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A comparison of the oral health status of children who are blind and children who are sighted in Istanbul.

The World Health Organization (2011) recently estimated that 285 million people are visually impaired worldwide: 39 million are blind and 246 million have low vision. In Turkey, the results of the disability statistics calculated by the Turkish Statistical Institute (2002) revealed that 12.29% of the total population was disabled and 0.60% of these people were visually impaired.

ORAL HEALTH OF INDIVIDUALS WITH VISUAL IMPAIRMENTS

Visual impairment may have an impact on oral health because of physical, social, or informational barriers that are related to the impairment (Edwards & Merry, 2002; Lebowitz, 1974). Previous studies reported that individuals with visual impairments tended to have a larger amount of dental plaque and were at a higher risk for dental diseases than were sighted individuals (Greeley, Goldstein, & Forrester, 1976; Schembri & Fiske, 2001). Anaise (1979) compared the periodontal status and oral hygiene of a group of Israeli teenagers who were blind and those who were sighted. His results suggested that the oral health of the sighted group was better than that of the group who were blind. Moreover, the students with low vision had lower rates of periodontal disease than did those who were totally blind.

Dental professionals should be aware of the inherent problems of and limitations imposed on patients by their sensory impairment (Mahoney, Kumar, & Porter, 2008; Schembri & Fiske, 2001). They should know the best ways to communicate with children who are visually impaired and to make them familiar with the dental setting. Maintaining oral health is central to a high quality of life because it limits the risks of disease. The oral health status of children with visual impairments should be investigated so their health care needs can be determined and preventive dental procedures can be implemented. The aim of the study presented here was to evaluate the oral health status of a group of children with visual impairments in Istanbul and to compare the oral health status of these children with that of sighted children.

METHODS

Ethical approval for the research was granted by the Yeditepe University Human Subjects Ethical Committee. Signed informed consent forms were obtained from the parents of all the participants according to the Helsinki Declaration.

Participants

Fifty children, aged 6-10, with no systemic diseases were randomly chosen from one primary public school for children who are visually impaired in Istanbul. All 50 children were totally blind. In addition, 50 sighted healthy children of the same age range were randomly chosen from one primary public school that was in the same socioeconomic district as the chosen primary public school for children with visual impairments in Istanbul. These children were in the control group (see Table 1).

Procedures

Intraoral examination. An experienced pediatric dentist performed the intraoral examination of all the children who participated in the study. The examinations of the children with visual impairments were performed after the children were allowed to touch and feel the dental chair, dental equipment, and instruments. Oral examinations were performed, and the dental findings were recorded at the Pediatric Dentistry Clinic of Yeditepe University.

Caries indexes. The prevalence and severity of dental caries were determined using the DMF (decayed-missing-filled) index. During the intraoral examination, the values for DMFT (decayed-missing-filled permanent teeth), DMFS (decayed-missing-filled permanent teeth surface), dft (decayed-filled primary teeth), dfs (decayed-filled primary teeth surface) were recorded.

DMFT and DMFS describe the amount-prevalence--of dental caries in permanent dentition. They are means to express the prevalence of caries numerically and are calculated by summing the number of decayed (D), missing (M), filled (F) teeth (T) or surfaces (S). In contrast, dft and dfs describe the amount--prevalence--of dental caries in primary dentition (prevalence of caries: DMFT and DMFS).
Box 1
Scores for the Plaque and Gingival Indexes

The Silness & Loe Plaque Index (PI) (Silness & Loe, 1964):

* Score 0: The tooth surface is clean.

* Score 1: The tooth surface appears clean, but dental plaque can be
removed from the gingival third with a sharp explorer.

* Score 2: Plaque is visible along the gingival margin.

* Score 3: The tooth surface is covered with abundant plaque.

The Loe & Silness Gingival Index (GI) (Loe & Silness, 1963):

* Score 0: Normal gingiva.

* Score 1: Mild inflammation, slight change in color, slight oedema,
no bleeding on probing.

* Score 2: Moderate inflammation, redness, oedema, glazing, and
bleeding on probing.

