Q&A: Interview with Pediatric Dentist Angela Stout, DMD

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Trisomy 21 Update

When should children with Down syndrome (DS) first go to the dentist?

At their first birthday, whether they have teeth or not. This initial visit is to examine their mouth, to detect any early problems, to get them used to the dentist, and to educate parents about dental health and hygiene.

What are the common dental problems in children with DS?

The eruption of teeth is often delayed. The large tongue relative to the size of the mouth makes thorough brushing of all tooth surfaces and flossing more challenging. Children with DS also tend to be mouth breathers, which reduces salivary flow so teeth don’t get cleared of debris as well, and then become more prone to cavities. As more teeth come in, crowding of the teeth also makes it more difficult to keep them clean, leading to periodontal or gum disease. Flossing should begin when two teeth start to touch. Missing teeth, mal-shaped teeth and irregularities in tooth enamel are also common anomalies associated with DS.

Are cavities more common in kids with DS?

They can be at higher risk for tooth decay. The shape of their teeth, tooth alignment and type of enamel formation can promote the progression of tooth decay. Baby teeth have thinner enamel to begin with, so cavities form and progress more easily. Teeth grinding and acid reflux can also damage the enamel which will make teeth more prone to decay. Reflux can cause potholes on the surface of the teeth, orangey/brown in color, instead of mountainous points, which are more prone to cavities.

How often should teeth be brushed?

At least twice a day — after breakfast and last thing before bed — and after lunch when possible. Teeth that are touching each other also need to be flossed. Gums should also be brushed, angling the toothbrush bristles at a 45 degree angle towards the gum line. It’s also important to brush the tongue. Children with DS can have deep fissures in their tongues which can harbor bacteria that can cause tooth decay and bad breath. Some children do better with electric toothbrushes. Most importantly, parents should continue to assist in brushing and flossing for their children.

What if a child won’t allow their teeth to be brushed?

Regular tooth brushing has to be part of a daily routine. Routine is vital to establishing healthy habits and getting a child used to dental care. It’s easier if tooth brushing (initially gum brushing) starts early, even as a baby. If a child refuses tooth brushing, gradually desensitize the child with manageable steps, such as: brush only the two front teeth for a week, then the front teeth and the canines, etc. You can also use a reward program, (“After we brush your teeth, then we’ll play your song/movie.”) You can use distraction, for example, brushing the teeth in front of the TV. Sometimes giving the child some control works (the child brushes, then the parent brushes). You may need two adults to brush properly.

Does plaque build up faster in children with DS?

It certainly can, especially when there is decrease in salivary flow from mouth breathing, when maligned or crowded teeth make brushing all surfaces harder, or when children are on frequent antibiotics. Frequent medications such as antibiotics can cause a pellicle on the surfaces of teeth and accumulate more plaque. These medications can be sugar-filled as well, putting the child at a higher risk for tooth decay. Some children will need cleaning every three months, especially if they have braces.

What about teeth grinding?

Teeth grinding (bruxism) wears enamel down, which makes teeth more prone to cavities and more temperature-sensitive.

Can teeth grinding be stopped or prevented?

If enamel is wearing down, we may try to make a mouthguard, but it’s hard to get kids to wear them. We can also put crowns on the back teeth to protect them. Grinding occurs more with mouth breathing, with large tonsils and adenoids, or sinus problems.

When do double rows of teeth have to be addressed?

This happens when the baby teeth are crowded together, so the permanent teeth coming in take the path of least resistance and erupt behind the baby teeth. Once the adult tooth is halfway erupted, it’s important to get the baby teeth out.

What about braces?

Braces may be needed because of crowded or crooked teeth, and because of underbites or posterior crossbites, which can put stress on the temporal mandibular joint (TMJ) over time. Many children tolerate orthodontic care well. A palate expander is often Phase 1 treatment. Phase 2 is brackets and wires. Tolerating braces and the care they require starts with getting children comfortable with the dentist. When braces are on, tooth brushing is even more important to prevent gum disease and tooth decay. Patients with braces may need a cleaning every three months.

What about sedation when children won’t cooperate with dental visits?

Many children with DS can cooperate with dental procedures without sedation if they start their dental experience early and become accustomed to the sights and sounds of dentistry. I will not sedate children with DS in my office because it can be difficult to protect their airway and neck, and there may be added risks from coincidental medical conditions. Many pediatric dentists have privileges to do dental care under anesthesia at local children’s hospitals. I try to combine dental procedures with other things a child may need to be treated for, such as ENT or ophthalmology procedures.

Take-home message

  • Start dental care at 1 year of age.
  • Make tooth brushing part of your child’s daily routine.
  • Encourage healthy eating habits, especially consuming fruits and vegetables and drinking water.
  • Limit juice, soda and sports drinks, and foods high in carbohydrates.
  • Establish an early relationship with the dentist to get children used to going to the dentist. If you don’t start until children are older, it’s harder for the dentist to earn their trust.

Dr. Stout can be reached by calling 215-233-0206 or via email at ams913@aol.com.