To evaluate the comparative status of oral health practices, oral hygiene and periodontal status...

C O M P A R AT I V E O R A L H E A LT H S T AT U S A M O N G S T B L I N D A N D S I G H T E D

78 Spec Care Dent is t 33(2 ) 2013 ©2012 Special Care Dentistry Association and Wiley Periodicals, Inc.

doi: 10.1111/j.1754-4505.2012.00296.x

A R T I C L E

The aim of this study was to evaluate

the comparative status of oral health

practices, oral hygiene, and periodontal

status amongst visually impaired and

sighted students. In this study, 142 visu-

ally impaired children from a blind

school in the age group of 6–18 years

were enrolled with a similar number of

age and sex matched sighted students

studying in different schools of

Chandigarh. The outcome variables were

oral hygiene practices, oral hygiene

status, and periodontal status. The visu-

ally impaired had been found to have

better oral hygiene practices, a nonsig-

nificant difference of oral hygiene scores

but a significantly high value for bleed-

ing scores as compared to sighted

students. Age wise comparisons showed

that bleeding scores were highly signifi-

cant in 9–11 years and 12–14 years age

group as compared to 6–8 years and

15–18 years age group. It could be

related that the increased prevalence of

bleeding sites despite of better oral

hygiene practices in visually impaired

group might be the result of their handi-

cap to visualize plaque.

A B S T R A C T To evaluate the comparative status of oral health practices, oral hygiene and periodontal status amongst visually impaired and sighted students Ashish Jain , MDS; 1 Jyoti Gupta , MDS; 2* Vyom Aggarwal , BDS; 3

Chinu Goyal , BDS 3

1 Prof. and Head, Department of Periodontics , Dr. H.S.J. Institute of Dental Sciences & Research ,

Chandigarh , India ; 2 Senior Lecturer , Department of Periodontics , Dr. H.S.J. Institute of Dental Sciences

& Research , Chandigarh , India ; 3 Lecturer, Department of Periodontics , Swami Devi Dayal Hospital and

Dental College, Barwala , Haryana , India .

* Corresponding author e-mail: [email protected]

Spec Care Dentist 33(2): 78-84, 2013

Despite the relatively high prevalence of visual impairment in India, 3 there is little available information regarding the dental health status and needs of such individuals. Some reports suggest that oral health is compromised in individu-als with visual impairments, who tend to have a higher incidence of dental caries and gingival disease. 4,5

However, other reports contradict this. 6,7 Very few studies have examined the health information needs of visually impaired individuals, and even fewer

have investigated the dental health needs of this group. 8 To determine the compar-ative oral health-care needs of individuals with visual impairments as well as sighted people, the oral-health status and experiences of such groups with respect to dentistry need to be estab-lished. To the best of our knowledge, there is no comparative data on visually impaired and age/sex-matched sighted individuals in a similar population. Therefore, the aim of this study was to determine and compare the oral-health

In t r oduc t i on Providing knowledge and awareness of the importance of oral health requires a struc-tured and customized program based on the target population. Nowadays, because oral health is considered to play a role in systemic health, 1 such awareness is increasingly important. However, special and medically compromised patients challenge dentists’ skills and knowledge not only for treating existing disease but also in disseminating treatment knowledge. The process of the development of oral diseases in disabled indi-viduals does not essentially differ from that in nondisabled individuals. However, because of their handicap, these individuals might react to diseases in different ways. Chang and Shih report that children with disabilities have higher levels of oral diseases because it is a priority to teach these children to manage their disabilities; conse-quently, oral hygiene is neglected. 2 Oral diseases like caries and periodontal diseases have specific etiologies, and these are preventable if proper awareness is imparted to individuals. However, generating awareness requires a starting point in terms of base-line data regarding not only the prevalence of a disease but also gaps in the knowledge of the target population that need to be addressed.

KEY WORDS: dental education ,

dental plaque , oral hygiene

scd_296.indd 78scd_296.indd 78 18/02/13 3:54 PM18/02/13 3:54 PM

Ja in et a l . Spec Care Dent is t 33(2 ) 2013 79


75% of the sighted individuals. Only 1.5% of the students in the visually impaired group brushed their teeth occa-sionally (i.e., not brushing daily) compared with 12% in the sighted group (Table 2 ).

