Lupine Publishers | Dental and Oral Health Journals
Abstract
Cardiac diseases require that there is the meticulous maintenance of
oral hygiene to avoid bacteremia, which has been associated
with rheumatic heart disease and bacterial endocarditis. The aim was to
establish the utilisation of oral health care and oral health
practices of the caregiver about the oral hygiene and caries experience
of children aged 3-12 years suffering from heart disease and
were attending three pediatric cardiology clinics in Nairobi, Kenya. The
study was descriptive and cross-sectional. It involved a study
sample of children suffering from different types of cardiac conditions
and attending the Pediatric cardiac clinics in three public
institutions in Nairobi Kenya. The instruments the caregivers used to
brush the children’s teeth were the toothbrush 61(75%);
chewing stick 14(17%) and 6 (8%) never cleaned their teeth. Children who
used a chewing stick had a lower dmft of 1.40±2.98
compared to a dmft of 3.22±3.59 among children who used the toothbrush,
with Mann Whitney U, Z p=0.024 (p≤0.05).The children
who brushed their teeth had a lower mean plaque score of 1.68±0.58
compared those who did not clean with a mean plaque of
2.28±0.40 with a Mann Whitney U, Z=-2.611, p=0.009(p≤0.05). It was noted
that the children who had visited a dentist had a higher
caries experience with a dmft of 4.18±4.13 and DMFT of 1.16±1.92.
However, the children who had never sought treatment at
a dental facility had lower dmft of 1.89±2.88; and DMFT of 0.36±1, and
the differences were statistically significant with Mann
Whitney U, Z p=0.008(p≤0.05). The plaque scores and caries experience
were high in children whose caregivers had low aggregate
utilisation of the oral health care facilities. However, those who had a
low aggregate of oral hygiene practices had slightly higher
plaque scores and caries experience.
Keywords: Cardiac Disease; Children; Utilisation; Oral Health Services; Caregivers
Introduction
Populations with chronic medical illness or other disabilities
had the most unmet needs for oral health services [1], with poor
oral hygiene and increased caries experience than the general
population. For a child from a low-income family with heart
disease, this means an added economic burden in an already tricky
situation [2], as heart diseases necessitate regular dental check-ups
and maintenance of meticulous oral hygiene. This concern has even
been highlighted with new proposals on changes in the guidelines
relating to prophylaxis against infective endocarditis [3,4]. The oral
conditions may have a considerable impact on the general health
status and quality of life of otherwise healthy children, but their
effects on those children with acute and chronic illness can be more
dangerous [5]. Children with cardiac defects and diseases are at
increased risk or even life-threatening complications [6]. Hence the
need for preventive dental health care geared to reducing the risks
associated with management of the oral conditions under general
anaesthesia. Also, the prolonged bleeding from warfarin medication
often taken By the children [7-10]. Poor oral hygiene may give rise
to a frequent bacteraemia under normal physiological conditions,
and this can lead to a permanent risk of developing heart disease
[11-14]. Two common oral diseases, namely periodontal and
dental caries, though preventable, are still more prevalent in Kenya
[15,16]. The children with heart disease have the disadvantage
that their caregivers are preoccupied with the with the primary
medical condition the cardiac disease, resulting in the neglect of
other facets of the child’s total health [17]. The Kenya National Oral
Health policy document has already indicated that the dmft value
for Kenyan 5-year old children as at 2002 was 1.5±2.2, while 43%
of 6-8-year-old children had caries [15], underscoring the fact that
caries is still very rampant amongst the child population in Kenya.
