Providing Exemplary & Purposeful Care to the Down Syndrome Patient within a Dental Setting

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8th Feb 2020 Health And Social Care Reference this

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Abstract

As a dental hygiene professional, one must be prepared to deal with all different types of patients. Along with the vast amounts of personalities, ethnicities, and cultures, a dental hygienist must also be properly equipped to deal with patients that have special needs, in particular, patients that are diagnosed with down syndrome. Down syndrome patients need more skilled training from the healthcare professional in understanding their social, emotional, and physical barriers in comparison with those who are not special needs. There are different techniques that can be utilized to help these patients have an enjoyable experience at the dental office, as well as allow the clinician to do their best to help keep the patient in as much of a healthy state as possible.

Keywords: Dental Professional, Dental Hygiene, Dental, Down Syndrom

Providing Exemplary & Purposeful Care to the Down Syndrome Patient within a Dental Setting

Dental Field Concerns.

 Persons with Down syndrome are steadily on the rise in the United States. Every year hundreds of children are born with Down syndrome. With thousands of people containing this disease, it makes it very relevant for a dental professional to fully understand what it is, why it occurs, and how you can most appropriately treat the patient upon the caregiver scheduling an appointment with the dental hygienist. With so many people out there with this disease, it is imperative that a dental professional feel comfortable and skilled enough to trust that they have the appropriate training to master this appointment. Training in the dental hygiene program can be very fast paced with a vast amount of information, so sometimes proper treatment for patients with disabilities such as the common Down syndrome can be easily overlooked. This research has been purposely focused for the dental hygiene professional to become familiar and comfortable with treating a patient that is diagnosed with Down syndrome.

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What is Down Syndrome.

 Down Syndrome is a defect that happens before conception. It is when during the developmental stages, an extra chromosome is formed. This chromosome is considered chromosome 21. Chromosomes make up the bodies DNA and Gene make up which determines several different things such as a person’s physical and mental thought processes (Genes and Genetics Explained 2012). The extra copy of the chromosome is named Trisomy, and since it is chromosome 21, Down syndrome can also be classified as Trisomy 21. It’s been reported that the United States alone averages 6,000 babies a year that are diagnosed with Down Syndrome average out to 1 out of every 700 babies (CDC 2018). Out of all these cases, it is also reported that 80% of diagnosed are done so to mothers that are under the age of 35 years and since it is a genetic condition, after the mother gives birth to one Trisomy 21 child, the chances are far greater that it will happen to the second child (NDSS 2018). This chromosomal condition can be characterized into 3 different forms. Trisomy 21, Translocation Down syndrome, and Mosaic Down syndrome are amongst the 3 with Trisomy 21 account for the biggest of Down syndrome cases. Trisomy 21 is responsible for approximately 95% of people diagnosed with Down syndrome. It is called Trisomy because instead of only having 2 copies of Chromosomal 21, the babies are born with 3 copies of it. Translocation Down syndrome occurs in only 3% of people with Down syndrome and attaches on to another chromosome. The last type is Mosaic Down syndrome which basically means that their chromosome 21 is mixed in with all the chromosome, and some may have 3 and some may have the normal 2. Mosaic Down syndrome only accounts for the last 2% of patients diagnosed with Down Syndrome (CDC 2018).

When diagnosed with Down syndrome, it remains with them for life since there is no cure at the moment. However, with a screening test, parents can usually know pretty early if their child is at risk for Down syndrome. CDC (2018) states, “Screening tests often include a combination of a blood test, which measures the amount of various substances in the mother’s blood (e.g., MS-AFP, Triple Screen, Quad-screen), and an ultrasound, which creates a picture of the baby (CDC 2018). Screening, however, does not guarantee there will be something wrong, but does help get the process started of seeing things that look suspicious such as abnormal extra fluid around the baby’s neck. This then convinces the doctors to run some diagnostic test to confirm what may be going on with the child while developing in the womb. Prenatal diagnostic test usually has a 100% accuracy for the mother on if the child has Down syndrome, which can help the families prepare a little in advance. Prenatal test includes chronic villus sampling (CVS) which needs to be done within the first 9 to 14 weeks, and amniocentesis can be administered within 15-20 weeks of gestation (NDSS 2018). Percutaneous umbilical blood sampling (PUBS) is also another determining factor that can be utilized by blood samples from the umbilical cord, amniocentesis test the fluid in the amniotic sac, and CVS test material in the placenta (CDC 2018).

