Year : 2009 | Volume
: 27 | Issue : 3 | Page : 151--157
Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents
S Kumar, J Sharma, P Duraiswamy, S Kulkarni
Department of Preventive and Community Dentistry, Darshan Dental College and Hospital, Udaipur, Rajasthan, India
Department of Preventive and Community Dentistry, Darshan Dental College and Hospital, Udaipur, Rajasthan
Aim: To assess the impact of socio-demographic and clinical variables on the oral hygiene and periodontal status in a sample of mentally disabled subjects. Materials and Methods: Study sample comprised of 171 mentally disabled subjects attending a special school in Udaipur, India. Oral hygiene status was assessed by Simplified Oral Hygiene Index (OHI-S) and periodontal status by Community Periodontal Index. Results: Stepwise linear regression analysis revealed that the best predictors in the descending order for oral hygiene index were disabled sibling, medical diagnosis, IQ level, education of mother and father. Having Down syndrome, less educated parents, poor economic status and a disabled sibling were the most important predictors for poor periodontal status. Conclusions: The present study highlighted that the oral hygiene and periodontal status of the present study population is poor and was influenced by medical diagnosis, IQ level, disabled sibling, parent«SQ»s level of education and economic status.
|How to cite this article:|
Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents.J Indian Soc Pedod Prev Dent 2009;27:151-157
|How to cite this URL:|
Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2021 Dec 3 ];27:151-157
Available from: https://www.jisppd.com/text.asp?2009/27/3/151/57095
The disabled form a substantial section of the community, and it is estimated that worldwide there are about 500 million people with disabilities.  Prevalence vary from country to country, the variance in prevalence may be attributed to ascertainment basis, the standardization methods employed from study to study.
The recent National Sample Survey Organization (NSSO) report  suggests that the number of disabled persons in the country is estimated to be 18.49 million which forms to about 1.8% of the total population and the mentally retarded population accounts to 0.44 million individuals. Mc Neil JM reported that the oral hygiene of mentally handicapped children is extremely poor and for this reason preventive procedures are very important. 
Although individuals who are disabled are entitled to the same standards of health and care as the general population, there is evidence that they experience poorer general and oral health, have unmet health needs and lower uptake of screening services ,
The oral health of the disabled may be neglected because of the disability condition, a demanding disease or limited access to oral health care. Moreover, because of their level of function and their limited ability to undergo an oral examination, the disabled present specific challenges when their oral health is assessed.  However, with appropriate planning, clear communication and carefully drawn limits to the service provided, the dramatic dental neglect experienced by the majority of these individuals can be successfully alleviated. 
In spite of the high level of dental disease, individuals with disabilities or illnesses receive less oral care than the normal population. Characteristically, it has been reported, 'dental treatment is the greatest unattended health need of the disabled'.  Some of the most important reasons may be inadequate recall systems, practical difficulties during treatment sessions, socioeconomic status and underestimation of treatment needs or pain, communication problems and bad cooperation. ,,,,
Mental retardation has been defined by the American Association of Mental Deficiency (AAMD) as 'Sub-average general intellectual functioning, which originates during the developmental period and is associated with impairment in adaptive behavior". 
Mental retardation can be defined as a deficiency in theoretical intelligence, which is congenital or acquired in early life. The AAMD classifies retardation into four categories according to their intelligence quotient as mild, moderate, severe or profound retardation. An individual is classified as having mild mental retardation if his or her IQ score is 50-55 to about 70; moderate retardation, IQ 35-40 to 50; severe retardation, IQ 20-25 to 35; and profound retardation, IQ below 20-25. 
The RCI-Rehabilitation Council of India Act, 1992 defines mental retardation as 'a condition of arrested or incomplete development of the mind of a person, which is specially characterized by sub-normality of intelligence'.
Even though "The persons with disabilities act, 1995" spells out the responsibility of the state toward protection of rights of persons with disabilities; provision of medical care, education, training, employment and rehabilitation, there is no legislation till date that makes a provision of dental services to the disabled population.
