U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES l National Institutes of Health l National Institute of Dental and Craniofacial Research

P

roviding oral care to people with Down syndrome requires 

adaptation of the skills you use every day. In fact, most people with 

mild or moderate Down syndrome can be successfully treated in 

the general practice setting. This booklet will help you make a difference in 

the lives of people who need professional oral care.

Down syndrome, a common genetic disorder, ranges in severity and is 

usually associated with medical and physical problems. For example, 

people with this developmental disability may have cardiac disorders, 

infectious diseases, hypotonia, and 

hearing loss. Additionally, most 

people with this disorder have mild or 

moderate mental retardation, while a 

small percentage are severely affected. 

Developmental delays, such as in 

speech and language, are common.

Practical Oral Care 

for People With Down Syndrome

contents

Health Challenges IN

down syndrome and 

Strategies for Care

2 . . . . . . . . . . . . . . . . . . . . . 

Mental retardation

Behavior management

3 . . . . . . . . . . . . . . . . . . . . . 

Medical conditions

Cardiac disorders

Compromised immune 

systems

Hypotonia

4 . . . . . . . . . . . . . . . . . . . . . 

Seizures

Hearing loss and deafness

Visual impairments

Oral health problems 

IN down syndrome 

and strategies for 

care

5 . . . . . . . . . . . . . . . . . . . . . 

Periodontal disease

Dental caries

6 . . . . . . . . . . . . . . . . . . . . . 

Orofacial features

Malocclusion

Tooth anomalies

7 . . . . . . . . . . . . . . . . . . . . . 

Trauma and injury

Additional Readings

Early professional 

treatment and 

daily oral care at 

home can allow 

people with Down 

syndrome to enjoy 

the benefits of a 

healthy mouth.
People with Down syndrome may present 

with mental and physical challenges that 

have implications for oral care. Before 

the appointment, obtain and review the 

patient’s medical history. Consultation 

with physicians, family, and caregivers is 

essential to assembling an accurate medical history. Also, determine who can legally 

provide informed consent for treatment.

Mental retardation. Although the 

intellectual ability of people with Down 

syndrome varies widely, many have mild 

or moderate mental retardation that limits 

their ability to learn, communicate, and 

adapt to their environment. Language 

development is often delayed or impaired 

in people with Down syndrome; they 

understand more than they can verbalize. 

Also, ordinary activities of daily living and 

understanding the behavior of others as 

well as their own can present challenges.

Listen actively, since speaking may 

be difficult for people with Down 

syndrome. Show your patient whether 

you understand.

Talk with the parent or caregiver to 

determine your patient’s intellectual 

and functional abilities, then explain 

each procedure at a level the patient can 

understand. Allow extra time to explain 

oral health issues or instructions and 

demonstrate the instruments you will 

use.

Use simple, concrete instructions, and 

repeat them often to compensate for any 

short-term memory problems.

Behavior management is not 

usually a problem in people with Down 

syndrome because they tend to be warm 

and well behaved. Some can be stubborn 

or uncooperative, but most just need 

a little extra time and attention to feel 

comfortable. Gaining the patient’s trust is 

the key to successful treatment.

Talk to the caregiver or physician 

about techniques they have found to 

be effective in managing the patient’s 

behavior. Share your ideas with them, 

and find out what motivates the patient. 

It may be that a new toothbrush at the 

end of each appointment is all it takes to 

ensure cooperation.

Schedule patients with Down syndrome 

early in the day if possible. Early 

appointments can help ensure that 

everyone is alert and attentive and that 

waiting time is reduced.

Set the stage for a successful visit by 

involving the entire dental team—from 

the receptionist’s friendly greeting to the 

caring attitude of the dental assistant in 

the operatory.

Provide oral care in an environment 

with few distractions. Try to reduce 

unnecessary sights, sounds, or other 

stimuli that might make it difficult for 

your patient to cooperate. Many people 

with Down syndrome, however, enjoy 

music and may be comforted by hearing 

it in the dental office during treatment.

