International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Oral Health Status of Intellectually Disabled 3-5 Years Children Attending

Special Schools in Rajasthan
Anshika Sharma1*, C.L Dileep2**, Anmol Mathur3*, Manu Batra4*, Diljot Kaur Makkar4*,
Vikram Pal Aggarwal1*
1
Post Graduate Student, Professor, 3Associate Professor, 4Assistant Professor,
2
*
Department of Public Health Dentistry, **H.O.D Department,
Surendera Dental College and Research Institute, Sri Ganganagar
Corresponding Author: Anshika Sharma

Received: 03/12/2015 Revised: 04/01/2016 Accepted: 12/01/2016

ABSTRACT

Introduction: The most difficult task existing in dental care programs for the intellectually disabled
(ID) children is to effectively improve the oral hygiene status. The aim of the study is to determine the
impact of intellectual disability levels on dental caries and oral hygiene status of 3-5 years preschool
ID children in Sriganganagar city, Rajasthan.
Methodology: The study sample comprised of 150 subjects who were intellectually disabled,
attending special schools in Sri Ganganagar city, Rajasthan. All the teeth were examined for dental
caries. Mouth mirrors and CPI probes were used according to the WHO criteria. Clinical assessment
of the oral hygiene status was done by using the simplified oral hygiene index Green and Vermilion.
Chi square test and ANOVA were used to compare categorical variables. Multivariate analysis was
carried out to test the risk factors associated with dental caries.
Results: The study consisted of 150 ID children who were divided into three groups. In the study
group, 71 (47.33 %) were mildly affected, 45 (30%) and 34(22.66%), were moderately and severely
affected, respectively. The mean dmft was found to be 3.066 ±2.84. The mean OHI-S scores rose
significantly as the severity of intellectual disability increased among the groups. Conclusion: This
study highlights the poor oral health status among ID Children. The NGOs, public health authorities
and dental professionals ought to come together to improve the plight of this group.

Key words: Oral health behavior, intellectually disabled children, Dental caries

INTRODUCTION conceptual, social, and practical adaptive

The American Health Association skills. [‎2]
defines a child with disability as a child, The recent National Sample Survey
who, for various reasons, cannot fully Organization (NSSO) report suggests that
make use of all his or her physical, mental the number of disabled persons in the
and social abilities. [‎1] In other words, a country is estimated to be 18.49 million
child who cannot play, learn, or do things which forms to about 1.8% of the total
those other children of his or her age can. population and the mentally retarded
According to AAIDD (American population accounts to 0.44 million
Association on Intellectual and individuals. [‎3]
Developmental Disabilities), Intellectual Children with an intellectual
disability is characterized by significant disability (ID) have been recognised to be
limitations both in intellectual functioning at risk of receiving inadequate dental care
and in adaptive behaviour as expressed in and having poor oral health, partly because

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of substantial dependence on others for the 3-5 years preschool ID children in
management of their oral care. [‎4] Sriganganagar city, Rajasthan.
Intellectual disabled have more
compromised medical condition and have MATERIALS AND METHODS
more dental problem may further An institutional based cross-
compromise their general health. These sectional study was conducted among a
individuals are also at a risk of developing cluster of intellectual disabled subjects
systemic complication arising from oral aged 3-5 years residing in an institution in
diseases such as compromised immunity, Sri Ganganagar, Rajasthan, India. The
endocarditis, etc. [‎5] ethical clearance was granted by ethical
The prevention and treatment of committee of the Surendera Dental
the early stage of oral disease lies in the College & Research Institute
provision of self care but this may be (SDCRI/IEC/2015/028) and permission to
difficult for challenged. [‎6] Dental caries is conduct the clinical examination of
the most prevalent disease among mentally subjects was obtained from the institution
retarded‎ children‎ worldwide‎ and‎ “dental‎ authorities. World Medical Association
treatment is the greatest unattended health Declaration of Helsinki principles for
need‎ of‎ the‎ disabled”. [‎7] Untreated caries Medical Research involving human
and associated infection can cause pain, subjects were followed to maintain the
discomfort and reduce intake of food ethics.
because eating causes pain and can worse Out of total 187 subjects present on
their quality of life and thereby growth.. the day of examination, 150 subjects were
Preschool children with intellectual enrolled in the study those who had
disability further require more attention parental consent/proxy consent. Students
towards oral health as this group of who were medically compromised or who
children are totally dependent on others for didn’t‎ have‎ the‎ consent‎ were‎ not‎
their oral health care and are more prone to considered for the study.
childhood caries. However, with The data was recorded during a
appropriate planning, clear communication face to face interview by a single
and carefully drawn limits to the service examiner. The Performa consisted of two
provided, the dramatic dental neglect sections - First section comprised of the
experienced by the majority of these information regarding type of disability,
individuals can be successfully alleviated. socio-demographic factors and oral
[‎8]
hygiene habits and second section was for
Literature on the dental oral health assessment of the child.
management of ID subjects is scarce The sample populations of children
compared with that of the normal child. with disability and respective IQ scores
Until recent years, the management of were derived from the databases of school
handicapped subjects was not even records. Children with IQ [‎9] scores 50-70,
mentioned in the undergraduate 35-50, and below 35 were classified into
curriculum of most dental schools in mild, moderate, severe/profound
different parts of the world. intellectual disability, respectively.
In a developing country like India Socioeconomic status (SES) was
further research in this field is required as accessed according to revised
there are few reports available relating to Kuppuswamy’s‎ Socioeconomic‎ Status‎
dental health of 3-5 years ID children. Scale [‎10] 2013 which is calculated by
Thus the aim of the study is to determine summation of individual scores of
the impact of intellectual disability levels education (1-7), occupation (1-10) and
on dental caries and oral hygiene status of income (1-12) of any of the parent.
Various categories according to scores are-

