|Year : 2016 | Volume
| Issue : 2 | Page : 164-170
Dental caries experience and treatment needs of institutionalized mentally challenged and normal children of age group 6–13 years in Mysore city
Vinayaka Konakeri1, Darshana Bennadi2, Maurya Manjunath3, C.V.K Reddy3
1 Department of Public Health Dentistry, Malabar Dental College and Research Centre, Malappuram, Kerala, India
2 Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, SSAHE, Tumkur, Karnataka, India
3 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
|Date of Web Publication||10-Jun-2016|
Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Agalkote, Tumkur - 572 107, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Dental negligence is very common among mentally challenged children. That might be due to their condition makes it difficult to maintain good general and oral health and so their dentition may be ravaged by dental problems. Aim: To assess and compare the dental caries experience and treatment needs of institutionalized mentally challenged and normal children of age group 6–13 years in Mysore. Materials and Methods: A descriptive cross-sectional study was conducted among institutionalized mentally challenged and normal children of age group 6–13 years in Mysore. Modified World Health Organization proforma and predesigned questionnaire to assess dental caries experience and treatment needs. Results: Means number of decayed, extracted, filled teeth and decayed, extracted, filled surface score was higher among mentally challenged compared to normal children. The findings were found to be statistically highly significant (P < 0.001). The mean number of decayed missing filled teeth and decayed missing filled surface score for mentally challenged and normal children in relation to gender were statistically significant (P < 0.05). Temporomandibular joint problems and dentofacial anomalies were common among mentally challenged children compared to normal children. Conclusion: Health professionals should, therefore, be aware of the impact of mental illness and its treatment on oral health, health personnel should receive training to support and provide all possible services to this population.
Keywords: Dental caries, dentofacial anamolies, mentally challenged, normal children, temporomandibular joint
|How to cite this article:|
Konakeri V, Bennadi D, Manjunath M, Reddy C. Dental caries experience and treatment needs of institutionalized mentally challenged and normal children of age group 6–13 years in Mysore city. J Indian Assoc Public Health Dent 2016;14:164-70
|How to cite this URL:|
Konakeri V, Bennadi D, Manjunath M, Reddy C. Dental caries experience and treatment needs of institutionalized mentally challenged and normal children of age group 6–13 years in Mysore city. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Nov 21];14:164-70. Available from: http://www.jiaphd.org/text.asp?2016/14/2/164/181893
| Introduction|| |
Mental health is one of the three important aspects of health (others being physical and social) incorporated in the World Health Organization (WHO) definition of health. Mental ill health is a worldwide problem. Children below 15 years constitute one-third of the global cases. WHO estimated that 10% of the world population has some form of mental disability, and 1% suffers from severe incapacitating mental disorders. In India, mental illness contributes to 30% of all cases of disability. Roughly 1–2% (7–14 million) of the population is affected, of which 30% are children, the majority of cases being those of mental retardation.,,
The maintenance of good general and oral health of such children is difficult, and their dentition may be ravaged by dental caries and periodontal disease. It can also be related to imperfect tooth formation and lack of knowledge by parents regarding an adequate oral health for these children. Dental care for special children is often neglected by parents and dentists. The term “special child” or “disabled child” are often reserved for those who are having an impairment which restricts or limits daily activity in some manner. These children need our attention more so because they are unable to take care of their basic oral health care needs.
Oral symptoms may be the first or only manifestation of a mental health problem, e.g., facial pain due to caries or self-inflicted injury, etc. Oral manifestations of bulimia nervosa can develop within 6 months of onset and enamel erosion is reported in sufferers of both anorexia and bulimia. Burning mouth syndrome includes anxiety and depression as etiological factors. The management of these “God's forbidden children” is a task which needs a special effort on the part of the dentist.
Oral health may be affected by the following: Limited understanding on the importance of oral health management, difficulties in communicating oral health needs, medications that impact on oral health and a fear of oral health procedures. Many studies have been conducted regarding dental caries, periodontal health.,,,,, Not many studies regarding occlusion status and treatment required among mentally challenged children comparing with normal children.
