Oral Hygiene Practices and Oral Health Status of People with Special Health Care Needs: A Multicentric Study of Special Schools in a Southern Indian Taluk

ABSTRACT

Objectives:

Individuals with special health care needs, face unique oral health challenges due to physical, cognitive, and behavioral limitations. They often exhibit a significantly higher burden of dental caries and periodontal diseases. The objective of the study was to assess the oral health status of individuals with special needs in five special schools and evaluate their oral hygiene practices and determine the influence of demographic factors on clinical outcomes such as dental caries, oral hygiene, and gingival inflammation.

Methods:

A cross-sectional study was conducted among 209 subjects with special needs residing at five special schools. Participants were examined for simplified oral hygiene index (OHI-S), decayed, missing and filled teeth (DMFT) index, and gingival index. Sociodemographic data and oral hygiene practices were also recorded. Statistical comparisons between groups were made using independent t tests and analysis of variance.

Results:

Autism was the most prevalent condition, affecting 72.2% of the participants. Although 98.1% of them reported brushing their teeth, the OHI-S score was 3.04 ± 1.4 and DMFT score was 3.21 ± 0.61, indicating a significant oral disease burden. Gender-specific analysis showed that males had significantly higher OHI-S scores (3.12 ± 0.7) compared to females (2.70 ± 0.6, P = 0.04), whereas females had a significantly higher number of missing teeth (1.47 ± 0.5) compared to males (0.66 ± 0.4, P = 0.049). Also, participants aged >20 years demonstrated the worst oral health indices, with significant increases in OHI-S, missing teeth, and gingival inflammation (all P < 0.05).

Conclusion:

The findings of this study indicate toward a severe oral health burden among individuals with special needs despite good basic oral hygiene routines. Hence, there is a need for targeted interventions, enhanced caregiver education, and early intervention programs to address the barriers affecting oral health in these individuals.

INTRODUCTION

Individuals with special health care needs (SHCN) include a broad group of people with various medical, developmental, physical, and psychological issues that require specific attention and care.[1] The World Health Organization (WHO) defines special needs subjects as those who have “a developmental, behavioral, or emotional disorder, a chronic illness, an injury, a congenital condition, or other health-related conditions requiring specialty care.” Physical limitations, cognitive impairments, and chronic diseases are some examples of these problems.[2,3] An estimated 1.3 billion people or 16% of the global population worldwide experience a notable disability today. People with disabilities have the right to the highest attainable standard of health as those without disabilities.[3] According to the reports of National Sample Survey Organization, 18.49 million individuals with disabilities comprise about 1.8% of the total population in India. Nearly 6%–10% of children in India are born with a disability, and probably, forming one-third of the total disabled population.[4]

Children with behavioral problems like anxiety, attention deficit hyperactivity disorder, and autism spectrum disorder; congenital abnormalities like trisomy 21, congenital heart disease, and developmental disorders like cerebral palsy or cognitive/intellectual disability disorders; and systemic diseases like childhood cancers are included as those with SHCN.[5,6] They usually pouch the food in their mouth due to lack of tongue coordination. They may exhibit teeth-grinding, tongue-thrusting, lip-biting, and gingival-picking habits. Some may even show an increased liking toward sugar-rich food and soft diet due to sensitivity toward texture of food. Children with cerebral palsy may demonstrate diminished manual dexterity affecting their routine oral hygiene practice. Their living circumstances, age, and the degree of their disability all have an impact on their dental health.[7,8] Furthermore, their capacity to maintain good oral hygiene may be severely limited by motor, sensory, and intellectual challenges, requiring additional help.[9,10,11] Communication with these children may be challenging due to the patient’s limitation; therefore, behavior advice might be difficult to provide and may interfere with the safe administration of dental treatment. Many issues might lead to delaying or denial of therapy, which can result in needless pain and an increase in treatment demand and expense.[12]

Dental treatments for SHCN individuals are frequently overlooked by both dentists and parents since dentists may be hesitant to treat them owing to fear and lack of awareness of the different illnesses that affect SHCN patients. On the other side, parents may prioritize other medical issues above oral healthcare, leading to a lack of awareness of the need for dental treatment, depression, and dejection. Financing and reimbursement concerns might also have an impact on their access to dental treatment.[13] Literature research showed lack of studies assessing the oral health status and oral health needs in Udupi Taluk of southern part of Karnataka. Hence, we aimed to assess the oral hygiene practices and oral health condition among individuals with SHCN from five special schools in our Taluk. This study seeks to shed light on the specific challenges faced by this vulnerable population.

