|Year : 2015 | Volume
| Issue : 3 | Page : 292-296
Oro-facial pain perception and barriers to assess oral health care among the children with intellectual disability: A cross-sectional study
G Radha, Abhishek Jha, V Swathi
Department of Public Health Dentistry, V S Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||14-Sep-2015|
Department of Public Health Dentistry, V S Dental College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Dental caries is one of the most prevalent diseases affecting children invariably across the world; a toothache is one of the common outcomes found to be associated with dental caries as pain perception is a subjective phenomenon reporting of pain may vary among different individuals. The aim of this study was to assess the difference in oral health status and pain perception related to oral health status among the children with intellectual disability (ID) and their normal counterparts. Materials and Methods: A cross-sectional study was conducted among 100 school children of 9-14 years with or without ID in Bangalore City, ethical clearance and informed consent were obtained. The study involved 50 children with ID and 50 children with non-ID (NID), of age group 9-14 years. A self-administered questionnaire was used to assess participant's demographic profile, self-assessed medical and dental conditions. Clinical assessment was done for recording dental caries and gingival status. Dental pain was measured using the "Dental Discomfort Questionnaire +" given by Versloot et al. Results: It was found that children with ID had a higher score for D(T), and M(T) compared to NID control. This difference was statistically significant. Children with ID showed higher discomfort due to pain. Except for chewing on one side all other questions showed a significant difference between the groups. Conclusion: It was found that children with ID had a higher caries experience compared to NID control and showed significantly higher pain experience than children with NID.
Keywords: Dental caries, intellectual disability, oral health care, pain perception
|How to cite this article:|
Radha G, Jha A, Swathi V. Oro-facial pain perception and barriers to assess oral health care among the children with intellectual disability: A cross-sectional study. J Indian Assoc Public Health Dent 2015;13:292-6
|How to cite this URL:|
Radha G, Jha A, Swathi V. Oro-facial pain perception and barriers to assess oral health care among the children with intellectual disability: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2021 Jun 15];13:292-6. Available from: https://www.jiaphd.org/text.asp?2015/13/3/292/165278
| Introduction|| |
Medical procedures have been shown to cause stress, anxiety, and pain in children. Since pain is an inherently subjective phenomenon, it is often said that the "gold standard" for pain assessment in both children, and adults is verbal-reporting.  Dental caries, tooth decay, predominantly affect children, and adolescents.  Research indicates that 5-33% of children experience at least one toothache during childhood.  However, reliable description of pain may be difficult for certain individuals including infants, very young children, individuals with intellectual disabilities (ID), and adults with severe dementia.
The American association of intellectual and developmental disability defines ID as "Intellectual disability is a disability characterized by significant limitations in both intellectual functioning and adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 18." An IQ below 70 (average IQ is 100) significant difficulty with daily living skills including looking after themselves, communicating, and taking part in activities with others.
In addition to the strong likelihood of experiencing dental pain, research has shown that 20% of children have dental fears and 21% engage in negative behaviors in a dental office.  Although seated in a dentist's waiting room anxiety may be mounting from auditory (hearing the whining noise of drilling), olfactory (specific smells), or visual triggers (menacing machines in dull colors). Even meeting the (smiling) dentist on entering the treatment room may raise anxiety. However, how does this work for young children or children with some form of cognitive limitations, is not known whether they are less vulnerable to anticipatory anxiety for the events to come. Most young children are not able to ask questions or express pain or anxiety in a recognizable manner.  Reliable description of pain may be difficult for children due to their cognitive immaturity and their inability to separate pain from fear and anxiety. Children with ID frequently have the added challenge of not being able to express their pain or verbalize it. This explains why these children were believed not to experience pain and were forced to undergo painful procedures on occasions without the proper control of pain. 
One major difficulty in the treatment of this heterogeneous group of children is the wide variety of causes for, and levels of, developmental delay. These aspects make each patient unique. The common denominator is that these children are not able to describe pain or discomfort. Therefore, dentists must find other ways to uncover these children's emotional state in the dental setting.  Currently, very little information is available regarding the disparity in dental pain. Hence, the current study was conducted with an aim to assess the difference in oral health status and pain perception related to oral health status among the children with ID and their normal counterparts. The objectives of the present study are to know the oral health status, pain related to oral cavity and barriers to access oral health care among the study subjects.
| Materials and methods|| |
A cross-sectional study was conducted among 100 school children of 9-14 years with or without ID; the study was conducted for 2 days in the month of June 2014, in Bengaluru City. Ethical clearance to conduct the study was taken from the institutional review board. Permission to conduct the study was taken from the school; informed consent was taken from the parents of the participants.