* Score 3: Severe inflammation, marked redness and oedema, ulceration,
tendency toward spontaneous bleeding.


Periodontal indexes. The values for the plaque index, gingival index, and oral hygiene index were evaluated for all the children. The Silness and Loe Plaque Index (PI) (Silness & Loe, 1964) and the Loe & Silness Gingival Index (GI) (Loe & Silness, 1963) were used to determine the children's periodontal status (see Box 1). A Williams-type periodontal probe (Hu-Fredy, Chicago) with a 0.5-millimeter tip was used for the assessment of the gingival index. The oral hygiene index values of the children were evaluated with the Simplified Oral Hygiene Index (OHI-S) (Greene & Vermillion, 1964). Erupting teeth and primary teeth were excluded. The mean values for each child were recorded and then calculated, and these data were used for statistical analysis.

Statistical analysis

All the data were analyzed using SPSS 10.0 statistical software. The differences in the DMFF, DMFS, dft, dfs values between the groups were compared using the Kruskal-Wallis test, and the differences in the PI, GI, and OHI-S values were compared using student t tests; p < .05 was set as statistically significant.

RESULTS

Caries index

Thirty percent of the sighted children and 20% of the children who were blind were diagnosed as caries-free (see Table 2). There were no significant differences in the prevalence of dental caries between the boys and the girls (p .05). The mean DMFT, DMFS, dft, and dfs values of the group who were blind were significantly higher than those of the sighted children (p < .05) (see Table 3).

Periodontal index

The mean PI values of the sighted children and the children who were blind were 0.63 and 1.5, respectively, and the mean GI values were 0.33 and 0.68, respectively. The mean PI, GI, and OHI-S values of the children who were blind were significantly higher than were those of the sighted children (p < .05). (see Table 4 and Figure 1).

DISCUSSION

Giving good oral instructions and tactile devices to improve the toothbrushing skills of children with visual impairments is considered the most important part of oral hygiene education (Mahoney et al., 2008; O'Donnell & Crosswaite, 1990). Adequate oral hygiene instructions may have a positive impact on individuals' oral hygiene habits and periodontal status, thereby maintaining or improving individuals' self-esteem (Ajwani & Ainamo, 2001; Schnuth, 1977).

This study revealed that the caries and periodontal index values of the children who were blind were significantly higher than were those of the sighted children, even though both groups live in the same socioeconomic district in Istanbul. This finding is in line with that of Watson, Moles, Kumar, and Porter (2010) for the adults with visual impairments in their study. In addition, it may reflect the fact that the group who were blind had regular dental care less frequently than did the sighted group. Similarly, Van Nieuwenhuysen, Carvalho, and D'Hoore (2002) reported fewer regular dental appointments among children with visual impairments than among nonprivileged (poor) children without disabilities.

Many studies have suggested that a reduced salivary flow rate results in a higher incidence of caries (Vehkalahti, Nikula-Sarakorpi, & Paunio, 1996; Vitorino, Calheiros-Lobo, Duarte, Domingues, & Amado, 2006). Dong and Dawes (1995) reported that the unstipulated salivary flow rate of blind and blindfolded people was significantly reduced. The higher incidence of caries among the children who were blind may be secondary to a low salivary flow rate. Therefore, we plan to test the salivary flow rates of these children in a further study.

Worthington, Hill, Mooney, Hamilton, and Blinkhorn (2001) investigated the effectiveness of an oral health education program for children. The children who attended the program had significantly lower mean plaque scores and greater knowledge of toothbrushing than did the children in the control group who did not attend the program. The disclosing tablets that were provided to the children in the program increased the children's motivation to brush their teeth because these tablets make it easier for children to see the dental plaque. However, using disclosing tablets for children who are visually impaired would not be beneficial. Therefore, we recommended conducting oral health education programs for these children and their parents in an appropriate format that takes into account the fact that the children are blind.

