Dental aspects of children with Down syndrome

In these patients, there is a strong predisposition to cardiovascular disease, seizures [1], leukemia[2,3], infections with hepatitis B virus (especially within institutionalized men)[4], upper respiratory tract infections [5], Alzheimer’s disease[6], obesity [7], thyroid diseases [8], cardiac anomalies [9], and obstructive sleep apnea [10,11]. Disruption of the proteostasis network and accumulation of misfolded proteins occur as a result of an abnormality in the number of chromosome 21 [12]. Errors in protein homeostasis could contribute to the observed pathology and decreased cell viability in children with Down syndrome [13].

In these patients, there is a strong predisposition to cardiovascular disease, seizures [1], leukemia [2,3], infections with hepatitis B virus (especially within institutionalized men) [4], upper respiratory tract infections [5], Alzheimer's disease [6], obesity [7], thyroid diseases [8], cardiac anomalies [9], and obstructive sleep apnea [10,11]. Disruption of the proteostasis network and accumulation of misfolded proteins occur as a result of an abnormality in the number of chromosome 21 [12]. Errors in protein homeostasis could contribute to the observed pathology and decreased cell viability in children with Down syndrome [13].
The systematic review and meta-analysis by Saghazadeh A et al, conducted in 2016, concluded that fi ndings of different micronutrient levels in people with Down syndrome raise the question whether these differences are related to the different metabolic profi les, the common comorbidities or merely refl ect Down syndrome [14].

Clinical characteristics
The changes in body of the children with Down syndrome are manifest trough the short stature, short legs and arms,

Oral manifestation
Open mouth with protrusion of the hypotonic and fi ssured tongue, macroglossia, hypoplastic upper jaw, short and hard palate, pseudoprogenic bite, delay eruption of the teeth [15], persistence of some deciduous tooth up to 15 years, the order of eruption of teeth is disturbed [16], hypodontia, microdontia, atypical form of dental crowns and taurodontism [17]. Also patients with Down syndrome can present periodontal disease, premature tooth loss, reduced salivary fl ow, crowding of teeth in both arches, and decreased occlusal vertical dimension.
Increased frequency of periodontal disease, reduced incidence of dental caries [18], often spilling of saliva from the mouth.
In these patients, cleft lip, cleft lip and palate or palate only occurs 3 times more often than in the general population.
The fi ndings by van der Linden MS et al showed that dental development in children with Down syndrome is similar to the development of control children and that a relationship exists between hypodontia and dental development [18,19].

Orthodontic treatment
Before starting of the implementation of the orthodontic treatment within the patients with Down syndrome, it is necessary to restore all decay teeth. If the patient is unable for clinical work, orthodontic treatment can be initiated with a mobile device [22], which usually carried extension of the upper jaw and, if necessary, '' pull '' of the front teeth due to the presence of the pseudoprogenia [23]. Treatment can be continued with a fi xed appliance that compensates dental chains, regulates the placement of the teeth in the dental chains and adjust dental bite [24]. Of course, given that there is some degree of disability in these patients, we must often make trade-offs in the orthodontic therapy [25]. during invasive dental treatment [27].
Considering the great emotional, psychological and material goods that require such member of a family and the modest effects of the expensive therapy, enormous efforts to the prenatal diagnosis are invested nowadays [28][29][30][31]. Prenatal diagnosis of a mother who previously gave birth to a child with trisomy, and in women who give birth after the age of 35 years, signifi cantly reduces the number of children born with the disease. However most of children with Down syndrome remain undetected prenatally.
Resently it's believed that with the analysis of certain ultrasonic parameters associated with the combination of determining  fetal-protein, estriol and  HCG [beta-chorionic gonadotropin] in the mother's blood at the 14th week of pregnancy can be assign degrees of urgency to certain group of pregnant women with the increased risk of delivering a child with trisomy 21. Kochova and its associates [32], considered that this group should undergo prenatal diagnosis by amniocentesis. In this manner 75-80% of pregnancies with a Down syndrome fetus can be detected.

Treatment
In the treatment of children with Down syndrome, the following health professionals are included: pediatricians, family medicine physicians, internists, pediatric dentists, but also the following specialists: a speech-language pathologist [33,34], a physical therapist, an occupational therapist and special education teachers play important role. The main priority of all centers for children with Down syndrome in the world is to provide adequate rehabilitation to these children and their training for independent survival.
Adults with disabilities in our country are employed at a signifi cantly lower rate than adults without disabilities. The situation of the unemployed persons with disabilities is also similar in other countries of the world, even in the United States [33].
Today in many research centers all over the world, the potential pathological mechanisms that cause altered cell physiology in Down syndrome are still under exploration.
We hope that they will contribute to the design of better therapeutic strategies that will improve the quality of life [34][35][36], of people with Downs syndrome.