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Year : 2016  |  Volume : 34  |  Issue : 3  |  Page : 257-261

Assessment of salivary and plaque pH and oral health status among children with and without intellectual disabilities

1 Department of Public Health Dentistry, V S Dental College and Hospital, Bengaluru, Karnataka, India
2 Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka, India
3 Department of Public Health Dentistry, New Horizon Dental College, Bilaspur, Chattisgarh, India

Date of Web Publication25-Jul-2016

Correspondence Address:
V Swathi
Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.186753

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Background: This study explores the association of disabilities and oral health. The aim of the study was to assess the salivary and plaque pH and oral health status of children with and without disabilities. Materials and Methods: A total of 100 schoolchildren (50 with disabilities and 50 without disabilities) were examined from 9 to 15 years age group. Saliva and plaque pH analysis were done to both the groups. Clinical data were collected on periodontal status, dental caries using WHO criteria. pH values of different groups, difference between the means were calculated using independent t-test, and frequency distribution was analyzed using Chi-square test. Statistical significance, P value was set at 0.05. Results: Mean plaque and salivary pH scores were lesser (5.73 and 5.67) in children with intellectual disabilities (IDs) (P< 0.001). Subjects with disabilities had also statistically significant higher CPI scores and decayed, missing, and filled scores than their healthy counterparts (P< 0.001). Conclusion: There is a statistically significant difference in plaque and salivary pH among children with and without ID with lower plaque and salivary pH among children with ID. In addition to this, the oral health was also more compromised in children with ID, which confirms a need for preventive treatment for these children.

Keywords: Caries, disabled individual, oral health, oral plaque pH

How to cite this article:
Radha G, Swathi V, Jha A. Assessment of salivary and plaque pH and oral health status among children with and without intellectual disabilities. J Indian Soc Pedod Prev Dent 2016;34:257-61

How to cite this URL:
Radha G, Swathi V, Jha A. Assessment of salivary and plaque pH and oral health status among children with and without intellectual disabilities. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2023 Jan 27];34:257-61. Available from: http://www.jisppd.com/text.asp?2016/34/3/257/186753

   Introduction Top

Disability is a condition or function judged to be significantly impaired relative to the usual standard of an individual or group. The term refers to an individual functioning, mental illness, including physical, sensory, cognitive and intellectual impairment, and various types of chronic diseases.[1] According to the World Health Organization (WHO) estimate, individuals with disabilities comprise 10% of the population in developed countries and 12% of that in developing countries.[2]

For persons with disabilities, the effect of dental disease on general health and function appears greater than for similar groups without a disability. They are at greater risk for poorer oral health than persons in the general population, due to more frequent oral infections and periodontal disease, enamel irregularities, moderate-to-severe malocclusion, and craniofacial birth defects. In addition, they often have a higher level of unmet dental need and poorer oral hygiene than the general population.[3] Improving the oral health of those with disabilities requires not only that they receive high-quality clinical care, but also that they gain access to the dental office in the first place.[4] The challenging behavior seen in some people with disabilities may pose a difficulty for dentists and could determine whether or not these patients will be treated in the dental surgery or referred for care in a hospital setting. Cooperation is often lacking in individuals with severe disability, and therefore, the successful treatment of these patients depends on the dentist's ability to manage the patient with appropriate behavior management techniques. An interdisciplinary approach to care, based on recognizing the patient's special needs, is of prime importance in ensuring quality dental service for these patients.[5]

Saliva plays an important role in maintenance of oral health as it keeps oral tissue moist and hydrated. It cleanses dental tissues regularly and reduces bacterial load, acts as buffer media and protects hard tissue from acid attack after sugar intake. Any deviation in flow rate, consistency, and composition may predispose the individual to a higher risk of oral diseases particularly dental caries.[6] Dental caries is closely linked to diet, salivation, and the presence of a bacterial biofilm on dental surfaces. The drop of plaque pH creates an environment that helps the growth of acidophilic microorganisms, such as Streptococcus mutans and the Lactobacilli, which find the ideal conditions for promoting caries and with further pH drop and creates areas of demineralization of the dental enamel. Plaque pH therefore plays a fundamental role in balancing the biofilm flora on the tooth surfaces.[6],[7]