There are a few reports on the oral health status of the mentally disabled population from India but none of those studies has explored the influence of various socio-demographic and clinical variables on the oral hygiene and periodontal status of this special population. This study therefore intended to determine the oral hygiene levels and periodontal status and to investigate the association between oral hygiene and periodontal status with various socio-demographic (age, gender, parent's education, income) and clinical variables (medical diagnosis, disabled sibling and IQ level) among mentally disabled children attending a special school in Udaipur, India.
Materials and Methods
The target population included all the mentally disabled children attending the special needs school in Udaipur.
The total eligible sample comprised of 171 mentally retarded children and adolescents between the ages 8 and 19 years with Down syndrome or cerebral palsy.
Ethical approval for the conduct of the study was availed from ethical committee for research of Darshan Dental College and Hospital, Udaipur.
Informed consent of parents or guardians and school authorities was obtained before the subjects were included in the study. The subjects were classified according to their medical diagnosis (Down syndrome and cerebral palsy). Prior to the dental examination, demographic information was registered for each subject: age, gender along with information regarding the education and income of parents. Clinical examination was done by a single examiner (SK) for the assessment of oral hygiene status with plane mouth mirror and No. 23 explorer according to criteria of simplified oral hygiene index by Greene and Vermilion. 
Periodontal status was assessed by Community Periodontal Index,  children below the age of 15 years were assessed for bleeding and calculus only as recording of periodontal pockets would be overestimated in this population because of false pockets. The intra-examiner reliability for various recordings ranged from 0.87 to 0.94.
Intelligence Quotient level for each subject was assessed using the Wechsler intelligence scale for children (WISC) for 5-16 years old children and Wechsler adult intelligence scale for more than 16 years old. Children and adolescents presented on the days of the survey were included and exclusion criteria comprised subjects who were uncooperative, had severe detrimental systemic disorders like cardiac defects and with unknown cause for mental disability or those subjects who had mixed disorders.
Data was entered into the spread sheets and was analyzed using the statistical package for social sciences (SPSS version 11.0).
In descriptive statistics the mean and standard deviation were used to describe the patterns of oral hygiene, which were calculated for all groups.
Chi-square tests were used to test the differences in frequencies between the age groups and for prevalence of periodontal disease. One-way Analysis of Variance (ANOVA) was used to test the differences in the mean scores of oral hygiene indicators.
Multiple linear stepwise regression analysis was executed to analyze the associations of various socio-demographic and clinical variables with the oral hygiene indicators.
Multiple logistic regression analysis was executed to test the associations of various independent variables with the oral hygiene and periodontal disease status. The odds ratios (OR) with 95% confidence intervals (95% CI) were used to estimate the relative risk of the various variables for the occurrence of poor oral hygiene and periodontal disease. Only those subjects aged 15 or more years were included in the multivariate analysis for occurrence of periodontal disease.
The effect of each independent variable was assessed adjusting for that of all others in the model.
For cross tabulation and logistic regression analysis age was dichotomized into young and old (0= 17-24 years and 1= 9-16 years), Gender was coded as 0 = 'male', 1 = 'female', mental retardation based on IQ level was coded 0 = 'mild' (mild and moderate), 1 = 'severe' (severe and profound), presence of disabled sibling was coded 0 = 'yes'; 1 = 'no'.
Fathers' and mothers' education were measured as the highest level of education completed and categorized from 1 = 'never attended school' to 3 = 'more than secondary education', which was later dichotomized as 0 = 'secondary and below', 1 = 'above secondary'.
Economic status was measured based on the family's annual income and was categorized from 1 = very poor to 4 = high income and then dichotomized into 0 = low (poor and very poor), 1 = high. Medical diagnosis was based on the school records, coded as 0 = 'Down syndrome' and 1 = 'cerebral palsy'.
