Article ID: WMC004539 ISSN 2046-1690

Dental Caries Status And Oral Health Needs among

Disabled Children Living In Care Centers In
Kathmandu Valley, Nepal
Peer review status:
No

Corresponding Author:
Dr. Jemish Acharya,
Lecturer, Community Dentistry,Nepal Medical College, GPO 8975,EPC 6004 - Nepal

Submitting Author:
Dr. Jemish Acharya,
Lecturer, Community Dentistry,Nepal Medical College, GPO 8975,EPC 6004 - Nepal

Other Authors:
Ms. Natkamol Chansatitporn,
Assistant Professor, Mahidol University,Biostatistics, Mahidol University,\nThailand - Thailand
Dr. Kulaya Narkasawat,
Associate Professor, Mahidol University,Epidemiology, Thailand - Thailand

Article ID: WMC004539

Article Type: Original Articles
Submitted on:06-Feb-2014, 07:24:54 AM GMT Published on: 06-Feb-2014, 10:15:53 AM GMT
Article URL: http://www.webmedcentral.com/article_view/4539
Subject Categories:DENTISTRY
Keywords:Dental Caries Status,Differently abled Children,Oral Health Needs
How to cite the article:Acharya J, Chansatitporn N, Narkasawat K. Dental Caries Status And Oral Health Needs
among Disabled Children Living In Care Centers In Kathmandu Valley, Nepal. WebmedCentral DENTISTRY
2014;5(2):WMC004539
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution
License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Source(s) of Funding:
None

