|Year : 2013 | Volume
| Issue : 1 | Page : 17-22
Oral hygiene status of mentally and physically challenged individuals living in a specialized institution in Mohali, India
Supreet Kaur1, Ranjan Malhotra2, Reefat Malhotra1, Harjit Kaur3, Virinder Singh Battu2, Amandeep Kaur2
1 Department of Periodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
2 Department of Periodontology and Oral Implantology, National Dental College and Hospital, Dera Bassi, Punjab, India
3 Department of Periodontics and Community Dentistry, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, India
|Date of Submission||13-Jul-2012|
|Date of Acceptance||02-Apr-2013|
|Date of Web Publication||20-Sep-2013|
Department of Periodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar - 143 001, Punjab
Source of Support: None, Conflict of Interest: None
Aim: To assess the oral hygiene and periodontal status of a group of mentally and physically challenged people living in a specialized institution in Mohali, Punjab, India.
Materials and Methods: Study sample comprised of 100 subjects who were either mentally challenged, physically challenged, or both, living in the All India Pingalwara Society, Palsora, Mohali, Punjab. Oral hygiene status was assessed by simplified oral hygiene index (OHI-S) and marginal line calculus index (MLCI). A comparison was made between mentally challenged and physically challenged groups. Analysis of variance and chi square tests were applied.
Results: Of the 100 subjects included, the mentally challenged group had the worst oral hygiene scores. The mean OHI-S scores of mentally challenged, physically challenged, and both mentally and physically challenged groups were 4.956 (standard deviation, 1.236), 2.581 (1.491), and 4.819 (1.752), respectively. The mean MLCI scores of mentally challenged, physically challenged, and both mentally and physically challenged groups were 77.972 (23.778), 30.529 (25.083), and 75.595 (31.181), respectively.
Conclusion: This study highlights the poor oral hygiene status of the study population. The oral hygiene levels were worst in the mentally challenged group. The social services, public health authorities, and dental professionals should come together to improve this condition.
Keywords: Mentally challenged, oral hygiene status, physically challenged
|How to cite this article:|
Kaur S, Malhotra R, Malhotra R, Kaur H, Battu VS, Kaur A. Oral hygiene status of mentally and physically challenged individuals living in a specialized institution in Mohali, India. Indian J Oral Sci 2013;4:17-22
|How to cite this URL:|
Kaur S, Malhotra R, Malhotra R, Kaur H, Battu VS, Kaur A. Oral hygiene status of mentally and physically challenged individuals living in a specialized institution in Mohali, India. Indian J Oral Sci [serial online] 2013 [cited 2019 Jul 15];4:17-22. Available from: http://www.indjos.com/text.asp?2013/4/1/17/118515
| Introduction|| |
The disabled people form a substantial section of the community, and it is estimated that worldwide there are about 500 million people with disabilities.  The National Sample Survey Organization Report (2002) suggests that the number of disabled persons in India is estimated to be around 18.49 million, which forms to about 1.8% of the total population. 
"The persons with disabilities act, 1995" states the responsibility of the state toward protection of rights of persons with disabilities; provision of medical care, education, training, employment, and rehabilitation. There is no legislation till date that makes a provision of dental services to the disabled population.  People with disabilities deserve the same opportunities for oral health and hygiene as those who are healthy, but sadly dental care is the most common unmet health care need of the disabled people. 
Oral health is a vital component of overall health, which contributes to each individual's well-being and quality of life by positively affecting physical and mental well-being, appearance, and interpersonal relations.  Most handicapped individuals start their lives with teeth and gums that are as strong and healthy as those of the normal people. However, their diet, eating pattern, medication, physical limitations, lack of cleaning habits, and attitudes of parents and health care providers, all contribute to poor oral health of the handicapped people. 
Their oral health condition may be influenced by age, severity of impairment, and living conditions. Individuals with special needs may have great limitations in oral hygiene performance due to their potential motor, sensory, and intellectual disabilities, and so are prone to poor oral health. ,,
Those who are very young, those with severe impairments, and those living in institutions are dependent on parents, siblings, or care givers for general care including oral hygiene. Many care givers do not have the requisite knowledge or values to recognize the importance of oral hygiene and do not themselves practice appropriate oral hygiene or choose a proper diet.  Many of them are emotionally or intellectually incapable of dealing with the health problems of their less fortunate affiliates. 
In recent years, there have been an increasing number of studies concerning the dental health of normal population. However, very little attention has been paid to the dental health of the physically and mentally challenged individuals, who actually require special care and attention.
