Material and Method: Down Syndrome patients underwent dental treatment under general anesthesia were evaluated retrospectively. General anest-hesia method, demographic variables, ASA scores, Oral Hygiene Index, Frankl scale, Houpt Scale, systemic diseases of the patients, antibiotic prophylaxis and dental treatments were examined as data.

Results: Female/male ratio was 62/51, mean age was 14.14±10.28. Most patients were ASA II with 67.3%. The oral hygiene index was poor (%38). While 84.81% of the patients were sedated, 15.2% were given general anesthesia. Tooth extraction with tooth filling was the most performed dental treatment. The most common systemic disease was of cardiac origin. Antibiotic prophylaxis was administered to 82 of the patients.

Conclusion: To treat patients with Down Syndrome, frequent use of general anesthesia and sedation, as well as frequent antibiotic prophylaxis, is required. In terms of these applications, it is necessary to create a treatment plan with the least risk to the patient.

Down syndrome (DS) is one of them, first described by Langdon Down in 1866, and has an incidence of 1.5 per 1000 live births ². It is the most common conge-nital mental anomaly, including several mental and behavioral alterations and physical malformations ^3,4. Moreover oral health of children with Down's synd-rome; can be adversely affected due to medications, treatments, or difficulties in daily basic tooth cleaning ⁵. It requires particular relevance and professional care due to mental disability and health problems ⁶.

Current dental problems can be treated with general anesthesia due to the lack of cooperation of patients, excessive dental procedures, and accompanying syste-mic diseases ^1,7. Depending on the patient's condi-tion, procedures ranging from minimal sedation to deep general anesthesia are performed ^8,9.

Children with Down syndrome are born with certain anatomical characteristics specific to the condition, including atypical fingerprints, small teeth, stunted growth, droopy ears, hypotonia, and a flattened nose ^8,10. As these patients age, they often experience increased obesity, which can pose challenges for vascu-lar access ¹¹. Moreover, these individuals commonly exhibit enlarged tonsils and adenoids, a narrowed subglottic area, a prolapsed epiglottis, and an enlarged tongue ^10,12. Specifically, their tonsils and adenoids are larger, the subglottic area is smaller, the tongue is en-larged and the epiglottis may droop (10, 12). App-roximately 10% to 40% of individuals with Down syndrome also have atlantoaxial instability ¹³. There-fore during treatment it is crucial to minimize head extension to prevent subluxation. Due to these unique characteristics, advanced airway devices should be readily available for intubation, as airway management can be complex ¹⁴. It is not recommended to admi-nister sedation to these patients in office settings and more specialized operating rooms are required ¹⁵.

Individuals with Down syndrome are at a higher risk of developing various systemic conditions, including cardiovascular diseases, leukemia, infections, osteopo-rosis, and endocrine, neurological, orthopedic, dental, auditory, and ophthalmic disorders. Approximately 40-50% of them exhibit ventricular septal defects, a type of congenital heart defect, which may necessitate anti-biotic prophylaxis for invasive dental treatments ¹⁶. Differences in their immune systems, zinc deficiency and anatomical variations make these individuals more susceptible to infections ¹⁷. Consequently, compro-mised dental health can pose a systemic disease risk, especially in those with concurrent medical issues. Therefore prophylactic regimens should be implemen-ted to mitigate potential risks for the patients ^17,18.

First, when treating children with DS, the need for subacute bacterial endocarditis prophylaxis should be determined. The clinical importance of bacteremia in healthy patients is low. However, in a patient prone to local bacterial colonization following a bacterial infec-tion, microorganisms may colonize through circulation and become a life-threatening condition such as infec-tive endocarditis ¹⁷. İE prophylaxis should be given before dental treatment of such diseases to obtain an appropriate serum antibiotic concentration.

In this retrospective study, considering all the above-mentioned risky situations, we aimed to determine the limits of when and how antibiotic prophylaxis and general anesthesia should be used in patients undergo-ing dental treatment with Down syndrome.

Inclusion criteria: patients who underwent dental tre-atment with general anesthesia and only those with Down's syndrome. Dental treatment cannot be perfor-med with local anesthesia due to exclusion criteria (patients undergoing local anesthesia and patients wit-hout information in their medical records).

2. Evaluation of general health
Due to the increase in life expectancy in patients with Down Syndrome, dental treatments are also a serious public health problem that is frequently on the agenda. Social awareness is essential to solve the problem wit-hout further difficulty. Dental treatment of DS patients is started before, especially by the pedodontics clinic, by screening the schools for disabled patients. These are the ones detected due to these scans in some pati-ents who are operated under general anesthesia.