Dependent variables were dichotomized into 0 = 'fair and good' (OHI-S scores ranging from 0 to 3) and 1 = poor (OHI-S scores from 3 to 6) for oral hygiene status whereas for periodontal status 0 constituted 'no periodontal disease' (CPI score 0) and 1 constituted 'presence of periodontal disease' (CPI scores 1, 2 and 3)
[Table 1] illustrates the general profile of the study population. There was no difference in the distribution of subjects according to age group but there was unequal gender distribution with males comprising 87.7% of the total sample. Poor debris status and oral hygiene status was exhibited by a major proportion of 77.2 and 67.6%, respectively. More than half the population (60.8%) was moderately mentally retarded and 56.1% subjects were with cerebral palsy. None of the subjects exhibited deep periodontal pockets but shallow pockets were presented by 66.4% subjects. More than three quarters (77.2%) of the population belonged to middle income group.
[Table 2] compares the Debris index (DI), calculus index (CI) and mean oral hygiene index (OHI-S) scores at various age groups amongst the study subjects.
There was a statistically significant difference (P = 0.001) between all the age groups for all the variables of Oral hygiene index. The oldest age group had the highest scores for all the indices measured and there was a definite trend where mean scores for all the indices gradually increased with increase in age.
The mean number of sextants with evidence of any of the periodontal conditions is illustrated in [Table 3]. Healthy sextants without any signs of periodontal disease were found in all age groups but contributed for only 0.4 sextants.
In the youngest age group 0.4 sextants were found to be healthy whereas in older age groups this number was observed to decrease abruptly with 0.1 being the mean number of healthy sextants in the oldest age group. The greatest periodontal destruction was manifested in the older age groups with 3.3 and 4.0 sextants presenting shallow periodontal pockets, whereas, calculus was widespread among the younger age groups.
Stepwise multiple linear regression analysis was executed to estimate the linear relationship between the dependent variables (DI, CI and OHI) and various independent variables, which revealed that the best predictors in the descending order for debris index were disabled sibling, medical diagnosis and age that explained a variance of 42.5% with presence of disabled sibling alone contributing for 23.2% variance. It is evident from [Table 4] that disabled sibling and medical diagnosis were significantly associated with all the oral hygiene indicators. In addition to those variables that were significantly associated with debris index, gender and parent's education were also associated with calculus scores. For the oral hygiene index, IQ level was one of the predictor in the model and the cumulative variance provided by all the predictors (disabled sibling, medical diagnosis, IQ level and parent's education) was 62.8%.
As shown in [Table 5], age, medical condition, disabled sibling and economic status were the most important predictors of oral hygiene status in addition to all other variables that maintained a statistically significant effect in the multivariate analysis. Thus, odds ratios for poor oral hygiene status were significantly higher among old than among young, individuals with a disabled sibling than those subjects who had no other disabled sibling, amongst subjects belonging to low-economic status than high and among those subjects having Down syndrome as compared to cerebral palsy.
A similar pattern was observed for periodontal status where odds ratios were significantly higher among males and old subjects as compared to females and younger residents. Having Down syndrome, less educated parents, poor economic status and a disabled sibling were the other most important predictors for poor periodontal status.
Oral health disparities are found among people with mental and physical disabilities. 
Though there is voluminous literature available on the oral health status of the disabled population, little research has been conducted to assess the impact of various socio-demographic and clinical variables on the oral hygiene and periodontal status of mentally disabled populations.
Subjects who did not cooperate in the clinical examination procedures were deemed as excluded and probably if these patients had been included, there would have been a higher possibility of finding poorer oral hygiene and periodontal status.
The mentally disabled subjects of the present study had a poorer standard of oral hygiene and greater prevalence of periodontal disease than that found in normal children of comparable age groups. The mean oral hygiene index of the study population was 3.80 ± 1.42, whereas it was observed to be in the range of 1.1-1.7 among school children of Davangere, India. 
Furthermore, the proportion of subjects with no periodontal disease in the present population was observed to be 3.5%, which is in strong disagreement to that of general population of the state of Rajasthan where the proportion of 12- and 15-year-old children without any signs of periodontal disease was 66.8 and 49.2%, respectively. The mean number of healthy sextants in the study population was 0.8 for the age group 13-16, whereas in the general population of the comparable ages in Rajasthan state it was found to be 3.7.  These results confirm the findings of other studies concerning the poor level of oral hygiene and high prevalence of periodontal disease among individuals with disabilities. ,,
The present study revealed that the overall oral hygiene status of the study population was poor with a prevalence rate of 4.7, 32.7 and 62.6% for good, fair and poor components, respectively, which is very poor than that of a previous study conducted on handicapped children attending special schools in Birmingham, UK  where it was observed that the good, fair and poor levels of oral hygiene of hearing impaired children was 69, 29 and 2%, respectively. Previous studies , have highlighted the importance of oral hygiene in the etiology of periodontitis.
