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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 4-10

Oral health status and barriers to utilization of services among down syndrome children in Bengaluru City: A cross-sectional, comparative study


Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India

Date of Submission03-Oct-2017
Date of Acceptance28-Dec-2018
Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Bhavna Sabbarwal
Room No. 9, Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka - 560 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_138_17

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  Abstract 

Introduction: Down syndrome (DS) is a common genetic disorder caused by the presence of an extra chromosome 21. Individuals with DS present with high prevalence of oral health conditions but oral health services are underutilized due to various reasons. Aim: The aim is to assess oral health status and barriers to utilization of oral health services among children with DS in Bengaluru city. Materials and Methods: A cross-sectional, comparative study was conducted among 100 DS children and compared with 100 non-DS (NDS) children in Bengaluru city. Clinical levels of oral hygiene were assessed using Oral Hygiene Index-Simplified (OHI-S) and caries according to WHO criteria (1997). Parents completed a structured questionnaire used to determine barriers to utilization of oral health services. Chi-square test, unpaired t-test, and Spearman's correlation were applied. Statistical significance was considered at P < 0.05. Results: Children with DS had a significantly higher mean OHI-S (3.05 ± 1.26) as compared to NDS children (1.65 ± 1.02) (P < 0.001). Mean decayed, missing, and filled teeth for DS and NDS group was 2.38 ± 3.41 and 0.66 ± 1.19, respectively, (P < 0.001), whereas mean Decayed, Missing, and Filled Teeth for DS and NDS group was 1.22 ± 1.63 and 1.78 ± 1.9, respectively, (P = 0.03). Mean awareness about child's dental problem was found to be significantly higher among DS group compared to NDS group. Accessibility was found to be positively correlated to dental visits among DS group (r = 0.30, P = 0.003). Conclusion: DS children had poor oral hygiene and considerable caries experience and faced certain barriers to utilization of oral health care services. Parental education as an integral component of oral health promotion programs should be introduced in special schools for better oral health.

Keywords: Barriers, children, dental caries, Down syndrome, oral health care services, oral hygiene, utilization


How to cite this article:
Sabbarwal B, Puranik MP, Uma S R. Oral health status and barriers to utilization of services among down syndrome children in Bengaluru City: A cross-sectional, comparative study. J Indian Assoc Public Health Dent 2018;16:4-10

How to cite this URL:
Sabbarwal B, Puranik MP, Uma S R. Oral health status and barriers to utilization of services among down syndrome children in Bengaluru City: A cross-sectional, comparative study. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2018 Jul 20];16:4-10. Available from: http://www.jiaphd.org/text.asp?2018/16/1/4/228297


  Introduction Top


Down syndrome (DS) is the most frequent chromosomal disorder with a risk of 1 out of 600–1000 live births. It is characterized by delayed mental and physical development and generalized growth deficiency. All individuals with DS are mentally impaired to some degree, ranging from mild to severe.[1],[2],[3]

As per the WHO, DS is one of the congenital abnormalities, classified under mental retardation.[4] Persons with DS are often with a short neck and underdeveloped mid-face. Affected individuals have greater risk of acquiring systemic conditions such as upper respiratory tract and chest infections. Approximately 50% have some forms of heart defect, usually ventricular septal defect; some may require antibiotic cover for invasive dental treatment.[2],[3],[5],[6]

Several dental characteristics have been described in children with DS. Some of these are macroglossia, fissured tongue, underdeveloped maxilla, tongue thrusting, congenitally missing teeth, malocclusion, high arch palate, increased salivation, and microdontia.[1],[7] Some may have increased risk of periodontal disease due to cariogenic food choices and reduced food clearance from the mouth.[7],[8] DS individuals need assisted care from parents or caretakers for daily oral care because of lack of manual dexterity.[8] All these conditions remain static or may increase with age.[2],[5],[6],[7],[8]

Earlier studies have reported barriers to utilization of oral health services among mentally retarded individuals including DS group.[9],[10],[11],[12],[13] Parents perceptions include lack of awareness and importance to dental visits,[9],[10] lack of perceived need,[11] low value to oral health,[11],[12] anxiety or fear,[9] financial considerations,[7],[9],[13],[14] lack of access [7],[11],[14] difficulty in getting an appointment,[10],[11] and lack of cooperation.[11] On the other hand, dental professionals perceived lack of workforce training of health personnel, insufficient sensitivity to patient's attitudes and needs as barriers for provision of care.[12] However, studies assessing barriers to utilization of oral health services specific to DS are scarce. Hence, a study was conducted with an aim to assess the oral health status and treatment needs and barriers to utilization of oral health services among DS children and compare with that of non-DS (NDS) children in Bengaluru city.


