Oral health practices, status, and caries experience among the visually impaired children in Chennai

Research Article Oral health practices, status, and caries experience among the visually impaired children in Chennai Arunasree Vadaguru Mallikarjuna 1, P. Ragul 1, M. Dhanraj 2, Ashish R. Jain 2 * ABSTRACT Background: Oral health has strong biological, psychological, and social consequences because it affects aesthetics and communication, and the quality of life is influenced by oral health status. Good oral health is important for proper mastication, digestion, appearance, speech, and health. Oral health is linked to happiness and good general health, and there is evidence that aesthetically unacceptable and functionally inadequate dentitions affect self-esteem, confidence, and socialization. Aim: The aim of this study is to assess the oral health practices, status, and caries experience among the visually impaired children. Materials and Methods: A cross-sectional study was conducted in blind schools of Chennai city. A total of 143 individuals aged between 13 and 18 years were included in the study. Permissions were taken from the respective schools. Data were collected by structured interview of each individual with a questionnaire. Questionnaire related to their frequency of brushing, brushing technique, type of oral hygiene aids, and frequency of changing toothbrush, tongue cleaning, mouth rinsing, and visit to the dentist. Clinical examination was done to record decay missing filling-tooth (DMFT) and simplified oral hygiene index (OHI-S) indices, and the values were tabulated. Results: The oral hygiene practices vary from moderateto-low grade. The mean DMFT and OHI-S scores were 1.58 ± 0.829 and 1.21 ± 0.773, respectively. Frequency of visiting dentist, in which 9.3% of the children visited the dentist yearly once, 30.1% visited in case of any problem, and rest 60.5% never visited a dentist. Conclusion: This study observed oral health practices are moderate in visually challenged children. Therefore, improved planning is needed and health programs should be organized to provide oral health education and services for such special group. KEY WORDS: Oral hygiene, Toothbrushing, caries, Visually impaired INTRODUCTION Blindness is defined by the World Health Organization as: Visual acuity of <3/60 m or corresponding visual field loss in the better eye with the best possible correction, having a meaning that while a blind person could see a distance of 3 m, a non-visually impaired person could see 60 m. Visual impairment relates to a person s eyesight which cannot be corrected to normal vision. The WHO estimates that there are 40 million blind persons in the world. Visually impaired individuals cannot visualize the plaque on the teeth surface, so even understanding the importance of oral hygiene is difficult for them which result in progression of dental caries as well as inflammatory disease of Access this article online Website: jprsolutions.info ISSN: 0975-7619 the periodontium. [1] Oral health education has been shown to have a positive impact in decreasing plaque score. [2] Visual impairment may impact on oral health through physical social or information barrier related to the impairment, attendant medical conditions, or lack information in a suitable format. Other obstacles include lack of services, lack of transport, inadequate resources or financial considerations, lack of social awareness, or lack of education and training of service provider. [3,4] There are very few studies that have examined the health information needs of visually impaired individuals and even fewer have investigated the dental health information needs of this group. [5] About dental prescribing, the European Commission has recognized the need for pharmaceutical information to be more accessible to people with visual impairment. [6] This applies equally to a dentist who may be prescribing medications to visually impaired adults. Oral health is an important aspect of 1 Department of Prosthodontics and Implant Dentistry, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 2 Department of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Poonamalle High Road, Chennai - 600 127, Tamil Nadu, India. Phone: +91-9884233423. E-mail: dr.ashishjain_r@yahoo.com Received on: 22-02-2018; Revised on: 25-04-2018; Accepted on: 28-05-2018 1276

