.................... ................................................ ARTICLE

Joseph Shapira, DMD, Ayala Stabholz, DMD

A comprehensive 30-month preventive dental health program in a pre-adolescent population with Down’s Syndrome: A longitudinal study

A comprehensive systematic pre- ventive dental health program was implemented in a young population with Down’s Syndrome during a 30 month period. Twenty children (nine boys and 11 girls), ages 8-13 (mean age, 11), participated in the study, which took place in three hostel-like apartments. The main goals of this program were to achieve good plaque control and subsequently pre- vent periodontal disease as well as to apply fissure sealants and fluo- rides in an attempt to prevent dental caries. The mean plaque and gingival indices as well as the percentage of bleeding sites decreased significant- ly (p < 0.01) following the adminis- tration of our oral health program. Caries experience, as indicated by DMFS, decreased from 1.35 to 1.05 surfaces per child, and the use of fis- sure sealants to prevent occlusal caries was proved to be 100% effec- tive. It is concluded that if the chil- dren’s efforts are integrated with those of a motivated dentist, dental hygienist, and staff, a well-planned preventive dental health program can lead to a high degree of success in the prevention of dental diseases in young populations with Down’s Syndrome.

hildren with Down’s Syndrome (DS) are known to C be greatly predisposed to perio-

dontal disease,l,* whereas their caries prevalence is lower than that of com- parable control^.^-^

The lower incidence of dental caries among this population is attributable to several factors, includ- ing an increased buffering capacity of saliva7 and the tendency of many of these patients toward bruxism, since susceptible occlusal surfaces are fre- quently flattened and smoothed. Still, when present, most caries foci among DS children have been found to be mainly in pits and fissures.8

While most of the dental needs of healthy children in the general popu- lation are met by restorations and extractions, only a small percentage of the dental needs of institutional- ized children with DS were met:6 Sixty-seven percent (the major frac- tion) of the DMF surfaces were found to be decayed at the time of examina- tion.

The critical factor for the high inci- dence of severe periodontal disease is the DS child’s inability to maintain proper oral hygiene. However, there are several conditions predisposing to the development of early perio- dontal disease, including poor occlusal relationship, particularly anterior and posterior crossbite. A high mandibular anterior frenum causes early mucogingival defects of the lower incisors. The forward posi- tion of the tongue produces addition- al abnormal forces on the lower ante-

rior teeth, which are already in cross- bite position. Severe periodontitis and early loss of the mandibular incisors are therefore common seque-

Periodontal treatment needs of adults with DS were found to be three times greater than among chil- dren with DS living in the same insti- tution.1° The authors suggest that this is further evidence of the importance of age in periodontal disease preva- lence, particularly among individuals with DS.

Several s t u d i e s l ~ ~ ~ - ~ ~ have com- pared the prevalence of periodontal disease in institutionalized patients with that of noninstitutionalized patients with mental retardation. Tesinil4rl5 reported that the difficulty encountered in low-functioning indi- viduals’ attempts to maintain ade- quate oral hygiene supports the con- tention that higher-functioning per- sons with mental retardation require constant monitoring to reinforce a prevention program. In institutions where a comprehensive preventive dental program does not exist, the clinical pattern of periodontal disease observed is that of generalized perio- dontitis with severe inflammation, tooth mobility, and spontaneous gin- gival bleeding.15

In two controlled studies involv- ing institutionalized adults and chil- dren with Down’s Syndrome, perio- dontal treatment needs and caries levels were evaluated.6,10

as in the present study, were com-

iae.9

Thirty-two DS children ages 8-13,

SCD Special Care in Dentistry, Vol16 No 1 1996 32

Table 1. Mean scores of PII, GI, and percentage of bleeding

sites before and after a 30-month oral health program.

age, 12 years 6 months). Only 18 individuals com-

Baseline After 30 Months pleted the peri- odontal portion of the study, since Plaque Index (PII) k SD 1.8 k 0.4 1.0 f 0.7‘

