Feild Study Blind

82Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

Oral health status of visually impaired Saudi Adults

Assistant Professor, Division of Periodontics, Department of Pe-riodontics and Community Dentistry, College of Dentistry, KingSaud University, Riyadh, Kingdom of Saudi Arabia.Correspondence: Dr. Aljoharah AL-Sinaidi, P.O. Box 60169,Riyadh 11545, Saudi ArabiaE-mail: [email protected]

Received for Publication: February 2, 2013Revision Received: March 26, 2013Revision Accepted: March 30, 2013

ORIGINAL ARTICLE

INTRODUCTION

Visual impairment is a major global health prob-lem. The World Health Organization (WHO) esti-mated that there were 161 million persons worldwidewith visual impairment in the year 20021,2 and themajority of them resided in developing countries, in-cluding Saudi Arabia.3

The usual recommendation for prevention andtreatment of periodontal diseases is to brush the teethtwice a day, clean interdentally at least once daily andmaintain a 3-month regular dental visits.4 People with

visual impairment are at an increased risk of develop-ing periodontal diseases because of their inability tovisually assess the effectiveness of plaque control, andto detect and recognize early signs of periodontaldisease. As a result, they may be unable to take thenecessary action to prevent or treat a particular oralcondition.5 Furthermore, visually impaired popula-tion usually face difficulties during tooth brushingincluding placing toothpaste on the brush and practic-ing traumatic brushing strokes that may damage theirperiodontium.5 In addition, the lack of dental knowl-edge and infrequent dental visits have been suggestedto affect the oral health of visually impaired popula-tion.6 In the literature, several studies highlighted theneed to provide more oral health education for visuallyimpaired subjects to maintain their oral health.6-8

Shih & Chang9 found that the oral health knowl-edge among visually impaired students were poorcompared to their sighted peers. In Saudi Arabia, very

ORAL HYGIENE PRACTICES AND PERIODONTAL HEALTH STATUS OFVISUALLY IMPAIRED SAUDI ADULTS IN RIYADH, SAUDI ARABIA

ALJOHARAH ABDULLAH AL-SINAIDI

ABSTRACT

This cross sectional study aimed to assess the periodontal health status and oral hygienepractices of visually impaired Saudi adults in Riyadh, Saudi Arabia. The study subjects wererecruited from the attendees of a general training program at The Blind Association Charity and KingKhaled Eye Specialist Hospital in Riyadh, Saudi Arabia. All Saudi adults who had visual impair-ment (ranging from low vision to total blindness) were eligible for the study. Fifty two Saudi adults(twenty four were males) with low vision or blindness were interviewed regarding their oral hygienepractices and were clinically examined to assess their periodontal health. The age ranged from 18 to87 years (mean age: 30 14.3 years). Around 67% of the study subjects were with low vision and 90.4%practiced oral hygiene measures. Nearly 80% of the study sample brushed their teeth less frequently(< once/day) or rarely, more than 70% never used the dental floss, toothpaste nor miswak and almost58% visited the dentist whenever needed. The mean values for plaque and bleeding indices were 65.6and 33.6 respectively. However, periodontal pockets deeper than 4 mm and clinical attachment losswere recorded in only 7.7% of the sample. It is concluded that visually impaired Saudi adults livingin Riyadh have poor plaque control, widespread gingivitis and limited access to the health careproviders. They need an oral health promotion program to maintain their periodontal health andimprove their quality of life.

Key Words: Visually impaired, oral hygiene habits/practices, periodontal health.



little information is available regarding the periodon-tal health status and oral hygiene of such individuals.Thus, the aim of the present study was to assess theperiodontal health status and oral hygiene practices ofvisually impaired Saudi adults living in Riyadh, SaudiArabia.

METHODOLOGY

This cross-sectional study was carried out on visu-ally impaired Saudi adults recruited from the attend-ees of a general training program at The Blind Associa-tion Charity and King Khaled Eye Specialist Hospitalin Riyadh, Saudi Arabia. The inclusion criteria wereSaudi adults who had visual impairment that rangedfrom low vision to total blindness. Subjects who wereuncooperative, systemically ill or had other disabili-ties were excluded from the study.

The study protocol was approved by the ethicalcommittee of College of Dentistry Research Center inKing Saud University and permission was obtainedfrom the managers of The Blind Association Charityand King Khaled Eye Specialist Hospital to interviewthe visually impaired Saudi adults and do clinicalperiodontal examination.