Further, in total, 58%, 37%, and 5% of the visually impaired group had good, fair, and poor oral hygiene, respectively. For the sighted students, 65%, 32%, and 3% had good, fair, and poor oral hygiene status, respectively (Table 2 ).

Regarding the periodontal status of the subjects by using the CPI index, 62.6% and 55% of the visually impaired and sighted individuals exhibited evi-dence of bleeding on probing in one or more sextants, respectively. Approximately 42% of the visually impaired individuals had calculus depo-sition in one or more sextants, and 2% had calculus in all six sextants. Similarly, 43.6% of sighted students had calculus in all sextants (here, the percentage refers to the total number of sighted students who exhibited evidence of calculus depo-sition [CPI score 2] irrespective of age group); notably, 6.3% had calculus depo-sition in all six sextants (Table 2 ).

The overall assessment of periodontal status from CPI scores revealed that all six sextants were healthy (CPI score 0) in 23 (16.2%) visually impaired subjects compared with 29 (20.5%) sighted stu-dents (Table 2 ).

Comparisons of parameters between groups The means of the various parameters in the two groups were compared using the Mann–Whitney U- test (Table 3 ). The mean OHI scores for the visually impaired and sighted groups were 1.34 and 1.176, respectively; the difference was not statistically significant. However,

(c) Periodontal status using the Community Periodontal Index (CPI). As per the rules of the CPI, periodon-tal pockets are not recorded for children less than 15 years of age. There were only 9 male and 8 female subjects in each of the 15–18 year vis-ually impaired and sighted groups. Among them, one child in the visually impaired group had a periodontal pocket at one site, while one child had periodontal pockets at two sites in the sighted group. Because these readings were inapplicable for statistical com-parisons for these two groups, these readings were dropped for practical purposes. Bleeding on probing (CPI score 1) and calculus deposits (CPI score 2) were also taken into account.

S ta t i s t i ca l ana ly s i s The measured parameters of the two groups were compared using the Mann–Whitney U- test. The measured parameters of the subjects in each group were then compared by age using the Mann–Whitney U- test. The Kruskal–Wallis test was used to compare the various age groups between the sighted and visually impaired groups; the means of each age group were further compared using the Mann–Whitney U- test.

Resu l t s Regarding oral-hygiene practices, 96.4% and 95% of the visually impaired and sighted groups practiced the horizontal method of toothbrushing while 3.5% and 5% used the vertical method, respec-tively. In total, 93.6% of the visually impaired group was in the habit of brushing once daily compared with only

practices, oral-hygiene status, and perio-dontal status in both visually impaired and sighted students.

Mate r i a l s and me thods Study population A total of 284 subjects were enrolled in this study. Of these, 142 visually impaired students were examined in a residential school for the blind. As this was the only blind school in the area, all of the chil-dren were enrolled. In this group, there were 83 male and 59 female subjects. The subjects ranged from 6 to 18 years of age. The subjects were further divided into various age groups. A total of 142 age-matched sighted male and female students for the specified age groups were randomly selected from more than two schools in the same area (Table 1 ).

The subjects in both the visually impaired and sighted groups participated in a regular oral-health awareness session and received instructions regarding oral-health practices as part of a community outreach program of a dental school located in the students’ respective areas.

Procedure The ethical approval for performing this study was approved by the Punjab University Ethical Committee, and verbal consent was obtained from the partici-pants. All the students were assessed by two trained and calibrated examiners to control for interexaminer variability. Before the main survey, a pilot study was conducted on 30 children of differ-ent age groups and interexaminer reliability was assessed using kappa sta-tistics; the kappa value was 0.7, which indicates a substantial level of agree-ment. 9 A general questionnaire regarding oral-health practices was conducted, fol-lowed by dental check-ups.

The following parameters were assessed:(a) Oral-hygiene practices-type of clean-

ing, material used, frequency of cleaning, and method of cleaning.

(b) Oral-hygiene status according to the Oral Hygiene Index- Simplified (OHI-S by Greene and Vermillion). 10

Table 1. Study population by age groups and gender.

