impact of oral diseases and disorders on oral-health-related quality of life of children with...

O R A L H E A LT H Q U A L I T Y O F L I F E O F C H I L D R E N W I T H C E R E B R A L P A L S Y

56 Spec Care Dent is t 34(2 ) 2014 © 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12028

A R T I C L E

The aim of this study was to investigate the impact of oral diseases and disor-ders on the oral-health-related quality of life (OHRQoL) of children with CP, adjusting this impact by socioeconomic factors. Data were collected from 60 pairs of parents–children with CP. Parents answered the child oral health quality of life questionnaire (parental-caregivers perception questionnaire and family impact scale) and a socioe-conomic questionnaire. Dental caries experience, traumatic dental injuries, malocclusions, bruxism, and dental fluorosis were also evaluated. The multivariate adjusted model showed that dental caries experience (p < 0.001) and the presence of bruxism had a negative impact (p = 0.046) on the OHRQoL. A greater family income had a positive impact on it (p < 0.001). Dental caries experience and bruxism are conditions strongly associated with a negative impact on OHRQoL of children with CP and their parents, but a higher family income can improve this negative impact.

A B S T R A C T Impact of oral diseases and disorders on oral-health-related quality of life of children with cerebral palsyJenny Abanto, DDS, MSc;1 Adriana Oliveira Ortega, PhD;2 Daniela Prócida Raggio, DDS, MSc, PhD;3 Marcelo Bönecker, DDS, MSc, PhD;4 Fausto Medeiros Mendes, DDS, MSc, PhD;3 Ana Lídia Ciamponi, DDS, MSc, PhD3*

1Postgraduate Student of Pediatric Dentistry and Orthodontics Department, Dental School, University

of São Paulo-USP, Brazil; 2Posdoc sutdent at Stomatology Department, Dental School, University of Sao

Paulo-USP, Brazil; 3Professor of Pediatric Dentistry and Orthodontics Department, Dental School,

University of São Paulo-USP, Brazil; 4Chairman Professor of Pediatric Dentistry and Orthodontics

Department, Dental School, University of São Paulo-USP, Brazil.

*Corresponding author e-mail: [email protected]

Spec Care Dentist 34(2): 56-63, 2014

The concept of Oral Health-related Quality of Life (OHRQoL) relates to the impact that oral health or disease has on the individual’s daily functioning and well-being.16 The development and trans-lation to several languages of instruments for assessing OHRQoL in children have occurred only recently. A few studies have demonstrated that oral diseases and

disorders show a negative impact on the life of normal children and/or their par-ents.16-18 Good quality of life is a key outcome for the individual and it is what has been desired by the society for all children. On the contrary, according to our knowledge, there are few studies focusing on the impact of oral health conditions on OHRQoL of CP children

I n t r oduc t i onCerebral palsy (CP) is a neurological disorder occurring in approximately 2 to 2.5 per 1,000 live births.1 CP describes a “group of disorders of the development of movement and posture, causing activity limitations that are attributed to nonprogressive distur-bances that occurred in the developing fetal or infant brain.”2 CP motor disorders may be accompanied by disturbances of sensation, cognition, communication, perception, and seizures2 and may present complex limitations in self-care functions, such as feed-ing, general and oral hygiene, and mobility. Family caregivers most often provide the principal responsibilities of disability management.3 Nevertheless, with regard to oral health aspects, the adequate performance is not always achieved due to a directly pro-portional relationship between the severity of cognitive/motor ability and the greater difficulty demonstrated by these individuals to understanding, moving, and receiving an effective oral care. Furthermore, some studies have shown that more severe neuro-logical damage in CP causes higher risk of oral diseases and disorders.4 For that matter and other parafunctional oral features, the high prevalence of oral diseases and disor-ders such as dental caries,4-6 traumatic dental injuries (TDIs),7,8 malocclusions,9,10 bruxism,11,12 and temporomandibular disorders13,14 are relatively common. Despite the lack of studies assessing dental fluorosis in CP population, the persistence of the path-ological primitive oral reflex of swallow in several of these individuals5,15 and the difficulty to perform an adequate oral hygiene with fluoride dentifrice may lead to the presence of this disorder.

KEY WORDS: cerebral palsy, quality of life, oral health, children

scd12028.indd 56 19/02/14 12:31 PM

Abanto et a l . Spec Care Dent is t 34(2 ) 2014 57


and their parents. Oral care of children with complex disabilities might be some-what daunting for caregivers and the provision of such care can also lead to detrimental impact on family life.