MATERIALS AND METHODS

This multicentric observational study was conducted in five institutionalized special schools in and around our taluk. Two hundred and nine individuals with SHCN residing in the school were screened and evaluated for oral hygiene practices and oral hygiene status. The participants included individuals with autism, cerebral palsy, Down syndrome, mental retardation, and non-verbal disorders. Prior permission was taken from the administrative authorities of these schools to conduct the study. Ethical approval for the study was obtained from the Institutional Ethics Committee (IEC Approval No: 114 2023).

There are seven schools for SHCN people in Udupi Taluk area. Written permission for oral examination of these individuals was obtained from five schools only, and all the individuals present on the day of examination in these five institutionalized special schools were recruited for the study.

INCLUSION CRITERIA

The inclusion criteria consisted of individuals with SHCN residing in five schools of Udupi Taluk. Those subjects whose caretakers/parents/guardians signed the informed consent were only recruited for the study.

EXCLUSION CRITERIA

The individuals who were not cooperative for complete oral examinations were excluded. The guardian/caregivers/parents who did not give their consent for dental examination were not considered for the study.

As the study participants of the present study were from institutional schools for special needs, caretakers were handling them for daily routine activities. During the study, majority of the participants were cooperative, and a very few of those who were not cooperative were able to record their oral examination with the support of care takers.

INTRAORAL EXAMINATION

The examination was conducted at the premises of the schools, where each child was escorted by their teacher or guardian to the designated examination room. Upon arrival, the child was seated comfortably in the examination chair. The “Tell-Show-Do” technique was employed to familiarize them with the examination process, ensuring clear communication before the procedure. A pretested and validated questionnaire was used to assess demographic variables like age, gender, and medical condition of the child, and six questions assessing the oral hygiene practices were put forth for the child. Prior to the intraoral examination, the questionnaire was filled by the guardian/caretaker/parent of the child.

The intraoral examination was meticulously performed using a mouth mirror and a standard dental probe for tactile inspection, along with a CPITN periodontal probe. The examination protocol adhered to strict calibration standards to ensure consistency and reliability. A single trained and calibrated examiner conducted the assessments. The study participants were assessed for various clinical parameters, including food debris, dental calculus, gingivitis, dental caries, restorations, and missing teeth. A clinical observation form was used to systematically record findings from the oral assessment.

ASSESSMENT CRITERIA

Dental caries was recorded using WHO criteria[14] and assessed using the decayed, missing and filled teeth (DMFT) index for primary dentition, DMFT index for permanent dentition, and deft and DMFT index for mixed dentition.[15]

Gingival status was evaluated based on gingival redness and bleeding using a blunt probe to trace the soft-tissue walls at the entry of the gingival sulcus. The gingival index was used to assess four gingival surfaces per tooth: mesio-facial papillae, facial marginal gingiva, disto-facial papillae, and lingual marginal gingiva. Gingival status was classified as normal (score = 0), mild inflammation (score = 1), moderate inflammation (score = 2), and severe inflammation (score = 3).

Oral hygiene status was assessed using the simplified oral hygiene index (OHI-S) by Miglani et al.[16] and its modification for deciduous dentition by Damle and Patel.[17] Six tooth surfaces—two anterior and four posteriors—were inspected, with adjacent teeth substituted if necessary. Oral hygiene status was categorized as good (score = 0–1.2), fair (score = 1.3–3.0), and poor (score = 3.1–6.0). Debris and calculus scores were graded on a scale of 0 to 3 for defined surfaces, and the recorded scores were used to calculate index values.