Hence, an attempt is made to assess and compare the dental caries experience and treatment needs of institutionalized mentally challenged and normal children of age group 6–13 years in Mysore and suggest possible measures that can be undertaken to improve the oral health of the children.
| Materials and Methods|| |
A descriptive cross-sectional comparative study was conducted among institutionalized mentally challenged and normal children of age group 6–13 years in Mysore. This study was carried out from June 2008 to November 2008. Ethical clearance was obtained from the Institutional Ethics Committee. Informed consent was obtained from the concerned school authorities and from the parents to examine the children.
The list of institutions for physically challenged children was obtained from occupational therapy and Rehabilitation Center in Mysore and list of residential schools were obtained from Block Education Office, Mysore. All the children available during time of survey from all the ten institutions for physically challenged and an equal number of age and gender matched normal children from six residential schools were included in the study by stratified random sampling method. Uncooperative mentally challenged children and normal children with systemic diseases or on medications were excluded. Pilot study helped to check the feasibility and relevance of format.
A total of 490 mentally challenged and normal children were examined in their respective schools in an ordinary chair or in their wheelchair under natural daylight using mouth mirror and probe. With predesigned questionnaire collected information regarding demographic details, oral hygiene practices, diet, medication from children/school teachers, caretakers, and filled by the examiner. Oral examination data was recorded in a modified WHO proforma 1997. The decayed missing filled/decayed, extracted, filled caries index of Klein et al. and Grubbel (1944) was used for recording the prevalence of dental caries. Temporomandibular joint (TMJ) and the dentofacial anomalies were assessed only for spacing and crowding in incisal segment using the WHO  criteria.
The intelligence quotient level record which was available in the institution was utilized during the process of the study. Samples were divided into four groups according to WHO Classification of Mental Retardation (1994). 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. Socioeconomic status has been classified according to B. G. Prasad's classification.
Data were subjected for statistical analysis using SPSS version 16.0 (SPSS Inc., New York, USA). Descriptive statistics, Chi-square test, contingency coefficient test, independent sample t-test and univariate two-way analysis of variance, general linear model were used for analyzing the results. The statistical significance was fixed at 0.05.
| Results|| |
The study population consists of 490 mentally challenged children as study group and as control an equal number of age and gender matched normal children in the age group 6–13 years were selected from 6 residential schools of Mysore. Each group had 300 male and 190 female children. The majority of parents of the study group belonged to lower class 175 (35.71%), whereas control group parents belonged to upper lower class 120 (24.49%). The majority of parents among study population were graduates, 54.1% for mentally challenged and 55.1% for normal children, only 5.1% of both groups were illiterate.
[Table 1] shows the distribution of the mentally challenged subjects according to socioeconomical status. Cerebral palsy with mental retardation 80 (50%) and Downs syndrome 25 (41.61%) condition children was found more common in lower-class socioeconomic families whereas children with only mental retardation was common in upper lower class 90 (34%) families. The results showed that in the lower socioeconomic status, the mental disability condition was more common.
|Table 1: Distribution of mentally challenged subjects according to socioeconomic status|
Click here to view
Majority of the study subjects (92.85%) in mentally challenged children (n = 455) and 91.83% of normal children (n = 450) used tooth brush and tooth paste to clean their teeth; 83.67% mentally challenged children (n = 410) brushed once daily where as 63.27% normal children (n = 310) brushed twice daily. The difference was highly significant (P< 0.001). Most of the mentally challenged children (56.12% (n = 275)) needed complete parents assistance, 32.65% (n = 160) needed partial assistance of care-taker/parents for oral hygiene practices, whereas only 11.92% (n = 55) did not need help. In the normal children, 96.93% (n = 475) did not need help for oral hygiene practices, only 3.06% (n = 15) needed partial assistance of parents. Majority of mentally disabled children (n = 375, 76.53%) never visited a dentist as compared to normal children (n = 225, 45.9%).
