Placa Bacteriana Gran número de...

Revisión sistemática: Pocos estudios de diseño adecuado

110 Spec Care Dent is t 30(3 ) 2010 ©2010 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2010.00136.x

O R A L H E A L T H O F P A T I E N T S W I T H D I S A B I L I T I E S

A R T I C L E

A B S T R A C TA systematic review of original studieswas conducted to determine if differ-ences in oral health exist betweenadults who have intellectual disabilities(ID) and the general population.Electronic searching identified 27 studies that met the inclusion criteria.These studies were assessed forstrength of evidence.

People with ID have poorer oralhygiene and higher prevalence andgreater severity of periodontal disease.Caries rates in people with ID are thesame as or lower than the general popu-lation. However, the rates of untreatedcaries are consistently higher in peoplewith ID. Two subgroups at especiallyhigh risk for oral health problems arepeople with Down syndrome andpeople unable to cooperate for routinedental care.

Evidence supports the need todevelop strategies to increase patientacceptance for routine care, additionaltraining for dentists to provide this care,and the development of more effectivepreventive strategies to minimize theneed for this care.

Oral health of patients with intellectualdisabilities: A systematic reviewPatrick L. Anders, DDS, MPH;1* Elaine L. Davis, PhD2

1Assistant Professor; 2Professor, Department of Oral Diagnostic Sciences, State University of New Yorkat Buffalo School of Dental Medicine Buffalo, New York.*Corresponding author e-mail: [email protected]

Spec Care Dentist 30(3): 110-117, 2010

Much of the research has compareddifferent groups of individuals with ID,often with no control or reference group.To date, no national studies have beenconducted to determine the prevalence oforal diseases among populations withdisabilities,3 making it difficult to deter-mine if the oral health of adults with IDdiffers from that of the general popula-tion. Such a comprehensive comparisonwould help establish whether disparitiesexist and could be a step toward develop-ing strategies to address the disparities ifany were found.

The objective of this review was toexamine the available literature concern-ing the oral health of adults with ID todetermine if differences in oral healthstatus exist between those who have IDand the general population.

MethodsSearch strategyElectronic searching was performedusing the following data bases: MED-LINE (1975–2008), PubMed ClinicalQueries, and PsychLIT. The search termsused were related to the patients of inter-est—dental care for the disabled, mentalretardation, and Down syndrome; theoral condition—caries, periodontal dis-ease, mouth diseases, tooth disease; andthe type of study—comparative study,randomized controlled trial, meta analysis or review. The search was limited toEnglish language literature from 1975 to October 2008, as studies conductedprior to 1975 predate the adoption of theDevelopmentally Disabled Assistance and

I n t r oduc t i onPoor oral health can lead to pain, difficulty eating, sleep disturbance, and decreasedself-esteem, all of which can have a dramatic impact on an individual’s quality of life.1

Dental caries and periodontal disease are among the most common secondary condi-tions affecting people with intellectual disabilities (ID).2 The oral health needs ofindividuals with ID are complex, and may be related to underlying congenital or devel-opmental anomalies as well as inability to receive adequate personal and professionalcare to maintain oral health.3 Research suggests that people with ID such as mentalretardation (MR), are more likely to have poor oral hygiene and periodontal diseaseand possibly more likely to have caries than people without ID.1,3 Many studies haveexamined the oral health of various groups of individuals with ID including children,4-7

institutionalized people,8-11 and specific ethnic groups.12-15 Recent studies have exam-ined the oral health of other convenience samples such as groups of athletesparticipating in the Special Olympics.16-18

KEY WORDS: oral health, specialcare, systematic review

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Criterios de inclusión:Adultos con retardo mental o situación similarAl menos una medición cuantitativa del estado de salud oralComparación con grupo de control sano

¡Sólo identifica 27 estudios!Conclusiones:

Peor higieneMás prevalencia y severidad EPMayor tasa de caries sin tratarGrupos de especial alto riesgo: S. Down, No cooperadores

¡Formación y medios!


O R A L H E A L T H O F P A T I E N T S W I T H D I S A B I L I T I E S

A R T I C L E

A B S T R A C TA systematic review of original studieswas conducted to determine if differ-ences in oral health exist betweenadults who have intellectual disabilities(ID) and the general population.Electronic searching identified 27 studies that met the inclusion criteria.These studies were assessed forstrength of evidence.

People with ID have poorer oralhygiene and higher prevalence andgreater severity of periodontal disease.Caries rates in people with ID are thesame as or lower than the general popu-lation. However, the rates of untreatedcaries are consistently higher in peoplewith ID. Two subgroups at especiallyhigh risk for oral health problems arepeople with Down syndrome andpeople unable to cooperate for routinedental care.