STATISTICAL ANALYSIS

Data were entered in the Excel and analyzed using Statistical Package for the Social Sciences SPSS version 23 (IBM Corp, Armonk, N.Y, USA). Descriptive analysis was done using parametric tests like chi-square test and Student’s t test and reported as percentages and mean with standard deviation. Independent t test was used to compare the parameters assessing the oral health status between males and females. Comparison of the oral health status among the three different age groups was done using analysis of variance (ANOVA) followed by post hoc Tukey’s test. P value < 0.05 is considered statistically significant.

RESULTS

The study included 209 individuals diagnosed with special needs, with a mean age of 19.61 ± 10.8 years (range: 7–72 years). The majority were male (68.4%), while 31.6% were female [Table 1]. With respect to the medical conditions, 72.2% of participants were autistic, while others had mental retardation (n = 30), Down syndrome (n = 20), cerebral palsy (n = 3), intellectual disability (n = 1), or non-verbal disorders (n = 4).

Table 1.

Sociodemographic details of study participants

Variables	N = 209	Percentage
Mean age in years (SD)	19.61 ± 10.8	Range 65 (7–72)
Gender
Male	143	68.4%
Female	66	31.6%
Medical conditions
Autistic	151	72.2%
Mental retardation	30	14.4%
Down syndrome	20	9.6%
Non-verbal	4	1.9%
Cerebral palsy	3	1.4%
Intellectual disability	1	0.5%

ORAL HYGIENE PRACTICES

Oral hygiene practices reported by the subjects are described in Table 2. Most participants (98.1%) reported brushing their teeth, with 84.2% able to brush independently, while 15.8% required assistance. About 90% reported brushing only once a day, while only 10% reported brushing twice every day. Almost all (99%) used toothbrushes and toothpaste, but none used additional oral hygiene aids like tongue cleaners, dental floss, mouthwashes etc.

Table 2.

Oral hygiene practices followed by the study participants

Oral hygiene practices followed	Responses	N	Percentage
Is the child brushing his/her teeth regularly?	Yes	205	98.1
	No	4	1.9
Is the child able to brush his/her teeth by himself/herself?	Yes	176	84.2
	No	33	15.8
Who is brushing the child’s teeth?	Self	176	84.2
	Caregiver	33	15.8
How many times does the child brush his/her teeth per day?	Once daily	188	90
	Twice daily	21	10
	More than twice	0	0
Is the child using toothbrush and toothpaste?	Yes	207	99
	No	2	1
Any other oral hygiene aids used by them? [tongue cleaner, dental floss, and oral mouth washes]	Yes	0	0
	No	209	100

ORAL HEALTH STATUS

The current oral health status of study participants is shown in Table 3. The overall oral hygiene of the study population was poor, with a mean OHI-S score of 3.04 ± 1.4. The mean DMFT score was 3.21 ± 0.61, indicating a significant caries burden. The gingivitis score was 1.12 ± 0.68, reflecting moderate gum disease.

Table 3.

Oral health status of study participants

Clinical parameters	Mean	SD
Oral hygiene index-simplified scores	3.04	1.4
Decay teeth	2.11	1.5
Missing teeth	0.92	0.8
Filled teeth	0.19	0.5
DMFT score	3.21	0.61
Gingivitis score	1.12	0.68

DMFT = decayed, missing and filled teeth

COMPARISON OF ORAL HEALTH STATUS BASED ON GENDER

Males had significantly higher OHI-S scores (3.12 ± 0.7) compared to females (2.70 ± 0.6) (P = 0.04), indicating poorer oral hygiene scores, as shown in Figure 1. However, females had significantly more missing teeth (1.47 ± 0.5) compared to males (0.66 ± 0.4, P = 0.049). Other parameters, including decay teeth, DMFT score, and gingivitis score, showed no statistically significant differences. Figure 1 shows the gender-wise comparison of the oral health status.

Figure 1.

