Prevalence of dental caries in patients with intellectual disabilities from the Association of Exceptional Children ’ s Parents and Friends of Southern Brazil

Objective This study was conducted to determine the prevalence and severity of dental caries, missing and restored teeth (DMFT) and the efficiency of oral health programs for patients with intellectual disabilities, from age 11 to 38, who attended at the Association of Exceptional Children’s Parents and Friends (APAE) in Passo Fundo, southern Brazil. Methods The prevalence of dental caries was assessed by DMFT in 109 patients. The mean and standard deviation were evaluated by One-way ANOVA with 5% significance level. Results 47 of the evaluated students were female and 62 male, with moderate mental disability, Down syndrome, cerebral paralysis and epilepsy. The DMFT average was 3.93 for 11-14 years, 3.47 for 15-19 years, 4.74 for 20-30 years and 5.68 for the group 31-40 years. There were no significant differences among the DMFT index, gender and intellectual disability for the groups. Conclusion Patients had acceptable oral hygiene within their limitations, suggesting that prevention and dental care program developed in APAEPF/RS could be used as a model for health care for patients with intellectual disabilities in other institutions and other cities. Indexing terms: Dental auxiliaries. Dental staff. Oral health. Professional competence.


Methods
The prevalence of dental caries was assessed by DMFT in 109 patients.The mean and standard deviation were evaluated by One-way ANOVA with 5% significance level.
Results 47 of the evaluated students were female and 62 male, with moderate mental disability, Down syndrome, cerebral paralysis and epilepsy.The DMFT average was 3.93 for 11-14 years, 3.47 for 15-19 years, 4.74 for 20-30 years and 5.68 for the group 31-40 years.There were no significant differences among the DMFT index, gender and intellectual disability for the groups.

Conclusion
Patients had acceptable oral hygiene within their limitations, suggesting that prevention and dental care program developed in APAE-PF/RS could be used as a model for health care for patients with intellectual disabilities in other institutions and other cities.
Indexing terms: Dental auxiliaries.Dental staff.Oral health.Professional competence.
Patients with intellectual disabilities and dental caries MS TRENTIN et al.
Given the lack of studies of the oral health of ID in Passo Fundo/RS-Brazil, and in the nearby region, in southern Brazil, the aim of the present paper is to determine the DMFT index of students attending the Association of Exceptional Children's Parents and Friends (APAE/PF) and to associate it with the preventive measures used at that Institution.The present study aims to evaluate whether patients APAE/PF have DMTF higher than they have patients without special needs.

INTRODUCTION
Patients with intellectual disabilities (ID) are those who do not fit into normal physical, intellectual or emotional parameters such as growth patterns, mental development and emotional control.These individuals require special education and additional assistance at appropriate centers for a period of time during their lives or indefinitely.Patients with severe mental disability often present the need for dental care because of the close relation among oral health and balance of stomatognathic functions such as mastication, phonation, and swallowing.Therefore, measures are taken to prevent diseases that leads to inflammation and infection that cause pain and affect the individual's general health 1 .
According to the World Health Organization (WHO) 2 10% of the population in developed or developing countries has some kind of physical or mental disability.In less developed countries, this rate ranges between 15% and 30%.In Brazil, there are 45.6 million patients with disabilities, as shown by the 2010 census conducted by the Brazilian Institute of Geography and Statistics (IBGE) 3 .
There is a consensus agreement about the poor oral hygiene of ID 4 .This can be explained by their difficulty in understanding the importance of oral health, lack of motivation, manual dexterity and difficulties related to lack of communication, macroglossia, hypermotor or hypomotor activity, and physical limitation.In addition, lack of information of legal guardian and the many concerns and problems surrounding them, make oral health less of a priority, leading to its deterioration.
The most prevalent disease in the oral cavity are dental caries.Over the years, there has been a decline in Decayed, Missing and Filled Teeth DMFT index: (decayed permanent teeth, lost and restored) and deciduous teeth decayed, missing and restored (dmft).Comparing the latest surveys of the Project SB Brazil 2003 and 2010, it was noticed a decrease in DMFT at 12 years, from 2.8 to 2.1.Ages 15 to 19 fell from 6.1 to 4.2, while from 35 to 44 years, the reduction was from 20.1 to 16.3.The dmft at 5 years decreased from 2.8 to 2.35.
In the field of oral health, epidemiology has dealt with the collective diagnosis of the most prevalent oral diseases since the late 1930s, with the advent of the DMFT index [5][6] .It has still been the most widely used index on a global scale, serving as reference for the diagnosis of diseases of permanent teeth and for the formulation and assessment of oral health programs [7][8][9] .
Patients with 5-10 years in the Institution.3: patients over 10 years in the Institution.
Age was stratified in order to avoid bias towards deciduous and permanent teeth, in compliance with WHO recommendation 2 .Patients younger than 11 years older than 38 years and those with physical disabilities were excluded of the study.Dental caries was clinically assessed by two dental undergraduate students from the University of Passo Fundo (UPF-RS/Brazil), previously trained to use the DMFT index.
The data were tabulated using the SPSS 20.0 for Windows (IBM Corporation 1 New Orchard Road Armonk, New York 10504-1722 United States), and the mean and standard deviation were calculated for each variable.It was also conducted ANOVA and post hoc (Tukey's test) at a 5% significance level for the association of the DMFT index with age, intellectual disabilities and gender.The criteria used for evaluation of dental caries was the DMFT index proposed by Klein and Palmer 6 , standardized by WHO 2 as detailed below (Chart 1).This evaluation was based on 28 permanent teeth of all patients of the study, the index DMFT represents disease and its consequences.years (25.9%).Table 1 shows the distribution of patients in relation to different degrees of disability.71% of the analyzed patients had moderate mental disability, 9% cerebrall paralysis, 4.3% mental disability and epilepsy and 13.8% Down's Syndrome.2).
Table 3 shows the mean and standard deviation of differents degrees of disabilities.It's observed that in moderate mental disorder (1) there was an average of 5.204 and dp (2.961) for decayed components, 20.81 and dp (3.86) for healthy teeth.For Cerebral Paralysis (2), it was observed that 20 teeth were decayed, 16 lost, 2 filled and only 8 were healthy.For mental disability and epilepsy (3), there was a homogeneity of data: average of 4.8 and SD: 2:34 to decayed teeth, missing teeth 10 , 12 restored and healthy.For patients with Down syndrome (4), it was observed that the average of decayed teeth was 4.52, lost 4.59, filled, 5.68 healthy and 16.47.