Prior to the interview, the nature and purpose ofthe study were explained to the enrolled subjects. Theparticipation was voluntary and written informedconsents were obtained. The interview composed ofquestions about demographics, vision status and oralhygiene practices. The questions were developed byreviewing the literature and some modifications weremade. They were written in Arabic language andvalidated through a pilot study.

The clinical periodontal examination was con-ducted in the charity and hospital after seating thestudy subject in an ordinary chair using penlight,gloves, masks, wrapped and sterilized mouth mirrors,explorers and periodontal probes. The examinationconsisted of the assessments of the plaque index (PI)10

and bleeding upon probing (BOP).11 Probing pocketdepth (PPD) and clinical attachment level (CAL) werealso recorded on six sites per tooth (mesiobuccal,midbuccal, distobuccal, mesiolingual, midlingual, anddistolingual) using the manual periodontal probe (Wil-liams, Hu Friedy, USA). All third molars, retainedroots and teeth which were partially impacted, badly

broken or inaccessible for examination were excluded.After clinical examination, the subjects received oralhygiene instructions, toothbrushes, tooth pastes anddental floss.

The interview and clinical oral examination wereperformed by two dentists who were trained and cali-brated for reproducibility before the start of the study.Investigator calibration was conducted by followingthe calibration protocol of Araujo et al.12 and thestandard error (SE) of measurement was calculated.The trained dentists were able to provide reproduciblemeasures below 0.5 mm.

The collected data were statistically analyzed us-ing the Statistical Package for Social Sciences (SPSS)version 15. The responses to the interview questionswere recorded in numbers (N) and percentages (%).The PI and BOP scores were calculated as the percent-age of sites with plaque or bleeding over the totalnumber of sites charted. The clinical parameters (PI,BOP, PPD and CAL) were expressed as means standard deviations (SD). The associations betweenthe clinical parameters and demographic data werestatistically analyzed with the unpaired Student-t testand the statistical significance was set at P < 0.05.

RESULTS

Fifty two subjects fulfilled the inclusion criteriaand were enrolled in the study. The ages rangedbetween 18 to 87 years (mean age was 30 14.3 years).Of these, 24 were males, 47 were educated and 17 wereblind. Upon clinical examination, the mean PI was65.6 23.2 and BOP was 31.6 18.2. In 48 subjects,PPD was 4 mm or less and there was no clinicalattachment loss (Table 1). Table 2 presents the plaqueand gingival bleeding scores of the study sample. Morethan 20% of plaque and gingival bleeding were scoredin 49 (94.2%) and 36 (69.2) subjects respectively. Theresults of oral hygiene practices are shown in Table 3.47 (90.4%) subjects practiced different oral hygienemeasures. However, only 11 (21.2%) subjects brushedtheir teeth twice or more daily and only one adult usedthe dental floss. Regarding the dental visits, only 12(23%) subjects used to visit the dentist regularly (onceevery 3 or 6 months).



Table 4 reveals the associations between the par-ticipants demographic data and their plaque andbleeding scores. Both plaque and gingival bleedingindices were significantly higher in males than fe-males (p < 0.01). The plaque and bleeding scores werehigher in older (> 40 years) than younger (< 40 years)aged subjects and in completely blind individuals com-pared to the others with low vision, however, thedifferences were not found to be statistically signifi-cant (p > 0.05).

TABLE 1: DEMOGRAPHIC AND CLINICALCHARACTERISTICS OF THE STUDY SAMPLE

(n = 52)

Age (years) 30 14.3Age range 18 87Gender

Male 24 (46.2)Female 28 (53.8)

Marital statusMarried 17 (32.7)Not married 35 (67.3)

Education Educated (> secondary level) 47 (90.4)Not educated 5 (9.6)

Vision statusLow vision 35 (67.3)Blindness 17 (32.7)

PI65.6 23.2BOP 31.6 18.2PPD

< 4mm 48 (92.3)> 4mm 4 (7.7)

Clinical attachment lossPresent 4 (7.7)Absent 48 (92.3)

: mean standard deviation,: number (percentage) of subjects.