A very few or no studies for this special group of handicapped are available in this part of Punjab. Hence, an attempt is made in the present study, to assess oral hygiene status of the physically and mentally challenged people living in the All India Pingalwara Society at Palsora, Mohali, Punjab.
| Materials and Methods|| |
All information and observations were done according to WHO's 1987 recommendations. Oral hygiene index - simplified (OHI-S) and marginal line calculus index (MLCI) were taken to assess the oral hygiene of these patients.
Individuals with severe mental retardation or serious medical disorders and those who were highly uncooperative were excluded from the study.
The study was well planned and arranged for maximum efficiency and ease of examination. The patients were examined on a chair or stool with examiner standing behind the chair. Instruments were placed within the easy reach of the examiner. Platform table was used to keep the instruments and recording forms. The recording assistant was allowed to sit close enough to the examiner, so that the instructions and codes could be easily heard and the examiner could see that the findings were being recorded correctly.
Oral hygiene status was examined by using a probe, an explorer and a plane mouth mirror. Examination was carried out by the investigator and recorded by a trained recorder throughout the study. Light source: In all the locations, natural light was used and the subject was placed in such a way that maximum illumination was obtained. Sufficient numbers of sterilized instruments were taken to avoid the interruption during examination. Chemical method of sterilization was followed using Savlon and concentrated Betadine solution. After survey, all the instruments were autoclaved.
The ethical approval for conduct of the study was availed from ethical committee for research of National Dental College and Hospital, Dera Bassi.
Oral hygiene index: Simplified
Six index teeth were selected with one surface each to be examined for both the components. 
Criteria for recording:
The OHI-S score for the individual is total of debris index and calculus index.
- Only fully erupted permanent teeth are scored.
- Natural teeth with full crown restorations and surfaces reduced in height by caries or trauma are not scored. In this case, second or third molars are scored and in anterior region the central incisor on the opposite side of the midline is substituted.
The values for DI-S and CI-S may range from 0 to 3.
The OHI-S values range from 0 to 6
Marginal line calculus index
In this index, only the cervical areas on the lingual surfaces of the mandibular right and left, central and lateral incisors are examined.  The cervical third of each lingual surface is divided into a distal half and a mesial half. A score on the scale of percentage is given as 0, 12.5, 25, 50, 75, and 100%.
MLCI per tooth = average of 2 units for each tooth.
MLCI score per person = totaling the score per tooth/number of teeth examined.
Statistical data analysis
Data were entered into the spread sheets and were analyzed using the Statistical Package for the Social Sciences (17.0 J for Windows; SPSS Japan). One-way analysis of variance (ANOVA) was used to test the differences in the mean scores of oral hygiene indicators. Chi square tests were used to test the differences in frequencies between various groups and for the prevalence of periodontal disease.
| Results|| |
[Table 1] illustrates the general profile of the study group. There was unequal age group and gender distribution. Of the total study population, 47% was less than 30 years of age. Sixty-seven percent of the study population was males. More than half the population (53%) was mentally challenged, 26% were physically challenged, and 21% were both mentally and physically challenged. Physically challenged subjects were subcategorized according to the nature of handicap; they were divided into orthopedic, blind, and compound handicap groups. The compound subgroup was separated and made into a new group 'both physically and mentally challenged' to simplify the results, as the individuals have characteristics of both. Orthopedic handicap group comprised of 26% of physically challenged. Blind patients being very less in number (only 1) were not included in the study. Only 30% of the population self-brushed, whereas 70% brushed with assistance.
[Table 2] shows the mean OHI-S and MLCI scores of the individual groups. There was statistically significant difference (P < 0.001) between mentally challenged and physically challenged subjects for mean score of both OHI-S and MLCI scores. The mentally challenged group had the highest scores of the indices recorded. Sixty-nine percent of the total population had poor oral hygiene index scores, 25% had fair, whereas only 6% had good oral hygiene index scores [Table 3]. Most of the poor oral hygiene scores belonged to the mentally challenged group [Figure 1]. The mean MLCI [Figure 2] of the mentally challenged, physically challenged, and both physically and mentally challenged groups was 77.792, 30.529, and 75.595, respectively. Of the physically challenged people who brushed with assistance, 60.9% had fair oral hygiene levels, 21.7% had good oral hygiene levels, whereas only 17.4% had poor levels of oral hygiene [Figure 3]. Maximum number of people from the mentally challenged group who had poorest MLCI scores were those who self-brushed [Figure 4].
|Figure 3: Comparison of three groups of OHI-S with number of people who self-brush or brush by assistance|
Click here to view
|Figure 4: Comparison of three groups of OHI-S with number of people who self-brush or brush by assistance|
Click here to view
|Table 3: OHI-S and MLCI levels of no. of subjects of different disability groups, further divided by those who self brush or brush by assistance|
Click here to view
| Discussion|| |
The removal of plaque and debris from the teeth is a skill that can be mastered only when an individual has the dexterity to manipulate the toothbrush and understands the objectives of these activities.  Most of the studies , performed for evaluating the oral hygiene status of disabled people found poor oral hygiene levels, which is confirmed in this study as well.
