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Original Article

A comparison of oral hygiene status and dental caries

experience among institutionalized visually impaired
and hearing impaired children of age between 7 and
17 years in central India
Venugopal K. Reddy, Kshitij Chaurasia, Ajay Bhambal, Ninad Moon1, Eshwar K. Reddy2
Department of Public Health Dentistry, Peoples College of Dental Sciences & Research Centre, Peoples University, Bhanpur, Bhopal,
1
Periodontics, RKDF dental college, Bhopal, Madhya Pradesh, 2SIMS college of Physiotherapy, Guntur, Andhra Pradesh, India.

ABSTRACT

Address for correspondence:

Aim: The aim of this study is to compare the oral

hygiene status and dental caries experience among

institutionalized visually impaired and hearing
impaired children of age between 7 and 17 years in
Bhopal city of Madhya Pradesh located in Central
India. Materials and Methods: A total of 95 hearing
impaired and 48 visually impaired children
of age between 7 and 17 years were recruited
from special care institutions (one institution of
hearing impaired and two institutions of visually
impaired) in Bhopal city. Information related to
different study variables was obtained from both
groups. Oral hygiene index simplified (OHI[S]),
decayed,extracted, filled teeth (deft and DECAYED,
MISSING, FILLED TETTH (DMFT)) indices were
used to record the oral hygiene status and dental
caries experience. Results: Mean OHI(S) score for
hearing impaired was 1.15 0.72 while it was
1.51 0.93 for visually impaired children (P < 0.05).
Mean DMFT score was 1.4 1.95 and 0.94 1.45
among hearing impaired and visually impaired
respectively. The hearing impaired had a mean
deft score of 0.47 1.01 and in visually impaired it
was 0.19 0.79 and the difference was statistically
significant (P < 0.05). Conclusion: Oral hygiene
status of hearing impaired children was better
than visually impaired and the difference was
statistically significant. There was no significant
difference between both groups with respect
to DMFT. The hearing impaired children had
significantly higher deft than visually impaired.

KEYWORDS: Dental caries experience, hearing

impaired, institutionalized, oral hygiene status,
visually impaired
141

Dr. Venugopal K. Reddy, Department of Public Health Dentistry,

Peoples College of Dental Sciences & Research Centre, Peoples
University, Karond-Bhanpur Bypass Road, Bhopal-462 037,
Madhya Pradesh, India.
Email: venureddy2@gmail.com
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Website:
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DOI:
10.4103/0970-4388.117963
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Introduction
Disability is an umbrella term that includes problem
in body function or structure, difficulty encountered
by an individual in executing a task or action or
problem experienced by an individual in involvement
in life situations. It is a complex phenomenon
reflecting an interaction between features of a
persons body and features of the society in which he
or she lives.[1] About 15% of the worlds population
lives with some form of disability of which 2-4%
experience significant difficulties in functioning.[2]
Disability is more complex among children. Visual
impairment and hearing impairment constitutes a
significant proportion among all disabled children.
Visual impairment refers to a condition where a
person suffers from any of the following conditions:
Total absence of sight or visual acuity not exceeding
6/60 or 20/200 in the better eye even with correction
lenses or limitation of the field of vision subtending an
angle of 20 or worse. Hearing impairment has been
defined as loss of 60 dB or more in the better ear in
the conventional range of frequencies. According to a

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Reddy, et al.: Oral hygiene status and dental caries experience

recent report, globally 19 million children are visually

impaired out of which 1.4 million are irreversibly
blind. The prevalence ranges from 0.3/1000 children
aged 0-15 years in affluent countries to 1.5/1000
children in very poor communities.[3,4] According
to Titiyal et al., there were probably 280,000-320,000
visually impaired children in India.[5] On the other
hand, according to a study report in the year 2000,
the prevalence of hearing impairment in children was
0.05-0.23% in developed countries and 0.2-0.42% in
developing countries.[6] In India, 0.4% children are
hearing impaired.[7]
These children are usually dependent on parents or
guardians for carrying out daily activities including
oral care.[8] Studies performed by Anaise in Israel,[9]
Shaw et al. in UK[10] and Purohit et al. in South India[11]
found poor oral health attributes among special care
children. Shaw et al.[10] in 1986 and Rao et al.[8] in 2005
reported poor oral hygiene status among special care
children. A Study report of Purohit et al. in 2010 in
South India[11] showed a dental caries prevalence of
89.1% in special care children. They had significantly
higher DMFT and deft than their healthy counterparts.
These study reports clearly indicates that children with
disabilities remain as a highly neglected group of the
human society with very high unmet needs requiring
special attention. Therefore, they are a special challenge
to dental public health.
There were studies[9-11] reported in the literature
comparing the dental health of special care children
with normal children. However, only limited
studies have been done comparing dental health of
different kinds of special care children. Comparing
oral health attributes between different groups of
special care children would be helpful in obtaining
baseline data to understand oral health needs of these
children and accordingly recommending appropriate
preventive measures. Therefore, the present study
was undertaken with an aim to compare the oral
hygiene status and dental caries experience among
institutionalized visually impaired and hearing
impaired children of age between 7 and 17 years in
Bhopal city of Madhya Pradesh located in Central
India.