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Upper class (26-29), upper middle (16-25), on 20 subjects using the Performa. Intra-
Middle/Lower middle (11-15 ), Upper examiner reliability was assessed using the
Lower (5-10), Lower (<5). kappa statistic, which was found to be 0.82
The second section of Performa for the parameters studied, showing a good
consists of oral examination. Caries degree of consistency in the observations.
examination was tooth-specific and all the Type III clinical examination was
teeth were examined. Mouth mirrors and conducted by the examiner.
CPI probes were used according to the Statistical analysis – The chi square
WHO criteria. [‎11] Clinical assessment of and ANOVA test was used to compare
oral hygiene status was done with a mouth between categorical variables. Multivariate
mirror and No. 23 explorer according to analysis was executed to test the risk
criteria of simplified oral hygiene index by factors associated with dental caries.
Green and Vermilion. [‎12] Statistical analysis of the data was done
The examiner training and using IBM SPSS. Statistics Windows,
calibration was done at SDCRI Dental Version 20.0. (Armonk, NY: IBM Corp).
College, Rajasthan. Pilot study was done
RESULTS
Table 1: Socio-demographic characteristics of study population
Attributes Mild Moderate Severe p value
N (%) N% N%
Gender
Male 19 (26.76) 42(93.33) 26(76.47) <0.0001
Female 52 (73.24) 3(6.67) 8(23.53)
Family type
Nuclear 10 (14.08) 22(48.89) 24(70.59) <0.0001
Joint 61 (85.92) 23(51.11) 10 (29.41)
Income (INR)
<10000 9 (12.68) 5(11.11) 11(32.35) 0.002
10000-20000 38(53.52) 17(37.78) 6(17.65)
>20000 24(33.80) 23(51.11) 17(50)
Mother Education
Illiterate 6(8.45) 3(6.67) 4(11.76) 0.88
School level 12(16.90) 10(22.22) 7(20.59)
Graduate, 53(74.65) 32(71.11) 23(67.65)
Postgraduate
Father Education
Illiterate 11(15.49) 8(17.78) 7(20.59) 0.32
School level 27(38.02) 16(35.56) 6(17.65)
Graduate, 33(46.48) 21(46.67) 21(61.76)
Postgraduate
Socioeconomic class
Upper 28(39.44) 19(42.22) 10(29.41) 0.48
Middle 23(32.39) 17(37.78) 11(32.35)
Lower 20(28.17) 9(20) 13(38.24)
Brushing habits
Yes 62(87.32) 26(57.78) 18(52.94) 0.0001
No 9(12.68) 19(42.22) 16(47.06)
Tooth cleaning
Self 23(32.39) 17(37.78) 3(8.82) <0.0001
Mother cleaning 44(61.97) 9(20) 7(20.59)
Under supervision 4(5.63) 19(42.22) 24(70.59)
Frequency of tooth brushing
Once A Day 58(81.69) 25(55.56) 17(50) 0.37
Twice A Day 4(5.63) 1(2.22) 1(2.94)
>Twice A Day 0 0 0
Visit to dentist
Never 3 (4.23) 10(22.22) 13(38.24) <0.0001
Once 52 (73.24) 16(35.56) 7(20.59)
≥Twice 16 (22.54) 19(42.22) 14(41.18)

