Effects of Dental Follow-up on Oral Health, Antibiotic Prescriptions, and Hospitalizations in Pediatric Home Care Patients: A Single-Group Quasi-Experimental Study

ABSTRACT

Objective:

To evaluate oral health, antibiotic prescriptions, and hospitalizations before and after dental follow-up among children assisted by the Home Care Service (HCS).

Methods:

This single-group quasi-experimental, nonrandomized study was conducted at the HCS of the Clinical Hospital, at a Federal University in Brazil. This study involved 29 children undergoing invasive mechanical ventilation and gastrostomy. Oral healthcare data were collected at two time points: T1 (December 2021) and T2 (December 2022). Dental interventions and oral health education activities were conducted between January and December 2022. Monthly data on hospitalizations and antibiotic prescriptions were collected for 2021 and 2022. Oral health assessment was based on the simplified oral hygiene index, gingival bleeding, and gingival hyperplasia.

Statistical analysis was performed using the Wilcoxon paired test, with a 5% significance level.

Results:

There was a reduction in gingival bleeding (47.4%, P = 0.044) and the presence of dental plaque (50.0%, P = 0.011) and calculus (50.0%, P = 0.024). The number of antibiotic prescriptions decreased by 51.5% (P = 0.043). No significant difference was observed in the hospitalization rates (P > 0.050).

Conclusion:

Over the course of the dental follow-up, homebound pediatric patients showed a reduction in dental plaque, calculus, gingival bleeding, and antibiotic use. This is particularly relevant given that children with disabilities who are homebound often lack access to dental care. Regular dental checkups can reduce plaque accumulation, gingival bleeding, calculus formation, and the need for antibiotic prescriptions. Therefore, integrating dentists into home care teams may strengthen the relationship between improved oral health, reduced antibiotic use, and lower hospitalization rates in vulnerable pediatric populations.

INTRODUCTION

A person with a disability is defined as an individual with long-term physical, mental, intellectual, or sensory impairments that, in interaction with various barriers, may hinder full participation in the society.[1] Oral healthcare has become increasingly important for the restoration of the general health and quality of life of individuals with disabilities. This is particularly true for hospitalized or bedridden patients with acute or chronic respiratory insufficiency who often undergo systemic treatments and are dependent on respiratory support.[2,3]

Although hospital and outpatient settings are traditionally recognized as the primary contexts for healthcare delivery, it is emphasized that the home and community constitute the environments in which most children receive their daily medical care. This model of care assumes particular relevance for the promotion of health and well-being among children with disabilities.[4,5] Consequently, a progressive increase in this population has been observed, resulting in an increasing number of children being discharged from hospital to the home with specialized medical equipment and/or requiring structured home healthcare services.[4]

Oral health is characterized by intraoral homeostasis, which facilitates essential functions, such as chewing, speaking, swallowing, and breathing, and is, therefore, fundamental to well-being. Poor oral health is associated with various systemic conditions including cardiovascular diseases, diabetes mellitus, respiratory diseases, and obesity.[6,7] In this context, oral healthcare, especially for individuals with disabilities, plays a crucial role in preventing multiple systemic disorders.[8]

Homebound and bedridden patients with disabilities and exacerbated chronic conditions often require oral healthcare but are unable to access conventional dental services. Therefore, adapted dental care approaches, incorporating strategies that prioritize comprehensive, continuous, and humanized care, are necessary. Home Care Services (HCSs) are organized by a multidisciplinary team to support prolonged healthcare delivery.[9,10]

In Brazil, the classification of HC complexity level in public services prioritizes cases that require the most healthcare resources, considering the frequency of visits, intensity of required care, and need for equipment. These levels are categorized as home care (HC) 1, HC2, and HC3. HC1 patients require less frequent visits and minimal intervention from multiple professionals and are often managed through primary care units or rehabilitation centers. In contrast, HC2 and HC3 patients are referred to the HCS because of their need for more intensive care, multidisciplinary teams, and complex procedures. HCS teams in public service healthcare in Brazil are classified as type 1 or 2 depending on the population size of the municipality, with type 1 for populations ≥40,000 and type 2 for smaller municipalities.[11]

Currently, the multidisciplinary team responsible for high-complexity pediatric HC in Brazil includes physicians, nurses, physical therapists, and nursing assistants or technicians but does not include a dentist.

