Evaluation of Periodontal Status and Treatment Needs of Institutionalized Intellectually Disabled Individuals in Lebanon.

AIMS AND
OBJECTIVES: No reported data is available on the periodontal health and treatment needs of the intellectually disabled in Lebanon. To evaluate the periodontal condition and treatment needs of institutionalized intellectually disabled individuals in Lebanon.
MATERIALS AND METHODS: A total of 272 individuals (141 males and 131 females) aged 15 years and 35-44 years were examined. Periodontal health was recorded following the community periodontal index of treatment needs (CPITN), and treatment need was assigned accordingly. The IBM® SPSS® statistics 20.0 and Stata/SE 11.1 statistical packages were used to carry out all statistical analyses. Statistical analysis was performed using linear regression (P ≤ 0.05).
RESULTS: Healthy periodontium was recorded in 26.1%, bleeding on probing in 27.9%, supra-/sub-gingival calculus in 31.3%, pockets of 4-5 mm in 11% and ≥6 mm in 3.7%. The largest proportion of the sample was in need for oral hygiene instruction and calculus removal (42.3%). Age, geographical location, consumption of carbohydrate-rich meals and sweets between meals were significantly associated with CPITN score severity in multivariate analysis (P < 0.05). Gender, severity of disability, frequency of tooth brushing, and caretaker characteristics were not significant predictors of CPITN (P > 0.05).
CONCLUSION: The predominantly poor periodontal health and social inequalities warrant nationwide preventive oral health programs in addition to planning the provision of treatment services to meet existing treatment needs.

INTRODUCTION

The definition of disability is socially constructed and relies on the interpretation of impairment, which may manifest either as a physical or mental state or both.[1] Intellectual disability occurs when impairment impedes cognitive and adaptive functioning, and it is the most common developmental disorder that inhibits full participation in society for hundreds of millions of people.[2]

Good oral health is essential for appearance, speech, proper mastication, and digestion and has a strong impact on general health.[3] Periodontal diseases are the most common noncontagious group of conditions afflicting humans.[4] Several epidemiological studies have noted that individuals with disabilities tend to have poorer oral hygiene and a greater prevalence and increased the severity of periodontal disease than the general population.[56] The prevalence and severity of periodontal disease in the disabled are usually associated with factors such as age, type of disability, institutionalization, socioeconomic status (SES), availability of dental care, and type of treatment offered.[7] Nonetheless, there appears to be a general agreement that dental treatment is one of the greatest unattended health needs of disabled individuals.[78] On the one hand, this may be due to poor patient cooperation and underestimation of treatment needs.[9] In addition, the demand for dental care can often be limited either by the disabled individual's incapacity to accurately convey their symptoms or by the parent or caregivers to evaluate their oral condition.[10]

The World Health Organization (WHO) has been collecting data on periodontal diseases since 1969, initially using the periodontal index of Russell and the simplified oral hygiene index but more recently these have been replaced by the community periodontal index of treatment needs (CPITN).[11] Adopted by the WHO, the CPITN method of assessing periodontal condition provides standardized and comparable measurements of treatment needs that enable use by health planners and comparisons between populations. The index has been extensively used so that the WHO Global Oral Data Bank now contains comprehensive data from many countries around the world.[12] On the other hand, the periodontal condition of intellectually disabled individuals has not nearly been sufficiently assessed, especially in developing and lower-income countries.[13] According to official national estimates based on registration with the Lebanese Ministry of Social Affairs (MSA), there are at least 27,500 intellectually disabled individuals in Lebanon, an estimate that represents more than 28% of all disabled Lebanese individuals.[14] However, despite recent growing research interest in the oral health of disabled individuals, the oral health and conditions of intellectually disabled persons in Lebanon have not yet been assessed.

The objective of the present study was to evaluate the periodontal health status and treatment needs of institutionalized intellectual disabled persons in Lebanon.

MATERIALS AND METHODS

A nation-wide cross-sectional study was conducted between November 2015 and April 2016. The target population was set as all institutionalized Lebanese individuals with intellectual disabilities in the age groups 15 and 35–44 years residing across the six Lebanese governorates. Ethical approval of the research protocol was obtained from the Ethical Research Committee and the Faculty of Medical Sciences at the Lebanese University (protocol no. 53/2016, 12-07-2016) in addition to the MSA in Lebanon (protocol no. 589, 02-02-2015).