DISCUSSION

This study was designed to assess the oral hygienepractices and periodontal health status and of visuallyimpaired Saudi adults in Riyadh, Saudi Arabia. Suchan assessment is considered essential for adequate

TABLE 4: CORRELATION BETWEENDEMOGRAPHIC DATA AND PLAQUE AND

BLEEDING SCORES

Demographic PI (%) BOP (%)variables Mean SD Mean SD

Age< 40 years 26.9 0.60 18.2 0.65> 40 years 28.6 0.38 22.9 0.95

P-value 0.1 0.2 Gender

Male 69. 9 20.1 33.4 18.7Female 61.9 25.3 29.5 17.7

P-value 0.01* < 0.01*

Vision statusLow vision 65.8 21.7 28.6 16.6Blindness 64.7 26.7 37.7 19.6

P-value 0.2 0.2

SD: standard deviation;*: statistically significant at p-value < 0.05

TABLE 3: ORAL HYGIENE PRACTICES OF THESTUDY SAMPLE (n = 52)

Oral hygiene practices N %

Practicing oral hygieneYes 47 90.4No 5 9.6

Brushing frequency> Twice/day 11 21.2< Once/day 32 61.5Rarely 9 17.3

FlossingYes 1 1.9No 51 98.1

Use of toothpasteYes 6 11.5No 46 88.5

Use of miswakYes 12 23.1No 40 76.9

Dental visitsOnce every 3 months 2 3.8Once every 6 months 10 19.2Symptomatic 30 57.7Never 10 19.2

TABLE 2: PLAQUE AND BLEEDING SCORES OFTHE STUDY SAMPLE (n= 52)

Scores N %

PI (%)< 20 3 5.8> 20 49 94.2

BOP (%)< 20 16 30.8> 20 36 69.2



understanding of the oral healthcare needs of thisspecial group of people and establishing effective pre-ventive programs.

According to OLeary et al.10 the goal for individu-als to maintain periodontal health was to reach levelsof plaque score of 20% or less. In the present study, thesubjects presented unsatisfactory levels of plaque con-trol as almost 95% of them had PI > 20% with a meanplaque score of 65.6%. As a result of their unacceptableplaque control, 70% of the study participants hadwidespread gingivitis (> 30% of sites had gingivalbleeding) as there is a general acceptance of highcorrelations between the dental plaque and presenceof gingivitis.13-15

Although most of the study subjects were educated(90.4% completing at least secondary school educa-tion), it was somewhat disappointing to find that themajority brushed their teeth less frequently (< oncedaily) or rarely and many did not use toothpaste,dental floss or miswak. In addition, the participantsbehaviors toward dental visits appeared to be inad-equate as more than 50% indicated symptomatic at-tendance and 20% have never been to the dentistbefore. These findings are in agreement with otherstudies that showed limited knowledge on preventionand preventive dental measures among Saudiadults.16,17 Such unfavorable habits resulted in poorplaque control and gingival inflammation. Previousstudies indicated that unfavorable oral hygiene prac-tices had negative effects on the health of periodon-tium.18

The observations that both plaque and gingivalbleeding indices were higher in males than females,older than younger individuals and completely blindsubjects compared to the subjects with low vision arein agreement with several studies. Grossi et al.19 andKinane20 found that periodontal diseases were moreprevalent in older age groups and they consideredageing as one of the identified risk factors for periodon-titis. However, Wennstrm et al.21 reported that peri-odontal diseases were more prevalent and severe inthe elderly because of the cumulative destruction overa lifetime period rather than an age related intrinsicdeficiency or abnormality that affects susceptibility toperiodontal infection. Regarding gender, Grossi et al.22

showed that the periodontal diseases were more preva-lent and more severe in men than in women. Men are

reported to exhibit poorer oral hygiene and fewer visitsto the dentist than do women.23,24 Furthermore, it hasbeen suggested that female hormones; especially es-trogen, are likely to protect against destructive peri-odontal bone loss25 and this may explain the increaseof periodontal disease seen in men.

Considering the vision status, subjects with lowvision showed a trend toward better plaque and bleed-ing scores than the blind ones. Other studies alsofound that blind people were more likely to havehigher plaque and bleeding scores.5-9

Among the study subjects, four blind adults hadgeneralized chronic periodontitis (> 30% of sites hadclinical attachment loss and PPD > 4 mm). Thosesubjects were the oldest among the study sample andthey never practiced oral hygiene nor visited a dentistbefore.

The possible limitations of the present study wouldbe the small sample size which may not truly representthe whole visually impaired Saudi adults. So furthererstudies with a larger sample size are required.

CONCLUSION

Within the limitations of the present study, it canbe concluded that the visually impaired Saudi adultshave poor plaque control and widespread gingivitis asthey unsatisfactorily practice oral hygiene measuresand have limited access to the oral health care provid-ers. Thus, they need preventive oral health care pro-grams and increased accessibility to the dental healthcare providers.

REFERENCES

1 Resnikoff S, Pascolini D, Etyaale D, Kocur I, PararajasegaramR, Pokharel GP, et al. Global data on visual impairment in theyear 2002. Bull World Health Organ 2004; 82: 844-845.