The study consists of 150 divided into three groups. Out of which 71
intellectually disabled (ID) children, (47.33 %) were mildly affected, 45 (30%)

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were moderately and 34(22.66%) were group subjects, it was found that 47.06 %
severely affected. Table 1 illustrates the of severely ID children did not brush their
distribution of socio-demographic teeth as compared to 13% of mildly ID
characteristics, oral health behaviour children ( p<o.ooo1). 70.59% of severely
variables among the group subjects. A ID children and 42.22 % of moderately ID
statistically significant difference was children reported to be dependent on
detected among all the socio-demographic guardians for their tooth cleaning (p
variables in the groups, except for parental <0.0001). The frequency of dental visit
education and SES class (p>0.5). When was quite less among severely ID children
brushing habits was compared among the as compared to other groups (p <0.0001).

Table 2. Comparison of Mean dmft and OHI-S scores with intellectual disability levels among ID children
Clinical Mild Moderate Severe p-
variables (mean±sd) (mean±sd) (mean±sd) value
dmft
dt (2.71±1.80) (2.36±1.54) (2.97 ± 2.09) 0.02
mt 0.17±0.56 (0.77 ±1.79) (0.36 ± 0.78) 0.03
ft 0 0 0 0
dmft 3.0±2.13 2.76±2.08 3.44±2.84 0.043
OHI-S 1.1±0.73 1.8±1.26 2.7±0.81 <0.04

Table 3. Risk factor analysis of the relationship between sociodemographic characteristics and caries experience in ID children
Variables Caries No caries OR (95% CI) P
N N
Gender
Male 77 10 2.85 (1.20-6.74)
Female 46 17 1 0.0174
Intellectual disability
Mild 54 17 1
Moderate 39 6 2.41 (0.88-6.55) 0.09
Severe 30 4 2.50 (0.78-8.04) 0.124
Education
Illiterate 21 5 0.96 (0.31-3.0) 0.95
School level 41 8 1.18 (0.45-3.06) 0.74
Graduate and postgraduate 61 14 1
Income
<10000 18 7 0.59 (0.20-1.74) 0.34
10000-20000 53 8 1.53 (0.58-4.05) 0.40
>20000 52 12 1
Occupation
Profession 43 15 1
Clerical, shop-owner, farmer 57 7 2.84 (1.07-7.57) 0.04
Unemployed 23 5 1.60 (0.52-4.98) 0.41
Socioeconomic class
Upper 51 6 1
Middle 43 9 0.56 (0.19-1.71) 0.31
Lower 29 12 0.28 (0.09-0.84) 0.02
OHI-S
Good 29 13 1
Fair 65 12 2.43 (0.99-5.96) 0.05
Poor 29 2 6.50 (1.35-14.41) 0.01
Brushing habits
Yes 82 24 1
No 41 3 4.0 (1.14-14.06) 0.03
Sugar score
Excellent 12 7 1
Good 31 6 3.01 (0.84-10.82) 0.09
Watch out zone 80 11 4.24 (1.38-13.07) 0.01
Visit to dentist
≥Twice 55 10 1
Once 51 17 0.55 (0.23-1.30) 0.17
Never 17 0 6.62 (0.37-13.38) 0.20
Reason for dental visit
Preventive 37 22 1 <0.0001
In need 86 5 10.23 (3.6-29.07)

