BACKGROUND

TOP ABSTRACT BACKGROUND SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Dental care is consistently reported as one of the top medical needs of children with disabilities.^1,2 Derrick-Griffith and Pezzementi³ reported that in the very poor state of Alabama, a larger proportion of Special Olympics athletes had untreated decay compared with the national average for Special Olympics athletes.

The South has the highest poverty rate of any region in the United States and also has a disproportionately larger share of the nation’s poor, with 41.1 percent of poor people living in the South, although only 35.7 percent of the nation’s population lives in the South.⁴ With respect to oral health disparities, the prevalence of untreated decay is more than twice as high for people living below the poverty level compared with those at or above the poverty level.⁵

People with intellectual and physical disabilities have poorer oral health than does the general population.¹ Intellectually disabled people may require assistance or support from caregivers to maintain their oral health. They also may engage in behavior that can adversely affect their oral health, such as lip biting and tongue thrusting. The number of people who live in institutions has decreased by 75 percent between 1967 and 1997.⁶ Although the quality of life for people with intellectual disabilities has improved in the smaller-group living arrangements, access to dental care is more difficult than it was in the centralized institution model, with its on-site dental facilities.

Barriers to care have arisen as a result of the movement to bring people with disabilities out of institutions and into communities. The task of finding dentists who treat special-needs patients may be especially challenging for people with limited literacy skills. Oral health for this population depends on the number of willing health care providers within the locality in which they live. With more than 1.5 million people with intellectual and physical disabilities depending on Medicaid for health care coverage, additional barriers to care include financing and funding issues such as Medicaid policies and administrative procedures, the number and location of dentists accepting Medicaid, the lack of coverage for patients older than 19 years and the value placed on oral health by patients’ caregivers.⁷

Barriers to care have arisen as a result of the movement to bring people with disabilities out of institutions and into communities.

Specialized care, such as sedation or general anesthesia, may be required because of the severity of oral disease or the patient’s inability to cooperate with treatment. Because patients with intellectual disabilities often cooperate poorly with dental treatment, the therapy often has been extraction, resulting in a low number of restored teeth and a high number of missing teeth.⁸ Considering of all these barriers to care and the fact that poorer children are one-third more likely to have an existing special health care need than are children who are not poor,¹ we postulated that the higher rates of poverty in the Southeast might result in an exacerbation of the oral health disparity for people with intellectual disabilities in this region.

We initiated this study to obtain preliminary data regarding the oral health disparities of people with intellectual disabilities that are associated with poverty. The purpose of this study was to describe and quantify the extent of oral health disparities, if any, among people with intellectual disabilities in the southeastern United States, the poorest region in the nation.

	SUBJECTS AND METHODS

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Study population. The examiners assessed the oral health status of athletes (both dentate and edentulous) with intellectual disabilities with or without a physical disability. They obtained written, informed consent from parents or guardians. From March to July 2002, 12,099 Special Olympics athletes were examined by previously calibrated volunteer dentists and dental students at 53 sites, including 1,891 athletes from seven southeastern states: Alabama, Arkansas, Florida, Louisiana, South Carolina, Tennessee and West Virginia.

Data collection. An oral health screening is a measurement of oral health status based on visual evidence of pathology present in a sample of a population; the results of the assessments are used to plan services to address the identified needs. This differs from a diagnostic oral examination in clinical practice, in which the goal is to identify treatment needs of an individual. Because of inherent potential variability among screeners, the criteria used to reliably measure oral conditions in the population must emphasize reproducibility of results rather than meticulous detection of the earliest signs of disease.

Although the oral health screening examinations were noninvasive, the examiners used universal precautions for infection control. Before conducting screening examinations, examiners were calibrated by completing a standardization course developed by the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta.⁹

The screening examination consisted of a visual tour of the mouth that was repeated for each condition being assessed and recorded, starting from the same point (the upper right quadrant) to reduce recording errors. A complete screening examination included measurements of gingivitis, untreated decay, missing molars, sealants, restorations and treatment urgency. The entire screening procedure was completed in less than 10 minutes to minimize the likelihood that athletes would become impatient and possibly not complete the examination.¹⁰ For each condition, if the examiner was unsure, he or she recorded it as nondisease status.