3. Evaluation of oral health
Routine examinations of the patients were carried out, whether they applied to the clinic themselves or were determined by the health screenings. Oral and dental examinations and radiological imaging were performed. Especially incompatible patients who could not be thoroughly examined and whose imaging could not be performed to the desired extent were sent to the anesthesia evaluation polyclinic. Patients planned to be operated on under general anesthesia were evaluated according to Frankle (F) and Houpt (H) scales. Patients with F1-2 and H1-2 were included in the appointment list for general anesthesia or sedation ^19,20.

4. Dental treatments
Although periodontological disease is a common prob-lem in DS patients, our patients received general anest-hesia or sedation to treat the following diseases.

Preventive treatment includes systematic sca-ling/cleaning, fluoride application, and placement of sealants where appropriate. Restorative treatment: It is the treatment that includes the restoration of material losses in the hard tissues of primary teeth and permanent teeth.

Surgical procedures: The surgical treatment comprises various procedures such as extractions of both simple and impacted teeth, gingivectomies, frenectomies, and other minor oral surgeries. Additionally, it involves surgical interventions for dental implants, jaw fracture repair, removal of cysts in the jawbones, maxillary expansion through surgical implantation, as well as plaque placement and removal operations.

Examination under anesthesia (without intervention)

5. Preoperative evaluation
The patients were evaluated preoperatively, and a phy-sical examination was performed. Blood tests and con-sultation were required, if necessary. Comorbidities and drugs used were recorded, and necessary precauti-ons were taken. All patients were fasting for at least 6 hours for sedation and general anesthesia. Information was given about the anesthesia procedure, and written informed consent was obtained from the legal guardi-ans of the patients after the necessary explanations about possible risks.

6. Antibiotic proflaxia
Prophylaxis was given to those with cardiac disease and immune problems. Usually, penicillin was used. Cephalosporins were used for allergy sufferers.

7.Intra-operative period
During the dental procedure, peripheral oxygen satura-tion, heart rate, blood pressure, and end-tidal carbon dioxide levels were continuously monitored in accor-dance with the guidelines set by ASA. Based on the patients' medical condition and their ability to coopera-te, various anesthetic agents and techniques were emp-loyed to ensure optimal safety and comfort.

8. Post-operative period
At the end of the procedure, the patients were monito-red for about 20 minutes in the recovery unit. The pati-ents were taken to the inpatient unit without any decre-ase in vital functions. Oral nutrition started after 1 hour in patients undergoing sedation with an inhalation agent, after 2 hours for those undergoing sedation with an intravenous agent, and after 4 hours, respectively, for general anesthesia. Patients who tolerated oral inta-ke were discharged the same day. The patients who could not take oral treatments because of nausea and vomiting or those who needed time to recover were followed up and treated in the inpatient service for 24 hours

9. Statistical analysis
The data obtained from the study was recorded in Mic-rosoft Excel 2010. Subsequently, the data were subjec-ted to analysis using the SPSS software package (ver-sion 17.0, SPSS Inc., Chicago, Illinois, USA). Descrip-tive statistics, including frequencies, percentages, and mean±standard deviations, were calculated. The study variables were subjected to a descriptive analysis, whe-rein arithmetic means, frequencies, and percentages were computed and presented in the form of tables.

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Table 1: General Characteristics of Patients with Down syndrome.

The most common systemic disease was of cardiac origin. The most common of these was the operated VSD (Table 2).

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Table 2: Concomitant diseases.

According to the Frankl scale, 21% of the patients were F1(n= 24), 79% were F2 (n= 89), according to the Houpt Scale, 33% were H1 (n= 37), and 67% were H2 (n= 76). In the absence of ASA1 patients, ASA2 was 67.3% (n= 76), and ASA3 was 32.7% (n= 37) (Table 3).

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Table 3: Frankl scale, Houpt Scale and ASA classification 20,21.

When the patients were evaluated in terms of general anesthesia indications, 33% were Group A, 17% were Group B, and 50% were Group C (Table 4).

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Table 4: Indications for the use of general anaesthesia for dental treatment.

DS patients often suffer from periodontal disease due to poor oral hygiene, a ketogenic diet, and inadequate oral care. They need restorative treatment more often than their peers. Some patients need orthodontic treat-ment due to tooth deficiencies and anomalies, and they may be indicated for prosthesis applications at an ear-lier age. It has become commonplace under today's conditions to talk about dental implant treatments in these patient groups. All these treatments are perfor-med in our clinic under general anesthesia or sedation ²³. Consistent with the literature, most patients (80%) underwent conservative treatments, including restorati-ve and tooth extractions. While patients who apply to the oral diagnosis department of the faculty of dentistry are directed to the relevant departments according to the treatment requirement, these patients, most of whom are in the pediatric age group, are treated in the general operating room, especially because of difficulty in cooperation ²².

