User:Dent g14/sandbox

Down’s syndrome is a genetic condition that delays cognitive ability, mental retardation (average IQ of 50), physical growth and facial characteristics and it is one of the most common genetic causes of learning impairment which occurs approximately one in every 800 live births. This is the result from individuals that have the presence of an extra chromosome (47 instead of the usual 46). There are three types of Down's syndrome: Trisomy 21, Translocation and Mosaicism. 95% of the population that has Down's syndrome has Trisomy 21, 3% has translocation and Mosaicism accounts for 2% of the known cases of Down’s syndrome.

Oral  findings  in  patients  with  Down  syndrome

There are several differences that can be found with patients diagnosed with Down’s compared to a healthy adult. One of the pronounced findings a dentist can see during an intraoral examination is macroglossia, a disorder in which the tongue is larger than normal. This can cause some difficulty for the dentist to not only examine the teeth but also during dental procedures  e.g removing plaque or calculus lingually as the tongue may obstruct their view or getting in the way of the dental instruments. To manage this, the dentist can ask the patient to relax their tongue as some patients have strong tongue thrust and ask the nurse to retract the tongue using the tip of the fast suction. Other findings that can be found are: hypodontia, microdontia and periodontal disease. This can be shown during teeth charting where the lower 5s are missing bilaterally which are common in hypodontia cases. Furthermore, oral hygiene is poor as there are visible soft plaque and calculus lower incisor region. When a Basic Periodontal Examination was done, the patient scores 2’s in all sextants apart from a 3 at the lower anterior sextant which shows that the patient has generalised gingivitis and localised periodontitis in the lower anterior sextant.

Relationship between periodontal disease and Down syndrome

Periodontal diseases are caused by a shift in the balance of the resident microflora and an inflammatory immune response to it in the oral cavity. Both dental biofilms and Non- dental biofilms factors can induce periodontal disease. Dental biofilms are known as dental plaque and mature to become calculus. Examples of non-dental biofilm factors are inflammatory/ immune responses, reactive processes, genetic/developmental disorders. Patients with Down’s are associated with low saliva flow rate, low salivary pH and an impairment of their immunological system. The immunity of down’s shows that there are reduced amounts of immunoglobulin A in saliva, neutrophil chemotaxis and decreased amounts of T and B cell counts. Lack of these important immune cells along with other external factors such as poor compliance of dental hygiene or other common Down’s underlying disorders such as diabetes does not help with their periodontal health therefore causing them to have higher persistence of microbial shift. Increase inflammatory mediators such as interleukin-1, interleukin-6, tumour necrosis factor alpha and prostaglandins induces osteoclastogenesis which results in alveolar bone loss. Hence, this increases the incidence of developing periodontal disease. In Down’s the severity of periodontal disease advances rapidly throughout their life if not treated, it can cause loss of periodontal attachment, alveolar bone loss, and severe gingival inflammation. These may be the cause of the lower 1s Grade 1 mobility.

The capacity assessment and consent process

Patient’s consent is when a permission is given before patients receive any type of examination or treatment. Informed consent can be done verbally, written and implied. Dentists have to assess the patient’s capacity first, whether patients are able to comprehend and retain information to the decision keeping in mind the consequences of having or not having the treatment during the decision making process. There are a few questions that the dentist can ask themselves to assess the patient’s capacity: 1. Does the patient have all the relevant information to make a decision?, 2. If they have decided, have they been informed on the alternatives? 3. Were the information given needed to be presented in an easier way for them to understand? 4. Apart from verbal communication, were there any other methods used? 5. Are there/were there anyone that helped with communication? E.g interpreter 6. Were there specific times of the day or specific locations when the person could understand better? 7. Could the decision be put off to check if the patient can make the right choice when circumstances are right for them? Dentists have to respect the patient’s autonomy, consent has to be voluntary and the decision cannot be affected by the pressure from others. A shared decision making whereby the patient reaches a decision supported by a health care professional considering their interests, value and evidence-based research. It is important that during a shared decision making, dentists should discuss all the different treatment options avoiding dental jargon to prevent confusion, risk and benefits, double check the patient's understanding, give the patient time to consider their decision and most importantly document the discussion that they had with the patient. As the 26 year old patient is diagnosed with Down Syndrome with moderate learning disability and anxious during the dental visit, it is likely that he has an impaired capacity and hence, he is an incompetent adult who unable to give an informed consent. Therefore, it will be possible to appoint personal guardians who will be able to make decisions on his behalf, who in this case would be his mother or his appointed carer provided with the valid documents.

