejpd.2018.19.03.14

Osteoporosis in Down Syndrome https://doi.org/10.1016/j.jmu.2013.10.015

T score -1 to -2.5 indicates low bone mass. -2.5 or lower is osteoporosis
Patients with DS have a high prevalence of osteoporosis. However, in DS, bone mineral
density (BMD) can be underestimated due to short stature.
Muscle contraction places the greatest physiological load on bone, and so the strength of
bone must adapt to muscle strength.It can be argued that deficiencies in muscle contraction
represent the major cause of bone weakness (secondary bone disease). Therefore, if muscle
hypotonia is reported in patients with DS, a resulting osteopenia would be observed.
thyroid dysfunction, abnormalities of sexual development, and nutritional troubles also
contribute.
DS more prone to hypothyroidism but hyper can occur too. Frequent testing to make sure
TSH and T4 remain within a normal range is needed.
excess of T4 speeds up the work of osteoclasts, making it difficult for the bone-building
osteoblasts to keep up. If the osteoclasts work faster than the osteoblasts, your bones lose
density (strength), become fragile and/or brittle raising the risk for fracture.

Orthodontic considerations
roots of the teeth in patients with Down syndrome tend to be small and conical.
also contributes to early tooth loss in periodontal disease
severe periodontal disease (esp in mandibular incisors and maxillary molars) : thought to be
related to a lowered host response due to the compromised immune system in Down
syndrome
amount of plaque and calculus seen on the teeth is not proportionate to the severity of the
disease
An anterior open bite and class III malocclusion may be due to proclination of the incisor,
under-development of the maxilla and a more anterior position of the hypoplastic mandible.
Posterior crossbite occurred in 65% of patients due to maxillary transverse hypoplasia
Study models : Impression must be taken as quick as possible, with fast set type or low
viscosity impression material due to high gag reflex and anxiety
Extra-oral diagnostic xrays better tolerated than intra-oral
Removable appliances are better tolerated than fixed
Fixed appliance:
In uncooperative patients,may require sedation for bonding.
Straight wire technique can be chosen because it has minimal wire changes. Treatment
with self ligating bracket is also beneficial since it can reduce the visiting time and no
ligature wire or elastomeric modules make teeth brushing easier to be done.
Retention : If the cooperation is doubtful, it is better to use permanent retainer such as
bonded lingual retainer.
Caries frequency in Down syndrome patients can be minimized with preventive measures
such as fluoride topical application, fissure sealant, fluoride tooth paste suggestion and non
cariogenic food and beverage consumption

Dental Implants (needs more research for conclusion- most say higher failure rate, but
reason poorly understood)

Dental implant survival is lower in individuals with DS than in the general population

Due to osteoporotic features and tendency for interproximal bone loss( Lustig, J. P.,
Yanko, R., & Zilberman, U. (2002). Use of dental implants in patients with Down
syndrome: a case report. Special Care in Dentistry, 22(5), 201–
204. doi:10.1111/j.1754-4505.2002.tb00271.x )
References
Abanto, J., Ciamponi, A. L., Francischini, E., Murakami, C., de Rezende, N. P. M., &
Gallottini, M. (2011). Medical problems and oral care of patients with Down
syndrome: a literature review. Special Care in Dentistry, 31(6), 197–
203. doi:10.1111/j.1754-4505.2011.00211.x
Effect of a 1-week intense myofunctional training on obstructive sleep apnoea in children
with Down syndrome Magnus von Lukowicz,1 Nina Herzog,1 Sebastian Ruthardt,2 Mirja
Quante,1 Gabriele Iven,2 Christian F Poets

Orthodontic treatment considerations in Down syndrome patients Sianiwati Goenharto

Department of Orthodontics Faculty of Dentistry, Airlangga University Surabaya – Indonesia
Dental Journal Vol. 45. No. 1 March 2012