Dental study of handicappedchildren attending special schools inBirmingham, UK

Dentistry for HandicappedLinda Shaw, Elizabeth T. Maclaurinand T. Donaid FosterDepartment of Childrens Dentistry andOrthodontics, Ttie Dental School, University ofBirminghann, Birmingham, England

Shaw L, Maclaurin ET, Foster TD: Dental study of handicapped children attendingspecial sehools in Birmingham, UK. Community Dent Oral Epidemiol 1986; 14:24-7,

Abstract - The prevalence of dental caries, the levels of oral hygiene and theperiodontal treatment requirements were assessed in 3562 handicapped childt-en and1344 randomly selected normal children attending schools in Birtningham, UK,The effect of different types of hat-tdicapping condition on these paratneters was alsoevaluated. This investigation showed that there were few differences in caries preva-lence when compat-ing handicapped childt-en with children attending nortrtal schools.However, the provision of dental cat-e showed significant differences, with thehandicapped children receiving less restorative treatment. There were also sig-nificantly poorer levels of oral hygiene and a greater prevalence of periodontaldisease in the handicapped children attending special schools. The type of handicap-ping condition had a significant effect on the periodontal problems observed; thosechildren with mental retardation having the poorest levels of oral hygiene and thegreatest periodontal treatment requirements.

Key words: dental caries, epidemiology;handicapped children; orai hygiene;periodontal treatment requirements

L. Shaw, Department of Childrens Dentistry &Orthodontics, Birmingham Dental Schooi, St.Chad's Queensway, Birmingham B4 6NN,England

Accepted for publication 6 June 1985

The Court Report "Fit for the future"(1) recommended that the dental healthof handicapped children should bebrought up to, and tnaintained at, thelevel of that provided for other children.This recommendation was biised uponprevious studies which showed higherlevels of untteated dental disease inhandicapped children than in nonnalchildren (2, 3), However, ANtjRRSON (4,5) has recently reported a fall in theprevalence of caries in normal children,

BROV/N & ScHOtJEL (6) reviewed 32studies of handicapped children and re-ported that they tended to have pooreroral hygiene than their nonnal counter-parts and a greater prevalence tind in-creased severity of periodontal disease.Comparison between studies was difficultbecause of lack of comtnon indices,but there was a suggestion that oral hy-giene was less adequate and deterioratedmore with age in subjects with cerebralpalsy and mental retat-dation, includingDo-wn's Syndrome, The available datadid not permit comparison between vari-ous handicapped gt-oups.

The aims of the present study were,therefore, firstly to assess the prevalenceof dental caries, the levels of oral hygiene

and the periodontal treattnent tequire-ments of the special school children; sec-ondly, to compare the data from theseparatneters with that from a group ofchildt-en attending normal schools; and,thirdly, to investigate the effect of differ-ent types of handicap on these factors.

Material and methods

In Birti-iingham in 1981 there were 3562children on the school rolls attending 44special schools and speeial units. Mostof the ehildren lived at home, and noneof the children were institutionalized ona permanent basis. These childt-en t-epre-sent the tnore severely handicapped asit is present educational and paediatricpolicy to integrate as many handicappedchildren as possible wilhin normalschools. At the titne of exatnination thenumber of special school children avail-able was 3423. The Area Dental Officer.selected eight nonnal schools as beingrepresentative of the city's population.From these .schools 1344 ehildren werecompletely randotnly selected to form acontrol group.

Initial training and calibt-ation of theexaminer was followed by a pilot study

to finalise the diagnositic eriteria. In or-der to check examiner t-eproducibililyand determitie any possible shift in diag-nostic standat-ds, one of the specialschools was selected randomly by an ad-ministrative assistant at the conclusionof the study and all the children werere-exatnined. The school was thereforeunknown to the examiner at the time ofthe original a,s,sesstnents, A random 10%of children in the control group was alsore-examined.

All children were examined while seat-ed in a school chair or in their wheel-chairs. Illumination was provided by anAnglepoise latnp wilh 60 watt bulb. Afterdrying the teeth with a dental napkinthe examination was carried out using anAsh No, 3-plane mouth mirrot-.