  Materials and Methods Top


A cross-sectional, comparative study was conducted among DS and NDS children and their parents/caregivers (study participants) from May to September 2016. Ethical clearance was obtained from the institutional ethical committee. Necessary permission was obtained from hospital, special, and regular school authorities. Informed consent was obtained from the parents of the study participants after explaining the purpose and procedure clearly. Principal investigator was trained and calibrated before start of the study to ensure reliability (k = 0.80).

A 19-item questionnaire was developed based on previous literature.[9],[10],[11],[12],[13],[15],[16] Cross-cultural validation of questionnaire was performed by means of backtranslation (English to Kannada) method. Readability and comprehension were assessed during the pilot study. Necessary corrections and modifications were made. Internal consistency of questionnaire was found to be good (Cronbach's alpha = 0.89).

The sample size was calculated based on the prevalence of poor oral hygiene during the pilot study; measured by Oral Hygiene Index-Simplified (OHI-S) which was the most common finding affecting their oral health, using the formula:



Where P = Prevalence of poor oral hygiene, that is, 80%, statistical power = 80%, Zα= 1.96 at 95% confidence interval (CI), E = margin of error-10%

The sample size was found to be 96 which was rounded off to 100. Hence, 100 DS children from hospital and special schools and age- and gender-matched NDS children from regular schools were recruited. Children with other intellectual disabilities or systemic conditions which are known to influence oral health, uncooperative children, and those who have undergone dental prophylaxis in the last 6 months were excluded from the study.

Data were collected using a self-administered questionnaire followed by clinical examination. Besides demographic profile, medical history, oral hygiene practices, and dental visits were recorded. Socioeconomic status was assessed using Modified Kuppuswamy classification. A self-administered 19 items structured, validated questionnaire was completed by the parents. This questionnaire included barriers to utilization of oral health services with following domains: awareness (1 item), attitude (1 item), cost (1 item), difficulty in obtaining care due to disability related to DS (3 items), accessibility (4 items), dentist-related factors (5 items), and fear (4 items). Responses were recorded on three-point scale (yes, no, and sometimes/don't know/uncertain).

Among the domains awareness, attitude, cost, and fear were assessed for both the study groups. Whereas accessibility, dentist-related factors, and difficulty in obtaining care due to disability were assessed specifically for the DS group. Intraoral assessment of hard and soft tissues was performed and OHI-S,[17] decayed, missing, and filled teeth (dmft)/Decayed, Missing, and Filled Teeth (DMFT) index (WHO criteria 1997)[18] were recorded.

The data collected were entered into MS Excel Spreadsheet. Responses were coded and weights were assigned. Data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 22. Chi-square test was used to find out difference between proportions. Unpaired t-test was used to find difference in mean scores between clinical variables. Spearman's correlation was done to find out correlation among barriers to utilization of oral health services and dental visits among study participants. Binary logistic regression was applied to check relationship between barriers to utilization of oral health services and dental visits among study participants. Statistical significance was set at 5% (CI 95%).


  Results Top


In this study, the age ranged from 6 to 17 years among DS (10.64 ± 3.21) and NDS group (11.61 ± 2.48) with similar means. Among DS group (N = 100), 57% were male and 43% were female. Among NDS group (N = 100), 49% were male and 51% were female [Table 1]. Majority of study participants in both the groups belonged to middle class.
Table 1: Demographic characteristics of the study groups

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Among the DS children, cardiac (12%), immunological (5%), ENT (25%) and vision problems (30%), and medication (12%) were reported. While difficulty in eating and chewing (21%), food spilling while eating (16%), and sleeping with mouth open (43%) were also observed. Family history of DS (11%) and other illness (7%) were found in DS group.

Among the study groups, 57% DS and 16% NDS children, reported visiting a dentist. Among those who visited dentist, majority reported to have visited dentist in the last 6 months to 1 year or more (DS: 86% and NDS: 94%). Tooth decay (DS: 45.61% NDS: 56.25%) and pain (DS: 29.82% NDS: 37.5%) were the main reason for dental visits in both the groups. Restoration (31.57%) and extraction (42.10%) were the most common treatment received by DS group while restoration (56.25%) and oral prophylaxis (NDS: 25%) among NDS group. Among DS group 84.21% were satisfied with the treatment, whereas among NDS group, 93.75% were satisfied with the treatment.

Child's oral hygiene care was predominantly maintained by the mothers. Almost all the study participants in both the groups used toothbrush and toothpaste to clean their teeth and horizontal or vertical method of toothbrushing were common in both the groups. Among DS group: 2% used floss; 3% interdental aids; 21% mouthrinse while 19% used tongue cleaner. Among NDS group, 31% used tongue cleaner.