The MSA provided a list of the 49 registered institutions caring for disabled persons distributed throughout the Lebanese territory along with the number of registered disabled persons belonging to the age groups of interest. All but one institution, located in Mount Lebanon, approved of participation in the study. These 48 institutions combined cared for 291 individuals belonging to the target age groups (164 adolescents aged 15 years and 127 adults aged 35–44 years). All individuals were approached and were eligible for participation. Four individuals were absent, and 15 were noncooperant with the oral examination, resulting in the examination of a total of 272 individuals (age 15: 152 individuals; age 35–44: 120 individuals). Before the subject examination, written consent was requested from their parents, legal guardians, or institution caretakers.

DATA COLLECTION

Clinical data were collected through an oral examination, and supplementary information on background characteristics and behavioral factors was collected through a questionnaire filled by each subject's primary caretaker (either parent or guardian at the institution). The questionnaire explored background characteristics (age, sex, and governorate of residence), arrangement with the institution and characteristics of primary caretaker (relation to the disabled person and education), type of disability and severity, oral hygiene practices, and dietary habits.

The second stage of the study consisted of a clinical examination aiming to assess each subject's periodontal condition. All examinations were carried out by a trained dental practitioner with more than 15 years of experience in providing oral care to disabled individuals (the researcher), who examined each person seated in a chair under adequate room lighting using mouth mirrors and the WHO probe to determine the bleeding response, the presence of supra- or sub-gingival calculus and probing depths.[15] Disabled persons who were absent or unable to cope with the clinical examination and whose lack of cooperation prevented the adequate collection of all measures of interest were excluded from the study.

The criterion used to assess periodontal condition was the CPITN which is based on the measurements of bleeding, calculus, and pocket depth.[11] The dentition was divided into six sextants (one anterior and two posterior tooth regions in either arch) defined by teeth numbers 17–14, 13–23, 24–27, 37–34, 33–43, and 44–47. A sextant was examined only if there were two or more teeth present and these were not indicated for extraction. When only one tooth remained in the sextant, it was included in the adjacent sextant. The highest CPITN sextant scores were used to classify each subject into one of four different treatment need categories [Table 1].

Table 1

Periodontal status (community periodontal index of treatment needs) and assessment of treatment needs

STATISTICAL ANALYSIS

Means and standard deviations were generated for CPITN scores across the two age categories and across all other variables of interest. Bivariate analyses between CPITN as the outcome and the various background and behavioral factors were conducted using simple linear regressions to estimate the degrees of freedom, F statistics and P values. Variables associated with CPITN at P < 0.2 at the bivariate level were included in the subsequent multivariate modeling. The final multiple linear regression was then used to estimate regression coefficients, standard errors, 95% confidence intervals (CIs) and two-sided P values. Statistical significance was set at 0.05. The IBM® SPSS® statistics 20.0 and Stata/SE 11.1 (U) (USA) statistical packages were used to carry out all statistical analyses.

RESULTS

DESCRIPTIVE CHARACTERISTICS

A total of 272 individuals, 152 (55.9%) adolescents age 15 years and 120 (44.1%) adults between the ages of 35–44 years were examined. The sample was almost equally distributed between males (51.84%) and females (48.16%). Overall, 26.1% of the subjects had healthy periodontal tissue and bleeding on probing was recorded in 27.9% [Table 2]. Although CPITN scores were worse in the older age category, even at age 15 years 7.2% of the examined individuals displayed at least one periodontal pocket of 4–5 mm. In the adult sample, 24.1% of those examined presented with periodontal pocketing of at least 4–5 mm, 8.3% of whom displayed pocket depths of at least 6 mm [Table 2].

Table 2

Percentage distribution of examined institutionalized physically challenged persons by periodontal health and treatment needs (n=272)

FACTORS ASSOCIATED WITH COMMUNITY PERIODONTAL INDEX OF TREATMENT NEEDS

At the bivariate level, three background and four behavioral factors were associated with CPITN severity (P < 0.05) [Table 3]. The relationship of the primary caretaker to the disabled individual and their level of education were not significantly associated with CPITN (P = 0.313 and 0.940, respectively). Mean CPITN scores were statistically significantly larger in adults (P < 0.001); males (P = 0.045) and in those residing in the area of Mount Lebanon (P < 0.001). Among the behavioral factors recorded, the availability of a toothbrush (P = 0.004), brushing frequency (P = 0.007), type of meals consumed (P = 0.001), and sweet consumption between meals (P < 0.001) were significantly associated with CPITN score. Regarding the oral hygiene, higher scores were recorded for subjects not having a toothbrush (2.23 ± 01.30 compared to 1.34 ± 1.07) and for those who do not brush their teeth (2.17 ± 1.15) while the lowest CPITN scores were noted in those who brush at least 2/day with or without help (1.10 ± 1.10 and 1.15 ± 1.08, respectively) [Table 3]. In addition, individuals who consumed predominantly home-cooked meals had lower CPITN scores than those mainly consuming fast food and pastries (1.09 ± 0.99 compared to 2.33 ± 0.82) and those consuming sweets between meals more than 2/day had the highest CPITN scores (1.85 ± 1.06) compared to all other levels of sweet consumption (1.06 ± 1.10–1.29 ± 1.11).

