Abstract
Background: Oral health is a critical component of overall well-being. However, students with disabilities (SWDs) face unique challenges in maintaining oral hygiene and accessing dental care. This study aims to explore oral health behaviours, dental care utilisation, and barriers to accessing dental care among SWDs in Al-Ahsa, Saudi Arabia, from the perspectives of their parents. Methods: A descriptive cross-sectional study was conducted among parents of SWDs in Al-Ahsa, Saudi Arabia. Data were collected using a validated questionnaire covering oral health behaviours, dental care utilisation, and barriers to care. The sample size was determined based on the SWDs population in the region. Data were analysed using descriptive and analytical statistics, with significant associations identified at p < 0.05. Results: Findings revealed that 45.7% of SWDs brushed irregularly, with only 16.8% brushing twice a day or more. Dental flossing was reported by just 4.3% of SWDs. Emergency-based dental visits were common (51.9%), and 29.5% of SWDs had never visited a dentist. Significant associations were found between maternal education and tooth brushing frequency (p = 0.004) and between parental education and the frequency of dental visits (p = 0.035). The most reported barriers included fear of treatment (47.1%), difficulty finding willing dentists (45.5%), and long wait times for appointments (44.7%). Conclusions: The study emphasises the pressing need for targeted interventions to improve oral hygiene practices and enhance accessibility to dental services for SWDs.
Keywords: oral health, disabilities, dental care utilisation, barriers to dental care, parental perspective, Saudi Arabia
1. Introduction
The United Nations defines disabilities as long-term impairments—whether physical, mental, intellectual or sensory—that, when combined with social and environmental barriers, can restrict an individual’s full and equal participation in society [1]. The World Health Organization (WHO) has further explained that disabilities arise from the interplay between health conditions and various personal and environmental factors [2]. Children and young people with special educational needs and disabilities often face significant challenges in maintaining good oral hygiene. These challenges include reliance on inadequately trained parents or caregivers, limited mobility, oral aversion, clenching or biting on the toothbrush and hypersensitivity to oral stimulation [3]. Oral health is an integral part of overall health, with significant impacts on individuals’ well-being and daily functioning. The burden of oral diseases is immense, affecting almost 3.5 billion people worldwide, with untreated dental caries being the most prevalent condition, impacting around 2 billion individuals [4]. Untreated dental caries can severely affect their ability to eat, speak, learn, and sleep, leading to pain, infection, and reduced school attendance. These negative impacts not only hinder a child’s educational performance but also contribute to broader social inequalities, disproportionately affecting those from disadvantaged backgrounds [4]. Persons with disabilities (PWDs) are at greater risk for poor oral health, and they face greater challenges in accessing health care [2]. Previous studies have shown that PWDs often face barriers to accessing and utilising oral health care, leading to poorer oral health outcomes and higher rates of unmet dental needs. These studies identify challenges across a wide range of disabilities, including physical, sensory, intellectual, autism spectrum disorder, and multiple disabilities. Commonly identified barriers—including availability of appropriate services, accessibility, affordability, and awareness—indicate that disabilities alone are not the sole cause of oral health disparities among PWDs [5,6,7,8,9]. Previous studies have highlighted the impact of disability on oral health and access to care, often focusing on disability-related factors [5,6]. However, there is a need to adopt a broader perspective beyond the biomedical model, considering multi-level barriers—including individual, professional, societal, and systemic barriers—that influence oral health care for PWDs [5,6]. In Saudi Arabia, the prevalence of persons with disabilities is a notable public health issue, with roughly one out of every thirty citizens experiencing some form of disability [10]. Previous research from Saudi Arabia has shown that PWDs, including students, have poorer oral health outcomes than their peers without disabilities [11,12]. This disparity in oral health status underscores the importance of understanding the specific challenges faced by this population. Caregivers play a critical role in this context by making decisions on behalf of the care recipient and managing their interactions with health services, and as supporters by assisting with oral care routines and facilitating dental visits [13,14].
Therefore, this study aims to explore oral health behaviours, dental care utilisation, and barriers to accessing dental care among students with disabilities (SWDs) in Al-Ahsa, Saudi Arabia, as reported by their parents. The study provides a descriptive cross-sectional analysis, examining how sociodemographic factors influence oral health practices and access to care among these students.
2. Methodology
2.1. Study Design and Setting
This descriptive cross-sectional study was conducted across 21 schools in Al-Ahsa, Saudi Arabia, providing education for SWDs. The study received approval from the Human Research Ethics Committee of the University of Western Australia (file reference—2022/ET000328 on 7 September 2022) and the Research Ethics Committee at King Faisal University (approval number KFU-REC-2022-APR-EA000553 on 5 April 2022), ensuring adherence to ethical guidelines. We obtained informed consent from all participants before they completed the questionnaire. We maintained participant confidentiality and data anonymisation throughout the study, with documents deidentified using codes and removing all identifying information, such as school names. The Planning and Development Department at the General Directorate of Education in Al-Ahsa, Saudi Arabia, granted permission to conduct the study at designated educational institutions.
2.1.1. Sampling
We employed a decentralised, convenience sampling technique to select participants, focusing on their accessibility and willingness to participate. Eligible participants for this study were students with disabilities officially registered as having disabilities within the education system in Al-Ahsa. The students ranged in age from 6 to 22 years, including children and young adults, with a variety of disabilities, including sensory disabilities (such as hearing or vision impairment), cognitive disabilities, autism spectrum disorder (ASD), and others with multiple impairments. All participants were enrolled in special education programs. Only students whose parents provided consent to participate were included in the study. Students without parental consent or who were not officially registered as having disabilities were excluded.
