EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
ARTICLE ABSTRACT To evaluate the presence and associated factors of erosive tooth wear (ETW) in children with cerebral palsy (CP), as well as its impact on the oral health-related quality of life (OHRQoL). Parents of 60 CP children, between 6 and 14 years of age, answered the Brazilian v ersion of the parental-caregivers p erception questionnaire (P-CPQ). The ETW diagnosis was performed by a single calibrated examiner according to the O’Brien´s modified index. Associated factors such as family income, behavioral factors, and type of CP were also collected. OHRQoL was measured through P-CPQ domains and total score, and Poisson regression was used to correlate ETW to associated factors and to the scores. ETW was present in 48.3% of the children. The multivariate adjusted model showed that the presence of ETW was associated with more than 2 days of soft drink intake per week (p = 0.003), daily intake of powdered juice (p = 0.002) and reported gastroesophageal reflux (p = 0.016). The family income higher than one Brazilian minimum wage showed a positive impact on the CP children’s OHRQoL (RR = 0.53; p ≤ 0.001). ETW in CP children is associated to frequent consumption of soft drinks, powdered juices, and reported gastroesophageal reflux; however, ETW has not a negative impact on the OHRQoL.
KEY WORDS: cerebral palsy, tooth erosion, quality of life
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Associated factors to erosive tooth wear and its impact on quality of life in children with cerebral palsy Jenny Abanto, DDS, MSc, PhD, post-PhD Student;1 Caleb Shitsuka, DDS, MSc, PhD Student;2* Christiana Murakami, DDS, MSc, PhD;3 Ana Lídia Ciamponi, DDS, MSc, PhD;4 Daniela Prócida Raggio, DDS, MSc, PhD;5 Marcelo Bönecker, DDS, MSc, PhD6 1
Post-PhD Student; 2PhD Student; 3PhD Student; 4Associate Professor; 5Associate Professor; 6Professor, University of São Paulo, Brazil. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(6): 278-285, 2014
Int r od uct ion
Cerebral palsy (CP) is a neurological disorder and the most common cause of severe physical disability in childhood,1 occurring in approximately 2–2.5 per 1000 children.2,3 The more severe the neurological damage in children with CP, the higher the risk of oral diseases,4-7 such as dental caries, periodontal diseases, bruxism, and erosion tooth wear.5
Erosive tooth wear (ETW) is defined as the accelerated loss of dental hard tissue through the combined effect of erosion and mechanical wear (abrasion and attrition) on the tooth surface.8 Its progression can lead to the appearance of new lesions along with the dissolution of enamel and dentine exposure possibly producing a complete destruction of the crown.9 Children with CP have a high risk for developing ETW,5,10-13 however, there are still scarce studies assessing ETW in children with CP and possible associated extrinsic and intrinsic factors.14 ETW may cause pain, discomfort,15,16 dentin hypersensitivity, and altered aesthetics,17,18 presumably having an impact on oral health-related quality of life (OHRQoL). Only one study performed in normoreactive schoolchildren’s showed that the presence of tooth erosion of low severity did not have a negative impact on the children’s perception of oral
health or on their daily performance.19 Nevertheless, to the best of our knowledge, there are no studies assessing the impact of ETW on the OHRQoL of CP children. Thus, the aim of this study was to evaluate associated factors involved in the presence of ETW and its impact on the OHRQoL in children with CP according to parent’s proxy reports.
Ma t er ia l a n d m e t h o d s
This study was independently reviewed and approved by the ethical committee of the School of Dentistry of the University of São Paulo, Brazil.
Sampling and procedures For this cross-sectional study, a convenience sample was selected. It comprised children with CP who attended the Center of Attendance for Special Needs
© 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12070
17/09/14 2:31 PM
EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
Patients—CAPE of the Dental School, University of São Paulo. The CAPE performs preventive and restorative treatments for individuals with different types of disabilities. The sampling was conducted in two steps: initially, all children from 6 to 14 years old, of both genders in the database system at the center were identified, resulting in a total of 75 children. The patients’ parents were contacted by telephone and information about the study was given. Parents who were fluent in Brazilian Portuguese and who were willing to participate in the study (all of them) signed an informed consent. The final sample size comprised of 60 children with CP and their respective parents.
