Download Comparative oral health of children and adolescents with cerebral

Journal of Disability and Oral Health (2011) 12/2 81-87
Comparative oral health of children and adolescents
with cerebral palsy and controls
Folakemi A Oredugba BDS FWACS MPH M SND RCS Ed
Department of Child Dental Health, College of Medicine, University of Lagos, Nigeria
Abstract
Objective: To determine the oral health condition of children and adolescents with cerebral palsy (CP) and compare with
controls of the same gender and age group.
Method: Participants in this study were children and young adults with CP attending three, day institutions for individuals
with disabilities. A questionnaire was used to obtain information on their bio-data, such as age, gender and educational
background of parents. An oral examination was then carried out to assess dental caries, oral hygiene status, gingivitis,
malocclusion and other dental anomalies. They were compared with controls of the same age and gender who attended
primary and secondary schools in the same area. Results: 139 subjects aged 4-19 years (mean 11.38 ± 4.36), comprising
69 (49.6%) subjects with CP, 70 (50.4%) controls; 52 (37.4%) females and 87 (62.6%) males participated in the study.
The mean dmft and DMFT of the CP group was 1.03 ± 2.5 and 1.3 ± 2.94, respectively whilst that of controls was 0.21
±0.65 and 0.13 ±0.47, respectively. Oral hygiene was good in 36.2% of CP and 68.6% of controls, and poor in 29.0% of
CP group compared with 11.4% of controls (p=0.00). Angle’s Class II malocclusion was found in 19 (27.5%) of the CP
group and 1 (1.4%) of the controls (p=0.00). Seven (10.1%) of the CP group had fractured teeth while crowding, spacing
of the anterior segment and gingivitis were more prevalent in the CP group.
Conclusion: Individuals with CP have poorer oral health than controls and are not provided with needed oral health care.
Key words: Cerebral palsy, oral health, children, adolescents
Introduction
Cerebral palsy (CP) is a neuromuscular disorder. It is defined as a group of disorders of development of movement
and posture, causing activity limitations that are attributable
to non-progressive disturbances, which have occurred in the
developing foetal or infant brain. Such disturbances include
hypoxia, trauma, infection, and hyperbilirubinaemia, but
biochemical and genetic factors may be involved (Scully
and Cawson, 2005). The motor disorders of CP are often
accompanied by disturbances of sensation, cognition, communication, perception, and/or by a seizure disorder (International Workshop on the Definition and Classification of
Cerebral Palsy: Bax et al., 2005).
CP may be classified into three main groups (Dougherty,
2009):
• Spastic (characterised by increased muscle tone)
• Dyskinetic (characterised by hypotonic, slow writhing movements (athetotic), abnormal postural control,
swallowing difficulties, problems of speech and coordination)
• Ataxic (characterised by involuntary movement, lack of
balance and depth perception).
Intellectual disability is present in a significant proportion
of individuals with CP, though the degree is variable (Bax
et al., 2005; Jones et al., 2007; Thorogood and Alexander,
2007).
The neuromuscular problems inherent in CP can affect
oral health significantly, such as changes in structure of the
orofacial region, development of para-functional habits,
feeding problems, difficulty with maintaining oral hygiene
and encountering barriers to oral care access (Dougherty,
2009).
People with CP are reported to have poor oral hygiene
and increased prevalence of dental caries, bruxism (Pope
and Curzon, 1991; dos Santos et al., 2003), malocclusion
(Franklin et al., 1996; Winter et al., 2008) and drooling
(Tahmassebi et al., 2003; Mathur et al., 2008) and traumatic
dental injuries (Holan et al., 2005). While several authors
agree on the high prevalence of poor oral hygiene (Nunn
and Murray, 1987; Pope and Curzon, 1991; dos Santos et
al, 2003; dos Santos and Nogueira, 2005), conflicting reports are observed in the literature concerning dental caries and traumatic dental injuries experience of this group of
individuals. Some authors reported increased prevalence of
dental caries (dos Santos et al., 2003; De Carmago and Antunes, 2008; Stevanovic and Jovicic, 2004), while some oth-
82 Journal of Disability and Oral Health (2011) 12/2
ers found a lower prevalence than in the populations without CP (Nielsen, 1988). Some authors attributed the high
prevalence of dental caries to prolonged use of medications
such as anticonvulsants, which have high sugar content, are
viscous and taken at night (Chambers et al, 1999; Siqueira
et al., 2007). At night, the oral pH falls below the critical
pH at which demineralisation occurs. In a study carried out
in Brazil, the high caries prevalence was attributed to poor
socioeconomic conditions, irrespective of type of CP, and
a high frequency of sugar consumption (De Carmago and
Antunes, 2008).