South Bangalore was taken as a place of study which has three schools enrolling children with ID a school was selected out of three schools based on convenience. The school enrolls both children with ID and non-ID (NID). A total of 65 children with ID were enrolled in the school at the time of the study, with age falling between 9 and 14 years, belonging to lower or upper lower socioeconomic status, out of which 50 children finally participated in the study, the reason for nonparticipation of 15 children with ID was either parents opted out or children who were extremely uncooperative for clinical examination. Similarly, a matched group comprising of 50 children with NID with similar background and demographic feature were selected for study.
A self-administered questionnaire containing closed and open-ended questions was used to assess participant's demographic profile, self-assessed medical and dental conditions. Clinical assessment was done for recording dental caries and gingival status, using World Health Organization 1997 oral health survey form.  Recording of oral health status was done in natural daylight using mouth mirror and community periodontal index probe. Two investigators were calibrated to do clinical examinations on children. Reliability of the two examiners was checked for measuring dental caries and gingival status, by performing a clinical examination on 10% of the sampled children with Kappa = 0.80.
- A history of ID as verified by the child's medical file or caregiver's reporting
- Children with decayed, missing, and filled teeth (DMFT)/dmft score of 2 or more
- Parents/caregivers who are able to read and understand the questionnaire
- Controls included age-matched children with NID, recruited from the same school.
Dental pain was measured using the "Dental Discomfort Questionnaire" (DDQ+). This questionnaire was originally developed by Versloot et al.  to measure possible dental pain-related behaviors in very young children and was subsequently modified to include children with learning disabilities. The investigators pretested the questionnaire prior to the study to check its readability and caregiver's understanding of questions. The questionnaire was translated into local language, and back translated and necessary corrections were made as required. The questionnaire consisting of 14 questions was provided to caregivers and investigator assisted them in filling out the questionnaire. For each question in the DDQ+, parent's rated the occurrence of the behavior as "never" coded as 0, "ocassionally" coded as 1, or "always" coded as 2.
Data were collected and were analyzed for descriptive statistics the mean of oral health outcome were collected and were compared among the study groups using independent t-test and questionnaire were analyzed with frequency distribution and Chi-square test was done. Data were analyzed by IBM SPSS Statistics for Windows, Version 19.0. (IBM Corp., SPSS, Armonk, NY, USA).
| Results|| |
Mean DMFT was calculated and compared, it was found that children with ID had a higher score for D(T), and M(T) compared to NID control. This difference was statistically significant [Table 1]. It was found that among ID group 40% were completely dependent on their caregiver for dental care while 36% were partially dependent on their caregivers, also 29% of caregivers answered that their children have received some kind of dental care in past.
A significant difference among the groups for caregivers and investigators perception of children's dental pain was seen. Question-related to an earache showed the higher frequency of children with ID. Children with ID showed higher discomfort due to pain. Except for chewing on one side all other questions showed significant difference [Table 2].
|Table 2: Comparison of DDQ items with dental caries between healthy children and children with ID in groups |
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The difference between groups based on sugar consumption was higher in children with ID and findings were significant [Table 3]. DMF score was higher for the higher frequency of sugar intake, and the difference between groups was higher for children with ID and findings were significant [Table 4]. All barriers equally affected the access to dental care in both groups but the time factor was one of the major factors effecting assessing the dental care and was quite high among children with ID. Response to dentist unwillingness to treat the children was not considered as a major barrier by both groups [Table 5].
| Discussion|| |
Improving oral health is a specific concern for individuals with disabilities, since oral health has both local and systemic consequences.  It increases the risk of infectious complications for patients presenting systemic diseases such as congenital cardiac disease, immunodeficiency, or diabetes, or those with internal prostheses and plays a direct role in the aggravation of chronic respiratory disease, which is the main cause of mortality in people with disabilities.  Individual with a mental disability, neurological, and behavioral problems may be related to undiagnosed and untreated because of improper diagnosis and poor access to dental care.  Hence, the present study was conducted to assess the oral health and related experience of pain in children with ID.
Among ID group 40% were completely dependent on their caregiver for dental care while 36% were partially dependent on their caregivers. Altun et al. found in their study that the majority of children with ID showed dependence on the caregiver for performing oral hygiene procedure.  Therefore; any prevention program should start by educating caregivers. Caregivers must be aware of their children's special needs, be motivated, and have the skills to provide the requisite oral care. 