Age groups Visually impaired Sighted

Males Females Males Females

6–8 years 16 7 16 7

9–11 years 25 20 25 20

12–14 years 33 24 33 24

15–18 years 9 8 9 8


80 Spec Care Dent is t 33(2 ) 2013 Comparat ive ora l hea l th s tatus amongst b l ind and s ighted


bleeding sites was significantly greater in the 12–14 year group. Between the 6–8 and 15–18 year groups, OHI, bleeding, and calculus scores were significantly higher in the 15–18 year group ( p = .045, p < .001, p = .036, respectively); in addi-tion, the number of healthy sextants was significantly greater in the 6–8 year group ( p = .045; Table 5 ).

In Between the 9–11 and 12–14 year groups, the number of healthy sextants was significantly greater in the 9–11 year group ( p = .008). Between the 9–11 and 15–18 year groups, the number of healthy sextants was significantly greater in the 9–11 year group ( p = .001), while the number of bleeding sites was signifi-cantly higher in the 15–18 year group ( p = .041; Table 5).

However, There were no significant differences between the 12–14 and 15–18 year groups; that is, the oral status of these groups was almost similar (Table 5 ).

For the sighted students, when 6–8 and 9–11 year groups were compared, the OHI ( p = .009) and calculus scores ( p < .001) were significantly greater in the 9–11 year group. In addition, the number of healthy sextants was signifi-cantly greater in the 6–8 year group ( p = .009). Between the 6–8 and 12–14 year groups, the 6–8 year group had a signifi-cantly greater number of healthy sextants ( p = .004). The mean OHI ( p = .002) and calculus scores ( p < .001) were signifi-cantly greater in the 12–14 year group. Between the 6–8 and 15–18 year groups, the calculus scores were significantly greater in the 15–18 year group.

None of the measured parameters were significantly different between the 9–11 and 12–14 year groups. Between the 9–11 and 15–18 year groups, the bleeding scores were significantly greater in the 9–11 year group ( p = .050). Finally, none of the measured parameters were significantly different between the 12–14 and 15–18 year groups; that is, their oral statuses were almost similar.

D i s cus s i on Visual Impairment have an impact on oral health through physical, social, or

15–18 year group, the number of bleeding sites was significantly higher in the visually impaired ( p < .01); consequently, the mean number of healthy sextants was higher in the sighted group ( p = .026; Table 3).

Intragroup comparisons by age Intragroup comparisons of the visually impaired and sighted groups by age (Table 4 ) were made using the Kruskal–Wallis test; furthermore, the means of the parameters for various age groups were compared using the Mann–Whitney U- test (Table 5 ).

In the visually impaired group, the number of bleeding sites was signifi-cantly greater in the 9–11 year group than in the 6–8 year group ( p = .005). There were significantly more healthy sextants in the 6–8 than the 12–14 year group. In addition, the mean number of

the mean bleeding scores for the two groups were 1.51 and 1.20, respectively, and the difference was statistically signif-icant ( p = .044).

Comparison intergroup comparisons by age The means of the various age groups were derived and compared using the Mann–Whitney U- test (Table 3 ).

For In the 6–8 year group, the mean bleeding and calculus scores were signifi-cantly higher in the visually impaired group ( p = .019). In the 9–11 year group, none of the parameters were significantly different between the two groups. In the 12–14 year group, the mean number of healthy sextants was significantly higher in the sighted group ( p = .029); meanwhile, the mean number of bleeding sites was significantly higher in the visually impaired group ( p = .013). In the

Table 2. Oral hygiene practices, OHIS scores, bleeding and cal-culus scores.

Visually impaired Sighted

Oral hygiene practices

Type of cleaning Brush 142 (100%) 137 (96.4%)

Finger 0 4 (2.8%)

Datun 0 1 (0.7%)

Material cleaning aid used Toothpaste 142 (100%) 138 (97.2%)

Toothpowder 0 4 (2.8%)

Frequency of cleaning Once daily 133 (93.6%) 108 (76.05%)

Twice daily 7 (4.9%) 17 (11.97%)

Occasional 2 (1.4%) 17 (11.97%)

Method of cleaning Horizontal 137 (96.4%) 135 (95%)

Vertical 5 (3.5%) 7 (4.9%)

OHIS scores

Good 82 (58%) 92 (65%)

Fair 53 (37%) 46 (32%)

Poor 7 (5%) 4 (3%)

CPI scores (bleeding and calculus scores)

Bleeding on probing evident in one or more quadrants

(CPI score 1)

89 (62.6%) 78 (55%)