Nicolaci and Tesini  have observed that the high prevalence of poor oral hygiene among handicapped individuals is usually more evident in the mentally retarded and there seems to be a correlation between the level of oral hygiene and severity of the handicap; and lack of proper oral hygiene has been suggested to be the principal cause of periodontal disease in individuals with handicapping conditions. , Prolonged retention of food particles in the oral cavity might result in more gingival inflammation and eventually lead to periodontal disease.
Martens et al.  has observed that children who were mildly mentally retarded had significantly better manual dexterity skills than the severely mentally retarded, which explains the findings in the present study that the odds for presence of good oral hygiene status was 1.2 times for subjects with mild retardation than among the severe ones.
The general increase in OHI-S scores with increase in age conforms to the previous findings  and this was found by Grants and Stern  to be due to cumulative effect of plaque and calculus with increase in age. There was a definite trend for periodontal disease with increase in mean number of sextants with periodontal pockets as the age increased which could be explained by the same reason.
Male subjects had poorer oral hygiene and periodontal status than their female counterparts as shown by the logistic regression analysis, Denloye OO  observed similar trend among mentally retarded children of Nigeria where higher OHI-S scores were recorded among males than females.
In multivariate analysis, education level of mother and father was significantly associated with both oral hygiene and periodontal status. This could be explained by the findings from a study among children with Down syndromes in Riyadh, which revealed that a higher percentage of children of illiterate mothers were found to use water only as a method of cleaning their teeth compared to other children  that could influence the oral hygiene status. Moreover, a high correlation between poor oral hygiene and the development and progression of periodontal disease has been well documented and the role of poor oral hygiene as a risk factor of periodontal diseases is well established. 
Moreover, the odds ratio for poor oral hygiene and periodontal status were significantly higher among Down syndrome subjects than those with cerebral palsy with an odds ratio of 12.82 (95% CI 5.09-18.23) and 11.78 (95% CI 3.98-14.72), respectively. This observation confirmed previously reported data on the high prevalence of periodontal disease in populations with Down syndrome. ,
Furthermore, Orner  has reported a significant correlation between oral hygiene and periodontal conditions in these children.
Income status of the parents was even significantly associated with oral hygiene and periodontal status confirmed by a previous study,  which observed that the oral hygiene status deteriorated as the income decreased.
Presence of a disabled sibling solely explained a variance of 33.7% for oral hygiene index apart from being an important risk factor for periodontal disease. It is cited by many authors  that parents of children with mental retardation go through a predictable progression of the stages of grief and adjustment, including shock, despair, guilt, withdrawal, acceptance an adjustment. Moreover, presence of another disabled child demands extra efforts from parents in performing daily oral hygiene procedures.
Besides, stage of mental retardation based on IQ levels influenced both oral hygiene and periodontal status in accordance with a previous study,  which observed that OHI-S among educationally subnormal moderate (ESN-M) was 2.21 when compared to educationally subnormal severe (ESN- S) where it was found to be 2.62.
The present study observed that poor oral health is a major problem for mentally disabled children and their oral health seemed to indicate a cumulative neglect, which may be a part of overall parental neglect of these children in relation to other basic health measures or may reflect the attitude that oral health lacks importance in the overall scheme of health management. The oral hygiene and periodontal status of the present population is poor and was influenced by medical diagnosis, IQ level, disabled sibling, parent's level of education and economic status. Oral health promotion programs should be aimed specifically at special needs schools and parents of disabled children. Oral health promotion should include facilitating access and regular use of oral health services. Taking into consideration the multifactorial influence on oral hygiene and periodontal status of the present disabled population, oral health promotion and intervention programs should be targeted and concentrated towards these risk groups.
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