According to numerous publications, the degree of intellectual impairment amongst patients with Down syndrome varies greatly between mild to moderate impairment. It is therefore crucial that the techniques used to shape and modify the patient’s behaviour, is tailored to suit his/her intellectual deficit and that it remains age appropriate.
It is understood that good communication is a vital aspect in ensuring patient cooperation. Therefore, to facilitate communication, attaining consent, and ultimately patient cooperation, it is advised that the primary caregiver be encouraged and allowed to be present and participate in the consultation and treatment process.
Ways in which the patient’s behaviour can be managed/shaped include scheduling appointments for earlier rather than later in the day. This ensures that the waiting time is at a minimal and that everyone involved in the consultation/treatment process is alert and attentive. Furthermore, the dental team and everyone involved, including the receptionist, needs to be as friendly and caring as possible, ensuring that the patient feels loved and welcome, which in tern sets the stage for successful treatment. It is also beneficial to ensure that the environment in which oral care will be performed does not provide distractions, but rather limits unnecessary sounds, sights, and other stimuli. However, playing soft background music has proven beneficial in comforting patients with Down syndrome. The consultation and treatment process needs to be planned in a step by step manor and be sure to explain each step prior to commencement. Introduce and explain everything in appropriate fashion, as to not startle or frighten the patient in any way. The way in which the appointment and subsequent appointments are carried out need to be kept consistent. By using the same personnel and modus, familiarity is established, ensuring better patient cooperation. Ensure to always compliment good behaviour/cooperation throughout the appointment and be very comforting if things do not go as planned and oral care is met with resistance.
The age old saying, “prevention is better than cure”, could never be truer when it comes to treating medically compromised patients, and is a fundamental aspect within any treatment approach. This involves consistent and extensive oral hygiene motivation, pit and fissure sealants, topical fluoride application and mechanical debridement and prophylaxis, commonly known as a ‘scale and polish’. Delayed fine motor skills/function and reduced muscle tone is a common fining amongst patients with Down syndrome, and results in reduced coordination and strength. Therefore, it is important that oral hygiene be performed by the primary caregiver, until the patient acquires the adequate skill.
With regards to conservative restorative treatment, all methods and modalities are indicated. Developmental defects of dentine and erosion lesions are common, and it is essential that these receive adequate attention. Treatment plans which include any form of pulp therapy, i.e. Root canal treatment or pulpotomies, should be avoided due to the high incidence of congenital heart defects amongst patients with Down syndrome.
There is a characteristic malocclusion in the dentition of patients with Down syndrome. However, the orthodontic treatment and correction of this malocclusion is often problematic due to low levels of patient compliance and mental instability. High levels of failure and an increase in the prevalence of dental decay and periodontal disease is common in Down syndrome patients receiving orthodontic treatment, and therefore should be avoided as far as possible.
General anaesthesia can be used to assist the successful treatment of a patient with Down syndrome. However, the physical and medical associations and manifestations of Down syndrome is important to note, as it could have implications on general anaesthesia. Chronic respiratory conditions and spinal cord damage, which are commonly associated with Down syndrome, may lead to pre-operative morbidities. It is therefore essential that a comprehensive consultation and examination be done in conjunction with the anaesthetist prior to general anaesthesia.
As mentioned before, congenital heart defects are a common finding amongst patients suffering from Down syndrome. These defects increase the risk of developing infective endocarditis, a rare but potentially fatal condition, and therefore requires special dental care. Studies have shown that poor oral health and the treatment needed to correct it can be positively correlated to an increase in the susceptibility to developing infective endocarditis. The importance then of good oral hygiene and regular dental check ups in patients with Down syndrome is highlighted.
Written by Dr Ruan Fourie