Oral health behaviors of preschool children with cerebral palsy: a case-control community-based study

ORAL HEALTH BEHAVIORS OF PRESCHOOL CHILDREN WITH CEREBRAL PALSY

A R T I C L E

298 Spec Care Dent is t 34(6 ) 2014 © 2012 Special Care Dentistry Association and Wiley Periodicals, Inc. doi: 10.1111/j.1754-4505.2012.00295.x

A R T I C L E

To describe and compare the oral health behaviors of preschool children with and without cerebral palsy (CP), and to assess the oral health knowledge and attitudes of their primary caregivers (PCGs). Seventy-two preschool children with CP were recruited from 23 Special Child Care Centers in Hong Kong. An age- (±3 months) and gender-matched sample of children from mainstream preschools was recruited as a “control group.” Assessment of children’s oral health behaviors and the PCGs’ oral health knowledge and attitudes was conducted using questionnaires. Preschool children with CP were less likely to have ever attended a dentist (p < 0.05). Tooth brushing frequency was similar between the two groups (p > 0.05), but PCGs of children with CP more frequently reported provision of tooth brushing assistance to their children (p < 0.001). PCGs in both groups had similar oral health knowl-edge and attitudes (p > 0.05). Difference in oral health behaviors existed between preschool children with and without CP. PCGs of children with and without CP had similar oral health knowledge and attitudes.

A B S T R A C T Oral health behaviors of preschool children with cerebral palsy: a case-control community-based study

Rennan Y. Du, BDS, MDS AdvDipPaediatrDent;1* Colman P. McGrath, BA, BDentSc (Hons), FDSRCS, DDPHRCS, MSc, FFDRCSI, PhD, MEd;2 Cynthia K.Y. Yiu, BDS, MDS, PhD, FHKAM, FCDSHK;3 Nigel M. King, BDS (Hons), MSc (Hons), PhD, LDS, RCS, Hon FDSRCS, FHKAM, FCDSHK, MRACDS4

1PhD student, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China; 2Clinical Professor in Dental Public Health, Periodontology and Public Health, Faculty of Dentistry,

The University of Hong Kong, Hong Kong SAR, China; 3Clinical Professor in Paediatric Dentistry,

Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of Hong Kong,

Hong Kong SAR, China; 4Winthrop Professor in Paediatric Dentistry, School of Dentistry, Faculty of

Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, Australia.

*Corresponding author e-mail: [email protected]

Spec Care Dentist 34(6): 298-302, 2014

It is also recognized that CP can give rise to a whole range of oral health prob-lems due to structural changes in the oro-facial region and para-functional oral habits associated with neuromuscular deficits.8 Furthermore, dental and facial trauma has been reported to be wide-spread, because of neuromuscular disability and instability.9,10 A high preva-lence of developmental enamel defects had been reported among children with CP, which varied with the tooth type and the gestational age of the children.11 The two most common oral diseases—dental caries and periodontal diseases are often reported to be worse among those with CP.12-16 Untreated caries and extractions

are common in children with CP.17,18 The health- and oral health-related quality of life of preschool children with CP were poorer than normal preschoolers.19

The key factors which influence dental caries and periodontal diseases are oral health behaviors, such as oral hygiene practices and utilization of dental services.20,21 Thus, it is impor-tant to identify oral health behaviors among specific groups that are at risk of developing these common oral diseases; and/or specific groups whose systemic health can be further compromised by oral diseases or their management.22,23 Children with CP are often highly dependent on their primary caregivers

I n t r oduc t i on“Cerebral palsy” (CP) describes a group of permanent disorders attributed to nonpro-gressive disturbances in the fetal or infant brain, which affects the development of movement and posture.1 CP is one the most common form of neuromuscular disabili-ties affecting children, with a worldwide prevalence of between 1.3 and 3.6 cases per 1,000 live births.2-7 The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication and neurological disturbances (such as epilepsy), and by secondary musculoskeletal problems.1 Thus, numerous systemic health problems are common among children with CP.

KEY WORDS: cerebral palsy, preschool children, oral health behaviors, oral health knowledge and oral health attitudes

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samples. Oral health attitudes responses were categorized by frequency of appro-priate responses and compared between the case and control groups using Chi-square statistics. Overall oral health attitude scores of PCG between the case and control groups were compared using Student’s t-test for independent samples.

Resu l t sMost of PCG who had children with CP (76.6%, 72/94) gave their consent to par-ticipate in the study. The mean age of the children was 56 ± 12 months (range from 30 to 77 months), of whom 54% were males. An age- and gender-matched control group of children from main-stream preschools was also recruited. The demographics of the PCG were simi-lar in terms of gender, level of formal educational attainment and family income level, Table 1 (p > 0.05).