Previous studies carried out in Nigeria on the oral health
of children with multiple disabilities showed poorer oral hygiene and more untreated decay (Oredugba and Sote, 2001;
Oredugba and Akindayomi, 2008). This study was carried
out to assess the oral health condition and treatment needs
of children and adolescents specifically with CP and to compare findings with that of healthy controls in the same environment.
Greene and Vermillon (1964) with a total score of 6. When
the index score was 0-0.9, oral hygiene was classified as
good, 1-1.9 (fair) and 2.0 and above (poor). Malocclusion
was assessed using Angle’s classification of malocclusion
(Class I, Class II and Class III).
Other parameters examined include gingivitis, hypoplasia
of the teeth, dental staining, supernumerary teeth and congenitally missing teeth. Subjects were divided into age groups:
up to 5 years, 6-10 years, 11-15 years and 16-20 years. To
determine reliability of data collection, questionnaire was
pre-tested on ten, randomly selected subjects.
The data collected were analysed using the health statistical software - Epi Info version 6a. Findings were compared
across the CP group and controls, by age group and gender,
using descriptive statistics, student’s t-test, chi square test,
Kruskal-Wallis H test and Fisher exact test where appropriate,
with a significance level set at p = 0.05.
Materials and method
Subjects were children and young adults in three day centres
for individuals with disabilities. Consent was obtained from
head teachers and parents prior to oral examination of the
children. Permission was also obtained from the Research,
Grants and Experimentation Ethics Committee of the College of Medicine of the University of Lagos. All parents or
guardians were requested to read and sign a consent form and
complete a questionnaire (Appendix I) on their children. All
children and young adults who returned completed and signed
consent forms and a completed questionnaire and were present in the centre at the time of study were examined. Those
who reported ill were excluded from participation on that day.
Information required from the questionnaire included child’s
age, gender, previous use of dental facilities, frequency of
tooth brushing, prescribed medications being used, parent’s
educational background and occupation. Socioeconomic
background was determined by classifying the educational
level of the mother, and where she did not reside with the
child, that of the father, into:
•
•
•
Upper class – Code 1- those who attended tertiary education
Middle class – Code 2- those who had up to secondary
school education
Lower class – Code 3 – those who had primary school
education or no education.
Thereafter, each subject was examined by one examiner, under natural daylight in the different centres, for dental caries,
using the decayed, missing and filled tooth (dmft) index for
the primary dentition and Decayed Missing and Filled Teeth
(DMFT) index for the permanent dentition. Oral hygiene was
assessed using the simplified oral hygiene index (OHI-S) of
Results
A total of 139 subjects, 69 (49.6%) with CP and 70 (50.4%)
controls participated in this study. There were 52 (37.4%)
females and 87 (62.6%) males, aged 4-19 years, mean age
11.38 ± 4.36 (Table 1). Parents of the majority of the subjects (49.6%) were of low socioeconomic background. Only
12 (8.6%) from the total population under study had visited the dentist previously, comprising 11 (15.9%) of the CP
group and 1 (1.4%) of the controls (Chi sq 7.53; p= 0.006).
The mean dmft of the CP group was 1.03 ± 2.5 while that
of controls was 0.21 ± 0.65 (p=0.01). The mean DMFT of
the CP group was 1.3 ± 2.94 and the controls 0.13 ± 0.47
(p=0.00). The major component of both the dmft and DMFT
Oredugba: Comparative oral health in cerebral palsy and controls 83
was the decayed components; the mean number of decayed
primary teeth was 1.01 ± 2.32 and 0.2 ± 0.52 (p=0.06) while
the mean number of decayed permanent teeth was 1.1 ± 2.17
and 0.11 ± 0.42 in CP and controls, respectively (p=0.00).