Homebound patients are at a high risk of developing serious infections and may present with systemic complications either due to their condition or therapeutic interventions.[12] Although the literature emphasizes the importance of oral care for medically compromised individuals and the need for daily professional attention, limited data exist on pediatric patients receiving home care support.[13] The integration of dentists into home visits remains limited, underscoring the need to strengthen the connection between healthcare teams and the communities they serve. Home visits play a fundamental role in promoting equity by addressing the needs of populations excluded from traditional dental care services and recognizing their specific vulnerabilities.[14]

Therefore, this study aimed to evaluate the oral health conditions of patients assisted by the HCS of the Clinical Hospital of a Federal University, as well as their frequency of hospitalizations and antibiotic prescriptions before and after regular dental follow-up. We hypothesized that dental follow-ups would be associated with changes in oral health, antibiotic prescriptions, and hospitalizations in this population.

MATERIALS AND METHODS

STUDY DESIGN AND SAMPLE

This was a single-group quasi-experimental, nonrandomized internal comparison study, conducted at the HCS of the Clinical Hospital of the Federal University of Uberlandia, located in Brazil. Since 1996, the HCS has supported hospital discharge of patients requiring HC. For the past 10 years, the service has been integrated into Brazil’s national “Better at home” program from the Ministry of Health and currently cares for more than 100 home-based patients.

The HCS provides home healthcare for patients requiring rehabilitation, palliative care, or who are bedridden and comprises a multidisciplinary team (EMAD) and a support team (EMAP). The latter is only activated when required to complement the clinical actions of EMAD. There is no mandatory inclusion of dental care professionals in the EMAD; dentists are involved only through the EMAP. As of 2021, children under HCS’s care had not undergone routine dental evaluations and did not benefit from preventive or therapeutic dental care.

All children aged up to 12 years and enrolled in HCS between January 2021 and December 2022 were included in this study. The exclusion criteria were as follows: patients who did not complete the minimum follow-up period; those with insufficient clinical information in their medical records; patients outside the defined age range (<4 years or >12 years); and cases in which the caregiver declined participation in the study. A total of 29 patients, encompassing the entire available sample, were monitored between 2021 and 2022. The absence of a control group was due to the difficulty in recruiting patients with the same comorbidities who were not receiving HC as hospitalized patients do not remain admitted long enough for follow-up. Additionally, selecting patients with different comorbidities or without comorbidities would have introduced control bias.

Oral health outcomes were evaluated at two time points: T1 (December 2021) and T2 (December 2022). Weekly or monthly dental visits for preventive care, education, treatment, and follow-up were conducted from January to December 2022, totaling 12 months of dental intervention.

The legal guardians of all participating children received information about the study protocol and consented for their participation through signed informed consent forms. Ethical approval was granted by the Research Ethics Committee of the University (CAAE 63903416.0.0000.5152).

HOME VISITS

For T1 and T2 assessments, the research team accompanied the EMAD during home visits. The dentists attended weekly follow-up visits independently. Clinical evaluations were performed using no. 5 mouth mirrors (Golgran, São Caetano do Sul, SP, Brazil), World Health Organization probes (Golgran), and headlamps. The instruments were sterilized at the University School of Dentistry sterilization center.

ORAL CLINICAL CONDITIONS—TRAINING AND CALIBRATION

Two dentists assisted by two recorders conducted the oral examinations. All underwent theoretical training on diagnosing enamel defects, caries, dental plaque, and calculus, followed by clinical calibration with 10 pediatric patients not included in the study sample. Calibration was repeated after 1 week. One pediatric dentistry specialist was considered the gold standard. Interexaminer Kappa values exceeded 0.87, and intraexaminer Kappa values exceeded 0.92.