In a study done by Yarat et al., salivary pH was statistically significantly higher (P = 0.03) and salivary flow rate of the Down's syndrome subjects was statistically significantly lower (P< 0.01) compared to healthy controls.[7] Ameer et al. had reported that the intellectually disabled group had the highest plaque scores and poor oral hygiene among the five groups taken in their study.[8] It was observed that in such groups, regular use of medications high in sugar, less clearance of food from the oral cavity, impaired salivary function, predilection for carbohydrate-rich foods, and oral aversions may compromise the oral health.[9] The dexterity required to clean the teeth may differ significantly between the normal and children with ID resulting in higher incidence in periodontal disease and dental caries among this special groups. Parents of such group are required to monitor the oral hygiene practices of this group, and in case of severe disability, oral hygiene should be provided by the parents for maintenance of acceptable level of oral hygiene.[10]

Saliva and plaque pH play an important role in maintaining oral health, and only sparse data are available about salivary and plaque pH difference among children with intellectual disabilities (IDs).

Hence, the aim of the present study was to assess the salivary and plaque pH differences and also the oral health status among children with and without IDs.

   Materials and Methods Top

The present cross-sectional study was done among school children of 9–14 years in Sri Sajjan Rao Vidya Samaste School, Bengaluru, Karnataka, India. The school has a special room and teaching faculty for children with IDs. The ethical clearance to conduct the study was taken from the Institutional Ethical Review board of Vokkaligara Sangha Dental College, Bengaluru. Informed consent was taken from parents of the study participants. Permission to conduct the study was obtained from the head of the school.

Sample and distribution of study subjects

A total of 100 study subjects, 50 non-ID group (NID) and 50 with ID were taken, based on convenient sampling from the same school. The school enrolls both children with ID and NID. A total of 65 children with ID were enrolled in the school at the time of the study, with age group between 9 and 14 years, belonging to lower or upper lower socioeconomic status, out of which 50 children finally participated in the study, the reason for nonparticipation of 15 children with ID was either parents opted out or children who were extremely uncooperative for clinical examination. Similarly, a matched group comprising 50 children with NID with similar background and demographic feature were selected for study. Hence, the final sample comprised 100 students. The study was conducted for duration of 15 days in June.

Children were distributed for disabling conditions, as per the classification given by Nowak modified to suit the present study as physically handicapped, mentally retarded, congenitally abnormal, childhood autism, and blind.[11]

Inclusion criteria were children with a history of ID as verified by the child's medical file or caregiver's reporting, children with decayed, missing, and filled teeth (DMFT)/dmft score of 2 or more parents/caregivers who are able to read and understand the questionnaire controls included age-matched children with NID, recruited from the same school. Exclusion criteria were children or parents who did not gave consent for participation in the study.

Clinical examination

All examinations were performed at the schools by two examiners, using a mouth mirror, sickle probe, WHO periodontal probe with day lighting and universal infection control procedures.

Data on dental caries and gingival status were recorded using WHO 1997 oral health survey form. Clinical examination was performed by two previously calibrated examiners.

Interexaminer diagnostic calibrations were performed for over 10% of the study sample; the Kappa score was over 90% and considered adequate. The data collected were analyzed, and the mean and standard deviation of each group were calculated and recorded.

Saliva and plaque sample collection

For saliva sample collection, the parents were asked to refrain their children from oral hygiene for 24 h and from food for at least 12 h and from drinking water hour before the sample collection. For normal children, the sample was collected in the similar way for disabled children with consent from parents. Unstimulated whole saliva was directly expectorated into clean, dry, sterilized glass tubes. After collecting 3 mL of saliva, it was diluted with 10 mL distilled water, the tubes cap closed and delivered to the Department of Chemistry and Research Laboratory of Bangalore Institute of Technology in <2 h for the estimation of the pH of all the collected samples. The plaque samples were collected from six different and easily accessible surfaces of the upper central incisors, the buccal surfaces of the upper first premolars and molars, lingual surfaces of the lower molars, and incisors with the help of sterile spoon explorer. Then, the sample was diluted with 10 mL of distilled water and analyzed similar to salivary sample.