(Table 2). The mean dmft and DMFT values according to
age group is shown in Figure 1. The mean dmft was 1.92
± 2.49 in the upper SEC of the CP group compared with
0.14 ± 0.28 in the lower SEC. The mean DMFT value was
however, higher in the lower SEC of the CP group (1.71)
compared with 0.67 in the middle SEC (p=0.00). (Table 3).
The mean OHI-S in the CP group was 1.48 ± 1.23 while
that of controls was 0.92 ± 0.84 (K-Wallis test 10.76;
p=0.00). Oral hygiene was good in 68.6% of controls and
36.2% of the CP groups while oral hygiene was poor in
11.4% of controls compared with 29.0% of the study group
(p=0.00) (Table 4). The mean OHI-S score was 0.78 ± 0.56
in the upper SEC of the CP group compared with 2.32 ±
1.39 in the lower SEC (Table 5). Oral Hygiene was good in
67.3% of females compared with 43.7% of males. Figure 2
shows the oral hygiene status according to the different age
groups in the CP group.
An Angle’s Class I occlusion was found in 48 (69.9%)
of controls and 65 (92.9%) of the CP group, while Class II
malocclusion was found in 19 (27.5%) of the CP group and
1 (1.4%) of controls (p=0.00). An Angles Class II Division
1 malocclusion was found in 9 (47.4%) of the 19 affected
young people in the CP group and an Angles Class II Division 2 malocclusion in 10 (52.6%) young people (Table 6).
A total of 7 (10.1%) of the CP group had fractured teeth.
None were found in the controls. Crowding and spacing of
the anterior segment was also more prevalent (18.8% and
17.4%) respectively, in the CP group versus the controls
(p=0.00). Gingivitis was found in 37.7% of the CP group
and 24.3% of controls, although the difference was not significant (p=0.12) (Figure 3). However, significantly more
males (40.2) than females (15.4) had gingivitis (p=0.00).
Table 1 Demographic characteristics of the study population
Variable
CP group
Control
Age (years)
Range
4 -19
Mean
11.42±4.56
Age group
<5
6-10
11-15
16-20
11.35±4.19
Total
11.38±4.36
10 (14.5)
22 (31.9)
17 (24.6)
20 (29.0)
10 (14.3)
22 (31.4)
20 (28.6)
18 (25.7)
20 (14.4)
44 (31.7)
37 (26.6)
38 (27.3)
24 (34.8)
45 (65.2)
28 (40.0)
42 (60.0)
52 (37.4)
87 (62.6)
Socioeconomic Class
Upper
Middle
Lower
17 (85)
23 (46)
29 (42)
3 (15.0)
27 (54)
40 (58)
20 (14.4)
50 (36)
69 (49.6)
Previous dental visit
Yes
No
11 (15.9)
58 (84.1)
1 (1.4)
69 (98.6)
12 (8.6)
127 (91.4)
Total
69 (49.6)
70 (50.4)
139 (100)
Gender
Female
Male
Table 2 Mean decayed, missing and filled teeth (dmft/DMFT) according to study groups
Index
CP group
dmft
1.03±2.5
0.21±0.65
p =0.01*
DMFT
1.3±2.94
0.13±0.47
p=0.00*
Decayed (d)
1.01±2.32
0.2±0.52
p=0.06
Decayed (D)
1.1±2.17
0.11±0.42
p=0.00*
*Significant
Control
84 Journal of Disability and Oral Health (2011) 12/2
Figure 1. Mean dmft / DMFT according to age group in the CP group
Table 3 Mean dmft / DMFT of the study population according to socioeconomic class
Group
Upper class
Middle class
Lower class
dmft
Study
1.92± 2.49
Control
0.58±1.1
0.14±0.28
p= 0.01*
0
0.17±0.29
0.25±0.78
p = 0.72
Study
0
0.67±0.99
1.71±2.44
p=0.00*
Control
0
0.19±0.47
0.06±0.19
p=0.29
DMFT
*Significant
Table 4 Oral hygiene status of the study population
Group
Good OH
N (%)
Fair OH
N (%)
Poor OH
N (%)
Total
N (%)
CP group
25 (36.2)
24 (34.8)
20 (29.0)
69 (49.6)
Controls
48 (68.6)
14 (20.0)
8 (11.4)
70 (50.4)
Total
73 (52.5)
38 (27.3)
28 (20.1)
139 (100.0)
Chi square
15.01
P
0.00* (Significant)
Table 5 Mean OHI-S score of the study population according to socioeconomic class (SEC)
Group
Upper SEC
Middle SEC
Lower SEC
CP
0.78±0.56
0.94±0.58
2.32±1.39
Chi square =24.57; p=0.00*
Control
0.8±0.7
0.85±0.83
0.98±0.87
Chi square=0.54;
p=0.76
*Significant
Oredugba: Comparative oral health in cerebral palsy and controls 85
Figure 2. Oral hygiene of the CP group according to age group
Table 6 Angle’s classification of malocclusion in the study population
Study group Angles I Angles II ( Div 1
Div 2)
N (%)
N (%)
N (%)
CP group
48 (69.6)
Controls
65 (92.9)
