|Year : 2017 | Volume
| Issue : 4 | Page : 284-290
Assessment of dental caries, oral hygiene status, traumatic dental injuries and provision of basic oral health care among visually impaired children of Eastern Odisha
Vinay Suresan, Diptajit Das, Avinash Jnaneswar, Kunal Jha, Gunjan Kumar, Goutham Bala Subramaniam
Department of Public Health Dentistry, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||15-Sep-2017|
Department of Public Health Dentistry, Kalinga Institute of Dental Sciences, Campus-5, KIIT University, Patia, Bhubaneswar - 751 024, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: The magnitude and severity of oral health problems in visually impaired population are worse than in general population, and they tend to have more untreated dental diseases and more problems accessing dental care. Aims: The aim of this study is to assess dentition status and treatment needs, oral hygiene status, and traumatic dental injuries among institutionalized children attending special schools for the visually impaired in eastern Odisha. Settings and Design: A descriptive, cross-sectional study was conducted using a universal sampling protocol. Subjects and Methods: American Dental Association Type III clinical examination was carried out using plane mouth mirrors and community periodontal index probes under adequate natural illumination by a single examiner assisted by a trained recording assistant. After completion of the study, all participants were provided with basic oral health care through outreach programs. Statistical Analysis: Comparisons were done using Student's t-test, analysis of variance, and Chi-square test. Results: Caries prevalence for primary and permanent dentition was 15% and 46%, respectively. Mean oral hygiene index-simplified (OHI-S) was 2.43 ± 1.03. The prevalence of traumatic dental injuries was 11%. A statistically significant difference in mean decayed, missing, and filled teeth (DMFT/dmft) was observed in children consuming liquid sugar as compared to solid and those consuming sticky sugars as compared to nonsticky. A statistically significant difference in mean OHI-S scores was observed when compared with frequency of changing toothbrush. Conclusions: This sample of visually impaired children has a high prevalence of dental caries, traumatic dental injuries, and poor oral hygiene. Unmet needs for dental caries were found to be high indicating very poor accessibility and availability of oral health care.
Keywords: Blindness, child, dental caries, oral hygiene
|How to cite this article:|
Suresan V, Das D, Jnaneswar A, Jha K, Kumar G, Subramaniam GB. Assessment of dental caries, oral hygiene status, traumatic dental injuries and provision of basic oral health care among visually impaired children of Eastern Odisha. J Indian Soc Pedod Prev Dent 2017;35:284-90
|How to cite this URL:|
Suresan V, Das D, Jnaneswar A, Jha K, Kumar G, Subramaniam GB. Assessment of dental caries, oral hygiene status, traumatic dental injuries and provision of basic oral health care among visually impaired children of Eastern Odisha. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2018 Mar 23];35:284-90. Available from: http://www.jisppd.com/text.asp?2017/35/4/284/214926
| Introduction|| |
The World Health Organization (WHO) defines blindness as “a corrected visual acuity in the better eye of <3/60 and severe visual impairment as a corrected acuity in the better eye of <6/60.” According to the Indian National Sample Survey of 2003, about 1.8% were physically, visually, or hearing impaired  and visual impairment was the most frequently occurring disability. There were 10,634,881 visually impaired people who represented nearly 49% of all the disabled Indians. Visual defects are one of the most common causes of disability in the world, and visual impairment in childhood is often part of a multiple disability disorder.
Total visual impairment is one disorder that may result in frequent hospitalization, separation from family, and slow social development. Difficulty in assessing the capabilities of a child with blindness may result in him/her being considered developmentally delayed. The visually impaired children face a lot of challenges in executing their daily chores and are dependent on their caretakers. Health-care policy in India does mention about people with disability and provides them with few benefits, but their oral health care stays significantly neglected.
