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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 9  |  Page : 1175-1179

Does obstructive sleep apnea affect oral and periodontal health in children with down syndrome? A preliminary study


1 Department of Pediatric Dentistry, Marmara University, Faculty of Dentistry, Maltepe, Basibuyuk Saglik Kampusu, 34854, Istanbul, Turkey
2 Department of Periodontology, Marmara University, Faculty of Dentistry, Maltepe, Basibuyuk Saglik Kampusu, 34854, Istanbul, Turkey
3 Department of Pulmonary Diseases, Istanbul University, Istanbul Medical Faculty, Topkapı Mahallesi, Turgut Özal Millet Cd, 34093 Fatih/İstanbul, Istanbul, Turkey
4 Department of Pediatric Pulmonology, Marmara University, Medical Faculty, Fevzi Çakmak Mahallesi, Muhsin Yazıcıoğlu Cd No: 10, 34899 Pendik/İstanbul, Istanbul, Turkey

Date of Acceptance23-Apr-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Dr. M A Durhan
Department of Paediatric Dentistry, Marmara University, Faculty of Dentistry, Maltepe, Basibuyuk Saglik Kampusu – 34854, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_97_19

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   Abstract 


Objective: Children with Down syndrome (DS) are at increased risk for obstructive sleep apnea (OSA) compared with children without DS, with reported prevalence of 31 ± 75% among clinical-based samples. We aimed to find out whether there is any effect of OSA on periodontal and dental health in children with DS. Material and Methods: Overnight polysomnography (PSG) was performed. OSA was defined as Apnea-Hypopnea Index (AHI) ≥ 1/h. Children received a full mouth periodontal and dental examination that included probing depths (PD), plaque index (PI), gingival index (GI), and bleeding on probing (BOP) on six sites per tooth. Decay, decay - Missing, missing - Filling, filling - Tooth, tooth (DMFT—for permanent tooth/dmft—for primary tooth) scores were calculated. Results: Children were divided into two groups depending on whether they were diagnosed with OSA or no OSA. Group 1 (DS with OSA) and Group 2 (DS without OSA) included 11 children (age = 11.5 ± 2.2) and 7 children (mean age = 9.7 ± 2.3), respectively. Subjects in Group 1 displayed statistically significantly higher levels of GI (P = 0.020) and BOP (P = 0.006) than Group 2. Conclusion: OSA is an important problem for DS and may affect oral health negatively. Based on our findings, OSA can be associated with impaired gingival health in DS children and close follow-up may be necessary for this group.

Keywords: Down syndrome, oral health, OSA


How to cite this article:
Durhan M A, Agrali O B, Kiyan E, Ikizoglu N B, Ersu R, Tanboga I. Does obstructive sleep apnea affect oral and periodontal health in children with down syndrome? A preliminary study. Niger J Clin Pract 2019;22:1175-9

How to cite this URL:
Durhan M A, Agrali O B, Kiyan E, Ikizoglu N B, Ersu R, Tanboga I. Does obstructive sleep apnea affect oral and periodontal health in children with down syndrome? A preliminary study. Niger J Clin Pract [serial online] 2019 [cited 2019 Oct 14];22:1175-9. Available from: http://www.njcponline.com/text.asp?2019/22/9/1175/266174




   Introduction Top


Prevalence of obstructive sleep apnea (OSA) is 2 to 6% in children.[1],[2] Children with Down syndrome (DS) are at an increased risk for OSA when compared with children without DS, with reported prevalence rates of 31 ± 75% among clinical-based samples and are predisposed to upper airway obstruction due to multiple factors.[1],[3],[4] Midface and maxillary hypoplasia and relative tongue enlargement cause smaller dimensions of the airway.[1],[5] Diagnosis of OSA can be made on history, examination, polysomnography (PSG), limited channel testing, and oximetry. Overnight PSG, which requires a nocturnal stay in a sleep facility, is the gold standard for the diagnosis of OSA. The severity of OSA is classified on the basis of the patient's Apnea-Hypopnea Index (AHI).[6],[7],[8]

Periodontal disease is a chronic infection of the tooth-supporting structures caused mainly by gram-negative bacteria and spirochetes. Periodontal disease has been linked to coronary heart disease, diabetes mellitus, stroke, atherosclerosis, preterm birth, rheumatoid arthritis, and recently to OSA.[9] The evidence that inflammatory mediators play a role in the pathogenesis of OSA and periodontitis and the fact that they both share same risk factors suggest a potential association between the two conditions.[10] Also, higher prevalence of dental plaque formation and periodontal problems together with higher levels of inflammatory markers were noticed in patients with OSA.[11]

In this study, we aimed to find out if there is any effect of OSA on periodontal and dental health in children with DS hypothesizing that DS children with OSA have impaired periodontal and dental health.