The study was descriptive and cross-sectional where all the
patients aged 3 to 12 years and their caregivers attending paediatric
cardiology clinics over a three month period at Kenyatta National
Hospital (KNH), Gertrude’s Garden Children’s Hospital (GGCH) and
Mater Hospital. A Purposive sampling had been used to select the
study hospitals. Based on Kliegman. study, the study population
sample was determined as 79 cases. However, 81 patients were
recruited in the study. A semi-structured questionnaire was used
to collect information on the socio-demographic characteristics
of the children and the parent/guardian habits on oral health
practices and utilization of oral health services. As children waited
to consult the cardiologist clinical examinations done to record the
oral health status. The examination was conducted using sterilized
instruments and under natural daylight, with the participants
seated on a chair facing the window. Great care was taken during
periodontal probing for gingivitis, to avoid initiating bleeding that
could lead to septicaemia as the children were not on prophylactic
antibiotics. The results were recorded on predesigned individual
questionnaire sheets, and a record of dental caries and plaque was
done. The dental caries was then recorded as dmft for the primary
dentition and DMFT in the permanent [18,19], and the dental
plaque was marked based on the Loe and Silness plaque score
index [20]. Before commencement of the study, the examiner was
calibrated by an experienced paediatric dentist on the collection
of data relating to dental caries, and dental plaque Cohen’s kappa
index score of 0.87 and 0.85 (n=10) was obtained for dental caries
and plaque score respectively. The questionnaire was pre-tested
before use. A duplicate clinical examination was also performed
by the examiner to determine intra-examiner consistency, with
results of Cohen’s kappa index score of 0.91 and 0.86 (n=12) being
obtained for dental caries and plaque score respectively.
Data analysis
The data collected was cleaned, coded and analyzed using
SPSS version 17-computer software from SPSS Inc. IL. The results
obtained were compared and tested using Kruskal Wallis Chi-square
and Mann Whitney U statistical tests, with statistical significance
pegged at 95% confidence interval.
Results
The 81 children in the study, 44 (54.3%) were males and 37
(45.7%) females. Their ages ranged between 3-12 years with a
mean age of 8.16 years (± 2.81 SD), and the 6-9-year-olds accounted
for the most substantial proportion of 33 (40.7%) compared to
the 3-5 year-olds who formed 16(19.8%). The differences in ages
and gender were not statistically significant Chi χ2 =1.287, two
df, p=0.525(p≤0.05). A total of 37(46%) children were from rural
areas, 28(34%) were from Nairobi, and 16(20%) were from other
urban centres other than Nairobi. The distribution of the children
according to the type of heart disease, rheumatic (RHD) accounted
for 36(44.5%) while infective endocarditis (IE) affected 4(4.9%).
The duration since diagnosis of the cardiopathy ranged from less
than one year to 12 years. Nearly half of the children, 40 (49%)
had been diagnosed with the disease for a duration of between
1 to 5 years, while those who had been diagnosed more than five
years and those less than one year accounted for 30% and 21%
respectively. The caregivers’ oral health care practices that included
how the child’s teeth were brushed; the frequency of brushing; and
whether tooth brushing was supervised showed that 75(93%)
children cleaned their teeth and 6(7%) children did not clean their
teeth. Of the group that cleaned their teeth, 33(44%) did it twice a
day, 29(39%) once a day while 16% once in a while/occasionally.
About supervision, 62 (83%) reported cleaning their teeth without
supervision while 13 were assisted by the caregivers. Inquiry on the
ways the child’s teeth were cleaned, 75% (61) of the children used
toothbrush and the rest of the results were as shown in Figure 1.
The children who used toothpaste were 59 (79%) while 16 (21%)
never use any toothpaste.
Figure 1:
Considering the utilisation of oral health care services by
children with heart diseases; fifty-nine (72.8%), children had never
visited a dentist or utilised oral health services. Among the 22
(27.2%) children who had been to a dentist, the dental procedure
during the last appointment included extraction 10 (12.3%). Also
cleaning/prophylaxis (1(1.2%)), consultation ; check-up 9(11.1%)
and fillings 2(2.5%).Caregiver’s oral healthcare practices and the
dental caries experience about the children five children who never
cleaned their teeth had a higher dmft of 2.93±2.50 compared to a
lower dmft of 2.89 ±3.54 among the 56 children who cleaned their
teeth, and the differences were insignificant with p=0.957(p≤0.05).