In view of lack of research assessing OHRQoL in a biologically and cogni-tively susceptible group of children, the aim of our study was to assess the impact of dental caries experience, TDIs, malocclusions, bruxism, and dental fluorosis, adjusted by socioeconomic factors, on the OHRQoL of children with CP, as well as the impact of children’s oral conditions on the whole family.

MethodsThis study was independently reviewed and approved by the ethical board of the Dental School—University of São Paulo (Brazil).

Sampling and data collectionThis is a cross-sectional study with a con-venience sample that was composed of children with CP attending the Center Attendance for Special Needs Patients (CAPE) of the Dental School, University of São Paulo (SP), Brazil. A total of 75 parents of children with CP, age range from 6 to 14 years, and registered in the database system of the center were contacted and invited to participate in the investigation. Those who were not fluent in Brazilian Portuguese, not living in fluoridated area, and changed address or refused to participate in the study were excluded (n = 15). The final sample comprised a total of 60 patients. All of them were informed about the nature of the research and signed the informed consent. Children received all necessary dental care.

On the day of the dental appoint-ment, we invited one of the parents to answer two questionnaires: one was related to children’s OHRQoL and the other was focused on socioeconomic conditions. All interviews were con-ducted before the oral clinical examination and in case of doubt, the explanation was only given to parents after the interview and oral clinical examination, so as not to influence the outcomes. A single interviewer was

trained for the delivery of each question.Another previously calibrated exam-

iner carried out the child’s oral examination for dental caries, TDI, mal-occlusion, bruxism, and dental fluorosis in a dental unit, by means of an operat-ing light, a three-in-one syringe for drying the teeth, plane mouth mirrors, and periodontal probes. The intraexam-iner reliability was established by re-examining 10 (16.67% of sample) patients and values for Kappa agreement of 0.95 for dental caries, 0.91 for TDI, 1.0 for malocclusions, and 0.83 for dental fluorosis were obtained.

Children’s oral examinationWe measured the experience of dental caries using the dmft and DMFT indexes, described by the World Health Organization (1997).19 For most children with mixed dentition, the caries index was obtained by the sum of the dmft and DMFT scores. For the computation of mean dmft/DMFT index, we sum the individual average values and divided by the total number of examined children. The percentage of children affected by the disease was described by assessing the Knutson index (1944),20 and two groups were obtained: children who have or have experienced dental caries (dmft/DMFT > 0) and children who have never had experienced dental caries (dmf/DMFT = 0). White spot lesion caries were not considered.

We analyzed the TDI data according to the classification and the presence of at least one kind of anterior trauma.21 Anterior malocclusions traits were also assessed. Anterior open bite and overjet greater than 4 mm were categorized into having these disorders.

Dental fluorosis was assessed accord-ing to its presence and severity.22 The severity of fluorosis was categorized into: mild (TFI = 1–3), moderate (TFI = 4–5), and severe (TFI = 6–9).

We evaluated the presence of brux-ism based on the criteria of a previous study.12 A questionnaire was answered by the caregiver, a person who necessarily had to be with the individual during most of the time including during sleep hours. The caregiver had to answer yes

or no to the following question: Does the child/adolescent have the habit of clenching or grinding the teeth? Any involuntary activity of the masticatory muscles that would result in clenching or grinding of the teeth was considered as bruxism.23 In order to be considered positive, the parafunction had to be pre-sent in the last 3 months.12 Bruxism that had already been abandoned was not computed and its presence was con-firmed by the observation of tooth wear during clinical examination.

Children OHRQoL questionnaireThe OHRQoL instrument used in this study was a 47-item questionnaire that combines the validated Brazilian version of the Parental-Caregiver Perceptions Questionnaire (P-CPQ)24 and the Family Impact Scale (FIS)25 components of the Child Oral Health Quality of Life Questionnaire (COHQOL©). This instru-ment evaluates the perception of parents on OHRQoL of children age range from 6 to 14 years. We asked the questions referring to the frequency of events in the last 3 months. The items were scored using a five-point Likert scale (response options: never = 0, once or twice = 1, sometimes = 2, often = 3, every day or almost every day = 4). A “Don’t know” response option was also provided, and scored as 0. This finding has previously been reported; however, it did not show significant alterations for the overall results. It also prevents loss of valuable information that would occur if complete data from participants with nonresponse to some items were deleted. We counted the number of “Don’t know” responses, but they were excluded from the total questionnaire score for each patient.

