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Year : 2016  |  Volume : 14  |  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

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 Publication15-Mar-2016

Correspondence Address:
Sonal Kothari
C/o Sudarshan Chhajed, B-102, Ratnakar 2, Prerna Tirth Derasar Road, Satellite, Ahmedabad - 380 015, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-5932.178718

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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 2023 Dec 6];14:35-40. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2016/14/1/35/178718

  Introduction Top

The disabled form a substantial section of the society, and there are about 500 million people with disabilities worldwide.[1] 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.[2]

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.[3] 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.”[4]

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,[5] Belgium,[6] South Canara, India [7] and Udaipur, India [8] 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.[9],[10],[11]

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.[12] 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.[13],[14]

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 Top

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.[15] 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.

Statistical analysis

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 Top

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].
Figure 1: Age and gender distribution of mentally retarded subjects

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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].
Figure 2: Oral hygiene practices of mentally retarded subjects

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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 Top

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.[16] The mean OHI-S score for mentally disabled in the present study was found to be 2.51 similar to previous studies [8],[17],[18] Anders and Davis [19] 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.[20] The general increase in OHI-S scores with an increase in age group confirms with previous reports,[16],[21],[22] and this was found by Grants and Stern [23] 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.[8],[16],[24] 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.[24]

In the present study, male subjects had poorer oral hygiene than their female counterparts. Denloye [25] 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.[26] Similarly, Jain et al.[8] 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 [25] found high OHI-S score at the different age group of noninstitutionalized as compared to institutionalized while Tesini [16] reported contradictory findings. According to Denloye [25] 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.[19],[27],[28] Vigild [29] 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.[17] 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.[24]

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.[24] 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.[30] 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.[31] 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.[32]

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 Top

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 Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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