I. Caring for the Teeth and Gums of Children with Down Syndrome II. Early Preventive Dental Care

Dr. Jonathan Sierk, DDS
Down's Update
I. January/February 2009 Volume 26, Issue 11, p. 4
II. March/April 2009 Volume 27, Issue 2, p. 4
  Reprinted with the permission of the Mile High Down Syndrome Association and of the author.

I. Caring for the Teeth and Gums of Children with Down Syndrome

Children with Down syndrome are at an increased risk for developing problems with their teeth and gums. Early preventive dental care and rigorous home hygiene will help reduce many of these problems and eliminate some of them entirely. This article will relate the problems children can develop, describe how Down syndrome can complicate the oral condition, and finally instruct children and families on how to care for the teeth at home.

Dental diseases

Most parents are familiar with gum disease and dental cavities as the main oral health problems that children develop. In addition to these concerns, children with Down syndrome develop an increased number of canker sores, oral yeast infections and destructive periodontal problems.

Dental decay is the result of bacteria in our mouths converting fermentable carbohydrates into acid, which over time creates the infected holes in our teeth that we know as cavities. Eliminating dental decay requires restoring or filling existing cavities and changing dietary and hygiene habits.

Periodontal disease is the gradual loss of bone and supporting structures around our teeth due to inflammation. Gum disease can cause teeth to fall out over time if the bone and surrounding structures cannot hold the teeth in place. Many patients with Down syndrome develop significant periodontal problems by their teen years.

Complicating factors of Down syndrome

Natural cleansing of the mouth via saliva for patients with Down syndrome can be compromised due to a dry mouth from medications or from mouth breathing. Mouth breathing also creates more hard tartar deposits on the teeth, which can worsen gum disease.

The mouths of patients with Down syndrome tend to be smaller than average, therefore making it harder to brush the teeth. The tongue may seem larger, when in reality it is most likely only relatively larger due to a small mouth. Getting the toothbrush into all areas may be more challenging as a result. Poor muscle tone of the cheeks and tongue may also reduce the mouth's ability to cleanse itself. Food debris can stay on the surface of teeth longer and cause more decay if not properly cleaned off.

This tendency to have a small mouth can be complicated by misshapen teeth or an imperfect biting relationship. Crowded teeth are more difficult to take care of and may worsen periodontal problems. Children with Down syndrome tend to have reduced immune responses and therefore more infections due to a lower number of T-cells. This makes them much more susceptible to developing destructive periodontal disease.

It seems to be a widely held belief that patients with Down syndrome develop fewer dental cavities than average. Many parents have heard this and it may be a myth based on outdated research. The thing to remember is that the negative outcomes of these cavities may be worse for children with Down syndrome. Clearly preventing dental problems before they start is the best strategy for all patients.

Preventive strategies for home and at the dental office To prevent dental problems it is important to take a child to the dentist early. The American Academy of Pediatric Dentistry recommends the first dental visit within six months of the eruption of a child's first tooth. This is usually between ages one and two.

At home, a child's teeth should be brushed at least two times a day. Ideally, you should brush your child's teeth after breakfast and at bedtime. It is not necessary to use toothpaste with fluoride until a child has mastered the swallowing reflex and will not ingest the toothpaste, around age 3-5 years on average.

Depending on a child's age and development, they will need assistance brushing their teeth. It is important to introduce to a child how they should care for their teeth. Children with Down syndrome often benefit from using a mechanical toothbrush to better access difficult areas of the mouth. They may also find it more enjoyable to brush their teeth with a mechanical brush and will consequently spend more time at it. Some children have limited fine motor control and use of a floss holder should be considered.

It is important to establish a consistent schedule for brushing and caring for your child's teeth. You should try to use the same location and time so children will be comfortable and make it part of their daily routine.

Oral rinses should be used at home as well to reduce development of decay and gum disease. Fluoride rinse can be sprayed or brushed on the teeth if the child has not yet mastered the swallowing reflex. Brushing on a fluoride rinse at night can greatly reduce the number of cavities children develop.

In addition, an antimicrobial rinse such as Listerine, or chlorhexidine by prescription, can be used to reduce the progression of gum disease. Antimicrobial rinses should be not be used at the same time of day as a supplemental fluoride rinse, so after the morning brushing would be ideal. Children with Down syndrome tend to develop cracks or fissures in their tongue and lips that house bacteria. Daily brushing of the tongue, in conjunction with a rinse, can reduce the bacterial levels in a child's mouth.

Diet modification is very important in reducing dental problems. Due to breathing primarily through the mouth and the use of some medications, children with Down syndrome can be dehydrated and often thirsty. You should use sugar-free medications and vitamins whenever possible. It is also important that your child drink plenty of water to remain hydrated, especially in arid climates.

Significant dental decay can develop if a child drinks sweetened beverages throughout the day to quench their thirst. Sports drinks and fruit juice can be as destructive as soda pop to the teeth, if a child's teeth and mouth are exposed to them over long periods of time on a daily basis. Foods high in sugar should not be used as rewards or motivational tools regularly. All children should avoid grazing and sipping patterns of food intake to reduce dental decay, and their caloric intake should match their level of activity.

Preventive care at the dental office is important as well. Dentists treating patients with Down syndrome should be aware of gum disease developing. This may mean taking more frequent x-rays looking for bone loss around the teeth, or prescribing a mouth rinse or medication to reduce inflammation of the gums.

Crowded teeth and small mouths contribute to developing orthodontic problems. An orthodontic consultation and possible intervention may be helpful to prevent some gum problems, or to reduce biting forces if the teeth in one area of the mouth are being worn down unevenly due to bruxism or grinding.

