Comparative oral health of children and adolescents with cerebral palsy and controls

Transcription

1 Journal of Disability and Oral Health (2011) 12/ Comparative oral health of children and adolescents with cerebral palsy and controls Folakemi A Oredugba BDS FWACS MPH M SND RCS Ed Department of Child Dental Health, College of Medicine, University of Lagos, Nigeria Abstract Objective: To determine the oral health condition of children and adolescents with cerebral palsy (CP) and compare with controls of the same gender and age group. Method: Participants in this study were children and young adults with CP attending three, day institutions for individuals with disabilities. A questionnaire was used to obtain information on their bio-data, such as age, gender and educational background of parents. An oral examination was then carried out to assess dental caries, oral hygiene status, gingivitis, malocclusion and other dental anomalies. They were compared with controls of the same age and gender who attended primary and secondary schools in the same area. Results: 139 subjects aged 4-19 years (mean ± 4.36), comprising 69 (49.6%) subjects with CP, 70 (50.4%) controls; 52 (37.4%) females and 87 (62.6%) males participated in the study. The mean dmft and DMFT of the CP group was 1.03 ± 2.5 and 1.3 ± 2.94, respectively whilst that of controls was 0.21 ±0.65 and 0.13 ±0.47, respectively. Oral hygiene was good in 36.2% of CP and 68.6% of controls, and poor in 29.0% of CP group compared with 11.4% of controls (p=0.00). Angle s Class II malocclusion was found in 19 (27.5%) of the CP group and 1 (1.4%) of the controls (p=0.00). Seven (10.1%) of the CP group had fractured teeth while crowding, spacing of the anterior segment and gingivitis were more prevalent in the CP group. Conclusion: Individuals with CP have poorer oral health than controls and are not provided with needed oral health care. Key words: Cerebral palsy, oral health, children, adolescents Introduction Cerebral palsy (CP) is a neuromuscular disorder. It is defined as a group of disorders of development of movement and posture, causing activity limitations that are attributable to non-progressive disturbances, which have occurred in the developing foetal or infant brain. Such disturbances include hypoxia, trauma, infection, and hyperbilirubinaemia, but biochemical and genetic factors may be involved (Scully and Cawson, 2005). The motor disorders of CP are often accompanied by disturbances of sensation, cognition, communication, perception, and/or by a seizure disorder (International Workshop on the Definition and Classification of Cerebral Palsy: Bax et al., 2005). CP may be classified into three main groups (Dougherty, 2009): Spastic (characterised by increased muscle tone) Dyskinetic (characterised by hypotonic, slow writhing movements (athetotic), abnormal postural control, swallowing difficulties, problems of speech and coordination) Ataxic (characterised by involuntary movement, lack of balance and depth perception). Intellectual disability is present in a significant proportion of individuals with CP, though the degree is variable (Bax et al., 2005; Jones et al., 2007; Thorogood and Alexander, 2007). The neuromuscular problems inherent in CP can affect oral health significantly, such as changes in structure of the orofacial region, development of para-functional habits, feeding problems, difficulty with maintaining oral hygiene and encountering barriers to oral care access (Dougherty, 2009). People with CP are reported to have poor oral hygiene and increased prevalence of dental caries, bruxism (Pope and Curzon, 1991; dos Santos et al., 2003), malocclusion (Franklin et al., 1996; Winter et al., 2008) and drooling (Tahmassebi et al., 2003; Mathur et al., 2008) and traumatic dental injuries (Holan et al., 2005). While several authors agree on the high prevalence of poor oral hygiene (Nunn and Murray, 1987; Pope and Curzon, 1991; dos Santos et al, 2003; dos Santos and Nogueira, 2005), conflicting reports are observed in the literature concerning dental caries and traumatic dental injuries experience of this group of individuals. Some authors reported increased prevalence of dental caries (dos Santos et al., 2003; De Carmago and Antunes, 2008; Stevanovic and Jovicic, 2004), while some oth-

