I N T E L L E C T U A L D I S A B I L I T Y A N D I M PA C T O N O R A L H E A LT H
ARTICLE ABSTRACT The objective was to assess the oral health status, the treatment needed, and the type of dental health services access of intellectually disabled (ID) subjects in Teresina, Brazil. The sample consisted of 103 ID subjects matriculated in centers for special needs people and 103 siblings. Results were analyzed using paired t-test, chi-square test, and odds ratio. ID subjects had fair (63.1%; p < .001) and their siblings had a good oral hygiene (n = 103 [55.3%]; p < .005). ID had more decayed (3.52; p < .005), and missing teeth (1.17; p = .001), fewer dental restorations (1.67; p = .012) and had a greater need for tooth extraction (21.4%; p = .002) than their siblings. Thirty percent of ID subjects had never received dental treatment and had difficulty accessing public health services. Their treatment needs were, therefore, higher than non-ID subjects. The access to oral health services was unsatisfactory, thus it is important to implement educational and health promotion inclusion policies for people with ID.
KEY WORDS: intellectual and developmental disabilities, oral health, dental caries
262 S p e c C a r e D e n t i s t 3 3 ( 6 ) 2 0 1 3
scd_12015.indd 262
Intellectual disability and impact on oral health: a paired study Juliana Santos Oliveira, MSc;1* Raimundo Rosendo Prado Júnior, DDS;2 Kássio Rafael de Sousa Lima, BDS;3 Heylanede Oliveira Amaral, BDS;3 José Machado Moita Neto, PhD;4 Regina Ferraz Mendes, DDS2 1Masters
in Health Sciences, Federal University of Piauí, Teresina, Piauí, Brazil; 2Professor of the Masters Course in Health Sciences, Restorative Dentistry Department, Federal University of Piauí, Teresina, Piauí, Brazil; 3Student of Federal University of Piauí, Teresina, Piauí, Brazil; 4Doctor of Chemistry, Chemistry Department, Federal University of Piauí, Teresina, Piauí, Brazil. *Corresponding author e-mail: [email protected] Spec Care Dentist 33(6): 262-268, 2013
Int r od uct ion Intellectual disability is defined as a significantly lower than average intellectual functioning, which manifests before the age of 18 years, through limitations in at least one adaptive skill.1 This condition might be associated with physical factors, environmental factors or a combination of the two, and influences the capacity of individuals to adequately respond to certain social expectations.1,2 It is estimated that 80% of intellectually disabled (ID) subjects live in developing countries.3 In Brazil, the incidence rate of this condition is 11.5 per 100 live births.4 ID subjects may have deficient oral hygiene, especially when motor disability is associated with their condition.5 Inadequate oral hygiene might also be associated with low family income and a low level of schooling, factors that might result in limited access to dental health services.5-8 There is usually an association between intellectual disability and a high prevalence of caries and the need for restorative procedures.5 Comparative studies show that people with intellectual disability have poor oral health, a higher rate of periodontal diseases and more limited access to dental services than people without disabilities. However, their caries experience is still controversial when compared with control groups.5,9,10 Since 2007, Brazil has been a signatory of the Convention of the North
Atlantic Treaty Organization (NATO), which guarantees the rights of people with disabilities. Brazil has committed itself to adhere to the social inclusion policy that is part of the NATO norms and regulations and includes promoting the health of this group of people in the country.11 Furthermore, non-Brazilian studies have revealed the need to improve the oral health status of ID subjects as well as their access to dental services.9,10 Currently, people with disability have a lower level of access to oral health services than people without disability.9 It is important to acknowledge this disparity in order to develop strategies that improve the oral health conditions of ID subjects.9 There are no studies in Brazil on the oral health of ID subjects compared with non-ID subjects. The objective of this study is to evaluate the oral hygiene, caries experience, treatment needs, and access to oral health services of ID subjects and their non-ID siblings. The subjects of this study have Down syndrome, cerebral palsy, or
©2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12015
05/10/13 11:34 AM
I N T E L L E C T U A L D I S A B I L I T Y A N D I M PA C T O N O R A L H E A LT H
autism. The hypothesis is that the ID subjects have a poorer oral health status and more difficult access to oral health services than their non-ID siblings.