Plan a step-by-step evaluation, starting 

with seating the patient in the dental 

chair. If this is successful, perform 

an oral examination using only your 

fingers. If this, too, goes well, begin 

using dental instruments. Prophylaxis 

is the next step, followed by dental radiographs. Several visits may be needed to 

accomplish these tasks.

Try to be consistent in all aspects of 

providing oral health care. Use the same 

staff, dental operatory, appointment 

times, and other details to help sustain 

familiarity. The more consistency you 

provide for your patients, the more 

likely that they will be cooperative. 



Health Challenges in Down 

Syndrome and Strategies for Care

Address your 

patient directly 

and with respect.
down syndrome

Comfort people who resist oral care and 

reward cooperative behavior with compliments throughout the appointment.

Use immobilization techniques only 

when absolutely necessary to protect 

the patient and staff during dental treatment—not as a convenience. There are 

no universal guidelines on immobilization that apply to all treatment settings. 

Before employing any kind of immobilization, it may help to consult available 

guidelines on federally funded care, your 

State department of mental retardation/

mental health, and your State Dental 

Practice Act. Guidelines on behavior 

management published by the American 

Academy of Pediatric Dentistry (www.

aapd.org) may also be useful. Obtain 

consent from your patient’s legal guardian and choose the least restrictive technique that will allow you to provide care 

safely. Immobilization should not cause 

physical injury or undue discomfort.

Medical conditions. Though their 

average life expectancy has risen to the 

mid-50s, people with Down syndrome are 

still at risk for problems in nearly every system in the body. Some problems are manifested in the mouth. For example, oral 

findings such as persistent gingival lesions, 

prolonged wound healing, or spontaneous gingival hemorrhaging may suggest an 

underlying medical condition and warrant 

consultation with the patient’s physician.

Cardiac disorders are common 

in Down syndrome. In fact, mitral valve 

prolapse occurs in more than half of all 

adults with this developmental disability. 

Many others are at risk of developing valve 

dysfunction that leads to congestive heart 

failure, even if they have no known cardiac 

disease. To reduce the risk of bacterial 

endocarditis, consider antibiotic prophylaxis (www.americanheart.org). Consult the 

patient’s physician if you have questions 

about the medical history.

Compromised immune systems

lead to more frequent oral and systemic 

infections and a high incidence of periodontal disease in people with Down syndrome. Aphthous ulcers, oral Candida

infections, and acute necrotizing ulcerative 

gingivitis are common. Chronic respiratory 

infections contribute to mouth breathing, 

xerostomia, and fissured lips and tongue.

Treat acute necrotizing ulcerative gingivitis and other infections aggressively.

Talk to patients and their caregivers 

about preventing oral infections with 

regular dental appointments and daily 

oral care.

Stress the importance of using fluoride 

to prevent dental caries associated with 

xerostomia.

Use lip balm during treatment to ease 

the strain on your patient’s lips.

Hypotonia affects the muscles in 

various areas of the body, including the 

mouth and large skeletal muscles. When 

it involves the mouth, it leads to an imbalance of forces on the teeth and contributes 

to an open bite. If the muscles controlling facial expression and mastication are 

affected, problems with chewing, swallowing, drooling, and speaking can result. A 

related problem is atlantoaxial instability, a 

spinal defect that increases the mobility of 

the cervical vertebrae and often leads to an 

unsteady gait and neck pain.

Maintain a clear path for movement 

throughout the treatment setting. 

Determine the best position for your 

patient in the dental chair and the safest 

way to move his or her body, especially 

the head and neck. Talk with the physician or caregiver about ways to protect 

the spinal cord. Use pillows to stabilize 

your patient and make him or her more 

comfortable.



More than half 

of all adults with 

Down syndrome 

experience mitral 

valve prolapse.
Seizures sometimes occur in this population, especially among infants, but can 

usually be controlled with anticonvulsant 

medications. The mouth is always at risk 

during a seizure: Patients may chip teeth or 

bite the tongue or cheeks. People with controlled seizure disorders can easily be treated 

in the general dental office.

Consult your patient’s physician. Record 

information in the chart about the frequency of seizures and the medications 

used to control them. Determine before 

the appointment whether medications 

have been taken as directed. Know 

and avoid any factors that trigger your 

patient’s seizures.