The following subscale scores were structured by summing the responses to conceptually based, discrete subsets of items: oral symptoms domain—06 items; functional limitations domain—08 items; emotional well-being domain—7 items; and social well-being domain–10 items. In addition, scores from 14 items on the impacts of the child’s oral condition on parents and other family members were summed to create the FIS.

scd12028.indd 57 19/02/14 12:31 PM

58 Spec Care Dent is t 34(2 ) 2014 Ora l hea l th qua l i ty o f l i fe o f ch i ld ren wi th cerebra l pa lsy


Parents also answered two questions on global ratings. One of them on the child’s oral health “How would you rate the health of your child’s teeth, lips, jaws, and mouth?” and another on the impact of the oral/orofacial condition on his or her overall well-being “How much is your child’s overall well-being affected by the condition of his/her teeth, lips, jaws, or mouth?”. They had a five-point response format from “excellent” to “poor” for the child’s oral health and from “not at all” to “very much” for the overall well-being.

The total questionnaire score and scores for individual subscales (domains) were generated by the sum of the numer-ical response codes. Higher scores indicate worse OHRQoL or vice versa.

Socioeconomic questionnaireWe invited one of the parents to answer a questionnaire on their socioeconomic conditions.26 It included data on house property (no or yes), marital status of parents (married or separated parents), household crowding (≤1 or >1 inhabitant per room), number of siblings (none, one, two, or more), mother’s and father’s education (less than 8 years or 8 years or more), and family income. We calculated the family income by adding up the monthly wages of active members of the family and dividing it by the current Brazilian minimum wage (BMW; 1 BMW = US$ 220.00 per month) (≤1 BMW, ≤2 BMW, ≥3 BMW).

Data analysisA descriptive analysis for the overall mean instrument scores and for the individual domains was analyzed for

differences between specific oral diseases and disorders, and socioeconomic factors. For this initial exploratory analysis, we used the Kolmogorov–Smirnov in order to consider the normality distribution of the values. After this procedure, we used parametric and nonparametric tests.

We performed the univariate Poisson Regression analysis with robust variance to correlate the overall mean instrument score to each clinical oral condition. Since we previously observed that socioeconomic factors can exert significant influence on HQoL responses,27,28 we included these factors in univariate analysis and adjusted for the final model. In this analysis, the out-come was employed as a count outcome, as performed previously.29 The rate ratios (RR) and 95% confidence intervals (95% CI) were calculated. Later, a multivariate model was built with the covariates, selected by a forward stepwise procedure with p < 0.20 as the cutoff point. A multivariate Poisson regression analysis correlated overall mean score outcome to oral health covariates adjusted by socioeconomic factors. The covariates remained in the model if p < 0.05. Statistical analyses were carried out in Stata 8.0, 2003 (Stata Corp, College Station, TX).

Resu l t sMothers answered most of the question-naires (97.0%). The mean age of the patients was 9.13 years, resulting in a total of 49 patients with mixed dentition and 11 with permanent dentition. Dental

caries experience was present in 55% of the sample. The mean index for mixed dentition (dmft + DMFT) was 2.06. The separate mean dmft and DMFT indexes were 2.00 and 0.43, respectively. TDI, malocclusion, bruxism, and dental fluorosis were present in 55.0%, 61.7%, 51.7%, and 18.3% of children, respectively. Only 18.3% of the examined children exhibited fluorosis (TFI = 1–3), and therefore data were evaluated according to their presence or absence.

The mean total score of the instrument was 17.28 (Table 1). Means and variance scores observed by domains are also described in Table 1. Table 2 shows the mean difference between oral diseases and disorders for each domain and for the mean overall score. When evaluating the mean overall score, it could be observed that the presence of dental caries and bruxism showed a negative impact on OHRQoL (p = 0.007 and p = 0.013, respectively). Regarding each domain, there was a significant difference between the experience of dental caries, as well as the presence of bruxism, to the OHRQoL–emotional well-being domain (p < 0.05). Factors such as having experience of dental caries and the presence of injuries to hard dental tissues (enamel fracture and enamel/dentin fracture, in its majority) were associated with a lower OHRQoL concerning the FIS domain (p = 0.025 and p = 0.015, respectively). The presence of injuries to periodontal tissues has shown a negative impact on children’s oral symptoms domain (p = 0.016).

Dental caries experience, presence of bruxism, household crowding, father’s level of education, and low family income were all associated with the outcome variables (Table 3), and evaluated by means of the univariate analysis, considering both oral conditions and socioeconomic factors. These were the only covariates assumpted for the multivariate model. The final multivariate adjusted model was composed only of three covariates: dental caries, bruxism, and family

Table 1. Mean score and variance for each domain and for the overall OHRQoL instrument.