Methodology The study was carried out in Teresina, capital of the State of Piauí, Brazil. The study design was based on the pairing between siblings, thus controlling social and family factors and the age of the study sample. The interest in their intellectual disability was based on their limited functional skills and movements, and how this could interfere with their oral health. The subjects are assisted at public centers for special needs people (SNP), which are run by the local government. To enroll in such centers, a medical diagnosis of their condition is required. The most common diagnoses of the ID subjects are Down syndrome, cerebral palsy or autism. There are some other rare syndromes, such as Hunter, Gaucher and Cornelia de Lange syndromes. The centers provide educational and health care services, such as medical services, physical therapy, phonoaudiology, psychological support. Two of the centers provide dental assistance. There are currently 650 ID people under treatment at four centers in Teresina city. Their age ranges from 1 month to 36 years of age, and they attend the centers on a daily basis, either in the morning (8:00–12:00 AM) or in the afternoon (14:00–18:00 PM). This study was approved by the Ethics Committee and Research at the Federal University of Piauí (protocol: 0137.0.045.000–10). The subjects’ caregivers who agreed to participate in the study signed a consent form. Data were collected between March 2011 and March 2012. The sample consisted of the subjects with the most common diagnoses (Down syndrome, cerebral palsy, or autism) or with intellectual disability that is not associated with a health condition. The following inclusion criteria were adopted: being older than 12 years old, having one sibling that is up to 5 years
Oliveira et al.
scd_12015.indd 263
younger or older, siblings having the same parents (genetic control), and living in the same dwelling for at least two daily shifts. The non-ID siblings constituted the negative control group. These siblings also had to be capable of self-feeding. Pairing is a strategy used by researchers to make data more reliable when comparing two groups that may be different regarding a given variable, but are similar in other aspects.12 One hundred and six subjects out of the 650 ID subjects and the same number of siblings were selected according to the inclusion criteria. However, two caregivers refused to sign the consent form and one ID subject did not cooperate during the examination and these data could not be collected. Thus, the sample consisted of 103 ID subjects: 15.8% of the population and 97.2% of those who met the inclusion criteria. There were 26 (25.2%) subjects with cerebral palsy, 20 (19.4%) with Down syndrome, 11 (10.7%) with autism, and 46 (44.7%) with other conditions. The study included 103 siblings, one sibling per ID subject. The 547 ID-subjects who were not selected had a diagnosis of a rare syndrome, were younger than 12 years old, or did not have a sibling who fit the inclusion criteria. The siblings were not enrolled at the same center, since the centers specialize in disabled people. The data collection was carried out by a single examiner in two stages. In the first stage, the family’s socio-economical variables (gender, age, monthly income— in Brazilian minimum salaries, and schooling level), oral health habits, and data regarding the ID subject’s access to health services were supplied by the caregiver and registered on a form. Caregivers were asked if they had received oral health treatment at other health centers (specifying whether public or private) when it was not offered by the specialist disability center. The caregiver is the person responsible for the ID subject’s daily care, including feeding and oral hygiene. The caregiver’s role was self-reported by the person who was with the ID subject at
the time of the data collection. If the accompanying person said they were not the caregiver, data collection was postponed. The caregiver was usually the mother or the father. The second stage of data collection consisted of an oral physical examination. The centers provided permission to use their facilities for the oral examinations. These examinations were carried out in a classroom, under natural and artificial light (using a flash light), in a knee-to-knee position. Cotton roll field isolation was carried out and a dental explorer and mirror were used for the dental examination. The presence of dental biofilm was recorded using the Simplified Oral Health Assessment Index (OHI-S) modified by Greene and Vermillion.13 Basic fuchsine (Eviplac™) was used to disclose dental biofilm and the presence of dental calculus was also recorded and scored from 0 to 3. The ratio between the number of surfaces with dental biofilm or dental calculus and the number of teeth examined was used to classify the subject’s oral hygiene as: good (score below 1.2), fair (1.3 to 3), or poor (3.1 to 6). Caries experience was scored using the Decayed, Missing and Filled Teeth Index (DMF-T), following the standard methodology of the World Health Organization.14 It consists of the sum of the number of decayed and missing teeth due to caries plus the number of filled teeth divided by the number of subjects. The higher the score, the higher the caries experience. The DMF-T index was used to determine the dental treatment needs. The negative control group was submitted to the same protocol.
