Effectiveness of an oral hygiene instruction on the plaque score among hearing impaired children- A cross-sectional study
Aim: To evaluate the effectiveness of an oral hygiene instruction on the plaque scores among hearing impaired children.
Materials & method: A total of 56 institutionalized children with hearing impairment in the age range 5-17 years were selected for the study. Oral hygiene status was assessed using Turesky–Gilmore–Glickman modification of the Quigley Hein Plaque Index (MQPI), dentition status along with DMFS were recorded. Oral hygiene education along with the proper tooth brushing technique was demonstrated using a tooth model. Oral hygiene status was reassessed after 21 days and the data obtained was analyzed
Oral health plays an important role in the overall health of children, and, in particular it is more important for children with special health need. Children are prone to oral health problems when their oral hygiene maintenance is poor. Dental caries is the most prevalent and widespread disease seen in children and among the disabled it is the greatest unattended health need1. Children with hearing impairment (CHI) seem to be one such group lacking adequate oral health awareness to maintain their oral health owing to communication barriers2,3
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Hearing impairment (HI) forms major disability affecting many children world-wide. There are 23,000-25,000 children (aged 0-15 years) who are permanently deaf or hard of hearing in UK4. According to National Sample Survey Organization in India, 0.4% of 1065.40 million children are hearing impaired and every child in 1000 live births suffers from HI.5 Hearing impairment primarily influences communication, on which it can have a devastating effect6. As the degree of loss increases, psychological, emotional and social disturbances generally become more pronounced.6The extent of disturbance also depends on age of onset, training, and acceptance of disability6. Various factors contribute to the significant problems experienced by this population group in accessing health care and in communicating with doctors such as lack of sign language and due to the lack of awareness training among health service staff and the shortage or absence of aids to communication7.
People with disabilities deserve the same opportunities for oral health and hygiene as those who are healthy. Previous studies have found hearing impaired children have poorer oral hygiene than non-hearing impaired children8,9. Plaque and gingival indices in disabled children after a mechanical plaque control were significantly different compared with those of non-disable children10. Although numerous plaque control methods have been proposed, tooth brushing using a correct technique is effective in controlling plaque is safe, easy to use and cost effective.11
With respect to the importance of assessing the oral health care needs among these special groups of population and lack of studies carried out on this issue in the pertinent population, the aim of the study was to evaluate the effectiveness of an oral hygiene instruction on the plaque scores among hearing impaired children.
Materials and methods
A cross-sectional study was conducted in National Residential School for Deaf, Bangalore , an institution for the deaf and dumb children which comprised of 56 children aged between 4-17years.Prior written consent was obtained from the school and also the intervention of the study design was been explained. Ethical clearance was obtained from
A total of 56 children participated in the study which included both male and female. Children present on the day of the examination were included. Those who were not willing to participate or those unwell were excluded. General information about the respondent’s oral hygiene habits and frequency of dental visits were obtained using a questionnaire. Dental examination was performed using dental mirror and a probe in broad daylight in accordance with WHO guidelines12. Oral examination included: number of teeth, presence of caries, restorations and number of extracted teeth and plaque score. Acquired data was entered in the dental records for each patient. For the assessment of dental status, the DMFS (decayed, missing, filled) index was used and the Turesky—Gilmore–Glickman modification of the Quigley–Hein plaque index (1970)13 was used to assess the plaque score. Plaque was assessed on the facial and lingual surfaces of all the teeth. A plaque score per person was obtained by totaling all the plaque scores and dividing by the number of surfaces examined. A score of 0 to 5 was assigned to each facial and lingual non-restored surface of the tooth as shown in Fig 1. Scoring was as follows:
0 = no plaque/debris
1 = separate flecks of plaque at the cervical margin of the tooth.
2 = a thin continuous band of plaque (up to 1 mm) at the cervical margin of the tooth.
3 = a band of plaque wider than 1 mm but covering less than one third of the crown of the tooth.
4 = plaque covering at least one third but less than two thirds of the crown of the tooth.
5 = plaque covering two thirds or more of the crown of the tooth.
Figure 1.Tooth areas graded by the Turesky et al Modified Quigley Hein Plaque Index
Following initial examination, oral hygiene instructions regarding the importance of maintaining a good oral hygiene, development of dental caries and the tooth brushing technique in the form of manual demonstration of tooth brushing on tooth models was given. The technique of tooth brushing demonstrated was dependent on the age group of the child. Children younger than 8 years, because of their limited manual dexterity were being demonstrated with the horizontal scrub technique and those older than 8 years, modified bass technique was demonstrated. A tooth brush and toothpaste (Colgate,India-1000 ppm of maximum available fluoride) was given to all the participants to standardize the process. After 3 weeks, once again plaque scores were recorded and statistically analyzed with baseline scores.