Materials and Methods

A cross-sectional study was conducted among
institutionalized visually impaired and hearing
impaired children in Bhopal city during August
2011, for a period of 3 months. All these institutions
were run by the state government. The minimum age
requirement for admitting the special care children into
these institutions was that children should have been
7 years old. All the special care institutions in Bhopal
city boarding the special care children were invited to
participate in the study. Out of these, one institution
of hearing impaired and two institutions of visually

impaired children were finally agreed to participate in

the study. A total of 143 special care children of age
between 7 and 17 years participated in the study, of
whom 95 were hearing impaired and 48 were visually
impaired.
Ethical clearance was obtained from the institutional
ethical committee and permission was obtained from
heads of the special care institutions before the study
was scheduled. Informed consent and verbal assent
were obtained from both the guardians and children
respectively prior to the interview and clinical
examination of children. Children present on the day
of examination were included in the study. Those
who were not willing to participate or unwell were
excluded.
A close-ended questionnaire was designed to
record information on oral hygiene practices,
previous day sugar exposure, tobacco related habits,
presence or absence of dental pain and utilization
of dental services. The responses for the close
ended questionnaire were recorded with the help
of guardians of both groups. The interview was
followed by the clinical examination of children by
the calibrated examiner. Cohens Kappa coefficient
for assessment of dental caries was 0.84, indicating
good intra examiner reliability.
Type III clinical examination was carried out using
mouth mirror and explorer under good illumination
by a single examiner. Sufficient number of presterilized
instruments was carried to the institutions on the
day of examination to avoid interruption during
the examination. Examination was carried out by a
single examiner with recording assistant. During the
examination, children were seated in a chair with
examiner standing in front and the trained assistant
standing in close vicinity to the examiner to record
the findings. The examination was done under
adequate natural illumination. Oral hygiene status
was recorded using Greene and vermillions oral
hygiene index simplified (OHI[S])[12] and dental caries
in permanent and primary dentition was recorded
using Klein, Palmer and Knutsons DMFT index[13]
and DMFT index proposed by Gruebbel.[14] After the
examination, children in need of dental treatment
were referred to the dental college for rendering
specialty care.

Statistical analysis

Statistical analysis was performed using Statistical

Package for the Social Sciences version 17.0 (SPSS
Inc. 233 South Wacker Drive, 11th Floor, Chicago,
II,60606-6412). Chi-square analysis was used to
explore the association between explanatory variables
and oral health. Mann-Whitney U test was used to
compare the categorical variables between visually
impaired and hearing impaired children. Statistical
significance was fixed at P 0.05.

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Reddy, et al.: Oral hygiene status and dental caries experience

Results

Table 1: Distribution of the study subjects

according to age and gender

In the present study, 143 special care children

in the age group of 7-17 years were examined.
They were sub-divided to two age groups, i.e.,
7-12 years and 13-17 years. Most of them belonged
to the later age group. Majority of the children were
males. No significant differences (P > 0.05) were
noted between the two groups for age and gender
[Table 1]. Furthermore, there were no significant
differences (P > 0.05) between the two groups for
tooth brushing habits, last day sugar exposure,
tobacco related habits, dental pain and utilization
of dental services. Most of these children were
brushing regularly once a day using toothpaste
without any supervision and none of them had ever
visited a Dentist [Table 2].

