Periodontal+Case+6+-+Down's+Syndrome

Case #6 Down's Syndrome  

**__I. Overview of Down's Syndrome:__ **
 Trisomy 21 or what many people know it as is Down syndrome which is a condition that affects one out of every 800-1,000 births. This is the result of an extra chromosome of the twenty first group. With this special group of individuals becoming increasingly active in the community, work and school need to also have their dental care attended to. With this condition many dental concerns come into place which are the following, but not limited: MPV (mitral valve prolapse), they have lower number of T-cells (which weakens their immune system and are more prone to infections including periodontal disease), upper respiratory disease (can further aggravate their mouth breathing), xerostomia, and fissuring of the tongue. Including with these conditions they have a greater incidence of apthous ulcers, oral candida infections, and ANUG. They also have a higher incidence of epilepsy, diabetes, leukemia, and hypothyroidism.

In addition, many of the patients generally have hypotonia which is a reduced degree of muscle tone and affects the musculature of the head and the oral cavity as well as the large skeletal muscles. There is an imbalance of forces between the lips and cheeks and with the tongue and the tongue being the greatest of the two. This is the correlation between the tongue and the open bite. Due to the loss of muscle tone, the chewing is less effective and there is less cleansing of the teeth. Another factor affecting is a theory in which ligamentous laxity is seen throughout the body causing hyperflexibility of the joints and it is also speculated that this can affect the ligaments of the teeth. This is a condition that can affect 10-20% of this population and can affect the mobility of the C1 and C2 cervical vertebrae which can be of concern when reclining the patient back in the dental chair (to avoid potential harm to the spinal cord).

The main focus for this special group of patients is their home oral care. The severity of their condition will dictate the clinician how to, how much, and what hygiene products will be appropriate for the individual patient or the care provider. Many of these special groups of patients have facial bone arrangement in which allows for pocketing food in the cheeks, habitual tongue movements, swallowing habits or mouth breathing. All of the mentioned conditions play a very important role in constructing the ideal home care plan for that individual patient. 

__**II. Medical history **__
Patient is 8 years of age. His mother states that chief complaint is, "His gums bleed alot and teeth are discolored". Pt.'s gums bleed when mom brushes them, pt. has sensitivity to cold temperatures, patient grinds teeth, patient gets recurrent apthous ulcers. Patient has allergy induced asthma, patient was hospitalized for bronchitis when he was 6 years of age. He was also diagnosed with Mitral Valve Prolapse at 4 years old and was given antibiotic prophylactic regimen for any future dental appointments. Patient is farsighted and wears glasses for this. Pt. occasionally suffers from gastroenteritis symptoms. Patient's vaccinations are current. Patient is currently receives albuterol by nebulizer as needed for asthma.

__**III. Gingival description (refer to photo above) **__  Free: Gen. erythematous, gen. scalloped with localized loss of architecture, gen. edematous, gen. smooth. Attached: Gen. pink, gen. firmly bound, gen. smooth with loss of stippling

__**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">IV. Assessment findings: **__
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 * <span style="font-family: 'Comic Sans MS',cursive;">Salivary Flow: Inadequate
 * <span style="font-family: 'Comic Sans MS',cursive;">MBI: 85%, BOP: 95%
 * <span style="font-family: 'Comic Sans MS',cursive;">PI: 100%
 * <span style="font-family: 'Comic Sans MS',cursive;">Recession: No areas noted, but Down's syndrome patients may typically present with these findings
 * <span style="font-family: 'Comic Sans MS',cursive;">Furcations: No areas noted, but Down's syndrome patients may typically present with these findings
 * <span style="font-family: 'Comic Sans MS',cursive;">Mobility: (+) #'s 24, 25
 * <span style="font-family: 'Comic Sans MS',cursive;">Fremitus: (+) #'s 8, 9
 * <span style="font-family: 'Comic Sans MS',cursive;">Mucogingival defects: None
 * <span style="font-family: 'Comic Sans MS',cursive;">Attachment loss: None
 * <span style="font-family: 'Comic Sans MS',cursive;">Angles Class: Angles Class III with anterior end to end bite
 * <span style="font-family: 'Comic Sans MS',cursive;">ADA I, AAP Generalized moderate gingivitis due to plaque and calculus, modified by systemic factors. RCC code: light

<span style="font-family: 'Comic Sans MS',cursive;">__**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">V. OHI: **__ <span style="color: #800080; font-family: 'Comic Sans MS',cursive;"> > <span style="font-family: 'Comic Sans MS',cursive;"> >
 * <span style="font-family: 'Comic Sans MS',cursive;">Motivational Theory:
 * <span style="font-family: 'Comic Sans MS',cursive;">Social Cognitive Theory bases the patient's environmental factor as a major influence on their oral health. Since it is based on the psychosocial factors, the parent/caregiver must implement oral health home care. Interactive care, as well as modeling, should be displayed between the patient and parent because mental retardation may range from normal to severe. It is encouraged to initiate this in the patient's daily activities.
 * <span style="font-family: 'Comic Sans MS',cursive;">The patient would most likely not present the capabilities or dexterity to floss or brush properly. Therefore, the parent/caregiver plays in important role in maintaining their oral health daily.
 * <span style="font-family: 'Comic Sans MS',cursive;">Educate caregiver on patient's risk/prevalence of periodontal disease.
 * <span style="font-family: 'Comic Sans MS',cursive;">Electronic toothbrush (based on patient's compliance)
 * <span style="font-family: 'Comic Sans MS',cursive;"> Importance of flossing- patient's malocclusion increases risks for plaque retention

