Article ID: WMC004539 ISSN 2046-1690 Dental Caries Status And Oral Health Needs among Disabled Children Living In Care Centers In Kathmandu Valley, Nepal Peer review status: No Corresponding Author: Dr. Jemish Acharya, Lecturer, Community Dentistry,Nepal Medical College, GPO 8975,EPC 6004 - Nepal Submitting Author: Dr. Jemish Acharya, Lecturer, Community Dentistry,Nepal Medical College, GPO 8975,EPC 6004 - Nepal Other Authors: Ms. Natkamol Chansatitporn, Assistant Professor, Mahidol University,Biostatistics, Mahidol University,\nThailand - Thailand Dr. Kulaya Narkasawat, Associate Professor, Mahidol University,Epidemiology, Thailand - Thailand Article ID: WMC004539 Article Type: Original Articles Submitted on:06-feb-2014, 07:24:54 AM GMT Article URL: http://www.webmedcentral.com/article_view/4539 Subject Categories:DENTISTRY Published on: 06-Feb-2014, 10:15:53 AM GMT Keywords:Dental Caries Status,Differently abled Children,Oral Health Needs How to cite the article:acharya J, Chansatitporn N, Narkasawat K. Dental Caries Status And Oral Health Needs among Disabled Children Living In Care Centers In Kathmandu Valley, Nepal. WebmedCentral DENTISTRY 2014;5(2):WMC004539 Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None Competing Interests: None WebmedCentral > Original Articles Page 1 of 13
Dental Caries Status And Oral Health Needs among Disabled Children Living In Care Centers In Kathmandu Valley, Nepal Author(s): Acharya J, Chansatitporn N, Narkasawat K Abstract Various attempts are being made to better the situation of dental caries in Nepal, nevertheless, the problem of caries among differently abled children still seems to have reached a still. The general objective of this study is to identify the dental caries status by prevalence and severity (DMFT), knowledge and attitude in oral health practices and the oral health needs among differently abled children aged 12-15 age group living in care centers in Kathmandu, Nepal. It is a cross sectional study with 120 respondents. Data was collected using constructed questionnaire and analyzed using percentage, arithmetic mean, standard deviation, Chi square using level of significance at 0.05 and Mann-Whitney test. There was significant association between the type of disability and DMFT scores of the children. The dental caries prevalence in the study population was 98.3% and the mean DMFT of the children was 4.80±3.01.56.90% in case of physically disabled children and 34.50% of children showed "high" severity of dental caries.95% of the children needed treatment, the decayed component being the highest area of treatment need. The means of knowledge, attitude and practice were 5.57±1.72, 19.95±4.95 and 5.10±1.99 respectively. There was significant difference of means of DMFT by the type of disability of children. Sensory disabled children had higher mean (2.48±0.65) than physically disabled children(2.06±0.79).based on the analysis it was seen mandatory that special attention be given to disabled children to improve the dental caries status and their knowledge, attitude and practice.it is also suggested that along with encouraging oral health education programs, it was necessary that their treatment needs be fulfilled. Introduction Dental caries have historically been considered the most important part of the global burden of oral diseases. Oral health is an essential part of the general health and well being of an individual. Dental caries is a chronic infectious diseases caused by bacterial by products that dissolve on the enamel surface of teeth. It has been found that 60-70% of schoolchildren all over the world suffer from dental cavities and 99% of adults have dental caries.(1)the World Health Organization along with the FDI World Dental Federation founded a goal in the year 2000 for oral health was the to have 50% of the 5-6 years old children caries free and the global average of DMFT in 12-13 years old to be no more than 03(2).According to the World Health Organization, between 110 million (2.2%) and 190 million (3.8%) people 15 years and older have significant difficulties in functioning and have been referred to as people with who are differently abled. In Nepal, 1.2% of the total population is living with some kind of physical disability. Out of that the major affected age group is seen to be the children with 33.3% having dental problems and were living with some kind of disability.(2).studies on other populations showed that differently abled people had more dental diseases and unmet dental problems compared to their normal counterparts.