Short term management and options for providing treatment

Since the patient is anxious and nervous it will be good to start with gaining their trust/rapport and build a relationship with them. A non- pharmacological behaviour management can be introduced. Examples of these can be voice control: where a controlled alteration of voice, volume, tone or pace to influence and direct his behaviour, another could be behaviour shaping and positive reinforcement: this is can be done by selective reinforcement where facial expression, positive voice modulation, verbal praise are given when the patient is in a good behaviour. Gaining a patient's trust or calming the patient down takes time and should not be rushed.

Next reassure his mother about the mobility of lower incisors that it is not related to Down’s syndrome per se but due to the periodontal health of her child, leave and monitor and would take IOPA radiographs of the lower incisors when the patient is cooperative for radiographs. In addition, lateral oblique jaw view technique can be used to assess interproximal caries of the posterior teeth.

Do supragingival scaling, polishing Quadrant scaling, root surface debridement of the lower anteriors without local anaesthesia first and If the patient cannot tolerate the procedure then LA should be introduced. When choosing a local anaesthetic, I would note on giving scandonest instead of lignocaine as even though the patient does not have a past medical history of cardiovascular disorders. This is because 45%- 50% of patients diagnosed with Down’s syndromes have congenital cardiac disorders. Since the patient is not cooperative for radiographs he is also likely that he is not to be cooperative for this, therefore I would suggest the treatment to be done under respiratory anaesthesia. Oral hygiene instruction focusing on bass technique and using soft bristles 2 minutes, 30 seconds per quadrant, spit don’t rinse, twice daily most importantly last thing before going to bed. Interdentally, floss/interdental brushes/single tuft brushes (whichever most comfortable) can be introduced.Present Oral Hygiene instruction to both mother and patient using the Tell Show Do technique. Prescribe 2800ppm fluoride toothpaste, and Corsodyl Daily Defence which contains 0.06% Chlorhexidine and Digluconate 0.0553% sodium fluoride (250ppm) and advise to use 1 or 2 times daily at least 1 hour before/after toothbrushing.

Application of fissure sealant onto the upper and lower posterior teeth, and if the patient isn’t cooperative with the procedure (might be due to difficulty of moisture control, use dry tip), an alternative could be just using Duraphat fluoride varnish 22600 ppm for the meantime and advise the patient and his mother that he cannot drink or eat for the next 30 min.

Diet advice should be given as well. Snacks, biscuits and fizzy drinks that he is having at the day care should be limited within meal times. Even though the mother stated that he has a low cariogenic diet, a diet diary should be given to the mother to track what the patient’s diet is like. It helps the dentist to analyse what type of food or drinks that the patient takes. A diet diary consists of 1 week or 2 weekdays and 1 weekend days with specific times where food/drink can be noted down. Advise on hidden sugars in foods/drinks and to avoid them and set alternatives should be given. The mother could speak to the carers at the day centre about this.

Long term management

Oral hygiene instructions as well as diet advice must be reinforced every visit. The white spot lesions on the buccal surface of the upper central incisors can fade away if a patient follows good oral/dental hygiene as these will go through slow remineralisation and this can be improved in 6 months.

Desensitisation techniques to be used each visit on local anaesthesia handpieces, suction and radiographs (X-ray holders and intraoral film), breathing techniques also can be introduced to manage his anxiety and nervousness. When he is classified as cooperative, fissure sealants can be applied on the posteriors, bitewings should be taken to assess interproximal caries and bone levels.

When his periodontal health has improved, refer the patient to a dental hygienist for regular cleaning. Regarding the mobile lower incisors, a discussion on bonded retainer on the lower anteriors to apply retention and stability onto the teeth can be done. If the patient is concerned about the aesthetics of the lower teeth, missing lower 5s can be replaced using dental implants or bridges. Moreover, it can cause the upper opposing tooth to overrerupt. Lower removable partial dentures are not recommended as they increase the risk of caries and have a harmful effect on the periodontal health if the management and care is not adequate.

The patient should come in 3 monthly intervals and when there is an improvement of behaviour and dental/oral hygiene, patients should come in every 6 months or 12 months for check up.