Association of Dental Neglect Scale and Severity of Dental Caries among Nursing Students: A Cross-Sectional Study.

AIMS: The aim of this study is to assess the utilization of available dental services and home dental care practices in a sample of nursing students and to seek out the correlation if any, between the Dental Neglect Scale (DNS) scores and severity of dental caries. SUBJECTS AND METHODS: The study was conducted among 630 nursing students aged 18-21 years from the area of South Bangalore. The study was cross-sectional in design and a convenience sampling method was adopted to get the desired sample size. A prestructured questionnaire was administered to the students in their classrooms. Following this, a brief oral examination was conducted using mouth mirror and light for the detection of any visible carious lesions.
RESULTS: The dental attendance variable was found to be significantly associated with the DNS scores (P < 0.001). The DNS scores were significantly higher (P < 0.001) among those who had visible caries than those who do not. A very good correlation was obtained between scores of DNS and the caries severity (P < 0.001, r = 0.773).
CONCLUSIONS: The DNS can be a very good predictor of the dental attendance pattern as well as clinically assessed severity of carious lesions. Copyright:

INTRODUCTION

Dental neglect can be explained in terms of not giving due value to oral health and negative attitudes and oral health behaviors. Neglecting oral health can affect the standards of life of both children and adults as dental neglect is often related to lack of proper care which can lead to various functional, psychological, and social disabilities.[12] Dental neglect can be a very good predictor of abnormalities related to oral health measured by various indices of caries, oral hygiene status, periodontal status, etc.[34]

The Dental Neglect Scale (DNS) can assess various dimensions related to self-care practices, receiving professional dental care, oral health awareness, etc.[3] The DNS was pilot tested by Straus et al. in 1994 which was a self-reported scale of 9 items which included oral health-care practices, utilization of dental care, and dental neglect.[5]

The comparison of dental neglect and dental indifference scales was done in a study by Jamieson LMand Thomson WM.[6] Dental indifference is defined as “… an attitude which consists of a significant undervaluing of teeth and lack of interest in oral health manifesting itself in oral neglect.”[78]

When DNS was used among parents to evaluate their children's oral health-care practices and attitudes, it was observed that children who were least likely to visit a dentist within the past 2 years had more caries and their parents reported higher dental neglect.[7]

The DNS with 6-items was successfully used among adults in various studies. More number of carious and missing teeth were found in those with greater DNS scores.[789]

Studies conducted among adolescents in countries where oral health care is universally available like England[10] and Norway[11] had shown results of irregular dental attendance in this age group. Nursing students form a special group who might be aware of the consequences of neglecting oral health. Moreover in this adolescent age group[121314], since they are able to influence their dental attendance pattern, they might fail to receive professional dental care also.

This study aims to assess the utilization of available dental services and home dental care practices in a sample of nursing students and to seek out the correlation if any, between the DNS scores and severity of dental caries.

SUBJECTS AND METHODS

The study was conducted among 630 nursing students aged 18–21 years from the area of South Bangalore. For sample size calculation, 95% confidence interval, 45% prevalence, 95% precision, and 10% margin of error were used. A convenience sampling method was adopted to get the desired sample size. Sample size is achieved by the data collected from seven nursing schools from the city.

Ethical clearance and informed consent

The Institutional ethics committee gave ethical clearance for the study and the authorities of the respective nursing colleges gave the official permissions. The participants who gave written and oral informed consent were allowed to fill the questionnaire.

Questionnaire administration phase

A prestructured questionnaire was administered to the students in their classrooms. The questionnaire consisted of demographic data such as age and sex followed by the 6-items of the DNS [Table 1]. The 5-point scale had answers ranging from “Definitely no” to “Definitely yes” for each item. The scores ranged from 6 to 30, and higher scores indicated greater dental neglect. Two questions were regarding the use of dental services.

Table 1

The Dental Neglect Scale items

1	I keep up my home dental care
2	I receive the dental care I should
3	(Reversed) I need dental care, but I put it off
4	I brush as well as I should
5	I control snacking between meals as well as I should
6	I consider my dental health to be important

Clinical examination

Examination of the oral cavity was done using light and mouth mirror. Each tooth was examined for the presence or absence of decay. The severity of decay was assessed based on the modification of the criteria given by the WHO Guide to Oral Health Epidemiological Investigations 1979.[15]

Sound tooth-no visible evidence of caries

Moderate caries-visible loss of tooth substance (WHO score 1 or 2)

Severe caries-visibly undermined enamel (WHO score 3 or 4).

Statistical analysis

For the comparison of mean scores, t-tests were used and one-way ANOVA was used to examine the overall relationship between degree of dental caries and DNS scores. Spearman's rho was used to find out the correlation between DNS scores and severity of dental caries.

RESULTS

Among the 610 participants, 328 answered yes and 302 answered no to the question whether they had a dental check-up in the past 3 years. The mean DNS score was lower (10.63) among those who had a dental check-up than those who do not (16.61).

Among all the participants, 244 answered yes and 386 answered no to the question whether they are currently going to a dentist or not. The mean DNS score was lower (9.74) among those who had a dental check-up than those who do not (15.87).

Visible caries was present in 350 participants and absent in 280 participants. The mean DNS score was higher (15.93) among those who had visible caries than those who do not (10.46).

Among the participants, 169 had severe caries, 181 had moderate caries, and 280 had no visible caries. The mean DNS score was higher (18.33) among those who had severe caries than those who had moderate caries (13.69) and the lowest mean score for DNS was among those had no visible caries (10.46).

The dental attendance variable (had a dental check-up in the past 3 years) was found to be significantly associated with the DNS scores (P < 0.001) when t-test for the equality of means was used to analyze the data [Table 2].