Orodental anomalies such as palatal defects (2%), peg laterals (7%), microdontia (18%), hypodontia (16%), and macroglossia (88%) were observed in DS group only. Frequency of hypoplasia (DS: 53% NDS: 41%), occlusal wear (DS: 35% NDS: 4%), and tongue thrusting (DS: 90% NDS: 9%) were found to be higher in DS than NDS group. Similarly, crowding (DS: 57% NDS: 30%), spacing (DS: 32% NDS: 17%), crossbite (DS: 30% NDS: 18%), and open bite (DS: 21% NDS: 8%) were also higher in DS than NDS group.

OHI-S score in DS group was 3.05 ± 1.26 (Debris Index-Simplified [DI-S]: 2.17 ± 0.76; Calculus Index-Simplified [CI-S]: 0.88 ± 0.61). Among NDS group 1.65 ± 1.02 (DI-S: 1.31 ± 0.68; CI-S: 0.34 ± 0.42). Mean debris, calculus, and OHI-S score was significantly higher in DS group as compared to NDS group (P< 0.001) [Table 2].
Table 2: Mean Oral Hygiene Index-Simplified scores among the study groups

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Caries experience was measured by dmft/DMFT. Mean dmft scores were significantly higher in DS group (2.38 ± 3.41) than NDS group (0.66 ± 1.19) (P< 0.001). Mean DMFT scores were significantly lower in DS group (1.22 ± 1.63) than NDS group (1.78 ± 1.90) (P = 0.03) [Table 3].
Table 3: Mean caries experience (decayed, missing, and filled teeth/Decayed, Missing, and Filled Teeth) among study groups

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Parents responded to questions related to barriers to utilization of oral health services. Mean score for awareness was significantly higher among DS group (0.97 ± 0.70) as compared to NDS group (0.72 ± 0.75) (P = 0.02). While there was no significant difference between both the groups regarding mean attitude ([DS 1.06 ± 0.85, NDS 1.08 ± 0.93]) (P = 0.87), cost ([DS 0.82 ± 0.80, NDS 0.75 ± 0.88]) (P = 0.56), and fear scores ([DS 2.77 ± 2.31, NDS 2.55 ± 2.34]) (P = 0.50) [Table 4].
Table 4: Responses of the study groups according to questions on barriers to utilization of oral health services

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Parents with awareness regarding the presence of dental problem in their children were more likely to utilize oral health services (dental visit) among both the groups with the association being significant in NDS group. Despite the attitude of considering dental treatment as important as medical treatment parents were less likely to utilize oral health services (dental visit) among DS group (0.66 [95% CI 0.28–1.56]) (P = 0.35), whereas NDS group is more likely to utilize oral health services (dental visit) (1.13 [95% CI 0.37–3.41]) (P = 0.82). Among DS group those who considered cost of dental treatment as high were less likely to have dental visits (0.59 [95% CI 0.26–1.34]) (P = 0.28). Among NDS group, despite high cost were more likely to visit a dentist (2.22 [95% CI 0.74–6.68]) (P = 0.15). Despite the presence of dental fear in parents/children participants in DS group were more likely to visit a dentist (2.22 [95% CI 0.91–5.40]) (P = 0.08), whereas among NDS group, those who were having dental fear were less likely to visit a dentist (0.58 [95% CI 0.20–1.71]) (P = 0.33) [Table 5].
Table 5: Logistic regression analysis about barriers affecting dental visits among study groups

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Mean scores for barriers to utilization of oral health services among DS group and correlation with dental visits are presented in [Table 6]. A weak but significant negative correlation was found between “difficulty in obtaining care due to disability” and “dental visits” (r = −0.19, P = 0.05). A weak significant positive correlation was found between “accessibility” and “dental visits” (r = 0.30, P = 0.003) [Table 6].
Table 6: Correlation between barriers to utilization of oral health services and dental visits among Down syndrome group

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Among Down syndrome group, those who were having difficulty in obtaining care due to routine chores of their DS child were less likely to have dental visits (0.80 [95% CI 0.90–4.67]) (P = 0.09) than those who cited no difficulty. Those who had accessibility to dental clinic were twice more likely to visit a dentist (2.05 [95% CI 1.04–2.90]) (P = 0.03) than those who had limited access. Those who cited dentist-related factors as barriers were less likely to visit a dentist (0.28 [95% CI 0.07–1.07]) (P = 0.06) than who did not [Table 7].
Table 7: Logistic regression analysis between barriers affecting dental visits among Down syndrome group

