Dental caries prevalence and treatment needs of

ORIGINAL RESEARCH Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India Sharath Asokan, Muthu MS, Sivakumar N

Department of Pediatric Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India

Received Review completed Accepted PubMed ID

: : : :

ABSTRACT

02-08-07 27-12-07 28-12-07 18797099

Purpose: To assess the prevalence of caries and the treatment needs of Down syndrome children in the Indian city of Chennai. Materials and Methods: Among the130 Down syndrome children examined, only the children aged ≤15 years were included in the study (n = 102). There were 57 male and 45 female children in the total study sample. A specially prepared case record was used to record the findings for each child. The dentition status and the treatment needs required were recorded. Comparisons of the findings were done based on age and gender distribution. Results: Twenty-nine per cent of the total sample of Down syndrome children was found to be caries-free. Extraction (in 38 children) and one-surface filling (in 26 children) were the most needed specific treatments for primary and permanent teeth, respectively. Oral prophylaxis (99%) was the most required treatment in the overall treatment category. Conclusions: Contrary to the findings of earlier studies, the percentage of caries-free Down syndrome children was found to be lower in our study. However, their basic needs like oral prophylaxis, restorations and extractions remain the same and can be easily fulfilled by an efficient, community-based dental team. Key words: Dental caries prevalence, Down syndrome, Trisomy 21

Down syndrome is a congenital autosomal anomaly characterized by generalized growth and mental deÞciency.[1-2] The risk for this chromosomal aberration is one out of 600-1000 live births. Approximately 95% of Down syndrome cases have the extra chromosome 21, resulting in a chromosome count 47 instead of the normal 46. The other 5% of chromosomal abnormalities include translocation (3%) and mosaicism or partial trisomy (2%). Down syndrome has also been referred to by the terms Trisomy 21, Trisomy G or Mongolism.[1]

Stabholz et al, showed that 84% of the Down syndrome children examined were caries-free.[8] As no published data is available on the prevalence of caries and treatment needs of Down syndrome children in the South Indian city of Chennai, this study was planned with the following aims and objectives: 1. To assess the prevalence of dental caries and treatment needs of children with Down syndrome. 2. To compare the age-wise and sex-wise distribution of the above Þndings.

Down syndrome children have characteristic orofacial features. The most common oral Þndings in these children include mouth breathing, open bite, macroglossia, Þssured lips and tongue, angular cheilitis, delayed eruption of teeth, missing and malformed teeth, microdontia, crowding, malocclusion, bruxism, poor oral hygiene and a low level of caries.[3-5]

MATERIALS AND METHODS

Brown and Cunningham showed that 44% of the Down syndrome children they examined were caries-free.[6] Johnson and Young reported a low incidence of dental caries both in the primary and permanent dentition.[7] Correspondence: Dr. Sharath Asokan, E-mail: [email protected] Indian J Dent Res, 19(3), 2008

A descriptive cross-sectional study was planned to assess the status of dental caries in children with Down syndrome in Chennai. A total of 130 Down syndrome children were examined in this study. The children belonged to 15 special schools in Chennai. All the children had been admitted to the school after prior investigations to conÞrm the syndrome. Consent was obtained both from the parents and the concerned school authority to carry out the study. Only children aged ≤15 years (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 assigned to three groups as mentioned in Table 1. 224

Asokan, et al.

225

11.4 133 29.0 320 9.1 74 49.8 109 16.9 59 34.0 192 0 0 19

5.9

88.6 1031 71.0 84 90.9 740 50.2 110 83.1 291 66.0 373 0 0

*Chi-square test was used to calculate the P value

Prevalence of dental caries: In group I (n = 13), 94.1% of all

Decayed teeth

RESULTS

94.1

Age-wise comparisons of the Þndings were done among the three different groups and within the same age group; differences between the male and female samples were assessed. A comparison of each Þnding between the total male (n = 57) and female (n = 45) samples, irrespective of their age group was also done. The proportions of different Þndings were estimated from the sample for each study group. Proportions were compared by using either the Chi-Square test or Chi-Square test with Yates continuity correction, as explained in the footnotes below the tables. In the present study, P < 0.05 was considered as the level of signiÞcance.