The differences in the frequency of tooth cleaning, the eleven
children who cleaned their teeth once in a while had a higher dmft
of 3.36±5.29 and the 23 children who cleaned twice a day had lower
dmft of 2.68±2.77, but.difference was not statistically significant
with p=0.936(p≤0.05). The children who used a chewing stick had
a lower dmft of 1.40±2.98 compared to a dmft of 3.22±3.59 among
the 46 children who used the toothbrush, with the difference was
not statistically significant, p=0.024(p≤0.05). The children who
had visited the dentist apparently had a higher caries experience
with dmft of 4.18±4.13 and DMFT of 1.16±1.92 when related to the
children who had never visited a dentist, who had lower dmft of
1.89±2.88; and DMFT of 0.36±1. These differences in the results
were statistically significant, p=0.008(p≤0.05). The rest of the
results are as shown in Table 1. When the caregivers were classified
into two groups based on the responses to the oral healthcare
practices as being favourable or unfavourable practices,53 (86%)
caregivers fell in the unfavourable oral healthcare practices. Fiftythree
children whose caregivers displayed unfavourable practices
had a higher dmft of 3.62±3.54 compared to dmft of 2.74±2.85
among the eight children whose caregivers displayed favourable
oral healthcare practices. The difference was statistically significant
with Mann Whitney U, Z= -1.297, p=0.197(p≤0.05). The mean
plaque score was significantly lower among the 75 children
who reported to cleaning their teeth with mean plaque scores of
1.68±0.58, compared to a higher mean PS of 2.28±0.40 among the
six children who never cleaned their teeth with p=0.009(p≤0.05).
Those children who used the toothbrush had lower mean plaque
scores of 1.64±0.61. The children who cleaned more than twice
a day had the lowest mean plaque score of 1.55±0.63; and those
who cleaned their teeth occasionally had the highest mean plaque
scores of 1.99±0.41, though these differences were not statistically
significant with χ2 =0.067, 1df, p =0.936 (p≤0.05), Table 2. The
mean plaque scores among the 22 (27%) children who had been to a
dentist was mean PS of 1.68±0.55 compared to higher plaque score
of 1.83±0.61 among the 59 (73%) children who had never been to
a dentist Table 2. However, the difference was not significant, with
p=0.422 (p≤0.05)
Table 1:
Table 2:
Discussion
Despite the majority of the respondents, 75(93%), with the
majority reporting that their children cleaned their teeth, only
33(44%) of these children cleaned their teeth at least twice a
day, 62(83%), of them, cleaning their teeth without supervision
by the caregivers. Seven children had never visited a dentist to have teeth cleaned teeth cleaned. Also, some children had
occasional cleaning of their teeth, and this puts the children the
risk of developing early childhood caries, gingivitis, and poor oral
health. The poor oral health may which may give rise to frequent
transient bacteremia during mastication or tooth brushing. Other
studies among children with heart diseases have reported that 55
% of the children brushed their teeth twice a day [21,22] and that
46.1% of the children brushed three times a day. Owino et al [26]
reported that 67.5% of the 12-year-old children in a peri-urban
area brushed their teeth. Franco et, al [25] in their study considered
as disappointing the percentage of children with congenital heart
disease who had never visited a dentist, a reflection of other
results obtained in studies by Silva et al [23], Saunders et al.[18],
and Fonseca et al [5]. In this study, the very high percentage of the
children examined had never seen a dentist, with only 22(27.2%)
of the children have been to a dentist before the stu dy. Moreover,
even though, most of the treatment, which had been offered during
their visit to the dentist, was extraction, just as reported in a study,
Ober et al [24]. The finding is alarming since the American Heart
Association recommends that children with heart disease should
visit a dentist for the institution of preventive measures.
The lower frequency of dental visits in this study compared to
other studies in developed countries could be because of the reasons
that include the fact that; most of the caregivers are ignorant on the
importance of preventive dental care among the children with heart
disease. Most of the patients examined were of lower socioeconomic
status, therefore, could not afford the treatment. Also; the dental
facilities in Kenya are limited, inaccessible and most of them lack
skilled dental personnel who are well trained to offer treatment
to children with special needs. The use of other tooth cleaning
devices like the chewing stick was illustrated in this study. Majority
of the children who were using this device were mostly from rural
areas where other tooth cleaning aids may not be available. The
outstanding fact was that the children examined were from different
residential backgrounds. The patients who used the chewing stick
in this study had significantly lower dental caries experience than
those who used the toothbrush. The low caries experience in the
children who used the chewing stick may be because they could
not afford the snacks between meals. The low could probably be
explained by the fact most of the children who used the chewing
stick were from rural areas where the dental caries experience was
shown to be lower compared to urban centres possibly because of
the difference in the diet. Also, some studies have demonstrated the
cariostatic and bacteriostatic properties of some specific species of
trees, which are used as chewing sticks. It is also possible that a few
children who started to use the brush late in life after severe early
childhood caries had been established could have skewed the high
caries experience illustrated among the children who were using
the brush.