Evidence supports the need todevelop strategies to increase patientacceptance for routine care, additionaltraining for dentists to provide this care,and the development of more effectivepreventive strategies to minimize theneed for this care.

Oral health of patients with intellectualdisabilities: A systematic reviewPatrick L. Anders, DDS, MPH;1* Elaine L. Davis, PhD2

1Assistant Professor; 2Professor, Department of Oral Diagnostic Sciences, State University of New Yorkat Buffalo School of Dental Medicine Buffalo, New York.*Corresponding author e-mail: [email protected]


Much of the research has compareddifferent groups of individuals with ID,often with no control or reference group.To date, no national studies have beenconducted to determine the prevalence oforal diseases among populations withdisabilities,3 making it difficult to deter-mine if the oral health of adults with IDdiffers from that of the general popula-tion. Such a comprehensive comparisonwould help establish whether disparitiesexist and could be a step toward develop-ing strategies to address the disparities ifany were found.

The objective of this review was toexamine the available literature concern-ing the oral health of adults with ID todetermine if differences in oral healthstatus exist between those who have IDand the general population.

MethodsSearch strategyElectronic searching was performedusing the following data bases: MED-LINE (1975–2008), PubMed ClinicalQueries, and PsychLIT. The search termsused were related to the patients of inter-est—dental care for the disabled, mentalretardation, and Down syndrome; theoral condition—caries, periodontal dis-ease, mouth diseases, tooth disease; andthe type of study—comparative study,randomized controlled trial, meta analysis or review. The search was limited toEnglish language literature from 1975 to October 2008, as studies conductedprior to 1975 predate the adoption of theDevelopmentally Disabled Assistance and

I n t r oduc t i onPoor oral health can lead to pain, difficulty eating, sleep disturbance, and decreasedself-esteem, all of which can have a dramatic impact on an individual’s quality of life.1

Dental caries and periodontal disease are among the most common secondary condi-tions affecting people with intellectual disabilities (ID).2 The oral health needs ofindividuals with ID are complex, and may be related to underlying congenital or devel-opmental anomalies as well as inability to receive adequate personal and professionalcare to maintain oral health.3 Research suggests that people with ID such as mentalretardation (MR), are more likely to have poor oral hygiene and periodontal diseaseand possibly more likely to have caries than people without ID.1,3 Many studies haveexamined the oral health of various groups of individuals with ID including children,4-7

institutionalized people,8-11 and specific ethnic groups.12-15 Recent studies have exam-ined the oral health of other convenience samples such as groups of athletesparticipating in the Special Olympics.16-18

KEY WORDS: oral health, specialcare, systematic review

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ALTERACIONES ORALES EN DISCAPACITADOS

Placa BacterianaAcumulación incrementadaDificultades en la eliminación

Gran número de caries

Gingivitis

Factores Modificadores SistémicosSíndromes

Imposibilidad de individualizar los casos

¿HAY CARACTERÍSTICAS ESPECÍFICAS EN LA AFECTACIÓN ORAL SEGÚN LOS SÍNDROMES?

SÍNDROME DE DOWN

Trisomía del par 21España: 1/15.000 nacidos vivosRelacionado con edad materna + 40Tendencia a infecciones (respiratorias, urológicas,…)Defectos inmunológicos (celiaquía,…)Retardo mental de variada importancia

SÍNDROME DE DOWN Y PERIODONTITIS

Elevada prevalencia de periodontitis agresivas.

Alteraciones morfológicas de los dientes (reducción del tamaño radicular)

Gran dificultad en cumplimentar la higiene (intelectual y física -macroglosia-)

Alteraciones en la respuesta tisular e inmune

Alterada quimiotaxis de los PMN

Flora específica similar a periodontitis agresiva (P.gingivalis, Aac, F. Nucleatum,…)

Alta tasa de progresión de la enfermedad, cada 9 años

Los pacientes con SD presentan peores parámetros periodontales que otros discapacitados o que el grupo de control sano


P E R I O D O N T A L H E A L T H I N D O W N S Y N D R O M E

A R T I C L E

A B S T R A C TFifty-five dentate patients with Downsyndrome (DS) and 74 with mental dis-ability non-Down (MR) were comparedto 88 control subjects. Subjects in theMR and Control groups were matchedby gender and ethnicity to subjects withDS. All subjects were nonsmokers.Periodontal evaluation included plaqueindex (PI), gingival index (GI), bleedingon probing (BOP), and clinical periodontalattachment levels. Caries and missingteeth were recorded. Measures of per-sonal dental hygiene and the frequencyof professional dental care were alsorecorded. Most subjects brushed theirteeth at least once per day, but did notfloss. Both groups with DS and MR hadsignificantly more missing teeth, moreBOP, and higher GI and PI levels thanthe control group. Patients with DS hadmore attachment loss (AL) than theother two groups (p < .001). IncreasedAL in patients with DS was not associ-ated with differences in socioeconomicstatus, personal/professional dentalcare, or mental disability.

