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Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 214-220

Oral health status and microbial load of Streptococcus mutans in children with Cerebral palsy in a tertiary care hospital in Delhi

1 Department of Pedodontics and Preventive Dentistry, UCMS and GTB Hospital Delhi, Delhi, India
2 Microbiology, UCMS (University of Delhi) and GTB Hospital, Delhi, India
3 Paediatrics, UCMS (University of Delhi) and GTB Hospital, Delhi, India

Date of Submission27-Apr-2020
Date of Decision11-Jun-2021
Date of Acceptance04-Jul-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Namita Kalra
Department of Pedodontics and Preventive Dentistry, UCMS (University of Delhi) and GTB Hospital, Delhi 110 095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_194_20

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Background: Cerebral palsy (CP) is a childhood debilitating condition which impairs the physical and mental ability of an individual to maintain oral health. Aim: The objective of the present study was assessment of dental neglect and burden of treatment needs of children affected with CP as compared to normal children in a tertiary care hospital in Delhi. Settings and Design: A sample size of 104 children of age group of 6–14 years was selected, in which 52 children of CP (case group) and 52 normal school children (control group) were recruited. Materials and Methods: Children from both groups were examined, and calculation of drug master files (DMFS), defs, oral hygiene index (OHI), and gingival index was done. The presence of trauma and malocclusion was assessed. Present caries activity was assessed by the level of Streptococcus mutans present in saliva in both groups. Treatment needs were then assessed based on intraoral findings. Statistical Analysis: Data were analyzed by SPSS 20.0 software. Student's t-test and nonparametric statistical tests such as Chi-square test and Mann–Whitney test were used as per the nature of variables studied for statistical analysis with the level of significance denoted at P < 0.05. Results: The mean DMFS, gingival index, OHI, and treatment needs were observed to be higher in the CP group. Increased S. mutans levels were observed in saliva of CP patients. Defs score, trauma, and malocclusion were not statistically significantly higher in CP group as compared to the control group. Conclusion: Cerebral palsy group had a poor oral and gingival health, a higher DMFT and burden of treatment needs and an increased risk of further caries progression due to high caries activity indicated by increased level of salivary Streptococcus mutans than the control group.

Keywords: Cerebral palsy, oral health, Streptococcus mutans

How to cite this article:
Kaushal D, Kalra N, Khatri A, Tyagi R, Singh N P, Aggarwal A, Saha R. Oral health status and microbial load of Streptococcus mutans in children with Cerebral palsy in a tertiary care hospital in Delhi. J Indian Soc Pedod Prev Dent 2021;39:214-20

How to cite this URL:
Kaushal D, Kalra N, Khatri A, Tyagi R, Singh N P, Aggarwal A, Saha R. Oral health status and microbial load of Streptococcus mutans in children with Cerebral palsy in a tertiary care hospital in Delhi. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Aug 11];39:214-20. Available from: http://www.jisppd.com/text.asp?2021/39/2/214/322497

   Introduction Top

Cerebral palsy (CP) is a primary debilitating condition of childhood. According to definition, “CP describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior; by epilepsy; and by secondary musculoskeletal problems.”[1] Due to impaired motor function, these children have a decreased ability for maintaining oral health.[2] Lack of oral hygiene due to inadequate plaque control, higher intake of sweetened food items, and oral medications entails them for developing dental caries and periodontal diseases.[3] Impaired oral health and increased demand of treatment needs forms a vicious cycle with the general health and well-being of the patient. Neglected oral hygiene may be contributory to nutritional deficiencies such as protein energy malnutrition, endocrinal dysfunctions, and affected growth as observed in the form of decreased linear growth, weight loss, abnormal body composition, and decreased bone density.[4] It reflects the importance of necessary surveillance of treatment needs and prompt intervention to maintain dental as well as general health. Henceforth, the purpose of this study was to assess oral health status, present caries activity through assessment of Streptococcus mutans levels in saliva, and treatment needs burden of children affected with CP as compared to healthy children of the same age group and socioeconomic status.

