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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2016  |  Volume : 34  |  Issue : 3  |  Page : 285-290

Impact of various extra-oral factors on caries experience among mentally disabled children residing in Bhopal city, central India: A cross-sectional study

1 Department of Public Health Dentistry, Goenka Research Institute of Dental Science, Ahmedabad, Gujarat, India
2 Department of Public Health Dentistry, Peoples Dental Academy, Bhopal, Madhya Pradesh, India
3 Department of Public Health Dentistry, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India
4 Department of Public Health Dentistry, Sri Arbindo Institute of Medical Sciences, College of Dentistry and PG Institute, Indore, Madhya Pradesh, India

Date of Web Publication25-Jul-2016

Correspondence Address:
Sonal Chhajed
C/O, Sudarshan Chhajed, B-102, Ratnakar 2, Prerna Thirt Derasar Road, Satellite, Ahmedabad - 380 015, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.186744

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Background: Dental caries is the most common dental problem among the mentally challenged children. There are various extra-oral factors responsible for high caries experience among such children. Aim: The aim of the present investigation was to study the impact of various extra-oral factors on dental caries experience among mentally challenged children residing in Bhopal city, Central India. Materials and Methods: One hundred and fifty-two children between the age group 5 and 15 years were included in this descriptive cross-sectional study. A pretested pro forma was used to record information about socioeconomic status, demographic data, mental retardation (MR) type, and intelligent quotient. The clinical examination was performed to evaluate dental caries and treatment needs using the World Health Organization dentition status and treatment needs index. Results: The mean decayed, missing, and filled teeth (DMFT and dmft) were 2.32 and 2.21, respectively. Age, parent occupation, income, and intelligent quotient were significant predictors of both DMFT and dmft. In addition, socio-economic status and type of MR were significant predictors of only DMFT. Conclusion: Dental health professionals should, therefore, be aware of the various extra-oral factors responsible for high caries experience of mentally challenged children. They should understand and provide basic treatment needs to such children.

Keywords: Children, dental caries, disabled, mental retardation

How to cite this article:
Chhajed S, Bhambhani G, Agarwal R, Balsaraf S. Impact of various extra-oral factors on caries experience among mentally disabled children residing in Bhopal city, central India: A cross-sectional study. J Indian Soc Pedod Prev Dent 2016;34:285-90

How to cite this URL:
Chhajed S, Bhambhani G, Agarwal R, Balsaraf S. Impact of various extra-oral factors on caries experience among mentally disabled children residing in Bhopal city, central India: A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2023 Feb 6];34:285-90. Available from: http://www.jisppd.com/text.asp?2016/34/3/285/186744

   Introduction Top

Disability is defined as any restriction or lack of ability to perform an activity in a manner or within the range considered normal for a person.[1] In India, there are around 26.8 million people suffering from one or the other kind of disability. Out of that, 2.22 million are suffering from some form of mental disability which constitutes 0.2% of Indian population and 8.28% of the total physically challenged.[2]

Literature on the dental management of disabled subjects is scarce compared with that of the normal child. Until recent years, the management of disabled subjects was not even mentioned in the undergraduate curriculum of most dental schools in different parts of the world. Developmental disabilities can develop due to a variety of conditions which include cerebral palsy, Down's syndrome, mental retardation (MR), autism, seizure disorders, hearing and visual impairments, congenital defects, and even social or intellectual deprivation.[3]

Oral health maintenance is much difficult for these children. Poor oral health results into the most common dental problem, i.e., dental caries. Dental caries is the most prevalent disease among mentally challenged children worldwide and “dental treatment is the most unattended need of the disabled.”[4]

The reason being lack of co-operation and co-ordination, because of their mental disability. Apart from mental disability, a physical handicap or social conditions may severely affect the life of a mentally retarded child. Consequently, dental health habits and their relative importance in caries occurrence may be different from those of healthy individuals.[5] Previous studies suggest that the various extra-oral factors are also responsible for high caries experience among such children.[6],[7],[8] Keeping this in mind, the present study is conducted to evaluate interrelationship of various extra-oral factors with caries experience among mentally challenged children attending special schools in Bhopal city, Madhya Pradesh.