Patients with intellectual disabilities and dental caries
It could be also observed in this table, that there were significant differences when compared to healthy teeth (p =0.003) and lost (p =0.000) and age of patients by ANOVA test at 5%.Patients younger had higher levels of healthy teeth than patients with higher age.It can be observed that past experience of caries was more prevalent in older age groups (Table 4).It is observed in table 5 that there were no significant differences between genders (p = 0.368) compared with teeth decayed, missing, filled and healthy by ANOVA at 5% significance level.studies [8][9] .In these studies, ID had a higher prevalence and severity of dental caries compared to "non-special" patients 11 .The larger impairment of oral health in these patients can be explained by their physical, mental and social limitations, in addition to the use of systemic (psychoactive) drugs that can lead to the loss of oral integrity [12][13] .
Besides patient-specific factors, these studies correlate this high prevalence of dental caries with patients' socioeconomic background as families are often socially and emotionally disadvantaged and hardly provided with education on health, increasing the odds for oral diseases among these patients 3,[12][13][14][15][16] .Most patients assessed in this study had good oral hygiene, regardless of how severe their disabilities were.These data are consistent with studies reporting that institutionalized patients had better oral health than non-institutionalized ones 15,17 .
This finding could be related to the interdisciplinary work carried out at APAE/PF, the School of Dentistry of UPF have provided dental care for more than 15 years, through the Extension Project for Prevention of Oral Diseases.In addition the work of speech therapists, helped with the correction of aggravating factors such as mouth breathing and also played a crucial role in the reduction of dental caries in the local population.
No significant differences was observed in this study between the DMFT index and gender and severity of disabilities.Similar results were obtained from 750 twelveyear-old PSN in Flanders, Belgium 18 .The study included different types of disabilities (mild and moderate mental disability and motor and hearing impairment).Of the assessed PSN, 78% had dental caries, which was more common among individuals with mild mental disability (84%) and less common among those with physical disability.In a study of cariogram, it observed that the only variable that correlated with higher caries experience (DMFT) was the content of the diet 19 .
Previous study reported the higher need for treatment of people with disabilities is related to dental extractions and restorative procedures 20 .Given the results of this study and the studies reported above, it could be suggested that health professionals perform educational, health promotion, disease prevention, rehabilitation of the demands of treatment, oral hygiene instruction and healthy diet for students.
A previously work on cerebral paralysis patients, the DMFT index increased with age and with the severity of the disability, and so did the necessity of dental care 21 .