(3). The aims of this study were to assess the dental caries status, treatment needs and their oral health behavior among differently abled children of age group 12-15 and their associations with caries status inclusive of hearing/vision/speech disability in organizations in Kathmandu Valley, Nepal. The results of the study will be used to plan oral health interventions to promote preventive behavior for the prevention and control of incidence of dental caries and to plan oral health education programs to update their knowledge on oral diseases. Methods A cross sectional study was carried out among differently abled children living in care centers aged 12-15 years old in Kathmandu valley in Nepal. The aims of the study were to assess the dental caries status, treatment needs and oral health behavior of the children. The study was conducted in non government care centers in Kathmandu Valley, Nepal responsible for taking care of differently abled children of various WebmedCentral > Original Articles Page 2 of 13
age groups. From the total of 80 organizations in Kathmandu Valley, purposive sampling was done and 2 basic organizations for the study was selected.from the organization all the children were included based on the selection criteria comprising of children with physical impairment and sensory impairment. Differently abled children aged 12-15 years old living in the care centers were the target population. The same size was calculated using and the minimum sample size was derived as 109. An excess of 20% was taken to cover withdrawal issues and a total of 120 children were studied. Questionnaire data collection was done using 30 close ended questions after the survey protocol was reviewed and approved by the ethical committee followed by clinical examination. A pre test was conducted among 20 children in an organization to assess the reliability of the questionnaire using Cronbach's coefficient of alpha test(4). Only questions scoring > 0.7 were approved for conducting the interview. Standardization for the collection of data for oral health examination, questionnaire and a demonstration of examination and recording of data was done. For the hearing and speech impaired children, they were to fill out the questionnaire on their own by reading it. Assistance was provided by sign-language experts in case the children had doubts regarding any of the questions.for the vision impaired children, oral interview was conducted. After finishing the questionnaire interview, the examination for dental caries was conducted using the DMFT Index and the modified Oral health assessment form given by World Health Organization(5). Only permanent teeth were considered excluding all permanent third molars, if present. After this, the treatment needs of the children were assessed as per the dental caries status of the children. The study initiated after obtaining ethical approval from the Ethical Committee. Informed consent for the children was obtained from the authority of the care centers as the children were orphans and a No Objection letter "was obtained as a form of approval. It was explained that the children had the right to refuse and/or withdraw from the study at anytime without the need for any kind of explanation on their behalf. Differenly abled children aged 12-15 years old living in care centers in Kathmandu valley, Nepal who were able to read and write were included in the study. Children with visual disability who were able to communicate orally in local language were also included. However, those who were unable to communicate by the above mentioned means and those with mental disability were excluded. Statistical Analysis Descriptive statistics and frequency distribution was calculated. Chi-Square tests were used to test the differences of proportion. P-value less that 0.05 was accepted as statistically significant. Mann-Whitney Test to compare the means of the types of disability/gender and severity of dental caries was done. Data was analyzed using the Statistical Package for Social Science (SPSS 16.0). Results 120 differently abled children were studied out of which 58(48.3%) were physically disabled, 58(48.3)% were sensory disabled and 3% presented with both physical and sensory disability. Out of the total population, 24.2% were 12 years old,30.8% were 13 years old,16.7% were 14 years old and 28.3% were 15 years old. Among the 120 children 55.8% were males and 44.2% were females. The education status of these children presented with 34.2% having education above the Secondary Level of Education,39.2% at secondary level,18.3% at primary level and 8.3% did not have any formal education at the time of the study 98.3% of the Children had at least 1 score of DMFT. For analyzing the dental caries status, the severity of dental caries was taken into reference and categorized as <1.26= "Low", 2.7-4.3="Moderate" and >4.4="High". For analyzing the dental caries status, the severity of dental caries was taken into reference and categorized as <1.26= "Low", 2.7-4.3="Moderate" and >4.4="High". Out of 118 children with caries,45.8% of them were in the high severity group, 36,7% in the moderately affected group,13.3% in the low severity group and 4.2% in the very low severity group. The grouping was done according to the WHO standards of dental caries severity index. Mean DMFT was 4.80±3.01 teeth per child. The highest fell in 3.6.