Competing Interests:
None

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Dental Caries Status And Oral Health Needs among
Disabled Children Living In Care Centers In
Kathmandu Valley, Nepal
Author(s): Acharya J, Chansatitporn N, Narkasawat K
Abstract
Various attempts are being made to better the
situation of dental caries in Nepal, nevertheless, the
problem of caries among differently abled children still
seems to have reached a still. The general objective of
this study is to identify the dental caries status by
prevalence and severity (DMFT), knowledge and
attitude in oral health practices and the oral health
needs among differently abled children aged 12-15
age group living in care centers in Kathmandu, Nepal.
It is a cross sectional study with 120 respondents.
Data was collected using constructed questionnaire
and analyzed using percentage, arithmetic mean,
standard deviation, Chi square using level of
significance at 0.05 and Mann-Whitney test. There
was significant association between the type of
disability and DMFT scores of the children. The dental
caries prevalence in the study population was 98.3%
and the mean DMFT of the children was
4.80±3.01.56.90% in case of physically disabled
children and 34.50% of children showed "high"
severity of dental caries .95% of the children needed
treatment, the decayed component being the highest
area of treatment need. The means of knowledge,
attitude and practice were 5.57±1.72, 19.95±4.95 and
5.10±1.99 respectively. There was significant
difference of means of DMFT by the type of disability
of children. Sensory disabled children had higher
mean (2.48±0.65) than physically disabled
children(2.06±0.79).Based on the analysis it was seen
mandatory that special attention be given to disabled
children to improve the dental caries status and their
knowledge, attitude and practice .It is also suggested
that along with encouraging oral health education
programs, it was necessary that their treatment needs
be fulfilled.
Introduction
Dental caries have historically been considered the
most important part of the global burden of oral
diseases. Oral health is an essential part of the
general health and well being of an individual. Dental
WebmedCentral > Original Articles
caries is a chronic infectious diseases caused by
bacterial by products that dissolve on the enamel
surface of teeth.
It has been found that 60-70% of schoolchildren all
over the world suffer from dental cavities and 99% of
adults have dental caries.(1)The World Health
Organization along with the FDI World Dental
Federation founded a goal in the year 2000 for oral
health was the to have 50% of the 5-6 years old
children caries free and the global average of DMFT in
12-13 years old to be no more than 03(2).According to
the World Health Organization, between 110 million
(2.2%) and 190 million (3.8%) people 15 years and
older have significant difficulties in functioning and
have been referred to as people with who are
differently abled. In Nepal, 1.2% of the total population
is living with some kind of physical disability. Out of
that the major affected age group is seen to be the
children with 33.3% having dental problems and were
living with some kind of disability.(2).Studies on other
populations showed that differently abled people had
more dental diseases and unmet dental problems
compared to their normal counterparts.(3).
The aims of this study were to assess the dental
caries status, treatment needs and their oral health
behavior among differently abled children of age group
12-15 and their associations with caries status
inclusive of hearing/vision/speech disability in
organizations in Kathmandu Valley, Nepal. The results
of the study will be used to plan oral health
interventions to promote preventive behavior for the
prevention and control of incidence of dental caries
and to plan oral health education programs to update
their knowledge on oral diseases.
Methods
A cross sectional study was carried out among
differently abled children living in care centers aged
12-15 years old in Kathmandu valley in Nepal. The
aims of the study were to assess the dental caries
status, treatment needs and oral health behavior of the
children. The study was conducted in non government
care centers in Kathmandu Valley, Nepal responsible
for taking care of differently abled children of various
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age groups. From the total of 80 organizations in
Kathmandu Valley, purposive sampling was done and
2 basic organizations for the study was selected.From
the organization all the children were included based
on the selection criteria comprising of children with
physical impairment and sensory impairment.
Differently abled children aged 12-15 years old living
in the care centers were the target population. The
same size was calculated using and the minimum
sample size was derived as 109. An excess of 20%
was taken to cover withdrawal issues and a total of
120 children were studied.
Questionnaire data collection was done using 30 close
ended questions after the survey protocol was
reviewed and approved by the ethical committee
followed by clinical examination. A pre test was
conducted among 20 children in an organization to
assess the reliability of the questionnaire using
Cronbach's coefficient of alpha test(4). Only questions
scoring > 0.7 were approved for conducting the
interview.
Standardization for the collection of data for oral health
examination, questionnaire and a demonstration of
examination and recording of data was done. For the
hearing and speech impaired children, they were to fill
out the questionnaire on their own by reading it.
Assistance was provided by sign-language experts in
case the children had doubts regarding any of the
questions.For the vision impaired children, oral
interview was conducted.
After finishing the questionnaire interview, the
examination for dental caries was conducted using the
DMFT Index and the modified Oral health assessment
form given by World Health Organization(5). Only
permanent teeth were considered excluding all
permanent third molars, if present. After this, the
treatment needs of the children were assessed as per
the dental caries status of the children.
The study initiated after obtaining ethical approval
from the Ethical Committee. Informed consent for the
children was obtained from the authority of the care
centers as the children were orphans and a No
Objection letter "was obtained as a form of approval. It
