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Year : 2014  |  Volume : 5  |  Issue : 1  |  Page : 101-107  

Correlation of oral health status of socially handicapped children with their oral heath knowledge, attitude, and practices from India

1 Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India
2 Department of Orthodontics, JSS Dental College and Hospital, Mysore, Karnataka, India

Date of Web Publication18-Feb-2014

Correspondence Address:
Raghavendra Shanbhog
Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Shivaratreshwar Nagar, Mysore 570 015, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-9668.127297

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Background: Information on oral health knowledge and practice in orphanage house children is essential for healthcare policy makers to promote oral health resources and address oral health needs of this unprivileged group of society. Objectives: To assess the source of information, level of knowledge, attitude, and practice toward oral hygiene and oral health among socially handicapped children from city of Mysore, Karnataka state, India. Materials and Methods: A cross-sectional survey was conducted among 488 children of 12-14 years of age living in five different orphanage houses of Mysore district. Data regarding knowledge and practice were collected through structured questionnaire and oral health status by type III clinical oral examinations by two trained examiners. Decayed, Missing, Filled, Teeth (DMFT) and OH I-S was then correlated with the above information. Spearman's correlation test was used to measure the correlation. Results: The final data analysis included 488 children, of which 216 (44.26%) were boys and 272 (55.74%) were girls. A total of 88.5% children showed one or more decayed teeth in their oral cavity, with an overall mean DMFT of 3.55. Among DMF, component D showed maximum value with mean 3.42, followed by components F and M. Correlation between source of information, knowledge, and attitude for oral health to oral hygiene index (OHI-S; P < 0.05) and gingival index (P < 0.001) showed highly significant negative values. Correlation between oral hygiene practice to OHI-S, DMFT, and gingival index (P < 0.001) showed highly significant (P < 0.001) negative values. Conclusions: Although children of orphanage have positive attitude toward oral health, knowledge and practice among children are still below the satisfactory level. The children did not receive appropriate information or, if informed, were not re-evaluated or reinforced for its practical application by the concerned authority. The findings of this study suggest that awareness on the importance of oral health needs to be enhanced among the orphanage children of Mysore.

Keywords: Knowledge, oral health, practice, socially handicapped children

How to cite this article:
Shanbhog R, Raju V, Nandlal B. Correlation of oral health status of socially handicapped children with their oral heath knowledge, attitude, and practices from India. J Nat Sc Biol Med 2014;5:101-7

How to cite this URL:
Shanbhog R, Raju V, Nandlal B. Correlation of oral health status of socially handicapped children with their oral heath knowledge, attitude, and practices from India. J Nat Sc Biol Med [serial online] 2014 [cited 2021 Mar 2];5:101-7. Available from:

   Introduction Top

According to WHO published, global review of oral health, despite great improvements in the oral health of populations in several countries, global problems still persist. This is particularly so among underprivileged groups in both developing and developed countries. [1] About 90% of school children worldwide and most adults have experienced caries, with the disease being most prevalent in Asian and Latin American countries. An improvement in oral health status, environmental risk factors such as diet, nutrition, and oral hygiene can play an important role in prevention of dental caries. [2]

Many surveys in different parts of the world have found brushing to be the best way to maintain oral health. [3],[4] Ninety percent of Americans brush at least twice a day, 97% of Koreans brush once a day, while in India only 69% of the population brushes their teeth. [5] Brushing the teeth daily twice with tooth brush and fluoridated tooth paste is the primary preventive method to maintain good oral hygiene. Other equally important preventive measures apart from brushing include use of floss, use of fluorides, and regular visit to dentist. [6] The need for regular dental check- up, use of floss, and fluoride supplements, however, is not appreciated in many parts of the world. [7]

Evidence have showed that good knowledge of oral health demonstrates better oral care practices. [8] Similarly, those with more positive attitude toward oral health are influenced by better knowledge in taking care of their teeth. Studies have showed that appropriate oral health education can help to cultivate healthy oral health practice. [9] The change to healthy attitude and practice can be brought about by giving adequate information, motivation, and practice of the measures to the subjects. [8],[10] In order to create such health education, the assessment of knowledge, attitude, and practice is essential.