   Materials and Methods Top

After clearance from the Institutional Ethics Committee, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, the study commenced with standardization of examination to be performed by a single examiner under supervision and random assessment of recorded data to avoid errors due to any misinterpretation on the part of the examiner. Case selection was based on inclusion criteria of a patient with a proven clinical medical diagnosis of CP.[5] Exclusion criteria for the study was any patient who underwent any surgical procedure performed to reduce salivary flow.[6]

In this study, considering a standard deviation of 2.25 units of drug master files (DMFS) to detect mean difference of 1.25 units in DMFS score between CP children and healthy control group children revealed by a previous study with 80% power and 0.05% level of significance, a sample of 52 participants in each group was calculated.[7] A sample size of 104 children of age group of 6–14 years was selected, in which 52 children of CP (case group) and 52 normal school children (control group) were recruited.

For oral examination of children with CP and children who formed the control group, relevant case history was recorded followed by indices recording in the sequence: oral hygiene index (OHI), gingival index, DMFS/defs, trauma, and malocclusion. No radiographic aid was, however, used for examination due to insufficient patient cooperation in CP cases.

Briefly the intraoral examination comprised

Assessment of oral hygiene based on OHI index was given by Green and Vermillion.[8] It was followed by the assessment of gingival index.[9] Dental caries and treatment needs recording were based on the WHO, Oral Health Surveys, Basic Method (1997 and 2013) criteria.[10],[11] The clinical examination of DMFS/defs was performed based on visual tactile criteria. Trauma was assessed as per Ellis classification of trauma.[12] Malocclusion was assessed as per Angle's classification for malocclusion.[13]

Microbiology assessment

The microbiological standardization was done for the following: (1) preparation of media (Mitis Salivarius Bacitracin [MSB] agar; HiMedia Laboratories Pvt Ltd), (2) inoculation of sample, and (3) S. mutans colony morphology characterization.

After indices assessment, 3 ml of saliva sample was collected from examined children after they were made to rinse their mouth to wash out any food debris and exfoliated cells. Unstimulated saliva was collected by asking the child to sit with their head slightly down during the period of collection. Saliva secretions were allowed to collect in the floor of the mouth and 25 children who could comply with commands were asked to spit into a sterile graduated jar until 3 ml of saliva was collected. In remaining 27 children who were unable to follow provided directions, a sterile graduated pipette was used for sample extraction from the patient's mouth and then was collected in a sample collection vial. The sample was then transferred to Microbiology laboratory for colony culture and characterization. Briefly, 1 loopful of salivary specimen was inoculated on MSB agar. Plates were incubated in CO2 incubator in microaerophilic environment (5% CO2 at 37°C for 48 h).[14] Colonies of S. mutans were identified by their colony characteristics. Semiquantitative culture technique was used for isolation and quantification of colony counts of S. mutans. The microbiological counts were expressed in colony-forming units per milliliter of saliva (colony-forming unit [CFU]/ml).

Statistical analysis

The data were analyzed by SPSS software version 20 (IBM Corp. Chicago, IL, USA). Student's-t-test and nonparametric statistical tests such as Chi-square test and Mann–Whitney test were used as per the nature of variables studied, with the level of significance denoted at P < 0.05.

   Results Top

The current study focused on children within age group of 6–14 years [Table 1]. The mean age in CP group was 7.03 ± 1.57. Gender distribution comprised 76.9% (40) males and 23.1% (12) females. One child had primary dentition and 51 were observed with mixed dentition in CP group.
Table 1: Profile of study population

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Control group (mean age: 6.47 ± 1.04) had a gender distribution of 55.8% (29) males and 44.2% (23) females. Deciduous dentition was observed in 3 children, while 49 had mixed dentition.

In CP group, 65% were affected with spastic quadriplegia, 19% with spastic diplegia, 5% with dystonia, and 9% with spastic hemiplegia.