2 82 Journal of Disability and Oral Health (2011) 12/2 ers found a lower prevalence than in the populations without CP (Nielsen, 1988). Some authors attributed the high prevalence of dental caries to prolonged use of medications such as anticonvulsants, which have high sugar content, are viscous and taken at night (Chambers et al, 1999; Siqueira et al., 2007). At night, the oral ph falls below the critical ph at which demineralisation occurs. In a study carried out in Brazil, the high caries prevalence was attributed to poor socioeconomic conditions, irrespective of type of CP, and a high frequency of sugar consumption (De Carmago and Antunes, 2008). Previous studies carried out in Nigeria on the oral health of children with multiple disabilities showed poorer oral hygiene and more untreated decay (Oredugba and Sote, 2001; Oredugba and Akindayomi, 2008). This study was carried out to assess the oral health condition and treatment needs of children and adolescents specifically with CP and to compare findings with that of healthy controls in the same environment. Greene and Vermillon (1964) with a total score of 6. When the index score was 0-0.9, oral hygiene was classified as good, (fair) and 2.0 and above (poor). Malocclusion was assessed using Angle s classification of malocclusion (Class I, Class II and Class III). Other parameters examined include gingivitis, hypoplasia of the teeth, dental staining, supernumerary teeth and congenitally missing teeth. Subjects were divided into age groups: up to 5 years, 6-10 years, years and years. To determine reliability of data collection, questionnaire was pre-tested on ten, randomly selected subjects. The data collected were analysed using the health statistical software - Epi Info version 6a. Findings were compared across the CP group and controls, by age group and gender, using descriptive statistics, student s t-test, chi square test, Kruskal-Wallis H test and Fisher exact test where appropriate, with a significance level set at p = Materials and method Subjects were children and young adults in three day centres for individuals with disabilities. Consent was obtained from head teachers and parents prior to oral examination of the children. Permission was also obtained from the Research, Grants and Experimentation Ethics Committee of the College of Medicine of the University of Lagos. All parents or guardians were requested to read and sign a consent form and complete a questionnaire (Appendix I) on their children. All children and young adults who returned completed and signed consent forms and a completed questionnaire and were present in the centre at the time of study were examined. Those who reported ill were excluded from participation on that day. Information required from the questionnaire included child s age, gender, previous use of dental facilities, frequency of tooth brushing, prescribed medications being used, parent s educational background and occupation. Socioeconomic background was determined by classifying the educational level of the mother, and where she did not reside with the child, that of the father, into: Upper class Code 1- those who attended tertiary education Middle class Code 2- those who had up to secondary school education Lower class Code 3 those who had primary school education or no education. Thereafter, each subject was examined by one examiner, under natural daylight in the different centres, for dental caries, using the decayed, missing and filled tooth (dmft) index for the primary dentition and Decayed Missing and Filled Teeth (DMFT) index for the permanent dentition. Oral hygiene was assessed using the simplified oral hygiene index (OHI-S) of Results A total of 139 subjects, 69 (49.6%) with CP and 70 (50.4%) controls participated in this study. There were 52 (37.4%) females and 87 (62.6%) males, aged 4-19 years, mean age ± 4.36 (Table 1). Parents of the majority of the subjects (49.6%) were of low socioeconomic background. Only 12 (8.6%) from the total population under study had visited the dentist previously, comprising 11 (15.9%) of the CP group and 1 (1.4%) of the controls (Chi sq 7.53; p= 0.006). The mean dmft of the CP group was 1.03 ± 2.5 while that of controls was 0.21 ± 0.65 (p=0.01). The mean DMFT of the CP group was 1.3 ± 2.94 and the controls 0.13 ± 0.47 (p=0.00). The major component of both the dmft and DMFT