Table 2(a): Dental caries prevalence - age-wise comparison

Radiographs and other investigations like pulp vitality tests were not carried out because of the lack of facilities and all the Þndings recorded were based on clinical judgment. The total numbers of sound and decayed primary and permanent teeth in each group were counted and the percentages of decayed and sound teeth calculated. The percentage of caries-free children in each group was also calculated.

Total 11 to 15 years (40) Primary Permanent (219) (814) n % n %

The examination was carried out with the children sitting on wooden or plastic chairs under an artiÞcial light. Each participant was subjected to a clinical assessment using a ßat dental mirror and an explorer. The Þndings were recorded in a specially prepared proforma prepared by the authors from the Department of Pedodontics, Meenakshi Ammal Dental College, Chennai. The status of the dentition and the treatment needs were recorded using the WHO oral assessment criteria (1997). Each tooth was examined and the status was deÞned by numbers for permanent teeth and by letters of the English alphabet for primary teeth. The teeth were marked as sound, decayed, Þlled with decay, Þlled with no decay, missing due to caries, missing due to other reasons, Þssure-sealed, unerupted, bridge abutment/crown/ veneer or traumatized, as recommended by the WHO. SpeciÞc treatment needs included preventive caries arresting care, Þssure sealant, one-surface Þlling, two or more surface Þllings, crowns, veneers/laminates, pulp care restoration and extraction. These speciÞc needs were marked in numbers except for Þssure sealant and preventive caries arresting care, which were marked as ‘F’ and ‘P’, respectively. The overall treatment required was categorized in the last section under the following headings: oral prophylaxis, ßuoride therapy, restorative treatment, extractions, and orthodontic correction.

301

Total (102) Primary Permanent (1104) (1164) n % n %

P*

Total 21 41 40 102


Female 13 16 16 45


Male 8 25 24 57

Particulars

Group I: 0 to 5 years Group II: 6 to 10 years Group III: 11 to 15 Years Total

Sound teeth

Table 1: Total sample distribution

Primary < 0.0001 Permanent 0.0002

Caries prevalence and treatment needs in down syndrome

Indian J Dent Res, 19(3), 2008


Asokan, et al.