BOP evident in all the six quadrants 6 (4.2%) 6 (4.2%)

Calculus deposits evident in one or more quadrants

(CPI score 2)

59 (41.5%) 62 (43.66%)

Calculus deposits evident in all the six quadrants 3 (2.11%) 9 (6.3%)

Subjects with all the six healthy quadrants 23 (16.2%) 29 (20.5%)




subjects. As shown in Table 2 , the calcu-lus scores of the visually impaired (41.5%) are marginally less than those of the sighted students (43.66%). The poorer OHI scores in the visually impaired group despite fewer calculus deposits may be due to the higher debris component (i.e., soft deposits) of the OHI in the case of the visually impaired. Despite the more consistent brushing habits of the visually impaired, these observations can be explained on the basis that although a toothbrushing regimen was enforced, there was no

pared with 17 in the sighted group. Because the visually impaired live in an institutional setup in which caretakers enforce a mandatory oral-hygiene rou-tine, they brush daily with a brush and toothpaste more regularly. Meanwhile, the sighted students live in family units and probably are not subjected to the same kind of enforced routine; hence, some do not brush daily or use dental aids.

However, the mean OHI scores and number of bleeding sites were signifi-cantly higher in the visually impaired

informational barriers related to impair-ment, attendant medical condition (and associated medical disorders), or a lack of customized information. Other barri-ers include a lack of education and training of service providers for a partic-ular population. 11 In this study, the oral-hygiene practices of the visually impaired subjects were actually more consistent than those of the sighted ones. All of the visually impaired used a tooth-brush and toothpaste for cleaning, and only 2 were occasional users of cleaning aids (i.e., they did not brush daily) com-

Table 3. Comparison of visually impaired and the sighted students for all parameters.

Test statistics a

Group OHIS Healthy sextants Bleeding Calculus

Visually impaired Mean 1.333 3.20 1.51 1.13

Std. deviation 0.7959 2.013 1.614 1.754

Sighted Mean 1.176 3.57 1.20 1.23

Std. deviation 0.7633 2.128 1.603 1.873

Mann–Whitney test ( p value) .274 .112 .044 * .630

Age (years) Group OHIS Healthy sextants Bleeding Calculus

6–8 Visually Impaired Mean 1.111 4.39 0.52 0.70

Std. deviation 0.8893 2.105 1.238 1.460

Sighted Mean 0.805 4.52 1.43 0.04

Std. deviation 0.6825 2.129 2.150 0.209

Mann–Whitney test ( p value) .212 .693 .040 * .019 *

9–11 Visually impaired Mean 1.270 3.71 1.36 0.93

Std. deviation 0.7413 1.766 1.417 1.657

Sighted Mean 1.325 3.18 1.44 1.38

Std. deviation 0.8355 2.279 1.686 2.003

Mann–Whitney test ( p value) .952 .340 .973 .168


Std. deviation 0.7598 2.022 1.807 1.924

Sighted Mean 1.269 3.47 1.11 1.40

Std. deviation 0.7196 1.928 1.423 1.869

Mann–Whitney test ( p value) .709 .029 * .013 * .530


Std. deviation 0.8960 1.269 1.269 1.734

Sighted Mean 0.971 3.65 0.53 1.82

Std. deviation 0.6530 2.149 0.800 2.243

Mann–Whitney test ( p value) .104 .026 * <.001 ** .885

*Denotes that the values are significant at 1% probability level.

**Denotes that the values are significant at 5% probability level.

aGrouping variable: group.




12–14 year olds, the sighted group had significantly more healthy sections. Consequently, the number of bleeding sites was significantly greater in the visu-ally impaired group. A similar trend was observed in the 15–18 year olds. Hence, although calculus deposition does not increase in the older age groups, the ten-dency toward bleeding increases significantly and the number of healthy sextant decreases significantly in the vis-ually impaired group compared with the sighted group. These observations can be explained as follows: Although the visu-ally impaired students received some basic dental treatment procedures through the mobile dental services, there were no extra efforts involving study material or staff training for educating the visually impaired as part of an out-reach program so as to customize the program according to their needs. However, it is understandable that there

Therefore, it appears that the visually impaired require an awareness program that educates them in the role of plaque in oral health. Although it would be tedi-ous to explain an entity that a person cannot see; nevertheless, a customized program needs to be devised to achieve the desired results.

