Find a Registered Dental Hygienist


Knowledge Network

CDHO Advisory: Down Syndrome









Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with Down syndrome.


Cite as College of Dental Hygienists of Ontario, CDHO Advisory Down Syndrome, 2023-04-02


Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).



Down syndrome


Advanced practice nurses
Dental assistants
Dental hygienists
Health professional students
Public health departments
Regulatory bodies


To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have Down syndrome, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.


Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Parents, guardians, and family caregivers of children, young persons and adults with Down syndrome.


For persons who have Down syndrome: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.



Terminology used in this Advisory

Resources consulted

Down syndrome, also known as trisomy 21, is a genetic condition in which a person usually has 47 chromosomes instead of the typical 46.

Other terminology includes

  1. Antibiotic prophylaxis, which  often needs to be considered for persons with Down syndrome because 
    1. more than half of all adult persons have some form of cardiac disorder
    2. antibiotic prophylaxis against infective endocarditis is considered appropriate for persons at highest risk of adverse outcomes from infective endocarditis who undergo dental procedures that involve
      1. manipulation of 
        1. gingival tissue 
        2. periapical region of teeth
      2.  perforation of the oral mucosa 
    3. some of the cardiac disorders require decisions about the advisability or otherwise of antibiotic prophylaxis 
      1. require advice from family physicians or specialists
      2. depend on knowledge that is subject to uncertainty
      3. may require a cardiology consultation.
  2. Cataract, loss of transparency of the lens of the eye.
  3. Glaucoma, increased pressure within the eye.
  4. Strabismus, eyes that 
    1. are misaligned 
    2. point in different directions.
  5. Hand-mouthing, putting the whole hand into the mouth.
  6. Hematemesis, the vomiting of blood, which may be obviously red or have an appearance similar to coffee grounds.

Overview of Down syndrome

Resources consulted


Down syndrome

  1. occurs in one in 781 live births in Canada
  2. is the most common single cause of human birth defects
  3. is associated with health problems, developmental delays and learning disabilities 
  4. is variable in its effects
    1. 85 percent in all children with Down syndrome survive the first year of life
    2. over 50 percent of persons with Down syndrome live beyond 50 years of age
  5. correlates in incidence with maternal age at conception, as follows. 


Down syndrome arises when the body has an extra copy of chromosome 21 (or, less commonly, has another aberration of chromosome 21), which causes problems in the development of the body and brain.

Risk factors

Down syndrome is associated with

  1. risk to a mother of giving birth to a child with Down syndrome that increases as she gets older 
  2. risk to  
    1. babies, of problems with breast feeding because of poor tongue control 
    2. older children and adults, of obesity
    3. adolescents, males and females, of sexual abuse and other types of abuse.

Signs and symptoms

Down syndrome signs and symptoms (see also multimedia and images)

  1. vary from person to person
  2. range from mild to severe
  3. include physical signs, which may not be visible in the new-born child, such as
    1. body frame: relatively small 
    2. cheeks: chubby 
    3. ears: small 
    4. eyes: variously
      1. large and round 
      2. with inner corners that are rounded instead of pointed
      3. with an upward slant 
      4. with white or brownish grey spots on the iris 
    5. face: flat 
    6. feet: small 
    7. hands
      1. small, short and wide
      2. with deep creases in the palm
      3. with short fingers
    8. head: may be round with a flat area on the back
    9. height: most children with the condition never reach their expected average adult height
    10. joints between the bones of the skull: separated
    11. ligaments: loose
    12. mouth
      1. small 
      2. tongue: relatively large 
    13. muscles
      1. tone: decreased at birth
      2. motor development: slow
    14. neck 
      1. short
      2. lax ligaments
    15. nose: flattened
    16. skin: excess at the nape of the neck
  4. involve delayed mental and social development, manifested in
    1. attention span: short
    2. behaviour: impulsive
    3. emotions: frustration and anger resulting from growing awareness of limitations
    4. intellectual abilities and adaptive behaviours: limited
    5. judgment: poor
    6. language development: delayed
    7. learning: slow
  5. manifest as seizures (CDHO Advisory) that 
    1. commonly resemble epileptic seizures, with jerking of arms and legs, and loss of consciousness
    2. may involve staring spells and momentary lapses of attention
    3. affect five to ten percent of persons with Down syndrome, several times the frequency in the general population
    4. affect more older than younger adults
  6. are linked with numerous comorbidities, complications and associated conditions.