Data collection On the day of the dental visit, one of the parents (preferably the one who spent most of the time with the child) was invited to answer a questionnaire on the children’s OHRQoL and data about family income and behavioral factors. The participants’ parents answered a structured questionnaire regarding factors previously reported to be frequently associated with ETW. Parents were asked whether the child frequently complained of acid reflux/regurgitation into the mouth or throat, which indicates overt vomiting or indigestion.20 Questions regarding dietary habits focused on frequency and daily intake of soft drinks and juices were also collected.20-22
OHRQoL measure The OHRQoL instrument used was the Brazilian version of the parental-caregivers perceptions questionnaire (P-CPQ).23 The instrument has a 45-item questionnaire and evaluates the perception of parents on OHRQoL of children aged 6–14 years. The parent proxy report was chosen due to the difficulties to assess self-report in most of these children. The questions referred to the frequency of events in the previous 3 months. The items were scored using a five point Likert scale (response options: never = 0, once or twice = 1, sometimes = 2, often = 3, every day or almost every day = 4). A
Abanto et al.
scd12070.indd 279
“Don’t know” response option was counted individually and considered as missing. A previous study with the same sample and measure used in this study showed that there were no significant differences between total and domains scores after excluding or not “Don’t know answers.”24 The following domains scores were created by adding the responses to conceptually based, discrete subsets of items: oral symptoms domain—six items; functional limitations domain—eight items; emotional well-being domain—seven items; social well-being domain—10 items and family impact domain—14 items. The total P-CPQ score were generated by summing the numerical response codes for individual domains. The range score of the instrument range from a minimum of 0 to a maximum of 180. Higher scores indicate a more negative impact on the OHRQoL or vice versa. These questionnaires were applied in face-to-face interviews by one interviewer blind to the children’s oral examinations and impairments characteristics. The interviews were completed before the oral clinical examination of the patient. Concerning the OHRQoL questionnaire, the interviewer was trained in the reading and intonation of each question and option of responses.
Children’s examination Impairment characteristic and oral examination of the child were collected by one trained and calibrated examiner with experience in children with CP. The type of CP was evaluated according to the topographic distribution: hemiplegia, diplegia, and quadriplegia.25 The examiner underwent two sessions of training and calibration exercises for ETW and dental caries diagnosis, with an interval of 1 week between sessions to assess intraexaminer reliability. The sessions were carried out by a benchmark (CM) with experience in diagnosis of ETW using the modified O’Brien index22,26 and the WHO dental caries diagnostic criteria.27 Reproducibility for ETW were obtained using a sample of 20 clinical slides and
20 extracted primary teeth from a human Tooth Bank, which represented all possible classification scores. For dental caries, reproducibility was obtained by oral clinical examinations of 10 children who did not form part of the study sample. The examination of ETW and dental caries were performed, after prophylaxis, in a dental unit under artificial lighting, a three-in-one syringe for drying the teeth, plane mouth mirrors. A modified version of the O’Brien index was used for ETW.22,26 The criteria of the modified O’Brien index for lesion depth and area are described in Table 1. For the evaluation of erosive lesion depth, this index attributes the scores 1, 2, and 3, respectively, for lesions into enamel, dentin, and close proximity pulp. For the evaluation of lesions area, the O´Brien index attributes the scores of 1, 2 and 3, respectively, to lesions involving one third, two thirds, or more than two thirds of the area of the surface being examined. For criteria of both lesion depth and area, score 0 refers to a sound dental surface. However, score 9, which refers to cases where the assessment could not be made. The palatal surface of upper incisors and the occlusal surface of lower molars were used as index teeth for assessment in this study. The prevalence of ETW was recorded as the percentage of children having at least one tooth with erosion. Subsequently, the clinical oral examination was realized for the presence of dental caries. DMFT and dmft were used to calculate the number of decayed, missing, filled teeth in the permanent and primary dentition, respectively.27 For children with mixed dentition, the caries index was obtained by the sum of the dmft and DMFT scores.