2.1.2. Sample Size
We used an online calculator (Raosoft, http://www.raosoft.com/samplesize.html, accessed on 8 January 2023) to determine an appropriate sample size, aiming for an absolute precision of 5% and a 95% confidence level. The calculation was based on the expected population of SWDs in Al-Ahsa, Saudi Arabia, estimated at 4344, according to the most recent data from Saudi Arabia’s Ministry of Education [15]. This resulted in a minimum required sample size of 354.
2.2. Instrumentation
We obtained informed consent from all participants. We aligned with the general objectives of our research [16]. While the original survey focused primarily on barriers to accessing dental care, we expanded it to cover a broader range of variables critical to our study. Specifically, we rearranged the original questions and added new items to capture essential oral health behaviours, such as frequency of tooth brushing and the use of dental floss, as well as detailed patterns of dental service utilisation, including the frequency of dental visits and types of dental procedures received. This process involved seeking expert input to ensure the relevance and comprehensiveness of the questionnaire.
To validate the modified questionnaire, we conducted pilot testing. Initially, the survey was piloted with five male and five female parents who provided feedback on item inclusion, wording clarity, and overall structure. Based on their feedback, we made adjustments to enhance the questionnaire’s effectiveness. We conducted a further pilot test with 10 parents to ensure the final version’s validity and clarity. The barrier scale, which included eight items, demonstrated a reliability coefficient of 0.79, as assessed using Cronbach’s alpha. Respondents ranked several barriers on a scale from 1 to 10, with 10 indicating the highest level of difficulty, following a procedure similar to the original survey [16]. We also used this scale to assess parental attitudes toward routine dental visits and satisfaction with dental care. The full version of the questionnaire used in this study is available in Supplementary File S1.
2.3. Data Collection
Data collection took place from February to June 2023. Each school independently identified eligible students with the assistance of teachers and staff from the Special Education Department and the School Health Affairs Department. We distributed 754 paper invitations to participate, including a consent form, study information, and questionnaire to eligible parents of SWDs attending special schools. Parents received reminders to encourage survey completion. Parents who agreed to participate signed the consent forms, completed the questionnaires, and gave them through SWDs, which were later collected by their schools. Parents were also informed that they could contact the lead researcher by email or arrange a meeting to discuss the study and address any questions. All eligible participants received a toothbrush and toothpaste to promote consistent brushing habits.
2.4. Statistical Analysis
We conducted data analysis using SPSS version 25.0 (IBM Corp, Armonk, NY, USA). We used descriptive statistics, including frequencies and percentages, to summarise sociodemographic variables, oral health behaviours, oral health utilisation, barriers to dental care, and parental attitudes toward and satisfaction with dental care. Chi-square tests determined associations among these factors, with statistical significance set at p < 0.05.
3. Results
The study achieved a response rate of 49.9%, with 376 parents successfully completing the survey. The study included mothers (52.1%), fathers (40.2%), and other caregivers such as sisters or grandmothers (7.7%). The distribution of student ages showed that 55.9% were ages 6–12, 33.8% were ages 13–17, and 10.4% were ages 18–22. Most mothers had education levels above high school (35.9%), followed by high school education levels (29.3%). Fathers also predominantly had education levels above high school (27.7%) or high school education levels (28.7%). Most mothers were unemployed (83.5%), whereas most fathers were employed (75.8%; Table 1).
Table 1.
Sociodemographic factors.
| Variables | N (%) |
|---|---|
| Student’s gender | |
| Male | 243 (64.6) |
| Female | 133 (35.4) |
| Student’s age | |
| 6–12 | 210 (55.9) |
| 13–17 | 127 (33.8) |
| 18–22 | 39 (10.4) |
| Relationship to the student: | |
| Mother | 196 (52.1) |
| Father | 151 (40.2) |
| Other (specify) | 29 (7.7) |
| Mother/female guardian education level | |
| Illiterate | 19 (5.1) |
| Elementary | 52 (13.8) |
| Intermediate | 60 (15.9) |
| High school | 110 (29.3) |
| Above high school | 135 (35.9) |
| Father/male guardian education | |
| Illiterate | 18 (4.8) |
| Elementary | 73 (19.4) |
| Intermediate | 73 (19.4) |
| High school | 108 (28.7) |
| Above high school | 104 (27.7) |
| Maternal occupation | |
| Employed | 62 (16.5) |
| Unemployed | 314 (83.5) |
| Paternal occupation | |
| Employed | 285 (75.8) |
| Unemployed | 91 (24.2) |
| Student’s education level | |
| Elementary | 244 (64.9) |
| Intermediate | 64 (17) |
| High school | 68 (18.1) |
| Student’s impairment condition according to school record | |
| Sensory | 149 (39.6) |
| Cognitive | 101 (26.9) |
| Autism Spectrum Disorder | 99 (26.3) |
| Severe Multiple Impairment | 27 (7.2) |
Regarding hand coordination and the ability to brush teeth, 71.0% of students could brush without limitations, whereas 18.6% could do so with some limitations. Regular tooth brushing (twice a day or more) was reported by 16.8% of SWDs, whereas 45.7% brushed irregularly. Dental flossing was uncommon, with only 4.3% reporting regular use. Sugar/sweets intake varied, with 48.1% of students in the study reporting consuming sweets at least once or twice a day in small quantities. A notable portion (28.5%) reported rarely consuming sweets daily, and when they did, it was in small quantities, whereas only 3.5% of the students never consumed sweets. However, 19.9% of the students consumed sweets frequently in large quantities, either once or twice a day or more than twice a day. Perceived oral health status was reported as excellent by only 14.4%, good by 40.1% and moderate to poor by 45.5% of participants (Table 2).