Gender-wise comparison of the oral health status

ORAL HEALTH STATUS: COMPARISON BASED ON AGE GROUPS

We observed that the oral health status of study participants deteriorated with progressing age, as shown in Figure 2. OHI-S scores increased significantly with age (P < 0.001), with the highest scores in individuals aged above 20 years (3.65 ± 1.5), as depicted in Table 4. Missing teeth were significantly higher in older individuals (P = 0.004), with those above 20 years having 2.15 ± 1.6 missing teeth. DMFT scores were significantly higher in older individuals (P = 0.005), with the highest scores in those above 20 years (4.69 ± 2.6). Gingivitis scores increased significantly with age (P < 0.001), with the highest scores in individuals aged above 20 years (1.53 ± 0.7).

Figure 2.

Box plot showing distribution of simplified oral hygiene index scores by age groups

Table 4.

Comparison of the oral health status of study population based on different age groups

Clinical parameters	Age group up to 10 years (a)	Age group 11–20 years (b)	Age group above 20 years (c)	P value
	Mean (±SD)	Mean (±SD)	Mean (±SD)
Oral hygiene index-simplified scores	2.46 ± 0.97	2.72 ± 1.2	3.65 ± 1.5	<0.001 c > a
Decay teeth	2.19 ± 1.3	1.98 ± 1.4	2.29 ± 0.9	0.8
Missing teeth	0.44 ± 0.4	0.32 ± 0.5	2.15 ± 1.6	0.004 c > a, c > b
Filled teeth	0.22 ± 0.6	0.11 ± 0.4	0.32 ± 0.7	0.078
DMFT score	2.84 ± 1.6	2.41 ± 1.5	4.69 ± 2.6	0.005 c > b
Gingivitis score	0.85 ± 0.45	0.92 ± 0.56	1.53 ± 0.7	<0.001 c > a, c > b

The ANOVA test used to compare the oral health status among the three age groups was followed by post hoc Tukey’s test. P value < 0.05 is considered statistically significant: “a”—age group up to 10 years, “b” —age group 11–20 years, “c” —age group >20 years.

This shows a progressive decline in oral health status with increasing age. The box plot of OHI-S scores across three age groups (up to 10 years, 11–20 years, and above 20 years) reveals a clear upward trend, indicating worsening oral hygiene in older individuals. Children aged ≤10 years show the lowest median OHI-S scores and a narrower interquartile range (IQR), reflecting better and more consistent oral hygiene.

In contrast, the group aged above 20 years exhibits the highest median and the widest score distribution, with several individuals showing extreme values, indicating poor and highly variable oral hygiene. This trend aligns with the statistical findings in Table 4, where the oldest group also showed significantly higher missing teeth, DMFT scores, and gingivitis prevalence. It is observed from the data obtained [Figure 2] that age is a critical factor influencing the deterioration of oral health among the SHCN group.

The box plot shown in Figure 2 compares OHI-S scores across three age groups: up to 10 years, 11–20 years, and above 20 years. A key observation is that the median OHI-S scores tend to increase with age, indicating poorer oral hygiene in older individuals. The youngest age group (up to 10 years) has the lowest median and IQR, suggesting relatively better and more consistent oral hygiene. The 11–20 year group shows a slightly higher median with a few outliers, suggesting greater variability in hygiene. The above 20 year group displays the highest median and widest IQR, reflecting poorer and more inconsistent oral hygiene, along with more extreme values. The upward trend in both median and IQR with age implies a potential decline in oral hygiene practices or increased challenges in maintaining oral health as individuals grow older.

DISCUSSION

The current study provides a comprehensive overview of the oral health practices and status of people with special needs from five special schools in and around our taluk. The most common medical conditions encountered among study participants were autism (72.2%), followed by Down syndrome, cerebral palsy, mental retardation, intellectual disability, and non-verbal disorders.