[FIGURE 1 OMITTED]

Moynihan (2002) suggested that children should reduce their intake of foods and beverages that contain sugar to improve their dental health. Accordingly, the results of our study suggest that there is a need for dietary guidance in schools for children who are visually impaired to enhance their oral health care.

CONCLUSION

Despite the dearth of research on the oral health status of children with visual impairments, we highly recommend that dentists consider these children to be at a high risk for caries and follow them at least four times a year. Proper education of teachers and parents regarding children's oral hygiene and toothbrushing should be encouraged. Better oral hygiene may reduce complications and improve the quality of life of children with visual impairments. Drinking fluoridated water; consuming calcium and phosphate-rich foods like cheese and milk; and chewing sugar-free gum, which will stimulate the production of saliva, may be recommended for these children. Since the incidence of children with special needs is increasing throughout the world, there is a need for further studies to improve the oral health status of children with visual impairments. In addition, further studies may be conducted in other countries to see if children with visual impairments have a higher incidence of dental needs and to determine the factors other than visual impairments that influence these findings.

REFERENCES

Ajwani, S., & Ainamo, A. (2001). Periodontal conditions among the elderly: Five-year longitudinal study. Special Care in Dentistry, 21, 45-51.

Anaise, J. Z. (1979). Periodontal disease and oral hygiene in a group of blind and sighted Israeli teenagers (14-17 years of age). Community Dentistry & Oral Epidemiology, 7, 353-356.

Dong, C., & Dawes, C. (1995). The effects of blindfolding and blindness on the unstipulated and chewing-gum stimulated flow rates of whole saliva. Archives of Oral Biology, 40, 771-775.

Edwards, D. M., & Merry, A. J. (2002). Disability part 2: Access to dental services for disabled people. A questionnaire survey of dental practices in Merseyside. British Dental Journal, 193, 253-255.

Greeley, C. B., Goldstein, P. A., & Forrester D. J. (1976). Oral manifestations in a group of blind students. ASDC Journal of Dentistry for Children, 4, 39-41.

Greene, J. C., & Vermillion, J. R. (1964). The Simplified Oral Hygiene Index. Journal of the American Dental Association, 68, 7-13.

Lebowitz, E. J. (1974). An introduction to dentistry for the blind. Dental Clinics of North America, 18, 651-659.

Loe, H., & Silness, J. (1963). Periodontal disease in pregnancy. Acta Odontologica Scandinavica, 21, 533-551.

Mahoney, E. K., Kumar, N., & Porter, S. R. (2008). Effect of visual impairment upon oral health care: A review. British Dental Journal, 204(2), 63-67.

Moynihan, P. J. (2002). Dietary advice in dental practice. British Dental Journal, 193(10), 563-568.

O'Donnell, D., & Crosswaite, M. A. (1990). Dental health education for the visually impaired child. Journal of the Royal Society of the Promotion of Health, 110(2), 60-61.

Schembri, A., & Fiske, J. (2001). The implications of visual impairment in an elderly population in recognizing oral disease and maintaining oral health. Special Care in Dentistry, 21, 222-226.

Schnuth, M. L. (1977). Dental health education for the blind. Dental Hygiene, 51, 499-501.

Silness, P., & Loe, H. (1964). Periodontal disease in pregnancy. Acta Odontologica Scandinavica, 22, 121-135.

Turkish Statistical Institute. (2002). Social security and health: Disability statistics. Retrieved from http://www.turkstat.gov.tr/ VeriBilgi.do?tb_id=5&ust_id=1

Van Nieuwenhuysen, J. P., Carvalho, J. C., & D'Hoore, W. (2002). Caries reduction in Belgian 12-year-old children related to socioeconomic status. Acta Odontologica Scandinavica, 60, 123-128.

Vehkalahti, M., Nikula-Sarakorpi, E., & Paunio, I. (1996). Evaluation of salivary tests and dental status in the prediction of caries increment in caries-susceptible teenagers. Caries Research, 30, 22-28.

Vitorino, R., Calheiros-Lobo, M. J., Duarte, J. A., Domingues, P., & Amado, F. (2006). Salivary clinical data and dental caries susceptibility: Is there a relationship? Bulletin du Groupement international pour la recherche scientifique en stomatologie & odontologie, 47(1), 27-33.