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  Discussion Top


DS is characterized by central growth deficiency with delayed mental and physical development ranging from mild to severe.[2] Furthermore, manual dexterity difficulties may lead to oral hygiene problems, which may lead to accumulation of plaque and debris, hence favoring development of gingivitis and periodontal disease.[9]

Earlier studies assessing barriers among mentally retarded children included children with DS.[6],[19],[20],[21],[22],[23] Studies have assessed systemic conditions [12],[15],[24] oral hygiene status [6],[7],[8],[9],[19],[20],[21],[25],[26],[27],[28],[29],[30] and practices [1],[6],[8],[9],[15],[16],[30],[31],[32],[33] dental caries [6],[7],[9],[16],[19],[20],[22],[23],[25],[26],[29],[30],[31],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] dental anomalies [1],[7],[9],[12],[25],[35],[36] dental visits patterns [10],[14],[15] and reasons [14],[15] among DS children. Limited studies have assessed barriers to utilization of oral health services [9],[10],[11],[12] among DS children.

The age of the DS children (10.64 ± 3.21) and NDS children (11.61 ± 2.48) ranged from 6 to 17 years. Mean age of DS group was less few studies (11.89–26.4)[7],[9],[10],[11],[19],[32] and more than others (9.37–10.52).[8],[15],[24],[30],[42]

Majority of the study participants in DS group were male. Earlier studies have shown that families tend to send male child to special schools/institutions more often compared to female child.[1],[9] Hence, a higher number of males were reported in most of the studies.

Regarding medical history, the prevalence of ENT problems were in-line with previous studies, whereas cardiac and vision problems were less than that reported in previous studies.[15],[25] Other conditions such as difficulty eating and chewing were reported which was similar to two previous studies.[24],[25]

Pattern of dental visits among DS group observed in the current study is due to referral by physicians for routine dental checkup. Proportion of DS individuals visiting a dentist was higher compared to a study [15] and lower than two studies.[14],[16] Duration of dental visit among both the groups is in-line with two studies.[15],[16] Tooth decay was the main reason for dental visits; other reasons were pain and general checkup. Extractions of teeth, restoration were some of the treatments reported in DS group. Previous studies have cited general checkup,[11] toothache [11] as reasons for dental visits and oral prophylaxis,[7] filling [7],[11] and extractions [7] as some of the treatment taken by both the groups. Among participants who availed dental services, majority expressed satisfaction in both the groups similar to previous studies.[14],[15]

Responsibility of oral hygiene care is primarily on caregivers as an interaction between caregivers and children promotes the healthy habits among children. They are often accountable for making decisions about their child's health.

Reduced manual dexterity, joint laxity (including the carpal joints), and the lack of comprehension of oral hygiene needs due to mental difficulties are some of the reasons cited in the previous literature. Hence, DS children often need supervision and assistance in the maintenance of oral hygiene.[35]

In the present study, majority of mothers in both the groups claimed that they take care of child's oral hygiene. In two studies,[15],[34] majority of the parents assisted their children for toothbrushing, whereas in another study [16] most of DS children reported brushing teeth by themselves. Almost all the study participants in both the groups used toothbrush and toothpaste to clean their teeth which was more compared to previous studies in DS [1],[6],[8],[9],[15],[32],[34] and NDS children.[9] In the current study, majority of DS children brushed their teeth once a day which is higher compared to previous studies.[8],[15],[31],[32],[34] Half of the participants in DS group changed their toothbrush in <3 months. Very few among DS group used mouth rinse and dental floss which is comparable to a study.[9]

DS children have a variety of oral conditions associated with the syndrome. Slow rate of cell growth and a consequent reduced cell number that characterized the DS may be responsible for the underdevelopment of the upper jaw, the delayed dental development and the reduction in number and size of teeth.

Lower proportions of palatal defects (cleft palate) were present among DS children in this study compared to a study.[1] Tongue thrusting and macroglossia were the most common conditions observed in this study which was similar to studies reported in the literature.[1],[21]

Dental anomalies such as crowding and hypoplasia were observed among more than half of the DS children which was more than two studies.[7],[9] Occlusal wear, spacing, crossbite, and open bite were found among up to one-third of the study participants which was similar to earlier studies.[1],[9],[13] Discrepancy in shape (Peg laterals) and size (Microdontia) of teeth were comparable to previous studies.[1],[9],[21],[35]

Individuals with DS may have great limitations in oral hygiene performance due to their manual dexterity, sensory, and intellectual disabilities and so are prone to poor oral health.[20],[25],[44],[45] Mean OHI-S score among DS children in this study was found to be higher compared to previous studies.[20],[25],[29],[30]

Poor oral hygiene and malocclusion was found among DS children which might contribute to development of dental caries.[9] Because of delayed eruption of both primary and permanent dentition caries prevalence is expected to be less compared to NDS children.