Diagnostic criteria I

Caries - The caries status was recordedusing the DMFT index (7), A tooth wasregarded as "deeayed" if, in the opinionof the examiner, after visual inspectionthere was a carious cavity that requiredfilling, extractioti or pulp treatmeiil. Ifdoubt existed the tooth was investigatedwith a 0,4 mm blunt probe and unless

Dental study of Birtninglunn handicapped children 25

Table L 5, 8, 12 and 15 yr olds: tnean DMFT, tnean dmft and component pat-ts

AgeSchoolgroup

No. atrisk DMFT D M

No. atF risk dmfl

12

12

15

15

SpecialNoniial

SpecialNormal

Special

Not-tnal

Special

Normal

91105

203103

335

99

358

116

2.962.77

11.1211.27

23,32

24.13

26.89)

127.37)

:

0.510.35

1.60

1.65

3.58

3.48

-

0.13*0.01*

0.17))*

0.05)

0.40

0.22

:

0.08

0.23

0.33

0.58

0.28

-

0.300.32

1.20

1.26

2.59

2.98

19.2619.43

12.101L84

4.95

5.13

2.00

1.33

1.050.77

2.251.90

-

-

-

_

0.570.38

0.83*0.45*

-

-

-

0.29O.IO

0.780.50

-

-

-

_

0.200.30

0.640.96

-

-

-

Mean of total population11.9

Mean of total population10.5

Speeial

Not-tnal

3218

1344

1.85))**

1.44)

0.21))**

0.11)

0.29))**

0.16)

1.35))*

1.17)

1.36

1.56

0.52))*

0.54)

0.42

0.34

0.42))*

0.68)

* P<0.05: **P<0.0\

the point entet-ed the lesion the tooth wasrecorded as sound. The catching of theprobe in a pit or fissure was not enoughto warrant the diagnosis of caries unlessthere was additional visual evidence ofit. This was sitnilar to the criteria usedin the 1983 Btitish Childten's DentalHealth Survey (8).

Otal hygiene status - Oral hygiene wasrecorded using the "Good, Fait-, Poor"index of ,IAMES et cd. (9). Teelh were clas-sified as "good" if no plaque was visible,"fair", if there was a small quantity ofplaque of appat-ently t-eccnt origin and"poor" if thet-e was considerable plaqueof long standing. One score was madefor the whole tnouth. The presence orabsence of calculus was also t-ecorded,

Periodontal treatment requirements -The children were classified as requiringa) oral hygiene instruction only, b)prophylaxis and oral hygiene instruction,or c) t-equiring assessment by a dentalsurgeon with a view to mote cotnplextreatment.

The data processing was carried outusing the following statistical tests:

Main study:Quantitative data: F test 1 = ]/FQualitative data x̂ test,

Reproducibility studies:Quantitative data: paired /-test.Qualitative data: x̂ test.

Results

At the time of the examination, the nutn-ber of speeial school children in Birtn-ingham was 3423, Qf these 3218 (94%)

wete examined, fn comparison with thenot-tnal population the age distributionof the special schoolchildt-en was tnark-edly skewed: 21 % of special school child-ren were aged 8 or less whilst 32"/o wet-eaged 14 yr or more. The cotnpai-able fig-ures for the normal population were 35%and 22%. The mean age of the specialschool children was 1.4 yr greater thanthe normal children.

Caries prevalence

A cotnparison of age groups when con-sidering caries experienee is mot-e t-ealisticbecause of the skewed age distribution.Table 1 gives the prevalence of caries innonnal and special schoolchildren for to-tal gt-oups and at the ages of 5, 8, 12 and15 yr to enable this cotnparison. At evet-yage the handicapped children were foundto have fewer teeth at risk. Amongst thespecial schoolchildren 36% were foundto be caries free compared to 42% olnormal children. It was found that whilst

the handicapped children attending spe-cial schools tended to have a slightlyhigher mean DMF at no age was thedifference significant. When the totalgroups were compared there was a sig-nificant difi'erence between them, with aDMF of 1,85 in special schoolchildrencompat-ed with 1.44 in the normal sehoolpopulation. This obviously reflects theage discrepancy. However, when theeotnponent parts of the tnean DMF wereanalysed by age group, there were differ-ences in the pt-o vision of care. The handi-capped children in special schools tendedto have tnore missing and decayed andfewer filled teeth than their normalcounterparts. The decayed eotnponent inthe pertnanent dentition was statisticallysignificantly higher in the handicapped 8atid 12 yr olds (P<0,05),

When the caries experience of thehandicapped children was analysed bytheir major handicapping condition, al-though the mean DMF's ranged from2,16 in the childt-en with epilepsy to 1.00