The mean number of decayed, extracted, filled teeth (deft) and decayed, extracted, filled surface (defs) score was highest among mentally challenged compared to normal children (P< 0.001) [Table 2]. The mean number of decayed teeth and decayed surface (DT and DS) score was higher among mentally challenged children (1.3 ± 1.6 and 2.0 ± 2.5) than normal children (1.0 ± 1.5 and 1.6 ± 2.5) (P< 0.001). The total mean number of decayed, missing filled teeth (DMFT) score was 1.8 ± 1.9 for mentally challenged and 1.6 ± 2.1 for normal children. The mean number of decayed missing filled surface (DMFS) score was 3.7 ± 4.9 for mentally challenged and 3.3 ± 4.7 for normal children (P< 0.53, P < 0.40 respectively) [Table 3].
|Table 2: Mean number of decayed, extracted, filled teeth and decayed, extracted, filled surface among study population|
Click here to view
[Table 4] shows the prevalence of dental caries according to the severity of mental disability where the difference was significant in relation to DMFT and DMFS but was not significant with deft and defs. Caries experience in deciduous dentition was found to significantly increase with an increase in socioeconomic status. This observation is the reverse of the observation, that in permanent dentition [Table 5].
|Table 4: Prevalence of dental caries according to severity of mental disability|
Click here to view
|Table 5: Distribution of caries experience of study population in relation to their socioeconomic status|
Click here to view
The mean number of DMFT and DMFS score for mentally challenged and normal children in relation to gender were statistically significant (P< 0.05). In both groups females had significantly less caries experience than males. Whereas in the deciduous dentition, there was no statistically significant difference between the two genders.
The prevalence of TMJ problems was 16.54% among mentally challenged children and 7.14% among the normal children. This difference in the prevalence of TMJ disorders was found to be statistically highly significant between two groups [Figure 1]. [Figure 2] shows the distribution of study populations according to dentofacial anomalies. The findings were statistically highly significant (P< 0.001). Malocclusion conditions such as crowding, spacing of teeth, and TMJ disorders were frequent among physically challenged children.
|Figure 1: Distribution of temporomandibular joint problems among study population. Contingency coefficient 0.102; P = 0.001 (highly significant)|
Click here to view
|Figure 2: Distribution of study population according to dentofacial anomalies. Contingency coefficient = 0.263; P < 0.001 (highly significant)|
Click here to view
Concerning primary dentition, 1.9 ± 2.4 teeth and 3.0 ± 4.3 teeth surfaces required restorative treatment in mentally challenged children, whereas 1.0 ± 1.8 mean number of teeth and 1.4 ± 2.5 mean number of teeth surfaces in normal children and the difference was statistically significant (P< 0.001). In permanent dentition similar trend was observed. Mentally challenged children had more untreated DT, less filled teeth than the normal children. And the treatment provided it was more likely to be in the form of extraction rather than restorative care [Figure 3]. Concerning the gingival treatment requirement, 93% of mentally challenged children and 70% of normal children required oral hygiene instructions and oral prophylaxis.
|Figure 3: Distribution of study population according to treatment needs. P = 0.001 (highly significant)|
Click here to view
Orthodontic treatment needs for crowding and spacing among mentally challenged was high, i.e. 42.86% compare to normal children [Figure 2]. Considering treatment requirement for TMJ problems, 16.54% of mentally challenged children and 7.14% normal children needs treatment for TMJ problems such as reduced jaw mobility, clicking tendencies, and pain [Figure 1].
| Discussion|| |
This study showed that dental caries was high among mentally challenged children compared to normal children. Normal children showed a higher number of filling as compared to the study group. As normal children can be easily taken to the dentist for treatment and to the maintenance of oral hygiene.,,,,, The findings of our study are in agreement with previous studies ,,,,, conducted at various places in that the caries prevalence in deciduous dentition in mentally challenged children was slightly higher than in our study.
Mentally challenged children have more DSs, less filled surfaces than the normal children. The findings were in agreement with studies.,, However, filled and extracted components in the normal children were higher compared to mentally challenged children indicating greater accessibility to treatment care by normal children.
