|Year : 2016 | Volume
| Issue : 4 | Page : 364-369
Dental neglect among children in Chennai
Deepa Gurunathan, Arunachalam Karthikeyan Shanmugaavel
Department of Paediatric and Preventive Dentistry, Saveetha Dental College, Chennai, Tamil Nadu, India
|Date of Web Publication||29-Sep-2016|
Saveetha Dental College, Chennai - 600 077, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Child dental neglect is the failure of a parent or guardian to meet the child's basic oral health needs such that the child enjoys adequate function and freedom from pain and infection, where reasonable resources are available to family or caregiver. Aim: The aim of the study is to evaluate the phenomenon of dental neglect among children in Chennai and to associate dental neglect with oral health status of children aged 3-12 years. Materials and Methods: This is a cross-sectional study involving 478 pairs of parents and children. Dental neglect scale and a questionnaire were used to assess the dental neglect score among parents of the children involved in the study. Oral health status of children was clinically assessed using oral hygiene index, decayed, extracted, filled teeth (def(t)), pulp, ulcers, fistula, abscess (pufa), decayed, missing, filled teeth (DMFT), PUFA as per the World Health Organization criteria and pufa/PUFA index. Student's t-test and one-way ANOVA were used appropriately for statistical analysis using SPSS software version 20.0. Results: A significant higher dental neglect score was reported among the parents who reside in the suburban location (P < 0.001), whose educational qualification was secondary (P < 0.001) and who have not availed any dental service for >3 years (P = 0.001). A significant higher DMFT (P = 0.003), deft (P = 0 < 0.001), pufa (P = 0.011), and debris index (P = 0.002) scores were seen in the higher dental neglect group. Conclusion: Child dental neglect is seen among the parents whose educational qualification was secondary, who reside in the suburban location, and who have not utilized the dental services for more than 3 years in Chennai. This dental neglect results in poorer oral health of children.
Keywords: Children, dental neglect scale, parents
|How to cite this article:|
Gurunathan D, Shanmugaavel AK. Dental neglect among children in Chennai. J Indian Soc Pedod Prev Dent 2016;34:364-9
| Introduction|| |
Oral health plays a very important role in the general well-being of individuals, and parents' behavior and attitudes influence the oral health of their children.  Dental neglect is defined as parents' persistent failure to take precautions and provide necessary dental treatment to maintain the child's oral health and to ensure their freedom from pain and infection. ,
Dental neglect is seen at each and every step of life with different reasons involved with it. Although child dental neglect appears to be an isolated problem, in reality, it may be an indicator of other types of abuse.  In addition, children who suffer from poor oral health are 12 times more susceptible to have lesser activity days than those who do not.  Child dental neglect leads to malnutrition which has an impact on adulthood health. ,
It is the responsibility of parents to pursue health-related necessities of their children. In this regard, the lack of parent's or guardian's attention will have a negative influence on the child's oral status. Investigating dental neglect among children would identify the specific reason for the failure to prevent and treat dental caries. Thereby, it provides opportunity for the government and health care personnel to address the issue at root level.  However, the World Health Organization (WHO) has reported that neglect has to be distinguished from factors that include poverty and lack of dental service, implying that it can be stated as neglect only when reasonable resources are available to the family or caregiver. 
The dental neglect scale (DNS) appears to be an appropriate method for objectifying dental neglect. It has satisfactory health index, can be easily measured, apparently unaffected by the observation process, and has to be manipulated statistically. DNS for children assesses the extent to which a parent or caretaker cares for the child's teeth, receives professional dental care, and believes oral health to be important.  Hence, DNS helps to identify the reason for poor oral health in children. Parents and responsible adults are the principal people in the children's development in the 1 st years of life. Thus, the interventions that are directed toward parents' beliefs and attitudes about oral health may be beneficial in the prevention of oral problems such as dental caries. 
There are various case reports, case-control studies, and cohort studies in the literature regarding dental neglect in children. However, these studies have not evaluated the complete parent's perspective regarding the child's oral care.  Hence, the aim of this study was to investigate dental neglect among children in Chennai and to examine its association with key demographic features and dental health status.
| Materials and Methods|| |
Ethical approval for the study was obtained from the Institutional Review Board. This cross-sectional study was conducted for a week's time in a book exhibition program in Chennai. This ensured that participants involved in the study were randomly selected from the entire Chennai population. On the first 2 days of the event, a pilot study which involved 100 participants was conducted, and sample size for the main study was calculated using (Department of Psycholgy, University Manheim, Germany) GPower version 3.1 based on its result. The continuous variable was dichotomized to find the relationship between dental neglect and caries status. The mean decayed, extracted, filled teeth (deft) scores for the low and high DNS groups were 2.165 and 2.981, respectively. The estimated sample size with type I error 5% and power of a test (beta) set at 95% was 408. Considering 10% dropouts, the sample size was set at 450. The participants included children aged from 3 to 12 years, and the questionnaire was answered by their parents. An informed consent was obtained from the participating parents. The parents were asked to fill in a comprehensive questionnaire which included demographic details, visits to dentist, and seven questions of DNS.  Two calibrated dentists carried out the oral examination in children. Children with the consent from parents to participate in the survey were examined. Oral examination of children was conducted using disposable mouth mirror and blunt ball-ended probe (0.5 mm) in natural day light. Teeth were recorded according to the Federation Dentaire Internationale Numbering System oral hygiene, and dental caries status was assessed by the simplified oral hygiene index  and WHO  criteria. Pulp, ulcers, fistula, abscess (PUFA)/pufa for permanent and deciduous teeth was calculated using the pufa index to assess the severity of untreated caries. 