1 (1.4)
113 (81.3)
20 (14.4)
Total
CP group only: Chi sq
19 (27.5) (9 (47.4) 10 (52.6))
7.68 P
1
-
Angles III
N (%)
Total
N (%)
2 (2.9)
69 (49.6)
4 (5.7)
70 (50.4)
6 (4.3)
139 (100.0)
0.02*
Overall Chi sq 19.42 and p = 0.00*
Figure 3. Other anomalies observed in the study population
86 Journal of Disability and Oral Health (2011) 12/2
Treatment needs
Restorative treatment, including amalgam and glass
ionomer cement restorations for carious teeth and composite restoration of fractured anterior teeth was required
by 41% of the CP group, while 39.7% were thought to
benefit from orthodontic treatment. Up to 63.8% of the
CP group also required oral prophylaxis and hygiene instructions.
Discussion
Children and adolescents with CP in this study had higher
mean dmft/DMFT than controls. This finding is similar
to previous studies (dos Santos et al., 2003). Some authors did not however, observe any significant difference
in caries rate between CP individuals and controls but
found more untreated decay than in controls (Pope and
Curzon, 1991). Contributory factors might be poor masticatory muscular control which encourages food stagnation in the buccal and labial sulci and poor manual dexterity as observed in most individuals with CP. Another
contributory factor for an increase in dental caries is that
many of the children are on sweetened medications to
control seizures and other medical problems. The most
commonly prescribed anticonvulsant in our environment
is Carbamazepine, which most parents claimed they used
for their children. Most of the parents also reported using some un-disclosed herbal medicines. Prescribed anticonvulsants are sweetened, highly viscous and used at
night, which enhances the progression of dental caries
(Siqueira et al., 2007). However, from this study, it was
not possible to determine the effect of these medications
on dental caries because there were inconsistent reports
on type and dose of medication.
The mean dmft value was also found to be higher in the
CP group from the higher social class while the DMFT
was significantly higher in the lower social class. Apart
from the effect of sweetened medications, cariogenic
drinks and snacks are also affordable by parents of the
high social class to pacify and pamper their young children. With increasing age, proper surveillance on diet
and oral care reduces, especially in children of the lower
social class. Parents of high social class may be able to
afford caregivers for their children, which may not be
possible with those from the lower socioeconomic class.
Oral hygiene was also found to be significantly poorer
in the CP group than controls in this study, especially with
increasing age. Several studies have also reported poor
oral hygiene in individuals with CP (Nunn and Murray,
1987; Pope and Curzon, 1991; dos Santos et al., 2003;
dos Santos and Nogueira, 2005). The general effects of
CP on these individuals make tooth brushing difficult.
At the early age groups, they are dependent on parents
and caregivers for tooth brushing and other general body
care. As they age, they are left alone to carry out these
daily activities, which may not be done effectively.
In this study, nearly all the subjects cleaned their mouths
only once a day. The most important factors in the maintenance of good oral hygiene are the frequency and effectiveness of tooth brushing and ability to control the
masticatory musculature, which are all deficient in this
population. Parents and caregivers need to be advised on
oral health issues concerning themselves and their wards,
and that these individuals require supervision despite
their age. In a Turkish study by Subasi et al (2007), it was
observed that mothers’ irregular tooth brushing habit was
a risk factor for their children’s lack of a regular brushing
habit. Many of these subjects will benefit from assistive
devices such as electric toothbrushes and toothbrushes
with large handles.
