|Year : 2016 | Volume
| Issue : 1 | Page : 35-40
Impact of various sociodemographic factors on oral hygiene of mentally retarded residing in Bhopal city, Madhya Pradesh: A cross-sectional study
Sonal Kothari1, Ajay Bhambal2, Vrinda Saxena3, Garima Bhambhani2, Poonam Dubey2
1 Department of Public Health Dentistry, Goenka Research Institute of Dental Science, Ahmedabad, Gujarat, India
2 Department of Public Health Dentistry, People's College of Denstal Sciences and Research Centre, Bhopal, Madhya Pradesh, India
3 Department of Public Health Dentistry, Peoples Dental Academy, Bhopal, Madhya Pradesh, India
|Date of Web Publication||15-Mar-2016|
C/o Sudarshan Chhajed, B-102, Ratnakar 2, Prerna Tirth Derasar Road, Satellite, Ahmedabad - 380 015, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Oral health of the mentally retarded (MR) has received scant attention in the literature compared with the normal child even though they are much sufferer. Aim: To assess the impact of various sociodemographic factors on oral hygiene of MR subjects of Bhopal city. Materials and Methods: A descriptive cross-sectional study was conducted among 267 MR subjects enrolled at various institutions of Bhopal city. A pretested proforma was used to record information about demographic data, socioeconomic status, the intelligent quotient of inmates, type of mental retardation, and dietary habits. The clinical examination was done to evaluate oral hygiene of subjects using oral hygiene index-simplified (OHI-S). Descriptive statistics, Student's t-test, analysis of variance and multiple linear regression analysis was applied using Statistical Package for Social Sciences (SPSS) software. Results: The mean OHI-S of MR was found out to be 2.51. Male had mean OHI-S of 2.95 while female had 1.65. Noninstitutionalized had poorer oral hygiene with mean OHI-S of 3.2. According to the degree of mental retardation, profound had the highest OHI-S score, i.e. 3.71 while mild had the lowest score, i.e. 1.01.
Keywords: Mentally retarded, oral hygiene, sociodemographic factors
|How to cite this article:|
Kothari S, Bhambal A, Saxena V, Bhambhani G, Dubey P. Impact of various sociodemographic factors on oral hygiene of mentally retarded residing in Bhopal city, Madhya Pradesh: A cross-sectional study. J Indian Assoc Public Health Dent 2016;14:35-40
|How to cite this URL:|
Kothari S, Bhambal A, Saxena V, Bhambhani G, Dubey P. Impact of various sociodemographic factors on oral hygiene of mentally retarded residing in Bhopal city, Madhya Pradesh: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2020 Aug 13];14:35-40. Available from: http://www.jiaphd.org/text.asp?2016/14/1/35/178718
| Introduction|| |
The disabled form a substantial section of the society, and there are about 500 million people with disabilities worldwide. Census 2011 has revealed that over 26.8 million people in India are suffering from one or the other kind of disability. Among the total disabled, 14.9 million are males and 11.8 million are females. Out of that, around 2.22 million are suffering from some form of mental disability which constitute 0.2% of Indian population and 8.28% of the total disabled.
According to the International Classification of Impairments, Disabilities, and Handicaps, impairment is defined as any loss or abnormality of psychological, physiological or anatomical structure or function, disability as any restriction (resulting from an impairment) or lack of ability to perform an activity in a manner or within the range considered normal for a person, and handicap as the disadvantage for a given individual, resulting from an impairment or a disability which limits or prevents the fulfillment of a role that is normal for that individual. Mental retardation has been defined by the American Association of Mental Deficiency as “subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior.”