<span style="font-family: 'Comic Sans MS',cursive;">__**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">VI. Treatment Plan Appointments: **__
<span style="font-family: 'Comic Sans MS',cursive;"> Appt #1: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #2: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #3: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #4: <span style="font-family: 'Comic Sans MS',cursive;">
 * <span style="font-family: 'Comic Sans MS',cursive;">RMH
 * <span style="font-family: 'Comic Sans MS',cursive;">Medical consult for patient's Mitral Valve Prolapse
 * <span style="font-family: 'Comic Sans MS',cursive;">Pt. must take antibiotic regimen 1 hour prior to appointment
 * <span style="font-family: 'Comic Sans MS',cursive;">Depending on patient's compliance radiographs may be taken- Pedo FMX
 * <span style="font-family: 'Comic Sans MS',cursive;">DDS exam
 * <span style="font-family: 'Comic Sans MS',cursive;">PI
 * <span style="font-family: 'Comic Sans MS',cursive;">OHI- to caregiver and patient
 * <span style="font-family: 'Comic Sans MS',cursive;">Nutritional counseling
 * <span style="font-family: 'Comic Sans MS',cursive;">2nd check in
 * <span style="font-family: 'Comic Sans MS',cursive;">Full mouth scale or deplaque (in the absence of calculus)
 * <span style="font-family: 'Comic Sans MS',cursive;">ApF fl. tx (foam) for 4 minutes (based on patient's compliance)
 * <span style="font-family: 'Comic Sans MS',cursive;">OHI-to caregiver and patient
 * <span style="font-family: 'Comic Sans MS',cursive;">Review patient's nutritional habits with parent or caregiver
 * <span style="font-family: 'Comic Sans MS',cursive;">Restorative treatment or evaluation for caries
 * <span style="font-family: 'Comic Sans MS',cursive;">3 month recall

<span style="font-family: 'Comic Sans MS',cursive;">**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">__VII. Additional treatment:__ **
> <span style="font-family: 'Comic Sans MS',cursive;"> > <span style="font-family: 'Comic Sans MS',cursive;">
 * <span style="font-family: 'Comic Sans MS',cursive;">Nutritional Counseling to parent/caregiver:
 * <span style="font-family: 'Comic Sans MS',cursive;">Educate parent or caregiver to reduce fermentable carbohydrates
 * <span style="font-family: 'Comic Sans MS',cursive;">Excessive sugars or acidic foods
 * <span style="font-family: 'Comic Sans MS',cursive;">Importance of routine maintenance
 * <span style="font-family: 'Comic Sans MS',cursive;">Suggest automatic toothbrush if patient is compliant
 * <span style="font-family: 'Comic Sans MS',cursive;">At-home fluoride rinses and toothpaste
 * <span style="font-family: 'Comic Sans MS',cursive;">Stress importance of flossing patient's teeth
 * <span style="font-family: 'Comic Sans MS',cursive;">Avoid alcohol-based rinses to prevent xerostomia
 * <span style="font-family: 'Comic Sans MS',cursive;">Avoid reclining patient to supine positions to avoid potential harm to the patient's back
 * <span style="font-family: 'Comic Sans MS',cursive;">Recommend tongue brushing to prevent halitosis with prominent fissured tongue
 * <span style="font-family: 'Comic Sans MS',cursive;">Consider night guard (based on patient's compliance) for patient's bruxism
 * <span style="font-family: 'Comic Sans MS',cursive;">Carefully monitor wound-healing
 * <span style="font-family: 'Comic Sans MS',cursive;">Educate caregiver on etiology and recurrence of apthous ulcers

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<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">__Multiple Choice Questions:__
<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">1. A common oral finding in down syndrome patients are: <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Microdontia <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Enlarged tonsils due to mouth breathing <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Macroglossia <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. Fissured tongue <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">e. All the above

<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">2. Adults with Down's Syndrome age prematurley. Many over the age of 40 develop an Alzheimer's-like dementia with pathologic brain changes similar to those of Alzheimer's disease. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Both statements are true. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Both statements are false. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. First statement is true, second statement is false. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. First statement is false, second statement is true. <span style="font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="font-family: arial,helvetica,sans-serif;"> <span style="font-family: 'Comic Sans MS',cursive;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">3. Periodontal disease in Down's Syndrome patients is predominant: <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Due to decreased immune deficiency. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Due to leukocyte function being impaired by chemotaxis and phagocytosis. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Due to patient's age playing a factor in the destruction of bone. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. Due to patient's abnormal toungue thrust from macroglossia. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">4. Which angles class is most common in Down's Syndrome? <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Class I <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Class II <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Class III <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 81%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">5. Necrotizing ulceratie gingivitis (NUG), superimposed over gingivitis or periodontitis, has been found more in patients with down syndrome in those with other types of mental retardation. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">A. True <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">B. False <span style="font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">6. Teeth #s 8, 9, 24 and 25 all exhibit: <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Fluorosis <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Microdontia <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Macrodontia <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. Amelogenesis imperfecta <span style="font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">7. The maxillary lateral incisors pictured most likely are displaying: <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Congenitally missing due to patient's condition. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Delayed in eruption due to Down's Syndrome. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Showing signs of attrition due to patients occlusion. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. Erosion due to acidic environment. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">e. both a and b <span style="font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">8. A clinician should suggest what type of Oral hygiene instruction for this patient? <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. C-flossing method <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Bass brushing technique <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Fones brushing technique <span style="font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">9. What oral hygiene product would be beneficial for this patient? <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Glide floss <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Rubber tip stimulator. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Interproximal aid with a large handle. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. Listerine mouth wash.

<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">10. As a clinician, special precautions are considered in which of the following due to the patient's condition: <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">a. Sitting position. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">b. Fluid suctioning. <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">c. Increased gag reflex <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-size: 90%;">d. All the above

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<span style="color: #800080; font-family: 'Comic Sans MS',cursive; font-size: 18px;">__**Multiple choice questions**__
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