Oral findings of Down syndrome children in Chennai city,... : Indian Journal of Dental Research (original) (raw)
Down syndrome (DS) is the most frequent chromosomal disorder manifested in newborns worldwide; the risk for this chromosomal aberration is one out of 600 to 1000 live births. DS has also been referred by the terms Trisomy 21, Trisomy G, or Mongolism. In 1838, Esquirol gave the first description of a child who probably had DS. In 1866 John H. Langdon Down published an article titled “Observation on an Ethnic Classification of Idiots” describing accurately some of the features of this syndrome that today bears his name.[1] In 1959, Jerome LeJeune and Patricia Jacobs independently determined that DS was caused by Trisomy of the 21st chromosome.[1]
Down syndrome is a congenital autosomal (non-sex chromosome) anomaly characterized by generalized growth and mental deficiency.[2] DS children have characteristic orofacial features. The most common oral findings in these children include mouth breathing, open bite, macroglossia, fissured lips and tongue, angular cheilitis, delayed eruption of teeth, missing and malformed teeth, microdontia, crowding, malocclusion, bruxism, poor oral hygiene, and low level of caries. Cohen et al. reported poor oral hygiene and abundant calculus and materia alba in DS children.[2] Gullikson found bruxism in 78.8% of the DS children examined.[3]
As there is no published data on the prevalence of the oral findings in DS children in Chennai city (South India), the present study was carried out with the following aims and objectives:
- To assess the oral soft and hard tissue findings of the children with DS including the anomalies
- To compare the age-wise and sex-wise distribution of the above findings.
MATERIALS AND METHODS
A descriptive cross-sectional study was planned to assess the oral soft and hard tissue findings of the children with DS in Chennai city. A total of 130 DS children were examined for the study. The children belonged to 15 special schools in Chennai city, India. All the children had been admitted in the school after prior investigations to confirm the syndrome. Consent was obtained both from the parents and the concerned school authority to carry out the study. All children aged 15 years and below (n = 102) were included in this study irrespective of their personal, medical, and dental history. A single examiner examined all the 102 children. The children were divided into three groups as seen in Table 1.
The examination was carried out with the children sitting on wooden or plastic chairs under an artificial light. Each participant was subjected to a clinical assessment using a flat dental mirror and an explorer [Figure 1]. The findings were recorded in a specially prepared proforma which had four sections. The proforma was prepared by the authors from the Department of Pedodontics, Meenakshi Ammal Dental College, Chennai. The first section of the proforma included a brief personal history and family history. Parents' age, consanguinity in parent's marriage, and incidence of the defect in the family were recorded. Oral hygiene practices of the children were elicited. Any anomalies of the oral cavity, both soft and hard tissues were examined and positive findings were recorded in the second section. Defects in occlusion and the temporomandibular joint were registered in the proforma in the third and fourth sections, respectively. The prevalence of all the findings was determined.
Age-wise comparisons of the findings between the three different groups were done and within the same age group, differences between the male and female sample were assessed. A comparison of each finding between the total male (n = 57) and female (n = 45) sample irrespective of their age group was also done. Proportions of different findings were estimated from the sample for each study group. Proportions were compared by either Chi-square test and Chi-square test with Yates continuity correction appropriately as explained below the tables. In the present study, P < 0.05 was considered as the level of significance.
RESULTS
Oral hygiene measures
It was found that only 16 out of the 21 (76.2%) children in group I had the habit of regular tooth brushing and all of them used tooth brush and tooth paste [Figure 2]. In group II, all the 41 (100%) children had the habit of regular tooth brushing and all of them used tooth paste. In group III, all the 40 (100%) children had the habit of regular tooth brushing and all of them used tooth paste. The percentage of use of toothbrush was also more in the older groups (II and III) when compared with group I (P = 0.004) as seen in Table 2.