Oral health is an important aspect of overall health which is all the more important for those with special health needs. A study conducted in Boston, Belgium, South Canara, India  and Udaipur, India  showed that mentally retarded (MR) have a high prevalence of dental diseases. In disabled individuals, the process of developing dental diseases does not differ from nondisabled individuals. There are no differences in the prevention of the diseases and the treatment modalities among these groups. The main factor related to oral problems in disabled individuals is the inadequacy of the plaque removal from the teeth. Motor coordination problems and muscular limitation in disabled individuals along with the difficulty in understanding the importance of oral hygiene in mentally disabled individuals have resulted in the progression of inflammatory diseases.,,
According to the persons with disability act 1995 disabled in India have the equal opportunities, equal participation and equal right to health as the normal population. 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 health, have high unmet health needs and lower uptake of health care services.,
Lack of literature about the prevalence of dental diseases among the MR population of central India is the reason behind conducting this study. As per our search, none of the studies is available which determines the oral hygiene of MR in central India. Hence, this study intends to assess the oral hygiene status of MR subjects of Bhopal city. The study also reveals the impact of various sociodemographic factors on oral hygiene of these subjects.
| Materials and Methods|| |
A descriptive cross-sectional study was designed to evaluate oral hygiene of MR residing in Bhopal city, Madhya Pradesh, Central India. According to social justice department of Madhya Pradesh government, there are 14 such shelter homes, which provide social and rehabilitative support in Bhopal city. A cluster random sampling methodology was used for selection of the study subjects. All the subjects who were present on the day of examination were included in the study. Only, MR subjects of various institutions were included in the study. Children affected with hearing, visual abnormalities, physically handicapped, orthopedic defects, and medically compromised were excluded from the study. The ethical approval was taken from research committee of the institute and consent for participation was taken from subject's legal representatives.
A pilot test was conducted among 52 MR people residing in one of the mental institution of Bhopal to assess the feasibility of the study and to assess the validity and accuracy of the predesigned proforma, the reliability of the examiner and to know the communication difficulties while examining oral cavity of this group of subjects.
A pretested proforma was used to record all required information about the subjects. The first part of proforma records the details about demographic data, socioeconomic status, the intelligence quotient (IQ) of inmates, type of mental retardation, oral hygiene habits and dietary habits. This part of proforma was filled by one of the authors by interviewing inmates/caretakers before the examination. IQ and type of mental retardation were taken from the updated record files of the subjects.
The second part of proforma consisted of the assessment of oral hygiene status using oral hygiene index-simplified (OHI-S) given by Greene and Vermillion, 1964. The examination was done using mouth mirror and explorer no. 5. The examination of all subjects was done by a single examiner, and there was a single recorder to record the data as per examiners instruction. The intra-examiner reliability of the examiner was assessed by using the Weighted kappa statistics −0.92 for OHI-S.
The data were retrieved from precoded survey proforma to a computer. A master file was created in the Microsoft excel sheet for the purpose of data analysis by using Statistical package for Social Sciences (SPSS) software version 20. Long produced by SPSS Inc., it was acquired by IBM in 2009. Descriptive statistics was used to calculate the number, percentages, mean and standard deviation for variables. Student's t-test was used to compare two groups, and one-way analysis of variance test was used to compare more than two groups along with post-hoc analysis which was done specifically to find out the association within the group. P < 0.05 was accepted as statistically significant and P < 0.01 was set to be highly statistically significant. Multiple linear regression analysis was executed to analyze the association of various sociodemographic and clinical variables with the oral hygiene status.
| Results|| |
The study subjects consisted of total 267 MR subjects with 170 males and 97 females. The mean age of subjects was 18.6 years. Maximum number of subjects was belong to 16–20 years of age [Figure 1].