Oral health has strong biological, psychological, and social consequences because it affects esthetics and communication, and quality of life is influenced by oral health status. It has been reported that “dental treatment is the greatest unattended health need of the disabled.” The magnitude and severity of oral health problems in disabled people are worse than in general population, and disabled people have more untreated dental diseases and more problems accessing dental care. The severity of their oral problems has been attributed to lack of awareness, inability to access oral care facilities, diet, eating patterns, medication, physical limitations, lack of oral hygiene, and attitudes of parents and health providers, all of which contribute to poor oral health.
Studies have shown that people with disability have a higher incidence of dental caries ,, and consistently poorer state of oral hygiene , with various levels of periodontal diseases.,, The main reason for higher prevalence of dental caries is their inability to visualize plaque and its inadequate removal during oral hygiene procedures which also results in the progression of inflammatory diseases of the periodontium. Yet, another most common oral health problem would be traumatic dental injuries. Visually impaired children are considered to be at higher risk to traumatic injuries owing to multiple factors such as falls, accidents met at home or outside, increased overjet, and inadequate lip coverage. The consequences of incisal trauma include alteration in physical appearance, speech defects, and psychological or emotional impacts, thus affecting the child's quality of life.
In the recent years, there have been an increasing number of studies concerning the oral health status of general population. However, very little attention has been paid to the oral health status of the visually impaired population. An extensive literature search has revealed that no data regarding the dental caries status, traumatic dental injuries, and oral hygiene status for visually impaired population were available in the state of Odisha. Hence, a study was conducted aimed at assessing the dentition status and treatment needs, oral hygiene status, and traumatic dental injuries among institutionalized children attending special schools for the visually impaired in eastern Odisha. Objectives also included:
- Comparison of caries experience to history of sugar intake
- Comparing oral hygiene index-simplified (OHI-S) scores to oral hygiene practices
- Provision of basic oral health care.
| Subjects and Methods|| |
A descriptive, cross-sectional study was conducted to assess the prevalence of dental caries, traumatic dental injuries, and assessment of oral hygiene status among institutionalized visually impaired children residing in eastern Odisha. After explaining the nature and purpose of the study, permissions and list were obtained from the Department of Social Security and Empowerment of Persons with Disabilities, Government of Odisha. This list consisted of 5 institutionalized visually impaired schools with a total population of 250 children residing in them. Permission for conducting the study and clinical examination was obtained from the Department of Social Security and Empowerment of Persons with Disabilities, Government of Odisha and the head of the respective schools. Written proxy consent was obtained from the head of the schools, and verbal consent was taken from the participants. Ethical clearance was obtained from Institute Ethics Committee (KIMS/KIIT/IEC/20/2016).
A universal sampling protocol was chosen owing to a meagre 250 participants. This study included participants who were permanent residents of the school, obtained informed consent from their parents/guardians, and who were present during the day of examination. Participants with any other disability or syndromes, under medication for any illness for 15 days and uncooperative participants were excluded from the study.
Training and calibration of the examiner and recording assistant (internee) was carried out under expert guidance before the start of the study. During this, 10% of the participants were re-examined to assess intra-examiner reliability, and reliability was found to almost perfect agreement according to kappa score (ϰ) of 0.9.
The data collection sheet consisted of the following indices and questions:
- Demographic data
- Dentition status and treatment needs (WHO oral health assessment form, 1997)
- OHI-S - Greene and Vermillion, 1964
- Traumatic dental injuries (injuries to the hard dental tissues and the pulp) - WHO in its application of International Diseases of Dentistry and Stomatology, 1994
- Semi-structured, closed-ended questionnaire assessing oral hygiene practices and sugar consumption history.
American Dental Association Type III clinical examination  was carried out using plane mouth mirrors and community periodontal index probes under adequate natural illumination. Participants were made to sit on a chair with comfortable arm rest in an upright position. The examiner was seated next to the participant. All the examinations were carried out by a single examiner assisted by a trained recording assistant who was sitting close enough to the examiner so that instructions and codes could be easily heard and the examiner was able to see the data being entered correctly. A total of 25–30 participants were examined every day. The study was carried out for a period of 4 months from April 2016 to July 2016.