Total sample distribution
Oral hygiene measures: Age wise comparison
Oral soft tissue anomalies [Tables 3 and 4]
In group I, pulled down angle of the mouth was seen in 81% of the sample (n = 17). Everted lower lip was evident in 52.4% of the sample (n = 11). Only one girl (4.8%) had chapped lower lip and a defect in the palate. Angular cheilitis was present only in one boy (4.8%) in group I. Fissured or scalloped tongue was seen in 14.3% of the sample (n = 3). Macroglossia was seen in 42.9% of the children (n = 9). It was found that 47.6% of children had the habit of protrusion or tongue thrusting (n = 10). Lip incompetence was seen in 9.5% of the children (n = 2). Enlarged tonsils were evident in six children (28.6%) and all of them were girls. Other anomalies like frequent ulcerations of oral mucosa and defects of lower lip accounted for 14.3% of the oral anomalies. There was a statistically significant difference in the presence of enlarged tonsils between the male and female category in group I (P = 0.046).
In group II, pulled down angle of the mouth was seen in 63.4% of children (n = 26). Everted lower lip was evident in 65.9% of the sample (n = 27). It was found that 19.5% of children had chapped lower lips (n = 8). Angular cheilitis was present in eight boys and four girls (29.3%). Defects in the palate were seen in 36.6% of the children (n = 15). Fissured or scalloped tongue was seen in 46.3% of the sample (n = 19). Macroglossia was seen in 68.3% of the children (n = 28). Thirty-nine of the children had the habit of protrusion or tongue thrusting (n = 16). Lip incompetence was seen in 4.9% of the children (n = 2). Enlarged tonsils were evident in 12.2% of the children (n = 5).
In group III, pulled down angle of the mouth was seen in 55% of the children (n = 22). Everted lower lip was evident in 72.5% of the sample (n = 29). Thirty percentage of children had chapped lower lips (n = 12). Angular cheilitis was present in five boys and five girls (25%). Defects in the palate were seen in 20% of the children (n = 8). Fissured or scalloped tongue was seen in 50% of the children (n = 20). Macroglossia was seen in 67.5% of the children (n = 27). Forty percentage of the children had the habit of protrusion or tongue-thrusting (n = 16). Lip incompetence was seen in 10% of the sample (n = 4). Enlarged tonsils were evident in 30% of the children (n = 12).
Defects in the palate and fissured tongue [Table 4] were found to be more common in groups II and III than group I (P = 0.02). Other anomalies like frequent ulcerations of oral mucosa and defects of lower lip were statistically more significant in group I than the other groups (P = 0.003).
Dental anomalies
In group I microdontia was seen in 9.5% of the children (n = 2; both in girls). Hypoplasia and partial anodontia (4.8% each) were seen in only one girl in group I. It was found that 14.3% of the children had crown variants (n = 3). Delayed eruption of primary teeth was evident in 8.6% of the children (n = 2; both in girls). It was found that 23.8% of children had spacing between the teeth (n = 5). Delay in the eruption of primary teeth showed a statistically significant difference (P = 0.046) between the male and female category in group I [Table 5].
In group II, microdontia was seen in 9.8% of children (n = 4). Hypoplasia (4.9%) was seen in two boys and none of the girls had this defect. Partial anodontia was seen in 9.8% of the sample (n = 4). It was found that 12.2% of the children had crown variants (n = 5). Delayed eruption of primary teeth and supernumerary teeth were not evident in this sample of children. It was found that 29.3% of the children had delayed eruption of permanent teeth (n = 12). Retained deciduous teeth were seen in 1.7% of the children (n = 13). Twenty-two of the children had spacing between the teeth (n = 9).
In group III, microdontia was seen in 27.5% of the children (n = 11). Hypoplasia (10%) was seen in two boys and two girls. Partial anodontia was seen in 12.5% of the children (n = 5). Twenty-five percentage of the children had crown variants (n = 10). Delayed eruption of primary teeth and supernumerary teeth were not evident in this sample of children. Forty percentage of the children had delayed eruption of permanent teeth (n = 19). Retained deciduous teeth were seen in 47.5% of the children (n = 19). Twenty percentage of the children had spacing between the teeth (n = 8).
A statistically significant difference was found in the presence of retained deciduous teeth and delay in eruption of primary and permanent teeth as seen in Table 6. Delayed eruption of primary teeth was found only in group I (P < 0.0001). Delayed eruption of permanent teeth (P = 0.004) and retained deciduous teeth (P = 0.0007) were more common in groups II and III than group I. Sex wise comparison of the dental anomalies examined between the total male and female samples showed no statistical significant difference in any of the findings except delay in primary teeth eruption [Table 6].