Mean scores (± SD) Variance

Total OHRQoL instrument Domains 17.28 (13.25) 1–69

Oral symptoms (6) 6.05 (4.17) 0–15

Functional limitations (8) 5.62 (4.07) 0–17

Emotional well-being (7) 0.85 (1.97) 0–9

Social well-being (10) 0.75 (1.11) 0–4

Family impact scale (14) 3.32 (4.76) 0–24

scd12028.indd 58 19/02/14 12:31 PM



income (Table 4). Dental caries experi-ence and the presence of bruxism were associated with a negative impact on the OHRQoL (RR = 1.75, CI 95% = 1.29–2.36, p < 0.001) and (RR = 1.31, CI 95% = 1.00–1.72, p < 0.05), respec-tively, and family income greater than one BMW demonstrated a positive impact on the OHRQoL in children with CP (RR = 0.51, CI 95% = 0.33–0.81, p < 0.001).

The results for global ratings showed that 10%, 10%, 35%, 40%, and 2% of the parents assessed their children’s oral health as “excellent,” “very good,” “good,” “fair,” and “poor,” respectively. Parents were also asked whether the overall well-being of their children was affected or not by the oral/orofacial conditions, and their answers were 43%—“not at all,” 15%—“very little,” 20%—“some,” 17%—“a lot,” and 5%—“very much.”

D i s cus s i onThe importance of assessing OHRQoL in all patients, including population with special needs, has been based on the pos-sibility of understanding the impact of diseases, disorders, and patient socioeco-nomic status, as well as to plan appropriate dental treatments according to the profile of each population.30 To our knowledge, only a few studies have

Table 2. Mean difference between oral diseases and disorders for each domain and for overall questionnaire.Oral diseases and disorders

n OS (±SD) FL (±SD) E-WB (±SD) S-WB (±SD) FIS (±SD) Mean score

(±SD)

Dental caries experience

dmft/DMFT > 0 33 (55.0) 6.2 4.0 6.3 4.5 1.4 2.5 0.8 1.2 4.5 5.8 21.4 15.1

dmf/DMFT = 0 27 (45.0) 5.9 4.5 4.7 3.4 0.2 7.9 0.7 1.0 1.9 2.5 12.3 8.3

p value 0.789* 0.133* 0.014 0.947 0.025* 0.007*

Traumatic dental injuries

Presence 33 (55,0) 6.5 4.6 5.6 3.2 0.9 1.9 0.8 1.2 3.8 4.7 17.7 12.6

Absence 27 (45.0) 5.5 3.6 5.6 5.0 0.8 2.0 0.7 1.0 2.7 4.8 16.8 14.2

p value 0.344* 0.967* 0.657 0.860 0.128 0.792*

Injuries to the hard dental tissues and the pulp

Presence 23 (38.3) 6.8 4.4 6.0 3.4 0.9 2.1 0.9 1.4 4.8 5.3 19.1 13.4

Absence 37 (61.7) 5.6 4.0 5.4 4.5 0.8 1.9 0.7 0.9 2.4 4.2 16.2 13.2

p value 0.287* 0.614* 0.635 0.959 0.015 0.410*

Injuries to the periodontal tissues

Presence 7 (11.7) 9.6 4.9 5.9 3.0 0.6 1.5 1.0 1.4 1.9 2.0 14.4 11.6

Absence 53 (88.3) 5.6 3.9 5.6 4.2 0.9 2.0 0.7 1.1 3.5 5.0 17.7 13.5

p value 0.016* 0.870* 0.666 0.476 0.533 0.549*

Malocclusion

Presence 37 (61.7) 6.3 4.2 5.9 3.9 1.2 2.3 0.6 1.0 3.9 5.7 18.4 14.8

Absence 23 (38.3) 5.7 4.1 5.1 4.3 0.3 1.0 1.0 1.3 2.3 2.5 15.5 10.4

p value 0.565* 0.432* 0.060 0.382 0.510 0.410*

Bruxism

Presence 31 (51.7) 6.5 4.1 6.4 4.4 1.5 2.5 0.8 1.0 4.5 6.0 21.3 15.9

Absence 29 (48.3) 5.6 4.2 4.8 3.6 0.2 0.8 0.7 1.3 2.1 2.4 13.0 7.9

p value 0.375* 0.148* 0.007 0.330 0.052* 0.013*

Dental fluorosis

Presence 11 (18.3) 7.4 3.8 6.1 3.1 1.5 1.8 0.5 0.5 2.3 2.2 18.4 9.3

Absence 49 (81.7) 5.8 4.2 5.5 4.3 0.7 2.0 0.8 1.2 3.6 5.1 17.0 14.0

p value 0.251* 0.673* 0.042 0.838 0.755 0.768*

OS = oral symptoms, FL = functional limitations, E-WB = emotional well-being, S-WB = social well-being, FIS = familiar impact scale.SD = standard deviation *, t-test Mann–Whitney test.

scd12028.indd 59 19/02/14 12:31 PM



assessed the OHRQoL of special care patients.3,31 Hence, the aim of this study was to assess the impact of oral diseases and disorders on OHRQoL of children with CP.