Table 2.
Distribution of oral health behaviours and perceived oral health status.
| Variables | N (%) |
|---|---|
| Hand coordination and ability to brush own teeth | |
| None | 15 (3.9) |
| Severely limited | 24 (6.4) |
| Able to do with some limitation | 70 (18.6) |
| Able to do with no limitation | 267 (71.0) |
| Tooth brushing | |
| Twice a day or more | 63 (16.8) |
| Once a day | 121 (32.2) |
| Irregular | 172 (45.7) |
| Never | 20 (5.3) |
| Dental flossing | |
| Yes | 16 (4.3) |
| No | 360 (95.7) |
| Sweets intake | |
| Never | 13 (3.5) |
| Rarely in small quantities | 107 (28.5) |
| Once or twice a day in small quantities | 181 (48.1) |
| Once or twice a day in large quantities | 42 (11.1) |
| More than twice a day in large quantities | 33 (8.8) |
| Perceived oral health status | |
| Excellent | 54 (14.4) |
| Good | 151 (40.1) |
| Moderate | 120 (31.9) |
| Poor | 51 (13.6) |
Dental visits were generally infrequent, with 51.9% visiting the dentist only on an emergency basis and 29.5% never visiting at all. Tooth extractions (29.3%) and fillings (25.8%) were the most common dental procedures performed. Notably, only 27.4% of students received sedation for dental treatment. Among those who received sedation, the majority (41.0%) were treated under general anaesthesia in a hospital setting, followed by 20.3% who received oral medication for sedation, 13.5% who received minimal inhaled sedation (‘laughing gas’) and 2.9% who underwent IV conscious sedation. Additionally, 22.3% of the parents were unsure or could not remember the type of sedation used. The type of facility used for dental care varied, with hospitals being the most frequently visited (23.1%), followed closely by paediatric dental practices (22.3%; Table 3).
Table 3.
Oral health care utilisations.
| Variables | N (%) |
|---|---|
| Frequency of annual dentist visits | |
| Three or more times a year | 16 (4.3) |
| Twice a year | 20 (5.3) |
| Once a year | 34 (9.1) |
| Emergency basis only | 195 (51.9) |
| Never | 111 (29.5) |
| Past dental procedures | |
| Cleaning teeth | 75 (19.9) |
| Filling tooth/teeth | 97 (25.8) |
| Oral examination | 78 (20.7) |
| Crown/bridge | 1 (0.3) |
| Dentures (partial or complete) | 4 (1.1) |
| Root canal therapy | 23 (6.1) |
| Tooth extraction | 110 (29.3) |
| Emergency treatment | 58 (15.4) |
| Unknown | 72 (19.2) |
| Received sedation for dental treatment | |
| Yes | 103 (27.4) |
| No | 273 (72.6) |
| If received sedation, type | |
| General anaesthesia in a hospital | 42 (41) |
| IV conscious in a hospital or clinic setting | 3 (2.9) |
| Oral medication for sedation only in a hospital or clinic setting | 21 (20.3) |
| Minimal inhaled sedation (‘laughing gas’) | 14 (13.5) |
| Not sure/do not remember | 23 (22.3) |
| Type of facility for dental care | |
| Do not know | 80 (21.3) |
| Hospital | 87 (23.1) |
| Primary health centre | 62 (16.5) |
| Private general practice | 63 (16.8) |
| Paediatric general dental practice | 84 (22.3) |
Parents identified several barriers to dental care, with the most significant being fear of dental treatment (47.1%) and difficulty finding a dentist willing to treat their child (45.5%). This was closely followed by appointment wait times, which 44.7% of parents also rated as difficult. Financial barriers were another notable concern for 37.0% of parents. In contrast, transportation and distance were less problematic, with 42.0% of parents rating it as easy, while distance was somewhat difficult for 44.7% of parents (Figure 1).
Figure 1.
Barriers to dental care for students with disabilities: parents’ perspectives.
Caregivers’ satisfaction with current dental care indicated that only 37.0% were satisfied, whereas 34.8% were somewhat satisfied, and 28.2% were not satisfied (Figure 2). The importance of access to routine dental care was highly valued, with 72.9% considering it important, whereas only 10.1% deemed it unimportant (Figure 3).
Figure 2.
Parental attitudes and satisfaction with dental care for students with disabilities.
Figure 3.
Importance of access to routine dental care.
We further analysed parents’ demographics to examine associations with the other reported variables. Statistically significant associations were found between maternal education and the frequency of toothbrushing (p = 0.004), with higher educational levels correlating with better oral hygiene practices. The relationship to the child also impacted the frequency of dental flossing (p = 0.012), with mothers more likely to report SWDs flossing. Sweets intake frequency significantly correlated with both maternal (p = 0.036) and paternal education levels (p = 0.04; Table 4). Furthermore, we found no statistically significant associations between parents’ perceived oral health status of SWDs and their demographics.
Table 4.
