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

Abstract

Introduction:

It was observed that compared to the general population, mentally challenged subjects have higher rates of poor oral hygiene. Gingivitis is a common finding with moderate or severe variety reported most commonly. Periodontal 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 oral health need.

INTRODUCTION

Down 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 system deficiency, poor oral hygiene, delicate periodontal 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 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 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].

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 tissue	Tongue lesions	6 (85.7)	15 (78.9)	15 (93.8)	12 (85.7)	0.670	9 (81.8)	39 (86.7)	0.680
	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 tissue	Palate abnormalities	3 (42.9)	6 (31.6)	7 (43.8)	1 (7.1)	0.141	4 (36.4)	13 (28.9)	0.629
	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

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 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 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.