Table 2(b): Dental caries prevalence - age-wise comparison Particulars

0 to 5 years (21) n % 13 61.9 8 38.1

Caries-free children Children with caries

6 to 10 years (41) n % 6 14.6 35 85.4

11 to 15 years (40) n % 11 27.5 29 72.5

n 30 72

Total (102) % 29.4 70.6

P* 0.0005


Table 3(a): Dental caries prevalence - sex-wise comparison Particulars

Sound teeth Decayed teeth

Total male (57) Primary Permanent (621) (688) n % n % 438 70.5 626 91.0

Total female (45) Primary Permanent (483) (476) n % n % 346 71.6 405 85.1

Total (102) Primary Permanent (1104) (1164) n % n % 784 71.0 1031 88.6

Primary 0.74

183

137

320

Permanent 0.003

29.5

62

9.0

28.4

71

14.9

29.0

133

11.4

P*


Table 3(b): Dental caries prevalence - sex-wise comparison Particulars

Caries-free children Children with caries

Total male (57) n % 16 28.1

Total female (45) n % 14 31.1

Total (102) n % 30 29.4

41

31

72

71.9

68.9

70.6

P*

0.91


primary teeth and 61.9% of the children were caries-free. In group II (n = 6), 66% of all primary teeth, 83.1% of all permanent teeth and 14.6% of the children were caries-free. There was a signiÞcant difference in the prevalence of caries in primary teeth between the male and female samples in group II (P = 0.04). In group III (n = 11), 50.2% of all primary teeth, 90.9% of all permanent teeth and 27.5% of the children were caries free. There was a signiÞcant difference in the prevalence of caries in permanent teeth between the male and female categories in group III (P = 0.003). An age-wise comparison showed a signiÞcant difference in the prevalence of caries in primary (P < 0.0001) and permanent teeth (P = 0.0002) between the different age groups [Table 2a]. A signiÞcant difference in the percentage of caries-free children was also evident among the three groups (P = 0.0005) [Table 2b]. In the total sample, 71% of primary teeth (n = 784), 88.6% of permanent teeth (n = 1031) and 29.4% of the thirty children in this sample, were caries-free. There was a signiÞcant difference in the prevalence of caries in the permanent teeth of the male and female categories of the total sample (P = 0.003) as seen in Table 3a. There was no signiÞcant difference in the prevalence of decay in primary teeth and in the percentage of caries-free children between the male and female subsets of the total sample [Table 3b]. Specific treatment needs: In group I, 23.8 and 4.8% of the children needed one-surface and two-surfaces fillings, respectively for their primary teeth. In the same group, 9.5% of the children needed crown and preventive restorations for their primary teeth and 4.8% needed pulp care. Extraction Indian J Dent Res, 19(3), 2008

and Þssure sealants were not needed by any of the children belonging to this group. In group II, one-surface Þllings were required for primary and permanent teeth in 43.9 and 26.8% of the children, respectively. In the same group, two-surfaces Þllings were needed for primary and permanent teeth in 24.4 and 4.9% of the children, respectively. Pulp care therapy and crowns were required in the primary teeth of 14.6% of the children. Extractions were required in the primary and permanent teeth of 48.8 and 2.4% of the children respectively, and Þssure sealants by 14.6% of the children on their permanent teeth. Primary and permanent teeth required preventive restoration in 36.6 and 26.8% of children, respectively. In group III, 25 and 37.5% of the children needed one-surface Þllings for their primary and permanent teeth, respectively. Much lower percentages were seen (17.5 and 5%) for twosurface Þllings in primary and permanent teeth, respectively. Crowns and pulp care were needed for primary teeth in 5 and 10% of the children, respectively. More children (40%) needed primary teeth extraction than permanent teeth extraction (2.5%). Fissure sealants were needed on permanent teeth in 17.5% of the children. Preventive restorations were needed for primary and permanent teeth in 7.5 and 27% of the children, respectively. There was no signiÞcant difference in the speciÞc treatment required for both primary and permanent teeth between the male and female categories of groups I, II and III. An age-wise comparison of treatment needs showed signiÞcant differences in the speciÞc treatment required for primary teeth in different age groups [Table 4]. Extraction of teeth was required more in group II and III than in group I children (P = 0.0004). Preventive restorations were needed more by the children in group II than the other two groups (P = 0.002). Treatment for permanent teeth did not show any signiÞcant difference among the children of different age groups. There was no signiÞcant difference in the speciÞc treatment required for both primary and permanent teeth between the male and female categories of the total sample [Table 5]. 226

0.43 1 1 0.86 0.96 0.12 0.16 0.004 0.48 0.0004 0.002 -

In group II, oral prophylaxis and ßuoride therapy were needed in 100 (n = 41) and 85.4% (n = 35) of the children, respectively. Restorative treatment and orthodontic corrections were required in 70.8 (n = 32) and 53.7% (n = 22) of the children, respectively. Unlike group I, 48.8% of the children (n = 20) required extraction.

Total 11 to 15 years (40) Primary Permanent n % n % 10 25.0 15 37.5 7 17.5 2 5.0 2 5.0 0 0.0 4 10.0 0 0.0 18 45.0 1 2.5 3 7.5 11 27.5 0 0.0 7 17.5

Similar to group II, oral prophylaxis and ßuoride therapy were needed in 100 (n = 40) and 85% (n = 34), respectively, of the children in group III. Restorative treatment and orthodontic corrections were required in 72.5 (n = 29) and 53.7% (n = 33) of the children, respectively. Similar to group II, 50% of the children (n = 20) required extraction. There was no signiÞcant difference in treatment needs between the male and female categories of groups I, II and III. An age-wise comparison of the treatments required in different age groups however, showed a signiÞcant difference [Table 6]. Fluoride therapy ( P < 0.0001), restorations ( P = 0.001), extractions ( P = 0.0002) and orthodontic treatment (P = 0.0004) were needed more by the older children (groups II and III) than the younger children (group I). Orthodontic treatment was comparatively more necessary in group III than in group II children. There was no signiÞcant difference in the treatment needs between the male and female categories of the total sample [Table 7].