Data analysis Data analyses were performed using STATA 9.0 (Stata Corp., College Station, TX, U.S.A.). Initially, descriptive analyses assessed measures of central tendency (means and standard deviations) of total and individual domain scores of the P-CPQ.
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EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
Table 1. Diagnosis criteria for ETW scores of modified O’Brien index. Score
Depth
0
Normal–healthy
1
Enamel lesion—loss of surface characterization
2
Dentine lesion—loss of enamel exposing dentine
3
Lesion in proximity to pulp—possible to visualize redness of pulp through translucency of remaining tissue
9
Assessment not possible—missing element or full crown Area
0
Normal–healthy
1
Involving up to one third of surface
2
Involving up to two thirds of surface
3
Involving over two thirds of surface
9
Assessment not possiblemissing element, restoration, or sealant
Table 2. Mean score and variance for the total P-CPQ score and for each domain. P-CPQ domain
Mean scores (±SD)
Range observed
Oral symptoms
6.05 (4.17)
0–15
Functional limitations
5.62 (4.07)
0–17
Emotional well-being
0.85 (1.97)
0–9
Social well-being
0.75 (1.11)
0–4
Familiar impact scale
3.32 (4.76)
0–24
17.28 (13.25)
1–69
Total score
In a first moment, Poisson Regression with robust variance was performed to correlate family income, dental caries, behavioral factors, and type of CP to ETW. In a second moment, the Poisson Regression analysis correlated all these conditions to the total P-CPQ score and individual domains. In this latter analysis, the OHRQoL outcome was employed as a count outcome. The multivariate adjusted models were built with covariates selected by a forward stepwise procedure with p ≤ 0.20 as the cutoff point. The covariates were retained in the final model if p ≤ 0.05. For dichotomic analyses (Tables 2 and 3) we used prevalence ratio and for categorical analysis (Tables 4 and 5) we used rate ratios (RR). All these analyses with 95% confidence intervals were calculated.
280 S p e c C a r e D e n t i s t 3 4 ( 6 ) 2 0 1 4
scd12070.indd 280
R es ul t s
From a total of 75 children, five could not be contacted because they have moved, two children have died, three were hospitalized and from five of them, the parents did not want to participate in the study. Thus, the final sample was 60 patients (response rate = 85.6%) between 6 and 14 years of age. Cohen’s kappa values were calculated on a surface-bysurface basis separately for erosive lesion depth and area, based on the calibration exercises. The unweighted intrakappa values for lesion depth and for lesion area were 0.89 and 0.69, respectively. Weighted intraexaminer kappa values for lesion depth and for lesion area were 0.85 and 0.90, respectively. For dental caries, intrakappa statistic was 0.95. The proportion of children who had at least one tooth with ETW was 48.3%
(n = 29). Overall, most of the ETW lesions in children were confined to the enamel (82.8%) and only 17.2% of teeth involved dentin. A total of 60 patients (30 boys and 30 girls) participated in the study. The mean age (SD) of the children was 9.13 (2.2). Most of the questionnaires were answered by mothers (97%). The minimum and maximum score of impact reported on the total P-CPQ of the sample was 1 and 69, respectively. Table 2 displays the mean, standard deviation, and the range observed for the total P-CPQ score and for individual domains. In regard to the presence of ETW and associated factors, the univariate analysis showed that dental caries, the frequency of soft drink intake between meals, the daily intake of powdered juice and the reported gastroesophageal reflux were all correlated to ETW (p < 0.05; Table 3). The multivariate regression model (Table 4) showed that children who consumed more than 2 days by week of soft drink between meals, who have a daily intake of powdered juice, and reported gastroesophageal reflux had 1.86, 3.26, and 1.57 times more occurrence of having ETW, respectively. These differences were statistically significant (Table 4). Regarding the impact of ETW on children’s OHRQoL, the univariate analysis showed that ETW, ETW lesion depth, type of CP, and family income were correlated to some domains and total P-CPQ scores (p < 0.05; Table 5). The multivariate model adjusted by dental caries (Table 6) showed that the presence of ETW had not a negative impact on the family impact domain (RR = 0.45; p = 0.007) and total P-CPQ scores (RR = 0.65; p = 0.003). A family income higher than one Brazilian minimum wage also showed a positive impact on functional limitations domain, family impact scale, and total P-CPQ score (p < 0.05). Children with quadriplegia have a negative impact on the oral symptoms (RR = 2.30; p < 0.001) and functional limitations domains (RR = 1.79; p < 0.001).