Clinical Presentations of Patients with Down Syndrome.

 Although there are only 3 types of Down syndrome, there are still traits and characteristics that remain similar to every majority of Down syndrome patients. Many patients with Down syndrome are presented with hearing loss, sleep apnea, heart defects such as Mitrovalve prolapse and diastolic dysfunction, eye diseases, and ear infections (CDC 2018). Likewise, there are other visible characteristics that might help one identify a person diagnosed with Down syndrome. Many patients with Down syndrome can be characterized as having short and stubby fingers and hands, and transverse palm crease. These patients are usually present with lack of muscle tone, noticeable awkward waddle, short with a short neck, flattened face and nose that appears to be underdeveloped, cross eyes, and narrow opening eyes. These patients are also known to have seizures, Alzheimer’s disease, weakened immune system, and airway issues.  (Wilkins, E. M. (2017).

 When thinking of a special needs patient, most would think that the patient depends on the clinician or the caregiver to do everything for them. Down syndrome patient’s abilities can always vary upon severity, but most are very high function individuals. There may be some negative characteristics such as not being able to focus for long periods of time, the behavior may be spontaneous, stubborn, or there may be some delayed language development. Although, there are positives that come with Downs such as:

  • Socially advanced
  • High intellectual functions
  • Enjoy games and background music
  • Admire getting attention
  • Not very irritable, happy, sociable
  • Observant
  • Enjoy imitating

Knowing these different characteristics and traits can later play to the advantage of the clinician in order to better understand the patient. If the clinician is aware that the patient enjoys imitating, music, and games, then it would be advisable to have some fun light-hearted music playing in the background, and have some toothbrushes and teeth to play with to demonstrate appropriately to the patient. (Wilkins, E. M. (2017).

Dental Hygiene Considerations

Dental Characteristics that are common amongst Down Syndrome Patients.

 There are a variety of characteristics that are very common amongst persons with Down syndrome that can be observed in and around the oral mucosa. Some of these characteristics include a protruded tongue. Many do not keep their tongue inside their mouth. Mouth breathing occurs a lot amongst these patients, fissured and expanded tongue is present, and narrow and vaulted palate. One must also be aware of scars and broken or fractured teeth due to accidents that these individuals are prone to. Patients with Down syndrome are also present with irregular eruption patterns than those of normal children and adolescents. Along with irregular patterns, they also have congenitally missing teeth, microdontia is sometimes present, and pronounced spacing in-between teeth. These patients are usually present with posterior crossbites and Angle’s Class III (Park, J. U., & Baik, S.H. 2001). Knowing these things can give the clinician an opportunity to explain to the caregivers that this is normal for people with Down syndrome and to not be too alarmed.

Treatment Plan Modification.

 Patient Needs. In response to the patient’s conditions such as airway obstruction due to their sleep apnea, enlarged tonsils, and macroglossia, it is recommended that a clinician thinks about where to appropriate position chair in order for the patient to not gag, and to make sure you have constant suctioning for fluids. Semi-supine position might be best for the patient to feel most comfortable and at ease. Usually, the patient will do just fine if you slowly introduce new things to them and try not to just speed through without allowing the patient to get comfortable with you first because it might evoke unfavorable behavior problems (Wilkins, E. M. (2017).

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 Systemic Conditions. Due to patients having increased risk of heart defects, a clinician must first consider if the patient needs a medical clearance before working on them. It is imperative that dental professionals are communicating with their other health care providers if there are other systemic things currently going on. The risk with heart defects can also be correlated to their weakened immune system, and clinicians need to be aware if it patient needs to be medicated before undergoing dental procedures to prevent bacterial infections (Wilkins, E. M. (2017). Persons with Down syndrome also have issues with gastroesophageal reflux which is in part to having hypothyroidism (Underactive Thyroid – NIH 2016). Acid erosion would be visible by the clinician in response to the acid reflux. Celiac disease is also a prominent systemic disease which is good for counseling the patient and caregiver on if they are not aware. Patient’s caregiver should be advised that staying away from gluten might be most appropriate to the patient if they ever begin to see issues or intolerance (NIH 2018).

Dental Hygiene OHI Recommendations for Down Syndrome Patients.