Oral health behaviors of preschool childrenLess than a quarter of children with CP (23.6%, 17) have attended a dentist, when compared to 40.3% (29) in the control group p < 0.05 (Table 2). Among the children with CP who went to the dentist, 82.4% (14/17) visited the dentist in the past year. Among the children in the con-trol group, 79.3% (23/29) visited the dentist within the past year. The reason for dental attendance among the case

health knowledge, open ended responses to (i) causes of dental caries, (ii) ways to prevent dental caries, (iii) causes of peri-odontal diseases, and (iv) ways to prevent periodontal diseases were ascer-tained.27 Subjects were asked to cite the three most important factors in their open-ended responses, which were ana-lyzed and scored. The oral health knowledge score ranged from 0 to 3 for each of the four questions, giving a maxi-mum overall score of 12.21 Responses to an eight-item scale were used to assess the oral health attitude of PCG.28 A dental attitude score was constructed by counting the total number of statements (eight statements concerning oral health issues), which the caregivers showed a positive attitude. This score can range from 0 to 8, with a higher score indicat-ing a more positive attitude.

Additional information on sociode-mographic profile of PCG, including age, gender, level of formal educational attainment, and family income level were obtained.

Data analysisThe data was analyzed using the Statistical Package for Social Sciences (SPSS 16.0 for Windows). Oral health behaviors between the case and control groups of children were compared using Chi-square statistics. Oral health knowl-edge scores between the PCG of the case and the control groups were compared using Student’s t-test for independent

(PCGs).24 It is therefore of prime importance to ascertain PCGs’ knowl-edge and attitudes towards oral health, as they are likely to influence their chil-dren’s oral health behavioral practices.25,26

The aims of this study were to describe and compare oral health behav-ioral practices of preschool children with and without CP, and to assess the oral health knowledge and oral health atti-tudes of their PCGs.

Mate r i a l s and me thodsSampleThe sampling frame for this study was a complete list of Special Child Care Centres as identified from the Government Social Welfare Department, Hong Kong Special Administrative Region (HKSAR), China. Ninety-four children diagnosed with CP were identified from the 23 centers (5 in Hong Kong Island, 5 in Kowloon, 13 in New Territories) and their parent(s)/primary care givers were invited to participate in the study. As a control group, an age-(±3 months) and gender-matched sample of children from mainstream preschools in the geographi-cal areas were recruited. Approval to conduct the study was sought and obtained from the local Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB HKU: UW 08–448).

Data collectionInformation of children’s oral health behaviors and PCG’s oral health knowl-edge and their oral health attitudes were obtained using a structured question-naire. In assessing children’s oral health behaviors, the focus of the assessment was on (i) dental attendance (ever attended a dentist, time since last dental visit, reason for last dental attendance, experience of general anesthesia for dental treatment); (ii) oral hygiene prac-tices (frequency of tooth brushing, assistance when tooth brushing, use of toothpaste when brushing); and (iii) snacking habit (frequency of snacking in between meals). In assessing PCG’s oral

Table 1. Demographic background of preschool children with and without CP (n = 144).

CP (n = 72) % (n) Non-CP (n = 72) % (n) p-Value*

Parents education level*

None/primary 18.1% (13) 7.0% (5) 0.13

Secondary school 62.5% (45) 72.2% (52)

Tertiary 19.4% (14) 20.8% (15)

Family income (HKD per month)

Less than $10,000 38.9% (28) 33.3% (24) 0.29

$10,000–$19,999 37.5% (27) 50% (36)

$20,000 or above 23.6% (17) 16.7% (12)

Mother completed questionnaire 76.4% (55) 70.8% (51) 0.68

*p-Value obtained from Chi-square statistics.

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9.56 (SD 2.61), respectively (p > 0.05) (Table 3). There was no significant differ-ence in the knowledge of the cause of dental caries; cause of periodontal dis-eases, how to prevent dental caries and how to prevent periodontal diseases between PCG of the case and control groups (p > 0.05).

Oral health attitudes of caregiversThe overall mean oral health attitude scores among PCG of children with and without CP were 6.41 (SD 2.30) and 6.49 (SD 2.31), respectively (p > 0.05) (Table 4). No significant difference in their oral health attitudes was observed between PCG of children with CP and without CP (p > 0.05).

D i s cus s i onIt is widely acknowledged that oral health behaviors are central to good oral health, but there is a paucity of studies relating to oral health behavior among special needs/ special health care groups.29,30 This study benefits from being a community-based case-control study, describing the oral health behav-iors among preschool children with CP and compared to preschool children from mainstream schools. Although modest in size, the study yielded some interesting findings, which have implications for oral health care planning and oral health promotion activities targeting children with CP and possibly other persons with special health care needs.

The dental attendance of preschool children in the present study was low, which is comparable to findings of the 2001 Oral Health Survey in Hong Kong.31 Dental attendance was particu-larly poor among preschool children with CP, less than a quarter had ever visited a dentist since birth. Furthermore, among those who have visited a dentist, the rea-sons for the visit were predominantly problem/treatment-related. It is under-standable that oral health care needs of children with CP have to compete with their other health care needs.24,32 These children due to their compromised gen-eral health tend to receive the dental

A similar proportion of PCG in the case and control groups reported using tooth-paste while brushing their children’s teeth, 86.1% versus 93.1% (p > 0.05).