Association between sociodemographic and oral health behaviours.
| Sociodemographic Variables | Oral Health Behaviour Factors | p-Value | ||||
|---|---|---|---|---|---|---|
| Frequency of tooth brushing | ||||||
| Twice a day or more | Once a day | Irregular | Never | |||
| Mother’s education | ||||||
| Illiterate | 1 (1.6) | 3 (2.5) | 11 (6.4) | 4 (20) | 0.004 | |
| Elementary | 12 (19.1) | 18 (14.9) | 16 (9.3) | 6 (30) | ||
| Intermediate | 13 (20.6) | 17 (14.1) | 30 (17.4) | 0 | ||
| High school | 13 (20.6) | 38 (31.4) | 56 (32.6) | 3 (15) | ||
| Above high school | 24 (38.1) | 45 (37.2) | 59 (34.3) | 7 (35) | ||
| Relationship to child | ||||||
| Mother | 39 (61.9) | 61 (50.4) | 88 (51.2) | 8 (40) | 0.693 | |
| Father | 20 (31.8) | 51 (42.2) | 70 (40.7) | 10 (50) | ||
| Other | 4 (6.4) | 9 (7.4) | 14 (8.1) | 2 (10) | ||
| Father’s education | ||||||
| Illiterate | 3 (4.8) | 4 (3.3) | 9 (5.2) | 2 (10) | 0.490 | |
| Elementary | 13 (20.6) | 19 (15.7) | 38 (22.1) | 3 (15) | ||
| Intermediate | 13 (20.6) | 29 (23.9) | 25 (14.5) | 6 (30) | ||
| High school | 14 (22.2) | 37 (30.6) | 54 (31.4) | 3 (15) | ||
| Above high school | 20 (31.8) | 32 (26.5) | 46 (26.7) | 6 (30) | ||
| Maternal occupation | ||||||
| Employed | 13 (20.6) | 23 (19.0) | 23 (13.4) | 3 (15) | 0.459 | |
| Unemployed | 50 (79.4) | 98 (80.9) | 149 (86.6) | 17 (85) | ||
| Paternal occupation | ||||||
| Employed | 48 (76.2) | 93 (76.9) | 128 (74.4) | 16 (80) | 0.930 | |
| Unemployed | 15 (23.8) | 28 (23.1) | 44 (25.6) | 4 (20) | ||
| Frequency of dental flossing | ||||||
| Yes | no | p value | ||||
| Relationship to child | ||||||
| Mother | 14 (87.5) | 182 (50.6) | 0.012 | |||
| Father | 1 (6.3) | 150 (41.7) | ||||
| Other (specify) | 1 (6.3) | 28 (7.8) | ||||
| Mother’s education | ||||||
| Illiterate | 1 (6.3) | 18 (5) | 0.689 | |||
| Elementary | 4 (25) | 48 (13.3) | ||||
| Intermediate | 2 (12.5) | 58 (16.1) | ||||
| High school | 5 (31.3) | 105 (29.2) | ||||
| Above high school | 4 (25) | 131 (36.4) | ||||
| Father’s education | ||||||
| Illiterate | 1 (6.25) | 17 (4.72) | 0.672 | |||
| Elementary | 5 (31.25) | 68 (18.89) | ||||
| Intermediate | 2 (12.50) | 71 (19.72) | ||||
| High school | 3 (18.75) | 105 (29.17) | ||||
| Above high school | 5 (31.25) | 99 (27.50) | ||||
| Maternal occupation | ||||||
| Employed | 5 (31.3) | 57 (15.8) | 0.104 | |||
| Unemployed | 11 (68.8) | 303 (84.2) | ||||
| Paternal occupation | ||||||
| Employed | 10 (62.5) | 275 (76.4) | 0.204 | |||
| Unemployed | 6 (37.5) | 85 (23.6) | ||||
| Frequency of sweets intake | ||||||
| Never | Rarely in small quantity |
1–2×/day, small qty. |
1–2×/day in large qty. |
>2×/day in large qty. |
p-value | |
| Mother’s education | ||||||
| Illiterate | 0 | 7 (6.5) | 6 (3.3) | 3 (7.1) | 3 (9.1) | 0.036 |
| Elementary | 2 (15.4) | 26 (24.3) | 17 (9.4) | 4 (9.5) | 3 (9.1) | |
| Intermediate | 2 (15.4) | 14 (13.1) | 31 (17.1) | 4 (9.5) | 9 (27.3) | |
| High school | 3 (23.1) | 31 (28.9) | 53 (29.3) | 12 (28.6) | 11 (33.3) | |
| Above high school | 6 (46.2) | 29 (27.1) | 74 (40.9) | 19 (45.2) | 7 (21.2) | |
| Paternal education | ||||||
| Illiterate | 0 (0) | 7 (6.5) | 7 (3.9) | 1 (2.4) | 3 (9.1) | 0.04 |
| Elementary | 2 (15.4) | 24 (22.4) | 33 (18.2) | 11 (26.2) | 3 (9.1) | |
| Intermediate | 2 (15.4) | 18 (16.8) | 46 (25.4) | 4 (9.5) | 3 (9.1) | |
| High school | 2 (15.4) | 36 (33.6) | 42 (23.2) | 13 (30.9) | 15 (45.5) | |
| Above high school | 7 (53.9) | 22 (20.6) | 53 (29.3) | 13 (30.5) | 9 (27.3) | |
| Maternal occupation | ||||||
| Employed | 3 (23.1) | 18 (16.9) | 25 (13.8) | 12 (28.7) | 4 (12.1) | 0.180 |
| Unemployed | 10 (76.9) | 89 (83.2) | 156 (86.2) | 30 (71.3) | 29 (87.9) | |
| Paternal occupation | ||||||
| Employed | 11 (84.6) | 79 (73.8) | 136 (75.2) | 32 (76.9) | 27 (81.8) | 0.831 |
| Unemployed | 2 (15.4) | 28 (26.2) | 45 (24.9) | 10 (23.1) | 6 (18.2) | |
| Relationship to child | ||||||
| Mother | 5 (38.5) | 53 (49.5) | 101 (55.8) | 22 (52.8) | 15 (45.5) | 0.357 |
| Father | 7 (53.9) | 40 (37.4) | 71 (39.2) | 18 (42.6) | 15 (45.5) | |
| Other (specify) | 1 (7.7) | 14 (13.1) | 9 (4.9) | 2 (4.76) | 3 (9.1) | |
Table 5 shows the associations among parents’ demographics and oral health care utilisation variables. Fathers’ education level statistically and significantly correlated with the frequency of dental visits (p = 0.035), as did paternal occupation (p = 0.038). Higher educational levels among fathers and paternal employment status both correlated with more frequent dental visits.