Table 2

Association between dental neglect scale scores and the dental attendance variable (had a dental check-up in the past 3 years or not)

Independent samples test
DNS score	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	Df	Significant (two-tailed) (P)	Mean difference	Standard error difference	95% CI of the difference
								Lower	Upper
Equal variances assumed	0.459	0.498	−26.032	628	<0.001	−5.97	0.23	−6.42	−5.52
Equal variances not assumed			−25.966	615.259	<0.001	−5.97	0.23	−6.42	−5.52

DNS: Dental neglect scale, CI: Confidence interval

A highly significant association was observed between the dental attendance variable (currently goes to a dentist or not) and the DNS scores (P < 0.001) when t-test for the equality of means and Levene's test for equality of variances were used [Table 3].

Table 3

Association between dental neglect scale scores and the dental attendance variable (currently goes to a dentist or not)

Independent samples test
DNS score	Levene’s test for equality of variances		t-test for equality of means
	F	Significant (P)	t	Df	Significant (two-tailed) (P)	Mean difference	Standard error difference	95% CI of the difference
								Lower	Upper
Equal variances assumes	19.959	<0.001	−26.130	628	<0.001	−6.14	0.23	−6.60	−5.67
Equal variances not assumed			−27.667	603.354	<0.001	−6.14	0.22	−6.57	−5.70

DNS: Dental neglect scale, CI: Confidence interval

Another highly significant association was found between DNS scores and the presence or absence of visible caries. The DNS scores were found to be significantly higher (P < 0.001) among those who had visible caries than those who do not [Table 4].

Table 4

Association between dental neglect scale scores and the presence or absence of visible caries

Independent samples test
DNS score	Levene’s test for equality of variances		t-test for equality of means
	F	Significant	t	Df	Significant (two-tailed)	Mean difference	Standard error difference	95% CI of the difference
								Lower	Upper
Equal variances assumed	1.713	0.191	−21.812	628	P<0.001	−5.47	0.25	−5.96	−4.98
Equal variances not assumed		−22.014	615.788	P<0.001	−5.47	0.25	−5.96	−4.98

DNS: Dental neglect scale, CI: Confidence interval

Table 5 represents the association between DNS Scores and the severity of caries. The association was found to be highly significant (P < 0.001, F = 479.821, df = 2).

Table 5

Association between dental neglect scale scores and the severity of caries

One way ANOVA
Sum of squares	Df	Mean square	F	Significant (P)
Between groups	6534.233	2	3267.117	479.821	<0.001
Within groups	4269.260	627	6.809
Total	10,803.494	629

A very good correlation was obtained between DNS Scores and the severity of caries (P < 0.001, r = 0.773) [Table 6].

Table 6

Correlation between dental neglect scale scores and the severity of caries

Spearman’s rho	DNS score	Severity of caries
DNS score
Correlation coefficient	1.000	0.773
Significant (two-tailed) (P)	<0.001
n	630	630
Severity of caries
Correlation coefficient	0.773	1.000
Significant (two-tailed) (P)	<0.001
n	630	630

DNS: Dental neglect scale

DISCUSSION

Dental neglect in simple terms is neglecting dental health. In our study, the questionnaire with DNS items was given to nursing students to find out the association of DNS scores with dental attendance pattern, presence or absence of caries and the severity of caries as well.

Only one item in the 6 item DNS represents the attitude of the person and hence the domain related to attitude may not be equally represented which is a concern about DNS which still remains unanswered. Yet, the self-care and service domains can be effectively used for evaluating health promotion activities especially for pre- and post-intervention evaluations.[10]

A similar scale was developed called the Dental Indifference Scale which is more discriminative about each domain of dental neglect. In a comparative study of DNS and DIS by Jamieson and Thomson, construct validity and practical utility were found to be more for DNS whereas DIS was found to be more discriminative.[6]

The DNS scores were significantly associated with the dental attendance variable which is matching with the findings of the previous study by Thompson and Locker.[7]

According to the results of our study, the groups having no visible caries, moderate caries and severe caries were significantly different from each other. This can be compared to the findings of the study by Skaret et al.[16] in which the groups having no visible caries and those having severe caries were significantly different from each other, whereas no significant difference was observed between the groups not having caries and with moderate caries.[16]

The significant association of DNS scores to groups not having caries, with moderate caries and with severe caries may be explained by the fact that those who neglect their oral health tend to have moderate and severe carious lesions. Moreover, a person who is following proper oral health behaviors and who is regular in dental attendance pattern is less likely to have moderate or severe caries.[1718]

Our study group comprised nursing students who mainly belonged to the age group of 18–21 years. They were slightly elder than the adolescent age group. Internalization of behaviors occurs during the adolescent age.[19] Hence, youngsters of this age group can influence their dental health-care seeking behavior.[202122232425] Moreover, the youth at this age are more prone to develop dental caries and periodontal disease.[20]

There are certain limitations for the study. A convenience sampling method was used in the study which makes the findings less generalizable to the population. Second, the method of clinical examination used for the study was visual using light and mirror only which would have led to error in assessing presence or absence or even the severity of caries. A more meticulous examination using probe or X-rays might have revealed the actual picture of the carious lesions. Moreover, pre- and post-intervention comparison studies need to be conducted to assess the variations in DNS scores after the implementation of measures which were supposed to reduce dental neglect.

CONCLUSIONS

The DNS can be a very good predictor of the dental attendance pattern and clinically assessed severity of carious lesions. Hence, the DNS is found to objectively measure dental neglect even though the scale needs to be validated in different age groups, areas and situations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.