|Year : 2020 | Volume
| Issue : 4 | Page : 2045-2051
Oral hygiene negligence among institutionalized mentally disabled children in Mysore city—A call for attention
Darshana Bennadi1, Vinayaka Konekeri2, M Maurya3, Veera Reddy4, G Satish5, C V. K Reddy3
1 Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Sri Siddhartha Academy Higher Education, Agalkote, Tumkur, Karnataka, India
2 Department of Public Health Dentistry, Al-Azhar Dental College, Perumpillichira, P.O, Thodupuzha, Idukki, Kerala, India
3 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, India
4 Department of Public Health Dentistry, Government Dental College and Research Institute, Bellary, Karnataka, India
5 Ibn Sina National College for Medical Studies, Jeddah, KSA
|Date of Submission||30-Aug-2019|
|Date of Decision||17-Sep-2019|
|Date of Acceptance||31-Oct-2019|
|Date of Web Publication||30-Apr-2020|
Dr. Darshana Bennadi
Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Sri Siddhartha Academy Higher Education, Agalkote, Tumkur, Karnataka - 572 107
Source of Support: None, Conflict of Interest: None
Background: Oral health is integral part of general health. In certain conditions especially among mentally disabled, oral health is neglected. Studies have shown that mentally disabled population has the risk of poor oral health. People with disabilities deserve the same opportunities for oral health and hygiene as those who are healthy, but sadly dental care is the most common unmet health care need of the disabled people. Methodology: This comparative, descriptive cross-sectional study was conducted among institutionalized mentally disabled and normal children of age group 6–13 years in Mysore city. Results: Majority of mentally disabled children, that is, 36.73% (n = 180), had poor oral hygiene when compared with normal children, that is, 9.18% (n = 45). This difference was statistically highly significant (P < 0.000). The significant differences in the gingival status and severity of mental disability were seen (P < 0.001). The result showed that the gingival health worsens with increase in the severity of mental disability. Conclusion: The present study showed the dental negligence among mentally disabled children where the parents, caretakers, and dentists are responsible. Oral health promotion programs should be conducted for special group children, their parents, as well as caretakers.
Keywords: Brushing, gingival status, mentally disabled, normal children, oral health promotion, oral hygiene, oral hygiene status
|How to cite this article:|
Bennadi D, Konekeri V, Maurya M, Reddy V, Satish G, Reddy C V. Oral hygiene negligence among institutionalized mentally disabled children in Mysore city—A call for attention. J Family Med Prim Care 2020;9:2045-51
|How to cite this URL:|
Bennadi D, Konekeri V, Maurya M, Reddy V, Satish G, Reddy C V. Oral hygiene negligence among institutionalized mentally disabled children in Mysore city—A call for attention. J Family Med Prim Care [serial online] 2020 [cited 2021 Feb 27];9:2045-51. Available from: https://www.jfmpc.com/text.asp?2020/9/4/2045/283441
| Introduction|| |
Literature shows that the management of mentally disabled children for maintaining their oral hygiene and dental treatment is a big challenge for parents as well as dentists.
Mental retardation has been defined by the American Association of Mental Deficiency (AAMD) as a deficiency in theoretical intelligence that is congenital or acquired in early life. The AAMD classifies retardation into four categories according to intelligence quotient (IQ): mild IQ score is 50–55 to 70, moderate (IQ score 35–40 to 50); severe (IQ score 20–25–35); or profound retardation (IQ score below 20–25).
According to the National Sample Survey Organization Report (2002), 18.49 million number of disabled persons were reported, while the mentally retarded population amounted to 0.44 million individuals in India. "The Persons with Disabilities Act, 1995" states 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. People with disabilities deserve the same opportunities for oral health and hygiene as those who are healthy, but sadly dental care is the most common unmet health care need of the disabled people. Most of population have access to medical and health care services through primary health care especially rural areas. Through primary health care, we can reach unreachable population too. Primary health care play a very important role in the form of physical, mental, social, financial, and environmental service provider to special children. Where it is not only establishing home visit programmes through ASHA, Anganawadi workers, social workers where proper education to the expecting new parents as well as parents of special children can be done. Through the help of public–private partnerships it helps to mitigate barriers to access health services and medical services at the doorsteps.,,
Most handicapped individuals start their lives with teeth and gums that are as strong and healthy as those of the normal people. However, their diet, eating pattern, medication, physical limitations, lack of cleaning habits, and attitudes of parents and healthcare providers, all contribute to poor oral health of the handicapped people.