DISCUSSION
Detailed information about the distribution of caries and its biopsychosocial determinants is the first and foremost step in planning oral health programs, especially for patients with intellectual disabilities (ID) 11 .This issue has been dealt with in several clinical The authors also mention that children with moderate cerebral paralysis needed more dental care and had more decayed and missing teeth.Their results are similar to ours in that PSN in the 31-38 age group showed higher DMFT indices than in the other groups.In contrast, Ngcobo et al. 22 reported that children with disabilities (intellectual, learning and brain paralyzes) had lower prevalence of caries compared to the general population, regardless of disability.
In a study 23 , in Europe with patients aged 2 to 6, 7 to 12 and older than 13 years affected by mental disability, cerebral paralysis, autistic disorder, and Down's syndrome, dental caries was assessed according to WHO criteria.Neither deft nor DMFT indices varied significantly relating to the type of disability, but to oral hygiene.The author points out that autistic child have better oral hygiene than those with mental disability.However, our study did not find differences in the oral hygiene of students at APAE/ PF-RS as to the type of disability.
According to WHO criteria 2 it can be stated that the results of our study are encouraging, as most assessed patients showed good oral hygiene and are not so distant from those with mild to moderate prevalence.The DMFT index was slightly greater than expected, indicating high prevalence, is seen in older patients, aged between 20 and 38 years, with indices of 4.74 and 5.68, respectively.This is partly because younger patients have been followed up on a weekly basis by extension projects at APAE/PF-RS for about 15 consecutive years, with the aim of instructing students on how to take care of their oral health through practical and educational activities.When ID are younger, their parents have more control over their oral hygiene, but as they grow older, most of them seek to be more independent, refusing the constant help from their caregivers.
The results of our study are also related to the length of time (years) students attending at APAE.Since APAE has a permanent oral health extension work, this certainly influenced the results of our study.Therefore, 30 patients and 27.5% of the sample are in the Institution for 1-5 years.Patients with 5-10 years in the Institution, with 55 patients and 50.45%, and patients over 10 years in the Institution with 24 patients and 22% of the sample.
Prevention programs that include videos and manual training for people with special needs, regular professional assistance, dental plaque control, dietary control, water fluoridation and application of sealants are efficient measures for the prevention of dental diseases in these patients 14 .Furthermore, it requires that professionals prepare themselves for the care of patients with special needs [24][25] .In the study with 219 ID, concluded that special dental care programs are important for institutionalized patients with mental disability in order to reduce the prevalence of caries and periodontal disease [15][16][17] .Also, the studies with 12-year-old ID, highlighted the necessity to provide educators and parents with qualification in oral health 18 .
Possible limitations of this study occur because the survey had been conducted in an institution that has their own dental clinic and the students receive weekly instruction in oral hygiene.We suggest future research in this line to present solutions to these patients incorporating other APAE of southern Brazil.Therefore, it is important that legal surrogates also comply with oral hygiene practices together with the ID, as their caregivers often neglected the oral health of those who are more independent.Providing oral health education of parents, caregivers and nurses', strengthening prevention programs at a very young age, and encouraging dentists to set up a dental care system for this population with disabilities is an urgent need.
It may be concluded that students from APAE/PF-RS have good oral health, with a moderate DMFT index, Patients with intellectual disabilities and dental caries and that few patients have tooth losses.This is due in part to the fact that the sample is homogenous in terms of treatment of these individuals and that oral hygiene and motor coordination patterns are similar.Furthermore, we highlight another important factor, the existence of Interdisciplinary Programs and Extensive Promotion of Oral Health, linked to the UPF in APAE/PF-RS that due to its feature interdisciplinary, can serve as a model, extended to other institutions of the same character, and adapted according to their peculiarities.

CONCLUSION
Within the limitations of this study could be concluded that patients from APAE had acceptable oral hygiene to the dental procedure proposed.The observed DMFT indexes were relatively low for individuals with different levels of disability, but were not different among them.The older patients had higher caries rates and higher dental losses than the younger ones; It is important to have a focused, constant and multidisciplinary monitoring of patients with disabilities in institutions that have patients with intellectual disabilities.

Chart 1 .
Codes proposed by WHO for the DMFT index and their respective clinical meanings.

Table 1 .
Frequency and percentage (%) of patients analysed for diferents disabilities.

Table 2 .
Mean ± standard deviation of the DMFT among the different age groups.Regarding age, there was a higher prevalence of patients aged 15-19 years, and a lower prevalence of patients aged 31-38 years.The greater frequency and percentage of patients studied were of the age group of 15-19 years (43.5%),followed by the age group of 11-14 The mean DMFT index and the standard deviation were 3.93 and 3.48, for patients of the 11-14 age group, 3.47 and 2.95 for the 15-19 age group, 4.74 and 3.74 for the 20-30 age group, and 5.68 and 2.76 for the 30-38 age group.Patients in the 20-30 and 31-38 age groups had a higher DMFT index than younger patients, (4.74) and (5.68), respectively, which is considered by WHO as severe (Table

Table 3 .
Mean ± standard deviation of the components decayed, missing, filled teeth and healthy for the different degrees of disability of the patients analyzed.

Table 4 .
Comparison of average DMFT of patients with age (ANOVA p<0.05).

Table 5 .
Comparison of the mean DMFT index in relation to gender of patients (ANOVA p<0.05).
described dental caries and oral hygiene of 100 children and adults with mental disability in Hong Kong.The mean of DMFT index was 1.23 for 14 year-olds and 5.73 for the 25-35 age group.Similar results were observed in this study, in which age played a crucial role in the DMFT index where the most prevalent disease in the oral cavity was a cavity.Over the years there has been a decline in DMFT index and dmft.Comparing the latest surveys of the Project SB Brazil 2003 and 2010, it was noticed a decrease in DMFT at 12 years, from 2.8 to 2.1.Aged 15 to 19 fell from 6.1 to 4.2, while from 35 to 44 years, the reduction was from 20.1 to 16.3.The dmft at 5 years decreased from 2.8 to 2.35.The mean values were 3.93 for the 11-14 age group, 3.47 for the 15-19 age group, 4.74 for the 20-29 age group and 5.68 for the 30-38 age group, thus indicating that the DMFT index increased with age.In a study with Thai children aged 6 and 12 years, also concluded that the number of caries increased with age