Among all oral diseases and disor-ders assessed in this study, only dental caries experience and bruxism showed an association with the overall OHRQoL score. Despite our belief that these other clinical conditions (trauma, malocclu-sion, and dental fluorosis) could also have a negative impact on oral symptoms or functional limitations domains, no evidence was identified in the outcomes. These patients had already required dental treatment, and it could be suggested that they might have a higher score of disease and other conditions compared to those who do not seek dental care. The results found in the present study show a lower dmft/DMFT index mean value (2.06) compared to previous studies.4,6 Nevertheless, dental caries experience was sufficient to produce a negative impact on the overall questionnaire score, emotional well-being domain and FIS domain. Additionally, many parents described their children behavior as upset, irritable, frustrated, and anxious as a result of their oral conditions. Disrupted sleep in children and dental caries, taking time off of work, disagreement or conflict within the family, interference in the family general activities and financial difficulties, etc, were also mentioned by parents. Dental caries can produce symptoms. Therefore, parents may be quite concerned with the disease, considering that the severity of cognitive ability increases the difficulty for the children to express their feelings and discomfort, and it often creates a sense of uncertainty and frustration in their parents.32,33 A recent study focused on children with CP’s caregivers also showed that caregivers have a low quality of life due to the difficult task they have in caring for the oral health and preventing dental caries in these patients.3 The negative impact of the presence of dental caries on OHRQoL was also related in other studies with healthy children.16,17

Table 3. Univariate analysis for association between health, dental caries, and socioeconomic factors in relation to overall questionnaire.Covariates n (%) Robust RR (95% CI) p value*

Oral diseases and disorders


dmf/DMFT = 0 27 (45.0)

dmft/DMFT > 0 33 (55.0) 1.74 1.23–2.47 0.002

Traumatic dental injuries

Absence 27 (45.0)

Presence 33 (55.0) 1.05 0.71–1.57 0.793

Injuries to the hard dental tissues and the pulp

Absence 37 (61.7)

Presence 23 (38.3) 1.18 0.80–1.74 0.397

Periodontal injuries

Absence 53 (88.3)

Presence 7 (11.7) 0.82 0.45–1.48 0.503

Malocclusion

Absence 23 (38.3)

Presence 37 (61.7) 1.19 0.82–1.73 0.364

Bruxism

Absence 29 (48.3)

Presence 31 (51.7) 1.64 1.16–2.30 0.005

Dental fluorosis

Absence 49 (81.7)

Presence 11 (18.3) 1.08 0.75–1.56 0.691

Socioeconomic conditions

House property

No 16 (26.7)

Yes 44 (73.3) 0.81 0.58–1.13 0.220

Marital status of parents

Married 54 (90.0)

Separated 6 (10.0) 1.23 0.76–2.01 0.399

Household crowding

≤1 inhabitants per room 37 (61.7)

>1 inhabitants per room 23 (38.3) 1.50 1.02–2.20 0.038

Number of siblings

None 15 (25.0)

One 28 (46.7) 1.33 0.90–1.97

Two or more 17 (28.3) 1.43 0.79–2.59 0.305

Mother’s education

<8 years 32 (53.3)

≥8 years 28 (46.7) 0.87 0.61–1.26 0.471

Father’s education

<8 years 42 (71.2)

≥8 years 17 (28.8) 0.57 0.38–0.85 0.006

Family income

≤1 BMW 21 (35.0)

≤2 BMW 24 (40.0) 0.61 0.43–0.86

≥3 BMW 15 (25.0) 0.35 0.22–0.58 < 0.001

*Calculated by Qui-square Test.Robust RR: robust rate ratio.