Studies have shown that individuals with intellectual disabilities have poor oral hygiene and higher rate of gingivitis. Oral hygiene is one of the causal factors in the development of gingival or periodontal disease. These subjects have the highest dental negligence as compared with normal population.,,,,,,
The oral health of subjects is directly dependent upon their physical and mental abilities, their cooperativeness, and motivation of the support staff. Maintenance of good oral hygiene is difficult for mentally disabled children as frequently they lack muscular coordination and recognition of the importance of brushing and flossing. In many instances, the oral hygiene care of these children will be taken care by another person such as generally parent, guardian, or caregiver. Unfortunately, oral health care is one of the greatest unattended health needs of these God forbidden children. It has been observed that oral health disparities among these subjects were associated with practical difficulties in acceptance of routine treatment sessions, inadequate skills of dentists and hygienists to provide dental care, lack of effective preventive strategies to minimize the need for this care and negative attitudes, and lack of supervision by the parent, guardian, or caregiver toward oral health.,,,
There are a few reports on the oral hygiene and gingival status of the mentally disabled population from India. Hence, an attempt had been made to assess and compare the oral hygiene and gingival status of institutionalized mentally disabled and normal children of age group 6–13 years in Mysore city and had explored the influence of sociodemographic, level of mental retardation, and clinical variables of this special population.
| Methodology|| |
The descriptive cross-sectional study was conducted among institutionalized mentally disabled and normal children of age group 6–13 years in Mysore city. The list of institutions for disabled children was obtained from the Occupational Therapy and Rehabilitation Center in Mysore, and list of residential schools were obtained from Block Education Office, Mysore. Before the start of the survey, informed consent was obtained from the concerned school authorities and from the parents to examine the children.
All the children available during the time of survey from all the 10 institutions for disabled, and an equal number of age- and gender-matched normal children from six residential schools was included in the study by stratified random sampling method. Ethical clearance was obtained from the Institutional Ethics Committee JSS Dental College and Hospital ethical committee board in October 2009.
- Study group: Uncooperative children
- Control group: Subjects with systemic diseases, on long-term medication.
Training and calibration of the examiner were done on 20 subjects, who were examined twice using diagnostic criteria on successive days, and then the results were compared to know the diagnostic variability. Agreement for assessment was 90%.
Examination and collection of data
The investigator carried out the examination solely. Earlier to the main study, a pilot study was carried out on 20 disabled children to check the feasibility and relevance of format.
A total of 490 mentally disabled children comprising 300 males and 190 females attending all the 10 institutions for disabled children in the age group of 6–13 years were examined, and age- and gender-matched equal number of normal children was examined in their respective schools in an ordinary chair or in their wheel chair under natural daylight using mouth mirror and probe (American Dental Association Type 3 examination).
The study involved completion of predesigned questionnaire and examination using indices such as Oral Hygiene Index-Simplified (OHI-S) of Greene and Vermillion (1964) and Gingival Index by Loe and Silness (1963). The examination was carried out in their respective institutions. The IQ level record which was available in the institution was utilized during the process study. Samples were divided into four groups according to the World Health Organization Classification of Mental Retardation (1994).
Socioeconomic status has been classified according to the Modified B.G. Prasad Classification.