±3.14 with maximum of 17 teeth in one child. The mean missing teeth was 0.16±0.45 per child and the mean no of filled teeth was 1.04±0.81 per child.the maximum number of filled teeth in one child was 4 in number. Among the total children, the average number of teeth examined in each child was 27.7.The proportion of teeth needing treatment out of the total 120 children was 114(95% ). From this,92.5% required fillings in their teeth whereas 2.5% needed rehabilitative care in the form of a fixed or removable partial denture for their missing teeth.regarding the decayed component WebmedCentral > Original Articles Page 3 of 13
of teeth in the children, it was seen that 12.5% of the teeth each child required fillings. Out of this 167 teeth(10.4%) were decayed in children with physical disabilities. Among the sensory disabled children, 246(15.1%) of teeth needed fillings. The mean score for knowledge was 5.57±1.72 per child and for attitude was 19.95±4.95per child.the mean score for practice was 5.10±1.99 per child. The results summarized that the percentage of correct answers obtained from the children on their knowledge of the etiology of dental caries ranged from 12.50% to 80%. Least knowledge was obtained regarding Fluoride at 12.50%. In terms of attitude, good attitude was shown towards prevention of dental caries by 41.70% of the children. 65.40% of the children answered that they brushed their teeth twice everyday.however, only 29.20% of the children said that they go to visit the dentist once every six months showing poor utilization of services. Chi-Square tests were applied to find the association between these categorical items of the general characteristics and the dependent variable The results showed that 55.2% of children aged 12 years fell in the "High" caries group.males presented with 46.3% falling in the "High" caries group.. Among the disability types, sensory disabled children had "High" caries of up to 56.9% of the children falling in this group. Children with both types of disability were not included in the analysis as only 4 children belonged to that particular group. The knowledge and attitude of the children was regrouped into" Good-Fair(6-10) and "Poor(1-5) for knowledge and "Good-Fair (21-230)" and Poor(10-20) for attitude for the purpose of analysis.the new cut off point was taken as per their respective means. 57.4% of the children having "Poor" Knowledge fell into the "High" caries group while 43.6% of children having poor attitude fell into the "High" caries group. This was not statistically significant. The DMFT status among disabled children when compared with the gender and types of disability gave varied results. In males the mean was 2.29±0.73 per child and 2.26±0.76 per child in female.this was not statistically significant. Normality test using Kolmogorov-Smirnov test was performed and the distribution was not normal in both gender and type of disability. In the types of disability, comparison of the dental caries status between physical and sensory disability was considered and the mean DMFT was higher among children with sensory disability. On performing Mann-Whitney Test, it was seen that the mean was 2.06±0.79 per child and 2.48±00.65 per child in physical and sensory disabled children respectively. This was statistically significant. Discussion The aim of this study was to assess the dental caries status, treatment needs and their oral health behavior among differently abled children of age group 12-15 living in Kathmandu Valley, Nepal. In the present study, the prevalence estimate for caries was higher among the sensory disabled than among the physically disabled children significantly. The results of the study showed a very high proportion of dental caries among differently abled children with a high 98.3%. This has been in approximate with past studies that revealed the dental caries prevalence among disabled children aged 9-12 years as having 93.1% and 13-17 years having prevalence of 88.37% (6). The severity of dental caries was used to assess the associations between the factors due to the high prevalence in the