Medical investigation

Down syndrome is 

  1. confirmed as a diagnosis after birth
  2. detected by prenatal screening
  3. investigated soon after birth with tests that include
    1. chromosome studies
    2. echocardiogram to detect heart defects
    3. ECG
    4. X-rays of the chest and gastrointestinal tract
  4. screened closely with 
    1. dental examinations, every 6 months
    2. hearing tests, every 6–12 months
    3. pap smears and pelvic examinations, in accordance with prevailing guidelines
    4. thyroid testing, every 12 months
    5. X-rays of the upper or cervical spine between ages 3–5 years
    6. eye examinations, every 12 months during infancy.


Down syndrome 

  1. lacks a cure 
  2. despite considerable effort, continues to lack widely accepted medical treatments for the mental retardation associated with the condition 
  3. has seen vast improvements in care for children and adults with the condition, which 
    1. have brought
      1. considerably improved quality of life 
      2. increased life expectancy 
      3. to many persons productive lives well into adulthood
    2. involve
      1. medical care, health monitoring and healthy living
        1. of relevance to oral healthcare
          1. providing antibiotic prophylaxis, as appropriate, during oral healthcare procedures
          2. addressing swallowing difficulties, which may persist throughout the adolescent years 
          3. providing oral hygiene services
        2. generally
          1. providing behavioural training to 
            1. encourage independence
            2. help persons and their families deal with the  person’s frustration, anger, and compulsive behaviour
          2. providing children with
            1. exercises for gross and fine motor skills
            2. integration into normal classes at school
            3. occupational therapy
            4. special education and attention at school
            5. speech and language therapy focused on expressive language and intelligibility
          3. preventing obesity by 
            1. decreasing caloric intake and increasing activity 
            2. emphasizing a well-balanced diet
          4. following protocols usual for well children, including
            1. immunizations 
            2. childcare generally
            3. oral healthcare
          5. effectively treating skin infections with 
            1. antibiotic ointment or systemic antibiotic therapy
            2. frequent bathing or showering
            3. normal hygiene
            4. weight reduction
          6. providing regular, periodic hearing, eye tests and other screening
          7. encouraging social and recreational programs with friends
          8. evaluating and treating behavioural problems, such as
            1. disruptive behaviour disorders
            2. eating problems
            3. elimination difficulties
            4. phobias
            5. self-injurious behaviour
          9. evaluating and treating psychiatric disorders, such as depression, and self-talk. 


Down syndrome is controlled to some degree by

  1. genetic counseling for persons with a family history of Down syndrome 
  2. Down syndrome screening tests.


Down syndrome prognosis 

  1. is improving because persons with the condition are living 
    1. longer than ever before
    2. independent and productive lives well into adulthood despite physical and mental limitations
  2. is clouded by 
    1. heart problems at birth, which
      1. affect about 50 percent of children with the condition
      2. if severe may lead to early death
    2. certain types of leukemia (CDHO Advisory) which may cause early death
    3. dementia (CDHO Advisory) which may occur in adults with the condition. 

Social considerations

Down syndrome social factors

  1. create family and family caregiver needs for help with
    1. supportive care or counseling
    2. respite care, and behaviour management techniques
    3. referrals for respite care 
    4. parenting problems 
    5. transferring the child to adult health care
  2. involve planning requirements for 
    1. alternative long-term living arrangements such as community living
    2. updating of estate planning and custody arrangements 
  3. draw on support groups, such as those in
    1. Canada
    2. US

Multimedia and images

Genetics of Down Syndrome

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with Down syndrome but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions for Down syndrome are as follows.