overall health, for all children, and is particularly more important for children with special health needs. The oral health of children who are visually impaired tends to be compromised as they are at a disadvantage and are often unable to adequately apply the techniques which necessary to control plaque. [7] Dental caries is the most prevalent disease among children worldwide and dental treatment is the greatest unattended health need of the disabled, particularly more so, in those with special health needs. [8] The presentation of caries is highly variable; however, the risk factors and stages of development are similar. The oral health of disabled people may be neglected because of a focus on their disabling condition, other major disease(s), or limited access to oral healthcare. It has been reported, dental treatment is the greatest unattended health need of the disabled. [9] Some of the reasons for this may be inadequate recall systems, practical difficulties during treatment sessions, the socioeconomic status of the disabled person, pain, underestimation of treatment needs, communication problems, and poor patient cooperation. Visual impairment was the most frequently occurring disability, followed by speech, hearing, movement, and mental disabilities 10. In poor societies, many disabled persons find it difficult to survive; nutritional status is very low, and services are inadequate, and hence, disabled people often live in extreme poverty, misery, and despair, leading to dependency and deprivation. [10] The prevalence of blind children globally is estimated to be 1.4 million, three-quarters of whom live in the poorest regions of Africa and Asia. [11] In low-income countries, the prevalence of childhood blindness may be as high as 1.5/1000 children. [12] Such a high prevalence, alongside poor management of resources, may result in huge impacts. Childhood blindness impacts negatively on longevity, with up to 60% of blind children dying within one year of losing their eyesight. [13] Earlyonset blindness may impact psychomotor, social, and emotional development thus adversely affecting the visually impaired young child. [11] Childhood blindness in developing countries is a result of acquired factors such as measles, ophthalmia neonatroum, traditional eye medicine, and especially corneal scarring related to malnutrition and vitamin A deficiency. [11] A study conducted in five camps for internally displaced people in Khartoum, Sudan, reported a prevalence of 1.4/1000 children suffering from blindness. In this case, the reported leading cause was corneal opacities (40%), from vitamin A deficiency, trauma, or measles. Opacities were followed by amblyopia (32.5%). [14] Due to the visual impairment, the children experience difficulty in maintaining oral hygiene as they are unable to visually comprehend the oral health practices.the aim of this study was to assess the oral health knowledge, practice, oral hygiene status, and the prevalence of dental caries among visually impaired children in a blind school in Chennai. Aim The aim of this study is to assess the oral health practices, status, and caries experience among the visually impaired children. MATERIALS AND METHODS The study was conducted in Government Higher Secondary School for Blind, in Chennai city. Permissions were taken from the respective schools. The study population comprised children studying in 6 th 10 th STD. Sampling technique used was convenient sampling technique. A total of 143 children were examined. Armamentariums used were as follows: No. 3 plane mouth mirror, No. 23 shepherds probe, and (WHO) CPI probe. The study tool comprised a questionnaire which was based on the three domains, namely, sociodemographic details, oral hygiene practices, and oral health status. A structured interview was conducted in their regional language. The questionnaire comprised following items: Frequency of brushing, Brushing technique, Type of oral hygiene aid used, Frequency of changing the toothbrush, Tongue cleaning, Mouth rinsing, and Visit to a dentist. Question-related to brushing technique was done by asking them to show the motion in which they brush and the type of brush was recorded by tactile sensation. Clinical examination was done by the examiner to check for the decay missing filling-tooth (DMFT) and simplified oral hygiene index (OHI-S) indices of Green and Vermillon (1964). [10] RESULTS A total of 143 blind school children were subjected to the study; wherein, 39 children were girl and 104 children were boy. An age group in the range of 13 18 years children were included in the study. The mean age was calculated to be 15.37 ± 2.14 years. Brushing frequency 53% children responded that they brushed twice a day, whereas 47% children answered that they brushed their teeth only once in the morning [Graph 1]. Oral hygiene aids used by the children to brush their teeth, 98% of children used toothbrush and toothpaste to brush their teeth, and only 2% used toothpowder to clean their teeth [Graph 2]. The type of toothbrush used by the children, in which around 1277

34.9% of the children used a hard type of toothbrush and only 25.6% of the children used soft type, 20.9% used medium type, and rest 18.6% never noticed [Graph 3]. The technique of brushing, 77% of the children used the horizontal motion of brushing, and 16% combined and 7% vertical motion of brushing technique [Graph 4]. The frequency of changing toothbrush, 76.7% of the children change their brush in <1 month, 14% of them change once in 3months, 2.3% change once in a year, and rest 7% change when flared [Graph 5]. The frequency of visiting dentist, in which 9.3% of the children visited the dentist yearly once, 30.1% visited in case of any problem and rest 60.5% never visited a dentist [Graph 6 and Table 1]. The oral hygiene practices vary from moderateto-low grade. The mean DMFT and OHI-S scores were 1.58 ± 0.829 and 1.21 ± 0.773, respectively [Table 2]. DISCUSSION According to the WHO visual impairment is defined as, visual acuity of <3/60 m or corresponding visual field loss in the better eye with the best possible correction which means that a visually impaired person can see up to 3 m distance, whereas a non-visually impaired person can see up to 60m distance. Dental disease is one of the common problems found in the community, oral healthcare is important to all normal individuals for proper mastication, digestion, appearance, and speech; however, it even more important for disabled individuals. The process of developing oral disease, prevention, and treatment modalities does not differ in disabled individual from normal individuals. A previous study in Mangalore, Karnataka, India, found a mean DMFT of 2.48 ± 2.02 in hearing-impaired and 5.92 in blind children (aged 6 to 18 years), which is high compared to the present study. In the same study, the mean dft was 2.6 ± 3.37 for hearing-impaired and 0 for visually impaired participants. [10] Broadly, similar findings came from a study in Davangere, Karnataka, which reported a mean DMFT 1.64 for the deaf, [15] and from another study in Bangalore, Karnataka, which reported a mean DMFT 2.1 for Graph 1: Brushing frequency Graph 4: Technique of brushing Graph 2: Oral hygiene aids used by the children to brush their teeth Graph 5: Frequency of changing toothbrush Graph 3: Type of toothbrush used by the children Graph 6: Frequency of visiting dentist 1278