Periodontal health in Down syndrome:Contributions of mental disability,personal, and professional dental careAhmed Khocht, DDS, MSD;1* Malvin Janal, PhD;2 Bobby Turner, DMD3

1Associate Professor, Temple University School of Dentistry, Philadelphia, Pennsylvania; 2ResearchAssociate, University of Medicine and Dentistry, Newark, New Jersey; 3Director, Dental Services, East Central Regional Hospital, Gracewood, Georgia.*Corresponding author e-mail: [email protected]


The objectives of this study were tocompare periodontal disease statusbetween subjects with and without DS inorder to determine the influence ofmental disability on periodontal disease,and to evaluate the influence of socioeco-nomic status, personal dental hygiene,and professional dental visits on diseasestatus in these persons.

Mate r i a l s and me thodsThis study was conducted in cooperationwith the Georgia Department of HumanResources/Georgia Regional Hospitals

(GRH) in Atlanta, Savannah, andAugusta. The study protocol and consentforms were approved by the GeorgiaRegional Hospital Institutional ReviewBoard. The study included three subjectgroups: DS, mental disability non-Down(MR), and a control group (C). Both thegroups of subjects with DS and MR wererecruited from the GRH healthcare sys-tems in Atlanta, Savannah, and Augusta,Georgia. All subjects with DS and MRwere patients of record at the threehospital locations; some were institution-alized while others were outpatientsliving in group homes or with their

I n t r oduc t i onDown syndrome (DS) is a genetic disease known as trisomy 21. The condition is asso-ciated with an extra chromosome No. 21 in affected individuals, giving them a totalchromosome count of 47. It is generally produced by an abnormal segregation of chro-mosomes during cell division (maternal meiotic nondisjunction). DS is the mostcommon chromosomal disorder, with an estimated prevalence of 9.2 cases per 10,000live births in the U.S.1-2 Different racial groups are equally affected.3 The condition isassociated with characteristic dysmorphic features, mental disability, congenital heartdefects, and altered immune responses. In developed nations, life expectancy of indi-viduals with DS has improved with average life expectancy reaching 50 to 60 years.4-5

Periodontal disease is a serious and morbid oral condition among people with DS.Gingivitis and periodontitis begin early and their severity increases with age.6

Periodontal disease is a significant cause of tooth loss among individuals with DS.7 Inaddition to mental disability, altered immune/inflammatory responses in patients withDS are important contributing factors to their increased susceptibility to periodontitis.8-10

Managing periodontal disease in patients with DS is difficult and challenging. Thevalue of a long-term preventive dental program on controlling periodontal diseases inthese patients is not fully understood. Also, the effects of oral hygiene habits, familyincome, and parent education on periodontal status of persons with DS are not known.

KEY WORDS: periodontitis, Downsyndrome, mental retardation, dental pre-ventive program, oral hygiene,socioeconomics

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A R T I C L E

A B S T R A C TFifty-five dentate patients with Downsyndrome (DS) and 74 with mental dis-ability non-Down (MR) were comparedto 88 control subjects. Subjects in theMR and Control groups were matchedby gender and ethnicity to subjects withDS. All subjects were nonsmokers.Periodontal evaluation included plaqueindex (PI), gingival index (GI), bleedingon probing (BOP), and clinical periodontalattachment levels. Caries and missingteeth were recorded. Measures of per-sonal dental hygiene and the frequencyof professional dental care were alsorecorded. Most subjects brushed theirteeth at least once per day, but did notfloss. Both groups with DS and MR hadsignificantly more missing teeth, moreBOP, and higher GI and PI levels thanthe control group. Patients with DS hadmore attachment loss (AL) than theother two groups (p < .001). IncreasedAL in patients with DS was not associ-ated with differences in socioeconomicstatus, personal/professional dentalcare, or mental disability.