scd12028.indd 60 19/02/14 12:31 PM



Regarding bruxism in children with CP, the high prevalence (51.7%) findings of the current investigation are in accord-ance with other studies.6,12 There is lack of evidence about the neurobiology of bruxism in terms of etiology and patho-physiology, but it is known that neurological alterations are closely related to this parafunction.12,13 Some neuroleptic drugs, commonly taken by individuals with CP, are also thought to contribute to the etiology of bruxism.23 Bruxism can produce negative conse-quences such as destruction of dental tissues, restoration and prosthesis frac-tures, or exacerbation of temporomandibular disorders. For that matter, a negative impact on oral symp-toms and functional limitations domains was expected. Nevertheless, it only showed an impact in the overall OHRQoL score and emotional well-being domain. It should be emphasized that bruxism was reported by caregivers, but this does not invalidate our results or the methodology used, since the wear observed in clinical exam could infer past bruxism. Severity of bruxism was not assessed in this study, though most of the patients presented a mild destruc-tion of dental tissues. Oral symptoms or functional limitations such as dental sen-sibility or muscular pains that are frequently correlated with the severity of

the disorder were not observed. The impact on the emotional well-being domain may have occurred considering the involvement of psychological factors (like stress and anxiety) that are also implicated with the etiology of brux-ism.34 Parents may recognize feelings of irritability, frustration, and anxiety in their children, when the disorder has already been detected.

The high prevalence of TDI (55%) found in this study confirmed the results of recent reports.7,8 These data suggest that TDI has been seriously neglected in patients with CP. When evaluating the presence any type of trauma, TDI did not show an impact of OHRQoL. When inde-pendently evaluated, the presence of injuries to anterior hard dental tissues was associated with a lower OHRQoL, regarding the FIS domain. The aesthetic impact of enamel or enamel/dentin frac-tures raises more concern among parents than their children’s. In the current study, only injuries to periodontal tissues (sub-luxation, luxations, or avulsion) showed an impact on the oral symptoms domain, which contains items on oral health, such as pain, bleeding gums, mouth sores, etc. These items led to an increase in the scores in the overall questionnaire. Considering the severity of this kind of TDI, this result was partially expected. Locker (2007)35 also described a negative

impact on OHRQoL of healthy school-children with severe TDI.

Malocclusion and dental fluorosis did not show any negative impact on OHRQoL. Although the high prevalence of malocclusion (61.7%) found in this study, it seems that the OHRQoL instru-ment was not developed specifically to measure the impact of different maloc-clusions and dental fluorosis. Also, some of the questions in the oral symptoms and functional limitations domains are not nec-essarily relevant to children with these disorders. Still, malocclusion has showed a negative impact on schoolchildren’s quality of life, mainly in the psychosocial domains, rather than conditions that influence oral health, such as oral or functional problems.18

The use of fluoride dentifrices (1.000 ppm) is widely disseminated and applied throughout the Brazilian people. This may partially explain the low caries prev-alence and the presence of mild fluorosis (prevalence—18%; severity—100% TFI = 1–3) observed in this population. Moreover, the presence of fluorosis in these children did not bring a significant impact on OHRQoL. Recent studies35 assessing the impact of fluorosis on the quality of life in healthy children have also demonstrated that mild and very mild fluorosis are not a concern, showing a little impact on OHRQoL. Such results show that the risks are lower than the benefits offered by this method of fluo-ride use, even if you consider that these children possibly ingest some of the den-tifrice due to compromised oral motor conditions. As this is the first research that evaluates fluorosis in CP children, we believe that it should be more investi-gated in the near future.

Some studies in healthy children demonstrated that socioeconomic dispar-ity such as gender, household crowding, parent’s education, and family income are, in turn, associated with a negative impact on the OHRQoL.36 In this study, some disparities like higher household crowding and father’s education less than 8 years showed a negative impact on emotional well-being domain and oral symptoms/functional limitations domains, respectively. These disparities can be

Table 4. The multivariate fitted model of covariates associated with overall questionnaire.Covariates Robust RR (95% CI) p value*


dmf/DMFT = 0

dmft/DMFT > 0 1.75 1.29–2.36 <0.001

Bruxism

Absence

Presence 1.31 1.00–1.72 0.046

Family income

≤1 BMW

≤2 BMW 0.55 0.42–0.73 <0.001

≥3 BMW 0.51 0.33–0.81 0.004

*Test Wald Chi-square: p < 0.001.Robust RR: robust rate ratio.

scd12028.indd 61 19/02/14 12:31 PM



associated with low family income, for instance, in assessing dental care, and maybe for this reason, after adjustment in the multivariate regression analysis, a highly significant association was found between low family income and the neg-ative impact on the OHRQoL of children with CP. De Camargo and Antunes (2008)37 studied some socioeconomic factors in children with CP. They showed that there is a significant association between a low family income and high levels of untreated dental caries and need for dental treatment. This fact could lead to a poorer OHRQoL in these patients. They also described that children with CP, who had at least one sibling, pre-sented higher prevalence of untreated dental caries. In spite of this result, the present study did not find any associa-tion between number of siblings and a negative impact on OHRQoL. It is there-fore important to assess socioeconomic conditions in general when dealing with oral health and OHRQoL in special care patients.