   Materials and Methods Top

This was a descriptive cross-sectional study conducted among 152 mentally challenged children under the age group of 5–15 years attending special schools in Bhopal city, Central India. Children and adolescent who were present on the day of examination were included in the study. Those with serious systemic disorders and unco-operative children were excluded from the study. Ethical approval was taken from the Institute Ethical Committee and informed consent was taken from the guardians of all children.

Information from all the children was recorded in two parts. Firstly, the proforma was filled about their demographic details, socioeconomic status, intelligent quotient (IQ) of inmates, type of MR, and institutionalization status. All such information were recorded by interviewing inmates/caretakers before examination. IQ and type of MR were taken from the updated record files of the subjects. Socioeconomic status was recorded using Kuppuswamy scale modified in 2007.[9] This scale takes account of education, occupation, and income of the family to classify study groups into high, middle, and low socioeconomic status. The second part of proforma was recorded by doing an oral examination. The diagnosis of caries was made visually and confirmed with the World Health Organization (WHO) probe when necessary. The decayed, missing, and filled teeth (DMFT and dmft) index adapted from the WHO 1997,[10] were used to assess the caries status. The criteria for diagnosis and coding (primary tooth codes within parentheses) are:

  • Code 0 (A) Sound
  • Code 1 (B) Decayed
  • Code 2 (C) Filled, with decay
  • Code 3 (D) Filled, no decay
  • Code 4 (E) Missing, as a result of caries
  • Code 5 Missing, as any other reason
  • Code 6 (F) Sealant varnish
  • Code 7 (G) Bridge abutment or special crown
  • Code 8 Unerupted tooth (crown)/unerupted root
  • Trauma T (T) Trauma.

The decay-component included all teeth with Code (1) and Code (2). The missing-component comprised teeth with Code (4). The filled-component included only teeth with Code (3). Teeth with Code (0), (5), (6), (7), and (9) were not included in the DMFT. A tooth was considered present in the mouth when any part of it was visible or could be touched with the tip of the probe without displacing the soft tissues. If a permanent and a primary tooth occupy the same tooth space, both status of the permanent tooth and the primary tooth was recorded in the mixed dentition stage (i.e., age 6–12).

Caries is recorded as present when a lesion in a pit or fissure, or on a smooth tooth surface, has an unmistakable cavity, undermined enamel, or a detectably softened floor or wall. All dental observation were made by one dentist on portable chair with standard dental mirror and explorer under natural light.

Statistical analysis

Data were entered into the computer from the precoded survey form. The master file was created in the Microsoft Excel Sheet and was analyzed using Statistical Package for Social Sciences software version 20 (IBM). Descriptive statistics was performed to calculate mean, standard deviation, number, and percentages. Means were compared using independent t-test (for 2 independent samples) and ANOVA test (for more than 2 independent samples). Multiple linear regression analysis was performed to obtain extra-oral predictors of dental caries. P < 0.05 was accepted as statistically significant and P < 0.01 was set to be highly statistically significant.

   Results Top

Totally 152 subjects participated in the study with mean age of 11.3 years. [Table 1] represents general background characteristic of all subjects. 73 (48.3%) children were under 5–10 years of age and 79 (51.7%) were under 11–15 years of age. Eighty-five (56.3%) were male and 67 (43.7%) were female. More than 50% were institutionalized. [Table 2] and [Table 3] represent DMFT and dmft score according to the age and showed statistically significant difference between the two age group. DMFT was more in the 11–15 years, whereas dmft score was more in 5–10 years. [Table 4] and [Table 5] shows multiple linear regression analysis with DMFT and dmft as a dependent variable, respectively. Age, parent occupation, income, and IQ were significant predictors of both DMFT and dmft. In addition, socioeconomic status and type of MR were significant predictors of only DMFT. [Table 6] represents comparison within significant predictors. Parents occupation as a semi-skilled worker, low income, and lower socioeconomic status were significantly responsible for high caries experience. Patients with cerebral palsy and Down syndrome showed a higher level of caries experience as compared to autism. Children with severe and profound MR had higher DMFT and dmft scores.
Table 1: General background characteristic of all subjects