was explained that the children had the right to refuse
and/or withdraw from the study at anytime without the
need for any kind of explanation on their behalf.
Differenly abled children aged 12-15 years old living
in care centers in Kathmandu valley, Nepal who were
able to read and write were included in the study.
Children with visual disability who were able to
communicate orally in local language were also
included. However, those who were unable to
WebmedCentral > Original Articles
communicate by the above mentioned means and
those with mental disability were excluded.
Statistical Analysis
Descriptive statistics and frequency distribution was
calculated. Chi-Square tests were used to test the
differences of proportion. P-value less that 0.05 was
accepted as statistically significant. Mann-Whitney
Test to compare the means of the types of
disability/gender and severity of dental caries was
done. Data was analyzed using the Statistical
Package for Social Science (SPSS 16.0).
Results
120 differently abled children were studied out of
which 58(48.3%) were physically disabled, 58(48.3)%
were sensory disabled and 3% presented with both
physical and sensory disability. Out of the total
population, 24.2% were 12 years old,30.8% were 13
years old,16.7% were 14 years old and 28.3% were 15
years old. Among the 120 children 55.8% were males
and 44.2% were females. The education status of
these children presented with 34.2% having education
above the Secondary Level of Education,39.2% at
secondary level,18.3% at primary level and 8.3% did
not have any formal education at the time of the study
98.3% of the Children had at least 1 score of DMFT .
For analyzing the dental caries status, the severity of
dental caries was taken into reference and categorized
as <1.26= "Low", 2.7-4.3="Moderate" and
>4.4="High". For analyzing the dental caries status,
the severity of dental caries was taken into reference
and categorized as <1.26= "Low", 2.7-4.3="Moderate"
and >4.4="High". Out of 118 children with
caries,45.8% of them were in the high severity group ,
36,7% in the moderately affected group,13.3% in the
low severity group and 4.2% in the very low severity
group. The grouping was done according to the WHO
standards of dental caries severity index. Mean DMFT
was 4.80±3.01 teeth per child. The highest fell in
3.6.±3.14 with maximum of 17 teeth in one child. The
mean missing teeth was 0.16±0.45 per child and the
mean no of filled teeth was 1.04±0.81 per child.The
maximum number of filled teeth in one child was 4 in
number.
Among the total children, the average number of teeth
examined in each child was 27.7.The proportion of
teeth needing treatment out of the total 120 children
was 114(95% ). From this,92.5% required fillings in
their teeth whereas 2.5% needed rehabilitative care in
the form of a fixed or removable partial denture for
their missing teeth.Regarding the decayed component
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of teeth in the children, it was seen that 12.5% of the
teeth each child required fillings. Out of this 167
teeth(10.4%) were decayed in children with physical
disabilities. Among the sensory disabled children,
246(15.1%) of teeth needed fillings.
The mean score for knowledge was 5.57±1.72 per
child and for attitude was 19.95±4.95per child.The
mean score for practice was 5.10±1.99 per child. The
results summarized that the percentage of correct
answers obtained from the children on their knowledge
of the etiology of dental caries ranged from 12.50% to
80% . Least knowledge was obtained regarding
Fluoride at 12.50% . In terms of attitude, good attitude
was shown towards prevention of dental caries by
41.70% of the children. 65.40% of the children
answered that they brushed their teeth twice
everyday.However, only 29.20% of the children said
that they go to visit the dentist once every six months
showing poor utilization of services.
Chi-Square tests were applied to find the association
between these categorical items of the general
characteristics and the dependent variable The results
showed that 55.2% of children aged 12 years fell in
the "High" caries group .Males presented with 46.3%
falling in the "High" caries group.. Among the disability
types, sensory disabled children had "High" caries of
up to 56.9% of the children falling in this group.
Children with both types of disability were not included
in the analysis as only 4 children belonged to that
particular group. The knowledge and attitude of the
children was regrouped into" Good-Fair(6-10) and
"Poor(1-5) for knowledge and "Good-Fair (21-230)"
and Poor(10-20) for attitude for the purpose of
analysis.The new cut off point was taken as per their
respective means. 57.4% of the children having "Poor"
Knowledge fell into the "High" caries group while
43.6% of children having poor attitude fell into the
"High" caries group. This was not statistically
significant. The DMFT status among disabled children
when compared with the gender and types of disability
gave varied results. In males the mean was 2.29±0.73
per child and 2.26±0.76 per child in female .This was
not statistically significant. Normality test using
Kolmogorov-Smirnov test was performed and the
distribution was not normal in both gender and type of
disability. In the types of disability, comparison of the
dental caries status between physical and sensory
disability was considered and the mean DMFT was
higher among children with sensory disability. On
performing Mann-Whitney Test, it was seen that the
mean was 2.06±0.79 per child and 2.48±00.65 per
child in physical and sensory disabled children
respectively. This was statistically significant.
WebmedCentral > Original Articles
Discussion
The aim of this study was to assess the dental caries
status, treatment needs and their oral health behavior
among differently abled children of age group 12-15
living in Kathmandu Valley, Nepal. In the present study,
the prevalence estimate for caries was higher among
the sensory disabled than among the physically
disabled children significantly.
The results of the study showed a very high proportion
of dental caries among differently abled children with a
high 98.3%. This has been in approximate with past
studies that revealed the dental caries prevalence
among disabled children aged 9-12 years as having
93.1% and 13-17 years having prevalence of 88.37%
(6).
The severity of dental caries was used to assess the
associations between the factors due to the high
prevalence in the caries proportion. The high DMFT