Among MR subjects, 53.5% were institutionalized, and 46.4% were noninstitutionalized. Majority of the subjects (47.2%) were suffering from Down syndrome, while 33% were of cerebral palsy and 19.1% were suffering from Autism. According to IQ, 17.2% had mild, 34.8% had moderate, 33.3% had severe, and 14.6% had the profound type of mental retardation. The subjects affected from the mild type of mental retardation were mostly female while subjects affected from the severe and profound type of retardation were mostly males. Majority (59.6%) of the study subjects belongs to the lower upper lower class, and most of the subjects were vegetarian (83.9%) as per Kuppuswamy's classification. About 54.3% had sugar exposure only once in a day, and 37.8% had twice in a day [Table 1].
|Table 1: General profile and background characteristics of the mentally retarded subjects|
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Majority of the MR subjects (74.5%) used a toothbrush for cleaning their teeth. More than half (54.7%) of the MR clean their teeth twice in a day; 80.14% uses toothpaste, and 64.7% were supervised while brushing. Subjects visiting the dentist irregularly (those who had never visited and visit only when there is a problem) were 86.9% while only 13.1% of subjects visit regularly to the dentist in every 6 months [Figure 2].
Mean scores for OHI-S gradually increased with increase in age [Table 2]. Mean OHI-S scores significantly increased with increase in the degree of retardation. Profound had the highest OHI-S score, i.e. 3.71 while mild had the lowest score, i.e. 1.01 [Table 3].
|Table 2: Age-wise comparison of oral hygiene status among the mentally retarded subjects|
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|Table 3: Mean oral hygiene index-simplified scores of mentally retarded population according to degree of mental retardation|
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Multiple linear regression analysis was executed to estimate the linear relationship between the OHI-S as the dependent variable and various independent variables. It revealed that the best predictors in the descending order for OHI-S score as the dependent variable were age, gender, institutionalization, use of toothbrush, and supervision by caretakers [Table 4].
|Table 4: Multiple linear regression analysis with oral hygiene index-simplified score as a dependent variable among mentally retarded subjects|
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Comparison within different significant predictors of OHI-S showed that male, noninstitutionalization, use of finger, and nonsupervision during oral hygiene practice were reported to be responsible for high OHI-S score [Table 5].
|Table 5: Comparison within significant predictors of oral hygiene index-simplified among mentally retarded subjects|
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| Discussion|| |
Ralp Waldes once said, “the first wealth of life is good health.” Being born as a normal child is life's greatest blessing. Disabled forms one of the groups of such people, in whom, dental disease and its treatment present several problems. They have difficulties in understanding the effects of behavior on health, the benefits of dental treatment and the process of accessing appropriate and necessary health services.
Oral hygiene has been implicated as a casual factor in the development of dental caries and periodontal diseases in MR individuals. The mean OHI-S score for mentally disabled in the present study was found to be 2.51 similar to previous studies ,, Anders and Davis  reviewed 27 studies of individuals with mental retardation and reported that such individuals tend to have poorer oral hygiene. The reason for poor oral hygiene in disabled population has been attributed to less ability to understand instructions, low powers of concentration, and lack of motor skills and innate skills and lack of manual coordination. The general increase in OHI-S scores with an increase in age group confirms with previous reports,,, and this was found by Grants and Stern  to be due to the cumulative effect of plaque and calculus with an increase in age.
A significant difference between OHI-S scores of mild, moderate, severe, and profound MR subgroups was observed. Mild had the least (mean OHI-S, 1.01) and profound (mean OHIS, 3.71) had the highest OHI-S scores similar to other studies.,, Thus, standard of oral hygiene deteriorated with the severity of intellectual disability, which seems to confirm a correlation between the level of oral hygiene and severity of the disability. It was suggested this could be due to their insufficiency to brush their teeth themselves or dependence of subjects for oral hygiene maintenance on parents or caregivers.
In the present study, male subjects had poorer oral hygiene than their female counterparts. Denloye  observed a similar trend among MR children of Nigeria, where higher OHI-S scores were recorded among males than females. It has been suggested that girls tend to practice better oral hygiene than boys because of their greater social awareness, and thus their oral hygiene is superior to that of boys. Similarly, Jain et al. reported bad oral hygiene of male as compared to their female counterpart.