However, groups of people such as socially handicapped children are often denied access to health information and knowledge due to a number of reasons for example in-accessibility and nature of the disadvantage that may necessitate participation of specialized professionals. Healthy personality development and full unfolding of potentialities are hampered in socially handicapped children by certain elements in their social environment such as parental inadequacy, environmental deprivation, and emotional disturbances. [11] The pattern of orphanage living is different from that of family living, as the latter provides physical security, food, and shelter but is devoid of psychological security. These children form a population at risk with reference to abnormal psychosocial development. [12]

The modern concept of dental caries involves the interaction between genetic and environmental factors in which biological, social, behavioral, and psychological components are expressed in a highly complex and interactive manner. [13] There are very few specific studies describing the status of dental caries in orphan children living under institutionalized care in India. [14],[15] Since these children are socially deprived, they form a perfect group to study the influence of knowledge attitude and practice of oral hygiene verses actual oral hygiene status and oral disease conditions. The aim of this study was to assess the sources of information on oral health, level of knowledge, attitude, and practice towards oral hygiene and oral health among the socially handicapped children from city of Mysore (Karnataka, India) and to determine the relationship between oral health knowledge, attitude, and practice to dental caries as well as oral hygiene status and gingival health condition.

   Materials and Methods Top

A cross-sectional survey was conducted among 488 children aged 12-14 years with a mean age of 13.6 years, of which 216 (44.26%) were boys and 272 (55.74%) were girls, living in five different orphanage houses of Mysore district. Participants were randomly selected from five different orphanage houses, which were either run by government authority or aided by government. For this study, a minimum sample size of 488 children was required to estimate the association between caries experience (Decayed, Missing, Filled, Teeth; DMFT > 0) and a child's overall well-being, with 95% confidence interval, 80% statistical power, and assuming 45% prevalence of impacts in children with and without caries experience, respectively. Ethical approval for the study was obtained from the Ethical Committee of the JSS Dental College and Hospital JSS University, Mysore. A letter was sent to primary care giver of all five orphanages, explaining the aims of the study and asking them for their consent for concerned orphanage children to participate in the study. Also, children who participated in the study were informed regarding the aim of the study and their consent was obtained.

Data collection

Data were collected through structured questionnaires and type III clinical oral examinations. Two examiners who had prior experience in epidemiological surveys participated in this study. They undertook a training and calibration exercise before the survey. A sample size of 25 children was used to train the examiners and test the feasibility of the dental examination and the interview procedures. During the fieldwork, duplicate examinations were carried out on randomly selected children to assess intra- and inter-examiner agreement. Intra and inter examiner reliability was assessed using kappa statistics that was in the range of 0.8, showing good reproducibility.

Clinical examination

Children were clinically examined seated on a chair with back rest under natural light conditions and examiner standing behind the subject. Before the clinical examination, wet gauze pads were used to clean the tooth surfaces of loose debris. Visual examination was conducted with a plane dental mirror and explorer only. Radiographs were not taken.

Dental caries was recorded at tooth level according to the WHO diagnostic criteria, [16] and the DMFT index was calculated as the sum of DMFT. The simplified oral hygiene index (OHI-S) [17] was used to assess the oral hygiene status, as score represents both debris and calculus (proxy indicators of oral hygiene) in one score, thereby permitting the correlation of oral hygiene with knowledge, attitude, and practice scores separately. Gingival index (GI) [18] was used to assess the gingival status.

Questionnaire survey

The questionnaire survey included 22 items with closed-ended questions. The questioner was prepared to assess the sources of information on oral health knowledge, attitude, and practice of children living in the orphanages. Keeping the study group in mind, questions were translated into Kannada, the regional language, and the questionnaire was pretested to obtain better understanding and response from the children. The questionnaire consisted of four parts. Five questions (questions 1-5) assessed sources of information on oral health, eight questions (questions 8-15) assessed knowledge, two questions (questions 6 and 7) assessed attitude, and seven questions (questions 16-22) assessed oral health practice of orphanage children. The children received a full explanation of how to fill in the questionnaire. Children themselves recorded questionnaire provided to them. Furthermore, the investigator was always available during the completion of the questionnaire and the participants were encouraged to approach the investigator whenever they needed to clarify at any point.

Statistical analysis

The collected data were processed by means of the Statistical package for the social sciences (SPSS) version 17.0. Sources of information on oral health knowledge, attitude, and practice scores were calculated separately and were then correlated with OHI-S, DMFT, and GI scores. Spearman's correlation test was used to measure the correlation.