Oral soft tissue anomalies: Age wise comparison
Occlusion anomalies
In group I, malalignments were seen in 19% of the children (n = 4). Nineteen percentage of the children had attrition and tooth wear (n = 4). Midline deviation was seen in 19% of the sample (n = 4; all were girls). Anterior open bite was present only in 4.8% of the sample (n = 1; one boy). It was found that 33.3% of the children had anterior crossbite (n = 7). Midface deficiency was seen in 71.4% of the sample (n = 15). Only one girl (4.8%) had posterior crossbite in group I. Mandibular prognathism was evident in 47.6% of the children (n = 10).
In group II, malalignments were seen in 41.5% of the children (n = 17). Twelve children (29.3%) had attrition and tooth wear. Midline deviation was seen in 4.9% of the sample (n = 2). Anterior open bite was present in 34.1% of the children (n = 14). It was found that 36.6% of the children had anterior crossbite (n = 15). Midface deficiency was seen in 82.9% of the sample (n = 34). Posterior crossbite was seen in 4.9% of the sample (n = 2). Mandibular prognathism was evident in 51.2% of the children (n = 21).
In group III, malalignments were seen in 55% of the children (n = 22). Three children (7.5%) had attrition and tooth wear and all three of them were boys. Midline deviation and anterior open bite [Figure 3] were seen in 10% (n = 4) and 32.5% (n = 13) of the children. Twenty children (15 boys and 5 girls) had anterior crossbite [Figure 4]. Midface deficiency [Figure 5], posterior crossbite and mandibular prognathism were seen in 70%, 32.5%, and 55% of the children.
An age wise comparison of the occlusion anomalies between the three groups showed that there was statistically significant difference in the occurrence of malalignments, anterior open bite and posterior crossbite, and in the presence of attrition and wear facets [Table 7]. Malalignments and anterior open bite (P = 0.03) were more evident in groups II and III than group I. Posterior crossbite (P = 0.0009) was more common in group III than the other two groups. Attrition and wear facets were more significantly seen in group II than groups I and III (P = 0.04) [Table 8].
Temporomandibular joint anomalies
In group I, deviation was seen in 9.5% of the children (n = 2; both were girls). In group II, deviation of the joint was seen in 2.4% of the sample (n = 1; one boy). In group III, 5% of the children (n = 2) had deviation of the joint. None of the children in the total sample had any pain, clicking and restriction in joint movement. An age wise and sex wise comparison of the temporo mandibular joint (TMJ) findings revealed no statistically significant difference (results not shown).
DISCUSSION
Oral hygiene measures
All the children examined had the habit of brushing at home under parental supervision or the parents did the brushing for them. Shyama et al. concluded that supervised tooth brushing program was effective in reducing plaque and gingivitis scores in DS in Kuwait.[4] Poor muscular coordination and parent's low education and care could be the reason for reduced usage of tooth brush in the younger age groups. As the plaque scores are not quantified, the efficiency of plaque removal cannot be interpreted from this study.
Oral soft tissue anomalies: Sex wise comparison
Dental anomalies: Age wise comparison
Dental anomalies: Sex wise comparison
Armamentarium
Poor oral hygiene and severe gingivitis
Anterior open bite
Anterior crossbite with bilateral posterior crossbite
Midface deficiency, incompetent lips with tongue thrusting habit
Oral soft tissue anomalies
Cohen and Winer observed that secondary local factors such as tongue thrusting and lack of lip seal could contribute to the development of periodontal disease.[5] In this study, it was found that most of the children with incompetent lips had severe gingival and periodontal problems [Figure 2]. Hennequin M et al. assessed the oral health problems in a sample of children with DS (204) and compared it with their siblings (161). The prevalence of chewing problems did not improve with age and the prevalence of bleeding gums and mouth breathing increased with age. The prevalence of tongue protrusion reduced with age.[6] This finding is in agreement with our study where the percentage of tongue thrusting reduced from 47.6% in group I to 39% in group II and 40% in group III. Scully et al. investigated the prevalence of orofacial soft tissue lesions in a group of 77 DS patients. The incidence of angular cheilitis and lip fissure appeared to be increased in DS patients.[7] In the present study, angular cheilitis was seen in 22.5% of total sample and chapped lower lips were evident in about 20.6% of the total sample.