We observed a mean OHI-S score of 3.04 ± 1.4 and a DMFT score of 3.21 ± 0.61 in our study participants. These data indicated a significant burden of dental caries due to insufficient plaque control in this population. The mean gingivitis score of 1.12 ± 0.68 further illustrates the prevalence of moderate periodontal inflammation among these subjects. Most of the participants in our study (98.1%) reported brushing their teeth regularly, with 84.2% able to brush independently, while 15.8% required caretaker assistance. About 90% reported brushing only once a day, while only 10% reported brushing twice every day. Almost all (99%) used toothbrushes and toothpaste, but none used additional oral hygiene aids like tongue cleaner, floss, or mouth rinses. These findings were similar to those of previous studies by Purohit et al.[18] and Shyama et al.,[19] who also noted that majority of their participants use brushing aids like toothpaste and toothbrushes. We noted a discrepancy as most of the participants self-reported about following oral hygiene practices but depicted poor clinical oral health indices. This underscores the need to not only reinforce proper techniques of brushing but also implement adjunctive preventive measures tailored to the physical and cognitive abilities of SHCN people. Similar observations were seen in previous studies, and they state that motor skill limitations or challenges is one of the constant reasons for maintenance of poor oral hygiene routines.[18,19] The increased risk of dental caries may be attributed to other key factors like frequent consumption of sugar-rich foods and prolonged use of sweetened medicinal syrups.[20,21] However, according to the National survey, only 60% of children were using toothbrush and toothpaste.[4] This variation could be due to the different socioeconomic status and the guidance provided by the teachers and caretakers from the special schools in our setup. Hence, environmental and family support plays a significant factor in the quality of life of individuals with SHCN.

Gender-based analysis of the oral health findings revealed no significant difference in the DMFT scores. But the OHI-S indices showed males had significantly higher scores compared to females (3.12 ± 0.7in males vs. 2.70 ± 0.6 in females, P = 0.04), indicating poor oral hygiene maintenance by males as compared to females. However, females experienced a statistically significant higher number of missing teeth (1.47 ± 0.5 vs. 0.66 ± 0.4 in males, P = 0.049). Literature also shows that females with SCHN frequently exhibit higher rates of missing teeth compared to the general population.[22] Institutionalized elderly populations, which included females with cognitive impairment, showed significant missing teeth counts (>20 teeth missing on average), with concomitant poor oral hygiene status such as calculus accumulation and poor denture hygiene indices (>80%) along with poor oral health-related quality of life.[22] Similarly, a female subgroup of psychiatric inpatients also demonstrated an average of 7.3 missing teeth, with poor oral hygiene. A study in institutionalized elderly noted females and those with mild cognitive impairment had worse and higher tooth loss.[23] There are multiple factors which can be attributed to these variations: level of physical and cognitive impairment reducing self-care ability and complicating oral hygiene maintenance, limited access to dental care or specialized training among general practitioners resulting in suboptimal dental management for SHCN populations, socioeconomic disparities affecting dental service utilization, and preventive care adherence. These discrepancies suggest the need for gender-specific preventive strategies and further investigation into the factors predisposing female patients to risk of higher tooth loss enhanced training and resources for health care professionals to manage oral health in SHCN populations.[24] Structured oral health prevention programs emphasize early detection and treatment, particularly for females with cognitive or physical impairments,[22] and community and caregiver education on the importance of oral hygiene, facilitating access to dental services.[25]

Furthermore, an age-related comparison demonstrated a clear trend that with increasing age, there was a marked decrease in markers of oral health. Participants aged above 20 years showed the poorest oral hygiene (OHI-S of 3.65 ± 1.5) compared to those in younger age groups: OHI-S of 2.46 ± 0.97 for children up to 10 years and 2.72 ± 1.2 for those aged 11–20 years, (P < 0.001). In addition, while the decay component did not differ significantly among the groups, missing teeth and overall caries experience (DMFT) were significantly higher in older individuals (P = 0.004 and P = 0.005, respectively). Gingivitis scores also increased with age (P < 0.001), hinting at the cumulative impact of prolonged inadequate oral care. A longitudinal cohort study in Norway noted a marked decline in perceived dental health and an increase in untreated caries from age 16–17 to 26–27, due to decreased regular dental visits and increased barriers, including financial constraints and dental anxiety.[26] The observation in the present study can be due to lack of school-based preventive oral health programs, accumulated adverse effects of chronic medications and systemic conditions, declined caregiver involvement and support for SHCN individuals transitioning to adult care, and biological aging effects on oral health.[24,27,28] Many health care systems also lack specialized dental services tailored for adults with SHCN. Hence, improved transitional care models linking pediatric and adult care, enhanced training and resources for providers serving adult SHCN patients, and multidisciplinary approaches integrating medical, dental, and social care are required.[29,30]