Table 2. All special schoolchildt-en: caries experience by major handicap: mean DMFT

Handicap

VisionHearingMetitally tetatdedEpilepsyMaladju,stedPhysically handicappedSpeeeli or languageBlood disotdet-sAulistnHeart

n

171240

172033

375502109

74318

Meanage

11.711.012,211,512.711.19.2

10.111,211,4

DMFT

1.821.761,882,162,131,771.06LOO1,26L94

D

0.230.180.220.260,190.200.15

.-0.100.35

M

0.270.230.320.260,290.300.17 (0.17 {0.15

-

F

,321.35.34.65.65.27

).74),83,00,59

26 SllAV/ ET AL,

Table 3. 5, 8, 12 and 15 yr olds: oral hygiene, calculus and periodontal treatment requirements

Age School groupOral hygiene %

Good Fail- PoorCalculus % Periodontal treatment tequitetnents %

present None Prophy Dentist assessment

55

88z'

1212

z'1515

z'All agesAll ages

z-* P<0.Q5. **

SpecialNormal

SpeeialNormal

SpecialNormal

SpecialNormal

SpecialNormal

P<O.Ol.

91105

203103

33599

358116

32181344

1191

5467

4965

5165

5273

207

6.833**

4329

4.101*

4631

7.267*

3934

12.159**

4124

161.817**

31

34

54

101

73

24

1912

1.417

3031

0.107

3732

0.936

2616

57.690**

7794

4768

4461

4335

4570

236

6.833**

5232

10.405**

5336

7.459**

5144

11.045**

5029

217.190**

00

10

33

61

51

in the children with blood disorders (Ta-ble 2), these groups had very low num-bers of children. None of the dilTerencesin mean DMF or in the individual com-ponents achieved statistical significance.

Oral hygiene status

There were highly significant differencesin oral hygiene performance betweennormal and special schoolchildren (Table3) "Good" oral hygiene was recorded in1,684 (52%) of the special schoolchildrenand in 1976 (73%) of the normal school-children, "Poor" oral hygiene was foundin 215 (7%) of handicapped and 42 (3%)of normal children. There was also ahighly significant difference in the pres-ence of calculus between the two groups;calculus was present in 875 (27%) of thehandicapped and 223 (16%) of the nor-mal children. These differences in ot-alhygiene and the presence of calculus wereshown in each year age group.

Although there was very little differ-ence in caries experience between thechildren with varying handicapping con-ditions, there were significant differencesin oral hygiene standards (Table 4),Those children classified as "mentally re-tarded" were least likely to have "good"oral hygiene; only 43% were so classified.Of the physically handicapped 58% had"good" oral hygiene compared to 66%of the maladjusted and 69% of the deafchildren. Although there were only sevenchildreti in the group with blood dis-orders, all of them were classified ashaving "good" oral hygiene,

Periodontai treatment requirements

In tertns of periodontal treattnenl re-quirements, 1637 (51%) of the handi-capped and 389 (29%) of the normalchildren required a prophylaxis while 96(3%) of the special schoolchildren and

15 (1%) of the normal childt-en requiredperiodontal assesstnent by a dentist,

1

Reproducibiiity of diagnosis i

There were no statistically signifieantdifferences found in the tooth analysesor in the eotnponent parts of the DMFTindex in the randomly selected 10% ofthe normal school population who werere-examined when the first and secondexaminations were eotnpared. Althoughmore variation was observed in the as-sesstnent of oral hygiene, calculus andperiodontal treatment requiretnents,none of these differences were statisti-cally significant,

Howevet-, although there were also nosignificant differences in mean DMFTbetween the first and second examina-tions of the special schoolchildren, whenan analysis was carried out on the "de-cayed" and "filled" fraction, there were

Table 4. All speeial sehoolehildren:

Group

VisionHearingMentally t-etardedEpilepsyMaladjustedPhysieally handicappedSpeeeh or languageBlood disordersAutismHeat-l

oral hygiene and |

No.

171240

172033

375502109

74318

OralGood

60694348665869

1007267

leriodontal

1 hygiene %

tt-eatment requiretnenls by tnajor

1

Fair Poor

36294842313730

2628

4299351

25

Calculus %present

38232842222621289

33

handicap

Periodontal trealtnentNone

35614039614958727044

Prophy

65365761364742283056

requireinetits "/oDentist assessment

033034

-

.1J

" • - !