It is seen that in the 6–8 year age group, calculus deposition was signifi-cantly higher in the visually impaired than in the sighted 6–8 year group; how-ever, this difference diminished with progressing age. This could be explained by the fact that the members of the 6–8 year group had recently entered the insti-tution. The calculus deposition decreases in the older visually impaired groups because these students had received dental checkups and preliminary dental treatment twice in the previous 2 years via a mobile dental van visiting from a nearby dental school. Among the

customized awareness program consider-ing the limitations of the visually impaired. Although general oral-health sessions are given by a nearby dental school, these programs make no extra effort to customize the program for visu-ally impaired individuals who obviously require different approaches toward basic things such as visualization of plaque and calculus deposits and understanding their role in oral health. This is sup-ported by the observations of Mann et al . in 1984, who concluded that because the visually impaired cannot visualize plaque on tooth surfaces, even understanding the importance of oral hygiene is difficult for them; in turn, this results in the pro-gression of caries and inflammatory diseases of the periodontium (e.g., gingi-vitis and periodontitis). 12 However, they did not compare the status of sighted individuals to any of their comparable visually impaired counterparts.

Table 4. Comparison of the different age groups in each of the groups (visually impaired as well as sighted) for all the parameters.

Test Statistics a,b

Group Age (years) OHIS Healthy sextants Bleeding Calculus

Visually impaired 6–8 Mean 1.111 4.39 0.52 0.70

Std. deviation 0.8893 2.105 1.238 1.460

9–11 Mean 1.270 3.71 1.36 0.93

Std. deviation 0.7413 1.766 1.417 1.657

12–14 Mean 1.399 2.65 1.86 1.37

Std. deviation 0.7598 2.022 1.807 1.924

15–18 Mean 1.576 2.12 2.12 1.41

Std. deviation 0.8960 1.269 1.269 1.734

Kruskal–Wallis test ( p value) .168 <.001 ** <.001 ** .192

Sighted 6–8 Mean 0.805 4.52 1.43 0.04

Std. deviation 0.6825 2.129 2.150 0.209

9–11 Mean 1.325 3.18 1.44 1.38

Std. deviation 0.8355 2.279 1.686 2.003

12–14 Mean 1.269 3.47 1.11 1.40

Std. deviation 0.7196 1.928 1.423 1.869

15–18 Mean 0.971 3.65 0.53 1.82

Std. deviation 0.6530 2.149 0.800 2.243

Kruskal–Wallis test ( p value) .015 * .032 * .261 .001 **



aKruskal–Wallis test. bGrouping variable: age (years).




sextants between the two groups is prob-ably due to the lack of proper education and motivation coupled with the inabil-ity of the visually impaired to visualize

as debris, dental plaque, and calculus compared with their sighted peers.

The significant difference in the number of bleeding sites and healthy

is essentially a gap in communication between the educator and the target pop-ulation as these children cannot see; hence, they understand less about entities such

Table 5. Comparison of the individual age groups in each of the groups (visually impaired as well as sighted) for all the parameters.