Mean dmft among DS group is almost similar to a study (2.43)[19] and more than few studies (0.58–1.9)[7],[20],[33] while less than other study (4.44).[31] Among NDS group, mean dmft in NDS group was 0.66 ± 1.19 which was formed by decayed component only. Mean dmft in NDS group was lower than one study (1.87 ± 3.04)[33] and higher than another study (0.07 ± 0.3).[7] Mean dmft in the current study among DS group was significantly higher compared to NDS group which is similar to the two studies [7],[33] and contrary to one study.[30]

In DS group, mean DMFT was 1.22 ± 1.63. This was lower than some studies (1.68–13.2)[9],[20],[22],[23],[25],[26],[30],[34],[35],[36] and higher than other (0.23–0.56).[7],[19],[33]

Among NDM group, the mean DMFT was 1.78 ± 1.9. This was lower than some studies (1.84–7.4)[9],[30],[33],[35],[36] and higher than one study (0.09 ± 0.29).[7] Mean DMFT in the present study among DS children was significantly lower than NDS children; this was similar to the few studies [30],[33],[36] reported in literature and contrary to one study [35] where caries experience in permanent dentition among DS children was found to be significantly higher compared to NDS children.

Poor access to oral care compounded by the behavioral and communication difficulties makes obtaining dental care hard for service users.[44] Mean awareness score was found to be significantly higher among DS group compared to NDS group. Participants who were aware of the presence of dental conditions in their child were more likely to visit dentist; significant among NDS compared to DS suggesting that despite being aware study participants in DS group might have some barriers which resulted in lesser odds of dental visits.

No significant difference was observed between mean attitude score of the study groups. Even with positive attitude participants among DS group were less likely to visit a dentist than NDS group. Although it was not significant, results indicated that some barriers might be preventing participants in DS group from visiting a dentist.

There was no significant difference between mean cost scores of the study groups. Study participants in DS group were less likely, and those in NDS group were more likely to visit a dentist when cost of dental treatment was perceived as high. Parents of DS children spend money for managing their child's medical conditions, and dental treatment might add to the burden on expenses. Similar finding was reported in one study among DS group.[13]

No significant difference was observed between mean fear scores of the study groups. Despite the presence of fear study participants in DS group were more likely to visit a dentist, whereas those in NDS group were less likely to visit. Physician's referral to the dental clinic among study participants in DS group might have diminished the dental fear while the same was not applicable to NDS group.

Individuals with DS are intellectually impaired and medically complex to varying degrees, which may interfere with their dental care in office. They have difficulty obtaining care due to disability and also face problems related to access to dental care and dentist-related factors.

In this study, dental visits were negatively correlated with difficulty obtaining care due to disability and dentist-related factors, and hence DS individuals were less likely to visit a dentist. Dental visits were positively correlated with accessibility, hence DS individuals who had access to oral health services were twice more likely to visit a dentist than who had no access which was statistically significant.

The present study has some limitations. Cross-sectional study design does not allow assessment of causality between barriers to utilization of oral health services and dental visits. Bias inherent in questionnaire studies might have occurred in the present study. In addition, the study was carried out on DS children attending special schools and one hospital in Bengaluru city. Hence, children not attending the special schools or residing in institutions for mentally retarded were beyond the scope of the study. Hence, further longitudinal studies are recommended for better understanding of oral health conditions and association between barriers to utilization of oral health services.

DS individuals should receive regular dental treatment and follow-up care when they are visiting the physician. Management of DS patients in dental office requires a sound knowledge of the conditions that will help in providing appropriate preventive and other care. A rigorous preventive regime such as oral hygiene instructions, diet counseling, and appropriate use of topical fluoride and fissure sealants should be implemented. Maintaining good oral hygiene and frequent professional cleanings are essential. To improve oral health of individuals with DS use of electric toothbrush, avoidance of sticky and sugary foods, and medication and chewing of xylitol products before sweetened medication are recommended.


  Conclusion Top


DS children had poor oral hygiene, considerable caries experience reflecting poor oral health status. DS children had awareness and positive attitude toward dental treatment. Barriers such as presence of medical conditions, cost of dental treatment, and dentist-related factors existed in DS group. Hence, individuals with DS had poor oral health and limited access to dental care. Oral health promotion programs in special care schools with parental education as an integral component are needed.

Acknowledgment

We would like to thank all the study participants and authorities of special schools.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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