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 Table 2 depicts the individual intellectual disability on dental caries and
components of dmft and OHI-S scores oral hygiene of 3-5 years ID children.
among the three groups. It was observed In the present study it was found
that with increasing level of intellectual that mean dmft for ID children was 3.066
disability, mean dmft and individual ±2.84 which is relatively more when
components in the groups showed a steady compared to a study conducted among
rise and it was found to be statistically similar aged normal children by
significant. Whereas Mean OHI scores Mahejabeen et al. [‎16] This difference of
also showed a significant rise as the disease prevalence is supported by Purohit
severity of intellectual disability increased et al but is in contrast to the study done by
among the groups (p < 0.05). Sagheri et al. [‎17] The increased risk of
Table 3 illustrates single factor caries experience in ID children might be
analysis for assessing the relationship related to complications such as seizures,
between the risk factors and dental caries and motor impairment, etc and that could
experience among the subjects. Boys were lower their physical abilities and be
more likely to have dental caries, as barriers to perform oral hygiene practices,
[‎18]
compared to girls with an odds ratio (OR) in addition to this medication may also
of 2.85. The odds for moderate ID children contribute towards the increased risk of
to have dental caries was 2.41 times where dental caries, as medication administered
as the odds for severely ID children having to control seizures in children is frequently
dental caries was 2.50 times more than laced with sugars to make it more
mild ID children. Subjects from joint palatable. The medication then reduces
families had 2.43 times more chances of salivary flow, making the child more
having dental caries than those from vulnerable to dental decay. [‎19] In the
nuclear family and it was found to be present study boys were found to have
statistically significant (p=0.04). more dental caries than girls however a
Statistically significant association was study conducted by Altun et al [‎1] reported
found between poor oral hygiene and lack to have more dental caries in girls. This
of tooth brushing habits with dental caries difference in caries prevalence may be due
(p<0.05). to the Indian social attitude of paying more
attention towards the diet of their male
DISCUSSION children [‎20] which consist of more frequent
Children with intellectual snacking than girls. [‎21]
disabilities often have limitations in their The oral hygiene (OHI-S) scores of
abilities to perform activities of daily the ID children in the current study are
living. They may have more marked oral seen to be increasing along with the
pathologies, either because of their actual increase in severity of intellectual
disability or for other medical, economic disability. Such association of oral hygiene
or social reasons, or even because their and degree of mental retardation is
parents find it very difficult to carry out supported by Martens et al [‎22] who
proper daily oral hygiene. [‎13] As a group, observed that children who were mildly ID
children with developmental disabilities had significantly better manual dexterity
are more likely to have unmet dental needs skills than the severely affected
than are typically developing children individuals, which explains the findings in
[‎14,‎15]
and are considered to be at greater the present study.
risk of developing dental disease, hence However a study conducted by Tesini et al
[‎23]
require more opportunity for dental and Gizani et al [‎24] showed no
services then healthy counterparts. difference in oral hygiene status and
Considering these points, this study was degree of mental retardation.
conducted to assess the impact of level of

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 In current study more than 80% of health educational programs for parents
mildly affected ID children were found to should be carried out to improve parental
be brushing at least once daily which is in skills in maintaining the oral health of their
accordance with the reduced plaque ID children.
accumulation and hence lower OHI-S
scores for the respective group. As the REFERENCES
severity of ID level increases, the brushing 1. Altun C, GuvenG, Akgun OM, Akkurt
habits were found to be declining as MD, et al. Oral health status of
severely ID children always have disabled individuals attending special
schools. Eur J Dent. 2010; 4: 361–66.
difficulties in self-cleaning and 2. Schalock RL, Luckasson RA, Shogren
communicating oral health needs which KA. The renaming of mental
affects their oral hygiene and moreover retardation: Understanding the change
mother’s‎ involvement‎ in‎ oral‎ hygiene‎ to the term intellectual disability.
practices of their children is found to be Intellect Development Disabil. 2007;
inadequate showing lack of parental 45(2):116-24.
awareness‎towards‎child’s‎oral‎health.‎ 3. National Sample Survey Organization
Limitations of the current study is (2003) Disabled persons in India. NSS
that children with intellectual disability Report No. 485 (58/26/1), New Delhi.
had significantly more borderline and 4. Brown RH, Treasure ET. Inequalities
definite motor problems than the normal in oral health: implications for the
delivery of care and health promotion.
children which has not been examined in NZ Dental Journal 1992; 88: 132-8.
the current study. To nullify the effect of 5. Thikkurissy S, Lal S. Oral health
socio-demographic factors involved in the burden in children with systemic
study, the siblings of the ID children could diseases. Dent Clin N Am
have been included in the research but it 2009;53:351-7.
was beyond the scope of the study. 6. Bhowate R, Dubey A. Dentofacial
Another limitation is that due to cross changes and oral health status in
sectional nature of the study, it did not mentally challenged children. J Indian
allow assessment or tracking changes in Soc Pedod Prev Dent. 2005 June;
oral health assessment with advancing 23(2): 71-73.
intellectual disability. So, further 7. Hennequin M, Faulks D, Roux D.
Accuracy of estimation of dental
longitudinal studies are recommended in treatment needs in special care
this direction. patients. J Dent. 2000;28:131–36.
8. Kumar S, Sharma J, Duraiswamy P,
CONCLUSION Kulkarni S. Determinants for oral
The results of the present study hygiene and periodontal status among
showed poor oral health among ID mentally disabled children and
Children. Thus there is an imperative need adolescents. J Indian Soc Pedod Prev
for comprehensive preventive treatment to Dent. 2009 Oct, 27, 151–157.
promote better oral health and prevent the 9. Goddard L, Davidson PM, Daly J.
development and progression of oral People with an intellectual disability
diseases, since the hallmark of in the discourse of chronic and
complex conditions: an invisible
management of such intellectually group. Health Rev. 2008; 32: 3.
disabled children is prevention. According 10. Vijaya K, Ravikiran E.
to the authors the best suited policy Kuppuswamy’s‎ socio-economic status
towards reducing oral health diseases scale-Updating income ranges for the
among ID children is making guardians year 2013. National Journal of
aware of the impact of intellectual Research in Community Medicine
disability and associated factors on the 2013; 2(2): 79-82.
child’s‎ oral‎ health.‎ Along‎ with‎ that‎ oral‎