  1. Death during adolescence from complications of 
    1. congenital heart disease
    2. infections
    3. leukemia (CDHO Advisory).
  2. Physical health conditions and birth defects, including
    1. celiac disease (CDHO Advisory)
    2. congenital heart disease that 
      1. occurs with varying degrees of severity in up to 50 percent of children compared to less than one percent in the general population
      2. is the most common cause of death in early childhood
      3. includes
        1. atrial septal defect
        2. ventricular septal defect
        3. atrioventricular septal defect
    3. developmental delay, which is common to all children with Down syndrome though it may not be apparent until the child is beyond infancy
    4. eye disorders, which occur in 60 percent of children, and which include
      1. congenital cataracts 
      2. far-sightedness, near-sightedness 
      3. glaucoma
      4. strabismus
    5. gastrointestinal abnormalities which cause
      1. complete obstruction of the small intestine in two to five percent of children
      2. poor movement abilities of the colon and or rectum in two percent of persons
    6. hearing impairment, caused by malformations of the middle or inner ear structures, and present to some degree in 40 to 75 percent of children 
    7. thyroid disorders, which 
      1. occur in about five percent of children 
      2. include hypothyroidism (CDHO Advisory)
    8. immunological compromise
    9. leukemia (CDHO Advisory) which occurs some 20-times more often than in the general population
    10. skeletal problems 
    11. sleep apnea (CDHO Advisory) which may affect as many as one in two persons. 
  3. Neuropsychological conditions, including
    1. anxiety (CDHO Advisory)
    2. dementia (CDHO Advisory) which 
      1. occurs as Alzheimer’s disease from the age of 40 onwards
      2. affects as many as 85 percent of older persons with Down syndrome
    3. depression (CDHO Advisory).
  4. Physical vulnerabilities and susceptibilities, including
    1. airway blockage during sleep
    2. teeth that appear later than normal and in a location that may cause problems with chewing
    3. chronic constipation
    4. compression injury of the spinal cord
    5. hip problems, with risk of dislocation
    6. weakness of the spine at the top of the neck 
    7. increased susceptibility to infections of the
      1. endocardium 
      2. respiratory system
      3. ears, resulting eventually in hearing loss
      4. eyes
    8. gastrointestinal blockage manifested in early and massive vomiting.

Oral health considerations

Resources consulted

Down syndrome and its comorbidities, complication and associated conditions create various considerations in the delivery of oral healthcare; these include