Statistical analysis A data bank was created using SPSS software v. 17 for Windows (2009, Cary, NC, USA). Results were analyzed using the paired student’s t-test, the chi-square test, and odds ratio at a 95% confidence interval. To measure the study’s intra-examiner accuracy, the examination was repeated for 21 randomly selected subjects (0.87 kappa was recorded for the caries index).
S p e c C a r e D e n t i s t 3 3 ( 6 ) 2 0 1 3 263
05/10/13 11:34 AM
I N T E L L E C T U A L D I S A B I L I T Y A N D I M PA C T O N O R A L H E A LT H
Table 1. Social and economical characteristics of ID and their siblings in Teresina, Brazil. Variable
ID
Age (years)
Gender Caregivers’ schooling level (years)
Income in Brazilian minimum salaries per month (US$ 261)
Siblings
N
%
N
%
12–14
18
17.5
19
18.4
15–19
40
38.8
40
38.8
20–34
43
41.7
41
39.8
34–36
2
1.9
3
2.9
Male
62
60.2
42
40.8
Female
41
39.8
61
59.2
1–5 primary
40
38.8
6–11 incomplete high-school
29
28.2
11 complete high school
27
26.2
11+ incomplete university
7
6.8
1
71
68.9
2
23
22.3
3 or 4
7
6.8
5 or up
2
1.9
Table 2. Oral health habits of ID subjects and their siblings in Teresina, Brazil. Variable
Category
ID
%
Siblings
%
p
Daily tooth brushing
Once or twice
52
50.5
29
28.2
.001
Three or more
51
49.5
74
71.8
Flossing frequency
χ2
Daily
9
8.7
33
32
Rarely
21
20.4
23
22.4
Never
73
70.9
47
45.6
ARTICLE ABSTRACT The objective was to assess the oral health status, the treatment needed, and the type of dental health services access of intellectually disabled (ID) subjects in Teresina, Brazil. The sample consisted of 103 ID subjects matriculated in centers for special needs people and 103 siblings. Results were analyzed using paired t-test, chi-square test, and odds ratio. ID subjects had fair (63.1%; p < .001) and their siblings had a good oral hygiene (n = 103 [55.3%]; p < .005). ID had more decayed (3.52; p < .005), and missing teeth (1.17; p = .001), fewer dental restorations (1.67; p = .012) and had a greater need for tooth extraction (21.4%; p = .002) than their siblings. Thirty percent of ID subjects had never received dental treatment and had difficulty accessing public health services. Their treatment needs were, therefore, higher than non-ID subjects. The access to oral health services was unsatisfactory, thus it is important to implement educational and health promotion inclusion policies for people with ID.