More frequent examinations and cleanings can help identify and prevent problems. Dental sealants can be placed in the grooves on the biting surfaces of teeth to prevent decay; unfortunately sealants do not prevent cavities on the tooth surfaces between teeth. A combination of fluoride treatments, sealants and diet modification can greatly reduce the amount of decay patients with Down syndrome develop.


Children with Down syndrome have unique concerns that can make them more susceptible to developing problems with their teeth and supporting structures. Identifying and treating these concerns with aggressive preventive therapies can help maintain a healthy mouth throughout a lifetime.

II. Early Preventive Dental Care

Early preventive dental care is very important to the health of children with Down syndrome. A child's first dental visit can cause anxiety for parents, the child and dentist alike. The purpose of this article is to explain why early dental care is important for children with Down syndrome, to describe the typical first dental visit for young children, and finally to give suggestions about what can be done to make a child's initial visit to the dentist a positive experience.

The purpose of early preventive care

Proper care for the teeth and surrounding structures can prevent dental problems from developing. Children with Down syndrome have unique medical and dental concerns that make them more susceptible to diseases of the teeth and gums. These patients tend to have reduced immune responses that can exacerbate conditions in the oral cavity. It is important to develop good habits early in life so they become part of the daily routine of self-care.

The American Academy of Pediatric Dentistry recommends that children see a dentist within six months of the eruption of their first tooth. Early visits to a dentist serve many purposes. The treating dentist will identify the risk of the patient developing dental cavities and gum disease. In addition, the dentist will instruct the patient and family in the most appropriate ways to care for the child's teeth at home. Parents will be able to address specific concerns they have about their child. The dentist and family will put together a plan to address urgent dental needs and active disease. Finally, a long-term plan for care will be implemented. Most people are instructed to visit the dentist every six months, but this may not be appropriate for everyone. Some patients with Down syndrome may benefit from a more frequent schedule of visits to prevent as many dental problems from developing as possible. For these reasons it is important that you visit a dentist that has experience treating patients with Down syndrome.

The first office visit

The dentist and staff should make the patient as comfortable as possible at a child's first visit. It is important that your dentist establish a positive rapport with all patients before beginning an examination or treatment. This can be difficult to accomplish with very young patients, but for older children it can be a very effective tool to set the tone for an appointment. Often patting a child gently on the shoulder or arm before an invasive examination of their head and mouth can warm the patient up to having a stranger in their personal space. Each child is unique, and their specific needs should be addressed during their visit.

Your child's teeth will be examined and probably cleaned at the first visit. Additional services like x-rays and fluoride treatments may be accomplished, depending on the age and cooperation level of your child. Nearly all children under age two will require a parent to help with a dental examination. Sometimes young patients will cooperate while in a parent's lap. But often at an early age the parent or caregiver will need to help the dentist with examining the child by reclining the child in their laps and holding the patient's hands.

After information has been gathered, the family and dentist will decide if any dental treatment is needed at that time. They will discuss what medical concerns may be interacting with the teeth and mouth and what needs to be done, or what further tests are needed. The dentist will anticipate what problems the patient and family may encounter in the near and long term and counsel them on ways to deal with the concerns.

Many patients with Down syndrome have a very relaxed approach to medical settings and have positive experiences at the dental office. Often these patients can be treated very easily in the traditional dental setting. Usually all that is needed is a little more time and attention to make them comfortable. The patient and dental staff will have to exercise patience with one another to make the first visit a successful one.

Preparing your child

The key to positive dental visits for children with Down syndrome and children in general is to start at a young age. Patients will get more comfortable with new experiences after more exposure to them.

Children with Down syndrome tend to get their teeth later than average and because of this some parents may feel that visiting the dentist is not a priority. Because the permanent teeth tend to come in later as well, it is very important to maintain the baby teeth as long as possible and early preventive care can help accomplish this.

Communication between the family and dental staff is extremely important. Often children with Down syndrome understand what they hear better than is realized. Because their expressive language may not be as developed as their comprehension, parents and caregivers play a critical role in explaining their child's language skills to the dental office staff.

Some parents may be apprehensive about how their child or the dentist will react to the office situation. You should choose a dentist who has experience working with children with Down syndrome and who has a warm office environment to ensure the best experience possible for your child. Because children react better to dental visits in the morning when they are fresh, it's a good idea to schedule your child's first dental visit in the morning.

Books and videos are available that can expose your child to what to expect at the dentist's office. A calm, relaxed approach by parents and caregivers also sets a positive tone for the appointment. Children can sense if parents and the dental staff are uncomfortable and that may cause some apprehension for them. Parents can calm nervous children by clearly explaining in non-threatening language what to expect at the dental visit. For example you can say, "The dentist will count and clean your teeth. After that, he will take some pictures of your teeth to make sure they are healthy."

If you pick the right office for your family, get your child comfortable at an early age and schedule morning visits, the dental office does not have to be a source of anxiety for you or your child.

Planning leads to positive experience

With the right planning, preparation and office environment, children with Down syndrome can have positive initial dental visits. Early preventive dental care must take into account the unique medical and dental concerns of all patients. A comfortable dental environment makes for a happy patient and allows the dentist and caregivers to focus on the medical concerns of the patient rather than the anxiety often associated with a trip to the dentist.

Dr. Sierk is a pediatric dentist in Highlands Ranch, Colorado who treats many children with Down syndrome and focuses on the unique medical concerns of these patients. He is on staff at the Children's Hospital of Denver where he is an adjunct clinical professor. He can be reached at (303) 865-4066 or by email at Jon@SierkPediatricDentistry.com. com for further questions or comments.