Gingival Index (GI) * SD 1.9 0.4 1.1 2 0.6‘ two children con- % Bleeding Sites f SD 84.7 rt 14.8 52.6 k 28.8 sistently refused to

be examined for ‘p < 0.01; Wilcoxon signed-rank test.

pared with two control groups of similar age range: healthy children and children with mental retardation (non-DS) living in the same institu- tion. Caries experience showed sig- nificantly lower mean scores for the DS children compared with those of both control groups. As for the Periodontal Index of Treatment Needs (CPITN) used in both studies, it has been shown that no significant difference was found between the DS and the healthy populations. The possible reasons for these results have been discussed.1° However, when the older population in the same institution was examined and compared with healthy individuals as well as with the younger DS popu- lation, a highly significant difference was found. It appears that, among nonmaintained DS patients, the pro- gression and severity of periodontal disease are higher, which is why this population, at an early age, should receive special intervention during maintenance treatments.

ment a comprehensive preventive dental health program to respond systematically to the periodontal and caries-preventive needs of young DS populations.

The purpose of the present inves- tigation was to compare, against a clinical baseline, the clinical condition of a young group living in a hostel- like accommodation following a 30- month preventive dental health pro- gram.

It was therefore decided to imple-

Materials and methods Twenty children with DS (nine males and 11 females) participated in the study. Their age ranged between 8 and 13 years (mean age, 11; median

the presence of gingivitis and bleeding. .

All children underwent a clinical examination that included the record- ings of Plaque Index (P1I),I6 Gingival Index (GI)>7 and number of papillae that bled when a wooden toothpick was gently inserted interproximal- ly.18 The clinical recordings were done only on selected permanent teeth: 3,7,8,9,10, 14,30,26,25,24, 23, and 19. Caries experience was evaluated by the indices for decayed, missing, and filled surfaces (DMFs) and decayed, extracted, and filled surfaces (defs), according to the crite- ria defined by the WHO. The clinical recordings were evaluated by one examiner (AS for the periodontal indices and JS for the DMFs and sealant retention rates). Calibration was performed on five patients with four sites each, attaining a reliability of higher than 80%. The analysis of results was performed by combined DMFs and defs scores. The study was approved by the institutional ethical committee.

A specific preventive dental health program was tailored to this unique young population based on three main goals: the elimination of plaque, the application of topical fluo- rides, and the prevention of fissure caries by the use of fissure sealants.

Following the baseline examina- tion, an experienced dentist provided for all the children dental treatments that included fillings and fissure sealants. Oral hygiene instructions and supra- and subgingival scaling were provided by a trained dental hygienist.

The DS children live in the com- munity in three hostel-type accom- modations representing a transition phase toward mainstream living, with two large bedrooms in each hos-

tel and a large dining room for social activities. Since these were high-func- tioning individuals, their program involved a combination of oral hygiene self-care and practical, face- to-face implementation by the dedi- cated staff.

The staff members working with the DS children were educated about the various dental diseases, their eti- ology, and their prevention. They were exposed to different preventive techniques in an attempt to incorpo- rate that information into a meaning- ful daily program to achieve optimal oral health care for the DS subjects.

Where applicable, the children’s parents were also given the same instructions for use whenever their children were at home; thus, the par- ents became part of the ongoing den- tal health education program.

The program was evaluated peri- odically by the dental hygienist and/or by the senior dentist to deter- mine the efficacy of these preventive measures.

During the 30-month period, each individual received a periodontal maintenance treatment by the dental hygienist every four months (about seven times) and a dental mainte- nance treatment by the dentist every eight months (about three or four times). The periodontal maintenance treatment included reinforcement of oral hygiene instructions together with supra- and subgingival scaling. The dental maintenance treatment included the detection of new caries foci and their treatment. New teeth that had erupted received fissure sealants, whereas old fissure sealants were examined for retention and were re-applied as needed by the technique described by Simonsen.19 The dentist also evaluated the indi- vidual’s periodontal condition.

the investigators conducted detailed periodontal and dental examinations identical to baseline examinations.