Watson, E. K., Moles, D. R., Kumar, N., & Porter, S. R. (2010). The oral health status of adults with a visual impairment, their dental care and oral health information needs. British Dental Journal, 208(8), El5.

World Health Organization. (2011, October). Visual impairment and blindness (Fact Sheet 282). Retrieved from http://www. who.int/mediacentre/factsheets/fs282/en/

Worthington, H. V., Hill, K. B., Mooney, J., Hamilton, F. A., & Blinkhorn, A. S. (2001). A cluster randomized controlled trial of a dental health education program for 10-year-old children. Journal of Public Health Dentistry, 61, 22-27.

Didem Ozdemir-Ozenen, D.D.S., Ph.D., Assis. Prof. Dr., pediatric dentist, Department of Pediatric Dentistry, Faculty of Dentistry, Yeditepe University, Bagdat Cad. No: 238, 34728 Goztepe, Istanbul, Turkey; e-mail: <didem. ozdemir@yeditepe.edu.tr>. Elif Sungurtekin, D.D.S., Ph.D., lecturer, Department of Pediatric Dentistry, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey; e-mail: <elif sungurtekin@yeditepe.edu.tr>. Sule Cildir, D.D.S., Ph.D., Assoc. Prof. Dr., Department of Pediatric Dentistry, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey, and Department of Pediatric Dentistry, Anadolu Medical Suadiye Outpatient Clinic, Johns Hopkins Medicine, Istanbul, Turkey; e-mail: <sulecildir@yahoo.com.tr>. Nuket Sandalli, D.D.S., Ph.D., Prof. Dr., Department of Pediatric Dentistry, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey; e-mail: <nuket.sandalli@ yeditepe.edu.tr>.
Table 1
Age and gender of the sighted children and the children who were blind
(p = 1.201).

Age and              Sighted group               Blind group
gender     n         (Mean [+ or -] SD n         (Mean [+ or -] SD)

Age        50        7.40 [+ or -]  0.50         7.50 [+ or -] 0.50
Gender          Girls         Boys          Girls    Boys
n          50    23            22     50     21       24

Table 2
Percentage of caries-free children.

                                       Caries-free
Vision status                     n    children (n)   Percentage

Sighted group                     50        12            30
Visually impaired group           50        8             20

Table 3
Caries index results for the sighted children and the children who
were blind (SD).

Caries           Sighted group                Blind group
index    n    (Mean [+ or -] SD)    n      (Mean [+ or -] SD)        p

DMFT     50   0.80 [+ or -] 0.08    50   1.62 [+ or -] 0.20 ***   0.001
DMFS     50   0.98 [+ or -] 0.05    50   1.87 [+ or -] 0.80 *     0.020
dft      50   2.17 [+ or -] 0.80    50   4.35 [+ or -] 1.50 ***   0.001
dfs      50   3.30 [+ or -] 0.90    50   5.85 [+ or -] 1.20 *     0.032

* p < .05, *** p < .001.

Table 4
Periodontal index results for the sighted children and the children
who were blind (SD).

                                                 Visually
Periodontal         Sighted group              impaired group
index         n   (Mean [+ or -] SD)   n    (Mean [+ or -] SD)       p

PI            50  0.63 [+ or -] 0.20   50  1.5 [+ or -] 0.18 *    0.020
GI            50  0.33 [+ or -] 0.08   50  0.68 [+ or -] 0.12 *   0.030
OHI-S         50  0.76 [+ or -] 0.02   50  1.72 [+ or -] 0.21     0.042

* p < .05.
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Article Details
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Title Annotation:Around the World
Author:Ozdemir-Ozenen, Didem; Sungurtekin, Elif; Cildir, Sule; Sandalli, Nuket
Publication:Journal of Visual Impairment & Blindness
Article Type:Report
Geographic Code:7TURK
Date:Jun 1, 2012
Words:2530
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