2 Pascolini D, Mariotti S, Pokharel G, Pararajasegaram R, EtyaaleD, Negrel AD, et al. 2002 global update of available data onvisual impairment: A compilation of population based preva-lence studies. Ophthalmic Epidemiol 2004; 11: 67-115.

3 Tabbara K. Blindness in the eastern Mediterranean countries.Br J Ophthalmol 2001; 85: 771-777.

4 Kressin N, Boehmer U, Nunn M, Spiro A. Increased preventivepractices lead to greater tooth retention. J Dent Res 2003; 82:223-227.

5 Mohd-Dom T, Omar R, Abdul Malik NA, Saiman K. Self-reported oral hygiene practices and periodontal Status ofvisually impaired adults. Glob J Health Sci 2010; 2: 184-191.



6 Azrina AN, Norzuliza G, Saub R. Oral hygiene practices amongthe visually impaired adolescents. Annals Dent Univ Malaya2007; 14: 1-6.

7 Mahoney E, Kumar N, Porter S. Effect of visual impairmentupon oral health care: a review. Br Dent J 2008; 204: 63-67.

8 Yalcinkaya SE, Atalay T. Improvement of oral health knowl-edge in a group of visually impaired students. Oral Health PrevDent 2006; 4: 243-253.

9 Shih YH, Chang CHS. Knowledge of dental health and oralhygiene practices of Taiwanese visually impaired and sightedstudents. J Visual Imp and Blindness 2004; 98: 1-15.

10 OLeary T, Drake R, Naylor J. The Plaque Control Record. JPeriodontol 1973; 49: 39-43.

11 Ainamo J, Bay I. Problems and proposals for recording gingivi-tis and plaque. Int Dent J 1975; 25: 229-35.

12 Araujo M, Hovey K, Benedek J, Grossi S, Dorn J, Wactawski-Wende J, Genco R & Trevisan M. Reproducibility of probingdepth measurements using a constant force electronic probe:analysis of inter- and intra-examiner variability. J Periodontol2003; 74: 1736-1740.

13 Axelsson P, Lindhe J, Nystrm B. On the prevention of cariesand periodontal disease. Results of a 15-year longitudinal studyin adults. J Clin Periodontol 1991; 18: 182-189.

14 Drisko C. Nonsurgical periodontal therapy Periodontol 2000.2001; 25: 77-88.

15 Loe, H. Anerud, A, Boysen, H. & Morrison, E. Natural history ofperiodontal disease in man. Rapid, moderate, and no loss ofattachment in Sri Lankan laborers 14-46 years of age. J ClinPeriodontol 1986; 13, 431-445.

16 Almas K, Al-Malik T, Al-Shehri M, Skaug N. The knowledgeand practices of oral hygiene methods and attendance patternamong school teachers in Riyadh, Saudi Arabia. Saudi Med J2003; 24: 1087-1091.

17 Almas K, Albaker A, Felemban A. Knowledge of dental healthand disease among dental patients, a multicenter study inSaudi Arabia. Indian J Dent Res 2000; 11: 145-155.

18 Le H. Oral hygiene in the prevention of caries and periodontaldisease. Int Dent J 2000; 50: 129-139.

19 Grossi S, Zambon J, Ho A. Assessment of risk for periodontaldisease. I. Risk indicators for attachment loss. J Periodontol1994; 65: 260-267.

20 Kinane D. Causation and pathogenesis of periodontal disease.Periodontol 2000. 2001; 25: 8-20.

21 Wennstrm J, Serino G, Lindhe J, Eneroth L, et al. Periodontalconditions of adult regular dental care attendants. A 12-yearlongitudinal study. J Clin Periodontol 1993; 20: 714-722.

22 Grossi S, Genco R, Machtei E, et al. Assessment of risk forperiodontal disease. II. Risk indicators for alveolar bone loss. JPeriodontol 1995; 66: 23-29.

23 Christensen L, Petersen P, Krustrup U, Kjller M. Self-reportedoral hygiene practices among adults in Denmark. Comm DentHealth 2003; 20: 229-235.

24 Al-Shammari K, Al-Ansari J, Al-Khabbaz A, Dashti A, et al. Selfreported oral hygiene habits and oral health problems ofKuwaiti adults. Med Princ Pract 2007; 16: 15-21.

25 Genco R. Risk factors for periodontal disease. In: Rose L, GencoRJ, Cohen DW, Mealey BL, editors. Periodontal medicine. 2nded. St. Louis: B. C. Decker Inc; In: 2000; p 11-34.

Feild Study Blind

Documents

Transcript of Feild Study Blind