After the completion of the study, all the participants were provided with basic oral health care (oral prophylaxis, restorations, and extractions) through outreach programs conducted in their school premises using mobile dental unit.
Data were imported to SPSS Version 18.0 [SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc]. Results on continuous measurements were presented as mean ± standard deviation and results on categorical measurements were presented in numbers (%). Comparison between discrete data was done using Student's t-test and comparison between continuous data was done using analysis of variance. Comparison between proportions was done using Chi-square test. The outcome measures were assessed among the following age groups: 4–5, 6–12, 13–15, and 16–23 years, gender, and type of blindness (partial or complete). P = 0.05 was considered to be statistically significant.
| Results|| |
The total population of visually impaired children was 250, out of which 238 participants satisfied the inclusion criteria. The reason for excluding 12 participants was because of previous episodes of systemic illness, ongoing antibiotic therapy, and absenteeism during the study period. The distribution of study population according to various age groups are as follows: 10 (4.2) participants belonged to 4–5 years' age group, 83 (34.87) participants belonged to 6–12 years' age groups, 78 (32.77) participants belonged to 13–15 years' age group, and 67 (28.15) participants belonged to 16–23 years' age group. The gender distribution of the study population showed that there were 139 (58.4) male and 99 (41.6) female. The distribution of study population according to the type of blindness showed that there were 91 (38.23) partially blind participants and 147 (61.76) completely blind participants [Table 1].
Caries prevalence for primary dentition was 15% as 37 participants had a caries experience (decayed, missing, and filled teeth [dmft] >0) and 201 participants had no caries experience (dmft = 0). Similarly, for permanent dentition, caries prevalence was 46% as 109 participants had a caries experience (DMFT >0) and 129 had no caries experience (DMFT = 0). Mean dmft of the study population was 0.48 ± 1.54 and highest dmft was recorded among 4–5 years' age group (2.2 ± 2.57) and lowest among 13–15 years' age group (0.14 ± 0.61). This difference was statistically significant (P < 0.05) [Table 2]. Mean DMFT of the study population was 1.57 ± 2.30 and highest DMFT was recorded among 13–15 years' age group (1.92 ± 2.27) and lowest among 6–12 years' age group (1.26 ± 2.13). This difference was statistically significant (P < 0.05) [Table 3]. Mean DMFT was higher (2.02 ± 2.78) among females as compared to males (1.25 ± 1.83), and this difference was statistically significant (P < 0.05) [Table 3]. It was recorded that in both dentitions, none of the participants had any filled teeth (ft/FT = 0) component.
|Table 2: Comparison of decayed, missing, and filled teeth with age groups, gender, and type of blindness|
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|Table 3: Comparison of decayed, missing, and filled teeth with age groups, gender, and type of blindness|
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Assessing the treatment needs reflected that nearly half of the participants, i.e. 50 required one surface filling (47%), followed by two surface filling - 25 (21%), extraction - 20 (16%), pulp care - 14 (13%), fissure sealant - 1 (1%) and prosthesis - 1 (1%) [Figure 1].
According to the OHI-S, mean index scores, debris index-simplified (DI-S), and calculus index-simplified (CI-S) of the study population were 2.43 ± 1.03, 1.97 ± 0.79, and 0.47 ± 0.51, respectively. Mean CI-S was highest (0.68 ± 0.6) among 16–23 years' age group and lowest (0.27 ± 0.37) among 6–12 years' age group, and this difference was statistically significant (P < 0.05) [Table 4].