Method of pH estimation

The plaque and salivary samples were collected and mixed with 10 mL of distilled water in a glass test tube and was stirred for 5 min for homogeneity, and then pH was measured using glass micro-combination electrode. The electrode has a titanium tip covered with glass which can estimate pH of liquid in small quantity as 10 mL and gives the pH value on a digital display. The electrode was calibrated with buffer solutions with predetermined fixed pH.

Statistical analysis

Descriptive statistics for sociodemographic variables, pH values of different groups, and difference between the means was calculated using independent t-test, and frequency distribution was analyzed using Chi-square test. Statistical significance, i.e. P value was set at 0.05.

   Results Top

The present study comprised 100 children divided into two groups of 50 each. All study participants were taken from similar sociodemographic background as depicted in [Table 1]. Mean plaque pH scores were lower in children with IDs with a value of 5.73, which was statistically significant (P< 0.002) [Table 2] when compared to normal children.
Table 1: Demographic distribution of study participants

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Table 2: Mean plaque pH among the study participants

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Mean salivary pH scores were lower in children with IDs with a value of 5.67, which was statistically significant (P< 0.001) [Table 3] when compared to normal children. Mean values for decayed D (T), missing M (T), filled F (T) teeth and DMFT was calculated and when compared it was found that children with ID had higher value for D (T), and M (T) while children with NID had higher value for F (T) component [Table 4]. Children with NID showed higher frequency for community periodontal index (CPI) score 0 indicating better gingival status than children with ID which showed a CPI score 7. While CPI score 2 was also more in children with ID indicating inadequate oral hygiene practices. The finding was significant with value of 0.0042 [Table 5]. Mean CPI value was higher for children with ID than NID children and findings were not statistically significant [Table 6].
Table 3: Mean salivary pH among the study participants

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Table 4: Mean decayed missing filled teeth scores in nonintellectual disability children and children with intellectual disability

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Table 5: Frequency distribution of community periodontal index scores in healthy children and children with intellectual disability

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Table 6: Mean value of community periodontal index scores in healthy children and children with intellectual disability

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   Discussion Top

In the present study, it was seen that the mean plaque pH scores had significantly differed between normal and children with ID. The plaque pH scores were 5.73 for children with ID and 6.98 for NID with a statistically significant difference. Similarly, salivary pH scores were also lower in children with ID than NID children. The findings of the present study are in accordance with Stabholz et al. (1991) who found statistically significant difference in plaque and salivary pH between children with NID and children with ID who had comparatively lower salivary and plaque pH.[12] The results were contrary to the study done by Shapira et al. who did not find any statistically significant difference in plaque and salivary pH among the three group Down syndrome, children with other ID and healthy children.[13] The reason for such difference in pH appears to be increased colonization by certain pathological bacteria, poor motor control, and lack of “self-cleansing” leading to the accumulation of food debris in the mouth. Mouth breathing seen in many cases also reduces the protective function of saliva on the tooth surfaces such as buffering action which may lead to fall in plaque and salivary pH.[14]

In the current study, it was found that caries experience was higher among ID group, untreated dental caries was higher in this group, while filled teeth was higher in NID group, findings were statistically significant. These findings are in accordance to the study done by Shanbhag P et al.[15] who recorded a significantly higher decayed teeth among children with ID. The poor oral hygiene in intellectually disabled children can be attributed to decreased incidence of rinsing mouth after meals, along with the lack of interest in maintenance of oral hygiene and accumulation of food in the mouth for a longer time.[16]

In current study, it was also found that children with NID had better periodontal status than children with ID, later showed higher frequency of gingivitis and bleeding gums. The findings are in accordance with the study done by Oredugba and Ameer, who found that as the degree of severity of ID increased degree of gingivitis also increased.[17] Higher incidence of periodontal disease can be attributed to the lack of manual dexterity, which was in accordance with studies conducted by Pieper et al.[18] On the contrary, Shaw et al. assessed manual dexterity in their study, and showed that although periodontal health was poor among the group, it was not correlated with manual dexterity.[19]

Therefore, there is an urgent need for the government to take actively oral health promotion measures, intervening in the oral health of IDC. In addition, a supportive environment and comprehensive oral health educational programs for parents are also imperative, to improve parental skills in maintaining the oral health of their children, and provide an important basis for enhancing the role of parents in preventing dental caries among the children with ID. The study has put some light on disparity in oral health of children with ID, future studies with detailed biochemical and microbiological analysis in larger population is recommended.