Collected data subjected to statistical analysis using SPSS version 16.0 (SPSS Inc., New York, USA) was used. The statistical significance was fixed at 0.05.
| Results|| |
Study population consisted of 490 children in each mentally disabled and normal children group in the age group of 6–13 years of Mysore city. [Table 1] shows distribution of the mentally disabled subjects according to severity of mental retardation.
|Table 1: Distribution of the mentally disabled children according to severity of mental retardation|
Click here to view
Oral hygiene aid used, frequency, and method of brushing
Majority of the study subjects, that is, 92.85% mentally disabled children (n = 455) and 91.83% normal children (n = 450) used toothbrush and toothpaste to clean their teeth; 7% mentally disabled children (n = 35) and 5% normal children (n = 25) used finger and tooth powder; and 1% of mentally disabled (n = 5) and 1% normal children (n = 5) used other aids (neem stick, coal powder, brick powder, etc.) to clean their teeth. [Graph 1] shows significant difference in regard to frequency of toothbrushing among study population (P = 0.001). Majority of the study subjects, that is, 76.53% mentally disabled children (n = 375) and 43.88% normal children (n = 215), brushed in horizontal direction, whereas 9.18% mentally disabled children (n = 45) and 29.59% normal children (n = 145) brushed in vertical direction. The difference was statistically significant (P = 0.001). Majority of the study subjects, that is, 76.53% mentally disabled children (n = 375) and 75.51% normal children (n = 370) used medium bristled tooth brush to clean their teeth. A majority of the study subjects, that is, 77.55% mentally disabled children (n = 380) and 91.84% normal children (n = 465) used to change their toothbrush within 6 months. A majority of mentally disabled children, that is, 56.12% (n = 275), needed complete assistance, 32.65% (n = 160) needed partial assistance of caretaker/parents for oral hygiene practices, whereas only 11.92% (n = 55) did not need help [Graph 2]. Majority of children visited dentist for pain.
Oral hygiene status
Majority of mentally disabled children, that is, 36.73% (n = 180) had poor oral hygiene when compared with normal children, that is, 9.18% (n = 45). This difference was statistically highly significant (P < 0.000) [Table 2].
|Table 2: Distribution of the study population [Mentally disabled and normal children] according to oral hygiene status (According to simplified oral hygiene index by John. C. Greene and Jack. R. Vermillion, 1964)|
Click here to view
Majority of mild mentally disabled children, that is, 21.7% (n = 25), had good oral hygiene status, whereas 66.7% (n = 10) profound mentally disabled children had fair oral hygiene status and severely mentally disabled children, that is, 35.3% (n = 30), had poor oral hygiene status. This difference was statistically highly significant (P < 0.001). This result depicts that as severity of mental disability increases, the oral hygiene status worsens [Table 3].
|Table 3: Distribution of mentally disabled children according to oral hygiene status and severity of mental disability|
Click here to view
There was statistically significant difference between OHI-S status and socioeconomic status in normal children. The results depicts that better OHI-S status was seen as socioeconomic status increases, whereas in the mentally disabled, there was no statistically significant difference. There were statistical significant differences in both groups between OHI-S status and parent's level of education. The OHI-S status was found to increase with increase in the level of education.
The gingival status was assessed by criteria given by Loe and Sillness (1963) on four selected teeth (functional disability inventory: 16, 12, 32, and 36). 13.3% (n = 65) mentally disabled and only 6.1% (n = 30) normal children had severe gingivitis. Findings showed statistically highly significant difference between two groups in the gingival status (P < 0.001). The result shows that mentally disabled children had poorer gingival health than the normal children [Table 4]. The significant differences in the gingival status and severity of mental disability were seen (P < 0.001). The result showed that the gingival health worsens with increase in the severity of mental disability [Table 5]. There was no statistical significant difference between gingival and socioeconomic status among mentally disable children (χ2 = 10.0; P < 0.26).