Periodontal health in Down syndrome:Contributions of mental disability,personal, and professional dental careAhmed Khocht, DDS, MSD;1* Malvin Janal, PhD;2 Bobby Turner, DMD3

1Associate Professor, Temple University School of Dentistry, Philadelphia, Pennsylvania; 2ResearchAssociate, University of Medicine and Dentistry, Newark, New Jersey; 3Director, Dental Services, East Central Regional Hospital, Gracewood, Georgia.*Corresponding author e-mail: [email protected]


The objectives of this study were tocompare periodontal disease statusbetween subjects with and without DS inorder to determine the influence ofmental disability on periodontal disease,and to evaluate the influence of socioeco-nomic status, personal dental hygiene,and professional dental visits on diseasestatus in these persons.

Mate r i a l s and me thodsThis study was conducted in cooperationwith the Georgia Department of HumanResources/Georgia Regional Hospitals

(GRH) in Atlanta, Savannah, andAugusta. The study protocol and consentforms were approved by the GeorgiaRegional Hospital Institutional ReviewBoard. The study included three subjectgroups: DS, mental disability non-Down(MR), and a control group (C). Both thegroups of subjects with DS and MR wererecruited from the GRH healthcare sys-tems in Atlanta, Savannah, and Augusta,Georgia. All subjects with DS and MRwere patients of record at the threehospital locations; some were institution-alized while others were outpatientsliving in group homes or with their

I n t r oduc t i onDown syndrome (DS) is a genetic disease known as trisomy 21. The condition is asso-ciated with an extra chromosome No. 21 in affected individuals, giving them a totalchromosome count of 47. It is generally produced by an abnormal segregation of chro-mosomes during cell division (maternal meiotic nondisjunction). DS is the mostcommon chromosomal disorder, with an estimated prevalence of 9.2 cases per 10,000live births in the U.S.1-2 Different racial groups are equally affected.3 The condition isassociated with characteristic dysmorphic features, mental disability, congenital heartdefects, and altered immune responses. In developed nations, life expectancy of indi-viduals with DS has improved with average life expectancy reaching 50 to 60 years.4-5

Periodontal disease is a serious and morbid oral condition among people with DS.Gingivitis and periodontitis begin early and their severity increases with age.6

Periodontal disease is a significant cause of tooth loss among individuals with DS.7 Inaddition to mental disability, altered immune/inflammatory responses in patients withDS are important contributing factors to their increased susceptibility to periodontitis.8-10

Managing periodontal disease in patients with DS is difficult and challenging. Thevalue of a long-term preventive dental program on controlling periodontal diseases inthese patients is not fully understood. Also, the effects of oral hygiene habits, familyincome, and parent education on periodontal status of persons with DS are not known.

KEY WORDS: periodontitis, Downsyndrome, mental retardation, dental pre-ventive program, oral hygiene,socioeconomics

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120 Spec Care Dent is t 30(3 ) 2010 Per iodonta l hea l th in Down syndrome


correlation analysis was used to examinethe relation between AL and demograph-ics, dental hygiene, and professionaldental care. Multiple linear regressionmodels were used to determine whetherdifferences in AL between subjects withDS and those without were related tomental challenge, personal dental hygiene,and professional dental visits, while con-trolling for demographic and clinical riskfactors for periodontitis. These modelsforced the group effect on AL in Model 1,then used a stepwise procedure to searchfor significant demographic predictors ofAL in Model 2, and hygiene and profes-sional care predictors in Model 3.

The obtained samples included atleast 55 individuals per group. Samplesof this size provide statistical power of atleast 80% for the detection of moderateeffect sizes (approximately .55 standarddeviation units in an independent samples t-test, or a correlation !.4),assuming a two-tailed type 1 error rate of5%. Type 1 error rates of 5% were usedto define statistical significance.

Resu l t sTable 1 summarizes the demographicand dental care characteristics of eachgroup. The three groups were distributedsimilarly with regard to ethnicity andgender. Subjects with MR were olderthan Controls, and they were older thansubjects with DS. Family income andparent education were statistically similarin groups with DS and in Controlgroups. As these variables were missingin all but 10 subjects with MR, they werenot included in the analyses. Most of thesubjects with DS (58.2%) were livingwith their families while the majority ofthe subjects with MR (82.4%) were insti-tutionalized. The majority of subjects inall three groups brushed their teeth atleast once a day. The majority of the indi-viduals in the group with DS reportedusing only a conventional toothbrush,and changed their toothbrush more fre-quently than the other groups.

All subjects reported brushing withtoothpaste. The vast majority of Controlsubjects, but only a minority of subjectswith DS and MR, reported routine dental

flossing. The use of over-the-countermouthwash was common in all groups,but least likely in the group with MR. Allsubjects had frequent access to profes-sional dental care and the rates werehighest in the group with MR.