   Materials and Methods Top


Study population

This study was carried out by a multidisciplinary team at the Marmara University, Faculty of Dentistry, Department of Pediatric Dentistry; Marmara University, Medical Faculty, Department of Pediatric Pulmonology and Istanbul University, Istanbul Medical Faculty, Department of Pulmonary Diseases Istanbul, Turkey. Ethical approval for the study was obtained from the Ethics Committee of Marmara University Faculty of Dentistry with the number of 2015-17 and written consent was obtained from the parents. Subjects were recruited through Down Syndrome Association between January 2016 and June 2016 in Istanbul. All DS children between the ages of 7 to 14 years were invited to the study.

Overnight PSG

A full overnight PSG was performed at the Sleep Disorders Laboratory of the Istanbul University, Istanbul Medical Faculty, Department of Pulmonary Diseases. The recorded parameters were electroencephalography (C3A2, C4A1, O1A2, O2A1), right and left oculography, chin electromyogram, anterior tibial electromyogram, electrocardiography, pulse oximetry and pulse waveform, thoracic and abdominal inductance plethysmography, nasal thermistor, nasal pressure transducer, audio recording, and body position. Staging of sleep and the scoring of respiratory events and arousals were performed according to the American Academy of Sleep Medicine pediatric criteria.[12] A diagnosis of OSA was established with AHI ≥1/h on PSG. Also body mass index (BMI) scores of the participants were recorded.

Intraoral examination

Children had a full mouth periodontal and dental examination including probing depths (PD), plaque index (PI), gingival index (GI), and bleeding on probing (BOP) on six sites per tooth. DMFT/dmft Decay, decay - Missing, missing - Filling, filling - Tooth, tooth (DMFT—for permanent tooth/dft—for primary tooth) scores were recorded.

Patient allocation

Twenty-five DS children (age range: 7–14 years) who were contacted through Down Syndrome Association accepted PSG and oral examinations and were initially included in the study. Seven of these were later excluded from the study because they did not want to have a PSG or had insufficient data from the sleep study. A total of 18 children (10 female and 8 male, mean age = 10.4 ± 3.4 years) completed the study. Eleven children (age = 11.5 ± 2.2 years) were diagnosed with OSA and 7 children (mean age = 9.7 ± 2.3 years) had normal PSG. Children were divided into two groups depending on whether OSA was diagnosed or not.

Data analysis

We summarized the study using descriptive statistics (e.g. mean, median, standard deviation, percentage). Statistical analyses were performed using the SPSS 20.0, and intergroup differences were analyzed with Mann–Whitney U test (P < 0.05). Comparison of differences between groups was analyzed by the Kruskal–Wallis test.


   Results Top


[Table 1] illustrates the general and clinical profile of the study population. Age and BMI were similar in both groups (P = 0.085 and P = 0.635, respectively). GI (P = 0.020) and BOP (P = 0.006) scores were significantly higher in Group I (DS subjects with OSA). PD (P = 0.930), PI (P = 0.104), and DMFT/dmft values (P = 0.425) were also similar in both groups.
Table 1: Demographic and clinical parameters

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   Discussion Top


This study addresses the periodontal and dental health related to OSA in a small group of children with DS. In the current literature, there is no data about this subject. Babies born with DS have life-long health problems and addition have limited communication skills. Thus, dental practices encouraging children with intellectual disabilities to cooperate with dentist's instruction can be a major challenge.[13] Addition of impairment of oral health to general health problems can adversely affect children's quality of life. Number of studies revealed that DS children had lower caries index compared with non-DS children, in spite several studies found out no differences while other studies revealed that DS children/individuals had higher caries index.[14] This situation can often be a reflection of other accompanying health problems in these children. Considering the high prevalence of OSA and special needs to maintain the daily oral care in DS children, these children may face greater oral health problems than healthy children. Therefore, it is important to encourage parents/guardians to seek dental care during early ages, when preventive procedures and education are still possible. An appropriate approach to address these determinant factors may lead to a reduction in the prevalence of periodontal and dental problems. The first starting point of our study was to evaluate general periodontal and oral health findings in patients with OSA in DS. Al Habashneh et al. suggested that the patients with high risk of OSA were more likely to have periodontitis (OR = 2.3; 95% CI: 1.03/5.10) compared to patients with low risk of OSA.[15] Similarly, a higher prevalence of periodontitis has been shown in OSA patients.[11] Al-Jewair et al. indicated the statistically significant association between periodontal problems and OSA.[10] On the other hand, Loke et al. concluded that OSA was not significantly associated with the prevalence of moderate/severe periodontitis and the periodontal parameters including PD and BOP.[16] Moreover, it has been demonstrated that children with DS had similar caries, lower PI, and lower gingival bleeding index values compared to children without DS.[17] On the contrary, higher levels of sIgA have been reported in DS children aged 7 to 12 years compared with controls (370 mg/l vs 128 mg/l sIgA) and this was associated with a lower prevalence of caries in the children with DS. Another study did not detect any significant differences in the dmft status between the children with DS and their siblings; however, the GI was significantly higher in DS children.[18] Tsilingaridis et al. studied the relationship between matrix metalloproteinases (MMPs) and issue inhibitor of MMPs (TIMPs) in the gingival crevicular fluid of subjects with DS compared with healthy controls. They concluded that DS subjects with gingivitis exhibit higher concentrations of MMPs in gingival crevicular fluid with an altered relationship between MMP-8 and TIMP-2, which might impair the periodontal tissue turnover.[19] In the current study, the simplest and most validated periodontal and oral parameters including PD, PI, GI, and BOP and DMFT/dmft scores were documented. To our limited knowledge, this has been the only study which evaluated these parameters of DS children with OSA. In our study, there was no significant difference between the groups regarding the PD, PI, and DMFT/dmft values.