|Table 4: Distribution of the study population [[Mentally disabled and normal children]] according to gingival status|
Click here to view
|Table 5: Gender wise distribution of study population [Mentally disabled and normal children] according oral hygiene status, gingival status|
Click here to view
Nine percent (n = 25) mentally disable children had severe, 32% (n = 85) moderate, and 53% (n = 155) mild gingivitis of graduate parents. Similar observation was found in normal group, and the differences in gingival status and literacy were statistically significant (P < 0.01). The result depicts that the gingival health worsens with decrease in parent's level of education. There was statistically significant difference between oral hygiene status and gender of study population, and the results showed that the gingival status was significantly better in females than the males in both disabled and normal children [Table 5].
| Discussion|| |
The three principal components—impairment, disability, and handicap—would operate independently, with impairment addressing impact on the body; disability to impact on the person; and handicap to impact on the person interacting with the environment. The main factor related to gingival/periodontal problems in disabled individuals is the inadequacy of the plaque removal from the teeth. The children face greater challenges to proper oral hygiene, often due to a lack of basic manual skills and intellectual abilities that preclude adequate practices, such as tooth brushing.
Oral hygiene status
A highly significant difference in oral hygiene status in the two groups was observed. Mentally disabled children had significantly poorer oral hygiene. The findings of the study were in agreement with studies., 14, ,,,,,,,,,,
Oral hygiene status according to severity of mental disability
Differences in level of oral cleanliness between different degrees of mental disability were statistically highly significant. From data, it was observed that as degree of mental disability increases the oral hygiene status worsens. The findings of our study were in agreement with other studies.,, This can be attributed to the fact that because of poor muscle coordination, associated systemic and physical conditions, medications, these children were unable to perform their daily oral hygiene measures.
Oral hygiene status according to socioeconomic status
It was observed that in normal children, higher social class children had better oral hygiene than the lower class. The OHI-S scores significantly increased steadily as the economic status decreased. In disabled children, there was no significant difference in OHI-S status. This was in agreement with other studies., Studies showed that parents of children with mental retardation go through adjustment, including shock, despair, guilt, withdrawal, acceptance, and adjustment. Moreover, the presence of another disabled child demands extra efforts from parents in performing daily oral hygiene procedures.
Oral hygiene status according to parent's education level
The present study was in agreement with other study  where parental educational level directly related to oral hygiene status of the children as there were significant differences in OHI-S status and level of parent's education in both disabled and normal children. This can be due to differences in oral health awareness and provision of oral health aids and parental attitude toward the importance of oral health.
In the present study, the gingival status in disabled was universally poor compared to the normal children. Findings of the study were in agreement with studies conducted., 32, ,,, This can be attributed to the fact that because of poor muscle coordination, associated systemic and physical conditions, and medications, these children were unable to perform their daily oral hygiene measures.
Gingival status according to severity of mental disability
In the present study, it was observed that as severity of mental disability increases, the gingival health worsens. Similar results were found other studies.,,
Gingival status according to socioeconomic status
In the present study, it was observed that the socioeconomic status was directly correlated with the gingival health of normal children, whereas in disabled children, no statistical significant difference between socioeconomic status and gingival health.
Gingival status according to parent's education level
In the present study, it was also observed that in both groups gingival health directly correlated with the parental educational level. Children of illiterate parents had poorer gingival health than the graduate parents. This can be attributed to family income which can affect the food habits, health values, life styles, access to healthcare information, and affordability.
Oral hygiene status and gingival status according to gender
In the present study, it was observed that in normal children, females had significantly better gingival and oral hygiene status than the males. This can be attributed to the differences in oral hygiene practices, dietary habits, and parental/caretaker's oral hygiene awareness. It can also be attributed to the fact that females are more conscious about oral hygiene than the males. However, contradictory findings were observed among schoolchildren in Sharjah, UAE. In mentally disabled children, there was no significant difference in oral hygiene status between the two genders, but there was a significant difference in the gingival status. Females had significantly better gingival health than the males. The findings of our study are not in agreement with studies conducted in Singapore in 1991, Nigeria in 1995, and Udaipur, where they found that there was no significant difference between males and females. A possible explanation for the findings of our study might be due to the differences in severity of mental disability and associated systemic conditions, medication and differences in parental/caregiver's oral hygiene awareness, and oral hygiene care provided. Male subjects had poorer oral hygiene and periodontal status than their female counterparts as shown by the logistic regression analysis. Other studies , have shown the similar trend among mentally retarded children's oral hygiene in regard to gender.