Be prepared to manage a seizure. If 

one occurs during oral care, remove 

any instruments from the mouth and 

clear the area around the dental chair. 

Attaching dental floss to rubber dam 

clamps and mouth props when treatment begins can help you remove them 

quickly. Do not attempt to insert any 

objects between the teeth during a seizure.

Stay with your patient, turn him or her 

to one side, and monitor the airway to 

reduce the risk of aspiration.

Hearing loss and deafness may 

further complicate poor communication 

skills, but these, too, can be accommodated with planning. Patients with a hearing problem may appear to be stubborn 

because of their seeming lack of response to 

a request.

Patients may want to adjust their 

hearing aids or turn them off, since the 

sound of some instruments may cause 

auditory discomfort.

If your patient reads lips, speak in a normal cadence and tone. If your patient 

uses a form of sign language, ask the 

interpreter to come to the appointment. 

Speak with this person in advance to 

discuss dental terms and your patient’s 

needs.

Visual feedback is helpful. Maintain eye 

contact with your patient. Before talking, eliminate background noise (turn off 

the radio and the suction). Sometimes 

people with a hearing loss simply need 

you to speak clearly in a slightly louder 

voice than normal. Remember to 

remove your facemask first or wear a 

clear face shield.

Visual impairments such as 

strabismus (crossed or misaligned eyes), 

glaucoma, and cataracts can affect people 

with Down syndrome.

Determine the level of assistance your 

patient requires to move safely through 

the dental office.

Use your patients’ other senses to 

connect with them, establish trust, 

and make treatment a better experience. Tactile feedback, such as a warm 

handshake, can make your patients feel 

comfortable.

Face your patients when you speak and 

keep them apprised of each upcoming 

step, especially when water will be used. 

Rely on clear, descriptive language to 

explain procedures and demonstrate 

how equipment might feel and sound. 

Provide written instructions in large 

print (16 point or larger). 



Record in the patient’s chart 

strategies that were successful in 

providing care. Note your patient’s 

preferences and other unique 

details that will facilitate treatment, 

such as music, comfort items, and 

flavor choices.
down syndrome

People with Down syndrome have no 

unique oral health problems. However, 

some of the problems they have tend to 

be frequent and severe. Early professional 

treatment and daily care at home can 

mitigate their severity and allow people 

with Down syndrome to enjoy the benefits 

of a healthy mouth.

Periodontal disease is the most 

significant oral health problem in people 

with Down syndrome. Children experience rapid, destructive periodontal disease. 

Consequently, large numbers of them lose 

their permanent anterior teeth in their 

early teens. Contributing factors include 

poor oral hygiene, malocclusion, bruxism, 

conical-shaped tooth roots, and abnormal 

host response because of a compromised 

immune system.

Some patients benefit from the daily 

use of an antimicrobial agent such as 

chlorhexidine. Recommend an appropriate delivery method based on your 

patient’s abilities. Rinsing, for example, 

may not work for a person who has 

swallowing difficulties or one who 

cannot expectorate. Chlorhexidine 

applied using a spray bottle or toothbrush is equally efficacious.

If use of particular medications has led 

to gingival hyperplasia, emphasize the 

importance of daily oral hygiene and 

frequent professional cleanings.

Encourage independence in daily oral 

hygiene. Ask patients to show you how 

they brush, and follow up with specific 

recommendations on brushing methods or toothbrush adaptations. Involve 

patients in hands-on demonstrations of 

brushing and flossing.

Some people with Down syndrome 

can brush and floss independently, but 

many need help. Talk to their 

caregivers about daily oral hygiene. 

Do not assume that all caregivers know 

the basics; demonstrate proper brushing and flossing techniques. A power 

toothbrush or a floss holder can simplify 

oral care. Also, use your experiences 

with each patient to demonstrate sitting 

or standing positions for the caregiver. 

Emphasize that a consistent approach 

to oral hygiene is important—caregivers should try to use the same location, 

timing, and positioning.