Table 3

Bivariate associations between selected background and disabled characteristics and community periodontal index of treatment needs score (n=272)

A combination of 8 background and behavioral characteristics significantly explained CPITN score in the final multivariate model (F(19,252) =5.58, P < 0.001; R2 =0.2963) [Table 4]. Among these eight variables, only four were significantly associated with CPITN score while controlling for the remaining factors: age, governorate, type of meals consumed, and sweet consumption between meals (P < 0.05). Controlling for the remaining variables, the CPITN score in adults is larger by a mean of 0.49 compared to 15-year-old (95% CI: 0.22–0.75; P < 0.001). Individuals residing in Mount Lebanon and Bekaa also have more severe CPITN scores than those residing in the South (P = 0.001 and 0.026, respectively), while no differences were noted between those in Beirut and the North compared to the South (P = 0.06 and 0.405, respectively). Accounting for the effect of the remaining variables, the frequency of tooth brushing is not significantly associated with CPITN score. The latter is rather explained by consuming fast food and pastries instead of home-cooked meals (P = 0.045) and increased sweet consumption between meals, but only when more than 2/day compared to no consumption at all (P = 0.004).

Table 4

Multivariate analysis showing associations between selected variables and community periodontal index of treatment needs, score (n=272)

PERIODONTAL TREATMENT NEEDS

A large proportion of the subjects examined required periodontal treatment. The most prevalent treatment need was plaque control and scaling (TN2), followed by oral hygiene instruction (TN1). The need for complex periodontal treatment (TN3) was required by only a small percentage of the overall examined sample (3.7%).

The majority of adolescents aged 15 were almost equally divided between those requiring oral hygiene instruction only and those additionally requiring scaling (34.2% and 34.9%, respectively), and only about 31% required no treatment. At age 35–44, however, more than half required oral hygiene instruction and scaling and slightly <10% additionally were in need for complex periodontal treatment [Table 2].

DISCUSSION

The findings of this study represent the first report evaluating the periodontal health and the treatment needs of institutionalized intellectually disabled individuals in Lebanon; it showed that only around one-quarter had healthy periodontal status and bleeding and calculus stood out as the predominant condition, affecting more than 50% of the sample. In addition to oral hygiene instruction, more than 40% were in need of professional prophylaxis including calculus removal and scaling/root planning. Higher CPITN scores were associated with the adult than the adolescent sample, and increasing age was a significant predictor of CPITN score severity when all other background and behavioral factors were taken into account. This general increase in CPITN scores or in other indicators of periodontitis with increasing age has been similarly reported in earlier investigations[16171819] and may be due to the cumulative effects of calculus and the progressive nature of periodontal disease and the cumulative effects of periodontal breakdown over time.[20] Our results also support previous assessments of intellectual disabled populations reporting low prevalence of healthy periodontium and the predominance of bleeding and calculus.[917212223] Comparison to other populations in the region is limited owing to the extreme scarcity of similar research, but the limited data available on children/adolescents supports our findings in 15-year-old children. In children with Down's syndrome in the United Arab Emirates, only 10% had a healthy periodontium, around one-quarter require comprehensive prophylaxis including scaling and root planning while around 50% required additional complex periodontal treatment.[24] In another assessment of institutionalized mentally retarded children in Iran, <1% exhibited healthy periodontal tissue, but treatment needs were slightly less severe: three-quarters required only oral hygiene instructions, slightly less than a quarter required scaling and slightly over 1% were in need for complex periodontal treatment.[16]

Despite the importance of mechanical plaque removal to maintain a healthy periodontium and the intuitive belief that intellectual disability is associated with limitations in manual dexterity limiting proper tooth brushing,[25] the frequency of tooth brushing (with or without help) was not a significantly contributor to CPITN score severity when controlling for other background and behavioral factors. Although several studies do report limitations in manual dexterity in the intellectually disabled,[262728] this has not directly been linked to poor oral health outcomes such as periodontal disease.