The AAPD defines special health care needs as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs.14 Oral health is an inseparable part of general health and well-being. Individuals with SHCN may be at an increased risk for oral diseases throughout their lifetime.15 Physical disability such as hearing impairment can result in difficulties to reach an ideal health status of the teeth. Since children with hearing impairment are either dependent on their parents or care providers for their general and oral health care needs, it is the responsibility of the dental health care professional to design new and innovative ways to provide dental health education to these children.16 Education is one of the essential factor responsible for behavioral change in children. 17 Particularly, oral health education is the key to prevent oral diseases and it is always appropriate to educate school age children 18 and through them education can reach their families and community members as well.19
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To deliver quality health education, various approaches can be planned to have a better communication as communication is a key factor in conveying dental health education to the children with hearing impairment.16 According to the child’s development stage and motor skill oral hygiene instruction should be instructed. Variations in the ability of tooth brushing must be considered, especially with younger children. Intensive individual training of each child is also essential to achieve desired benefits of the technique.
`In the present study, the higher plaque score before OHE confirm poor oral hygiene status in children with hearing impairment similar to earlier studies.3-5,20,21 Hence, the prime motive of this study was to instill appropriate oral health awareness in these children.
After the initial examination, a sample of tooth brush and fluoridated tooth pastes were given to the children to motivate them toward active participation in the program. Oral hygiene education talk was given to children to make them understand the importance proper oral hygiene procedures and the development of dental caries. With the help of the school teacher using the sign language, and according to the age wise proper brushing technique were being demonstrated. It was seen that almost all of the children showed a keen interest to learn the proper brushing technique.
Majority of the children in this study use the horizontal scrub technique and Fones technique. The use of the horizontal scrub technique has been reported as a method of choice in young children in various studies because of the inability to apply other tooth brushing techniques.22-24 Tooth brushing skill and the required manual dexterity for tooth brushing are developed in children aged 8 years and above.25Mescher et al26 reported that children age 6 years and younger do not have the hand functions which are required for tooth brushing, and hence concluded that the sulcular brushing technique could be mastered by children 8 years and above. Kropfl27 reported that modified bass method to be significantly more efficacious than horizontal scrub method. Kremers et al28 and Zhang et al29 showed that Bass technique effectively removed interdental plaque when compared to other techniques.
Age comparison between older and younger age groups shows differences in the maintenance of oral hygiene which is also seen in this present study. Chronological age is a reasonable predictor of tooth brushing ability and manual tooth brushing skills are acquired better after 4-5 years of age.30 In the present study, it was seen that there was a significant plaque reduction in high school children (12-16 years) compared with primary school children (5-7years) and middle school children (8-11 years) indicating better motivational and performance skills in the older age group children compared with younger ones. This can be said to be influenced by the greater cognitive ability and the manner of learning and initiation in older age groups.
The results of this study showed that the OHE program was effective in improving their oral health status significantly and was equally successful in improving their oral health.
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- Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist 2002;22:26S-39.
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- Champion J, Holt R . Dental care for children and young people who have a hearing impairment. B r Dent J 2000;189:155-9.
- Jain M, Mathur A, Kumar S, Dagli R J, Duraiswamy P, Kulkarni S. Dentition status and treatment needs among children with impaired hearing attending a special school for the deaf and mute in Udaipur, India. J Oral Sci 2008;50:161-5.
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- Arunakul M, Kuphasuk Y, Boonyathanasit R. Effectiveness of oral hygiene instruction media on periodontal health among hearing impaired children. Southeast Asian J Trop Med Public Health. 2012 Sep;43(5):1297-303.
- WHO. Oral Health Surveys: Basic Methods. 4th Ed. Geneva: World Health Organization; 1997.
- Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker LA. A modified gingival index for use in clinical trails. Clin Prev Dent 1986;8(1):3-6.
- American Academy of Pediatric Dentistry. Definition of special health care needs. Pediatr Dent 2012;34(special issue):16.
- Lewis CW. Dental care and children with special health care needs: A population-based perspective. Acad Pediatr 2009;9(6):420-6.
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- Kumar S, Dagli R J, Mathur A, Jain M, Duraiswamy P, Kulkarni S. Oral hygiene status in relation to sociodemographic factors of children and adults who are hearing impaired, attending a special school. Spec C are Dentist 2008;28:258-64.
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- Kropf JL. Clinical Evaluation of Magnifying Lighted Mirror and Unwaxed Dental Floss as Oral Hygiene Adjuncts. Master’s Thesis, Ann Arbor, University of Michigan, School Dentistry; 1971. p. 124.
- Kremers L, Lampert F, Etzold C. Comparative clinical studies on 2 toothbrushing methodsâ€‘â€‘Roll and Bass technic. Dtsch Zahnarztl Z 1978;33:58â€‘60.
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