Among ID group 29% of caregivers answered that their children have received some kind of dental care in past. Although this was higher for NID children who was 41%, Brogεrdh-Roth et al. found that children with ID showed less frequent visit to dentists hence findings of the present study is in accordance with this study.  The reason may be under-reporting of pain and discomfort experienced due to dental caries by children with ID to their caregivers and negligence of oral health problem of children by a caregiver.
Caries experience was higher among the group with ID, untreated dental caries was higher in this group, while filled teeth were higher in NID group, and findings were significant. These findings are in accordance with the study done by Shawky et al., they recorded significantly higher decayed teeth among children with ID.  The reason quoted for such high experience of untreated dental caries is due to less frequent visit to the dental clinic, accordingly the lesser number of filled teeth.  Such untreated dental caries if not treated at the appropriate time may worsen with time and may result in pain and discomfort.
Most of the questions subjects with ID showed higher frequency. Question-related to an earache showed most significant results with higher frequency for children with ID. Altogether children with ID were more uncomfortable with their current oral health. Alaki and Bakry got similar findings as a present study with children with ID had more experience with pain and discomfort related to dental caries. 
The reasons for higher dental caries can be compromised oral hygiene, frequent consumption of sugary diet, and consumption of sugar in between meals. Decayed teeth increased with increase in the frequency of sugar intake and the frequency was especially higher for the decayed and missing teeth for which findings were significant. Children with ID showed a higher frequency of decayed and missing teeth compared to NID group.
Among the barrier, all barriers had an equal effect on assessing oral health but time for assessing was found to be one factor which inhibited ID group from assessing dental health care.
Our study has taken a small sample which might question about the representativeness of current study. We suggest a better sampling design with greater number of participants might give a better representation and will improve the external validity of the study, further we conducted our study to a limited sample because of lack of resources and because of unwillingness of other schools for participation. In future, a study comparing the experience of pain among groups of children with different types of intellectual disabilities can be conducted, which will give a better idea about the effect of type and extent of ID on experience of oral diseases and pain associated with it.
| Conclusion|| |
It was found that children with ID had higher caries experience compared to NID control and showed significantly higher pain experience than children with NID.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Merskey H, Bogduk N. Classification of Chronic Pain: Description of Chronic Pain Syndromes and Definitions of Pain Terms. 2 nd
ed. Seattle, Wash, USA: International Association of Study of Pain (IASP) Press; 1994.
Blinkhorn AS, Kay EJ, Atkinson JM, Millar K. Advice for the dental team on coping with the nervous child. Dent Update 1990;17:415-9.
Slade GD. Epidemiology of dental pain and dental caries among children and adolescents. Community Dent Health 2001;18:219-27.
Baier K, Milgrom P, Russell S, Mancl L, Yoshida T. Children's fear and behavior in private pediatric dentistry practices. Pediatr Dent 2004;26:316-21.
van Dijk M, Valkenburg A. Children with intellectual disabilities and pain perception: A review and suggestions for future assessment protocols. Eur Arch Paediatr Dent 2009;10:57-60.
Franck LS, Greenberg CS, Stevens B. Pain assessment in infants and children. Pediatr Clin North Am 2000;47:487-512.
World Health Organization. Oral Health Surveys - Basic Methods. 4 th
ed. Geneva: World Health Organization; 1997.
Versloot J, Veerkamp JS, Hoogstraten J. Dental Discomfort Questionnaire: Assessment of dental discomfort and/or pain in very young children. Community Dent Oral Epidemiol 2006;34:47-52.
Hennequin M, Moysan V, Jourdan D, Dorin M, Nicolas E. Inequalities in oral health for children with disabilities: A French national survey in special schools. PLoS One 2008;3:e2564.
Mojon P. Oral health and respiratory infection. J Can Dent Assoc 2002;68:340-5.
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.
Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist 2002;22 3 Suppl: 26S-39S.
Brogårdh-Roth S, Stjernqvist K, Matsson L, Klingberg G. Parental perspectives on preterm children's oral health behaviour and experience of dental care during preschool and early school years. Int J Paediatr Dent 2009;19:243-50.
Shawky S, Abalkhail B, Soliman N. An epidemiological study of childhood disability in Jeddah, Saudi Arabia. Paediatr Perinat Epidemiol 2002;16:61-6.
Alaki SM, Bakry NS. Dental pain in children with intellectual disabilities: Caregivers' perspective. Int J Dent 2012;2012:701608.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]