 Brushing & Mouth Rinsing. As far as instructions for the patient, it will vary based on the patient’s cognitive level or hand dexterity that is available. The clinician must be aware if the patient is motivated to brush his or her teeth themselves, and if they are able to do it appropriately. Possibly offering the patient a toothbrush with a big handle or showing the caregiver how to make one utilizing sponge or a tennis ball to make the handle larger for the patient would be great tips to ensure the patient does not struggle and become discouraged while brushing. It would be advisable to also teach the patient how to rinse with mouthwash after each meal to help reach every area of the mouth for proper oral health. Usually, these patients are on many medications for their different systemic issues which could also cause xerostomia, so the dental hygienist must be aware of this and inform patient and caregiver of the necessity to try using a mouthwash with zero alcohol or a Biotene product to keep the mouth from getting to dry (Wilkins, E. M. (2017).

Methods to deliver Oral Hygiene Instructions. Method of delivery will vary based on the patient’s cognitive level. The clinician must be aware of what patient is able to do and understand themselves or what may be necessary for caregiver to do for them. Although explaining to the caregiver is acceptable, it is recommended that clinician show patient and allow them to try, as well as show caregiver appropriate way to help the patient. The clinician needs to be aware that although caries rate can be low for these patients as children due to the spacing of teeth, there is still the possibility of obtaining caries if food remains on the teeth. Due to the patient having hypotonia, the weak muscles does not allow the masseter to completely chew the food all the way which, in result, causes food to be left on the teeth. Without proper maintenance or brushing, this could eventually cause decay. Not only can decay occur but caregivers must be educated on periodontal disease if there is poor oral health care at home. With malocclusion, bruxism, conical shaped roots, and compromised immune system, it makes them even more susceptible to periodontal disease. Allow the caregiver to understand how much bacteria can be in the mouth and the issues that periodontal disease can cause later for them financially and for the patient’s oral health and eating habits.

Community Involvement and Interventions. As a dental hygiene clinician, it is imperative that communities are being reached, educated, and encouraged to focus on their oral health and seek treatment. It usually is not that these individuals do not want to take care of their oral health, but perhaps it has been placed on the back burner amongst all other things and never been stressed. When clinicians go out into the community to different facilities or rehabilitation establishments, it allows one to bring awareness to all the individuals. Clinicians should be prepared to bring things for the Down syndrome patients so it can be interesting, interactive, and fun. Clinicians should also bring brochures or pamphlets to go home with caregivers, specifying the importance of oral health and how to prevent periodontal disease. Then it should be group specific somewhere on the pamphlet saying that one is trained and skilled in working with special needs or Down syndrome, this way the caregiver feels as if they will be in good hands if they bring them to the specified clinic. It is the clinician’s job to make the patient feel individualized and important, and to reveal to the caregiver the clinician really cares. Many times, patients without special needs are unaware of the importance of taking care of their oral health, so it is even more imperative for clinicians to advocate to caregivers of special needs who are already compromised and disadvantaged in many ways. One must show concern and that they are aware of all the other things that a caregiver must deal with on a daily basis, but to ensure them that the primary goal is to save the patient’s teeth and prevent malnutrition, and infection. If you clinician can go out in the community and make oral health a daily priority, then this is what makes a difference in patients lives long term.

 

Conclusion.

In conclusion, the findings of this research paper was to inform and educate dental hygienist on how to appropriately treat patients with down syndrome. More often than not, dental hygienist may not have the opportunity to work with a Down syndrome patient while in school, but it is imperative to still be able to adequately assess the patient’s needs and to be a well-rounded clinician that can treat any type of patient even if you only work for a private or general practice, and not a hospital setting. The skills that were addressed may not make the clinician an expert on every patient with Down syndrome, since each case can still vary greatly, but it will at least be a practical guide to be informed on the most common traits of Down syndrome, some appropriate steps to take, and know what it means to work with Down Syndrome, also known as Trisomy 21.

 

References

Abstract

As a dental hygiene professional, one must be prepared to deal with all different types of patients. Along with the vast amounts of personalities, ethnicities, and cultures, a dental hygienist must also be properly equipped to deal with patients that have special needs, in particular, patients that are diagnosed with down syndrome. Down syndrome patients need more skilled training from the healthcare professional in understanding their social, emotional, and physical barriers in comparison with those who are not special needs. There are different techniques that can be utilized to help these patients have an enjoyable experience at the dental office, as well as allow the clinician to do their best to help keep the patient in as much of a healthy state as possible.