Another observation for poor oral health status among SHCN is a lack of training among dentists in handling such cases. Hence, continuing dental education programs and undergraduate and post graduate training regarding effective and comprehensive management of these individuals are essential.[30,31] The observations in our study population showed a lack of comprehensive systemic care including oral health care for individuals with special needs. Although behavioral management strategies like the “Tell-Show-Do” technique were used during examinations, the clinical findings indicate that these measures may be insufficient to overcome the inherent challenges posed due to developmental, physical, or cognitive delay. The divergence between reported practices and clinical outcomes points to the necessity of enhancing caregiver training, adopting specialized preventive tools, and developing targeted educational programs for both individuals with SHCN and their families and caretakers.[32,33]

LIMITATIONS

The sample sizes were recruited through convenience sampling, and all of them were from institutionalized special schools of our taluk. The majority of patients were autistic, and a few had mental retardation, Down syndrome, cerebral palsy, intellectual disability, or non-verbal disorders. Also, as age was not an inclusive criteria for categorizing as special needs, people belonging to all age group (initial years to older individuals) diagnosed with special needs residing in the special schools were considered for the study.

Since we are not having enough individuals suffering from other SHCN disability, further analysis including multiple linear regression analysis of confounding variables was not considered in this study. This has been stated in the limitations.

CONCLUSIONS

This study highlights critical oral health shortcomings among subjects with special needs in Udupi Taluk. Despite high rates of self-reported brushing, the clinical outcomes demonstrated by high mean OHI-S scores and a substantial DMFT score reveal that routine oral hygiene practices are not sufficient to mitigate caries burden and gingival inflammation in this population. Gender-specific differences, with males exhibiting poorer oral hygiene and females having a higher frequency of missing teeth as well as a progressive decline in oral health with advancing age, underscore the multifactorial dimensions of oral health challenges. This evidence calls for a reevaluation of existing dental care practices among the special needs population. There is an urgent need to implement preventive strategies that go beyond conventional brushing methods. Introducing innovative and adaptive dental care tools and developing regular oral care and maintenance programs could significantly improve oral hygiene outcomes and quality of life. Moreover, the data suggest that tailored interventions addressing gender and age-specific disparities are vital for a more effective and equitable approach to oral health care. A multidisciplinary approach that involves dental professionals, special educators, caregivers, and policymakers is essential for translating these findings into practical improvements, ultimately enhancing the quality of life for people with SHCN.

CONFLICTS OF INTEREST

There are no conflicts of interest.

ETHICAL POLICY AND INSTITUTIONAL REVIEW BOARD STATEMENT

Ethical approval for the research was obtained from the Institutional Ethics Committee (IEC Approval No: 114 2023).

PATIENT DECLARATION OF CONSENT

Prior permission was secured from the administrative authorities of all five participating special schools. Informed consent was obtained from the parents or legal guardians of all participating subjects. The confidentiality and anonymity of the participants were strictly maintained throughout the study, and all data collected were used solely for research purposes.

AUTHORS CONTRIBUTIONS

YT: conceptualization, data curation, writing—original draft. DS: methodology, formal analysis, supervision. VP: validation, formal analysis, writing—review and editing. AT: investigation, resources, data curation, writing—original draft. YC: supervision, project administration, writing— review and editing. SC: resources, supervision, writing—review and editing. RS: visualization, validation, writing—review and editing. NS: formal analysis, validation, writing—review and editing. All authors have read and approved the final version of the manuscript.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

LIST OF ABBREVIATION

• SHCN: special health care needs

• DMFT: decayed, missing and filled teeth

• OHI-S: simplified oral hygiene index.

Funding Statement

Nil.