Table 2 summarizes the clinicaldental/periodontal measures for the threegroups. The group with DS showed agreater loss of clinical periodontal attach-ment than the Controls or those withMR. Control subjects had less bleeding

on probing (BOP), lower GI and PI, andfewer missing teeth than either of theother two groups. No teeth with clinicallyobvious carious lesions were detected.Thus, while both the groups with DS andMR had greater levels of gingival inflam-mation than the Controls, only thesubjects with DS had more AL. This sug-gests that mental disability alone isinsufficient to explain higher levels of AL.

Table 3 summarizes the relationbetween AL and demographic and dental

Table 1. Demographic and dental care measures by group.

Control group,n = 88

Down syn-drome, n = 55

Mental disabilitynon-Down, n = 74

p value

Age (years), mean (SD) range40.8 (11.9)18–73

36.2 (9.8)18–56

45.9 (13.7) 22–84 0.001

Males (%) 42.0 52.7 58.1 0.11

White (%) 70.5 78.2 81.1 0.26

Family income range (K$) 21–40 21–40 a 0.18

Mother education >HS (%) 51.4 38.6 a 0.19

Father education >HS (%) 44.2 45.7 a 0.87

Living in institution (%) 0 41.8 82.4 <0.001

Toothbrushing >once/day 76.1 60.0 75.7 0.08

Conventional brush (%) 73.9 61.1 94.4 <0.001

Brush change (months), mean (SD) 4.3 (2.6) 3.1 (2.1) 4.0 (2.3) 0.01

Flossing ever (%) 81.8 37.0 18.3 <0.001

Mouthwash ever (%) 76.1 67.9 54.9 0.02

Dental visits >once/year 52.3 63.0 81.9 0.001

aData missing.

Table 2. Clinical parameters.

Control group(C), n = 88

Down syndrome(DS), n = 55

Mental disabilitynon-Down (MR), n = 74

p value

Attachment loss (mm) 2.2 (0.08) 2.7 (0.10)a 2.2 (0.08) <0.001

Bleeding on probing (%) 24.8 (2.98)b 40.6 (3.78) 43.8 (3.25) <0.001

Gingival index 0.7 (0.03)b 0.9 (0.04) 1.0 (0.03) <0.001

Plaque index 1.2 (0.08)b 1.6 (0.10) 1.8 (0.08) <0.001

Missing teeth 1.8 (0.41)b 4.6 (0.52) 4.6 (0.45) <0.001

Data presented as mean (standard error, SE).aDS > C = M.bDS = MR > C.

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¿QUÉ ACTITUD PREVENTIVA O TERAPÉUTICA ES MÁS RECOMENDABLE?

En todos los parámetros periodontales estudiados se constata la importancia del

PARÁLISIS CEREBRAL

“Entidad nosológica que engloba trastornos invalidantes estáticos, no progresivos, causados por una lesión cerebral ocurrida durante los periodos prenatal o perinatal, antes de que el SNC alcance su madurez. El daño se

manifiesta como alteración en los centros motores, incluidos los

orofaríngeos”

PARÁLISIS CEREBRAL

0.05% de la población españolaLesión cerebral no evolutiva que afecta:

HablaTonoMovimiento

Problemas orales:Anomalías de nº y formaHipoplasias de esmalteCariesGingivitis y periodontitis (10%)Maloclusiones abigarradasBruxismoTraumatismos

MANEJO DEL PACIENTE CON PARÁLISIS CEREBRAL

Uso de depresores linguales

Restricción física ( Sujetarle las manos).

Control de la voz ( aumentar el tono )

No hacerle esperar

Trabajar muy rápido

En ocasiones es necesario sujetar la cabeza para evitar posibles movimientos.

La presencia de los padres o tutores

PACIENTES EPILÉPTICOS

•Traumatismos dentales frecuentes•Gingivitis e hiperplasias hidantoínicas•Tendencia a la gingivorragía(farmacológica)•Displasias en denticiones deciduas y permanentes•Lesiones en los tejidos blandos•Xerostomía•Usen prótesis fija y diques•No usen lidocaína

• Crisis en personas susceptibles

TRATAMIENTO ODONTOLÓGICO EN DISCAPACITADOS

¡Grandes necesidades de tratamiento periodontal básico!

Tratamiento causal o etiológico:EHODetartrajes supragingivalesRaspado, pulido y alisado radicularReevaluaciones periódicas

¡Grandes necesidades de tratamiento restaurador básico!Persisten grandes necesidades de exodoncias…

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