Nicolaci and Tessini  had observed that the high prevalence of poor oral hygiene among handicapped individuals is usually more evident in the mentally retarded, and there seems to be a correlation between the levels of oral hygiene and severity of the handicap. The reasons for poor oral hygiene in disabled children have been attributed to low powers of concentration and lack of motor skills. 
The present study also revealed that there is a significant difference in the oral hygiene levels of those who are mentally challenged and those who are physically challenged. Rao et al.,  also reported in 2005 that the oral hygiene levels in physically challenged children were better than mildly, moderately, and severely intellectually disabled children in their study. The mean OHI-S of physically challenged children in their study was found to be better (2.39 ± 1.29) as compared with that of the present study (2.581 ± 1.491). The better oral hygiene levels in physically challenged people can be attributed to the fact that they are able to understand the need for practicing good oral hygiene and are able to comprehend instructions given by care givers.
The mentally challenged group on the other hand had much poorer levels of oral hygiene. The overall mean OHI-S of mentally challenged subjects was found to be 4.956 ± 1.236, which is poorer than that found by Kumar et al.,  (3.80 ± 1.42) in 2009 in Udaipur, India. The mentally challenged individuals who brushed with assistance had a little better levels of oral hygiene as compared with those who self-brushed. In another study by Hashim et al.,  there was a statistically significant difference in the plaque and gingival indexes among the mentally disabled children who brushed their teeth themselves and those who were helped by others, with higher plaque scores in children who used to brush their teeth themselves than those who were helped by other persons.
Therefore, it can be stated that the most important variable in determining oral health status is the type of disability and how that disability impacts the maintenance of adequate or sound oral hygiene.  Some other explanations for the poor oral hygiene levels among the disabled may be a lack of knowledge about good oral hygiene practices among the concerned authorities, lack of motivation, the low priority given to oral health care in the society, and the generally poor socioeconomic status of parents or guardians. 
It is observed that the disabled individuals are generally incapable of obtaining an adequate oral hygiene level by manual brushing because of their limited motor skills and lack of knowledge of oral hygiene and effective brushing technique.  Some suggest that complete plaque removal with a conventional toothbrush is not realistic for this group. ,, According to some investigators, electric tooth brushes are especially well suited for people with reduced motor skills. , A specially designed manual toothbrush called the triple-headed brush has also been developed, which is designed to clean the oral, buccal, and occlusal surfaces of the teeth with a single stroke and is recommended for certain individuals with limited manual skills.  The local authorities and NGOs should come together and help the institutions in purchasing such type of aids for the disabled people.
| Conclusion|| |
According to the present study, the mentally challenged individuals have poor levels of oral hygiene, even more so in comparison with the physically challenged individuals living in the same institution. People with disabilities require a unique set of medical services that parents, guardians, and care givers are often familiar with, but the complications arising from oral health can be equally challenging and are often not managed well. This emphasizes the critical need of a frequently applied oral hygiene measure by dental professionals. The dental profession should be aware of its responsibilities and be prepared to play its part in improving the dental health of disabled individuals. Prevention should be the main objective, as these patients are often apprehensive and uncooperative in the dental clinic. Adequate follow-up of daily oral hygiene practices in self-sufficient handicapped individuals is needed. There is a strong need for improved education on chemical plaque control and in-service training programs on oral hygiene to the concerned groups. Parents and care givers should also be given suitable oral health education.