caries proportion. The high DMFT score can be because of poor dental service utilizations in part of the children as the results to the question "do you go to a dentist for routine check up once every six months?" resulted in only 29.20% answering the positive answer where as 46.70% of the children said that they "go to a dentist only when they have pain in their teeth". Normally, age has been found as a significant factor in determining the dental caries status among children. Adolescents are found to be more aware of their aesthetics and health contributing to the lower prevalence of dental caries in their age as compared to that younger children. The mean DMFT in this study was 4.80±3.01 per child which showed was very high.this was close to the results in a study conducted in Belgaum, India where in the mean DMFT per child in males was 3.48 and in females it was 3.98 (7) In terms of the type of disability, children with sensory disability had higher prevalence of caries and 56.9% of them fell in the "High" caries group compared to the 34.9% of physically disabled children in this group. This was concurrent with another study where in the decayed component was highest in sensory disabled children conducted in Iran. The reason behind this would be explained by their inability to communicate asking for treatment and the problems faced by them when explaining their problems compared to physical disabled children.contributory factors include inadequate funding and resources, insufficient trained dentists to treat patients with disabilities, and complex treatment needs requiring special care or general anesthesia. Majority of questions of knowledge, attitude and practice was not answered correctly by WebmedCentral > Original Articles Page 4 of 13
the children. Only 12.5% of the children answered correctly regarding the benefits of fluoride.this was contrary to the results of a study in Kuwait wherein 20% of the children studied knew about fluoride but were not sure if they were using it (8). Besides knowing that toothbrush should be used to clean their teeth only 36.70% of children used toothbrush and the remaining used toothpowder to clean their teeth. When seen from a comparative point of view this was not similar to a study conducted in Nepal to assess the KAP of children with no form of disability where 100% of them were using toothbrush (9). The findings in this study clearly demonstrates the picture of the dental caries status of the disabled children in Nepal which is well below the global goal of WHO to have the DMFT of children 12 years of age to be below 3 per child(1). Especially, regarding the differently abled population, the fact that this being the first study of its kind brings into notice the negligence this population has been facing for long. The services are available but due to a lack of knowledge and awareness in the society, the practice of going to the dentist for preventive care or the utilization of the available dental services are not very well seen. Conclusion(s) This was a cross sectional study done among differently abled children living in a care centre in Jorpati, Kathmandu,Nepal. The aims of this study were to assess the dental caries status, treatment needs and their oral health behavior among children of age group 12-15 living with disabilities and their associations with caries status inclusive of hearing/vision/speech disability in organizations in Kathmandu Valley, Nepal. However, by the nature of cross sectional study,the associations cannot be implied as being "causal".a follow up study has to be done to determine the causation of dental caries status by the independent variables involved in this study.the results from using purposive sampling produced unequal distribution of age and type of disability in this study. This affected the results of this study. It can be recommended to use one age group and one kind of disability in further studies.the answers given by the children could have been also subjected to recall bias. Some possible measures that can be followed to improve the dental caries status of the disabled children in Kathmandu valley,nepal are in terms of providing special focus to provide treatment to disabled children as per their special requirements. Training and oral health educations for the professionals so as to handle differently abled individuals would be highly helpful for the same. Different treatment needs of the children should be provided keeping in mind the kind of disability they suffer from. Provision of oral health education and their frequency is on the rise at present in Kathmandu. However, as mentioned earlier, they are generally aimed for the general