   Results Top

Data from questionnaire

Source of information on oral health and its maintenance

For maximum number of children (85.7%), primary care giver of the orphanage or teachers who taught these children in schools or orphanages failed to deliver information on oral health and its maintenance. Also, percentage of children who benefitted by information given in oral health checkup or education camps was found to be drastically low (3.3%); 11.3% of children previously visited a dentist for oral problems, of which only 1.6% got oral care instructions from dentists [Table 1].
Table 1: Frequency table for questions and answers

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Oral health knowledge

A majority of children (71.1%) knew that tooth brushing helps in preventing caries, whereas only 7.2% were aware that tooth brushing also helps in preventing gum diseases. A substantial number of children (92.8%) were not aware of type of paste (fluoridated or not) they were using and the type of brush to be used (93.6%) for better oral health and hygiene. Also, 96.7% of children were unaware of fluoride content of paste and its beneficiary effect on teeth. Only 4.9% of children knew about floss and nobody was aware of caries preventing the effect of floss [Table 1].

Oral health attitude

A total of 81.8% children said they know how to keep their oral cavity clean. However, 90.2% of them wanted to know more regarding methods, aids, and other relevant information regarding keeping their oral cavity clean and healthy [Table 1].

Oral health practice

All 100% of children reported that they were cleaning their teeth with brush and paste twice daily. However, before joining orphanage, only 72.1% of children were using brush and paste for cleaning their teeth. Other 27.9% were using other methods, namely tooth powder and brush (9.6%), tooth powder and finger (3.5%), finger and salt (9.2%), finger and charcoal (3.3%), and neem stick (2.3%). Before joining to orphanage considerable amount (95.1%) of children were used to brush once daily. No child was using mouth rinse or floss as an oral hygiene aid before or after joining the orphanage; 88.7% children had never visited the dentists in their life time [Table 1].

Data from clinical examination

Of 488, 88.5% children showed one or more decayed tooth in their oral cavity. A total of 27.9% children showed more than one but less than four decayed component in the mouth. Also, 60.6% of children showed more than four caries teeth in their oral cavity [Table 2]. Comparison of mean DMFT values with respect to the gender, showed little higher value for girls (3.73%) to that of boys (3.33%), which is statistically not significant [Table 3]. Comparing DMF components, D component showed maximum value with a mean of 3.42, followed by F of 0.38 and M of 0.35. The overall mean DMFT value was 3.55 [Table 4]. Frequency table for OHI-S showed 47.5% children with fair and 32.8% with poor oral hygiene. Only 19.7% children had good oral hygiene. GI showed 36.1% children with mild gingival inflammation and 27.9% with moderate gingival inflammation.
Table 2: Frequency table for DMFT

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Table 3: Mean values of DMFT according to gender

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Table 4: Mean values for DMFT

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Correlation between collected data

Correlation between source of information, knowledge, and attitude for oral health to OHI-S and GI showed highly significant negative values, suggesting that children with knowledge have good oral hygiene and gingival health status. No significant correlation was observed between the source of information, knowledge, and attitude for oral health to DMFT [Table 5]. Correlation between oral hygiene practice to OHI-S, DMFT, and GI shows highly significant negative relation, suggesting that children with poor practice have poor oral hygiene, poor gingival health status, and more number of decayed tooth. Highly significant positive correlation was observed between OHI-S and GI, suggesting that children with good oral hygiene have better gingival health status. DMFT showing highly significant positive correlation with OHI-S, suggesting that children with good oral hygiene have less number of caries [Table 6].
Table 5: Correlation between knowledge and oral health status

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Table 6: Correlation between practice and oral health status

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   Discussion Top

The main purpose of this study was to assess knowledge and practice to oral health of children living in orphanage houses toward preventive oral health measures. Oral health is a part of general health and, hence, affects the total well-being of an individual. We are aware that dental and oral diseases affect various aspects of quality of life.

Socially handicapped children are those who lack parental care and support. They lack basic information, motivation, and supervision provided by parents, especially in the initial days of their childhood. In addition, they are neglected and might be abused in the latter half of childhood by relatives and society in large. But once these children are recognized and institutionalized, primary care taker and teacher's of the orphanages become their responsible guardians. Therefore, the knowledge and information regarding general or oral healthcare maintenance for these children should be provided by these authorities.

However, this study showed that 82.5% of children did not received appropriate information or, if informed, not reinforced or re-evaluated for practical applications of information regarding oral health and its maintenance by the concerned authority. Also, only 11.5% children attended oral health education camps, indicating the frequency of arrangement of such camps although done is not sufficient in orphanage settings. Poor percentage (11.5%) of children visited dentists, indicating a need of frequent oral health checkups and treatment camps for this deprived group of population. Other remarkable data was that, of 11.5% children who visited dentist previously, only 1.6% received healthcare instructions from dentist, which shows that dentists also do not contribute much in educating the patients regarding oral healthcare maintenance.