KEY WORDS: intellectual and developmental disabilities, oral health, dental caries
262 S p e c C a r e D e n t i s t 3 3 ( 6 ) 2 0 1 3
scd_12015.indd 262
Intellectual disability and impact on oral health: a paired study Juliana Santos Oliveira, MSc;1* Raimundo Rosendo Prado Júnior, DDS;2 Kássio Rafael de Sousa Lima, BDS;3 Heylanede Oliveira Amaral, BDS;3 José Machado Moita Neto, PhD;4 Regina Ferraz Mendes, DDS2 1Masters
in Health Sciences, Federal University of Piauí, Teresina, Piauí, Brazil; 2Professor of the Masters Course in Health Sciences, Restorative Dentistry Department, Federal University of Piauí, Teresina, Piauí, Brazil; 3Student of Federal University of Piauí, Teresina, Piauí, Brazil; 4Doctor of Chemistry, Chemistry Department, Federal University of Piauí, Teresina, Piauí, Brazil. *Corresponding author e-mail: [email protected] Spec Care Dentist 33(6): 262-268, 2013
Int r od uct ion Intellectual disability is defined as a significantly lower than average intellectual functioning, which manifests before the age of 18 years, through limitations in at least one adaptive skill.1 This condition might be associated with physical factors, environmental factors or a combination of the two, and influences the capacity of individuals to adequately respond to certain social expectations.1,2 It is estimated that 80% of intellectually disabled (ID) subjects live in developing countries.3 In Brazil, the incidence rate of this condition is 11.5 per 100 live births.4 ID subjects may have deficient oral hygiene, especially when motor disability is associated with their condition.5 Inadequate oral hygiene might also be associated with low family income and a low level of schooling, factors that might result in limited access to dental health services.5-8 There is usually an association between intellectual disability and a high prevalence of caries and the need for restorative procedures.5 Comparative studies show that people with intellectual disability have poor oral health, a higher rate of periodontal diseases and more limited access to dental services than people without disabilities. However, their caries experience is still controversial when compared with control groups.5,9,10 Since 2007, Brazil has been a signatory of the Convention of the North
Atlantic Treaty Organization (NATO), which guarantees the rights of people with disabilities. Brazil has committed itself to adhere to the social inclusion policy that is part of the NATO norms and regulations and includes promoting the health of this group of people in the country.11 Furthermore, non-Brazilian studies have revealed the need to improve the oral health status of ID subjects as well as their access to dental services.9,10 Currently, people with disability have a lower level of access to oral health services than people without disability.9 It is important to acknowledge this disparity in order to develop strategies that improve the oral health conditions of ID subjects.9 There are no studies in Brazil on the oral health of ID subjects compared with non-ID subjects. The objective of this study is to evaluate the oral hygiene, caries experience, treatment needs, and access to oral health services of ID subjects and their non-ID siblings. The subjects of this study have Down syndrome, cerebral palsy, or
©2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12015
05/10/13 11:34 AM
I N T E L L E C T U A L D I S A B I L I T Y A N D I M PA C T O N O R A L H E A LT H
autism. The hypothesis is that the ID subjects have a poorer oral health status and more difficult access to oral health services than their non-ID siblings.
Methodology The study was carried out in Teresina, capital of the State of Piauí, Brazil. The study design was based on the pairing between siblings, thus controlling social and family factors and the age of the study sample. The interest in their intellectual disability was based on their limited functional skills and movements, and how this could interfere with their oral health. The subjects are assisted at public centers for special needs people (SNP), which are run by the local government. To enroll in such centers, a medical diagnosis of their condition is required. The most common diagnoses of the ID subjects are Down syndrome, cerebral palsy or autism. There are some other rare syndromes, such as Hunter, Gaucher and Cornelia de Lange syndromes. The centers provide educational and health care services, such as medical services, physical therapy, phonoaudiology, psychological support. Two of the centers provide dental assistance. There are currently 650 ID people under treatment at four centers in Teresina city. Their age ranges from 1 month to 36 years of age, and they attend the centers on a daily basis, either in the morning (8:00–12:00 AM) or in the afternoon (14:00–18:00 PM). This study was approved by the Ethics Committee and Research at the Federal University of Piauí (protocol: 0137.0.045.000–10). The subjects’ caregivers who agreed to participate in the study signed a consent form. Data were collected between March 2011 and March 2012. The sample consisted of the subjects with the most common diagnoses (Down syndrome, cerebral palsy, or autism) or with intellectual disability that is not associated with a health condition. The following inclusion criteria were adopted: being older than 12 years old, having one sibling that is up to 5 years
Oliveira et al.