3 Oredugba: Comparative oral health in cerebral palsy and controls 83 was the decayed components; the mean number of decayed primary teeth was 1.01 ± 2.32 and 0.2 ± 0.52 (p=0.06) while the mean number of decayed permanent teeth was 1.1 ± 2.17 and 0.11 ± 0.42 in CP and controls, respectively (p=0.00). (Table 2). The mean dmft and DMFT values according to age group is shown in Figure 1. The mean dmft was 1.92 ± 2.49 in the upper SEC of the CP group compared with 0.14 ± 0.28 in the lower SEC. The mean DMFT value was however, higher in the lower SEC of the CP group (1.71) compared with 0.67 in the middle SEC (p=0.00). (Table 3). The mean OHI-S in the CP group was 1.48 ± 1.23 while that of controls was 0.92 ± 0.84 (K-Wallis test 10.76; p=0.00). Oral hygiene was good in 68.6% of controls and 36.2% of the CP groups while oral hygiene was poor in 11.4% of controls compared with 29.0% of the study group (p=0.00) (Table 4). The mean OHI-S score was 0.78 ± 0.56 in the upper SEC of the CP group compared with 2.32 ± 1.39 in the lower SEC (Table 5). Oral Hygiene was good in 67.3% of females compared with 43.7% of males. Figure 2 shows the oral hygiene status according to the different age groups in the CP group. An Angle s Class I occlusion was found in 48 (69.9%) of controls and 65 (92.9%) of the CP group, while Class II malocclusion was found in 19 (27.5%) of the CP group and 1 (1.4%) of controls (p=0.00). An Angles Class II Division 1 malocclusion was found in 9 (47.4%) of the 19 affected young people in the CP group and an Angles Class II Division 2 malocclusion in 10 (52.6%) young people (Table 6). A total of 7 (10.1%) of the CP group had fractured teeth. None were found in the controls. Crowding and spacing of the anterior segment was also more prevalent (18.8% and 17.4%) respectively, in the CP group versus the controls (p=0.00). Gingivitis was found in 37.7% of the CP group and 24.3% of controls, although the difference was not significant (p=0.12) (Figure 3). However, significantly more males (40.2) than females (15.4) had gingivitis (p=0.00). Table 1 Demographic characteristics of the study population Variable CP group Control Total Age (years) Range 4-19 Mean 11.42± ± ±4.36 Age group <5 10 (14.5) 10 (14.3) 20 (14.4) (31.9) 22 (31.4) 44 (31.7) (24.6) 20 (28.6) 37 (26.6) (29.0) 18 (25.7) 38 (27.3) Gender Female 24 (34.8) 28 (40.0) 52 (37.4) Male 45 (65.2) 42 (60.0) 87 (62.6) Socioeconomic Class Upper 17 (85) 3 (15.0) 20 (14.4) Middle 23 (46) 27 (54) 50 (36) Lower 29 (42) 40 (58) 69 (49.6) Previous dental visit Yes 11 (15.9) 1 (1.4) 12 (8.6) No 58 (84.1) 69 (98.6) 127 (91.4) Total 69 (49.6) 70 (50.4) 139 (100) Table 2 Mean decayed, missing and filled teeth (dmft/dmft) according to study groups Index CP group Control dmft 1.03± ±0.65 p =0.01* DMFT 1.3± ±0.47 p=0.00* Decayed (d) 1.01± ±0.52 p=0.06 Decayed (D) 1.1± ±0.42 p=0.00* *Significant

4 84 Journal of Disability and Oral Health (2011) 12/2 Figure 1. Mean dmft / DMFT according to age group in the CP group Table 3 Mean dmft / DMFT of the study population according to socioeconomic class Group Upper class Middle class Lower class dmft Study 1.92± ± ±0.28 p= 0.01* Control ± ±0.78 p = 0.72 DMFT Study ± ±2.44 p=0.00* Control ± ±0.19 p=0.29 *Significant Table 4 Oral hygiene status of the study population Group Good OH Fair OH Poor OH Total N (%) N (%) N (%) N (%) CP group 25 (36.2) 24 (34.8) 20 (29.0) 69 (49.6) Controls 48 (68.6) 14 (20.0) 8 (11.4) 70 (50.4) Total 73 (52.5) 38 (27.3) 28 (20.1) 139 (100.0) Chi square P 0.00* (Significant) Table 5 Mean OHI-S score of the study population according to socioeconomic class (SEC) Group Upper SEC Middle SEC Lower SEC CP 0.78± ± ±1.39 Chi square =24.57; p=0.00* Control 0.8± ± ±0.87 Chi square=0.54; p=0.76 *Significant

5 Figure 2. Oral hygiene of the CP group according to age group Oredugba: Comparative oral health in cerebral palsy and controls 85 Table 6 Angle s classification of malocclusion in the study population Study group Angles I Angles II ( Div 1 Div 2) Angles III Total N (%) N (%) N (%) N (%) N (%) CP group 48 (69.6) 19 (27.5) (9 (47.4) 10 (52.6)) 2 (2.9) 69 (49.6) Controls 65 (92.9) 1 (1.4) 1-4 (5.7) 70 (50.4) Total 113 (81.3) 20 (14.4) 6 (4.3) 139 (100.0) CP group only: Chi sq 7.68 P 0.02* Overall Chi sq and p = 0.00* Figure 3. Other anomalies observed in the study population