The results for intergroup comparison of indices in CP group and control group are summarized in [Table 2] and [Figure 1]. CP group showed higher DMFS, OHI, and GI scores (P < 0.05). defs was not statistically significantly higher in CP group (P < 0.05).
Table 2: Mean decayed, missing, and filled permanent teeth, defs, gingival index, oral hygiene index score of patients with cerebral palsy compared with age matched controls

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Figure 1: Comparison of respective mean of drug master files, defs, GI, and oral hygiene index indices between cerebral palsy group and control group

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[Table 3] and [Table 4] show comparison of trauma and malocclusion association in both groups. No statistically significant difference was found for trauma occurrence (P = 0.603) and malocclusion (P = 0.812) occurrence between CP group and control group.
Table 3: Trauma occurrence amongst cerebral palsy patients and control group and its inter-group comparison

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Table 4: Distribution of cerebral palsy cases and controls according to type of occlusion and intergroup comparison for prevalence of malocclusion

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[Table 5] and [Figure 2] present tabulation of treatment needs. The CP group showed significantly higher need for procedures with pulpal involvement and postendodontic restorations, crowns, and extractions (P < 0.05). The control group required significantly higher preventive care, fissure sealants, and one surface filling.
Table 5: Treatment needs for cerebral palsy group versus control group

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Figure 2: Treatment needs comparison between cerebral palsy group and control group

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S. mutans (CFU/ml) in saliva was assessed and compared between CP group and control group in [Table 6]. In the present study, total (86%) of CP group samples had detectable levels (>103) of S. mutans in saliva, whereas (72%) control group samples had detectable levels (>103) of S. mutans. In CP group, a total of 32 samples had high S. mutans levels, out of which 16 samples had a CFU/ml count between (106 and 105) and 16 samples had a CFU/ml between (105 and 104) in saliva. In control group, only 13 patients had high S. mutans levels, out of which only 1 sample had a CFU/ml count (106–105), while 12 samples had a CFU/ml (105–104) in saliva. A “P value” of 0.008 indicates a significant correlation between the presence of high levels of S. mutans in salivary samples of CP group when compared to control group. Clinically low (<103) S. mutans levels were observed in 11 CP cases and 23 control group cases. S. mutans was not identified in quantifiable range in 9 CP cases and 16 control group cases.
Table 6: Streptococcus mutans levels in saliva (CFU/ml) and its comparison in study patients and controls

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   Discussion Top

CP is a group of disorder, in which intellectual and physical disability leads to an inability in comprehension of essential oral care and a relative lack of neuromuscular coordination to carry out daily activities in affected individuals. The present study tried to achieve a picture of comprehensive oral health of children with CP in comparison with children of normal age to demarcate intricate differences seen between the two and how the dental demands of special child differ from that of a healthy young child. However, few limitations for the study were lack of radiographic examination of both groups to comprehend the extent of carious lesions and any therapeutic intervention for caries control and oral hygiene maintenance amongst both groups.

In the present study, a higher DMFS was reported in permanent dentition in CP group than control group similar to an investigation by Santos et al., which revealed that the DMFS of children with CP was significantly higher than that of normal children (P < 0.05).[7] Similar findings were reported by other studies pointing possible reason behind increased caries experience to be food consistency, long-term uptake of oral medications combined with compromised oral motor functional skills, and difficulties in maintenance of oral hygiene.[15],[16],[17],[18]

Poor oral hygiene was observed evidently in both CP group and control group, but was statistically significantly higher in CP group in the present study and this observation was also made by other studies.[19],[20] Unsatisfactory oral hygiene in CP patients has often been associated with difficulty faced by parents in properly brushing their children's teeth and less developed self-help skills in these individuals. Furthermore, motor alterations and poor mental development decrease their ability to learn and maintain adequate dental hygiene and self-help skills.[21] As stated by Oredugba, as these children grow in age, they are left alone to carry out daily activities like other normal children, which may not be carried out effectively, thus be contributory to poor oral hygiene.[17]

Poor gingival health and a predisposition for periodontal disease development has been observed in CP children due to lack of oral hygiene, physical disabilities, malocclusion, complications of oral habits, and gingival hyperplasia caused by medications.[20],[22],[23] It was evidently observed in the current study.