Group Age (years) OHIS Healthy sextants Bleeding Calculus

Visually impaired group 6–8 Mean 1.111 4.39 0.52 0.70

9–11 Mean 1.270 3.71 1.36 0.93

Mann–Whitney test ( p value) .184 .078 .005 ** .600

6–8 Mean 1.111 4.39 0.52 0.70

12–14 Mean 1.399 2.65 1.86 1.37

Mann–Whitney test (p value) .068 .001 ** <.001 ** .218

6–8 Mean 1.111 4.39 0.52 0.70

15–18 Mean 1.576 2.12 2.12 1.41

Mann-Whitney test (p value) .045 * .001 ** <.001 ** .036 *

9–11 Mean 1.270 3.71 1.36 0.93

12–14 Mean 1.399 2.65 1.86 1.37

Mann–Whitney test (p value) .457 .008 ** .195 .334

9–11 Mean 1.270 3.71 1.36 0.93

15–18 Mean 1.576 2.12 2.12 1.41

Mann–Whitney test (p value) .268 .001 ** .041 * .081

12–14 Mean 1.399 2.65 1.86 1.37

15–18 Mean 1.576 2.12 2.12 1.41

Mann–Whitney test (p value) .502 .408 .265 .368

Sighted group 6–8 Mean 0.805 4.52 1.43 0.04

9–11 Mean 1.325 3.18 1.44 1.38

Mann–Whitney test (p value) .009 ** .009 ** .544 <.001 **

6–8 Mean 0.805 4.52 1.43 0.04

12–14 Mean 1.269 3.47 1.11 1.40

Mann-Whitney test (p value) .002 ** .004 ** .834 <.001 **

6–8 Mean 0.805 4.52 1.43 0.04

15–18 Mean 0.971 3.65 0.53 1.82

Mann–Whitney test (p value) .225 .190 .291 .001 **

9–11 Mean 1.325 3.18 1.44 1.38

12–14 Mean 1.269 3.47 1.11 1.40


9–11 Mean 1.325 3.18 1.44 1.38

15–18 Mean 0.971 3.65 0.53 1.82

Mann–Whitney test (p value) .217 .441 .050 * .703

12–14 Mean 1.269 3.47 1.11 1.40

15–18 Mean 0.971 3.65 0.53 1.82


Note: Grouping variable: age (years) means that the test statistics in this table are derived by comparing the various age groups for different parameters.






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sents the suitable intervention time for care in these children as all the parame-ters are relatively constant thereafter. This is concordant with the fact that the tendency toward gingival diseases increases near the prepubertal and puber-tal years. Thus, if a suitable program for dental education is instituted in these age groups, the visually impaired as well as sighted would receive the maximum ben-efit in terms of maintaining their oral hygiene and thereby avoiding inflamma-tory gingival conditions.

Conc l u s i on In this study, although visually impaired subjects practiced regular oral hygiene more often, they exhibited poorer oral hygiene and an increased prevalence of bleeding sites (i.e., gingivitis) compared with the sighted students. This is probably due to their inability to see plaque and the early signs of bleeding. More importantly, this discrepancy is due to the lack of a customized awareness program. Within the limitations of this study, age-wise comparisons showed that the 9–11 and 12–14 year groups shared the maximum burden of the disease. Hence, we suggest that a thorough dental education with a particular emphasis on the needs and learning abilities of children of these ages should be advocated by either dentists themselves or through healthcare-provid-ers at institutions. There is some evidence in the literature that highlights the need to provide more oral-health education for visually impaired people. 14-16 Therefore, these patients can be managed well with adequate training and alterations in den-tists’ routine preventive and treatment protocols. Providing comprehensive dental care for the visually impaired is not only rewarding but also a community service that health-care providers are obligated to fulfill.

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disease mat affect systemic diseases: inversion

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dental plaque on tooth surfaces and early signs of inflammation such as color changes and bleeding. In 2008, Mahoney et al . 13 concluded that the main dental problem afflicting visually impaired per-sons is the increased incidence of periodontal disease; this also supports the present findings.

Among the visually impaired stu-dents, the 6–8 year group had significantly more healthy sextants than other age groups. Meanwhile, the bleed-ing scores were significantly higher in the 12–14 and 15–18 year groups. Among the 9–11, 12–14, and 15–18 year groups, the 9–11 year group had the most healthy sextants while the 15–18 year group had the most bleeding sites. There were no significant differences in the parameters between the 12–14 and 15–18 year groups; therefore, the oral status was similar in these age groups. When sighted students in the various age groups were compared, the OHI and calculus deposit scores were significantly higher in the 9–11, 12–14, and 15–18 year groups than those in the 6–8 year group. This means that there was increased calculus deposition and hence poorer oral hygiene in the sighted group with the advancement of age. Moreover, the number of healthy sextants was significantly higher in the 6–8 year group, and the bleeding scores were sig-nificantly higher in the 9–11 year group than in the 6–8 and 15–18 year groups. Again, there were no significant differ-ences in any of the parameters among the 9–11, 12–14, and 15–18 year groups.

A limitation of this study is that there were more boys than girls in all the age groups. Second, the largest numbers of children were in the 9–11 year groups followed by the 12–14 years groups due to the available study population in the blind school.

However, this is still representative of the blind population in the area as this was the only blind school. The compari-son of the present findings with the literature is limited as there are no com-parative status evaluations of the visually impaired with age- and sex-matched con-trols. The observations of this study suggested that 9–14 years of age repre-


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