Preoperative evaluation in patients to be treated under general anesthesia or sedation; The duration of the procedure, the intensity of systemic problems, and difficult airway control are considered. While general anesthesia is preferred for long-lasting procedures, the patient may decide to divide the procedures and per-form them under sedation instead of general anesthesia, which may pose a high risk due to serious systemic problems. Or in a patient with a difficult airway, even if the procedure is short, if it is a problem to protect the airway safely during sedation, intubation can be prefer-red, and the patient can be directed to general anesthesia ⁸. Dental treatments can be postponed in patients with ASA III and above because they are not so impor-tant that they do not require taking a life risk. Our study shows that the sedation/general anesthesia rate is approximately 85/15%. For the reasons mentioned above, sedation preference is more important. The available data are compatible with the literature.

In particular, general anesthesia offers a relatively safe option for managing patients with behavioral and ad-justment problems ²⁴. Although it suggests that these patients are at higher risk of perioperative complicati-ons due to the presence of medical comorbidities, the available literature reports that these occur at a similar rate or less frequently than in the general population ⁹. In addition, even minor morbidities may occur more prominently in patients with special needs ¹⁰. Therefore, comprehensive preoperative evaluations are crucial to reduce the risk of surgery-related complicati-ons, especially in this cohort.

Around 50% of infants with Down syndrome are born with some form of heart abnormality. Among adults with Down syndrome, approximately 50% exhibit Mitral Valve Prolapse (MVP) and may require prophy-lactic antibiotics prior to undergoing dental procedures ¹⁷. According to our study, heart disease is the most common systemic disease accompanying DS. Among these, VSD is the most common. IE prophylaxis is recommended, especially in problems involving the heart valves. In surgical interventions, antibiotic prophylaxis is performed to provide sufficient antibio-tic levels in the tissue during and immediately after surgery, reduce bacterial flora, and reduce the possible contamination to the level the host can resist. The high need for antibiotic prophylaxis is closely related to cardiac diseases ²⁵. These indications can be listed as follows: History of previous infective endocarditis, Prosthetic Heart Valves, hypertrophic cardiomyopathy, Acquired heart valve diseases, Complex congenital cyanotic heart diseases Surgically corrected systemic or pulmonary shunts, Non-cyanotic congenital heart dise-ases (except secundum type ASD), Mitral valve pro-lapse with valvular insufficiency or severe valve thic-kening ²⁶.

Invasive procedures that may cause bleeding should be considered when performing prophylaxis. While there is a prophylaxis indication for tooth extraction, prophylaxis is not applied for a simple procedure such as fissure sealant in the same patient. Antibiotics used in prophylaxis and their doses are given in table 5.

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Table 5: Recommended prophylaxis in dental procedures 18.

The greatest risk that may arise due to antibiotics is anaphylaxis, which resolves with medical treatment. However, if IE occurs, it is necessary to struggle with a seriously complicated situation, which may have mor-tal consequences ¹⁸. Antibiotic prophylaxis was required in 73% of the patients treated in our clinic. We did not see any side effects from antibiotics in these patients. Penicillin was used frequently. Cephalosporin was preferred in patients with a history of allergy. We have also experienced that patients with DS need prophylaxis more frequently for dental procedures than healthy patients of the same age group.

The sensitive issue here is to take adequate precautions to solve the problem smoothly or with fewer problems. While the intensity of medical problems in DS patients who will receive dental treatment poses a risk regar-ding general anesthesia, antibiotic prophylaxis increa-ses some risks due to cardiac disease and immune problems. For this reason, dentists should focus on solving the problem with a holistic approach. Dentists should address these patients as both a public health problem and a personal problem requiring individual treatment outside their routine practice ²⁷. When the subject is handled from this point of view, the issues we draw attention to as two main topics in our study come to the fore.

As emphasized in the literature in our study, taking adequate precautions and working with the right team and equipment provided good results contrary to fears. While the anesthetic literature does provide assess-ments regarding patients with special needs, clinicians must acknowledge the challenges associated with eva-luating such individuals ²⁰. Furthermore, the presen-ce of multiple disorders, medical conditions, and ana-tomical and physiological changes can considerably complicate this process, particularly when comprehensive information is not readily accessible.

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