The collected data were tabulated and subjected to statistical analysis using SPSS software version 20.0, (SPSS Inc., Chicago Ill., USA) and levels of statistical significance were set at P < 0.05. In addition to descriptive statistics, t-test was used to examine the mean DNS, deft, debris index, and pufa scores according to sex, age, and residential address. One-way ANOVA was used to examine the mean DNS, deft, debris, and pufa index scores with respect to education, income, and dental services' utilized pattern. Frequency distributions of the response to DNS questions were produced. A median split of the DN score was used to divide the population into two groups that is high (DNS ≥17) and low (DNS ≤16). Then, Student's t-test was used to compare the mean decayed, missing, filled teeth (DMFT), deft, PUFA, pufa and debris scores between the low and high dental neglect groups.
| Results|| |
A total of 478 pair of parents and children participated in the study, of which female and male parents were 284 and 194, respectively. The mean age of the parents was 34.40 ± 6.54 years. Among 478 children who participated in the study, 386 children had both primary and permanent teeth. The remaining children had only primary dentition. [Table 1] and [Table 2] illustrate the comparison of mean dental neglect, deft, debris index, pufa, DMFT, and PUFA scores of the children with respect to sex, age, education, domicile, income, and last dental service utilized in years.
|Table 1: Comparison of the mean dental neglect scale, decayed, extracted, filled teeth, debris index and pulp, ulcers, fistula, abscess scores with respect to the demographic status|
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|Table 2: Comparison of the mean decayed, missing, filled teeth and pulp, ulcers, fistula, abscess scores with respect to the demographic status|
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There was no significant difference in the mean dental neglect score with respect to sex, age, and income. With respect to dental neglect scores, a significant higher dental neglect score was reported among the people who reside in the suburban location (P < 0.001), parents whose educational qualification was secondary (P < 0.001), and those people who have not availed any dental service for >3 years (P = 0.001). Post hoc Tukey's test revealed a significant difference in the dental neglect score between the caretakers whose educational qualification was secondary and graduate. Comparing the dental neglect and the oral health status, a higher DMFT (1.17) and debris index (1.21) scores were seen in the children whose parents' educational qualification was secondary. Similarly, a higher debris index (1.20) score was reported in children who live in the suburban areas. In addition, higher mean dental neglect score (18.12) was seen in the parents age group of 30-39 which corresponds to the higher mean deft (2.74), DMFT (1.12), pufa (0.85), PUFA (0.29), and debris index (1.08) scores. A higher deft (2.91), pufa (1.01), DMFT (1.10), and debris index (1.08) scores were reported by parents whose monthly income ranges between 10,000 and 15,000 and whose mean dental neglect score was 17.92. In the dental services utilized, a higher mean deft (3.184), DMFT (1.33), and debris index (0.90) scores were reported among the parents who have not utilized the services for 2 years.
The descriptive statistics for the response distribution in percentage to the dental neglect questions are shown in [Table 3]. With respect to items 1, 2, 5, and 7 questions given in the table, around 40%-70% of the people have responded saying "somewhat yes," which means that the child is maintaining his/her home dental care by brushing the teeth regularly and also receives the care from the dental office. Around 37% of them responded that they somewhat do not say no to the dental care needed for the child. In item 4, around 34% of the parents responded that the child definitely does not neglect the dental care needed for them. Regarding parental control of snacking between the meals, around 33% reported that they are not able to control the snacking habits of the children, while another 33% reported that they can somewhat control the child's between-meals snacking habit.
|Table 3: Response distribution to the dental neglect scale questions in percentage|
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[Figure 1] shows the comparison of the DMFT, deft, PUFA, pufa, and the debris index score between the higher dental neglect and the lower dental neglect groups. A significant higher DMFT (P = 0.003), deft (P = 0 < 0.001), pufa (P = 0.011), and debris index (P = 0.002) scores were seen in the higher dental neglect group when compared with the lower dental neglect group.
|Figure 1: Comparison of DMFT, deft, pufa, PUFA, and debris index between higher dental neglect and lower dental neglect groups. *P < 0.05 significant, P value calculated using Student's t-test. DMFT = Decayed, missing, filled teeth, deft = decayed, extracted, filled teeth, PUFA = Pulp, ulcers, fistula, abscess|
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| Discussion|| |
There is very scarce literature regarding the estimate of child dental neglect worldwide. Assessing child dental neglect among caretakers offers a linkage between dental health and socioeconomic factors, attitude toward dental health, and acceptability to dental treatment which have hitherto received less attention.  Literature states that early lesions progress to cavity in 2-3 years and these cavities can further give rise to symptoms such as pain and swelling, which are also considered to be features of neglect.  A systematic review  suggested that salient features of dental neglect include failure to seek or delay in seeking dental treatment, to comply with treatment plan, and failure to implement basic oral care. Hence, in this study, in addition to recording the caries status, the severity of caries was also evaluated (PUFA and pufa), , which interprets the degree of failure to seek dental treatment.