Description of oral health status and treatment needs. The examiners recorded each of the following oral health characteristics as present or absent (yes or no):

– gingivitis, defined as a significant deviation of either the free or attached gingiva from healthy gingiva in contour, texture or color on the facial surface of three or more permanent mandibular anterior teeth (cuspid to cuspid);

– decay, defined as the presence of at least one area of cavitation that would accommodate a 0.5-millimeter-diameter bur; both permanent and primary dentitions were included, except for third molars and all surfaces were considered, including root surfaces;

– molar decay, defined using the same definition for untreated decay found in permanent and primary molars;

– missing molars, defined as first or second permanent molars missing as a direct consequence of decay or periodontal disease;

– sealants, defined as any first or second permanent molar with a sealant;

– restorations, defined as any permanent or primary tooth with a restoration placed as a result of decay; crowns were not included because examiners could not determine if they had been placed as a result of trauma or decay;

– urgent treatment needs, defined as pain inside the mouth, possible pulpal involvement, or broken or missing restorations with decay;

– nonurgent treatment needs, defined as any or all of the following: no pain in the mouth; decay present but not involving the pulp; broken restorations with no recurrent decay, gingivitis or periodontal involvement.

The authors defined poverty as very poor or poor, on the basis of the poverty level for the state in which the athlete participated in the Special Olympics Special Smiles event.

Description of characteristics. The examiners recorded athletes’ ages in years, as reported by a parent or guardian. We defined poverty as very poor or poor, on the basis of the poverty level for the state in which the athlete participated in the Special Olympics Special Smiles event. (This international program was begun more than a decade ago by Dr. Steven Perlman and others in an effort to address the oral health concerns of people with special needs.)

We defined the southeastern region of the United States as Alabama, Arkansas, Florida, Louisiana, South Carolina, Tennessee and West Virginia. These states ranked among the 20 states with the highest percentage of their population living below the poverty level.¹¹ Louisiana is ranked first, or the poorest state, as measured by the largest percentage of people living below the poverty level (19.1 percent). West Virginia is ranked fifth (17.2 percent), Alabama is sixth (16.5 percent), Arkansas is eighth (15.4 percent), Tennessee is 12th (14.3 percent), South Carolina is 15th (13.4 percent) and Florida is 19th (12.5 percent).¹¹

We defined "very poor" as the four southeastern states that are among the 10 poorest states in the nation; these include Louisiana, West Virginia, Alabama and Arkansas. We defined "poor" as the three southeastern states that are among the 11th to 20th poorest states; these include Tennessee, South Carolina and Florida.

Statistical analyses. Using the ² test with P < .05, we computed the statistically significant differences between the proportions of athletes in each state with oral disease (gingivitis, decay and molar decay), missing molars, dental treatment received (sealants or restorations) and dental treatment needs (urgent and nonurgent). Separate odds ratios (ORs) and 95 percent confidence intervals (CIs) were computed to quantify the association between each oral health outcome and poverty among the Special Olympics athletes; to quantify the association between each oral health outcome and poverty after restricting the analyses by age; and to quantify the association between each oral health outcome and age after restricting the analyses by poverty level. We used software (Epi Info, Centers for Disease Control and Prevention, Atlanta) to perform the statistical analyses.¹²

	RESULTS

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Descriptive summary. Table 1 presents the descriptive characteristics of the athletes from each state, from the southeast region and from the United States.

The southeastern region had a greater prevalence of untreated decay than did the nation as a whole.