Plaque and gingival indices were calculated as means per site, whereas bleeding was calculated as the per- centage of bleeding sites out of all sites examined for gingival bleeding. The Wilcoxon signed-rank test was

At the end of the 30-month period,

34 SCD Special Care In Dentistry, Vol 16 No 1 1996

used to analyze the differences between the data before and the data after the oral health program inter- vention.

Results Table 1 shows the mean plaque and gingival indices as well as the per- centage of bleeding sites before and after the oral health program described. All mean periodontal parameters examined decreased sig- nificantly (p < 0.01) following the program (Table 1). Two individuals showed an increase in PlI, GI, and interproximal bleeding measure- ments at the end of the study as com- pared with their initial recordings. One subject had an increased P1I but not GI, and another had an increased, but less dramatic, GI and bleeding percentage but not PlI. An increase in bleeding recordings was noted in an additional examinee who had no increase in the other two indices. It can be noted that, prior to the start of our program, 13 out of 18 patients had 2 80% bleeding, whereas at the second examination only four indi- viduals had such a high bleeding per- centage, and 11 had < 50% of their examined sites that bled when a toothpick was inserted.

Caries experience as indicated by the DMFs (Table 2) was found to be 1.35 per child (the mean number of 27 decayed surfaces per 20 children). No missing or filled surfaces were found at the initial examination.

At the end of 30 months, the decayed surfaces (DS) were found to be 0.20 per child (4 DS per 20 chil- dren). The filled surfaces fraction (FS) was 0.85 per child (17 FS per 20 chil- dren). Six of the original 16 occlusal caries lesions (Table 2) were enlarged; these were mechanically prepared with a small rounded bur, and preventive composite sealant restorations were placed without the use of local ane~thetics.'~ The total DMFS at the end of the 30 months was therefore 1.05 (0.20 f 0.85) per child. Eighty percent of the affected surfaces were found in five of the 20 participants (25% of examined chil- dren).

Table 2. Number of decayed surfaces (DS)* per child and their distribution at the ini-

tial examination.

No. of DS' Occlusal Proximal Buccal Total Children per Child

10 0 5 1 4 1 5 2 2 1 3 4 1 4 1 1 2 4

1 6 6 6

1 8 4 4 8 20 16 9 2 27

"No missing (M) or filled (F) surfaces were found. The defs was combined with the

DMFs. Only two proximal surfaces were found for ds.

Fissure sealants were applied on all the available permanent teeth. At the beginning of the study, 117 per- manent molars and 104 premolars were sealed (Table 3). During the 30 months of the study, an additional 63 teeth were sealed. A total of 97% of the sealants were completely retained, and 3% were partially retained during the study period. Sealants were reapplied immediately to teeth with partially retained sealants. None of the sealants applied was completely lost.

Discussion In our study, the children who received the preventive dental health program belonged to the Trainable Mentally Retarded (TMR) popula- tion20 Although they may achieve self-maintenance in unskilled or semiskilled work under sheltered conditions in later life, TMR patients require considerable supervision and support in most endeavors. This was

the basis for planning our preventive dental health program, which could not be successful without daily rein- forcement and assistance from the staff as well as from some of the par- ents.

The results of our study agree with those of previous studies, all of which suggest that the prevalence of periodontal disease in mentally retarded persons is related to their oral hygiene s t a t ~ s . ' , ~ ~ - ~ ~ Cutress' showed that oral hygiene scores were significantly correlated with perio- dontal index scores for young DS patients as well as for other individu- als who are healthy or with retarda- tion. Goyings and Riekse22 found that periodontal disease in DS as well as in other institutionalized children decreased significantly following the implementation of an oral hygiene program. Our study reports only about the soft-tissue reaction to the accumulation of dental plaque, since the maximum age of the participants at the commencement of the program

Table 3. Distribution and retention of fissure sealants at the start and at the end of a

30-month program.