6 86 Journal of Disability and Oral Health (2011) 12/2 Treatment needs Restorative treatment, including amalgam and glass ionomer cement restorations for carious teeth and composite restoration of fractured anterior teeth was required by 41% of the CP group, while 39.7% were thought to benefit from orthodontic treatment. Up to 63.8% of the CP group also required oral prophylaxis and hygiene instructions. Discussion Children and adolescents with CP in this study had higher mean dmft/dmft than controls. This finding is similar to previous studies (dos Santos et al., 2003). Some authors did not however, observe any significant difference in caries rate between CP individuals and controls but found more untreated decay than in controls (Pope and Curzon, 1991). Contributory factors might be poor masticatory muscular control which encourages food stagnation in the buccal and labial sulci and poor manual dexterity as observed in most individuals with CP. Another contributory factor for an increase in dental caries is that many of the children are on sweetened medications to control seizures and other medical problems. The most commonly prescribed anticonvulsant in our environment is Carbamazepine, which most parents claimed they used for their children. Most of the parents also reported using some un-disclosed herbal medicines. Prescribed anticonvulsants are sweetened, highly viscous and used at night, which enhances the progression of dental caries (Siqueira et al., 2007). However, from this study, it was not possible to determine the effect of these medications on dental caries because there were inconsistent reports on type and dose of medication. The mean dmft value was also found to be higher in the CP group from the higher social class while the DMFT was significantly higher in the lower social class. Apart from the effect of sweetened medications, cariogenic drinks and snacks are also affordable by parents of the high social class to pacify and pamper their young children. With increasing age, proper surveillance on diet and oral care reduces, especially in children of the lower social class. Parents of high social class may be able to afford caregivers for their children, which may not be possible with those from the lower socioeconomic class. Oral hygiene was also found to be significantly poorer in the CP group than controls in this study, especially with increasing age. Several studies have also reported poor oral hygiene in individuals with CP (Nunn and Murray, 1987; Pope and Curzon, 1991; dos Santos et al., 2003; dos Santos and Nogueira, 2005). The general effects of CP on these individuals make tooth brushing difficult. At the early age groups, they are dependent on parents and caregivers for tooth brushing and other general body care. As they age, they are left alone to carry out these daily activities, which may not be done effectively. In this study, nearly all the subjects cleaned their mouths only once a day. The most important factors in the maintenance of good oral hygiene are the frequency and effectiveness of tooth brushing and ability to control the masticatory musculature, which are all deficient in this population. Parents and caregivers need to be advised on oral health issues concerning themselves and their wards, and that these individuals require supervision despite their age. In a Turkish study by Subasi et al (2007), it was observed that mothers irregular tooth brushing habit was a risk factor for their children s lack of a regular brushing habit. Many of these subjects will benefit from assistive devices such as electric toothbrushes and toothbrushes with large handles. Although gingivitis was more prevalent in the CP group, the difference was not significant (p=0.12). The prevalence of gingivitis was however significantly higher in males than in females (p=0.00). Mouth breathing and food pouching contribute to gingivitis especially in the anterior region in individuals with CP (Scully and Cawson, 2005). Periodontal disease has been reported to be common especially in older children with CP due to poor oral hygiene and complications of oral habits, physical disabilities, malocclusion and gingival hyperplasia caused by medications (National Institute of Dental and Craniofacial Research, 2004). Mouth breathing worsens the periodontal state and a papillary hyperplastic gingivitis may be seen even in the absence of phenytoin (Scully and Cawson, 2005). Early routine oral care and close supervision will prevent the untoward consequence of periodontal disease. There was a significantly higher prevalence of class II malocclusion among subjects in the CP group in this study, as was found in previous studies (Franklin et al., 1996; Winter et al., 2008). Only 47.4% of those with class II malocclusion had a class II division 1 malocclusion, in contrast to these previous studies which reported a higher prevalence of this type of malocclusion. This difference in the findings may be due to the smaller number of subjects examined in this study. There was also a high prevalence of crowding of the lower and spacing of the upper anterior segments. The class II malocclusion has been attributed to hypotonia of the orofacial musculature and forward thrust of the tongue (Pope and Curzon, 1991; dos Santos et al., 2003). This type of malocclusion predisposes to trauma of the anterior teeth, in addition to the poor gait and seizures (Dougherty, 2009). The act of placing metal objects in the mouth of children who experience seizures is still rampant in Nigeria. These objects can cause fractures and sometimes avulsion of the anterior teeth. This practice is being discouraged during oral health education programmes. Subjects with CP in this study showed a higher prevalence of crowding, spacing and anterior open bite. These