population. Disabled children should be focused to educate them regarding the prevention, etiology and treatment of dental caries as this would be helpful in reducing further increase in the dental caries index among them. Acknowledgement(s) This study succeeded by the attentive support of several individuals in some way extended their valuable assistance and help in its preparation and completion. I would like to express profound gratitude to Asst.Prof. Natkamol Chansatitporn and Co-preceptor Associate Prof. Dr. Kulaya Narksawat for the continuous support and valuable amount of their time without which this study would not have been complete. My sincere appreciation and heartfelt gratitude to Mr. Radheshyam Shrestha,Senior Administrative Officer, Nepal Disabled Association. References 1. World Health Organization. World Health Statistics 2008; Health Service Coverage (Includes oral health coverage by country for 1990-1999 and 2000-2006). 2. Country profile on Disability,Kingdom of Nepal;Japan International Cooperation Agency Planning and Evaluation Department 2002. 3. Akindayomi F. Oral health status and treatment needs of children and young adults attending a day centre for individuals with special health care needs. BMC Oral Health. October 2008. 4. WHO. Oral Health Survey:Basic Methods. 4th ed. Geneva 1997 5. Daniel WW. Biostatistics: A Foundation for Analysis in the Health Sciences 9th 6. Manish Jain AM, Santosh kumar,rushab J. Dagli,Prabu Duraiswamy, Suhas Kulkarni. Dentition status and treatment needs among children with impaired hearing attending a special school for the deaf and mute in Udaipur,India. Journal of Oral Science. 2008;50. 7. Siddibhavi. M. Oral Health Status of Handicapped WebmedCentral > Original Articles Page 5 of 13
Children Attending Various Special Schools in Belgaum City Karnataka.WebmedCentral Epidemiology. 2012;3(2):WMC003061 8. Shyama, Morris RE, Sugathan T, Honkala E. Dental caries experience of disabled children and young adults in Kuwait.. Community Dent Health. 2001 Sep18(3):1816. 9. Manoj. H. Evaluation of Knowledge attitude and practice about oral health care among secondary level students of rural nepal.a Questionnaire study.may 31,2011 WMC001805. WebmedCentral > Original Articles Page 6 of 13
Illustrations Illustration 1 Table 1.1: General Characteristics Variables Frequency(n) Percent(%) Age 12 years 29 24.2 13 years 37 30.8 14 years 20 16.7 15 years 34 28.3 Sex Male 67 55.8 Female 53 44.2 Education None 10 8.3 Primary school 22 18.3 Secondary school 47 39.2 Higher than Secondary school 41 34.2 Type of disability Physical 58 48.3 Sensory 58 48.3 Both 4 3.3 WebmedCentral > Original Articles Page 7 of 13
Illustration 2 Table 1.2 Proportion of Caries (n=120) Variables Total Male Female Dental Caries Status Numb er Percent Number Percent Number Percent At least 1 118 98.3 66 98.5 52 98.1 DMFT Caries Free 2 1.7 1 1.5 1 1.9 WebmedCentral > Original Articles Page 8 of 13
Illustration 3 Table 1.3: Number and percent by levels severity of Dental caries Variable Severity of dental caries Frequency Percent Low score (<2.6) 21 17.5 Moderate(2.7-4.4) 44 36.7 High (>4.4) 55 45.8 Total 118 100 WebmedCentral > Original Articles Page 9 of 13
Illustration 4 Table 1.4 Mean and Standard deviation of DMFT Variables Number Mean Std. Deviation Minimum Maximum Decayed Teeth(DT) Missing Teeth(MT) Filled Teeth(FT) 432 3.60 3.14 00 17.00 19 16 45 00 2.00 125 1.04.81 00 4.00 DMFT 576 4.80 3.01 00 18.00 WebmedCentral > Original Articles Page 10 of 13
Illustration 5 Table 1.5: KAP of children Knowledge Attitude Practice Variables Number Percent Good(9-10) 3 2.5 Fair(6-8) 70 58.3 Poor(0-5) 47 39.2 Mean 5.57 SD 1.72 Min=0 Max=10 Good(22-30) 47 39.2 Fair(16-21) 45 37.5 Poor(10-15 28 23.3 Mean 19.95 SD 4.95 Min=100 Max=10 good(8-10 12 10.0 poor(0-7) 108 90.0 Mean 5.10 SD 1.99 Min=0 Max=10 WebmedCentral > Original Articles Page 11 of 13
Illustration 6 Table 1.6: Association of general characteristics with DMFT status of the children Variables DMFT Status High Moderate Low P-value n % n % n % Age 12 years 16 55.20 7 24.10 6 20.7 13 years 20 54.10 12 32.40 5 13.5 0.19 14 years 10 50.00 7 35.00 3 15 15 years 9 26.50 18 52.90 7 20.6 Gender Male 31 46.30 25 37.30 11 16.4 0.93 Female 24 45.30 19 35.80 10 18.9 Type of Disability Physical 20 34.50 22 37.9% 16 27.6 0.01 Sensory 33 56.90 20 34.50 5 8.6 WebmedCentral > Original Articles Page 12 of 13
Illustration 7 Table 1.7: Comparison of average score of DMFT by gender and Type of Disability Variable Mean SD Z-Test P-value Gender Male 2.29 0.73 Female 2.26 0.76-0.21 0.85 Type of Disability Physical 2.06 0.79-2.88 Sensory 2.48 0.65 0.004 WebmedCentral > Original Articles Page 13 of 13