Keywords: Dental Professional, Dental Hygiene, Dental, Down Syndrom

Providing Exemplary & Purposeful Care to the Down Syndrome Patient within a Dental Setting

Dental Field Concerns.

 Persons with Down syndrome are steadily on the rise in the United States. Every year hundreds of children are born with Down syndrome. With thousands of people containing this disease, it makes it very relevant for a dental professional to fully understand what it is, why it occurs, and how you can most appropriately treat the patient upon the caregiver scheduling an appointment with the dental hygienist. With so many people out there with this disease, it is imperative that a dental professional feel comfortable and skilled enough to trust that they have the appropriate training to master this appointment. Training in the dental hygiene program can be very fast paced with a vast amount of information, so sometimes proper treatment for patients with disabilities such as the common Down syndrome can be easily overlooked. This research has been purposely focused for the dental hygiene professional to become familiar and comfortable with treating a patient that is diagnosed with Down syndrome.

What is Down Syndrome.

 Down Syndrome is a defect that happens before conception. It is when during the developmental stages, an extra chromosome is formed. This chromosome is considered chromosome 21. Chromosomes make up the bodies DNA and Gene make up which determines several different things such as a person’s physical and mental thought processes (Genes and Genetics Explained 2012). The extra copy of the chromosome is named Trisomy, and since it is chromosome 21, Down syndrome can also be classified as Trisomy 21. It’s been reported that the United States alone averages 6,000 babies a year that are diagnosed with Down Syndrome average out to 1 out of every 700 babies (CDC 2018). Out of all these cases, it is also reported that 80% of diagnosed are done so to mothers that are under the age of 35 years and since it is a genetic condition, after the mother gives birth to one Trisomy 21 child, the chances are far greater that it will happen to the second child (NDSS 2018). This chromosomal condition can be characterized into 3 different forms. Trisomy 21, Translocation Down syndrome, and Mosaic Down syndrome are amongst the 3 with Trisomy 21 account for the biggest of Down syndrome cases. Trisomy 21 is responsible for approximately 95% of people diagnosed with Down syndrome. It is called Trisomy because instead of only having 2 copies of Chromosomal 21, the babies are born with 3 copies of it. Translocation Down syndrome occurs in only 3% of people with Down syndrome and attaches on to another chromosome. The last type is Mosaic Down syndrome which basically means that their chromosome 21 is mixed in with all the chromosome, and some may have 3 and some may have the normal 2. Mosaic Down syndrome only accounts for the last 2% of patients diagnosed with Down Syndrome (CDC 2018).

When diagnosed with Down syndrome, it remains with them for life since there is no cure at the moment. However, with a screening test, parents can usually know pretty early if their child is at risk for Down syndrome. CDC (2018) states, “Screening tests often include a combination of a blood test, which measures the amount of various substances in the mother’s blood (e.g., MS-AFP, Triple Screen, Quad-screen), and an ultrasound, which creates a picture of the baby (CDC 2018). Screening, however, does not guarantee there will be something wrong, but does help get the process started of seeing things that look suspicious such as abnormal extra fluid around the baby’s neck. This then convinces the doctors to run some diagnostic test to confirm what may be going on with the child while developing in the womb. Prenatal diagnostic test usually has a 100% accuracy for the mother on if the child has Down syndrome, which can help the families prepare a little in advance. Prenatal test includes chronic villus sampling (CVS) which needs to be done within the first 9 to 14 weeks, and amniocentesis can be administered within 15-20 weeks of gestation (NDSS 2018). Percutaneous umbilical blood sampling (PUBS) is also another determining factor that can be utilized by blood samples from the umbilical cord, amniocentesis test the fluid in the amniotic sac, and CVS test material in the placenta (CDC 2018).

Clinical Presentations of Patients with Down Syndrome.

 Although there are only 3 types of Down syndrome, there are still traits and characteristics that remain similar to every majority of Down syndrome patients. Many patients with Down syndrome are presented with hearing loss, sleep apnea, heart defects such as Mitrovalve prolapse and diastolic dysfunction, eye diseases, and ear infections (CDC 2018). Likewise, there are other visible characteristics that might help one identify a person diagnosed with Down syndrome. Many patients with Down syndrome can be characterized as having short and stubby fingers and hands, and transverse palm crease. These patients are usually present with lack of muscle tone, noticeable awkward waddle, short with a short neck, flattened face and nose that appears to be underdeveloped, cross eyes, and narrow opening eyes. These patients are also known to have seizures, Alzheimer’s disease, weakened immune system, and airway issues.  (Wilkins, E. M. (2017).