7 Oredugba: Comparative oral health in cerebral palsy and controls 87 are all problems associated with abnormal positioning of tongue and cheek musculature, which are common in such individuals. Myotherapy and orthodontic appliances may help in relieving some of these anomalies in carefully selected subjects. From this study, 41% required restoration of carious and fractured teeth, 39.7% some form of orthodontic treatment and 63.8% oral prophylaxis. This treatment need is quite significant and it shows that individuals with disabilities are still not able to access required oral health care, especially since quite a number had attended the dental clinic previously. Although more subjects in the CP group attended the clinic than the controls, it was observed that these individuals only attended the clinic for emergencies. Behaviour management can be a challenge for dentists, as was reported in a previous study on Nigerian dentists (Oredugba and Sanu, 2006). Provision of dental treatment can be made more comfortable for both the patient and dentist through the use of mouth props, stabilisation and postural maintenance with cushions and physical interventions adapted for the individual patient (Dougherty, 2009). Dental professionals should be provided with such assistive devices in the clinics that will enhance effective behaviour management. This disability should also not be a barrier to receiving advanced restorative and orthodontic care which will eventually reduce discomfort and improve mastication. Orthodontic treatment can be provided to such patients where there is cooperation and support from the parent and / or caregiver. The introduction of institutional/community outreach in some dental schools in Nigeria will go a long way in addressing the issue of better access to care, which should also be extended to other dental institutions (Oredugba and Akinwande, 2008). It is concluded from this study that individuals with CP have poorer oral health and greater treatment needs than controls and have not received needed oral health care. Acknowledgments The author appreciates the cooperation of head teachers and parents of the special schools visited during this study. References Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, Jacobsson B, Damiano D. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol 2005; 47: Chambers HG, Weinstein CH, Mubarak SJ, Wenger DR, Siva PD. The effect of valproic acid on blood loss in patients with cerebral palsy. J Pediatr Orthop 1999;19: De Camargo MA, Antunes JL. Untreated dental caries in children with cerebral palsy in the Brazilian context. Int J Paed Dent 2008; 18: Dos Santos MTBR, Masiero D, Novo NF, Simionato MR. Oral conditions in children with cerebral palsy. J Dent Child 2003; 70: dos Santos MTBR, Nogueira MLG. 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Pediatr Dent 1999; 13: Scully C, Cawson RA. Neurological disorders I: Epilepsy, stroke and craniofacial neuropathies. In: Medical Problems in Dentistry. 5th Edition. pp Elsevier, Churchill Livingstone, Siqueira WL, dos Santos MT, Elangovan S, Simoes A, Nicolau J. The influence of Valproic acid on salivary ph in children with cerebra palsy. Spec Care Dentist 2007; 27: Stevanovic R, Jovicic O. Oral health in children with cerebral palsy. Srp Arh Celok Lek 2004; 132: Subasi F, Mumcu G, Kokksal L, Cimilli H, Bitlis D. Factors affecting oral health habits among children with cerebral palsy: pilot study. Pediatr Int 2007; 49: Tahmassebi JF, Curzon MEJ. Prevalence of drooling in children with cerebral palsy attending special schools. Dev Med Child Neurol 2003; 45: Thorogood C, Alexander MA. Cerebral Palsy: emedicine. Available at: Accessed December Winter K, Baccaglini L, Tomar S. A review of malocclusion among individuals with mental and physical disabilities. Spec Care Dent 2008; 28: Address for correspondence: Dr F Oredugba Department of Child Dental Health College of Medicine University of Lagos PMB Nigeria fola_ored@yahoo.com