Although gingivitis was more prevalent in the CP
group, the difference was not significant (p=0.12). The
prevalence of gingivitis was however significantly higher
in males than in females (p=0.00). Mouth breathing and
food pouching contribute to gingivitis especially in the
anterior region in individuals with CP (Scully and Cawson, 2005). Periodontal disease has been reported to be
common especially in older children with CP due to poor
oral hygiene and complications of oral habits, physical disabilities, malocclusion and gingival hyperplasia
caused by medications (National Institute of Dental and
Craniofacial Research, 2004). Mouth breathing worsens
the periodontal state and a papillary hyperplastic gingivitis may be seen even in the absence of phenytoin (Scully
and Cawson, 2005). Early routine oral care and close supervision will prevent the untoward consequence of periodontal disease.
There was a significantly higher prevalence of class
II malocclusion among subjects in the CP group in this
study, as was found in previous studies (Franklin et al.,
1996; Winter et al., 2008). Only 47.4% of those with
class II malocclusion had a class II division 1 malocclusion, in contrast to these previous studies which reported
a higher prevalence of this type of malocclusion. This
difference in the findings may be due to the smaller number of subjects examined in this study. There was also a
high prevalence of crowding of the lower and spacing of
the upper anterior segments. The class II malocclusion
has been attributed to hypotonia of the orofacial musculature and forward thrust of the tongue (Pope and Curzon,
1991; dos Santos et al., 2003). This type of malocclusion
predisposes to trauma of the anterior teeth, in addition to
the poor gait and seizures (Dougherty, 2009). The act of
placing metal objects in the mouth of children who experience seizures is still rampant in Nigeria. These objects
can cause fractures and sometimes avulsion of the anterior teeth. This practice is being discouraged during oral
health education programmes.
Subjects with CP in this study showed a higher prevalence of crowding, spacing and anterior open bite. These
Oredugba: Comparative oral health in cerebral palsy and controls 87
are all problems associated with abnormal positioning
of tongue and cheek musculature, which are common
in such individuals. Myotherapy and orthodontic appliances may help in relieving some of these anomalies in
carefully selected subjects.
From this study, 41% required restoration of carious
and fractured teeth, 39.7% some form of orthodontic
treatment and 63.8% oral prophylaxis. This treatment
need is quite significant and it shows that individuals
with disabilities are still not able to access required oral
health care, especially since quite a number had attended
the dental clinic previously. Although more subjects in
the CP group attended the clinic than the controls, it was
observed that these individuals only attended the clinic
for emergencies. Behaviour management can be a challenge for dentists, as was reported in a previous study on
Nigerian dentists (Oredugba and Sanu, 2006).
Provision of dental treatment can be made more comfortable for both the patient and dentist through the use
of mouth props, stabilisation and postural maintenance
with cushions and physical interventions adapted for the
individual patient (Dougherty, 2009). Dental professionals should be provided with such assistive devices in the
clinics that will enhance effective behaviour management. This disability should also not be a barrier to receiving advanced restorative and orthodontic care which
will eventually reduce discomfort and improve mastication. Orthodontic treatment can be provided to such patients where there is cooperation and support from the
parent and / or caregiver.
The introduction of institutional/community outreach
in some dental schools in Nigeria will go a long way in
addressing the issue of better access to care, which should
also be extended to other dental institutions (Oredugba
and Akinwande, 2008).
It is concluded from this study that individuals with CP
have poorer oral health and greater treatment needs than
controls and have not received needed oral health care.
Acknowledgments
The author appreciates the cooperation of head teachers and parents of the special schools visited during this
study.
References
Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B,
Jacobsson B, Damiano D. Proposed definition and classification of
cerebral palsy. Dev Med Child Neurol 2005; 47: 571-576.
Chambers HG, Weinstein CH, Mubarak SJ, Wenger DR, Siva PD. The
effect of valproic acid on blood loss in patients with cerebral palsy.