   Conclusion Top

The present cross-sectional study suggests that there is a statistically significant difference in plaque and salivary pH among children with and without ID with lower plaque and salivary pH among children with ID. In addition to this, the oral health was also more compromised in children with ID.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Glassman P, Miller C. Dental disease prevention and people with special needs. J Calif Dent Assoc 2003;31:149-60.  Back to cited text no. 1
Altun C, Guven G, Akgun OM, Akkurt MD, Basak F, Akbulut E. Oral health status of disabled individuals attending special schools. Eur J Dent 2010;4:361-6.  Back to cited text no. 2
Al Agili DE, Roseman J, Pass MA, Thornton JB, Chavers LS. Access to dental care in Alabama for children with special needs: Parents' perspectives. J Am Dent Assoc 2004;135:490-5.  Back to cited text no. 3
Kenney MK, Kogan MD, Crall JJ. Parental perceptions of dental/oral health among children with and without special health care needs. Ambul Pediatr 2008;8:312-20.  Back to cited text no. 4
Wilson KI. Treatment accessibility for physically and mentally handicapped people – A review of the literature. Community Dent Health 1992;9:187-92.  Back to cited text no. 5
Berkowitz RJ. Acquisition and transmission of mutans streptococci. J Calif Dent Assoc 2003;31:135-8.  Back to cited text no. 6
Yarat A, Akyüz S, Koç L, Erdem H, Emekli N. Salivary sialic acid, protein, salivary flow rate, pH, buffering capacity and caries indices in subjects with Down's syndrome. J Dent 1999;27:115-8.  Back to cited text no. 7
Ameer N, Palaparthi R, Neerudu M, Palakuru SK, Singam HR, Durvasula S. Oral hygiene and periodontal status of teenagers with special needs in the district of Nalgonda, India. J Indian Soc Periodontol 2012;16:421-5.  Back to cited text no. 8
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Norwood KW Jr., Slayton RL; Council on Children with Disabilities; Section on Oral Health. Oral health care for children with developmental disabilities. Pediatrics 2013;131:614-9.  Back to cited text no. 9
Nelson LP, Getzin A, Graham D, Zhou J. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatr Dent 2011;33:29-36.  Back to cited text no. 10
Nowak AJ. Dentistry for Handicapped Patients. St. Louis: C.V. Mosby; 1976.  Back to cited text no. 11
Stabholz A, Mann J, Sela M, Schurr D, Steinberg D, Shapira J. Caries experience, periodontal treatment needs, salivary pH, and Streptococcus mutans counts in a preadolescent Down syndrome population. Spec Care Dentist 1991;11:203-8.  Back to cited text no. 12
Shapira J, Stabholz A, Schurr D, Sela MN, Mann J. Caries levels, Streptococcus mutans counts, salivary pH, and periodontal treatment needs of adult Down syndrome patients. Spec Care Dentist 1991;11:248-51.  Back to cited text no. 13
Hennequin M, Faulks D, Veyrune JL, Bourdiol P. Significance of oral health in persons with Down syndrome: A literature review. Dev Med Child Neurol 1999;41:275-83.  Back to cited text no. 14
Shanbhag PP, Ram SM, Gupta B. Knowledge and oral health attitudes among care providers of children with intellectual disabilities: A cross-sectional study. J Contemporary Dentistry 2014;4:92-8.  Back to cited text no. 15
Shawky S, Abalkhail B, Soliman N. An epidemiological study of childhood disability in Jeddah, Saudi Arabia. Paediatr Perinat Epidemiol 2002;16:61-6.  Back to cited text no. 16
Oredugba FA, Akindayomi Y. Oral health status and treatment needs of children and young adults attending a day centre for individuals with special health care needs. BMC Oral Health 2008;8:30.  Back to cited text no. 17
Pieper K, Dirks B, Kessler P. Caries, oral hygiene and periodontal disease in handicapped adults. Community Dent Oral Epidemiol 1986;14:28-30.  Back to cited text no. 18
Shaw L, Shaw MJ, Foster TD. Correlation of manual dexterity and comprehension with oral hygiene and periodontal status in mentally handicapped adults. Community Dent Oral Epidemiol 1989;17:187-9.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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