ORAL HEALTH EVALUATION

Oral hygiene was assessed using the Simplified Oral Hygiene Index,[15] with scores ranging from 0 to 3 for the presence of plaque and calculus. The evaluated surfaces included the buccal surfaces of teeth 11/51, 31/71, 16/55, and 26/65 and lingual surfaces of teeth 36/75 and 46/85. Following the clinical examination, patients received oral hygiene care using a soft-bristle toothbrush (Oral-B Indicator Plus) and 1100-ppm fluoride toothpaste (Colgate) in age-appropriate quantities. Caries indices (Decayed, Missing, and Filled Teeth [DMFT] for permanent teeth and DMFT for primary teeth) were recorded.[14] Gingival hyperplasia and bleeding were also assessed (presence/absence).

DENTIST’S ROLE

The frequency of dental visits was determined by the patient’s clinical needs at baseline. A preventive protocol, consisting of monthly visits, was applied to patients requiring only oral health education and monitoring. For patients presenting curative demands (e.g., periodontal scaling or tooth extractions), a treatment protocol was implemented with weekly appointments until the clinical condition was resolved, after which they transitioned to monthly maintenance visits. Regardless of the frequency, all visits followed a standardized approach: caregivers received verbal instructions and practical demonstrations on oral hygiene (brushing technique, flossing, and positioning). To facilitate access to the oral cavity, mouth openers made of wooden spatulas and gauze were utilized. All clinical findings and treatment transitions were recorded in standardized dental charts to ensure protocol adherence.

ANTIBIOTIC PRESCRIPTIONS AND HOSPITALIZATIONS ASSESSMENT

To assess antibiotic prescriptions and hospitalizations, clinical records were reviewed for infectious events. Monthly records from January 2021 to December 2022 provided data on antibiotic use and hospital admissions (categorized as yes or no). These records were updated by EMAD healthcare professionals, including physicians, nurses, physical therapists, and nursing technicians. Dentists were not part of this routine reporting.

STATISTICAL ANALYSIS

Data on oral health and infection episodes were analyzed using Statistical Package for the Social Sciences (SPSS) for Windows (version 22.0; SPSS Inc., Chicago, IL, USA). Data distribution was assessed using the Shapiro–Wilk test, which indicated non-normality for all variables. The Wilcoxon paired test was applied. A significance level of 5% and a 95% confidence interval were adopted.

RESULTS

The sample consisted of 29 patients who were followed-up from 2021 to 2022, with no losses. The average age was 6 (standard deviation ± 5) years; 19 children (65.5%) were male and 10 (34.5%) were female. None of the evaluated children presented with carious lesions; therefore, this condition was excluded from the analysis.

Figure 1 presents the data on gingival hyperplasia, gingival bleeding, visible plaques, and calculus collected at T1 (without dental care) and T2 (after dental care). Although a 44.4% reduction in the presence of gingival hyperplasia was observed between T1 and T2, the Wilcoxon paired test showed no significant difference (P = 0.450). A significant difference was observed in the presence of gingival bleeding between the time points (P = 0.044, Wilcoxon paired test), with a 47.4% reduction in the number of patients presenting with bleeding. Evaluation of visible dental plaque showed a significant difference between T1 and T2 (P = 0.011, Wilcoxon paired test), with 50.0% reduction. The presence of calculus also showed 50.0% reduction at T2, which was a significant difference (P = 0.024, Wilcoxon paired test).

Figure 1.

Stacked bar graph representing the prevalence of oral health conditions—gingival hyperplasia, gingival bleeding, visible plaques, and calculus collected at T1 (without dental care) and T2 (after dental care). *Statistical difference between groups (P < 0.05, Wilcoxon paired test)

The results from a survey of antibiotic use over the months are shown in Figure 2. The boxplot represents the comparison between 2021 (T1) and 2022 (T2) regarding the number of months in which antibiotics were prescribed, considering urinary infections (a) and respiratory infections (b). The number of months in which antibiotics were prescribed was higher in T1, for respiratory infection, compared to T2 (T1 = 4.5 [0.0–8.5]; T2 = 0 [0.0–4.0]; P = 0.043, Wilcoxon paired test). For urinary infection, the Wilcoxon paired test showed no statistical difference between T1 and T2 (P > 0.05). Regarding the total number of hospitalization records, there were 23 recorded cases (14 patients) in 2021 and 27 (10 patients) in 2022, with no significant difference between the years (P = 0.450, Wilcoxon paired test).