J Pediatr Orthop 1999;19:492-495
De Camargo MA, Antunes JL. Untreated dental caries in children with
cerebral palsy in the Brazilian context. Int J Paed Dent 2008; 18:
131-138.
Dos Santos MTBR, Masiero D, Novo NF, Simionato MR. Oral
conditions in children with cerebral palsy. J Dent Child 2003; 70:
40-46.
dos Santos MTBR, Nogueira MLG. Infantile reflexes and their effects
on dental caries and oral hygiene in cerebral palsy individuals. J
Oral Rehab 2005; 32:880-885.
Dougherty NJ. A review of cerebral palsy for the oral health
professional. Dent Clin N Am 2009; 53: 329-338.
Franklin DC, Luther F, Curzon ME. The prevalence of malocclusion
in children with cerebral palsy. Eur J Orthod 1996; 18: 637-643.
Greene JC, Vermillon, JR. The Simplified Oral Hygiene Index. J Amer
Dent Assoc 1964;68: 7-13.
Holan G, Peretz B, Efrat J, Shapira Y. Traumatic injuries to the teeth
in young individuals with cerebral palsy. Dent Traumatol 2005;
21:65-69.
Jones MW, Morgan E., Shelton JE. Cerebral Palsy: Introduction and
diagnosis (Part I) J Pediatr Health Care 2007; 21: 146-152.
Mathur NN, Vaughan TL. Drooling: eMedicine. Available at: www.
emedicine.com/ent/topic629.htm. Accessed August 1 2008.
National Institute of Dental and Craniofacial Research. Practical
oral care for people with cerebral palsy. National Oral Health
Information Clearinghouse, Bethesda, MD; 2004.
Nielsen LA. Caries among children with cerebral pals. Proceedings of
the 9th Congress of the International Association of Dentistry for
the Handicapped. Philadelphia, PA. August 7-10, 1988.
Nunn JH, Murray JJ. The dental health of handicapped children in
Newcastle and Northumberland. Br Dent J 1987; 62: 9-14.
Oredugba FA, Akindayomi Y. Oral health condition and treatment
needs of children and young adults attending a day institution for
individuals with special needs. BMC Oral Health 2008; 8: 30.
Oredugba FA, Akinwande JA. Preparedness of dental undergraduates to
provide oral healthcare to individuals with special needs in Nigeria.
J Disabil Oral Health 2008; 9:81-86.
Oredugba FA, Sanu OO. Knowledge and behaviour of Nigerian
dentists concerning the treatment of children with special needs.
BioMedCentral Oral Health 2006; 6: 9.
Oredugba FA, Sote EO. Oral hygiene Status of handicapped children
in Lagos. Nig J Gen Pract 2001; 5: 75-79.
Pope JEC, Curzon MEJ. The dental status of cerebral palsied children.
Pediatr Dent 1999; 13:156-162.
Scully C, Cawson RA. Neurological disorders I: Epilepsy, stroke and
craniofacial neuropathies. In: Medical Problems in Dentistry. 5th
Edition. pp297-298. Elsevier, Churchill Livingstone, 2005.
Siqueira WL, dos Santos MT, Elangovan S, Simoes A, Nicolau J. The
influence of Valproic acid on salivary pH in children with cerebra
palsy. Spec Care Dentist 2007; 27: 64-66.
Stevanovic R, Jovicic O. Oral health in children with cerebral palsy.
Srp Arh Celok Lek 2004; 132: 214-218.
Subasi F, Mumcu G, Kokksal L, Cimilli H, Bitlis D. Factors affecting
oral health habits among children with cerebral palsy: pilot study.
Pediatr Int 2007; 49: 853-857.
Tahmassebi JF, Curzon MEJ. Prevalence of drooling in children with
cerebral palsy attending special schools. Dev Med Child Neurol
2003; 45: 613-617.
Thorogood C, Alexander MA. Cerebral Palsy: eMedicine. Available at:
www.emedicine.com/topic24.htm. Accessed December 12 2007.
Winter K, Baccaglini L, Tomar S. A review of malocclusion among
individuals with mental and physical disabilities. Spec Care Dent
2008; 28: 19-26.
Address for correspondence:
Dr F Oredugba
Department of Child Dental Health
College of Medicine
University of Lagos PMB 12003
Nigeria
Email: [email protected]