Snacking in between meals was common in both the case and control groups. There was no significant differ-ence in frequency of snacking (“twice or more” between meals) between children in the case and control groups, 36.1% versus 43.1% (p > 0.05).

Oral health knowledge of caregiversThe overall mean oral health knowledge score among PCG of children with and without CP were 9.47 (SD 2.93 and

group was predominantly problem/treat-ment related (88.2%, 15/17) and likewise for the control group 62.1% (18/29). Children with CP more frequently experi-enced general anesthesia for dental treatment (6.9%, 5), when compared to children in the control group (1.4%, 1).

In terms of oral hygiene habits, PCG in both the case and control groups reported that their children’s teeth were brushed at least twice a day: 70.8% (case group) versus 66.7% (control group) (p > 0.05). Primary care givers of children in the case group more frequently reported assisting their children with tooth brushing, when compared to PCG of children in the control group (p < 0.001).

Table 2. Oral health behaviors of preschool children with and without CP (n = 144).

CP (n = 72) % (n) Non-CP (n = 72) % (n) p-Value*

Dental Attendance

Ever attended the dentist

Yes 23.6.8% (17) 40.3% (29) 0.03*

No 76.4% (55) 59.7% (43)

Last dental visit

Within the past year 19.4% (14) 31.9% (23) 0.17

More than a year ago and never 80.6% (58) 68.1% (49)

Experience of general anesthetic for dental treatment

Yes 6.9% (5) 1.4% (1) 0.10

No 93.1% (67) 98.6% (71)

Tooth Brushing habits

Frequency of brushing

At least twice a day 70.8% (51) 66.7% (48) 0.59

Less than twice a day 29.2% (21) 33.3% (24)

Use of toothpaste when brushing

Yes 86.1% (62) 93.1% (67) 0.17

No 13.9% (10) 6.9% (5)

Assisted brushing with parent

Always 90.3% (65) 26.4% (19) <0.001*

Sometimes 6.9% (5) 55.6% (40)

Never 2.8% (2) 18.1% (13)

Snacking habit

Snacking habit between meals (usually)

Once 63.9% (46) 56.9% (41) 0.39

Twice or more 36.1% (26) 43.1% (31)

*p-Value obtained from Chi-square statistics.

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overall oral health knowledge and atti-tude of parents of Saudi children with CP is satisfactory.40 Likewise, oral health attitudes were generally favora-ble and comparable between the two groups. This may indicate that it is not the oral health knowledge, nor the oral health attitudes of PCG that needs to be changed. Rather, the problem lies in the fact that preschool children with CP do not have adequate access to dental care in Hong Kong. Therefore, the barriers that withhold these chil-dren from seeking dental care should be investigated and considered, when planning oral health care to this special needs group.

Conc l u s i onIn conclusion, findings from this com-munity-based case-control study in Hong Kong indicated that PCG of children with and without CP had similar oral health knowledge and attitudes. However, differences in oral health behaviors existed between preschool children with and without CP; particu-larly with respect to dental attendance. These findings are of potential value to improve oral health promotion activities targeting children with CP and other special health care groups.

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Table 3. Oral health knowledge among parents of preschool children with and without CP (n = 144).

CP (n = 72) Mean (SD)

Non-CP (n = 72) Mean (SD)

p-Value*

Knowledge of case of tooth decay 2.57 (0.84) 2.56 (0.73) 0.44

Knowledge of the cause of gum disease 2.14 (0.97) 2.21 (0.87) 0.80

Knowledge of tooth decay prevention 2.59 (0.87) 2.62 (0.70) 0.62

Knowledge of gum disease prevention 2.26 (0.91) 2.25 (0.87) 0.78

Overall scores 9.47 (2.93) 9.56 (2.61) 0.76

*p-Value obtained using Student's t-test statistics.

Table 4. Oral health attitudes among parents of preschool chil-dren with and without CP (n = 144).

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Poor teeth are detrimental to one’s appearance 97.2% (70) 94.4% (68) 0.40

State of my teeth is of great importance to me 100% (72) 97.2% (70) 0.15

Keeping natural teeth is not important 100% (72) 98.6% (71) 0.32

Dental problems can affect the body as a whole 93.1% (67) 87.5% (63) 0.26

False teeth will be less of a bother than natural teeth

91.7% (66) 95.8% (69) 0.30

Regular visits to the dentist prevent dental problems 100% (72) 93.1% (67) 0.02*

Overall percentage of appropriate answers 59.7% (43) 52.8% (38) 0.41

*p-Value obtained using Chi-square statistics.

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Oral health behaviors of preschool children with cerebral palsy: a case-control community-based study