The prevalence of OSA in the adolescent and child population with DS has been reported previously and varies considerably depending on the sample selection.[20],[21],[22],[23],[24] DS subjects are at increased risk for the development of OSA compared with non-syndromic patients. Physiologic differences in DS patients, including reduced oral cavity volumes, relative macroglossia, adenotonsillar hypertrophy, and muscular hypotonia, contribute to their increased rates of OSA.[25] Another important risk factor is obesity. Studies have shown that increased BMI poses a risk for OSA.[26],[27],[28] In our study, we made sure that the patient population and research groups were homogenous in determining BMI. This risk factor could have led to misinterpretation. OSA is associated with reduced quality of life and number of serious health problems such as daytime neurobehavioral problems, learning deficits, growth retardation, and cardiovascular complications. Patients with OSA may complain of having dry mouth, bad breath, gingival bleeding, and gingival swelling.[29] Dry mouth is a considerable oral disease that may affect oral health and even the patient's quality of life. Oral and dental symptoms include sensations of soreness and burning, difficulties in speaking, chewing and swallowing, mucosal atrophy, and an altered oral microbiome. Moreover, a significantly higher prevalence of enamel demineralization, dentinal sensitivity, and progressive dental caries, as well as periodontal disease is reported in patients with chronic dry mouth.[30] Compared with earlier study in adult, our DMFT/dmft score in DS subjects was similar to Acar et al.[31] On the other hand;, DS subjects with OSA displayed statistically significantly higher levels of GI and BOP than the individuals without OSA. Unlike our findings, Al-Hammad et al. showed that children between 3 and 8 years with OSA have less dental caries, plaque deposition, and gingival inflammation.[32] High BOP percentages and high GI scores indicate that gingival inflammation is a common finding in our study group and it is usually associated with high plaque levels. The clear association between PI and GI suggests that dental plaque–induced gingival inflammation in this group could be resolved by attention to oral hygiene (tooth brushing) and basic forms of periodontal treatment such as scaling.[33] In our study, while there was no statistically significant difference between PI values, the higher values of GI and BOP may indicate that there may be differences in systemic conditions of patients affecting their inflammatory response of the subjects.

A lower number of patients recruited for our study may be proposed as a limitation of our work. DS is a rare syndrome which is seen in one of 700 live newborns.[34] We included only 7- to 14-year-old DS patients. Furthermore, it was hard to provide sufficient co-operation to carry out the necessary examinations on this special group of subjects having mental retardation. We have experienced some difficulties in our patient population and completed the study with 18 patients. However, significant results have been achieved in this preliminary study.


   Conclusion Top


It is well known that DS may restrict the dental-treatment options provided or offered by the dental care service because of the degree of intellectual disability. The preliminary results of the current study suggest that OSA is an important and overlooked problem in young DS patients and maybe a cause for periodontal problems. We suggest that, especially for children with DS, the oral examination should be modified to include periodontal examination parameters in order to allow better understanding of the periodontitis and special attention should be paid to the presence of OSA, which may increase the risk of periodontal problems.

Ethical approval

Ethical approval for the study was obtained from the Ethics Committee of Marmara University Faculty of Dentistry with the number of 2015-17 and written consent was obtained from the parents. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Acknowledgements

The authors thank Down Syndrome Association, Istanbul for assisting to carry out the study. There is no conflict of interest. This study was not supported by any grant or company.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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