| Conclusion|| |
The present study showed the dental negligence among mentally disabled children where the parents, caretakers, and dentists are responsible. Hence, it is a call for attention toward these populations. Our national oral health policy should have special consideration for special group population. The oral hygiene and gingival status of the present population are poor and were influenced by medical diagnosis, parent's level of education, and economic status. Dental Council of India should make it mandatory that each dental college should adopt some special groups and reinforcing of adopting oral hygiene preventive procedures and incorporation of dental care services at regular intervals. Oral health promotion programs should be conducted for special group children, their parents, as well as caretakers. Effective oral health education with audiovisual aids, diet counseling, and step-by-step demonstration of oral hygiene practices to the children and parents/caretakers can be given.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th
ed. Washington: American Psychiatric Association; 1994.
National Sample Survey Organization. Disabled Persons in India. NSS Report No. 485 (58/26/1). New Delhi; 2003. Available from: http://www.mospi.nic.in>485_final.
[Last accessed on 2012 Dec 12].
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;27:151-7.
] [Full text]
Anzil KS, Kiran M, Keerthi L, Dinny D, Sudeep CP, Aravind A. Dental care utilization and expenditures on children with special health care needs- A review. Int J Appl Dent Sci 2017;3:25-8.
Dharmani CK. Management of children with special health care needs (SHCN) in the dental office. J Med Soc 2018;32:1-6. [Full text]
Hennequin M, Faulks D, Roux D. Accuracy of estimation of dental treatment need in special care patients. J Dent 2000;28:131-6.
Tesini DA. An annotated review of the literature of dental caries and periodontal disease in mentally retarded individuals. Spec Care Dentist 1981;1:75-87.
Anders PL, Davis EL. Oral health of patients with intellectual disabilities: A systematic review. Spec Care Dentist 2010;30:110-7.
Gerreth K, Borysewicz-Lewicka M. Epidemiological evaluation of gingivitis in special-care schoolchildren. Med Wieku Rozwoj 2009;13:283-91.
Tesini DA. Age, degree of mental retardation, institutionalization, and socioeconomic status as determinants in the oral hygiene status of mentally retarded individuals. Community Dent Oral Epidemiol 1980;8:355-9.
Svatun B, Gjermo P. Oral hygiene, periodontal health and need for periodontal treatment among institutionalized mentally subnormal persons in Norway. Acta Odontol Scand 1978;36:89-95.
Denloye OO. Periodontal status and treatment needs of 12-15 year old institutionalized mentally handicapped school children in Ibadan, Nigeria. Odontostomatol Trop 1999;22:38-40.
Kozak R. Dental and periodontal status and treatment needs of institutionalized mentally retarded children from the province of West Pomerania. Ann Acad Med Stetin 2004;50:149-56.
Morgan JP, Minihan PM, Stark PC, Finkelman MD, Yantsides KE, Park A, et al.
The oral health status of 4,732 adults with intellectual and developmental disabilities. J Am Dent Assoc 2012;143:838-46.
Cumella S, Ransford N, Lyons J, Burnham H. Needs for oral care among people with intellectual disability not in contact with community dental services. J Intellect Disabil Res 2000;44:45-52.
Nilima SK, Rahul P, Abhijit NG, Yojana P, Abhijeet S, Ritam NT, et al
. Oral hygiene status, periodontal status, and periodontal treatment needs among institutionalized intellectually disabled subjects in Kolhapur District, Maharashtra, India. J Oral Dis 2014;2014:11.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
Loe H, Silness J. The gingival index, the plaque index and retention index system. J Periodontal 1967;38:610.
The International Classification of Diseases-10. Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva: WHO; 1993. p. 140-1.