Erosive tooth wear in children with cerebral palsy
17/09/14 2:31 PM
EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
Table 3. Univariate analysis of possible factors associated with ETW. Covariates
Total N
With erosion n (%)
Age (6–14 years old)
Robust PR (95% CI)
p value
1.02 (0.91–1.15)
0.751
0.93 (0.55–1.58)
0.798
0.76 (0.45–1.29)
0.315
Gender Male
30
15 (50.0)
Female
30
14 (46.7)
Absence
27
15 (55.6)
Presence
33
14 (42.4)
Hemiplegia
24
12 (50.0)
Diplegia
16
6 (37.5)
0.75 (0.35–1.60)
0.455
Quadriplegia
20
11 (55.0)
1.10 (0.62–1.94)
0.742
Do not consume to twice a week
38
11 (28.9)
More than 2 days a week
22
18 (81.8)
2.83 (1.65–4.85)
ARTICLE ABSTRACT To evaluate the presence and associated factors of erosive tooth wear (ETW) in children with cerebral palsy (CP), as well as its impact on the oral health-related quality of life (OHRQoL). Parents of 60 CP children, between 6 and 14 years of age, answered the Brazilian v ersion of the parental-caregivers p erception questionnaire (P-CPQ). The ETW diagnosis was performed by a single calibrated examiner according to the O’Brien´s modified index. Associated factors such as family income, behavioral factors, and type of CP were also collected. OHRQoL was measured through P-CPQ domains and total score, and Poisson regression was used to correlate ETW to associated factors and to the scores. ETW was present in 48.3% of the children. The multivariate adjusted model showed that the presence of ETW was associated with more than 2 days of soft drink intake per week (p = 0.003), daily intake of powdered juice (p = 0.002) and reported gastroesophageal reflux (p = 0.016). The family income higher than one Brazilian minimum wage showed a positive impact on the CP children’s OHRQoL (RR = 0.53; p ≤ 0.001). ETW in CP children is associated to frequent consumption of soft drinks, powdered juices, and reported gastroesophageal reflux; however, ETW has not a negative impact on the OHRQoL.