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Table 2: Age-wise decayed, missing, and filled teeth scores of the population

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Table 3: Age-wise dmft scores of the population

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Table 4: Multiple linear regression analysis with decayed, missing, and filled teeth as a dependent variable

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Table 5: Multiple linear regression analysis with dmft as a dependent variable

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Table 6: Comparison within significant predictors

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   Discussion Top

For scoring dental caries, the DMFT and dmft indices adopted by WHO were used; this is well-accepted measure of caries prevalence and may reflect actual caries experience within the population studied. The mean DMFT for mentally challenged was recorded as 2.32, which is almost in line with the mean DMFT of 2.01 noted in the study conducted in Udaipur, Rajasthan.[6] On the other hand, Shaw et al.[11] noted mean DMFT of 9.59 among mentally challenged in the UK which is very high as compared to our result. In the present study mean decayed and missing component was 2.06 and 0.26, respectively; whereas none of the teeth were recorded as filled. Thus, this study reports a higher prevalence of untreated carious lesions in the disabled, thus agreeing with previous findings suggesting that the rate of treatment is frequently lower in the physically challenged.[12],[13] The mean dmft for primary teeth noted in the current study was 2.21. The overall prevalence of dental caries in this study was found to be 80.3% among mentally challenged, whereas Kozak [14] and Solanki et al.[15] showed that incidence of caries in mentally retarded children were 100% and 72.2, respectively.

There was increase in the DMFT scores with the age while there was a decline in dmft index in older age groups which obviously follows the natural exfoliation of primary teeth. Similarly, the previous studies showed steady increase in DMFT values with age and decrease in dmft score.[8],[16],[17]

This study did not report any significant difference between male and female caries status. The study conducted by Siddibhavi M B showed that females had higher DMFT rate than males,[8] while the study by Jain et al. showed male had high DMFT level.[6]

This study reported that the caries experience was highest among cerebral palsy patient with a DMFT score of 3.61, whereas Nallegowda et al. in 2005,[18] reported DMFT scores for cerebral palsy patient as 2.22. The DMFT score of subjects with Down syndrome reported as 3.18. However, there is conflict regarding caries prevalence in the subjects of Down syndrome. Some studies showed high prevalence of caries [19],[20] while some showed lower rate of dental decay among the subjects of Down syndrome.[21],[22] Delayed eruption, reduced time of exposure to a cariogenic environment, congenitally missing teeth, higher salivary pH and bicarbonate levels, microdontia, spaced dentition, and shallow fissures of the teeth, all contribute to lower risk of dental caries.[23] More recent studies, however, have shown that while the prevalence is lower, it is not as low as was once thought and it should not be assumed that people with Down syndrome would not develop dental caries.[24]

This study showed, caries experience was lowest among the patient of Autism. Previous study showed that the lower incidence of caries among autistics can be attributed to the good supervision in child's daily life activities such as tooth brushing, lack of in-between snacking, less cariogenic diet, and regular behaviour at meals.[25]

This study also reported high score of DMFT and dmft for the children with higher degree of MR, i.e., with less IQ. It is same in line with the study by Rao et al.[26] which stated that the prevalence of dental caries was higher in the severe mentally subnormal group. The high caries activity in these children can be attributed to their difficulty in maintaining oral hygiene, poor muscular co-ordination, and muscle weakness interfering with routine oral hygiene procedure.[27] Hence, it is the duty of dentist to evaluate those factors and educate their parents or guardians to look for curative and preventive treatment for such children. Furthermore, when a dentist has to attend such children, it is important that children's guardians should understand the patient's general conditions, etiology, natural history, complications, and prognosis.