International Journal of Health Sciences & Research (www.ijhsr.org) 230

Vol.6; Issue: 2; February 2016
 11. Purohit BM, Shashidhar A, Intellectual Disabilities in Guangzhou,
Meghashyam B. Oral health status and China. Int J Environ Res. 2014; 11:
treatment needs of children attending 11015-27.
special schools in South India: a 19. Burg VD, Jongerius JJ, Hulst PHV, et
comparative study. Spec Care Dentist; al. Drooling in children with cerebral
30(6): 235-241. palsy: Effect of salivary flow
12. Greene JC, Vermillion JR. The reduction on daily life and care. Dev
simplified oral hygiene index. J Am Med. Child Neurol. 2006; 48: 103–
Dent Assoc. 1964; 68, 7-13. 107.
13. McPherson M, Arango P, Fox H. A 20. Borooah VK. Gender bias among
new definition of children with special children in India in their diet and
health care needs. Pediatrics. 1998; immunization against disease. Soc Sci
102:137-40. Med. 2004; 58(9): 1719–31.
14. Lewis CW. Dental care and children 21. Thiruselvakumar D, Sinuvasan K,
with special health care needs: a Chakravarthy RS. Factors affecting
population based perspective. Acad food choice and attitude of choosing
Pediatr. 2009; 9 (6): 420–26. food items among adolescents in
15. Kagihara LE, Huebner CE, Mouradian South India. International Journal of
WE, Milgrom P, Anderson BA. Scientific and Research Publications.
Parents’‎perspectives‎on‎a‎dental‎home‎ 2014; 4(4):1-3.
for children with special health care 22. Martens L, Marks L, Goffin G, Gizani
needs. Spec Care Dentist 2011; 31(5): S, Vinckier F, Declerck D. Oral
170–7 hygiene in 12-year-old disabled
16. Mahejabeen R, Sudha P, Kulkarni S, children in Flanders, Belgium, related
Anegundi R. Dental caries prevalence to manual dexterity. Community Dent
among preschool children of Hubli: Oral Epidemiol. 2000; 28(1):73-80
Dharwad city. J Indian Soc Pedod 23. Tesini DA, Fenton SJ. Oral health
Prev Dent. 2006; 24:19-22. needs of person with physical or
17. Sagheri D, McLoughlin J, Nunn JH. mental disabilities. Dent Clin North
Dental caries experience and barriers Am. 1994; 38(3): 483-98
to care in young children with 24. Gizani S, Declerck D, Vinkier F,
disabilities in Ireland. Quintessence Martens L, Marks L, Goffin G. Oral
Int. 2013, 44, 159–69. health condition of 12-year-old
18. Zifeng Liu , Dongsheng Yu ,Wei Luo, handicapped children in Flanders
et al. Impact of Oral Health Behaviors (Belgium). Community Dent Oral
on Dental Caries in Children with Epidemiol. 1997; 25: 352-357.

How to cite this article: Sharma A, Dileep CL, Mathur A et al. Oral health status of intellectually
Disabled 3-5 years of children attending special schools in Rajasthan. Int J Health Sci Res. 2016;
6(2):225-231.

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