KEY WORDS: cerebral palsy, tooth erosion, quality of life
278 S p e c C a r e D e n t i s t 3 4 ( 6 ) 2 0 1 4
scd12070.indd 278
Associated factors to erosive tooth wear and its impact on quality of life in children with cerebral palsy Jenny Abanto, DDS, MSc, PhD, post-PhD Student;1 Caleb Shitsuka, DDS, MSc, PhD Student;2* Christiana Murakami, DDS, MSc, PhD;3 Ana Lídia Ciamponi, DDS, MSc, PhD;4 Daniela Prócida Raggio, DDS, MSc, PhD;5 Marcelo Bönecker, DDS, MSc, PhD6 1
Post-PhD Student; 2PhD Student; 3PhD Student; 4Associate Professor; 5Associate Professor; 6Professor, University of São Paulo, Brazil. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(6): 278-285, 2014
Int r od uct ion
Cerebral palsy (CP) is a neurological disorder and the most common cause of severe physical disability in childhood,1 occurring in approximately 2–2.5 per 1000 children.2,3 The more severe the neurological damage in children with CP, the higher the risk of oral diseases,4-7 such as dental caries, periodontal diseases, bruxism, and erosion tooth wear.5
Erosive tooth wear (ETW) is defined as the accelerated loss of dental hard tissue through the combined effect of erosion and mechanical wear (abrasion and attrition) on the tooth surface.8 Its progression can lead to the appearance of new lesions along with the dissolution of enamel and dentine exposure possibly producing a complete destruction of the crown.9 Children with CP have a high risk for developing ETW,5,10-13 however, there are still scarce studies assessing ETW in children with CP and possible associated extrinsic and intrinsic factors.14 ETW may cause pain, discomfort,15,16 dentin hypersensitivity, and altered aesthetics,17,18 presumably having an impact on oral health-related quality of life (OHRQoL). Only one study performed in normoreactive schoolchildren’s showed that the presence of tooth erosion of low severity did not have a negative impact on the children’s perception of oral
health or on their daily performance.19 Nevertheless, to the best of our knowledge, there are no studies assessing the impact of ETW on the OHRQoL of CP children. Thus, the aim of this study was to evaluate associated factors involved in the presence of ETW and its impact on the OHRQoL in children with CP according to parent’s proxy reports.
Ma t er ia l a n d m e t h o d s
This study was independently reviewed and approved by the ethical committee of the School of Dentistry of the University of São Paulo, Brazil.
Sampling and procedures For this cross-sectional study, a convenience sample was selected. It comprised children with CP who attended the Center of Attendance for Special Needs
© 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12070
17/09/14 2:31 PM
EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
Patients—CAPE of the Dental School, University of São Paulo. The CAPE performs preventive and restorative treatments for individuals with different types of disabilities. The sampling was conducted in two steps: initially, all children from 6 to 14 years old, of both genders in the database system at the center were identified, resulting in a total of 75 children. The patients’ parents were contacted by telephone and information about the study was given. Parents who were fluent in Brazilian Portuguese and who were willing to participate in the study (all of them) signed an informed consent. The final sample size comprised of 60 children with CP and their respective parents.
Data collection On the day of the dental visit, one of the parents (preferably the one who spent most of the time with the child) was invited to answer a questionnaire on the children’s OHRQoL and data about family income and behavioral factors. The participants’ parents answered a structured questionnaire regarding factors previously reported to be frequently associated with ETW. Parents were asked whether the child frequently complained of acid reflux/regurgitation into the mouth or throat, which indicates overt vomiting or indigestion.20 Questions regarding dietary habits focused on frequency and daily intake of soft drinks and juices were also collected.20-22
OHRQoL measure The OHRQoL instrument used was the Brazilian version of the parental-caregivers perceptions questionnaire (P-CPQ).23 The instrument has a 45-item questionnaire and evaluates the perception of parents on OHRQoL of children aged 6–14 years. The parent proxy report was chosen due to the difficulties to assess self-report in most of these children. The questions referred to the frequency of events in the previous 3 months. The items were scored using a five point Likert scale (response options: never = 0, once or twice = 1, sometimes = 2, often = 3, every day or almost every day = 4). A
Abanto et al.
scd12070.indd 279
“Don’t know” response option was counted individually and considered as missing. A previous study with the same sample and measure used in this study showed that there were no significant differences between total and domains scores after excluding or not “Don’t know answers.”24 The following domains scores were created by adding the responses to conceptually based, discrete subsets of items: oral symptoms domain—six items; functional limitations domain—eight items; emotional well-being domain—seven items; social well-being domain—10 items and family impact domain—14 items. The total P-CPQ score were generated by summing the numerical response codes for individual domains. The range score of the instrument range from a minimum of 0 to a maximum of 180. Higher scores indicate a more negative impact on the OHRQoL or vice versa. These questionnaires were applied in face-to-face interviews by one interviewer blind to the children’s oral examinations and impairments characteristics. The interviews were completed before the oral clinical examination of the patient. Concerning the OHRQoL questionnaire, the interviewer was trained in the reading and intonation of each question and option of responses.