 When thinking of a special needs patient, most would think that the patient depends on the clinician or the caregiver to do everything for them. Down syndrome patient’s abilities can always vary upon severity, but most are very high function individuals. There may be some negative characteristics such as not being able to focus for long periods of time, the behavior may be spontaneous, stubborn, or there may be some delayed language development. Although, there are positives that come with Downs such as:

  • Socially advanced
  • High intellectual functions
  • Enjoy games and background music
  • Admire getting attention
  • Not very irritable, happy, sociable
  • Observant
  • Enjoy imitating

Knowing these different characteristics and traits can later play to the advantage of the clinician in order to better understand the patient. If the clinician is aware that the patient enjoys imitating, music, and games, then it would be advisable to have some fun light-hearted music playing in the background, and have some toothbrushes and teeth to play with to demonstrate appropriately to the patient. (Wilkins, E. M. (2017).

Dental Hygiene Considerations

Dental Characteristics that are common amongst Down Syndrome Patients.

 There are a variety of characteristics that are very common amongst persons with Down syndrome that can be observed in and around the oral mucosa. Some of these characteristics include a protruded tongue. Many do not keep their tongue inside their mouth. Mouth breathing occurs a lot amongst these patients, fissured and expanded tongue is present, and narrow and vaulted palate. One must also be aware of scars and broken or fractured teeth due to accidents that these individuals are prone to. Patients with Down syndrome are also present with irregular eruption patterns than those of normal children and adolescents. Along with irregular patterns, they also have congenitally missing teeth, microdontia is sometimes present, and pronounced spacing in-between teeth. These patients are usually present with posterior crossbites and Angle’s Class III (Park, J. U., & Baik, S.H. 2001). Knowing these things can give the clinician an opportunity to explain to the caregivers that this is normal for people with Down syndrome and to not be too alarmed.

Treatment Plan Modification.

 Patient Needs. In response to the patient’s conditions such as airway obstruction due to their sleep apnea, enlarged tonsils, and macroglossia, it is recommended that a clinician thinks about where to appropriate position chair in order for the patient to not gag, and to make sure you have constant suctioning for fluids. Semi-supine position might be best for the patient to feel most comfortable and at ease. Usually, the patient will do just fine if you slowly introduce new things to them and try not to just speed through without allowing the patient to get comfortable with you first because it might evoke unfavorable behavior problems (Wilkins, E. M. (2017).

 Systemic Conditions. Due to patients having increased risk of heart defects, a clinician must first consider if the patient needs a medical clearance before working on them. It is imperative that dental professionals are communicating with their other health care providers if there are other systemic things currently going on. The risk with heart defects can also be correlated to their weakened immune system, and clinicians need to be aware if it patient needs to be medicated before undergoing dental procedures to prevent bacterial infections (Wilkins, E. M. (2017). Persons with Down syndrome also have issues with gastroesophageal reflux which is in part to having hypothyroidism (Underactive Thyroid – NIH 2016). Acid erosion would be visible by the clinician in response to the acid reflux. Celiac disease is also a prominent systemic disease which is good for counseling the patient and caregiver on if they are not aware. Patient’s caregiver should be advised that staying away from gluten might be most appropriate to the patient if they ever begin to see issues or intolerance (NIH 2018).

Dental Hygiene OHI Recommendations for Down Syndrome Patients.

 Brushing & Mouth Rinsing. As far as instructions for the patient, it will vary based on the patient’s cognitive level or hand dexterity that is available. The clinician must be aware if the patient is motivated to brush his or her teeth themselves, and if they are able to do it appropriately. Possibly offering the patient a toothbrush with a big handle or showing the caregiver how to make one utilizing sponge or a tennis ball to make the handle larger for the patient would be great tips to ensure the patient does not struggle and become discouraged while brushing. It would be advisable to also teach the patient how to rinse with mouthwash after each meal to help reach every area of the mouth for proper oral health. Usually, these patients are on many medications for their different systemic issues which could also cause xerostomia, so the dental hygienist must be aware of this and inform patient and caregiver of the necessity to try using a mouthwash with zero alcohol or a Biotene product to keep the mouth from getting to dry (Wilkins, E. M. (2017).