  1. the need to obtain and review the patient/client’s medical history prior to a dental hygiene appointment, necessary for 
    1. assembling an accurate medical history consulting with physicians, family and other caregivers 
    2. determining who can legally provide informed consent for treatment, which is important because
      1. the ability of the patient/client to give informed consent to treatment may be in question because
        1. he or she provides seemingly clear answers to questions that, in fact, he or she insufficiently understands
        2. consent is valid only when the patient/client 
          1. is provided with sufficient and understandable information to enable the decision-making 
          2. understands the information provided
          3. is capable of 
            1. acting voluntarily and not merely in response to pressure
            2. taking the particular decision
            3. weighing the information 
      2. where the patient/client appears unable to give consent that would be considered valid, it may have to be provided by a substitute decision-maker 
  2. consideration of antibiotic prophylaxis during the Procedures when the medical history suggests qualifying cardiac conditions
  3. care with head and neck movements because of the possibility of musculoskeletal instability of the neck owing to ligament laxity
  4. consideration of problems with the respiratory system, with particular reference to the potential for airway obstruction
  5. providing and encouraging effective dental hygiene involving
    1. well organized professional care aimed at ensuring sufficiency in the use and effectiveness of
      1. oral health services
      2. oral hygiene at home
    2. fluoride treatments, good dietary habits, and restorative care 
    3. understanding of the pattern of dental caries in Down syndrome, in which
      1. some children and young adults may have fewer caries than persons without the syndrome, a clinical situation rooted in 
        1. oral abnormalities such as   
          1. delayed eruption of primary and permanent teeth
          2. missing permanent teeth
          3. small-sized teeth with wider spaces between them, facilitating plaque removal 
        2. dietary supervision of children with Down syndrome aimed at combating obesity, which helps reduce consumption of cariogenic foods and beverages 
      2. some adults with Down syndrome are at an increased risk of caries because of
        1. xerostomia
        2. cariogenic food choices
        3. muscle flaccidity, which contributes to chewing problems and inefficient natural cleansing action, allowing food to remain on the teeth after eating 
    4. oligodontia 
    5. periodontal disease
  6. the possibility that the patient/client has health needs that 
    1. are unmet, unrecognized or misunderstood
    2. may create secondary health conditions in the mouth or elsewhere in the body
  7. limited oral, verbal or reading skills that may impede the patient/client in
    1. accepting advice or treatment
    2. persisting with oral-hygiene self-care
  8. dietary and nutritional problems, such as
    1. obesity
    2. refusal to eat
  9. gastrointestinal problems, such as
    1. constipation associated with
      1. intestinal obstruction due to inhibition of bowel motility which may result  if constipation remains undetected for too long
      2. medications
      3. mobility problems
    2. gastro-esophageal reflux disease (CDHO Advisory) manifestations of which include 
      1. dental erosion
      2. hand-mouthing 
      3. hematemesis
      4. increased risk of esophageal cancer
  10. epilepsy, which may create physical danger during the provision of oral healthcare
  11. behavioural problems which
    1. may constitute the patient/client’s means of communicating toothache or mouth pain, among other physical, mental, or social discomforts
    2. may impede cooperation during the provision of oral healthcare 
    3. may reflect psychiatric problems, such as dementia 
  12. overmedication, possibly arising because of
    1. healthcare providers’ difficulties in interpreting the patient/client’s symptoms
    2. delay or vagueness in reporting health problems
    3. the patient/client’s difficulties with adherence to a medication plan
  13. questions of discrimination may arise if a particular treatment is deemed inappropriate for an individual patient/client on grounds of
    1. intellectual disability
    2. communication problems
  14. lack of clarity on the part of the patient/client or the family or other caregiver about treatment and its continuity, a challenge which can be addressed with a written oral healthcare treatment plan that 
    1. is periodically and systematically reviewed
    2. persons or their family caregivers can use for communications with oral and other healthcare professionals
    3. identifies new oral health needs and tracks progress against those previously observed
    4. records conditions drawn to the attention of other healthcare providers
    5. enables family and other caregivers to make and keep notes, and to bring these for subsequent oral healthcare appointments.


Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Medications are available for treating effects, comorbidities, complications and associated conditions of Down syndrome, but not the condition itself. 

Available medications include

  1. antibiotics, for 
    1. antibiotic prophylaxis for qualifying cardiac conditions
    2. respiratory tract infections
    3. ear infections
  2. anticonvulsants, for seizures 
  3. anxiolytics, for relief of anxiety
  4. digitalis and diuretics, for cardiac management
  5. laxatives, for constipation, a particular problem with Down syndrome
  6. pain medication
  7. pneumococcal and influenza vaccination, for children with chronic cardiac and respiratory disease
  8. respiratory medications, such as metered dose inhalers
  9. thyroid hormone, for hypothyroidism, to 
    1. prevent intellectual deterioration
    2. improve the person’s overall function, academic achievement, and vocational abilities.

Side effects of medications used with Down syndrome

In the absence of evidence to the contrary, the side effects of medications used for Down syndrome are likely to be the same as those reported for persons without Down syndrome.


The dental hygienist in taking the medical  and medications history-taking should 

  1. consider the need for special techniques of communication with the patient/client
  2. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  3. explore the need for advice from the primary or specialized care provider(s)
  4. inquire about 
    1. pointers to cardiac defects, such as a history of previous use of antibiotic prophylaxis
    2. symptoms indicative of inadequate control of Down syndrome, such as behavioural and communication problems
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements
    5. problems with previous dental/dental hygiene care
    6. problems with infections generally and specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition


Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.


Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.