The caretakers who responded to the questionnaire were mostly mothers of the children. Hence, it helped us to know the complete home and professional dental care the child receives as the child is mostly with the mother during the preschool and even after the child starts to go to school. DNS was used in the present study to associate various factors that could influence dental care and the oral health of a child. DNS is an ideal instrument for assessing behavior and attitude toward oral health. As well, it is a good tool for population surveys that are aimed at identifying vulnerable groups to dental care. ,,
The median DNS score among parents in Chennai is 17.9, indicating mediocre oral health care for children (out of possible range: 6-30). This is higher than those of parents in Australia  which can be due to the availability of dental services and cultural differences between the places of study. This higher dental neglect scores are associated with poorer oral health as seen in previous reports , Since there is no available printed literature regarding the dental neglect score of parents of young children, a direct comparison between the studies is difficult. The children in this study with higher dental neglect score had a statistically significant higher caries and debris index when compared to children with lower dental neglect score as seen in Australia.  The present study showed that the dental neglect score is higher in caregivers aged above 30 years. The importance of oral health might not have been as a lifestyle practice for elder people in this population. However, we see that the present younger generation parents are more toward the maintenance of good oral health similar to results obtained by Shamta Sufia et al.  This is a positive aspect that the trend of importance of oral health is getting rooted into the society. , The mean dental neglect score among the mothers is high suggestive of requirement of dental education as mothers are important role models transferring values, norms, and attitude to their children. 
The results of the present study showed that the parents having income <15,000 and who have done secondary education showed lesser levels of positive dental attitudes which is similar to studies done by Freeman et al. and Williams et al. , Hence, there is a greater probability for the occurrence of oral diseases among children of low-income mothers,  which is in contrary to the result of AlGahnim et al.,  where it was stated that income does not play a role in attitude toward oral health. In the present population, it was observed that untreated caries resulting in pulpal involvement is seen in lower income group of population. However, the parents who have postgraduate education showed higher dental neglect in the study. This result might be misleading as only few postgraduate parents were involved in the study.
In the present study, a significant difference was observed in the dental neglect scores among parents residing in the suburban areas (P < 0.001) in comparison with parents of urban areas. This is essentially due to lesser awareness of oral health, availability, and usage of dental services.  Hence, the oral hygiene status and caries status are poorer when compared to children from urban areas.
The dental neglect among children is higher whose parents' last dental visit was before 2 and 3 years and symptom driven which is similar to the findings in South Australia.  The dental neglect is reflected in the poor oral health (debris index 0.90) of these children with significantly higher caries prevalence and untreated carious lesions (deft [3.184] and DMFT [1.33]). This suggests that the knowledge of parents regarding oral health and utility of dental services is limited as the frequency of dental visits suggests the oral health awareness among parents. 
It was observed in the present population that 34.1% of respondents showed indifference to take professional dental care. Parents who avoid bringing their children to scheduled dental appointments and previous negative experiences for the child indicate the development of risk for dental caries in 5-year-old children.  In addition, parents who do not give importance to their own dental treatment will not take their child to dental examination. , Although 70% of the parents in the present study state that their children brush their teeth, the oral hygiene status of children does not indicate it. There exists a disparity between the observed tooth brushing habit and that reported by mothers. Hence, the response of the parents regarding brushing has to be taken with caution.  Although more than half of the parents in the study population thought that they gave good home care to their children, the oral health status did not support their view. This was similar to a study done in Texas where it has been observed that parents perceived that their children "took care" of their teeth while the children reported that they had not given importance. 
In the studied population, parents were not confident about their control over the in-between meal snacking habit of their children. As well, the parents assumed that it is the responsibility of the child rather than themselves in terms of dietary habits. However, childhood dietary habits constitute an important factor in the etiology and progression of dental caries. Hence, guidance from parents is not only associated with good oral habits but also in the rational consumption of sugar.  In addition, Ferreira  also found that carious activity was higher in those patients who began tooth brushing without parental supervision and who began to consume sucrose before the 1 st year of life and who eat in-between the main meals. Similarly, the results of the present study indicate that the oral health and the caries status in children were poor whose parents showed negligence toward good brushing and snacking habit.
| Conclusion|| |
Dental neglect is present among parents of Chennai city. Education and domicile play an important role in the parent's knowledge and attitude toward good dental care. Hence, it is essential to identify the parents and children who are at risk of lesser oral care and initiate measures targeted to their needs.
The limitation of the present study is that the observations regarding dental neglect among parents was seen in a limited area. A multicentric study in Chennai can help us to have an overall view regarding child dental neglect. As well, dental screenings were carried out under natural light using a community periodontal probe and a mouth mirror. Use of radiographs might be helpful to associate DNS and dental caries experience.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]