Table 5.
Association between sociodemographic and oral health utilisation.
| Frequency Visiting a Dentist per Year | ||||||
|---|---|---|---|---|---|---|
| Three or More | Twice | Once | Emergency Basis Only |
Never | p-Value | |
| Father’s education | ||||||
| Illiterate | 0 (0) | 0 | 0 | 11 (5.64) | 7 (6.31) | 0.035 |
| Elementary | 5 (31.3) | 5 (25) | 5 (14.7) | 35 (17.9) | 23 (20.7) | |
| Intermediate | 1 (6.3) | 2 (10) | 7 (20.6) | 39 (20) | 24 (21.6) | |
| High school | 7 (43.8) | 7 (35) | 3 (8.8) | 57 (29.2) | 34 (30.6) | |
| Above high school | 3 (18.8) | 6 (30) | 19 (55.9) | 53 (27.2) | 23 (20.7) | |
| Mother’s education | ||||||
| Illiterate | 0 | 0 (0) | 2 (5.9) | 8 (4.1) | 9 (8.1) | 0.192 |
| Elementary | 2 (12.5) | 1 (5) | 4 (11.8) | 27 (13.9) | 18 (16.2) | |
| Intermediate | 7 (43.8) | 1 (5) | 4 (11.8) | 31 (15.9) | 17 (15.3) | |
| High school | 5 (31.3) | 8 (40) | 11 (32.4) | 57 (29.2) | 29 (26.1) | |
| Above high school | 2 (12.5) | 10 (50) | 13 (38.2) | 72 (36.9) | 38 (34.2) | |
| Maternal occupation | ||||||
| Employed | 1 (6.3) | 7 (35) | 4 (11.8) | 33 (16.9) | 17 (15.3) | 0.142 |
| Unemployed | 15 (93.8) | 13 (65) | 30 (88.2) | 162 (83.1) | 94 (84.7) | |
| Paternal occupation | ||||||
| Employed | 9 (56.25) | 19 (95) | 29 (85.29) | 142 (72.82) | 86 (77.48) | 0.038 |
| Unemployed | 7 (43.75) | 1 (5) | 5 (14.71) | 53 (27.18) | 25 (22.52) | |
| Relationship to child | ||||||
| Mother | 8 (50) | 12 (60) | 13 (38.2) | 105 (53.9) | 58 (52.3) | 0.419 |
| Father | 8 (50) | 8 (40) | 19 (55.9) | 72 (36.9) | 44 (39.6) | |
| Other (specify) | 0 | 0 | 2 (5.88) | 18 (9.23) | 9 (8.11) | |
| Type of facility | ||||||
| Do not Know | Hospital | Primary Health Centre | Private General Practice | Paediatric Dental Practice |
p-Value | |
| Paternal occupation | ||||||
| Employed | 64 (80) | 60 (68.9) | 42 (67.7) | 51 (80.9) | 68 (80.9) | 0.121 |
| Unemployed | 16 (20) | 27 (31.0) | 20 (32.3) | 12 (19.1) | 16 (19.1) | |
| Maternal occupation | ||||||
| Employed | 16 (20) | 13 (14.9) | 8 (12.9) | 9 (14.3) | 16 (19.1) | 0.723 |
| Unemployed | 64 (80) | 74 (85.1) | 54 (87.1) | 54 (85.7) | 68 (80.9) | |
| Relationship to child | ||||||
| Mother | 41 (51.3) | 42 (48.3) | 26 (41.9) | 38 (60.3) | 49 (58.3) | 0.426 |
| Father | 31 (38.8) | 37 (42.5) | 30 (48.4) | 21 (33.3) | 32 (38.1) | |
| Other (specify) | 8 (10) | 8 (9.20) | 6 (9.7) | 4 (6.4) | 3 (3.6) | |
| Mother’s education | ||||||
| Illiterate | 7 (8.8) | 3 (3.5) | 5 (8.1) | 3 (4.8) | 1 (1.2) | 0.144 |
| Elementary | 10 (12.5) | 14 (16.1) | 14 (22.6) | 7 (11.1) | 7 (8.3) | |
| Intermediate | 14 (17.5) | 10 (11.5) | 11 (17.7) | 11 (17.5) | 14 (16.7) | |
| High school | 20 (25) | 31 (35.6) | 18 (29) | 14 (22.2) | 27 (32.1) | |
| Above high school | 29 (36.3) | 29 (33.3) | 14 (22.6) | 28 (44.4) | 35 (41.7) | |
| Father’s education | ||||||
| Illiterate | 6 (7.5) | 4 (4.6) | 2 (3.2) | 2 (3.2) | 4 (4.8) | 0.772 |
| Elementary | 13 (16.3) | 13 (14.9) | 15 (24.2) | 16 (25.4) | 16 (19.1) | |
| Intermediate | 16 (20) | 17 (19.5) | 13 (20.9) | 15 (23.8) | 12 (14.3) | |
| High school | 22 (27.5) | 30 (34.5) | 19 (30.7) | 13 (20.6) | 24 (28.6) | |
| Above high school | 23 (28.8) | 23 (26.4) | 13 (20.9) | 17 (26.9) | 28 (33.3) | |
We found no statistically significant associations among sociodemographic factors and barriers to dental care, except for financial barriers and interior design barriers. Families with employed fathers were more likely to rate financial barriers as less difficult (p = 0.008). However, 66.91% of these families still considered financial barriers difficult, indicating that stable employment does not fully mitigate financial challenges to accessing dental care. Additionally, a higher percentage of mothers with higher education levels tended to report financial barriers as easier to manage compared to those with less education (p = 0.037), although a notable portion of these mothers still found financial barriers somewhat difficult (Table 6).
