Oral Health-Related Quality of Life and Dental Caries Status in Children With Orofacial Cleft: An Indian Outlook.

AIM: To assess the dental caries status and oral health-related quality of life (OHRQOL) among children with orofacial cleft reporting to a hospital in India.
MATERIALS AND METHODS: Subjects were divided into two groups. Group 1 cleft children (n = 80) and group 2 noncleft children (n = 80). Decayed, missing, and filled teeth (DMFT) Index, deft Index, and Children Oral Health Impact Profile questionnaire were recorded.
RESULTS: The mean DMFT was high in noncleft (3.51 ± 2.45) children than in cleft children (2.75 ± 2.68). The mean deft was high in noncleft (1.11 ± 0.96) children than in cleft children (0.86 ± 3.07).
CONCLUSION: Cleft children have negative impact on OHRQOL than noncleft children.

INTRODUCTION

Cleft lip (CL) and/or palate is the most common congenital craniofacial anomaly that has always been found in mankind.[1] Oral clefts are birth malformations that involve the oral cavity and may also affect the face.[2] Worldwide incidence of the (CL) and palate is 1 in 600 (1:600).[3] The overall worldwide prevalence of the CL with or without a cleft palate (CP) was 9.92/10,000. The prevalence of the CL was 3.28/10,000, and that of the CL and palate was 6.64/10,000.[4]

Clefts can be caused by a number of factors that affect the expectant mother early in the first trimester of pregnancy. These factors include infection and toxicity, poor diet, hormonal imbalance, and genetic interferences.[5]

Depending on the elemental characteristics of embryology, anatomy, and physiology of the defect, the varieties of CL and palate may be categorized as (1) those involving the lip and alveolus, (2) those involving the lip and palate, (3) those in which palate alone is affected, and (4) congenital insufficiency of the palate.[6]

Oral health–related quality of life (OHRQoL) measures are subjective indicators based on information provided by individuals about their oral health status and its impact on various aspects of their life. Measures of OHRQoL provide essential information when assessing the treatment needs of individuals and populations, as well as when making clinical decisions and evaluating interventions, services, and public health programs. Four domains are used to measure OHRQoL: oral symptoms, functional limitations, social well-being, and emotional well-being.[7] Hence, current study aimed to assess the dental caries status and OHRQOL among children with orofacial cleft reporting to a hospital in India.

MATERIALS AND METHODS

Study design

A cross-sectional descriptive study.

Study area

A hospital-based study (Smile Train Center, Department of Plastic Surgery, Sri Ramachandra Medical College and Hospital, Sri Ramachandra University, Chennai, Tamil Nadu, India).

Study population

This study was carried out in patients receiving care at the outpatient ward of the Department of Plastic Surgery, Sri Ramachandra Medical College and Hospital, Sri Ramachandra University, Chennai, Tamil Nadu, India.

Inclusion criteria

Cleft children

Age: 8–16 years

Children having purely congenital CL/CP and those having CL, alveolus, and palate who were not operated

Able to give informed consent and willing to participate

Not medically handicapped

Not having a special class for mental disabilities

Not having a mental disorder

Noncleft children

Age: 8–16 years

Have no significant medical history

Able to give informed consent and willing to participate

Exclusion criteria

Cleft children and noncleft children

History of any systemic disease

Not willing to participate

Approval and informed consent

Ethical approval was obtained from the Institutional Review Boards of Saveetha University and Sri Ramachandra University. Informed consent was obtained from parents or guardian of study participants.

Sample size estimation

Sample size required for the study was calculated to be n = 80 (each group), with 80% power at 5% α-error, based on the studies conducted by Stecslonicz et al. (2007)[8] and Paul et al. (1998)[9]. On the last day of examination, five patients were reported to outpatient ward. They were also included in the study, yielding a final sample size of 80.

Group

Group 1: Cleft children (n = 80)

Group 2: Noncleft children (n = 80)

Scheduling

Data collection was scheduled for a period of 1 month from December 1, 2012, to December 31, 2012. On an average, three individuals were examined per day.

Survey instrument

A validated questionnaire was obtained from Broder and Wilson-Genderson[10]. Information about the demographic data and dental caries status were obtained.

Child oral health impact profile

The child oral health impact profile (COHIP)[10] consisted of 34 items forming 5 conceptually distinct subscales: Oral Health, Functional Well-Being, Social/Emotional Well-Being, School Environment, and Self-Image. It also contains two items to measure treatment expectancy and two items to measure global health. Global health and treatment expectancy items are not used in computing the overall COHIP 25 score.

Following is a summary of the items and subscales (used with permission from Ralstrom[11]):

Oral Health: Items 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 measure specific oral symptoms that are not necessarily related to one another (e.g., pain, spots on teeth).

Functional Well-Being: Items 11, 15, 20, 23, 25, and 27 relate to the child’s ability to carry out specific everyday tasks or activities (e.g., speaking clearly, chewing).

Social/Emotional Well-being: Items 12, 16, 17, 19, 22, 24, 28, and 29 pertain to peer interactions and mood states.