Chandra S. Sociology and Health- Essentials of Community Medicine. 1st
ed. New Delhi: New Central Book Agency (P) Ltd; 1997. p. 75-9.
MacEntee MI. An existential model of oral health from evolving views on health, function and disability. Community Dent Health 2006;23:5-14.
Ameer N, Palaparthi R, Neerudu M, Palakuru SK, Singam HR, Durvasula S, et al.
Oral hygiene and periodontal status of teenagers with special needs in the district of Nalgonda, India. J Indian Soc Periodontol 2012;16:421-5.
] [Full text]
Shaw L, Maclaurin ET, Foster TD. Dental study of handicapped children attending special schools in Birmingham, UK. Community Dent Oral Epidemiol 1986;14:24-7.
Nunn JH. The dental health of mentally and physically handicapped children: A review of the literature. Community Dent Health 1987;4:157-68.
Nunn JH, Murray JJ. The dental health of handicapped children in Newcastle and Northumberland. Br Dent J 1987;162:9-14.
Palin-Palokas T, Hausen H, Heinonen O. Relative importance of caries risk factors in Finnish mentally retarded children. Community Dent Oral Epidemiol 1987;15:19-23.
Gizani S, Declerck D, Vinckier F, Martens L, Marks L, Goffin G, et al.
Oral health condition of 12-year-old handicapped children in Flanders (Belgium). Community Dent Oral Epidemiol 1997;25:352-7.
Mitsea AG, Karidis AG, Donta-Bakoyianni C, Spyropoulos ND. Oral health status in Greek children and teenagers, with disabilities. J Clin Pediatr Dent 2001;26:111-8.
Bhowate R, Dubey A. Dentofacial changes and oral health status in mentally challenged children. J Indian Soc Pedod Prev Dent 2005;23:71-3.
] [Full text]
Ivancić Jokić N, Majstorović M, Bakarcić D, Katalinić A, Szirovicza L. Dental caries in disabled children. Coll Antropol 2007;31:321-4.
Kawaguchi T, Nakashima M. Oral findings of institutionalized handicapped children. Fukuoka Shika Daigaku Gakkai Zasshi 1990;17:13-21.
Adenubi JO, Saleem PH, Martinez JN. Dental health care at the disabled children's rehabilitation center in Riyadh. Saudi Dent J 1997;9:9-13.
Waldman HB, Swerdloff M, Perlman SP. Children with mental retardation grow older. ASDC J Dent Child 1999;66:266-72, 229.
Forsberg H, Quick-Nilsson I, Gustavson KH, Jagell S. Dental health and dental care in severely mentally retarded children. Swed Dent J 1985;9:15-28.
Pope JE, Curzon ME. The dental status of cerebral palsied children. Pediatr Dent 1991;13:156-62.
Vyas HA, Damle SG. Comparative study of oral health status of mentally sub-normal, physically handicapped, juvenile delinquents and normal children of Bombay. J Indian Soc Pedod Prev Dent 1991;9:13-6.
] [Full text]
Saravanakumar MS, Vasanthakumari A, Bharathan R. Oral health status of special health care needs children attending a day care centre in Chennai. Int J Stud Res 2013;3:12-5. [Full text]
Choi NK, Yang KH. A study on the dental disease of the handicapped. J Dent Child (Chic) 2003;70:153-8.
Gopinath VK, Rahman B, Awad MA. Assessment of gingival health among school children in Sharjah, United Arab Emirates. Eur J Dent 2015;9:36-40.
] [Full text]
Vignehsa H, Soh G, Lo GL, Chellappah NK. Dental health of disabled children in Singapore. Aust Dent J 1991;36:151-6.
Denloye OO. Oral hygiene status of mentally handicapped school children in Ibadan, Nigeria. Odontostomatol Trop 1998;21:19-21.
da Cunha LD, Melo Proença MA, Rodrigues VP, Vasconcelos Pereira AF, Benatti BB. Relationship between periodontal status and degree of visual impairment in institutionalized individuals. Eur J Dent 2015;9:324-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]