score can be because of poor dental service
utilizations in part of the children as the results to the
question "do you go to a dentist for routine check up
once every six months?" resulted in only 29.20%
answering the positive answer where as 46.70% of the
children said that they "go to a dentist only when they
have pain in their teeth". Normally, age has been
found as a significant factor in determining the dental
caries status among children. Adolescents are found
to be more aware of their aesthetics and health
contributing to the lower prevalence of dental caries in
their age as compared to that younger children. The
mean DMFT in this study was 4.80±3.01 per child
which showed was very high.This was close to the
results in a study conducted in Belgaum, India where
in the mean DMFT per child in males was 3.48 and in
females it was 3.98 (7)
In terms of the type of disability, children with sensory
disability had higher prevalence of caries and 56.9% of
them fell in the "High" caries group compared to the
34.9% of physically disabled children in this group.
This was concurrent with another study where in the
decayed component was highest in sensory disabled
children conducted in Iran. The reason behind this
would be explained by their inability to communicate
asking for treatment and the problems faced by them
when explaining their problems compared to physical
disabled children.Contributory factors include
inadequate funding and resources, insufficient trained
dentists to treat patients with disabilities, and complex
treatment needs requiring special care or general
anesthesia. Majority of questions of knowledge,
attitude and practice was not answered correctly by
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the children. Only 12.5% of the children answered
correctly regarding the benefits of fluoride.This was
contrary to the results of a study in Kuwait wherein
20% of the children studied knew about fluoride but
were not sure if they were using it (8). Besides
knowing that toothbrush should be used to clean their
teeth only 36.70% of children used toothbrush and the
remaining used toothpowder to clean their teeth.
When seen from a comparative point of view this was
not similar to a study conducted in Nepal to assess the
KAP of children with no form of disability where 100%
of them were using toothbrush (9).
The findings in this study clearly demonstrates the
picture of the dental caries status of the disabled
children in Nepal which is well below the global goal of
WHO to have the DMFT of children 12 years of age to
be below 3 per child(1). Especially, regarding the
differently abled population, the fact that this being the
first study of its kind brings into notice the negligence
this population has been facing for long. The services
are available but due to a lack of knowledge and
awareness in the society , the practice of going to the
dentist for preventive care or the utilization of the
available dental services are not very well seen.
Conclusion(s)
This was a cross sectional study done among
differently abled children living in a care centre in
Jorpati, Kathmandu,Nepal. The aims of this study
were to assess the dental caries status, treatment
needs and their oral health behavior among children of
age group 12-15 living with disabilities and their
associations with caries status inclusive of
hearing/vision/speech disability in organizations in
Kathmandu Valley, Nepal.
However, by the nature of cross sectional study,the
associations cannot be implied as being "causal".A
follow up study has to be done to determine the
causation of dental caries status by the independent
variables involved in this study.The results from using
purposive sampling produced unequal distribution of
age and type of disability in this study. This affected
the results of this study. It can be recommended to
use one age group and one kind of disability in further
studies.The answers given by the children could have
been also subjected to recall bias.
Some possible measures that can be followed to
improve the dental caries status of the disabled
children in Kathmandu valley,Nepal are in terms of
providing special focus to provide treatment to
disabled children as per their special requirements.
WebmedCentral > Original Articles
Training and oral health educations for the
professionals so as to handle differently abled
individuals would be highly helpful for the same.
Different treatment needs of the children should be
provided keeping in mind the kind of disability they
suffer from. Provision of oral health education and
their frequency is on the rise at present in Kathmandu.
However, as mentioned earlier, they are generally
aimed for the general population. Disabled children
should be focused to educate them regarding the
prevention, etiology and treatment of dental caries as
this would be helpful in reducing further increase in the
dental caries index among them.
Acknowledgement(s)
This study succeeded by the attentive support of
several individuals in some way extended their
valuable assistance and help in its preparation and
completion. I would like to express profound gratitude
to Asst.Prof. Natkamol Chansatitporn and
Co-preceptor Associate Prof. Dr. Kulaya Narksawat for
the continuous support and valuable amount of their
time without which this study would not have been
complete. My sincere appreciation and heartfelt
gratitude to Mr. Radheshyam Shrestha,Senior
Administrative Officer, Nepal Disabled Association.
References
1. World Health Organization. World Health Statistics
2008; Health Service Coverage (Includes oral health
coverage by country for 1990-1999 and 2000-2006).
2. Country profile on Disability,Kingdom of
Nepal;Japan International Cooperation Agency
Planning and Evaluation Department 2002.
3. Akindayomi F. Oral health status and treatment
needs of children and young adults attending a day
centre for individuals with special health care needs.
BMC Oral Health. October 2008.
4. WHO. Oral Health Survey:Basic Methods. 4th ed.
Geneva 1997
5. Daniel WW. Biostatistics: A Foundation for Analysis
in the Health Sciences 9th
6. Manish Jain AM, Santosh kumar,Rushab J.
Dagli,Prabu Duraiswamy, Suhas Kulkarni. Dentition
status and treatment needs among children with
impaired hearing attending a special school for the
deaf and mute in Udaipur,India. Journal of Oral
Science. 2008;50.
7. Siddibhavi. M. Oral Health Status of Handicapped
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Children Attending Various Special Schools in