Figure 2.

Boxplot graphs representing the comparison between 2021 (T1) and 2022 (T2) regarding the number of months in which antibiotics were prescribed, considering urinary infections (a) and respiratory infections (b). Different letters indicate statistical significance difference between groups (T1 and T2, p < 0.05, Wilcoxon paired test)

DISCUSSION

Oral health is essential for physical and psychosocial quality of life and overall health.[16,17] Therefore, oral care for homebound, medically complex patients is vital to ensure their well-being. Children with disabilities have a high risk of developing severe infections due to therapeutic procedures or underlying conditions.[12] A balanced oral microbiota can act as a barrier against pathogenic microorganisms, modulate the immune system, produce beneficial substances, and degrade toxins.[18]

Oral bacteria can enter the bloodstream via the oral mucosa, making oral infections a potential cause of bacteremia and systemic infections.[19] Consequently, dental care and oral health promotion are effective in preventing or managing systemic conditions, potentially reducing respiratory infections, antibiotic use, and mortality in hospitalized patients.[20] The results of this study demonstrated a reduction in the number of antibiotics administered for respiratory infections during the year in which home-based dental care was provided to children with disabilities.

Recent studies have emphasized the importance of plaque removal and basic periodontal care in the prevention and management of gingivitis and periodontal disease, both of which are associated with gingival bleeding.[21,22] This reaffirms the importance of multidisciplinary work, including the dentist in both hospital and home settings, to prevent the onset and progression of fungal diseases and periodontal disease. Although the data cited are not specifically related to oral health evaluations in homebound children, these findings are consistent with those observed in the present study.

When analyzing infectious conditions, it was noted that the data found in previous research[23] reported that the presence of a dentist in intensive care units reduces the incidence of respiratory infections, reducing the need for antibiotics and the length of hospital stay. In addition, other study[24] validates a significant reduction in the incidence of pneumonia, the use of nonprophylactic antibiotics, and a decrease in mortality rates in the group receiving dental care. Furthermore, an association observed only with respiratory infections was expected in this study as the oral cavity has been considered a potential reservoir for respiratory pathogens.[25]

In the present study, no dental caries was found in any of the participating patients. This is due to the fact that the patients had gastrostomies. Caries develops through acid attacks resulting from the decomposition of metabolized sugar by bacteria. Since food is not consumed orally, the risk of caries is reduced. Previous studies reinforce that patients with gastrostomies have a lower rate of cariogenic bacteria when compared to patients without gastrostomies.[26] Conversely, a higher presence of calculus was observed in this population. This is explained by an imbalance in the oral bacterial flora, which may be due to lack of chewing and oral inactivity, also interfering with the pH of the oral cavity and creating a favorable environment for calculus formation. Furthermore, the presence of calculus may be related to the caregiver’s failure to prioritize oral hygiene since these patients do not use their mouths to eat, and caregivers may disregard the importance of oral hygiene.[26,27] It is noted that there was no significant difference in gingival hyperplasia as it is a side effect of anticonvulsant medications in which the gingival tissue is not the intended target.[28]

Throughout the 1-year follow-up, all visits included systematic oral hygiene guidance provided to patients’ caregivers at the end of each consultation. The implementation of these services, which had not previously been available, led to observable clinical changes from the onset of home-based dental care. Thus, it was possible to provide continuous intervention in oral care through the provision of technical support and individualized assistance tailored to each patient’s specific needs. However, despite the interventions performed, it was not possible to fully control the natural disease progression.