Dental caries. Children and young 

adults who have Down syndrome have 

fewer caries than people without this developmental disability. Several associated oral 

conditions may contribute to this fact: 

delayed eruption of primary and permanent teeth; missing permanent teeth; and 

small-sized teeth with wider spaces between 

them, which make it easier to remove 

plaque. Additionally, the diets of many 

children with Down syndrome are closely 

supervised to prevent obesity; this helps 

reduce consumption of cariogenic foods 

and beverages.

By contrast, some adults with Down syndrome are at an increased risk of caries due 

to xerostomia and cariogenic food choices. 

Also, hypotonia contributes to chewing 

problems and inefficient natural cleansing 

action, which allow food to remain on the 

teeth after eating.



Oral Health Problems in Down 

Syndrome and Strategies for Care

Tips for caregivers are available in the booklet

Dental Care Every Day: A Caregiver’s Guide, also part of this series.
Advise patients taking medicines that 

cause xerostomia to drink water often. 

Suggest taking sugar-free medicines if 

available and rinsing with water after 

dosing.

Recommend preventive measures such 

as topical fluoride and sealants. Suggest 

fluoride toothpaste, gel, or rinse, 

depending on your patient’s needs and 

abilities.

Emphasize noncariogenic foods and 

beverages as snacks. Advise caregivers 

to avoid using sweets as incentives or 

rewards.

Several orofacial features are characteristic of people with Down syndrome. 

The midfacial region may be underdeveloped, affecting the appearance of the lips, 

tongue, and palate.

The maxilla, the bridge of the nose, 

and the bones of the midface region are 

smaller than in the general 

population, creating a 

prognathic occlusal 

relationship. Mouth 

breathing may 

occur because of 

smaller nasal passages, and the 

tongue may protrude because 

of a smaller 

midface region. 

People with Down 

syndrome often have 

a strong gag reflex 

due to placement of 

the tongue, as well 

as anxiety associated 

with any oral stimulation.

The palate, although normal sized, 

may appear highly vaulted and narrow. 

This deceiving appearance is due to the 

unusual thickness of the sides of the 

hard palate. This thickness restricts the 

amount of space the tongue can occupy 

in the mouth and affects the ability to 

speak and chew.

The lips may grow large and thick. 

Fissured lips may result from chronic 

mouth breathing. Additionally, hypotonia may cause the mouth to droop 

and the lower lip to protrude. Increased 

drooling, compounded by a chronically 

open mouth, contributes to angular 

cheilitis.

The tongue also develops cracks and 

fissures with age; this condition can 

contribute to halitosis. 

Malocclusion is found in most 

people with Down syndrome because of 

the delayed eruption of permanent teeth 

and the underdevelopment of the maxilla. 

A smaller maxilla contributes to an open 

bite, leading to poor positioning of teeth 

and increasing the likelihood of periodontal 

disease and dental caries.

Orthodontia should be carefully 

considered in people with Down 

syndrome. Some may benefit, while 

others may not.

In and of itself, Down syndrome is not a 

barrier to orthodontic care. The ability 

of the patient or caregiver to maintain 

good daily oral hygiene is critical to the 

feasibility and success of treatment.

TOOth anomalies are common in 

Down syndrome.

Congenitally missing teeth occur more 

often in people with Down syndrome 

than in the general population. Third 

molars, laterals, and mandibular second 

bicuspids are the most common missing 

teeth.


down syndrome

Delayed eruption of teeth, often following 

an abnormal sequence, affects some children with Down syndrome. Primary teeth 

may not appear until age 2, with complete 

dentition delayed until age 4 or 5. Primary 

teeth are then retained in some children 

until they are 14 or 15.

Irregularities in tooth formation, such 

as microdontia and malformed teeth, are 

also seen in people with Down syndrome. 

Crowns tend to be smaller, and roots are 

often small and conical, which can lead to 

tooth loss from periodontal disease. Severe 

illness or prolonged fevers can lead to 

hypoplasia and hypocalcification.

• Examine a child by his or her first 

birthday and regularly thereafter to help 

identify unusual tooth formation and 

patterns of eruption.