Dental anomalies
Borea et al. clinically examined 50 DS children (30 males, 20 females; average age 12 years). Delay in eruption was seen in 19% of the female patients and 53% of the male patients.[8] The delay in eruption in the present study was more common in the boys (31.6%) than in the girls (22.2%) and it is in accordance with their study.
Occlusion anomalies
Cohen and Winer recorded Angle's class-III malocclusion in 30% and open bite in 4.8% of DS subjects. In this study, anterior open bite was evident in 27.5% of the total sample and the probable reason for the increase in percentage of anterior open bite could be attributed to the increased percentage of tongue thrusting habit (41.2%) in these children. Gullikson found bruxism in 78.8% of the DS children, but in this study the percentage of children with attrition of teeth is comparatively less (18.6%). Macroglossia, tongue thrusting habit and open bite could be the possible reasons for reduced tooth wear. In this study, malalignments were evident in 19% of the sample in group I and it increased to 41.5% and 55%, respectively, in groups II and III. The percentage of malalignments was found to increase with age and the results were in accordance with the study by Ondarza. A.[9] Cornejo et al. evaluated the oral health condition of children and youngsters with DS (total - 86; both the sexes in the age range of 3-19 years) and compared with control groups. The samples in their study exhibited a high frequency of retarded eruption, agenesis, Angle's type III malocclusion, posterior cross bite, and deficient gingival health.[10] In this study, mandibular prognathism was seen in 52% of the total sample and posterior crossbite was evident in 15.7% of the total sample and hence these results were in accordance with their study.
Occlusion anomalies: age wise comparison
Occlusion anomalies: Sex wise comparison
SUMMARY AND CONCLUSIONS
This study is one of the few studies, which has involved and examined more than 100 DS children. We have offered to treat all the children examined free of cost in our dental college. The following conclusions were derived from the results of this study:
- Tooth brushing was more evident among the older age groups (groups II and III) than the younger age group (group I).
- The commonest oral soft tissue anomaly evident was everted lower lips.
- Retained primary teeth were the most common dental anomaly found in this study.
- The most common occlusion anomaly in this study was midface deficiency.
- Deviation of the temporomandibular joint was seen in 5 children - 4.9% of the total sample.
REFERENCES
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2. Cohen MM, Winer RA, Shklar. Periodontal disease in a group of mentally subnormal children J Dent Res. 1960;39:745
3. Gullikson JS. Oral findings in children with Down's syndrome J Dent Child. 1973;40:293–7
4. Shyama M, Al-Mutawa SA, Honkala S, Honkala E. Supervised toothbrushing and oral health education program in Kuwait for children and young adults with Down syndrome Spec Care Dent. 2003;23:94–9
5. Cohen MM, Winer RA. Dental and facial characteristics in Down's syndrome J Dent Res. 1965;44:197–209
6. Hennequin M, Allison PJ, Veyrune JL. Prevalence of Oral health problems in a group of individuals with Down syndrome in France Dev Med Child Neurol. 2000;42:691–8
7. Scully C, Van Bruggen W, Diz Dios P. Down syndrome: Lip lesions (angular cheilitis and fissures) and candida albicans Br J Dermatol. 2002;147:37–40
8. Borea G, Magi M, Mingarelli Zamboni C. The oral cavity in Down syndrome J Pedod. 1990;14:139–40
9. Ondarza A, Jara L, Bertonati MI, Blanco R. Tooth malalignments in Chilean children with Down syndrome Cleft Palate Craniofac J. 1995;32:188–93
10. Cornejo LS, Zak GA, Dorronsoro de Cattoni ST, Calamari SE, Azcurra AI, Battellino LJ. Mucodental health condition in patients with Down syndrome of Cordoba City, Argentina Acta Odontol Latinoam. 1996;9:65–79
Keywords:
Down syndrome; oral findings; Trisomy 21
© 2008 Indian Journal of Dental Research | Published by Wolters Kluwer – Medknow