Shaw et al.,[29] who assessed manual dexterity in their study, similarly showed that, although periodontal health was poor, it was not correlated with manual dexterity. A possible explanation may be that, given the age of the examined subjects (15-year-old and 35–44-year-old) and in light of the already established presence of supra- and sub-gingival calculus, the severity of CPITN score may be set and cannot be reversed in the absence of actual mechanical removal of the irritating deposits. It must be emphasized that although data were collected on current tooth brushing practices, it is a history of oral hygiene practices and tooth brushing habits that more closely explain the periodontal conditions recorded on the day of clinical examination. It must also be considered that the frequency of brushing may not necessarily correlate with the efficiency of brushing and may not have been truly reflective of the oral hygiene status of the examined individual. Rather than brushing frequency, the significant predictors of CPITN score severity in our sample were the consumption of both predominantly carbohydrate rich meals (fast food) and sweets between meals more than twice a day. These results highlight the importance of dietary, behavioral factors in the maintenance of periodontal health, at least in conjunction with oral hygiene measures but perhaps even more importantly than the frequency of brushing in such vulnerable populations as the intellectual disabled. The prolonged retention of food particles in the oral cavity due to a lack of normal masticatory functions in intellectual disabled persons may result in increased gingival inflammation and eventually lead to bleeding and to periodontal disease. Owing to the difficulties in the provision of oral health instruction in a disabled population, the removal of sub- and supra-gingival calculus would facilitate the limited self-performed oral hygiene that may be taking place. Therefore, in addition to controlling carbohydrate intake, frequent oral prophylaxis, and calculus removal is crucial.

Previous studies have highlighted the importance of SES as a predictor of oral and periodontal health in intellectual disabled individuals, including variables such as parent education, geographical location, lack of organizational support, and overall SES category.[7173031] Our results highlight that the periodontal health of the institutionalized intellectual disabled individuals in Lebanon is also subject to significant socioeconomic inequalities regardless of all other background and behavioral characteristics assessed. Individuals who were cared for in institutions located in Mount Lebanon and Bekaa were likely to have significantly higher CPITN scores than those in all remaining governorates, those in Mount Lebanon in particular being the most vulnerable. The geographical location in our sample is likely to be a proxy variable for underlying socioeconomic disadvantages that may include parental education, financial stability, and inaccessibility to dental services, but nonetheless highlight the inequality in the distribution of periodontal disease even among the intellectual disabled population which is likely to already be suffering from greater unattended dental treatment needs in comparison to the general population.[32]

Although our results cannot be extrapolated to the general population of noninstitutionalized intellectually disabled individuals in Lebanon, several factors contribute to the importance of our study to the data on periodontal health in intellectual disabled individuals in Lebanon. The exhaustive survey that was conducted attempted to include all registered institutionalized intellectual disabled persons in Lebanon to produce data and conclusions that are externally valid and representative of the entire institutionalized population of interest. The use of the simple and straightforward CPITN index, in addition to the examination of an easily accessible population, offer the possibility of preliminary goal-setting using limited resources until more comprehensive research sheds light on the broader population of noninstitutionalized intellectually disabled individuals. The description of the treatment needs of this institutionalized population presents the opportunity for cost-effective prevention and intervention by various governmental and nongovernmental stakeholders responsible for the improvement of the oral health of the Lebanese population. Such programs must integrate the provision of treatment for existing disease with prevention of future disease by increasing the awareness of parents and institution caregivers regarding the importance of not only oral hygiene but also dietary behavioral factors in maintaining periodontal health.

Further prospective studies are needed to validate the results of this study on the determinants of periodontal disease in the intellectually disabled population and to establish cause-and-effect relationships. On the other hand, larger cross-sectional epidemiological studies not limited to the institutionalized population are needed to shed light on the oral health status of the entire intellectual disabled population in Lebanon so that appropriate prevention and intervention programs may then be tailored.

CONCLUSION

The majority of institutionalized intellectual disabled adolescents and adults in Lebanon are in need for periodontal treatment. Poor periodontal conditions are further aggravated by social inequalities between geographical locations. The significant contributions of dietary, behavioral factors emphasize the importance of implementing awareness and behavioral changes as part of prevention and treatment programs.

FINANCIAL SUPPORT AND SPONSORSHIP

Nil.

CONFLICTS OF INTEREST

There are no conflicts of interest.