No.' at No. at End Partial Total Start Sealant Loss Retention

Molars 117 145 6 139 (96%)

P r e m o 1 a r s 104 139 3 135 (98%)

221 284 9 275 (97%)

"Number of fissure sealants applied to all available permanent fissured teeth.

SCD Special Care in Dentistry, Vol16 No 1 1996 35

was 13 years-an age where the attachment loss that accompanies bone resorption is rare or hardly clin- ically noticeable.

Oral hygiene in relation to dental caries in persons who are mentally retarded has been lacking. The only direct correlation of oral hygiene fac- tors to caries prevalence was present- ed by Cutressl and Nowak,26 who suggested that oral hygiene does not appear to be a major factor in caries experience in populations with men- tal retardation.

DS patients demonstrate low inci- dence of dental ~ a r i e s , @ , ~ ~ - ~ ~ but when caries is present, 80% is found in the pits and fissures of posterior teeth. Our dental health program did not rely solely on the control of indi- vidual oral hygiene but included a periodic fluoride application and a thorough examination by a trained dentist who used fissure sealants whenever applicable in an attempt to prevent future caries.

In six of the original 16 occlusal caries lesions, preventive composite- sealant restorations were used when- ever the explorer was caught in iso- lated pits and fissures, indicating the existence of a caries lesion. This tech- nique, first described by Simonsen in 1978,19 included widening of the pits and fissures and removal of enamel that appeared to be affected by caries. When caries removal involved more than half of the total depth of the enamel, the cavity was filled with posterior composite material, while the sealant material was placed over the remaining intact pits and fissures.

Our results show a very high retention rate for the fissure sealants: 97% were retained after 30 months, with re-application of 4% and 3% in the molars and premolars, respective-

The sealants were applied accord- ing to the method described by Shapira and Eidelman in 1986.30 The teeth were mechnically prepared before sealant application in an attempt to remove plaque and organ- ic debris from the fissures together with surface enamel. Charbeneau3l and Straffon and D e n n i ~ o n ~ ~ reported similar retention rates following a

ly.

reapplication protocol. These studies showed that retention rates ranged from 88% to 96% at each annual eval- uation during a four- to seven-year follow-up. It is of great interest to observe from the results of the above- mentioned studies that the described preventive program proved to be 100% effective in occlusal caries pre- vention. It appears that maintaining an adequate recall system for sealant evaluation and reapplication could lead to a relatively high degree of caries prevention.

For comprehensive dental care program to be effective and efficient, basic program components with out- lined objectives should be tailored to a specific group. We devised a pro- gram that took into consideration the resident-to-staff ratio, the functioning level of the residents, and the avail- ability of the medical and paramed- ical staff for monitoring and treating those individuals on a reasonable schedule. Our population required both resident self-care and staff direct care on a daily basis and professional treatment by a hygienist/dentist on a periodic recall basis.

In a long-term study of the effects of manual and electric toothbrushes used by adults with mental retarda- tion, Bratel and Berggren33 have shown that reduced positive effects on plaque and gingival indices over time might indicate that re-instruc- tion in oral hygiene and continuous motivation are more important to a prophylactic program than the kind of brush used, and this was our basis for planning the preventive program.

Brushing is a voluntary physical activity and has two requirements: motivation and manual dexterity. Many people understand the need for and benefits of adequate brushing but cannot carry it out, especially in a population with mental retardation. Shaw et ~ 1 . ~ ~ showed no significant correlation among manual dexterity, comprehension scores, and periodon- tal indices in a group of physically challenged adults. They assumed that improving manual dexterity skills in a population with mental retardation would not necessarily result in an improvement in oral hygiene. Thus,

to achieve best results, these individ- uals would require active assistance in toothbrushing.