Maximum number of children believed that brushing is the only and best method to prevent the decaying process. Similar findings were noted in previous studies done by Russel et al., [19] Al-Sadhan, [20] and Al- Ansari et al., [21] Children did not know about other aids (like floss, mouth rinse, regular dental visit, and fluoride supplements) and their efficacy in preventing caries and maintaining oral health. This clearly shows that knowledge regarding oral health and its maintenance is poor in children and appropriate action is required. This was in contrast with the finding in San Francisco, where 75% of the 12-14 years old students used dental floss at least once a day [19] and, in Iraq, where over half of the students used dental floss once or more a week. [22]

In all five orphanages, children were provided with fluoridated toothpaste and brush by the government, and it is compulsory for them to brush twice daily there. Also, looking at the dietary aspect, the children of all orphanages are provided with low sugar, healthy fibrous diet. They consume sweets made of jiggery once weekly. Thus, government authorities are providing appropriate oral hygiene aids and non-cariogenic food that is healthy. But despite this, 86.9% of children showing decayed tooth in the oral cavity. The reason may be attributed to the poor oral hygiene practice among children before they joined the orphanage and their lack of knowledge regarding brushing technique, lack of supervision, and reinforcement. The result shows that 27.9% of children were not using brush and paste to clean the teeth before joining orphanage. Also, 95.1% children use to brush once daily. An Indian study shows little higher decayed component (94%) in normal children as compared to that in our study. Comparing male and female decayed ratio, girls showed little higher values than boys. Similar findings were observed in a previous study. [23]

Correlation between knowledge to OHI-S and GI showed statistically significant negative relation, indicating that children with lack of knowledge have bad oral hygiene and gingival status. This proves that knowledge plays a vital role and is very essential for maintaining good oral health status. Correlation between practice to OHI-S, GI, and DMFT also showed statistically significant negative relation, indicating that children with poor practices have poor oral hygiene, poor gingival status, and high caries rate. Oral hygiene related to caries showed that children with bad oral hygiene had more decayed component with bad gingival health status. This shows that maintenance of oral hygiene status plays a major role in maintaining disease free tooth. Therefore, along with knowledge, practice is a must in maintaining oral health. But good practice comes from adequate knowledge and application of the knowledge. The results of this study shows that maximum number of children have poor knowledge, associated poor practice, and poor oral health.

In summary, information regarding oral health and its maintenance plays a vital role in maintaining disease-free oral cavity. Along with knowledge, positive attitude, and practice, which is supervised and reinforced can bring drastic improvement in oral health. In the present study, although children had a positive attitude, they lacked knowledge and practical application. To correct this, we recommend the following:


  • Training and educational programs on "oral health and its maintenance" should be conducted for primary care givers and teaching and supporting staff of orphanages
  • Teaching staff of orphanage should in turn educate children regarding oral health and its maintenance, and their practice regarding the same should be supervised and reinforced
  • Oral health education and screening camps should be conducted on regular basis for this deprived group of society by dental health professionals
  • There is a need to decrease dependency on oral health personnel and encourage students to take responsibility for their own oral health. All the children of orphanages were attending schools. The school population of today is the adult of tomorrow; they should be educated so that a sense of responsibility may develop in them about oral health. Studies on oral health assessment and dental health education of children at an early age helps in improving preventive dental behavior and attitudes, which is beneficial lifelong. The schools may serve as the best platform for promotion of oral healthcare among teenagers. The oral health education programs should be intensified to promote oral healthcare as a lifelong practice. Oral health education activities should be incorporated into a school's curriculum in the form of educational materials and health promotion activities
  • Further studies evaluating the clinical consequences of untreated caries and quality of life of children residing in orphanages should be done to understand and plan for preventive and treatment programs at large.

   Conclusion Top

Exploring the links between clinical conditions and their personal and social outcomes not only promotes a more complex appreciation of oral health but also provides the opportunity to identify interventions to minimize the consequences of oral diseases by conducting orphanage-based dental health programs. The oral health knowledge, attitude, and practice among orphanage children are still below the satisfactory level. The findings of this study suggest that awareness on the importance of oral health needs to be enhanced among the orphanage children of Mysore.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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