|Table 4: Comparison of oral hygiene index-simplified with age groups, gender, and type of blindness|
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Traumatic dental injuries were noted in 11 (4.62%) out of 238 participants. Assessment of traumatic dental injury occurrence according to gender and type of blindness showed that it was highest among males - 10 (90.9%) and in completely blind children - 9 (81.8%). The prevalence of traumatic dental injuries according to conditions of dental trauma was highest among 13–15 years' age group as compared to the other age groups, and this difference was statistically significant (P < 0.05) [Table 5]. However, no statistically significant difference was observed in the conditions of dental trauma when compared with gender and type of blindness. Enamel fracture was the highest traumatic dental injury seen among 16–23 years, age group (51.4%), males (56.8%), and completely blind participants (78.4%).
|Table 5: Comparison of conditions of dental trauma with age groups, gender, and type of blindness|
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A statistically significant difference in mean DMFT/dmft was observed in children consuming liquid sugar as compared to solid and also in children consuming sticky sugars as compared to nonsticky (P < 0.05). However, no statistically significant difference in mean DMFT/dmft was observed when compared with frequency of sugar intake and time of intake.
A statistically significant difference in mean OHI-S scores was observed when compared with the frequency of changing toothbrush (P < 0.05). However, no statistically significant difference in mean OHI-S scores was observed when compared with the type of cleaning, materials used, method of cleaning, and frequency of brushing.
Basic oral health care was provided to all the participants in which 138 underwent oral prophylaxis, 63 underwent restorations, and 19 underwent extractions.
| Discussion|| |
Disabled participants are prone to have the more untreated dental disease, higher incidence of dental caries, poor oral hygiene status, and traumatic dental injuries. This was the first comprehensive oral health program conducted among visually impaired children of eastern Odisha. This program has provided us with the baseline data regarding the burden of oral health problem which has helped in planning basic oral health services for these children.
In the present study, the majority of the participants (58.4%) who participated were males which are similar with the studies conducted by Reddy et al. (81.2%), Solanki et al. (50.5%), and Naveen and Reddy (54.4%). However, contradictory results were found in studies carried out by Priyadarshini et al., where majority of the participants were females.
Caries prevalence for primary dentition was 15%, and for permanent dentition, it was 46%. Similar findings were obtained from studies conducted by Reddy and Sharma (40%) and Parkar et al. (47%). The current study population presented with a mean dmft/DMFT of 0.48 ± 1.54/1.57 ± 2.30. Comparing studies performed on similar populations, Tagelsir et al. (1.9 ± 2.8/0.4 ± 0.7) and Reddy and Sharma (0.17/1.1) reported lower scores whereas Solanki et al. (0.47/1.1) presented with similar result as ours. However, higher scores were reported by Al-Qahtani and Wyne (1 ± 1.9/3.8 ± 2.6) as compared to our study. The contrasting results may be explained by the fact that lower caries scores might be due to strict restrictions on sugar intake among those populations. On the other hand, higher scores might be due to noninstitutionalized nature of the schools, where the students might be exposed to considerable amount of sugars. Higher consumption of sweets, in between snacking and daily serving of sweet dish at school, could be the reason of the very high proportion of visually impaired children with decayed teeth.
When component parts of dmft/DMFT were analyzed, the decay component formed the major component, while there was no filled component. Thus, the lack of accessibility to dental care in the form of conservative management of dental caries is clearly evident among this population.
The present study revealed that majority of the participants (47%) required one surface fillings which is similar to a study carried out by Jain et al. (62.7%). This indicates that maximum number of the carious teeth required conservative treatment and the treatment strategies should also be directed toward conservative management, as against performing more number of extractions.
Oral hygiene status was assessed using the OHI-S which assesses both the soft and hard deposits on the tooth surface and is calculated as the sum of debris index and calculus index. The study population showed a fair oral hygiene status (2.43 ± 1.03) which is similar to a study conducted by Parkar et al. (2.0 ± 1.0). On the contrary, poor oral hygiene status was observed in studies conducted by Reddy and Sharma (0.4) and Solanki et al. (0.4). The suboptimal levels of oral hygiene could be attributed to lack of assistance or supervision of caregivers during the performance of oral hygiene practices. Another probable reason could be due to their low powers of concentration and lack of motor skills  which could cause difficulties in tooth brushing.