The caregivers’ aggregate oral healthcare practices did not
significantly influence the dental caries experience among the
children in the present study. The lack of differences in the gadgets
for cleaning the teeth may be due to the small sample size where there
was a loss of statistical power. Fifty-three (65; 4%) children whose
caregivers were classified as portraying “unfavorable practices”
had higher caries experience with mean dmft of 3.62±3.54 (n=53)
compared to 2.74±2.85 (n=8) among the children whose caregivers
reported “unfavorable practices” on oral care. The children who had
been to a dentist had a higher dmft than those children who had
never been to a dentist. This finding illustrates that children visit a
dentist when dental disease dental caries has already occurred and
that the majority of the treatment offered was curative to relieve
the symptoms, with little or no emphasis on preventive oral care.
The lack of focus on preventive oral care was further illustrated
by the high proportion of active, untreated caries component of
dmft compared to filled or extracted teeth. Despite the fact that
caregivers’ aggregate oral health care practices had no significant
relationship with the oral hygiene of the children as noted earlier,
thirteen children whose caregivers reported “favourable practices”
had lower plaque scores of 1.69 ±0.54. However, the plaque scores
of sixty-eight children whose caregiver’s had reported favourable
practices had a mean plaque score of 1.73±0.59 slightly higher.The
children who cleaned their teeth had significantly lower plaque
scores compared to those children who never cleaned teeth. The
children whose teeth were never cleaned were at high risk of
developing sub acute bacterial endocarditis when compared to
the children who cleaned teeth regularly. As during the tooth
brushing process, there is the mechanical removal plaque thus
reducing the possibility of increased bacterial colonization of the
plaque and reducing chances of bacteraemia during mastication.
It was noted the that toothbrushes were more effective in control
of plaque compared to the use of chewing sticks, though there
was no significant difference between the two groups. The results
of these study showed that children who had been to a dentist
displayed better oral hygiene than those children who had never
been to a dentist, though there was no statistical difference. The
difference perhaps indicates that the dentist visited previously
could have offered oral hygiene instructions on good tooth brushing
techniques. In addition to that, the caregivers’ aggregate oral
healthcare practices did not significantly influence dental caries
experience among the children. Those children whose caregivers
were classified as portraying “unfavorable practices “on oral care,
had higher caries experience with mean dmft of 3.62±3.54 (n=53)
compared to 2.74±2.85 (n=8).
The children who had been to a dentist had higher dmft than
those children who had never been to a dentist. The finding may be
rationalised that children who visited the dentist they did so when
dental caries had already occurred. The primary treatment offered
was curative to relieve the symptoms, with little or no emphasis
on preventive oral care. The situation was further illustrated by
the high proportion of active, untreated caries component of dmft
compared to filled or extracted teeth.
Conclusion
The utilization of oral health care and oral health practices of
the caregiver of the children was low, and only apparent used in
case of emergency mainly. The oral hygiene, gingival index and
dental caries experience in the study population was high.
Study limitations
The study was only for three months. Hence children who had
had appointments in the previous clinics were excluded. The small
sample size based in three cardiology clinics may have created a
bias. The clinic was limited to 3-23-year-olds excluding the older
children 13-17 this is the policy on how paediatric age cut off as
defined by the ministry of health.
Acknowledgment
We thank Professor Loice Gathece for contribution in the design
of the study. The Kenyatta National Hospital and the University
of Nairobi Ethics and Research Committee fors approval of the
proposal. Alice Lakati who helped in statistical work and Dr. E.
Kagereki and Dr. Kiprop for data entry. The Nurses and the staff at
the Paediatric Cardiac clinics at the KNH, Mater Hospital and the
Gertrudes’ Garden children Hospital for facilitating data collection
during the clinical examinations for the patients. We acknowledge
all the parents and children who participated in the study without
whom the study would not have been a success.
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