Institutional status was found to be one of the major determinants in oral hygiene conditions of the study group as the noninstitutionalized children had a higher OHI-S score than the institutionalized group. Similarly, Denloye  found high OHI-S score at the different age group of noninstitutionalized as compared to institutionalized while Tesini  reported contradictory findings. According to Denloye  better oral hygiene in the institutionalized group may be the reflection of better supervision of children by the nurses in charge of their welfare. The few previous studies also reported the same findings.,, Vigild  reported this may be due to the existence of noninstitutionalized children on soft high carbohydrate foods which contribute to the formation of abundant plaque which subsequently become calcified if not adequately removed. The oral hygiene status of these children then depends on how adequately the oral hygiene measures of noninstitutionalized children is carried out.
The lower socioeconomic status was not significantly associated with oral hygiene condition of the subjects. Similarly, Tesini. found that socioeconomic status is not a significant factor in the oral hygiene status of mental individuals. In spite of their socioeconomic status, they are living in the same institution sharing same environmental conditions. However, studies have shown an inverse relationship between socioeconomic status and oral hygiene.
In the present study, 74.5% of subjects used the brush as the mode of cleaning and 64.7% were supervised while cleaning their teeth. Whereas the previous study showed 64.5% uses a toothbrush and 43.9% were supervised while cleaning. The comparison of tooth cleaning modes in the present study suggests that the promotion of cleaning the dentition with a toothbrush will go a long way toward improving oral hygiene. The removal of dental plaque by tooth brushing the teeth significantly reduced the level of gingival inflammation which confirmed the fact that children with a mental handicap can be instructed in simple oral hygiene procedures and that they can carry out tooth brushing procedures themselves when they are given encouragement and motivation. Supervision by the caretakers while brushing was also significantly associated with improved oral hygiene.
Oral hygiene practices are voluntary physical activities that have at least two requirements Motivation and manual dexterity. Thus, poor oral hygiene is perhaps more prevalent among MR persons compared to other individuals. Good oral hygiene and semi-annual prophylaxis appointments may not be enough to prevent the progression of periodontal disease in these patients. These patients may need to be seen as often as every 3 months for scaling and root planning and may also benefit from the use of chlorhexidine mouth rinse and possibly systemic antibiotic therapy.
There is no comparison group taken in the study to better evaluate the oral hygiene status for that age. Periodontal conditions, dental caries, and treatment needs should also be taken into consideration for the subjects. These are some of the limitations of the study. To overcome these limitations, further studies need to be conducted on such populations in future. Meticulous oral examination of MR should be performed, and various factors affecting their oral health status need to be evaluated. With proper planning, clear communication, and carefully drawn limits to services provided, the dramatic oral health negligence experienced by so many of the disabled individuals can be successfully alleviated.
| Conclusion|| |
The present study reported poor oral hygiene among MR. Older age group, male gender, a higher degree of retardation, noninstitutionalization, no use of toothbrush and no supervision while cleaning were the major determinants of poor oral hygiene. Although, the study showed poor oral hygiene of the MR, which seemed to indicate a cumulative neglect of oral health. Because disabled children are recognized as a high-risk group for dental disease, they should also receive more preventive dental treatment. This study confirmed the need for strengthening organized preventive and restorative care for this population.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Watson N. Barriers, discrimination and prejudice. In: Nunn J, editor. Disability and Oral Care. London: World Dental Press Ltd.; 2000. p. 15-28.
World Health Organization. International Classification of Impairments, Disabilities and Handicaps: A Manual of Classification Relating to the Consequences of Disease. Geneva; World Health Organization; 1980. Available from: http://whqlibdoc.who.int/publications/1980/9241541261_eng.pdf
. [Last cited on 2014 Dec 05].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th
ed. Washington, DC: American Psychiatric Association; 1994.
Nicolaci AB, Tesini DA. Improvement in the oral hygiene of institutionalized mentally retarded individuals through training of direct care staff: A longitudinal study. Spec Care Dentist 1982;2:217-21.
Martens L, Marks L, Goffin G, Gizani S, Vinckier F, Declerck D. Oral hygiene in 12-year-old disabled children in Flanders, Belgium, related to manual dexterity. Community Dent Oral Epidemiol 2000;28:73-80.