Although dental caries experience, presence of bruxism, and some socioeco-nomic factors are strongly associated with a negative impact on OHRQoL of children with CP, 43% of parents related that the overall well-being of children has “not at all” been affected by oral/oro-facial conditions. This may have occurred because in most cases, the chil-dren’s overall well-being is most affected by the severity of the clinical condition of CP, rather than by the oral condition itself and/or because the severity of the oral diseases were not significant.

A limitation of this study is based on the difficulty to assess most clinics that treat patients with CP. For this reason, the authors selected a convenience sample in a main dental treatment center for special care patients. Also, two ques-tionnaires were answered by the patient’s parents on the family’s socioeconomic data together with a 47-item question-naire combining the P-CPQ and the FIS components of the COHQOL© question-naire. Patients were not allowed to answer the questionnaires. Therefore, only a limited number of CP patients were examined in this study and the

results cannot be extrapolated for all patients with CP. The influence of some characteristics of CP individuals, such as severity of cognitive ability, motor ability, and clinical type of CP, must be further investigated.

We concluded that dental caries experience and presence of bruxism are conditions strongly associated with a negative impact on OHRQoL of children with CP and their parents, though a higher family income can improve this negative impact. Such conditions should be evaluated and appropriately treated to ensure good daily functioning and well-being of children with CP.

Re fe r ences1. Odding E, Roebroeck ME, Stam HJ. The

epidemiology of cerebral palsy: incidence,

impairments and risk factors. Disabil Rehabil

2006;28:183-91.

2. Executive Committee for the Definition of

Cerebral Palsy. Proposed definition and

classification of cerebral palsy. Dev Med

Child Neurol 2005;47:571-6.

3. Rodrigues dos Santos MT, Bianccardi M,

Celiberti P, deOliveira Guaré R. Dental caries

in cerebral palsied individuals and their car-

egivers’ quality of life. Child Care Health Dev

2009;35(4):475-81.

4. Guaré R de O, Ciamponi AL. Dental caries

prevalence in the primary dentition of cere-

bral–palsied children. J Clin Pediatr Dent

2003;27:287-92.

5. Dos Santos MT, Nogueira ML. Infantile

reflexes and their effects on dental caries

and oral hygiene in cerebral palsy. J Oral

Rehabil 2005;32:880-5.

6. Rodrigues dos Santos M, Masiero D, Novo

N, Simionato MR. Oral conditions in

children with cerebral palsy. J Dent Child

(Chic) 2003;70:40-6.

7. Holan G, Peretz B, Efrat J, Shapira Y.

Traumatic injuries to the teeth in young

individuals with cerebral palsy. Dent

Traumatol 2005;21(2):65-9.

8. Costa MM, Afonso RL, Ruviére DB, Aguiar

SM. Prevalence of dental trauma in patients

with cerebral palsy. Spec Care Dentist

2008;28(2):61-4.

9. Franklin DL, Luther F, Curzon ME. The preva-

lence of malocclusion in children with cerebral

palsy. Eur J Orthod 1996;18(6):637-43.

10. Carmagnani FG, Gonçalves GK, Corrêa MS,

dos Santos MT. Occlusal characteristics in

cerebral palsy patients. J Dent Child (Chic)

2007;74(1):41-5.

11. Peres AC, Ribeiro MO, Juliano Y, César MF,

Santos RC. Occurrence of bruxism in a

sample of Brazilian children with cerebral

palsy. Spec Care Dentist 2007;27(2):73-6.

12. Ortega AO, Guimarães AS, Ciamponi AL,

Marie SK. Frequency of parafunctional oral

habits in patients with cerebral palsy. J Oral

Rehabil 2007;34(5):323-8.

13. Ortega AO, Guimarães AS, Ciamponi AL,

Marie SK. Frequency of temporomandibular

disorders signs in individuals with cerebral

palsy. J Oral Rehabil 2008;35(3):191-5.

14. Ortega Ade O, Ciamponi AL, Mendes FM,

Santos MT. Assessment scale of the oral

motor performance of children and adoles-

cents with neurological damages. J Oral

Rehabil 2009;36(9):653-9.

15. Senner JE, Logemann J, Zecker S, Gaebler–

Spira D. Drooling, saliva production, and

swallowing in cerebral palsy. Dev Med Child

Neurol 2004;46(12):801-6.