Children’s examination Impairment characteristic and oral examination of the child were collected by one trained and calibrated examiner with experience in children with CP. The type of CP was evaluated according to the topographic distribution: hemiplegia, diplegia, and quadriplegia.25 The examiner underwent two sessions of training and calibration exercises for ETW and dental caries diagnosis, with an interval of 1 week between sessions to assess intraexaminer reliability. The sessions were carried out by a benchmark (CM) with experience in diagnosis of ETW using the modified O’Brien index22,26 and the WHO dental caries diagnostic criteria.27 Reproducibility for ETW were obtained using a sample of 20 clinical slides and
20 extracted primary teeth from a human Tooth Bank, which represented all possible classification scores. For dental caries, reproducibility was obtained by oral clinical examinations of 10 children who did not form part of the study sample. The examination of ETW and dental caries were performed, after prophylaxis, in a dental unit under artificial lighting, a three-in-one syringe for drying the teeth, plane mouth mirrors. A modified version of the O’Brien index was used for ETW.22,26 The criteria of the modified O’Brien index for lesion depth and area are described in Table 1. For the evaluation of erosive lesion depth, this index attributes the scores 1, 2, and 3, respectively, for lesions into enamel, dentin, and close proximity pulp. For the evaluation of lesions area, the O´Brien index attributes the scores of 1, 2 and 3, respectively, to lesions involving one third, two thirds, or more than two thirds of the area of the surface being examined. For criteria of both lesion depth and area, score 0 refers to a sound dental surface. However, score 9, which refers to cases where the assessment could not be made. The palatal surface of upper incisors and the occlusal surface of lower molars were used as index teeth for assessment in this study. The prevalence of ETW was recorded as the percentage of children having at least one tooth with erosion. Subsequently, the clinical oral examination was realized for the presence of dental caries. DMFT and dmft were used to calculate the number of decayed, missing, filled teeth in the permanent and primary dentition, respectively.27 For children with mixed dentition, the caries index was obtained by the sum of the dmft and DMFT scores.
Data analysis Data analyses were performed using STATA 9.0 (Stata Corp., College Station, TX, U.S.A.). Initially, descriptive analyses assessed measures of central tendency (means and standard deviations) of total and individual domain scores of the P-CPQ.
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EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
Table 1. Diagnosis criteria for ETW scores of modified O’Brien index. Score
Depth
0
Normal–healthy
1
Enamel lesion—loss of surface characterization
2
Dentine lesion—loss of enamel exposing dentine
3
Lesion in proximity to pulp—possible to visualize redness of pulp through translucency of remaining tissue
9
Assessment not possible—missing element or full crown Area
0
Normal–healthy
1
Involving up to one third of surface
2
Involving up to two thirds of surface
3
Involving over two thirds of surface
9
Assessment not possiblemissing element, restoration, or sealant
Table 2. Mean score and variance for the total P-CPQ score and for each domain. P-CPQ domain
Mean scores (±SD)
Range observed
Oral symptoms
6.05 (4.17)
0–15
Functional limitations
5.62 (4.07)
0–17
Emotional well-being
0.85 (1.97)
0–9
Social well-being
0.75 (1.11)
0–4
Familiar impact scale
3.32 (4.76)
0–24
17.28 (13.25)
1–69
Total score
In a first moment, Poisson Regression with robust variance was performed to correlate family income, dental caries, behavioral factors, and type of CP to ETW. In a second moment, the Poisson Regression analysis correlated all these conditions to the total P-CPQ score and individual domains. In this latter analysis, the OHRQoL outcome was employed as a count outcome. The multivariate adjusted models were built with covariates selected by a forward stepwise procedure with p ≤ 0.20 as the cutoff point. The covariates were retained in the final model if p ≤ 0.05. For dichotomic analyses (Tables 2 and 3) we used prevalence ratio and for categorical analysis (Tables 4 and 5) we used rate ratios (RR). All these analyses with 95% confidence intervals were calculated.