scd_12015.indd 263
younger or older, siblings having the same parents (genetic control), and living in the same dwelling for at least two daily shifts. The non-ID siblings constituted the negative control group. These siblings also had to be capable of self-feeding. Pairing is a strategy used by researchers to make data more reliable when comparing two groups that may be different regarding a given variable, but are similar in other aspects.12 One hundred and six subjects out of the 650 ID subjects and the same number of siblings were selected according to the inclusion criteria. However, two caregivers refused to sign the consent form and one ID subject did not cooperate during the examination and these data could not be collected. Thus, the sample consisted of 103 ID subjects: 15.8% of the population and 97.2% of those who met the inclusion criteria. There were 26 (25.2%) subjects with cerebral palsy, 20 (19.4%) with Down syndrome, 11 (10.7%) with autism, and 46 (44.7%) with other conditions. The study included 103 siblings, one sibling per ID subject. The 547 ID-subjects who were not selected had a diagnosis of a rare syndrome, were younger than 12 years old, or did not have a sibling who fit the inclusion criteria. The siblings were not enrolled at the same center, since the centers specialize in disabled people. The data collection was carried out by a single examiner in two stages. In the first stage, the family’s socio-economical variables (gender, age, monthly income— in Brazilian minimum salaries, and schooling level), oral health habits, and data regarding the ID subject’s access to health services were supplied by the caregiver and registered on a form. Caregivers were asked if they had received oral health treatment at other health centers (specifying whether public or private) when it was not offered by the specialist disability center. The caregiver is the person responsible for the ID subject’s daily care, including feeding and oral hygiene. The caregiver’s role was self-reported by the person who was with the ID subject at
the time of the data collection. If the accompanying person said they were not the caregiver, data collection was postponed. The caregiver was usually the mother or the father. The second stage of data collection consisted of an oral physical examination. The centers provided permission to use their facilities for the oral examinations. These examinations were carried out in a classroom, under natural and artificial light (using a flash light), in a knee-to-knee position. Cotton roll field isolation was carried out and a dental explorer and mirror were used for the dental examination. The presence of dental biofilm was recorded using the Simplified Oral Health Assessment Index (OHI-S) modified by Greene and Vermillion.13 Basic fuchsine (Eviplac™) was used to disclose dental biofilm and the presence of dental calculus was also recorded and scored from 0 to 3. The ratio between the number of surfaces with dental biofilm or dental calculus and the number of teeth examined was used to classify the subject’s oral hygiene as: good (score below 1.2), fair (1.3 to 3), or poor (3.1 to 6). Caries experience was scored using the Decayed, Missing and Filled Teeth Index (DMF-T), following the standard methodology of the World Health Organization.14 It consists of the sum of the number of decayed and missing teeth due to caries plus the number of filled teeth divided by the number of subjects. The higher the score, the higher the caries experience. The DMF-T index was used to determine the dental treatment needs. The negative control group was submitted to the same protocol.
Statistical analysis A data bank was created using SPSS software v. 17 for Windows (2009, Cary, NC, USA). Results were analyzed using the paired student’s t-test, the chi-square test, and odds ratio at a 95% confidence interval. To measure the study’s intra-examiner accuracy, the examination was repeated for 21 randomly selected subjects (0.87 kappa was recorded for the caries index).
S p e c C a r e D e n t i s t 3 3 ( 6 ) 2 0 1 3 263
05/10/13 11:34 AM
I N T E L L E C T U A L D I S A B I L I T Y A N D I M PA C T O N O R A L H E A LT H
Table 1. Social and economical characteristics of ID and their siblings in Teresina, Brazil. Variable
ID
Age (years)
Gender Caregivers’ schooling level (years)
Income in Brazilian minimum salaries per month (US$ 261)
Siblings
N
%
N
%
12–14
18
17.5
19
18.4
15–19
40
38.8
40
38.8
20–34
43
41.7
41
39.8
34–36
2
1.9
3
2.9
Male
62
60.2
42
40.8
Female
41
39.8
61
59.2
1–5 primary
40
38.8
6–11 incomplete high-school
29
28.2
11 complete high school
27
26.2
11+ incomplete university
7
6.8
1
71
68.9
2
23
22.3
3 or 4
7
6.8
5 or up
2
1.9
Table 2. Oral health habits of ID subjects and their siblings in Teresina, Brazil. Variable
Category
ID
%
Siblings
%
p
Daily tooth brushing
Once or twice
52
50.5
29
28.2
.001
Three or more
51
49.5
74
71.8
Flossing frequency
χ2
Daily
9
8.7
33
32
Rarely
21
20.4
23
22.4
Never
73
70.9
47
45.6