Caries prevalence in permanent dentition was seen to be similar as in deciduous dentition, but there was no significant difference between two groups. The physically challenged children had got more untreated decay whereas greater treatment care was observed in the normal children. Findings of our study are in agreement with other studies.,,, It might be due to differences in dietary habits, geographical location and differences in social and cultural background, more severe mental and physical handicapping conditions, low power of concentration, and comprehension leading to the negligence of oral hygiene and improper brushing.
In a study conducted in Leeds, England  prevalence of caries in physically challenged children was lower than the control group in the permanent dentition. This difference can be attributed to improved dental health seen over recent decades in the child population as whole, different environmental conditions viz., dietary habits, oral hygiene practices, water fluoridation, use of community dental services, and differences in education and socioeconomic backgrounds.,,,,,
The study showed that there was no significant difference in caries prevalence in deciduous dentition and severity of the mental disability. However in permanent dentition, caries prevalence increased as the severity of the mental disability. The findings of our study were in agreement with other studies.,, The high caries prevalence was seen as the severity of mental disability increases, which can be attributed to their difficulty in maintaining oral hygiene because of poor muscle co-ordination, muscle weakness, and associated systemic diseases interfering with the routine oral hygiene procedures.,,
There was a significant increase in the deft and defs values in both groups with an increase in socioeconomic status. It might be due to the differences in nutritional status causing variation in the eruption of teeth, affordability for sweet and other pastry food for their children in the higher class group compared to lower class, differences in dietary habits, overall negligence of milk teeth.,, The findings of the study were not in agreement with a study conducted in Brazil  where they observed that the physically challenged children of low socioeconomic status had higher levels of caries prevalence. Some studies have showed that there was no significant difference in caries prevalence and socioeconomic status in both primary and permanent dentition.
In permanent dentition, it was observed that as social class decreases there was an increase in caries experience in both groups. The findings were in agreement with a study conducted in Brazil. Higher prevalence in the low socioeconomic group could be because of the general negligence of oral hygiene and the inability of this population to afford dental hygiene aids, lack of access to preventive care, and affordability of dental care.
Considering gender-wise caries experience, males in both groups showed a higher trend of caries (permanent dentition), but there was no statistically significant difference, and it was in line with Newcastle study. This higher trend might be due to the cultural and social differences.
In this study, it was observed that mentally challenged children had statistically significant TMJ disorders such as clicking tendencies, tenderness, and reduced jaw mobility as compared to normal children. The findings of our study are in agreement with study conducted in Hyderabad. This can be attributed to due to hypotonia and hyperextensibility of joints and uncoordinated and uncontrolled movements of the jaw and abnormal or immature oral function in children with mental disability.
This study showed that dentofacial anomalies were high among study group compared to normal children, and the difference was statistically highly significant. The findings of our study are in agreement with other studies., This can be attributed to the behaviors that adversely affect the oral health of physically challenged children which include lip-biting, tongue-trusting, finger sucking, and those involved in mastication such as excessive swallowing, food pocketing and bruxism, involuntary behaviors also adversely affect their oral health., Excessive medication causes gingival hyperplasia leading to displacement and delayed eruption of teeth.,
The unmet dental need was high in mentally challenged children when compared to normal children. The findings of our study were in agreement with other studies.,,, This also emphasizes that the mentally challenged children are still receiving less dental care than their normal counterparts.
There was an equal need of orthodontic treatment requirement for spacing in both mentally challenged and normal children. The results of our study are in agreement with studies conducted Newcastle and Northumberland. Mentally challenged children required a high percentage of TMJ problems treatment needs compared to normal children. The results of our study are in agreement with studies conducted in Hyderabad.
- Effective oral health education with audio-visual aids, diet counseling and step by step demonstration of oral hygiene practices to the children and parents/caretakers can be given. Dental institutions
- Government and nongovernment organizations should conduct regular preventive and curative services for these children
- The ministry of health may provide in-service training to primary health care workers, teachers, institutional staff and to parents/care takers to promote good oral health and provide preventive and curative dental care for the special needs children.