Two individuals in the present study group exhibited an increase in all three parameters measured fol- lowing the preventive program. These two older girls did not accept any direct assistance in their oral hygiene performance. Although they considered themselves mature enough to perform the task indepen- dently, they were actually unable to brush well, which resulted in elevat- ed plaque and inflammatory scores compared with those of the younger children.

This finding might also be a clue to the critical age after which such a preventive program should not be attempted. Those two girls entered the study at the age of 13. They might have already adopted self-mainte- nance habits which could hardly be changed during the 30 months of our intervention and thus showed a dis- crepancy from the rest of the study group. We can conclude, though, that preventive dental health programs should start around the age of puber- ty, when teen-agers are mature enough to understand and cooperate but are not too old to maintain their established habits.

Two other individuals showed high readings in only the inflamma- tory component of the examination (GI and bleeding). One of them became very nervous when she saw the toothpick being inserted into her mouth and made our examination almost impossible, a fact that could have influenced our recordings. Since the examinees had been introduced to the dental mirror and explorer in the past, their use did not evoke any fear, whereas the toothpick evoked some stress. One patient showed ele- vated GI and percentage of bleeding sites. This individual had malocclu- sion and tooth crowding, which might explain the gingival outcomes. Anterior and posterior crowding has been reported in 30% and 39% of DS patients, respectively, by Brown and C ~ n n i n g h a m . ~ ~ Brown35 observed an obvious correlation between the areas with continued periodontal

36 SCD Special Care in Dentistry, Vol 16 No 1 1996

health and the absence of crowding, whereas all subjects with crowded dentition or tight contact showed periodontal disease. This agrees with our findings for that specific individ- ual.

We did not use a control group in this study since we assumed that its length did not justify depriving other children of preventive dental care, particularly at ages (8-13) so critical to their future development. The recognition of the importance of den- tal health care does not always result in its proper implementation. It is only by integrating the best efforts and motivation of the children, the dental team, and the staff that these children can benefit from a compre- hensive preventive dental care pro- gram.

The authors wish to thank Ofra Eliahu, the dental hygienist, and the entire staff of the hos- tels affiliated with the Elwin Institute for Patients with Mental Retardation in Jerusalem. Without their assistance this work could not have been performed.

Dr. Shapira is an Associate Clinical Professor, Department of Pediatric Dentistry, and Dr. Stabholz is a Clinical Senior Lecturer, Department of Community Dentistry, at The Hebrew University-Hadassah Faculty of Dental Medicine, PO Box 12272, Jerusalem 91120, Israel. Correspondence should be addressed to Dr. Shapira.

1.

2.

3.

4.

5.

Cutress TW. Periodontal disease and oral hygiene in trisomy 21. Arch Oral Biol

Reuland-Bosma W, van Dijk LJ. Periodontal disease in Down’s syndrome: A review. J Clin Periodontol13:64-73, 1986. Winer RA, Cohen MM. Dental caries in Mongolism. Dent Progr 2217-9,1962. Orner G. Periodontal disease among chil- dren with Down’s syndrome and their siblings. J Dent Res 55:778-82,1976. Tesini DA. An annotated review of the lit- erature of dental caries and periodontal disease in mentally retarded individuals.

16:1345-55,1971.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

Spec Care Dent 1:75-87,1981. Stabholz A, Mann J, Sela MN, Schurr D, Steinberg D, Dori S, et al. Caries experi- ence, periodontal treatment needs, sali- vary pH, and Streptococcus mutans counts in a preadolescent Down syn- drome population. Spec Care Dent

Moser HW, Wolf PA. The nosology of mental retardation. Birth Defects 7117-34, 1971. Barnett ML, Press KP, Friedman D, Sonnenberg EM. The prevalence of peri- odontitis and dental caries in a Down’s syndrome population. J Periodontol

ODonnell JP, Cohen MM. Dental care for the institutionalized retarded individual. J Pedodont 9:3-38,1984. Shapira J, Stabholz A, Schurr D, Sela MN, Mann J. Caries level, Streptococcus mutans counts, salivary pH, and peri- odontal treatment needs of adult Down syndrome patients. Spec Care Dent