• Consider using a panoramic radio­graph 

to determine whether teeth are congenitally missing. Patients often find this 

technique less threatening than individual films.

• Maintain primary teeth as long as possible. Consider placing space maintainers where teeth are missing.

TRAUMA and INJURY to the mouth 

from falls or accidents occur in people with 

Down syndrome. Suggest a tooth-saving kit 

for group homes. Emphasize to caregivers 

that traumas require immediate professional 

attention and explain the procedures to follow 

if a permanent tooth is knocked out. Also, 

instruct caregivers to locate any missing pieces 

of a fractured tooth, and explain that radiographs of the patient’s chest may be necessary 

to determine whether any fragments have been 

aspirated.

Physical abuse often presents as oral trauma. 

Abuse is reported more frequently in people 

with developmental disabilities than in the 

general population. If you suspect that a child 

is being abused or neglected, State laws require 

that you call your Child Protective Services 

agency. Assistance is also available from the 

Childhelp® USA National Child Abuse 

Hotline at (800) 422–4453 or the National 

Clearinghouse on Child Abuse and Neglect 

Information (http://nccanch.acf.hhs.gov).

Making a difference in the oral health 

of a person with Down syndrome may 

go slowly at first, but determination can 

bring positive results—and invaluable 

rewards. By adopting the strategies 

discussed in this booklet, you can have 

a significant impact not only on your 

patients’ oral health, but on their quality 

of life as well.

Additional Readings

Hannequin M, Veyrune J-L. Significance of 

oral health in persons with Down syndrome: a 

literature review. Developmental Medicine and 

Child Neurology, 41:275–283, 1999.

Pilcher ES. Dental care for the patient with 

Down syndrome. Down Syndrome Research 

and Practice, 5(3):111–116, 1998.

Roizen NJ. Down syndrome. In Batshaw 

ML. Children With Disabilities (5th ed.). 

Baltimore, MD: Paul H. Brookes Publishing 

Co., 2002. pp. 307–320.



For more information about Down syndrome, contact

National Institute of Child Health and Human 

Development Information Resource Center

P.O. Box 3006

Rockville, MD 20847

(800) 370–2943

www.nichd.nih.gov 

NICHDInformationResourceCenter@mail.nih.gov
This booklet is one in a series on providing oral care for people 

with mild or moderate developmental disabilities. The issues and 

care strategies listed are intended to provide general guidance on 

how to manage various oral health challenges common in people 

with Down syndrome.

Other booklets in this series:

Continuing Education: Practical Oral Care for People

 With Developmental Disabilities

Practical Oral Care for People With Autism

Practical Oral Care for People With Cerebral Palsy

Practical Oral Care for People With Mental Retardation

Wheelchair Transfer: A Health Care Provider’s Guide

Dental Care Every Day: A Caregiver’s Guide

For additional copies of this booklet, contact

National Institute of Dental and Craniofacial Research

National Oral Health Information Clearinghouse

1 NOHIC Way

Bethesda, MD 20892–3500

(301) 402–7364

www.nidcr.nih.gov

This publication is not copyrighted. 

Make as many photocopies as you need.

NIH Publication No. 06–5193

Reprinted May 2006

Acknowledgments

The National Institute of Dental and Craniofacial Research 

thanks the oral health professionals and caregivers who 

contributed their time and expertise to reviewing and 

pretesting the Practical Oral Care series.

Expert Review Panel

• Mae Chin, RDH, University of Washington, Seattle, WA

• Sanford J. Fenton, DDS, University of Tennessee, Memphis, TN

• Ray Lyons, DDS, New Mexico Department of Health, 

Los Lunas, NM

• Christine Miller, RDH, University of the Pacific, 

San Francisco, CA

• Steven P. Perlman, DDS, Special Olympics Special Smiles, 

Lynn, MA

• David Tesini, DMD, Natick, MA

NATIONAL INSTITUTE OF

DENTAL AND CRANIOFACIAL

RESEARCH

National Institute of Dental 

and Craniofacial Research

Centers for Disease Control 

and Prevention

National Institute of Child Health 

and Human Development

Special Care Dentistry