Belgaum City Karnataka.WebmedCentral
Epidemiology. 2012;3(2):WMC003061
8. Shyama, Morris RE, Sugathan T, Honkala E. Dental
caries experience of disabled children and young
adults in Kuwait.. Community Dent Health. 2001
Sep18(3):1816.
9. Manoj. H. Evaluation of Knowledge attitude and
practice about oral health care among secondary level
students of rural nepal.A Questionnaire study.May
31,2011 WMC001805.

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Illustrations
Illustration 1

Table 1.1: General Characteristics

Variables Frequency(n) Percent(%)

Age
12 years 29 24.2
13 years 37 30.8
14 years 20 16.7
15 years 34 28.3
Sex
Male 67 55.8
Female 53 44.2
Education
None 10 8.3
Primary school 22 18.3
Secondary school 47 39.2
Higher than Secondary 41 34.2
school
Type of
disability
Physical 58 48.3
Sensory 58 48.3
Both 4 3.3

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Illustration 2

Table 1.2 Proportion of Caries (n=120)

Variables Total Male Female

Dental Caries Numb Percent Number Percent Number Percent
Status er
At least 1 118 98.3 66 98.5 52 98.1
DMFT
Caries Free 2 1.7 1 1.5 1 1.9

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Illustration 3

Table 1.3: Number and percent by levels severity of Dental caries

Variable
Severity of dental caries Frequency Percent

Low score (<2.6) 21 17.5

Moderate(2.7-4.4) 44 36.7
High (>4.4) 55 45.8
Total 118 100

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Illustration 4

Table 1.4 Mean and Standard deviation of DMFT

Variables Number Mean Std. Deviation Minimum Maximum

Decayed 432 3.60 3.14 00 17.00

Teeth(DT)

Missing 19 16 45 00 2.00
Teeth(MT)

Filled 125 1.04 .81 00 4.00

Teeth(FT)

DMFT 576 4.80 3.01 00 18.00

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Illustration 5

Table 1.5: KAP of children

Variables Number Percent

Knowledge
Good(9-10) 3 2.5
Fair(6-8) 70 58.3
Poor(0-5) 47 39.2
Mean 5.57 SD 1.72 Min=0 Max=10
Attitude
Good(22-30) 47 39.2
Fair(16-21) 45 37.5
Poor(10-15 28 23.3
Mean 19.95 SD 4.95 Min=100 Max=10
Practice
good(8-10 12 10.0
poor(0-7) 108 90.0

Mean 5.10 SD 1.99 Min=0 Max=10

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Illustration 6

Table 1.6: Association of general characteristics with DMFT status of the children

Variables DMFT Status

High Moderate Low P-value
n % n % n %
Age
12 years 16 55.20 7 24.10 6 20.7
13 years 20 54.10 12 32.40 5 13.5 0.19
14 years 10 50.00 7 35.00 3 15
15 years 9 26.50 18 52.90 7 20.6
Gender
Male 31 46.30 25 37.30 11 16.4 0.93
Female 24 45.30 19 35.80 10 18.9
Type of Disability
Physical 20 34.50 22 37.9% 16 27.6 0.01
Sensory 33 56.90 20 34.50 5 8.6

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Illustration 7

Table 1.7: Comparison of average score of DMFT by gender and Type of Disability

Variable Mean SD Z-Test P-value

Gender
Male 2.29 0.73
-0.21 0.85
Female 2.26 0.76
Type of Disability
Physical 2.06 0.79
-2.88
Sensory 2.48 0.65 0.004

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