During this study, we identified limited data regarding oral assessment and infectious conditions associated with hospitalization rates and antibiotic use in the highly complex pediatric population receiving HC before and after the dental follow-up. Recent studies have examined the association between home dental care and reduced hospital admissions, demonstrating its benefits. However, hospitalizations may occur for a variety of reasons. Nevertheless, access to home dental care can help prevent serious oral health complications in vulnerable populations with physical or cognitive disabilities.[29]

Therefore, the amount of existing research on this topic is scarce, and this study corroborates the need for further studies in this line of research. The differences found appear to indicate the importance of dental treatment. This is one of the few studies evaluating pediatric patients with disabilities receiving HC, thus encouraging reflection and modification of the structure of the public service responsible for serving this extremely vulnerable population. The study presented important limitations. First, it was conducted during the COVID-19 pandemic, which made it difficult to control the external research environment; however, none of the participating patients were diagnosed with COVID-19 during the study period. In addition, the small sample size limited the statistical power of the study, despite the inclusion of the entire population of patients registered in the HCS within the study setting. The absence of a control group also represents an important limitation of the present study. The main challenge was the difficulty in recruiting patients with comparable comorbidities who were not receiving HC as hospitalized patients typically do not remain admitted long enough to allow adequate follow-up. Furthermore, including patients with different comorbidity profiles or without comorbidities would have introduced significant control bias.

Despite the positive outcomes observed following dental intervention, the absence of a control group constitutes a significant limitation to establishing a direct causal relationship. As a longitudinal study, the findings may have been influenced by external confounding factors and temporal trends. Notably, the study period overlapped with the COVID-19 pandemic and seasonal respiratory cycles, both of which significantly impacted hospitalization patterns. Furthermore, in homebound populations, the natural progression of underlying chronic conditions and frequent pharmacological adjustments (polypharmacy) represent dynamic variables that may interfere with clinical outcomes.⁴ Consequently, while the association between oral healthcare and antibiotic prescriptions is clinically suggestive, these results should be interpreted with caution, highlighting the need for future randomized controlled trials to validate these findings.

CONCLUSION

It can be concluded that the prevalence of plaque, calculus, gingival bleeding, and the use of antibiotics for respiratory infections among pediatric patients receiving HC decreased during the year in which regular dental care was provided. However, it should be emphasized that these findings are suggestive rather than definitive.

CONFLICTS OF INTEREST

There are no conflicts of interest.

Ethical Policy and Institutional Review Board Statement

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki and approved by the Research Ethics Committee of the Federal University of Uberlândia, Brazil (CAAE 63903416.0.0000.5152

Authors contributions

Lilian R N Cantarelli - Concepts, design, data acquisition, manuscript preparation. Luiz Antônio B Cabral - Concepts, design, definition of intellectual content, literature search, data acquisition, manuscript preparation. Raí F Valadares - Definition of intellectual content, data acquisition, manuscript review. Maria Aline M Souza - Definition of intellectual content, data acquisition, manuscript review. Jaqueline V Bulgareli - Concepts, literature search, manuscript editing, manuscript review. Debora Souto-Souza - Design, literature search, data analysis, manuscript preparation, manuscript editing, manuscript review. Ana Paula Turrioni - Concepts, design, literature search, data analysis, manuscript preparation, manuscript editing, manuscript review.

Declaration of patient consent

The legal guardians of all participating children received information about the study protocol and consented for their participation through signed informed consent forms.

Data availability statement

The datasets generated and/or analyzed during the current study are available from the corresponding author upon request.

LIST OF ABBREVIATIONS

• DMFT Decayed, Missing, and Filled Teeth

• dmf Decayed, Missing, and Filled Primary Teeth Index

• EMAD Multidisciplinary team

• EMAP Support team

• HCS Home care service

• HC Clinics Hospital

• ICF Informed consent form

• OHI-S Simplified Oral Hygiene Index

• HCS Serviço de Atenção Domiciliar/home care service

Funding Statement

Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES) – Financial Code 0001, Conselho Nacional de Desenvolvimento Cientifico e Tecnologico – CNPq (INCT 406840/2022-9); Fundacao de Amparo a Pesquisa do Estado de Minas Gerais - FAPEMIG (RED-00204-23).