Even though many efforts have been made in the western world for improving the oral health status of disabled individuals, not much attention is given to this serious issue in India.  The health authorities, social services, medical and dental professionals should come together to alleviate the oral health negligence faced by this group. The present study is limited by small number of subjects present in the institution who were cooperative during the examination.
| References|| |
|1.||Watson N. Barriers, discrimination and prejudice. In: Nunn J, editor. Disability and Oral Care. London: World Dental Press Ltd; 2000. p. 15-28. |
|2.||Disabled persons in India. National Sample Survey Organization. Report No. 485 (58/26/1); 2003: A1. |
|3.||Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants of oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent 2009;27:151-7. |
|4.||Hennequin M, Faulks D, Roux D. Accuracy of estimation of dental treatment need in special care patients. J Dent 2000;28:131-6. |
|5.||Rao D, Hegde A, Munshi AK. Oral hygiene status of disabled children and adolescents attending special schools of South Canara, India. Hong Kong Dent J 2005;2:107-13. |
|6.||Kamatchy KR, Joseph J, Krishnan CG. Dental caries prevalence and experience among the group of institutionalized hearing impaired individuals in Pondicherry-A descriptive study. Indian J Dent Res 2003;14:29-32. |
|7.||Nunn JH. The dental health of mentally and physically handicapped children: A review of the literature. Community Dent Health 1987;4:157-68. |
|8.||Kamen S, Crespi P, Ferguson FS. Dental management of the physically handicapped patients. In: Special and Medically Compromised Patients in Dentistry. PSG Publishing Co, Inc; 1989. p. 25-6. |
|9.||Dahle AJ, Wesson DM, Thornton JB. Dentistry and the patient with sensory impairment. In: Special and Medically Compromised Patients in Dentistry. PSG Publishing Co, Inc; 1989. p. 66-7. |
|10.||Bonito AJ. Executive summary: Dental care considerations for vulnerable populations. Spec Care Dentist 2002;22:5s-10s. |
|11.||Friedrich WN, Friedrich WL. Psychosocial assets of parents of handicapped and nonhandicapped children. Am J Ment Defic 1981;85:551-3. |
|12.||Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13. |
|13.||Mühlemann HR, Villa PR. The marginal line calculus index. Helv Odontol Acta 1967;11:175-9. |
|14.||Pinkham JR. Oral hygiene in children: Relationship to age and brushing time. J Prev Dent 1975;2:28-31. |
|15.||Hashim NT, Gobara B, Ghandour I. Periodontal health status of a group of (Non-institutionalized) mentally disabled children in Khartoum state. J Oral Health Community Dent 2012;6:10-3. |
|16.||Nicolaci AB, Tesini DA. Improvement in the oral hygiene of institutionally mentally retarded individuals through training of direct care staff: A longitudinal study. Spec Care Dentist 1982;2:217-21. |
|17.||Full CA, Kerber PE, Boender P, Schneberger N. Oral health maintenance of the institutionalized handicapped child. J Am Dent Assoc 1977;94:111-3. |
|18.||Unkel JH, Fenton SJ, Hobbs G Jr, Frere CL. Tooth brushing ability is related to age in children. ASDC J Dent Child 1995;62:346-8. |
|19.||Kendall NP. Differences in dental health observed with in a group of non-institutionalized mentally handicapped adults attending day centres. Community Dent Health 1992;9:31-8. |
|20.||Mitsea AG, Karidis AG, Donta-Bakoyianni C, Spyropoulos ND. Oral health status in Greek children and teenagers, with disabilities. J Clin Pediatr Dent 2001;26:111-8. |
|21.||Gizani S, Declerck D, Vinckier F, Martens L, Marks L, Goffin G. Oral health condition of 12-year-old handicapped children in Flanders (Belgium). Community Dent Oral Epidemiol 1997;25:352-7. |
|22.||Rao DB, Hegde AM, Munshi AK. Caries prevalence amongst handicapped children of South Canara District, Karnataka. J Ind Soc Pedo Prev Dent 2001;19:67-73. |
|23.||Waldman HB, Perlman SP. Deinstitutionalization of children with mental retardation: What of dental services? ASDC J Dent Child 2000;67:413-7. |
|24.||Jongenelis AP, Wiedemann W. A comparison of plaque removal effectiveness of an electric versus a manual toothbrush in children. ASDC J Dent Child 1997;64:176-82. |
|25.||Doğan C, Alaçam A, Așici N, Odabaș M, Seydaoğlu G. Clinical evaluation of the plaque removing ability of three different toothbrushes in a mentally disabled group. Acta Odontol Scand 2004;62;350-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Oral Hygiene Status, Periodontal Status, and Periodontal Treatment Needs among Institutionalized Intellectually Disabled Subjects in Kolhapur District, Maharashtra, India
| ||Nilima S. Kadam,Rahul Patil,Abhijit N. Gurav,Yojana Patil,Abhijeet Shete,Ritam Naik Tari,Dhanashree Agarwal,D. T. Shirke,Prashant Jadhav |
| ||Journal of Oral Diseases. 2014; 2014: 1 |
|[Pubmed] | [DOI]|