Table 1: Oral hygiene practices in visually challenged children Question Option Percentage Frequency of brushing Twice daily 53 Once daily 47 Oral hygiene aids used by the children Toothbrush and toothpaste 98 Toothbrush and tooth powder 2 Types of toothbrush used by the children Hard 34.90 Medium 20.90 Soft 25.60 Never noticed 18.60 Technique of brushing Horizontal 77 Vertical 7 Combined 16 Frequency of changing toothbrush <1 month 76.70 Once in 3 months 14 Once in a year 2.30 When flared 7 Visiting the dentist Only in case of problem 30.10 Yearly once 9.30 Never 60.50 Table 2: DMFT and OHI S status in visually challenged children Index n Mean±SD DMFT 143 1.580.829 OHI S 143 1.210.773 DMFT: Decay missing filling tooth, OHI S: blind children. [16] A study conducted over 25 years ago in the United Kingdom (UK) reported a mean DMFT of 1.76 among the deaf, which is slightly lower than that found in the present study, whereas among blind it was 1.82, which is slightly higher than in the present study. [17] It was also evident that visually impaired children mostly went to the dentist only when their teeth hurt or when they had advanced oral problems. That might be lead to have a negative experience in the dental office. Due to a lack of information and preventive services, visually impaired adolescents had to receive more invasive and traumatic procedures. With lowintensity oral hygiene education and radical dental procedures performed by dentists, the children s knowledge and attitudes will always remain negative to the importance of oral health. Intensified focus on educational and preventive programs might help to keep those with disabilities from having negative dental experiences. [18-20] Patients with special needs would benefit from not only education about oral health but also improvements in their physical and social environment, which would have a major impact on oral well-being. [21] It is important to achieve some associated factors as well. Many children in this study appeared to have lacked important information about oral health and preventive methods. The most did not appear to know about the benefits of fluoride to dental health. Several factors, in addition to the oral health education programs, are known to be involved in the decrease of caries prevalence, such as fluoride in the drinking water, fluoridated toothpaste, and pit-fissure sealants, particularly in, disabled children. [22-24] Encouraging twice-daily use of fluoride toothpaste in high-risk children has the potential to close the dental health gap between disabled and not disabled children. Oral health education programs, nevertheless, are likely to be an important influence on the oral health of disabled children. [21,24] This study showed that visual impairment had moderate oral hygiene, consistent with previous studies. Visual impaired children were moderately knowledgeable about their oral care and did not realize the need to have regular dental visits. The percentage of children changing toothbrush in <1 month being so high tells us that most of them practice improper brushing technique. Most of them never visited a dentist. This indicates a lack of availability of oral health services for this disadvantaged population and intensive oral health initiatives should be galvanized to address this. CONCLUSION The practices pertaining to oral health was found to be moderate in visually impaired children. If dental health awareness programs are provided to the parents, caretakers, or the individuals at an early age, the incidence of dental caries can be prevented and oral health hygiene can be maintained. The present study shows that there is still room for prevention of oral diseases and little improvement in dental healthcare services can bring impressive results in reduction of dental caries and gingival diseases. REFERENCES 1. Mann J, Wolnerman JS, Lavie G. Periodontal treatment needs and oral hygiene for institutionalized individuals with handicapping condition. Special Care Dent 1984;4:173-6. 2. Zehaati H, Ghandhasi M, Motlagh M. An investigation on 1279

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