  1. Initiation of invasive dental hygiene Procedures is contra-indicated if the patient/client has any cardiac condition for which antibiotic prophylaxis is recommended in the guidelines set by the American Heart Association (AHA) unless the dental hygienist has consulted with either the patient/client’s physician, dentist, or registered nurse in the extended class and determined that it is appropriate to proceed if the patient/client has taken the prescribed medication per the AHA guidelines. 
  2. With an otherwise healthy patient/client whose symptoms are under control and whose treatment is proceeding normally, the dental hygienist should implement the Procedures, though these may be postponed pending medical advice, which may be required if the patient/client has 
    1. a history of
      1. heart defects or problems, and who may need antibiotic prophylaxis
      2. comorbidity, complication or associated condition of Down syndrome
      3. epilepsy or other effects of Down syndrome which could jeopardize physical safety during the Procedures
      4. atlantoaxial instability that cannot be appropriately managed in the dental hygiene setting
    2. not recently or ever sought and received medical advice relative to oral healthcare procedures
    3. recently changed significant medications, under medical advice or otherwise
    4. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    5. expressed or whose family caregiver has expressed deep concern about any aspect of his or her medical condition.


Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.


Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of Down syndrome, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.


  1. The dental hygienist should in conjunction with the patient/client and the family or other caregiver
    1. use special techniques of communication, as required
    2. urge the patient/client or family caregiver to alert any healthcare professional who proposes any intervention or test 
      1. that he or she has a history of Down syndrome
      2. to the medications he or she is taking
    3. should carefully and appropriately explain 
      1. swollen, cracked lips, mouth ulcers, dry mouth, and other conditions observed in the mouth 
      2. the oral health implications of delayed and or irregular eruption sequence of teeth 
      3. infection control within the oral cavity
      4. the importance of the family caregiver or the patient/client’s
        1. checking the mouth regularly for new signs or symptoms
        2. reporting to the appropriate healthcare provider any changes in the mouth
      5. the need for regular oral health examinations and preventive oral healthcare 
      6. oral self-care including information about 
        1. choice of toothpaste
        2. tooth-brushing techniques and related devices
        3. dental flossing
        4. mouth rinses
        5. management of a dry mouth, especially associated with medications
        6. adjuncts to oral self-care, such as reducing infection risk from toothbrushes with chemical rinses
      7. the importance of 
        1. an appropriate diet in the maintenance of oral health, which  involves
          1. non-cariogenic foods and beverages 
          2. avoiding candies and sweet foods as rewards
        2. adjustments to scheduling and duration of appointments to minimize stress and fatigue
        3. comfort level while reclining, and stress and anxiety related to the Procedures
      8. pain management.
  2. The dental hygienists’ communications for providing advice to or taking the medical or oral health history of the patient/client should
    1. begin by first acknowledging the patient/client, prior to addressing the family or other caregiver
    2. be addressed as far as possible to the patient/client, though, as required, an accompanying person should supplement the information provided by the patient/client
    3. include a check of verbal capacities for imbalance between receptive and expressive language skills; even when the person has limited or absent verbal skills, the history-taking should assume competence, and
      1. request the person to allow the accompanying caregiver to interpret
      2. where communication is non-verbal may include the use of communication aids
      3. be accompanied by a request to the person/client or caregiver for sight of treatment plans and available medical documentation and prescription lists, so these can be updated if necessary
      4. make clear that if the person wants the accompanying caregiver to leave during the consultation, the request will be respected
    4. focus on abilities, not disabilities 
    5. rely not only on words but also on pictures, gestures, and body language
    6. take account of challenging behaviour, to identify patterns associated with pain or discomfort
    7. be phrased in respectful language, unrushed in delivery and accompanied by explanations understandable to the patient/client. 



  1. Promoting health through oral hygiene for persons who have Down syndrome.
  2. Reducing the adverse effects, such as stress by
    1. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    2. using appropriate techniques of communication
    3. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet. 


  1. Causing oral healthcare to be avoided or neglected because of inadequate communication with the patient/client or family or other caregiver.
  2. Performing the Procedures at an inappropriate time, such as 
    1. in the absence of 
      1. consideration of any requirement for antibiotic prophylaxis
      2. necessary medical information relative to the patient/client’s medical condition, comorbidities, complications and associated conditions
    2. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with Down syndrome.
  4. Inappropriate management of pain or medication.






2011-10-01; 2018-10-08; 2023-04-02


College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists


College of Dental Hygienists of Ontario


College of Dental Hygienists of Ontario, Practice Advisors


Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow

Lisa Taylor

Giulia Galloro

Carolle Lepage


The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2018, 2023 College of Dental Hygienists of Ontario


1 Persons includes young persons and children.