School-Environment: Items 13, 18, 21, and 30 pertain to tasks associated with the school environment.

Self-image: Items 14, 26, 31, 32, 33, and 34 address positive feelings about self.

Treatment Expectancy: Items 35 and 36 measure expectations regarding the treatment process and outcomes.

Global Health: Items 37 and 38 assess overall feelings about oral and systemic health.

The statements are formatted to elicit self-reports from the subject. Responses for the seven positively worded items are recorded as “never” = 0, “almost never” = 1, “sometimes” = 2, “fairly often” = 3, and “almost all of the time” = 4. The positively scored items were (1) Item 14, “Been confident”; (2) Item 26, “Felt you were attractive”; (3) Item 31, “Have good teeth”; (4) Item 32, “Believe you will have good teeth”; (5) Item 33, “Believe you will have good health”; (6) Item 34, “Feel good about yourself ”; and (7) Item 35, “Will feel better.” When treatment is completed, scoring of the remaining 31 negatively worded items were reversed (“almost all of the time” = 0, “fairly often” = 1, “sometimes” = 2, “almost never” = 3, “never” = 4). Higher COHIP scores reflect more positive OHRQoL whereas lower scores reflect lower OHRQoL.

Subscales scores are calculated by summing the responses of the items specific to the subscale. The overall OHRQoL score is computed by summing the subscales scores. Treatment expectation scores and the overall health response are not included in the overall COHIP scale because these items are relevant only when the COHIP is used as part of a treatment assessment. Scores range from 0 to 140 for the overall scale. If more than two-thirds of the items in a subscale are missing, the subscale and the overall score are set to missing. If fewer items are missing for a subscale, the average of available items used and the sum of the subscale is calculated.

Clinical examination

Clinical examination was conducted by a single examiner who had been trained through a series of clinical training sessions at the Department of Public Health Dentistry, Saveetha Dental College and Hospital, Chennai. After recording the questionnaire, dental examinations were conducted in a dental chair using a mouth mirror and explorer (No: 5, Shepard’s Crook). Instruments used were sterilized using standard protocol. Only completely filled forms were considered for analysis.

Dental Caries examination was performed according to decayed, missing and filled teeth (DMFT) Index[12] and deft Index [13]

Statistical analysis

The data collected were entered in Microsoft Excel and analyzed using statistical software package, SPSS 17.0 (SPSS Inc, Chicago, IL, USA). Descriptive statistics were computed and independent t test was used to compare the mean scores of overall COHIP and their subscales.

RESULTS

Figure 1 depicts the distribution of study subjects. Among the 160 study subjects, 80 study subjects were group 1 (cleft children) and 80 study subjects were group 2 (noncleft children). In group 1 (cleft children), 63.8% and 36.2% were belonged to male and female, respectively. In group 2 (noncleft children), 55% and 45% were belonged to male and female, respectively.

Figure 1

Distribution of the study subjects

Figure 2 depicts the distribution of the study subjects based on cleft types. Among the 80 study subjects, 26 (32.5%) belonged to CL group, 26 (32.5%) belonged to CP group, and 28 (35%) belonged to CL alveolus and palate group.

Figure 2

Distribution of study subjects based on cleft types

Figure 3 depicts the mean deft score between groups. The mean deft score with cleft children and noncleft children was 0.86 ± 3.07 and 1.11 ± 0.96, respectively.

Figure 3

Comparison of mean deft score between groups

Figure 4 depicts the mean DMFT score between groups. Among the 80 cleft children group, the mean decayed teeth, missing teeth, filled teeth and DMFT were 2.64 ± 2.69, 0.00 ± 0.00, 0.08 ± 0.30, and 2.75 ± 2.68, respectively. Among the 80 noncleft children group, the mean decayed teeth, missing teeth, filled teeth, and DMFT were 1.96 ± 0.91, 0.21 ± 0.14, 1.06 ± 2.11, and 3.51 ± 2.45, respectively.

Figure 4

Comparison of mean decayed, missing, and filled teeth score between groups

Table 1 depicts the mean overall COHIP and subscales between groups. The mean Oral Health Well-being domain was 14.9 ± 7.9 and 31.3 ± 3.21 in cleft and noncleft children group, respectively. The mean Functional Well-being domain was 7.6 ± 2.7 and 19.3 ± 6.21 in cleft and noncleft children group, respectively. The mean Social/Emotional Well-being domain was 21.3 ± 8.1 and 26.2 ± 5.42 in cleft and noncleft children group, respectively. The mean School Environment domain were 12.1 ± 2.1 and 14.22 ± 0.9 in cleft and noncleft children group, respectively. The mean Self-Image domain was 14.7 ± 3.9 and 20.8 ± 0.88 in cleft and noncleft children group, respectively. The mean Treatment Expectancy domain was 4.2 ± 1.4 and 5.1 ± 0.22 in cleft and noncleft children group, respectively. The mean Global health domain was 2.9 ± 0.6 and 3.5 ± 1.12 in cleft and noncleft children group, respectively. The mean overall COHIP was 70.6 ± 14.2 and 111.82 ± 12.34 in cleft and noncleft children group, respectively.