Table 6.
Association of barriers with sociodemographic variables.
| Barrier | Variable | Easy (1–3) | Somewhat Difficult (4–7) |
Difficult (8–10) | p-Value |
|---|---|---|---|---|---|
| Finance | Relationship to child | 0.811 | |||
| Mother | 60 (54.55) | 69 (54.33) | 67 (48.20) | ||
| Father | 43 (39.09) | 48 (37.80) | 60 (43.17) | ||
| Other (specify) | 7 (6.36) | 10 (7.87) | 12 (8.63) | ||
| Mother’s education | 0.037 | ||||
| Illiterate | 2 (1.82) | 5 (3.94) | 12 (8.63) | ||
| Elementary | 13 (11.82) | 19 (14.96) | 20 (14.39) | ||
| Intermediate | 13 (11.82) | 22 (17.32) | 25 (17.99) | ||
| High school | 29 (26.36) | 37 (29.13) | 44 (31.65) | ||
| Above high school | 53 (48.18) | 44 (34.65) | 38 (27.34) | ||
| Father’s education | 0.176 | ||||
| Illiterate | 2 (1.82) | 6 (4.72) | 10 (7.19) | ||
| Elementary | 17 (15.45) | 26 (20.47) | 30 (21.58) | ||
| Intermediate | 26 (23.64) | 23 (18.11) | 24 (17.27) | ||
| High school | 26 (23.64) | 39 (30.71) | 43 (30.94) | ||
| Above high school | 39 (35.45) | 33 (25.98) | 32 (23.02) | ||
| Maternal occupation | 0.954 | ||||
| Employed | 19 (17.27) | 21 (16.54) | 22 (15.83) | ||
| Unemployed | 91 (82.73) | 106 (83.46) | 117 (84.17) | ||
| Paternal occupation | 0.008 | ||||
| Employed | 88 (80) | 104 (81.89) | 93 (66.91) | ||
| Unemployed | 22 (20) | 23 (18.11) | 46 (33.09) | ||
| Interior Design | Relationship to child | 0.048 | |||
| Mother | 90 (52.33) | 87 (53.05) | 19 (47.50) | ||
| Father | 63 (36.63) | 72 (43.90) | 16 (40) | ||
| Other (specify) | 19 (11.05) | 5 (3.05) | 5 (12.50) | ||
| Mother’s education | 0.473 | ||||
| Illiterate | 6 (3.49) | 10 (6.10) | 3 (7.50) | ||
| Elementary | 24 (13.95) | 19 (11.59) | 9 (22.50) | ||
| Intermediate | 24 (13.95) | 29 (17.68) | 7 (17.50) | ||
| High school | 55 (31.98) | 48 (29.27) | 7 (17.50) | ||
| Above high school | 63 (36.63) | 58 (35.37) | 14 (35) | ||
| Father’s education | 0.009 | ||||
| Illiterate | 5 (2.91) | 8 (4.88) | 5 (12.50) | ||
| Elementary | 30 (17.44) | 28 (17.07) | 15 (37.50) | ||
| Intermediate | 39 (22.67) | 30 (18.29) | 4 (10) | ||
| High school | 46 (26.74) | 52 (31.71) | 10 (25) | ||
| Above high school | 52 (30.23) | 46 (28.05) | 6 (15) | ||
| Maternal occupation | 0.555 | ||||
| Employed | 27 (15.70) | 26 (15.85) | 9 (22.50) | ||
| Unemployed | 145 (84.30) | 138 (84.15) | 31 (77.50) | ||
| Paternal occupation | 0.138 | ||||
| Employed | 138 (80.23) | 120 (73.17) | 27 (67.50) | ||
| Unemployed | 34 (19.77) | 44 (26.83) | 13 (32.50) |
Mothers as primary caregivers reported the highest difficulty with interior design barriers in dental facilities, with a statistically significant association (p = 0.048). Fathers with higher education levels were somewhat less likely to rate interior design barriers as difficult, although challenges persisted even among this group (Table 6).
Paternal education was statistically and significantly associated with perceived importance of routine dental care (p = 0.041). Other sociodemographic factors, such as the relationship to the child, maternal education, and parental occupation, did not show significant impacts on the perceived importance of routine dental care (Table 7). Additionally, regarding parents’ satisfaction with current dental services for SWDs, there was no association between satisfaction with current dental care and sociodemographic factors.
Table 7.