Treatment needs assessed in CP group showed significantly higher burden for interventional care, while the control group required significantly higher preventive care. Huang et al. reported that most of the treatment needs in CP children escalate with increasing age.[24]

Malocclusion had a nonsignificant prevalence in CP group in comparison to control group in this study in comparison to another study, which reported otherwise and stated malocclusion to be significantly evident in CP patients.[3]

An insignificant association of trauma occurrence was observed in children with CP as compared to control group children in this study and was substantiated by another study with similar outcome.[25] However, Holan et al. found increased risk of dental trauma in the CP population when compared to general population.[26] Increased risk of traumatic dental injuries in CP patients has been attributed to Class II malocclusion with prominent maxillary incisors, difficulties with ambulation, and occurrence of seizures.[27]

An increased caries risk was also seen in CP patients by assessment of caries activity by salivary test for S. mutans, which has been directly implicated as principle pathogen in the initiation and progression of dental caries.[28] Isolation of mutans Streptococci was greatly facilitated by the development of the selective MSB medium (MSB agar) for S. mutans and principle identification by characteristic morphology of its colonies on 5% sucrose containing MSB culture media.[29],[30] Jordan et al. observed a low microbial risk for caries when S. mutans levels were detected in lower limits in CFU/ml range of 103–104 and a higher caries risk when S. mutans were detected in CFU/ml range of 105–106. This low risk-high risk dichotomization may provide help in monitoring the microbiologic status of patient during progression of any caries preventive schedule.[31]

The CAMBRA protocol for caries risk assessment introduced by Featherstone also advises a scan for salivary S. mutans levels in children to assess the biologically predisposing factors, which may contribute to dental caries progression.[32] Caries risk assessment may be a contemporary tool for these children as they are already placed in the high-risk group due to being medically compromised. In special child care, establishment of dental home for early diagnosis and active intervention along with anticipatory guidance, follow-up, and referrals to suitable clinical stream may help in decreasing dental debilitation of child.[33]

Diet counseling to reduce and limit sugar exposures and to ensure apt nutritional needs may be provided to caretakers to prevent occurrence of malnutrition and further deterioration of mental development.[4],[32]

Since the child cannot perform brushing properly, assisted brushing and flossing while supporting the child's head must be provided by parent/caretaker. Mechanical power-driven brushes and chemotherapeutic measures like chlorhexidine spray may aid in maintenance of oral hygiene and reduction of plaque formation and reduce gingival inflammation[34] In addition, fluoridated toothpastes and topical fluoride application may decrease the dental caries activity and possibly arrest the active caries which are difficult to treat. Newer materials such as RMGIC, silver diamine fluoride, and combination of casein phosphopeptide-amorphous calcium phosphate have by far increased the fluoride incorporation in tooth and ease of use. They have been used for caries arresting and restorative care in normal children and may prove to be beneficial for CP cases as well as a treatment measure. The use of sedation through general anesthesia or conscious sedation may also be sought to intervene the already progressed carious lesion in patients who are unable to co-operate.[35]

The study did not make radiographic assessment to determine extent of caries due to difficulty faced during taking radiographs in CP group. However, to overcome the difficulties faced during radiographic imaging in CP cases, intraoral films with bitewing tab may be used for intraoral and periapical radiography along with an 18-inch long floss passed through a hole made in bitewing tab for easy retrieval of film. Rinn Snap-A-Ray or mouth props may be used as adjunct while taking intraoral radiographs. Extraoral radiographs such as panoramic radiography lateral jaw or a 45° projection may also be used if patient is unable to open their mouth. Modifications of film by bending corners of film to avoid irritation and using smallest possible film for taking radiographs can be done in CP-affected children to accommodate the film intraorally.[36],[37],[38]

If a CP affected child is able to maintain a good oral health, it may also help them in maintaining proper nutritional status and overall health. It might as well reflect upon the duty of dental fraternity to work hard toward matching up with their staggering oral demands whenever needed by providing optimal oral care through adaptation of special dental skills so that they can lead their lives with maximum content.

   Conclusion Top

CP group showed a higher observation of DMFS index than control group in permanent dentition. Measured defs of CP group was not significantly higher than the control group. Oral hygiene was found to be significantly poor in CP group. Gingival health in CP group was significantly poor as compared to control group. Treatment needs were observed to show a more preventive care requirement in control group whereas CP group required more invasive treatment including pulpectomy, stainless steel crowns, and extractions. Active caries and increased chances of further progression was represented by increased level of S. mutans in salivary samples of CP group as compared to control group.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

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


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