Cohen MM, Winer RA. Dental and facial characteristics in Down’s syndrome (Mongolism). J Dent Res 44:197-208,1965, Swallow JN. Dental disease in children with Down’s syndrome. J Ment Defic Res

Kroll RG, Budnick J, Kobren A. Incidence of dental caries and periodontal disease in Down’s syndrome. NY State Dent J

Tesini DA. Analysis of dental caries and periodontal disease in institutionalized and non-institutionalized mentally retarded individuals: the association with abnormal I.Q. level and institutional sta- tus (Master’s thesis #2708). Boston, MA: Tufts University, 1979. Tesini DA. Age, degree of mental retarda- tion, institutionalization and socioeco- nomic status of mentally retarded indi- viduals. Community Dent Oral Epidemiol

Silness J, Loe H. Periodontal disease in pregnancy. 11. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 22121-35,1964. Loe H, Silness J. Periodontal disease in pregnancy: I. Prevalence and severity. Acta Odontol Scand 21:533-51,1963. Loesche WJ, Clinical and microbiological aspects of chemotherapeutic agents used according to the specific plaque hypothe- sis. J Dent Res 58:2404-12,1979. Simonsen RJ. The preventive resin restorations: a minimally invasive, non- metallic restoration. Compend Contin

111203-8,1991.

57288-93,1986.

11:248-51,1991.

8:102-18,1964.

36:151-6,1970.

8:355-9, 1980.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35

Educ Dent 8:428-30,1987, Capute AJ. Developmental disabilities. Dent Clin North Am 18:557-77,1974. Sandler ES, Roberts MW, Wojcicki AM. Oral manifestation in a group of mentally retarded patients. J Dent Child 41:207-11, 1975. Goyings ED, Riekse DM. The periodontal condition of institutionalized children: improvement through oral hygiene. J Public Health Dent 28:5-15,1968. Snyder JR, Knopp JJ, Jordan WM. Dental problems of non-institutionalized mental- ly retarded children. Northwest Dent

Murray JJ, McLeod JP. The dental condi- tion of severely subnormal children in three London boroughs. Br Dent J

Brown RH, Cunningham WM. Some den- tal manifestations of Mongolism. Oral Surg 14:664-76,1961. Nowak AJ. The effects of dietary and brushing habits on the dental caries in noninstitutionalized handicapped chil- dren. J Dent Handic 3:15-9,1977. Wolf WC. Caries incidence in Down’s syndrome (Mongolism). J WI Dent SOC

Orner G. Dental caries experience among children with Down’s syndrome and their sibs. Arch Oral Biol20:627-34,1975. Steinberg AD, Zimmerman S. The Lincoln dental caries study: a three year evalua- tion of dental caries in persons with vari- ous mental disorders. J Am Dent Assoc

Shapira J, Eidelman E. Six year clinical evaluation of fissure sealants placed after mechanical preparation: a matched pair study. J Pediat Dent 8:204-5,1986. Charbeneau GT. Pit and fissure sealants. Int Dent J 32:215-22,1982. Straffon LH, Dennison JB. Clinical evalua- tion comparing sealant and amalgam after 7 years. Final report. J Am Dent

Bratel J, Berggren U. Long-term oral effects of manual or electric toothbrushes used by mentally handicapped adults. Clin Prev Dent 13:5-7,1991. Shaw L, Shaw MJ, Foster TD. Correlation of manual dexterity and comprehension with oral hygiene and periodontal status in mentally handicapped adults. Commun Dent Oral Epidemioll7187-9, 1989. Brown RH. A longitudinal study of peri- odontal disease in Down’s syndrome. New Zealand Dent J 74:137-44,1978.

39:123-33, 1960.

134~380-5,1973.

43:3-7, 1967.

97981-4,1978.

ASSOC 117751-5,1988.

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