The reliability of the parents, teachers and caretaker's response with respect to child's medical and dental history is an inherent weakness.
| Conclusion|| |
Mentally retarded children were suffering more with dental problems such as dental caries, TMJ problems, maintaining oral hygiene, and dentofacial abnormalities compared to normal children. Hence, treatment requirements were also more among mentally retarded children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mahajan BK. Text Book of Preventive and Social Medicine. 1st
ed. New Delhi (India): Jaypee Brothers Medical Publishers (P) Ltd.; 1991. p. 419-20.
Verma RK. Preventive measures in handicapped children. J Indian Dent Assoc 1981;53:173-4.
Ministry of Social Justice and Empowerment have Released the National Policy for Persons with Disabilities. Accessed from: http://www.socialjustice.nic.in/nppde.php?pageid=2. [Last accessed on 2009 Jun 23].
Damle SG. Text Book of Paediatric Dentistry. 3rd
ed. New Delhi: Arya (MEDI) Publishing House; 2006. p. 443-6.
Guaré Rde O, Ciamponi AL. Dental caries prevalence in the primary dentition of cerebral-palsied children. J Clin Pediatr Dent 2003;27:287-92.
Tandon S. Text Book of Pedodontics. 1st
ed. Hyderabad: Paras Publishing, Solutions for Health Care Professionals; 2001. p. 535-5.
Solanki J, Gupta S, Arya A. Dental caries and periodontal status of mentally handicapped institutilized children. J Clin Diagn Res 2014;8:ZC25-7.
Altun C, Guven G, Akgun OM, Akkurt MD, Basak F, Akbulut E. Oral health status of disabled individuals attending special schools. Eur J Dent 2010;4:361-6.
Nunn JH, Murray JJ. The dental health of handicapped children in Newcastle and Northumberland. Br Dent J 1987;162:9-14.
Pope JE, Curzon ME. The dental status of cerebral palsied children. Pediatr Dent 1991;13:156-62.
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.
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.
De Camargo MA, Antunes JL. Untreated dental caries in children with cerebral palsy in the Brazilian context. Int J Paediatr Dent 2008;18:131-8.
Rao DB, Hegde AM, Munshi AK. Caries prevalence amongst handicapped children of South Canara district, Karnataka. J Indian Soc Pedod Prev Dent 2001;19:67-73.
World Health Organization. Oral Health Surveys: Basic Methods. 4th
ed. Geneva: World Health Organization; 1999.
Klein H, Palmer CE, Knutson JW. Studies on dental caries: 1. Dental status and dental needs of elementary school children. J Public Health Rep 1938;53:751-65.
Gruebbel AO. Measurement of dental caries prevalence and treatment service for deciduous teeth. J Dent Res 1944;23:163-8.
World Health Organization. The ICD-10. Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva: World Health Organization; 1993. p. 140-1.
Chandra S. Sociology and Health-Essentials of Community Medicine. 1st
ed. Calcutta, New Central Book Agency (P) Ltd; 1997. p. 75-9.
Choi NK, Yang KH. A study on the dental disease of the handicapped. J Dent Child (Chic) 2003;70:153-8.
Simon EN, Matee MI, Scheutz F. Oral health status of handicapped primary school pupils in Dar es Salaam, Tanzania. East Afr Med J 2008;85:113-7.
Steinberg AD, Zimmerman S. The Lincoln dental caries study. I. The incidence of dental caries in persons with various mental disorders. J Am Dent Assoc 1967;74:1002-7.
Kawaguchi T, Nakashima M. Oral findings of institutionalized handicapped children. Fukuoka Shika Daigaku Gakkai Zasshi 1990;17:13-21.
Bhowate R, Dubey A. Dentofacial changes and oral health status in mentally challenged children. J Indian Soc Pedod Prev Dent 2005;23:71-3.
Nunn JH. The dental health of mentally and physically handicapped children: A review of the literature. Community Dent Health 1987;4:157-68.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]