Rao D, Amitha H, Munshi AK. Oral hygiene status of disabled children and adolescents attending special schools of South Canara, India. Hong Kong Dent J 2005;2:107-13.
Jain M, Mathur A, Sawla L, Choudhary G, Kabra K, Duraiswamy P, et al.
Oral health status of mentally disabled subjects in India. J Oral Sci 2009;51:333-40.
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.
Cutress TW. Periodontal disease and oral hygiene in trisomy 21. Arch Oral Biol 1971;16:1345-55.
Nunn JH. The dental health of mentally and physically handicapped children: A review of the literature. Community Dent Health 1987;4:157-68.
British Society for Disability and Oral Health. Guidelines for oral health care for people with a physical disability. London: British Society for Disability and Oral Health; 2000. p. 1-9.
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.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
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.
Al-Sufyani GA, Al-Maweri SA, Al-Ghashm AA, Al-Soneidar WA. Oral hygiene and gingival health status of children with down syndrome in Yemen: A cross-sectional study. J Int Soc Prev Community Dent 2014;4:82-6.
Krishna CS, Archana A. Evaluation of oral hygiene status and periodontal health in mentally retarded subjects with or without Down's syndrome in comparison with normal healthy individuals. J Oral Health Community Dent 2014;8:91-4.
Anders PL, Davis EL. Oral health of patients with intellectual disabilities: A systematic review. Spec Care Dentist 2010;30:110-7.
Snyder JR, Knopp JJ, Jordan WA. Dental problems of non-institutionalized mentally retarded children. Northwest Dent 1960;44:123-6.
Loe H. The natural history of periodontal disease in man. J Periodontol 1978;49:607.
Al-Haddad KA, Al-Hebshi NN, Al-Ak'hali MS. Oral health status and treatment needs among school children in Sana'a City, Yemen. Int J Dent Hyg 2010;8:80-5.
Grants AD, Stern IB. Periodontics in the tradition of Gottlieb and Orban, 6th
ed. St. Louis: C.V. Mosby, 1988; 236-48.
Kadam NS, Patil R, Gurav AN, Patil Y, Shete A, Tari RN, et al
. Oral hygiene status, Periodontal status and periodontal treatment needs among institutionalized Intellectually disabled subjects in Kolhapur District, Maharastra, India. Journal of oral diseases 2014; 535316;1-11.
Denloye OO. Oral hygiene status of mentally handicapped school children in Ibadan, Nigeria. Odontostomatol Trop 1998;21:19-21.
Dummer PM, Addy M, Hicks R, Kingdon A, Shaw WC. The effect of social class on the prevalence of caries, plaque, gingivitis and pocketing in 11-12-year-old children in South Wales. J Dent 1987;15:185-90.
de Jongh A, van Houtem C, van der Schoof M, Resida G, Broers D. Oral health status, treatment needs, and obstacles to dental care among noninstitutionalized children with severe mental disabilities in the Netherlands. Spec Care Dentist 2008;28:111-5.
Kaur S, Malhotra R, Kaur H, Battu VS, Kaur A. Oral hygiene status of mentally and physically retarded individuals living in a specialized institution in Mohali. Indian J Oral Sci 2013;4:17-22.
Vigild M. Periodontal conditions in mentally retarded children. Community Dent Oral Epidemiol 1985;13:180-2.
Stefanovska E, Nakova M, Radojkova-Nikolovska V, Ristoska S. Tooth-brushing intervention programme among children with mental handicap. Bratisl Lek Listy 2010;111:299-302.
Shapira J, Stabholz A. A comprehensive 30-month preventive dental health program in a pre-adolescent population with Down's syndrome: A longitudinal study. Spec Care Dentist 1996;16:33-7.
Stabholtz A, Shapira J, Shur D, Friedman, M, Guberman R, Sela MN. Local application of sustained release delivery system of chlorhexedine in Down's syndrome population. Clinical Preventive Dentistry 1991;13:9-14.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]