Gingivitis. Although the overall prevalence of gingivitis in the Southeast was slightly lower than the overall prevalence nationwide (Table 1), the prevalence of gingivitis was significantly higher in athletes from Louisiana (44.9 percent), Alabama (47.2 percent), Arkansas (40.4 percent) and South Carolina (53.1 percent) than it was in athletes from Tennessee (21.2 percent), Florida (27.9 percent) and West Virginia (27.5 percent). We compared each state’s prevalence of each oral health characteristic with that of the other states using the ² test, and we report these statistically significant results. For example, as shown in Table 1, the prevalence of gingivitis in Louisiana was 44.9 percent (207 of 461 athletes) and in West Virginia, the prevalence was 27.5 percent (25 of 91 athletes), which is statistically significant at the P < .05 level (P = .0021).

Decay. As shown in Table 1, the southeastern region had a greater prevalence of untreated decay (36.5 percent) than did the nation as a whole (28.2 percent). Athletes from Tennessee had a significantly greater prevalence of untreated decay than did athletes from Louisiana, South Carolina and Florida. Athletes from South Carolina also had a significantly lower prevalence of untreated decay than did athletes from Alabama (Table 1).

Molar decay. The prevalence of molar decay was greater in each southeastern state (20.9 to 35.9 percent) than it was in the nation as a whole (18.5 percent) (Table 1). When comparing the state-specific results, we found that athletes from Tennessee had a significantly greater prevalence of decay (35.9 percent) than did athletes from each of the other states (20.9 to 26.9 percent), except for Alabama (31.9 percent, which is not statistically different from Tennessee’s 35.9 percent). Athletes from Alabama had a significantly greater prevalence of molar decay than did athletes from Louisiana (21.7 percent) and West Virginia (20.9 percent).

Missing molars. The prevalence of missing molars was lower in the southeastern region (18.1 percent) than it was in the nation (19.2 percent), due in part to the lower prevalence of missing molars in athletes in Tennessee (4.8 percent) and Florida (11.4 percent). Tennessee had a significantly lower prevalence of missing molars than did each of the other states (11.4 to 30.8 percent) (Table 1).

Sealants. One measure of access to care is evidence of previous preventive treatment, such as the placement of sealants. Only 8.1 percent of athletes screened in the southeastern region had received sealants, a much lower percentage than the national average of 13.5 percent (Table 1). We found great variation in utilization of this preventive treatment throughout the southeastern region. Alabama, Louisiana and Tennessee had an exceptionally low prevalence of sealant use (7.0, 6.0 and 2.4 percent, respectively), while the prevalence for athletes in Florida and South Carolina was well above the national average (17.7 and 21.2 percent, respectively). The prevalence of sealant use was significantly lower in Tennessee than in all other states. Alabama and Louisiana had a significantly lower prevalence of sealant use compared with Arkansas, Tennessee, South Carolina and Florida.

Athletes from the southeastern region had a greater prevalence of urgent treatment needs than did athletes nationwide.

Restorations. Another measure of previous treatment is the presence of restorations. The results of our study show that the prevalence of restorations was 49.8 percent in the Southeast, compared with the nationwide prevalence of 58.1 percent (Table 1). The prevalence of restorations was significantly lower in Tennessee (26.4 percent) than in the other states (49.4 to 63.7 percent).

Treatment needs. Athletes from the southeastern region had a greater prevalence of urgent treatment needs (11.1 percent) than did athletes nationwide (8.4 percent) (Table 1). Athletes in the Southeast also had a greater prevalence of nonurgent treatment needs (31.1 percent) than did athletes nationwide (26.5 percent). The prevalence of urgent treatment needs was significantly lower in Louisiana (1.1 percent) than in West Virginia (15.4 percent), Alabama (17.4 percent), Arkansas (16.2 percent) and Tennessee (12.4 percent).

Measures of association. Oral health status and poverty. The association between oral health status and poverty is depicted in Table 2 as the OR. The OR is the ratio of the odds of the disease or health condition (for example, gingivitis, untreated decay, missing molars, urgent and nonurgent treatment needs) among people with the same exposure or risk factor (for example, very poor) relative to those who do not have the risk factor (for example, poor); as a ratio, it ranges in value between zero and infinity.