Methods to deliver Oral Hygiene Instructions. Method of delivery will vary based on the patient’s cognitive level. The clinician must be aware of what patient is able to do and understand themselves or what may be necessary for caregiver to do for them. Although explaining to the caregiver is acceptable, it is recommended that clinician show patient and allow them to try, as well as show caregiver appropriate way to help the patient. The clinician needs to be aware that although caries rate can be low for these patients as children due to the spacing of teeth, there is still the possibility of obtaining caries if food remains on the teeth. Due to the patient having hypotonia, the weak muscles does not allow the masseter to completely chew the food all the way which, in result, causes food to be left on the teeth. Without proper maintenance or brushing, this could eventually cause decay. Not only can decay occur but caregivers must be educated on periodontal disease if there is poor oral health care at home. With malocclusion, bruxism, conical shaped roots, and compromised immune system, it makes them even more susceptible to periodontal disease. Allow the caregiver to understand how much bacteria can be in the mouth and the issues that periodontal disease can cause later for them financially and for the patient’s oral health and eating habits.

Community Involvement and Interventions. As a dental hygiene clinician, it is imperative that communities are being reached, educated, and encouraged to focus on their oral health and seek treatment. It usually is not that these individuals do not want to take care of their oral health, but perhaps it has been placed on the back burner amongst all other things and never been stressed. When clinicians go out into the community to different facilities or rehabilitation establishments, it allows one to bring awareness to all the individuals. Clinicians should be prepared to bring things for the Down syndrome patients so it can be interesting, interactive, and fun. Clinicians should also bring brochures or pamphlets to go home with caregivers, specifying the importance of oral health and how to prevent periodontal disease. Then it should be group specific somewhere on the pamphlet saying that one is trained and skilled in working with special needs or Down syndrome, this way the caregiver feels as if they will be in good hands if they bring them to the specified clinic. It is the clinician’s job to make the patient feel individualized and important, and to reveal to the caregiver the clinician really cares. Many times, patients without special needs are unaware of the importance of taking care of their oral health, so it is even more imperative for clinicians to advocate to caregivers of special needs who are already compromised and disadvantaged in many ways. One must show concern and that they are aware of all the other things that a caregiver must deal with on a daily basis, but to ensure them that the primary goal is to save the patient’s teeth and prevent malnutrition, and infection. If you clinician can go out in the community and make oral health a daily priority, then this is what makes a difference in patients lives long term.

 

Conclusion.

In conclusion, the findings of this research paper was to inform and educate dental hygienist on how to appropriately treat patients with down syndrome. More often than not, dental hygienist may not have the opportunity to work with a Down syndrome patient while in school, but it is imperative to still be able to adequately assess the patient’s needs and to be a well-rounded clinician that can treat any type of patient even if you only work for a private or general practice, and not a hospital setting. The skills that were addressed may not make the clinician an expert on every patient with Down syndrome, since each case can still vary greatly, but it will at least be a practical guide to be informed on the most common traits of Down syndrome, some appropriate steps to take, and know what it means to work with Down Syndrome, also known as Trisomy 21.

 

References

  • Center for Disease Control (CDC) Birth Defects. (2018, February 27). Retrieved from https://www.cdc.gov/ncbddd/birthdefects/downsyndrome.html
  • NDSS (2018) Dental Issues & Down Syndrome. (n.d.). Retrieved from https://www.ndss.org/resources/dental-ssues-syndrome/
  • Genes and genetics explained. (2012, August 31). Department of Health & Human Services Retrieved from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/               genes-and-genetics#
  • NIH – Hypothyroidism (Underactive Thyroid). (2016, August 01). Retrieved from https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism
  • National Down Syndrome Society. (n.d.) What is Down Syndrome? Retrieved from https://www.ndss.org/about-down-syndrome/down-syndrome/
  • Park, J. U., & Baik, S.H. (2001). Classification of Angle Class III malocclusion and its treatment               modalities. Int J Adult Orthod Orthognath Surg, 16(1), 19-29.
  • Wilkins, E. M. (2017) Clinical Practice of the Dental Hygienist (12th Ed.). Philadelphia, PA: Lippincott Williams and Wilkins.

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