Association between sociodemographic variables and perceived importance of routine dental care for SWDs.
| How Important Is Your Access to Routine Dental Care | Not Important (1–3) |
Somewhat Important (4–7) |
Important (8–10) |
p-Value |
|---|---|---|---|---|
| Relationship to child | ||||
| Mother | 20 (52.63) | 31 (48.44) | 145 (52.92) | 0.836 |
| Father | 16 (42.11) | 29 (45.31) | 106 (38.69) | |
| Other (specify) | 2 (5.26) | 4 (6.25) | 23 (8.39) | |
| Mother’s education | ||||
| Illiterate | 0 (0) | 1 (1.56) | 18 (6.57) | 0.235 |
| Elementary | 5 (13.16) | 8 (12.50) | 39 (14.23) | |
| Intermediate | 8 (21.05) | 11 (17.19) | 41 (14.96) | |
| High school | 10 (26.32) | 26 (40.62) | 74 (27.01) | |
| Above high school | 15 (39.47) | 18 (28.12) | 102 (37.23) | |
| Father’s education | ||||
| Illiterate | 1 (2.63) | 0 (0) | 17 (6.20) | 0.041 |
| Elementary | 9 (23.68) | 15 (23.44) | 49 (17.88) | |
| Intermediate | 13 (34.21) | 14 (21.88) | 46 (16.79) | |
| High school | 8 (21.05) | 22 (34.38) | 78 (28.47) | |
| Above high school | 7 (18.42) | 13 (20.31) | 84 (30.66) | |
| Maternal occupation | ||||
| Employed | 3 (7.89) | 12 (18.75) | 47 (17.15) | 0.307 |
| Unemployed | 35 (92.11) | 52 (81.25) | 227 (82.85) | |
| Paternal occupation | ||||
| Employed | 3 (7.89) | 12 (18.75) | 47 (17.15) | 0.307 |
| Unemployed | 35 (92.11) | 52 (81.25) | 227 (82.85) |
4. Discussion
This study is among the first to comprehensively examine oral health behaviours, dental care utilisation, and barriers to accessing dental services among SWDs from the perspectives of their families. Despite a majority of parents reporting that SWDs were capable of brushing without limitations, irregular tooth brushing and low use of dental floss were common. These findings suggest that while physical capability exists, there may be gaps in oral health education or support, particularly in home environments. These results are consistent with other studies conducted in various regions of Saudi Arabia that have reported similar poor oral health practices among SWDs [12]. The statistically significant association between higher maternal education and more frequent tooth brushing suggests that a mother’s education level may play a crucial role in shaping oral hygiene practices. This aligns with a cross-sectional study from China involving 8446 families, which found that higher maternal education was significantly linked to more frequent tooth brushing among SWDs [17]. Similarly, a Romanian study of 814 schoolchildren showed a positive correlation between mothers’ education levels and increased tooth brushing frequency [18]. These findings consistently highlight the crucial role of maternal education in shaping children’s oral hygiene practices. However, the persistence of irregular brushing even among SWDs of more educated parents suggests that other factors, such as time constraints or lack of parental supervision, may also contribute. Our study also found a statistically significant association between the relationship to the SWDs and flossing, with mothers being more likely to report that SWDs floss. Despite this, the overall rate of flossing among SWDs remains very low (4.3%). This finding highlights that while mothers might be more involved in promoting flossing, the practice itself is rarely adopted.
Furthermore, this study found a notable association between daily sugar/sweets intake and parents’ education levels, particularly among those with education above high school. students of more educated parents were more likely to either never consume sweets or consume them rarely and in small quantities. However, it is also notable that some SWDs of more educated parents still engage in daily sweets consumption, whether in small or large quantities. This underscores the need for tailored and evidence-based approaches to improve oral health behaviours, particularly in the context of parental education and its influence on students’ oral health. Cochrane reviews have consistently highlighted the importance of such interventions. For instance, Riggs et al. (2019) emphasised the role of educational interventions that promote evidence-based nutritional guidelines, starting as early as pregnancy. These interventions are crucial for fostering healthier dietary habits and reducing the risk of early childhood caries by minimising the intake of sugary foods that contribute to dental problems [19]. Zhou et al. (2020) further supported the necessity of specific, evidence-based strategies to address unique challenges in maintaining oral hygiene, suggesting that comprehensive training for both caregivers and people with disabilities is crucial for improving oral health behaviours across diverse populations [20]. This could be facilitated within the school environment, where teachers play a pivotal role in reinforcing comprehensive oral health promotion, including structured oral health education, supervised toothbrushing programmes, and restricting the use of sugary foods. This approach is more effective when teachers have the resources and collaborate with parents and oral healthcare providers, as demonstrated in a recent study in the area [21].
Although a majority of parents acknowledged the importance of routine dental care, many SWDs still relied mostly on emergency visits, reflecting a reactive rather than preventive approach to oral health care. This is consistent with findings from a systematic review by Bhadauria et al. (2024) which identified similar patterns of care among individuals with disabilities, whereby dental services were primarily accessed during emergencies because of barriers to accessing regular care [22]. This disconnect between awareness and practice, along with lower satisfaction levels, raises concerns about accessibility. Furthermore, while oral health providers in the study area are predominantly general dental practitioners [23], the finding that primary health services were the least utilised in this study (with only 16.5% of participants reporting their use) further emphasises these concerns. Most dental care for people with disabilities is not inherently complex and can be effectively delivered in primary care and community settings, provided that dental healthcare professionals are properly prepared and have the right attitudes [24,25]
The statistically significant associations between paternal education (p = 0.035) and paternal employment (p = 0.038) with more frequent dental visits highlight the role of socioeconomic factors in access to care. Similarly, a recent scoping review by Fadila et al. (2024) emphasised the influence of these sociodemographic factors on dental visit patterns. However, the continued reliance on emergency visits, even among those with higher socioeconomic status, points to broader issues to be addressed [26].