The low socioeconomic status was significantly associated with high caries prevalence which was similar with findings reported by Jain et al.[6] However, another study showed no difference was observed between the social classes in this respect.[5] However, parent education was not a significant predictor of caries experience, whereas Jain et al.[6] showed association between low parent education with high caries experience.

There was no control group included in the study and no other oral parameters like oral hygiene status were taken into consideration. Furthermore, dietary habits and oral hygiene practices have not been recorded. These are few limitations of this study. To overcome these Further study in the same field is recommended to precisely understand the oral health problems of such children and to provide better care for same.

Evaluation of children with MR and affording them oral care and management is an urgent need of time. Attitude and knowledge of the oral health professionals are of utmost importance while rendering the oral health care to mentally challenged people. Dental team should be aware of the problems faced by mentally challenged, the dentist should have good patient management skills, and a sympathetic attitude, these factors helps to develop a healthy relation with the mentally challenged. With the advancements that we see today, it is important that full support and information should be provided to every individual to as to help him to live a better quality of life.

   Conclusion Top

The study showed high caries experience among disabled which require the high provision of dental services. Dental caries experience of mentally challenged children was related to various extra-oral factors such as age, type of retardation, IQ, socioeconomic status, income, and parent occupation. Therefore, people with mental health problems should be privileged with the same standards of care as the rest of the population. Dental health professionals should, therefore, be aware of the various extra-oral factors responsible for high caries experience of mentally challenged children and should understand and provide basic treatment needs to such children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

World Health Organization. International Classification of Impairments, Disabilities and Handicaps: A Manual of Classification Relating to the Consequences of Disease. Geneva: World Health Organization; 1980. Available from: http://www.whqlibdoc.who.int/publications/1980/9241541261_eng.pdf. [Last cited on 2014 Dec 05].  Back to cited text no. 1
Census of India 2011. Government of India, Ministry of Home Affairs; 2011. Available from: http://www.censusindia.gov.in/Census_And_You/disabled_population.aspx/. [Last cited on 2014 Dec 05].  Back to cited text no. 2
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Jain M, Mathur A, Sawla L, Choudhary G, Kabra K, Duraiswamy P, et al. Oral health status of mentally disabled subjects in India. J Oral Sci 2009;51:333-40.  Back to cited text no. 6
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Siddibhavi MB. Oral health status of handicapped children attending various special schools in Belgaum city, Karnataka. Webmedcentral Epidemiol 2012;3:WMC003061.  Back to cited text no. 8
Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy's socioeconomic status scale-updating for 2007. Indian J Pediatr 2007;74:1131-2.  Back to cited text no. 9
World Health Organization. Dentition status and treatment needs. Oral Health Surveys: Basic Methods. 4th ed. Geneva: WHO; 1997. p. 28.  Back to cited text no. 10
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Solanki J, Gupta S, Arya A. Dental caries and periodontal status of mentally handicapped institutilized children. J Clin Diagn Res 2014;8:ZC25-7.  Back to cited text no. 15
Liu HY, Huang ST, Hsuao SY, Chen CC, Hu WC, Yen YY. Dental caries associated with dietary and toothbrushing habits of 6-to 12-year-old mentally retarded children in Taiwan. J Dent Sci 2009;4:61-74.  Back to cited text no. 16
Vignehsa H, Soh G, Lo GL, Chellappah NK. Dental health of disabled children in Singapore. Aust Dent J 1991;36:151-6.  Back to cited text no. 17
Nallegowda M, Mathur V, Singh U, Prakash H, Khanna M, Sachdev G. Oral health status in Indian children with cerebral palsy – A pilot study. IJPMR 2005;16:1-4.  Back to cited text no. 18
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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