Table 1

Comparison of COHIP overall and subscale scores between groups

COHIP domains	Cleft group (n = 80)	Non-cleft group (n = 80)	P Value
Overall COHIP	70.6 ± 14.2	111.82 ± 12.34	0.011*
Oral Health Well-being	14.9 ± 7.9	31.3 ± 3.21	0.50
Functional Well-being	7.6 ± 2.7	19.3 ± 6.21	0.001*
Social/Emotional Well-being	21.3 ± 8.1	26.2 ± 5.42	0.022*
School Environment	12.1 ± 2.1	14.22 ± 0.9	0.05*
Self-Image	14.7 ± 3.9	20.8 ± 0.88	0.21
Treatment Expectancy	4.2 ± 1.4	5.1 ± 0.22	0.12
Global Health	2.9 ± 0.6	3.5 ± 1.12	0.66

*indicates P < 0.05 statistically significant

Independent t test showed that the relationship between mean “decayed,” “missing,” and “filled” component and total mean DMFT score between group was found to be statistically significant in the following domains Functional Well-being, Social/Emotional Well-being, School Environment, and Overall COHIP.

DISCUSSION

The congenital malformation may result in impairment of oral cavity and face, and thus knowing the magnitude of the damage and repairing it at the earliest time as possible bring benefits for patients, families, and caregivers. CL and palate are defects caused by an incomplete fusion of the nasal processes and the palatal processes between the late embryonic and early fetal period. The most important etiologic factors are considered to be genetic in nature, but environmental factors also have been identified to have a limited role. These patients usually require a comprehensive medical and dental treatment over an extended period of time.[14]

According to epidemiological aspect, this study indicates that the prevalence of orofacial cleft was found to be more in males (63.8%) than females (36.2%), which is consistent with several other studies.[2151617] The most prevalent type of cleft was CL alveolus and palate (CLAP), which was 35%. Similarly a study by Al Omari and Al Omari[18] reveals 48% of cases were affected with CLAP.

The mean deft scores for the current study were (0.86 ± 3.07) and (1.11 ± 0.96) in cleft and noncleft children, respectively. The mean DMFT scores for the current study were (2.75 ± 2.68) and (3.51 ± 2.45) in cleft and noncleft children, respectively. Whereas in the study conducted by Shashni et al.[19], the mean DMFT were (10.14 ± 6.09) and (12.73 ± 3.42) in cleft and noncleft children, respectively. The variation in dental caries experience could be due to the difference in methodology, study groups and differing age groups, diet, and environment factors between the studies.

Among the cleft children group, the mean score for Oral Health Well-being domain was 14.9 ± 7.9, which is higher than the study conducted by Ward et al. (17.7 ± 4.7),[20] Geels et al. (17.5 ± 6.7),[21] and Konan et al. (35.89 ± 6.10).[22] The mean score for Functional Well-being domain was 7.6 ± 2.7, which is higher than the study conducted by Ward et al. (24.8 ± 5.9),[20] Geels et al. (21.3 ± 6.2),[21] and Konan et al. (23.59 ± 4.37).[22]

The mean score for Social/Emotional well being was 21.3 ± 8.1, which is higher than the study conducted by Ward et al. (24.3 ± 6.7),[20] Geels et al. (22.2 ± 10.6),[21] and Konan et al. (31.25 + 6.13).[22] The mean score for School Environment was 12.1 ± 2.1, which is higher than the study conducted by Ward et al. (13.1 ± 3.0),[20] Konan et al. (17.29 + 2.69),[22] and lower than the study conducted by Geels et al. (5.3 ± 1.8).[21] The mean score for Self-Image was 14.7 ± 3.9, which is higher than the study conducted by Ward et al. (15.7 ± 4.3),[20] Konan et al. (19.75 + 5.50),[22] and lower than the study conducted by Geels et al. (8.7 ± 3.3).[21]

The mean score for treatment expectancy and global health was 4.2 ± 1.4 and 2.9 ± 0.6, respectively, which is which is higher than the study conducted by Ward et al.[20].

The mean score for overall COHIP was 70.6 ± 14.2, which is higher than the study conducted by Ward et al. (95.6 ± 18.3),[20] Geels et al. (75.1 ± 22.5),[21] and Konan et al. (127.80 + 17.16).[22]

The results of this study indicate that clefts children have a significant impact on OHRQoL. Our results confirm that children with orofacial clefts had statistically significantly lower OHRQoL than control children for the overall COHIP score and for the Functional Well-being, Social/Emotional Well-being, and School Environment subscales. In contrast, some studies (Warschausky et al.,[23] Jokovic et al.,[7] Locker et al.,[24] Wogelius et al.[25]) have found that clefts children have less impact on HRQoL. These findings may be due to differences in sample size and/or study population, as well as the use of different questionnaires.

CONCLUSION

Cleft children have negative impact on OHRQOL than noncleft children in the aspects of Functional Well-being, Social/Emotional Well-being, and School Environment subscales.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.