Because oral disease develops over time, athletes’ ages can affect the prevalence of the disease. Consequently, we restricted our analyses of the association between poverty and oral health according to age, and we compared states that had similarly aged athletes (namely, the very poor states, with a mean age of 24.9 years, and the poor state of South Carolina, with a mean age of 23.1 years) (Table 3).

Oral health status and age. To quantify the association between oral health status and age, we restricted the analyses according to poverty level (Table 4) by including only those states with similar poverty-level rankings (Tennessee, South Carolina and Florida), as well as by comparing the oral health status of athletes in the older group (South Carolina, with a mean age of 23.1 years) with that of athletes in the younger group (Tennessee and Florida, with a mean age of 12.1 years). After removing the effect of poverty, we found that athletes in the older group were four times more likely to have gingivitis (OR = 4.00; 95 percent CI: 2.58 to 6.21), almost six times more likely to have at least one sealant (OR = 5.75; 95 percent CI: 3.03 to 10.89), about five times more likely to have at least one missing permanent molar (OR = 4.71; 95 percent CI: 2.57 to 8.60) and approximately one-half as likely to have a restoration (OR = 0.54; 95 percent CI: 0.36 to 0.83) than were athletes in the younger group. Although untreated decay was more prevalent in athletes in the younger group, this finding was not statistically significant (OR = 0.67; 95 percent CI: 0.42 to 1.05).

	DISCUSSION

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Participants in the Special Olympics may have better access to care than the general population of people with intellectual disabilities.

This report focuses on the oral health status of noninstitutionalized Special Olympics athletes. Although no data are available to indicate whether Special Olympics athletes are representative of people with intellectual disabilities in the United States, it is reasonable to expect that our findings underestimate the severity of oral health problems for this group, because the athletes had to be able to cooperate in order to compete, and they were provided information about Grottoes of North America, a charitable group that sponsors dental treatment for children with special needs ("www.masonicinfo.com/dentistry.htm"). Thus, participants in the Special Olympics may have better access to care than the general population of people with intellectual disabilities.

Different survey designs, reporting methods and definitions of oral health status limit our ability to compare results across studies of people with intellectual disabilities. It is not appropriate to compare the results from our study with those of other studies that use the standard oral health measure of decayed, missing, filled teeth (DMFT),¹³ because the Special Olympics screening examinations used the unique definition of decayed, missing and filled teeth described above. Although it would be desirable to use the standard definition to be able to compare the results from different studies, we are limited to the analyses reported here, in which examiners used the same definition of oral health status and treatment needs throughout the Special Olympics screenings, and all examiners completed standardized training.

Although we report preliminary data regarding oral health characteristics, our findings indicate that after restricting the analyses by age, athletes from the poorest states were more than one and one-half times as likely to have restorations and almost one-third as likely to have sealants compared with athletes from the less poor state of South Carolina (Table 3). These data support the contention that in addition to the finding of poorer oral health among people with intellectual disabilities compared with the general population, poverty level has an effect on oral health status.

On further assessment of the effect of age versus poverty level, we found that the unusually young age of athletes screened in Tennessee and Florida seemed to explain much of the oral health disparities among athletes in this study. That is, for the younger group, molars had erupted more recently; thus, not as much time had elapsed for athletes to develop the oral diseases detected by the screening examination. Athletes in Tennessee (4.8 percent) and Florida (11.4 percent) had a significantly lower prevalence of missing molars than did athletes in all other states in the region (22.3 to 30.8 percent), except South Carolina, which was not significantly different from Florida (Table 1).

Preventive dental care programs should consider paying special attention to people with poor ability to cooperate and those with Down syndrome.

After removing the effect of poverty, we found that these young athletes were almost six times less likely to have sealants than were older athletes, most likely because of the recent eruption of their molars (Table 4). As shown in Table 1, athletes in Florida and Tennessee had a much lower prevalence of restorations, which appears to be associated with both age and poverty (OR = 1.6 after removing the effect of age [Table 3]) and OR = 0.5 after removing the effect of poverty [Table 4]). Although a patient needed to have seen a dentist to receive restorations, he or she also had to have decay; consequently, this is not as good a measure of access to care as is sealant use.