Total 6 to 10 years (41) Primary Permanent n % n % 18 43.9 11 26.8 10 24.4 2 4.9 6 14.6 0 0.0 6 14.6 0 0.0 20 48.8 1 2.4 15 36.6 11 26.8 0 0.0 6 14.6

DISCUSSION


One-surface filling Two-surfaces filling Crown Pulp care Extraction Preventive restoration Fissure sealant

Total 0 to 5 years (21) Primary Permanent n % n % 5 23.8 0 0 1 4.8 0 0 2 9.5 0 0 1 4.8 0 0 0 0.0 0 0 2 9.5 0 0 0 0.0 0 0 Particulars

Table 4: Specific treatment needs - age-wise comparison 227

Asokan, et al.

Overall treatment required: In group I, oral prophylaxis and ßuoride therapy were needed in 95.2 (n = 20) and 28.6% (n = 6) of the children, respectively. Restorative treatment and orthodontic corrections were each required in 33.3% (n = 7) of the children. No child in this group however, needed extraction.

Total (102) Primary Permanent n % n % 33 32.4 26 25.5 18 17.6 4 3.9 10 9.8 0 0.0 11 10.8 0 0.0 38 37.3 2 2.0 20 19.6 22 21.6 0 0.0 13 12.7

Primary

P* Permanent


Brown and Cunningham (1961) examined 80 institutionalized Down syndrome individuals (1-39 years) and found that 44% of the sample was caries-free. Stabholz et al, examined the prevalence of dental caries in 32 Down syndrome children, aged 8-13 years and found 84% of them to be caries-free. Barnett et al, compared the prevalence rates of periodontitis and dental caries in 30 Down syndrome patients and 30 matched, mentally handicapped controls. The results revealed a greater prevalence of periodontitis and a lower prevalence of dental caries in Down syndrome patients compared to the mentally retarded controls.[9] Morinushi et al, conducted a study in 1995 to evaluate the incidence of dental caries in 75 Down syndrome children in the age group of 2-18 years. They found 46.1% of these children with 61.4% of children below the age of Þve years to be caries-free.[10] The Þndings of our study however, differ from those of the above studies. Our results showed a lower percentage Indian J Dent Res, 19(3), 2008


Asokan, et al.

Table 5: Specific treatment needs - sex-wise comparison Particulars

One-surface filling Tw-surfaces filling Crown Pulp care Extraction Preventive restoration Fissure sealant

Male (57) Primary Permanent n % n % 18 31.6 14 24.6 10 17.5 2 3.5 6 10.5 0 0.0 5 8.8 0 0.0 20 35.1 1 1.8 11 19.3 12 21.1

Female (45) Primary Permanent n % n % 15 33.3 12 26.7 8 17.8 2 4.4 4 8.9 0 0.0 6 13.3 0 0.0 18 40.0 1 2.2 9 20.0 10 22.2

Total (102) Primary Permanent n % n % 33 32.4 26 25.5 18 17.6 4 3.9 10 9.8 0 0.0 11 10.8 0 0.0 38 37.3 2 2.0 20 19.6 22 21.6

0

0

0

0.0

8

14.0

0.0

5

11.1

0.0

13

12.7

Primary

P* Permanent

0.98 0.82 1 0.53 0.76 0.87

0.99 1 1 0.92

-

0.89


Table 6: Treatment required - age-wise comparison Particulars Oral prophylaxis Fluoride therapy Restoration Extraction Orthodontic treatment

Total (102) n % 101 99.0 75 73.5 68 66.7 40 39.2 62 60.8

0-5 years (21) n % 20 95.2 6 28.6 7 33.3 0 0.0 7 33.3

6-10 years (41) n % 41 100.0 35 85.4 32 78.0 20 48.8 22 53.7

11-15 years (40) n % 40 100.0 34 85.0 29 72.5 20 50.0 33 82.5

P* 0.14