Age groups
(in years)

Mean OHI(S) score was found to be 1.15 0.72 (mean

debris index (simplified) [DI(S)] score = 0.7 0.38
and mean calculus index (simplified) [CI(S)] score =
0.45 0.51) for hearing impaired children while it
was 1.51 0.93 (mean DI(S) score = 0.86 0.46 and
mean CI(S) score = 0.65 0.7) for visually impaired.
Statistically, there was no significant difference
(P > 0.05) between the two special groups for mean
debris and calculus scores. However, mean OHI(S)
score was found to be significantly different (P < 0.05)
between both groups with the hearing impaired
having better oral hygiene than visually impaired
children [Table 3].
Mean DMFT score was found to be 1.4 1.95
among hearing impaired and 0.94 1.45 among
visually impaired. However, the difference was not
statistically significant (P > 0.05). Hearing impaired
children had a mean DMFT score of 0.47 1.01 and in
visually impaired it was 0.19 0.79 and the difference
was statistically significant (P > 0.05) with the hearing
impaired having higher DMFT than the visually
impaired.

7-12
13-17
Total
Gender
Male
Female
Total

Type of handicap
Hearing
impaired
(%)
43 (45.3)
52 (54.7)
95 (100)

Visually
impaired
(%)
22 (45.8)
26 (54.2)
48 (100)

69 (72.6)
26 (27.4)
95 (100)

39 (81.2)
9 (18.8)
48 (100)

Chi-square
value

P value

0.004

0.95

1.28

0.258

Table 2: Responses to the questions by study

subjects
Type of handicap
Chi-square P value
value
Hearing
Visually
impaired (%) impaired (%)
Do you brush your teeth regularly?
Yes
92 (96.8)
48 (97.9)
0.135
0.71
No
3 (3.2)
1 (2.1)
How many times do you brush your teeth in a day?
Once
81 (85.3)
41 (85.4)
0.001
0.98
Twice
14 (14.7)
7 (14.6)
What material do you use to clean your teeth?
Toothpaste
90 (94.7)
44 (91.6)
0.51
0.47
Toothpowder
5 (5.3)
4 (8.4)
Have you consumed sweets on last day?
Yes
36 (37.9)
19 (39.6)
0.038
0.84
No
59 (62.1)
29 (60.4)
Do you use any form of tobacco?
Yes
8 (8.4)
4 (8.3)
0.0
0.98
No
79 (91.6)
42 (91.7)
Are you suffering from dental pain?
Yes
16 (16.8)
6 (12.5)
0.46
0.49
No
79 (83.2)
42 (87.5)
Have you ever visited a Dentist?
Yes
0
0

No
95 (100)
48 (100)
Questions

Table 3: Mean scores of study subjects for OHIS(S), DMFT and deft indices
Oral health findings

Type of handicap
Hearing impaired children mean (SD)
0.7 (0.38)
0.45 (0.51)
1.15 (0.72)
1.38 (1.93)
0.02
0
1.4 (1.95)
0.34 (0.77)
0.14 (0.37)
0
0.47 (1.01)

Debris index (S)

Calculus index (S)
OHI(S)
D
M
F
DMFT
d
e
f
deft

Visually impaired children mean (SD)

0.86 (0.46)
0.65 (0.7)
1.51 (0.93)
1.02 (1.47)
0.02
0
0.94 (1.45)
0.19 (0.79)
0
0
0.19 (0.79)

Z value

P value

1.71
1.65
2.10
0.55
0.009

1.05
1.75
2.01

2.05

0.089
0.099
0.034*
0.58
0.99

0.29
0.079
0.04*

0.04*

*Significant (P<0.05)

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Reddy, et al.: Oral hygiene status and dental caries experience