The higher prevalence of molar decay in athletes in Tennessee and Alabama coincides with the very low prevalence of sealant use (Table 1). Because molars are so important to long-term chewing function, we find it disappointing that the prevalence of untreated molar decay in the southeastern region was 28.3 percent compared with the national average of 18.5 percent (a more than one and one-half times greater prevalence).

Sealants were almost six times more prevalent among the older group than among the younger group (OR = 5.75; 95 percent CI: 3.03 to 10.89), after we restricted analyses by poverty level (Table 4). This finding possibly is due to the difficulty in maintaining a dry field to place sealants on younger patients, or sealants are not being placed as frequently as they have been in the past. Also, as shown in Table 4, the untreated decay was more prevalent in the younger group, but this was not statistically significant (OR = 0.67; 95 percent CI: 0.42 to 1.05), and it may be explained by the significantly higher prevalence of missing molars among the older group. Unfortunately, extraction eliminates disease and may be elected if the dentist does not know how to manage the patient to perform restorative treatment.

A longitudinal study of people with intellectual disabilities conducted in Sweden reported a very low incidence of dental caries. However, this finding may not be comparable to the situation in the United States, because the professional cleanings in Sweden were provided approximately every three months for 8 years.¹³ This is twice as frequent as most U.S. practitioners routinely recommend. The high prevalence of periodontal disease in people with Down syndrome is thought to be due to alterations in immunological response.¹⁴ Thus, preventive dental care programs should consider paying special attention to people with poor ability to cooperate and those with Down syndrome.¹⁴ Oral health can be a low priority of those who care for people with intellectual disabilities, because they might assume that nothing is wrong if the individual does not complain and, therefore, conclude that there is no need to see a dentist.¹³

	CONCLUSIONS

TOP ABSTRACT BACKGROUND SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The results of this study enhance our understanding of the role that poverty plays in the oral health status of people with intellectual disabilities (with or without physical disability). Among the Special Olympics athletes who received screening examinations, those in the southeastern region of the country were more likely to have unmet dental treatment needs than were athletes nationwide. Although tooth loss results from oral diseases such as dental caries and periodontal diseases, it also reflects patients’ and/or caregivers’ attitudes about the need for regular dental visits, dentists’ comfort with treating this patient population, the availability and accessibility of dental care, and the prevailing standard of care.

Athletes from very poor states were almost one-third as likely to have had a sealant placed and more than one and one-half times as likely to have a restoration as were athletes from the poor states. We suggest that sealants should be provided to all people, regardless of poverty level, to prevent tooth loss that can adversely affect overall health as well as quality of life.¹⁵ This suggestion is reinforced by the finding that older athletes were almost five times more likely to have a missing permanent molar than were younger athletes from similarly poor states (Table 4). Further studies are needed to evaluate the role of poverty when comparing the oral health status of people with intellectual disabilities with that of the general U.S. population.

Previous studies reported that even when Medicaid and the Children’s Health Insurance Program eliminated direct costs for dental care, other barriers to care resulted in the persistence of unmet treatment needs.¹⁶ Barriers to care included few willing health care providers, care-givers’ inability to obtain time off from work, difficulty accessing public transportation for people with disabilities and lack of child care services for other children in the family.

A survey of dentists’ willingness to treat special-needs patients found that only 20 percent feel comfortable doing so.¹⁷ A 1993 survey of all U.S. and Canadian dental schools showed that the average lecture time devoted to treatment of patients with disabilities was only 12.9 hours. The average clinical instruction time was 17.5 hours. A follow-up survey conducted in 1999 showed a decrease in this training.¹⁸ The level of training among practicing dentists is unknown.

One possible approach to addressing these barriers is the implementation of community programs in which dental students provide dental treatment in schools for people with intellectual disabilities. This would meet their needs and provide training to future dentists so that they are more comfortable addressing the oral health needs of this population.