Barriers to dental care, particularly fear of treatment, wait time for dental appointments, and difficulties in finding willing dentists, were the most frequently reported. These challenges highlight the need for more dental professionals trained in managing SWDs and the development of more welcoming dental environments. Enhancing dental environments with sensory adaptations, such as dimmed lighting, calming music, weighted blankets, and tactile familiarisation, as well as assistive technologies like hearing aids, sign language interpreters, and braille materials, can significantly reduce anxiety and improve cooperation during dental visits in persons with disabilities, including SWDs [27,28]. Despite the benefits of these adaptations, there remains a critical need for education and training for both current and future dentists to enhance their preparedness and attitudes in managing SWDs, which could ultimately lead to improvements in dental care access for SWDs [29,30].
Although financial barriers were less frequently cited compared to these challenges, they remain a significant concern, particularly for parents without stable employment. The statistically significant association between financial barriers and paternal employment (p = 0.008) indicates that while employment may reduce financial challenges, it does not eliminate them, as a notable percentage of employed fathers still reported financial difficulties. Similarly, the statistically significant association between mothers with higher education levels and better management of financial barriers (p = 0.037) suggests that educational attainment may offer some advantages in navigating these challenges, although financial barriers remained significant for many. This may be attributed to the fact that, despite their educational advantage, the majority of mothers included in this study are unemployed (83.5%), limiting financial resources and exacerbating financial barriers. This underscores the complexity of these barriers, indicating that financial and other access issues persist, even among families with stable employment or higher education levels [26]. Reducing treatment costs and improving insurance coverage have been shown to enhance access to dental services for SWDs, offering a potential solution to these financial challenges [6].
Furthermore, there was a statistically significant association (p = 0.048) between maternal education and difficulty with interior design barriers, with mothers reporting more difficulty with interior design barriers in dental facilities. This may reflect their role as primary caregivers and their heightened awareness of the physical environment’s impact on their SWDs’ comfort. This finding underscores the critical importance of adopting universal design principles in dental facilities to ensure these environments are both physically accessible and disability-friendly [31,32].
This suggests that financial stability alone is insufficient to overcome the challenges of accessing consistent and comprehensive dental care for persons with disabilities. International research supports this view, identifying a range of barriers, from physical accessibility to the availability of trained professionals [33], and emphasising the need for education, training, and increasing awareness about dental hygiene and annual dental check-ups to improve access to care [18].
While the findings provide valuable insights, it is important to acknowledge the limitations of this study. The findings may not be generalisable beyond the study region. The reliance on a non-random sampling method and self-reported data may introduce bias, and the cross-sectional design limits causal inference. The response rate of 49.9% was relatively high compared to similar studies [16,34]; however, it may still introduce some response bias. Additionally, the study does not capture the perspectives of oral health care providers, which could offer further insights into barriers to care for SWDs.
The study underscores the need for policies that promote training in managing SWDs and better integration of dental services with other health services to provide comprehensive care. Nowghani et al. demonstrated that multidisciplinary training initiatives designed for healthcare students from various disciplines, such as dental science, dental hygiene, speech and language therapy, and nursing, significantly improved self-efficacy and awareness of barriers to oral care for people with disabilities [35]. Additionally, healthcare policymakers can further improve oral health outcomes for SWDs by investing in cost-effective dental public health intervention strategies. These can be implemented through dental schools and providers in SWD schools, including school-supervised toothbrushing programs, pit and fissure sealants, fluoride varnish applications, mobile dental clinics, and tele-dentistry [36,37,38,39,40,41]. Mobile clinics deliver dental care directly at schools, while tele-dentistry enables remote consultations and follow-ups.
5. Conclusions
The findings highlight significant disparities in oral health behaviours and access to dental care among the study population. These results highlight the need for active collaboration between oral healthcare providers, educators, families, and health policymakers to address these challenges. Targeted educational interventions, particularly for mothers, could significantly enhance SWDs’ oral hygiene practices. Future policies should prioritise the implementation of effective preventive and interventional strategies, which can be strategically integrated through schools to improve the overall oral health of SWDs within the study region and beyond. Additionally, future researchers should evaluate the effectiveness of these initiatives and policy changes in improving oral health outcomes and reducing barriers to care among SWDs.
Acknowledgments
The author would like to acknowledge the University of Western Australia for their support. The authors extend their appreciation to the King Salman Center for Disability Research for funding this work through Research Group no. KSRG-2023-025.
Supplementary Materials
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/healthcare12191955/s1, File S1: Parent Questionnaire. File S2: STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies.
Author Contributions
F.Y.I.A. and E.K. were responsible for designing the questionnaire. F.Y.I.A. conducted the data collection and took the lead in drafting the initial manuscript. All authors contributed to the data analysis and interpretation. M.T. and E.K. made significant revisions to the manuscript. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
The study was approved by the Human Research Ethics Committee at the University of Western Australia (file reference—2022/ET000328 on 7 September 2022) and the Research Ethics Committee at King Faisal University (approval number KFU-REC-2022-APR-EA000553 on 5 April 2022).
Informed Consent Statement
Informed consent was obtained from all participants before their inclusion in the study.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Conflicts of Interest
The authors declare that there are no conflicts of interest.
Funding Statement
The authors extend their appreciation to the King Salman Center for Disability Research for funding this work through Research Group no. KSRG-2023-025.
Footnotes
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.