280 S p e c C a r e D e n t i s t 3 4 ( 6 ) 2 0 1 4
scd12070.indd 280
R es ul t s
From a total of 75 children, five could not be contacted because they have moved, two children have died, three were hospitalized and from five of them, the parents did not want to participate in the study. Thus, the final sample was 60 patients (response rate = 85.6%) between 6 and 14 years of age. Cohen’s kappa values were calculated on a surface-bysurface basis separately for erosive lesion depth and area, based on the calibration exercises. The unweighted intrakappa values for lesion depth and for lesion area were 0.89 and 0.69, respectively. Weighted intraexaminer kappa values for lesion depth and for lesion area were 0.85 and 0.90, respectively. For dental caries, intrakappa statistic was 0.95. The proportion of children who had at least one tooth with ETW was 48.3%
(n = 29). Overall, most of the ETW lesions in children were confined to the enamel (82.8%) and only 17.2% of teeth involved dentin. A total of 60 patients (30 boys and 30 girls) participated in the study. The mean age (SD) of the children was 9.13 (2.2). Most of the questionnaires were answered by mothers (97%). The minimum and maximum score of impact reported on the total P-CPQ of the sample was 1 and 69, respectively. Table 2 displays the mean, standard deviation, and the range observed for the total P-CPQ score and for individual domains. In regard to the presence of ETW and associated factors, the univariate analysis showed that dental caries, the frequency of soft drink intake between meals, the daily intake of powdered juice and the reported gastroesophageal reflux were all correlated to ETW (p < 0.05; Table 3). The multivariate regression model (Table 4) showed that children who consumed more than 2 days by week of soft drink between meals, who have a daily intake of powdered juice, and reported gastroesophageal reflux had 1.86, 3.26, and 1.57 times more occurrence of having ETW, respectively. These differences were statistically significant (Table 4). Regarding the impact of ETW on children’s OHRQoL, the univariate analysis showed that ETW, ETW lesion depth, type of CP, and family income were correlated to some domains and total P-CPQ scores (p < 0.05; Table 5). The multivariate model adjusted by dental caries (Table 6) showed that the presence of ETW had not a negative impact on the family impact domain (RR = 0.45; p = 0.007) and total P-CPQ scores (RR = 0.65; p = 0.003). A family income higher than one Brazilian minimum wage also showed a positive impact on functional limitations domain, family impact scale, and total P-CPQ score (p < 0.05). Children with quadriplegia have a negative impact on the oral symptoms (RR = 2.30; p < 0.001) and functional limitations domains (RR = 1.79; p < 0.001).
Erosive tooth wear in children with cerebral palsy
17/09/14 2:31 PM
EROSIVE TOOTH WEAR IN CHILDREN WITH CEREBRAL PALSY
Table 3. Univariate analysis of possible factors associated with ETW. Covariates
Total N
With erosion n (%)
Age (6–14 years old)
Robust PR (95% CI)
p value
1.02 (0.91–1.15)
0.751
0.93 (0.55–1.58)
0.798
0.76 (0.45–1.29)
0.315
Gender Male
30
15 (50.0)
Female
30
14 (46.7)
Absence
27
15 (55.6)
Presence
33
14 (42.4)
Hemiplegia
24
12 (50.0)
Diplegia
16
6 (37.5)
0.75 (0.35–1.60)
0.455
Quadriplegia
20
11 (55.0)
1.10 (0.62–1.94)
0.742
Do not consume to twice a week
38
11 (28.9)
More than 2 days a week
22
18 (81.8)
2.83 (1.65–4.85)