Discussion
In the present study, 143 institutionalized disabled
subjects (95 hearing impaired and 48 visually
impaired) of age between 7 and 17 years were
examined. They were treated as children according
to the childs definition given by United Nations
Childrens Fund,[15] which states that any individual
up to 18 years of age should be designated as a child.
These institutionalized children were designated
disabled according to criteria given by Persons with
Disabilities (Equal Opportunities, Protection of Rights
and Full Participation) Act, 1995,[16] which defines
blindness as a condition where a person suffers from
total absence of sight or visual acuity not exceeding
6/60 or 20/200 in the better eye even with correction
lenses or limitation of the field of vision subtending an
angle of 20 or worse. Deafness has been defined as loss
of 60 dB or more in the better ear in the conventional
range of frequencies.
The demographic information related to both groups
reveals that there was no significant difference
between both groups with respect to age and gender
composition. There was also no significant differences
between both groups regarding their brushing habits,
last day sugar exposure, tobacco related habits and
utilization of dental care and thus did not influenced
the study results. The assessment of oral hygiene
status, which was based on Greene and Vermillions
categorization of OHI(S) scores[12] (Good: 0.0-1.2; Fair:
1.3-3.0; Poor: 3.1-6.0) revealed that the oral hygiene
status of the hearing impaired children was found
to be significantly better than visually impaired
(P < 0.05). This may be perhaps due to the fact that
hearing impaired children can visualize the act of
tooth brushing, which is still one of the most common
means of maintaining oral hygiene especially, in
developing countries like India. As the act of tooth
brushing was not supervised, the role of other factors
like technique of tooth brushing, motor skills and
obtaining the help from guardians was ignored which
might have an impact on oral hygiene status of both
groups. This finding was in agreement with the study
reports of Shaw et al. in Birmingham, in which hearing
impaired were having better oral hygiene than other
handicapped groups.[10] In an another study done by
Altun et al. comparing different handicapped groups,
poor oral hygiene status was found among subjects
with mental retardation than other handicapped
groups.[17]
The assessment of dental caries experience among
these groups revealed certain interesting facts. There
was no significant difference between both groups
with respect to mean DMFT. This is likely because both
groups were institutionalized and thus should have
exposed to similar dietary patterns including the sugar
consumption. Our study finding is in agreement with
study carried out by Shaw et al.[10] and Altun et al.,[17]

in which mean DMFT was not significantly different

between different handicapped groups. But our finding
is not in agreement with the study report of Jain et al.[7]
in India who reported a significantly higher mean
DMFT in hearing impaired group. On the other hand,
mean DMFT was significantly higher among hearing
impaired children as compared with visually impaired
children. This may be perhaps due to the exposure of
hearing impaired to a different living environment
that includes various factors such as socio-economic
status, peer influence, Illiteracy, lack of awareness
towards oral health among the parents, which might
have encouraged the frequent consumption of refined
sugars resulting in a higher DMFT before their
admission to the special care institutions. Our finding
is in agreement with the study results of Al-Qahtani
and Wyne in March 2004 at Riyadh, Saudi Arabia
who reported a higher mean DMFT score in hearing
impaired.[18]
Many children of both groups were also suffering from
dental pain, which was untreated and none of them
had any filled tooth until the date of examination as
they neither visited a Dentist nor a qualified dental
surgeon is been appointed by the authorities to take
care of their dental problems. This implies that both
groups were completely deprived of dental care
with very high unmet needs. These findings are in
agreement with the study reports of Jain et al. in India
and Brown in Saudi Arabia revealing a high need for
dental care among handicapped children.[7,19] Thus,
these underserved children need a special attention by
the Dentist community.
The only limitation of the present study was that no
data was recorded about the level of mental capacity
and motor skills of the study subjects as it was
beyond the scope of this research. Further, studies
are recommended in this direction in order to achieve
more definite conclusions.

Conclusions
The oral hygiene status of the hearing impaired
children was better than visually impaired children
and the difference was statistically significant. The
mean DMFT was not significantly different between
both handicapped groups. The mean DMFT was
significantly higher among the hearing impaired
subjects than among visually impaired.

Recommendations

Oral health education must be given to these special

groups according to their handicapped status.
Guardians of these handicapped groups should be
trained by the public health dentistry departments
of dental colleges in basic oral health on a periodic
basis as they play a vital role in delivering oral
health education, assistance in dental care to these
special groups and in making appropriate referrals.

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Reddy, et al.: Oral hygiene status and dental caries experience

There should be separate wards in pedodontics

department of the dental colleges in order to take
care of oral health needs of these special groups.

10.

Acknowledgments

11.

We would like to thank all the staff and children of the special
care institutions in Bhopal city for rendering their valuable
support during the study.

12.

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How to cite this article: Reddy VK, Chaurasia K, Bhambal

A, Moon N, Reddy EK. A comparison of oral hygiene status and
dental caries experience among institutionalized visually impaired
and hearing impaired children of age between 7 and 17 years in
central India. J Indian Soc Pedod Prev Dent 2013;31:141-5.
Source of Support: Nil, Conflict of Interest: None declared.

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2013 | Vol 31| Issue 3 |