16. Malden PE, Thomson WM, Jokovic A,

Locker D. Changes in parent–assessed oral

health–related quality of life among young

children following dental treatment under

general anaesthetic. Community Dent Oral

Epidemiol 2008;36:108-17.

17. Do LG, Spencer A. Oral health–related qual-

ity of life of children by dental caries and

fluorosis experience. J Public Health Dent

2007;67:132-9.

18. O’Brien C, Benson PE, Marshman Z.

Evaluation of a quality of life measure for

children with malocclusion. J Orthod

2007;34:185-93.

19. World Health Organization. Oral health sur-

veys, basics methods, vol. 65. Geneva: Word

Health Organization; 1997.

20. Knutson JW. An index of the prevalence of

dental caries in school children. Public

Health Rep 1944;59(8):253-80.

21. Andreasen JO, Andreasen FM. Classification,

etiology and epidemiology. In Textbook and

color atlas of traumatic injuries to the teeth,

3rd ed. Copenhagen: Munksgaard; 1994.

22. Thylstrup A, Fejerskov O. Clinical appear-

ance of dental fluorosis in permanent teeth

in relation to histologic changes. Community

Dent Oral Epidemiol 1978;6:315-28.

23. Lavigne GJ, Kato T, Kolta A, Sessle BJ.

Neurobiological mechanisms involved in

scd12028.indd 62 19/02/14 12:31 PM



sleep bruxism. Crit Rev Oral Biol Med

2003;14:36-46.

24. Goursand D, Paiva SM, Zarzar P, Pordeus IA,

Grochowski R, Allison PJ. Measuring

parental–caregiver perceptions of child oral

health–related quality of life: psychometric

properties of the Brazilian version of the

P–CPQ. Braz Dental J 2009;20:169-74.

25. Goursand D, Paiva SM, Zarzar PM, Pordeus

IA, Allison PJ. Family Impact Scale (FIS):

psychometric properties of the Brazilian

Portuguese language version. Eur J Paediatr

Dent 2009;10:141-6.

26. Jarman B. Identification of under privileged

areas. Br Med J 1983;286:1705-9.

27. Oliveira LB, Sheiham A, Bönecker M.

Exploring the association of dental caries

with social factors and nutritional status in

Brazilian preschool children. Eur J Oral Sci

2008;116:37-43.

28. Pappa E, Kontodimopoulos N,

Papadopoulos AA, Niakas D. Assessing the

socio–economic and demographic impact on

health–related quality of life: evidence from

Greece. Int J Public Health 2009;54:241-9.

29. Biazevic MG, Antunes JL, Togni J, deAn-

drade FP, deCarvalho MB, Wünsch–Filho V.

Immediate impact of primary surgery on

health–related quality of life of hospitalized

patients with oral and oropharyngeal cancer.

J Oral Maxillofac Surg 2008;66:1343-50.

30. Jokovic A, Locker D, Stephens M, Kenny D,

Tompson B, Guyatt G. Validity and reliabil-

ity of a questionnaire for measuring child

oral–health–related quality of life. J Dent Res

2002;81:459-63.

31. Baens–Ferrer C, ,Roseman MM, Dumas HM,

Haley SM. Parental perceptions of oral

health–related quality of life for children

with special needs: impact of oral

rehabilitation under general anesthesia.

Pediatr Dent 2005;27:137-42.

32. Breau LM, Camfield CS, McGrath PJ, Finley

GA. Risk factors for pain in children with

severe cognitive impairments. Dev Med Child

Neurol 2004;46:364-71.

33. Morris C, Kurinczuk JJ, Fitzpatrick R,

Rosenbaum PL. Do the abilities of children

with cerebral palsy explain their activities

and participation? Dev Med Child Neurol

2006;48:954-61.

34. Cuccia AM. Etiology of sleep bruxism: a

review of the literature. Recenti Prog Med

2008;99(6):322-8.

35. Chankanka O, Levy SM, Warren JJ,

Chalmers JM. A literature review of

aesthetic perceptions of dental fluorosis

and relationships with psychosocial aspects/

oral health–related quality of life.

Community Dent Oral Epidemiol 2010;38:

97-109.

36. Locker D. Disparities in oral health–related

quality of life in a population of Canadian

children. Community Dent Oral Epidemiol

2007;35:348-56.

37. De Camargo MA, Antunes JL. Untreated

dental caries in children with cerebral palsy

in the Brazilian context. Int J Paediatr Dent

2008;18:131-8.

scd12028.indd 63 19/02/14 12:31 PM

impact of oral diseases and disorders on oral-health-related quality of life of children with...

Documents