' j

'•A%^i

.3

'1

Dental study of Birmittgliam handicapped children 27

found to be a significantly greater nutn-ber of restorations at the second exam-ination and a lower nutnber of cariouslesions (t = 2,ll, 28 df, P<0.05). It wasdiscovet-ed that restorative care had beenprovided for sotne childt-en in the periodthat had elapsed between the two exam-inations.

Discussion

The main findings in this present studyshow that the caries pt-evalence was verysimilar in the childt-en in special schoolswhen compat-ed with those in nonnalschools. It is invalid to compate directlythe total tnean DMFT of the nortnalschoolchildt-en with that of the specialschoolchildren due to the difference of1,3 yr between the tnean age of thegroups. The caries prevalence was relatedto the age diflct-encc, with the older spe-cial school group having tnore pertna-nent teeth at risk and a higher cariesexperience than the nortnal school group.When the data wet-e analysed for eachyear grouping the special schoolchildt-entended to have fewer teeth at risk anda slighdy higher tnean DMFT than thenormal childt-en, Howevet-, analysis ofeach age group showed that there wereno statistically significant differences be-tween the special and not-tnal schoolchil-dren's tnean DMFT which confit-tns theconclusions of BROWN & SCHODHL (15),A major factor identified in pt-eviousstudies as affecting the ptevalence of car-ies is whether the children are institution-alised. Very few of the children in thisstudy were insdtutionalised, and none ona permanent basis. This gave gt-eater va-lidity to the cotnparison between handi-capped and normal children.

Marked diffet-ences have previouslybeen reported in the component parts ofthe mean DMF (2, 10, 11), In Ihe pt-esentstudy, two differences in the provisionof treatment wet-e apparent. The specialschoolchildren tended to have tnore mis-sing and decayed leeth than the not-tnalchildt-en (Table 1), The proportion of themean DMFT that was restoted wasfound to be lower in the handicappedchildren in evei-y age gi-oup. The tt-endsfound in this study are similar to thosein other studies but, due to the low cariesprevalence and the stnall amount of ac-tive decay, the t-esults are of far less sta-

tistical and clinical importance. Sec-ondly, there were tnajor differences in thetreattnent provided in the primat-y andpertnanent dentitions. Teeth were less li-kely to be filled in the primary dentitionin special schoolchildt-en. This also etn-phasizes the fact that handicapped child-ren are still receiving less dental eare thantheir nortnal counterparts, and that whentt-eattnent is provided it is mot-e likely tobe in the fortn of extractions rather thanrestot-ative care.

The current investigation has alsoconfinned the poorer levels of ot-al hy-giene and greater prevalence of calculusand peridontal disease in handicappedchildren attending special schools eotn-pared with chiidten in not-mal schools.

Although many studies have com-pared the ot-al hygiene and periodontalconditions of handicapped children withnot-tnal childt-en, few have cotnpat-ed theot-al hygiene and periodontal conditionfound in children with diffet-ing handi-caps. There were significant diffet-eticesbetween the types of handicapping con-ditions in this study; tnentally retat-dedchildren were least often found to have'good" oral hygiene and required tnoslpet-iodontal treatment. Childt-en with itn-paired hearing and communication prob-lems had tnueh better ot-al hygiene.

The mentally retarded group con-tained sotne of the most severely handi-capped ehildten who, in some instances,wet-e also physically impaired such thatthey would have difficulty in using atoothbrush, ft is therefore this group ofchildren who should be regarded as apriority, SHAW et al. (12) have shownthat severely intellectually handicappedchildt-en can be instructed in oral hygieneand can cart-y out toothbrushing pt-o-cedures for themselves if encouragementand motivation is provided by schoolstaff. POOL & JAFFE (13) have also detn-onstrated the improvement in gingivalhealth that can be obtained by institutingtoothbrushing in special schools. Autho-rities in dentistry have often failed to re-cognise that the best means of establish-ing good dental hygiene in the t-etardedis not only through increased efforts andexpertise of dental professionals in ser-vices provided, but also through system-atic instruction of handicapped personsin self-cat-e dental hygiene skills.

Acknowledgtnents - We at-e most grateful tothe Dcpartt-ncnl of Health and Social Securityfor Ihe funding of ihis .study, lo Dr R. ,T.ANtHittsoN for assistanee with the data pro-cessing, and to all the school staff and pupils.

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