Visually impaired children also suffer from traumatic dental injuries which constitute a major health hazard. The results of the present study show that the prevalence of traumatic dental injuries was 4.62%, which was in accordance with a study conducted by Al-Alousi (6%). However, higher scores were obtained in a study conducted by Varghese et al. (37.8%). The prevalence of traumatic dental injuries was highest among 13–15 years' age group as compared to the other age groups, and this difference was statistically significant. Contrasting results were obtained from a study conducted by Varghese et al., where no statistical significant difference was noted. Relatively high prevalence in other studies could be attributed to the lack of social inclusion policies both inside and outside the school environments. Although the school floor was leveled all around, several pillars supporting the buildings lined the playground which clearly formed a risk for accidents. Improvements in the physical environment, closer supervision of children, and adoption of health safety policies such as providing safe environment to play and provision of specific and appropriate public places for sports activities with impact absorbing surfaces could minimize injuries when children fall.
None of the participants in the present study received any form of treatment for their teeth fractures indicating poor awareness among parents and caretakers in these schools regarding the consequences and treatment protocol for traumatic dental injuries.
The purpose of selecting institutionalized schools was to maintain uniformity in their dietary habits, restricted use of sugar other than what is present in their routine diet. Students from these schools are only exposed to liquid sugar in the form of milk which is supplied in their daily diet; hence, they have very minimal chance of exposure to any other form of sugars. In this study, the DMFT/dmft scores were compared with frequency, time of intake, form, and consistency of sugar intake. A statistically significant difference in mean DMFT was observed in children consuming liquid sugar (2.31 ± 2.46) as compared to solid (1.13 ± 1.88). This is in accordance with the study conducted by Basha et al., reason being that holding sugar-containing beverages in the oral cavity for a prolonged time or its constant sipping increases the risk of caries.
In this study, the OHI-S scores were compared with the type of cleaning, materials used, method of cleaning, frequency of brushing, and frequency of changing toothbrush. A statistically significant difference in mean OHI-S scores was observed when compared with the frequency of changing toothbrush; once (2.43 ± 0.99) as compared to twice (2.31 ± 0.61) (P < 0.05). As the act of toothbrushing in visually impaired is difficult to supervise, the role of other factors such as frequency of changing toothbrush is ignored which might have an impact on their oral hygiene status.
Basic oral health education and oral health care in the form of oral prophylaxis, restoration, and extraction were provided to all the study participants after the study was completed through outreach programs.
A limitation of the present study was that the sample size was not representative of the visually impaired children population of either the state of Odisha or of entire India. Another important drawback of this study was the variability in the sugar consumption from three different institutionalized schools even though attempt was made to select the participants having similar sugar consumption.
- The results of this study should be supported with studies conducted with a larger sample size so that the results could be generalized
- Survey programs for the caretakers to assess their knowledge about oral hygiene maintenance
- Need for individual training in oral care and plaque control to reduce the prevalence of dental caries
- Educating the staff of institutions, caregivers, and also the individual children about primary preventive approaches
- Application of pit and fissure sealants to the permanent molars and premolars soon after eruption and advising their parents for regular monitoring and maintenance of fissure sealants
- Educational institutions should include oral health as part of training or socialization programs.
Of the utmost importance when working with special children is emphasizing the need for excellent preventive dental care. Certain modifications to behavioral management approaches, based on degree of disability, psychological development, and social integration, may facilitate the provision of dental treatment.
| Conclusions|| |
This sample of visually impaired children has a high prevalence of dental caries, traumatic dental injuries, and poor oral hygiene. Unmet needs for dental caries were found to be high indicating very poor accessibility and availability of oral health care.
The authors would like to thank Dr. Sourav Sen for giving valuable insight into the statistical analysis of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]