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QUI NTESSENCE I NTERNATI ONAL

PEDIATRIC DENTISTRY
Dental caries experience and barriers to care in
young children with disabilities in Ireland
Darius Sagheri, DDS, MDentSc, Dr Med Dent, PhD
1
/Jacinta McLoughlin,
BDentSc, MDS
2
/June H. Nunn BDS, MA, PhD
3
Objective: Dental caries among preschool children remains a signicant dental public
health problem. In Ireland, there are no national data available regarding dental caries lev-
els in preschool children. Furthermore, the number of young children with disabilities and
their dental caries levels remains unknown. The aim of the present study was to measure
the dental caries levels in a sample of preschool children with disabilities. Method and
Materials: A toam o trainod and oalibratod dontists oxaminod a samplo o all 0- to 6-yoar-
old preschool children with disabilities in two health service administrative areas under
standardized conditions. Dental caries was recorded using WHO criteria. Results: Of a
total o 422 partioipants, 337 datasots woro inoludod in tno study. O tnoso 337 oxaminod
onildron, approximatoly 75.1% nad a oognitivo disability and 12.9% nad a nonoognitivo
disability. n 12% o tno onildron, a diagnosis nad not yot boon ostablisnod. Dontal oarios
at dentin level was detected from the age of 4 years. The overall mean decayed/missing/
hllod tootn (dmt) was 0.49 (SD, 1.39). Tno analysis o moan dmt lovols in onildron witn
positivo (dmt > 0) sooros rovoalod a moan dmt o 1.14. Conclusion: The evidence from
this study demonstrated that dental caries levels in preschool children with disabilities in
Ireland are low when compared with the general population. Furthermore, children aged 3
yoars or youngor oxnibitod no dontal oarios at dontin lovol and tnorooro woro not aootod
by oarly onildnood oarios. An ad|ustmont o ourront oral noaltn provontion praotioo may
lead to a further reduction in dental caries levels in this section of the child population.
(Quintessence Int 2013;44:159169)
Key words: oarios oxporionoo, disability, roland, prosonool onildron, primary tootn
1
Associate Professor in Oral Health Services Research,
Department of Public and Child Dental Health, Dublin Dental
School and Hospital, Trinity College, University of Dublin,
Ireland.
2
Senior Lecturer in Public Dental Health, Department of Public
and Child Dental Health, Dublin Dental School and
Hospital,Trinity College, University of Dublin, Ireland.
3
Professor in Special Care Dentistry, Department of Public and
Child Dental Health, Dublin Dental School and Hospital, Trinity
College, University of Dublin, Ireland.
Correspondence: Dr Darius Sagheri, Department of Public and
Child Dental Health, Dublin Dental School and Hospital, Trinity
College, Lincoln Place, Dublin 2, Republic of Ireland. Email:
darius.sagheri@tcd.ie
Oral health is an integral part of general
health and signicantly affects the well
being and quality of life.
1
Altnougn tno
prevalence and severity of dental caries in
the general population has fallen dramati-
cally in developed countries in the past few
decades, dental caries has remained a
problem for a signicant proportion of
young children. Dental caries among pre-
school children remains a signicant dental
public health problem, especially among
socially disadvantaged groups in society.
2

In Ireland, there are no national data on
dental caries levels in preschool children
availablo. Tno olosost approximation to tnis
age group are data for 5-year-old children.
Tno 2002 national survoy o onildron's oral
noaltn in roland snowod tnat 36.9% o onil-
dron in huoridatod aroas and 54.5% o onil-
dren in nonfluoridated areas had
oxporionood dontal oarios.
3
The plight of
children with disabilities is unknown,
although evidence from the literature would
indicate that their dental caries levels are
similar to, if not less than, that of children
without disability.
4
Dental caries in young
children, especially if it progresses often
necessitates recourse to a general anes-
thetic for treatment to be carried out. This is
especially true for children with disabilties.
This is unacceptable given that dental car-
160 VOLUME 44 NUMBEP 2 FEBPUAPY 2013
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Sagheri et al
ies is a preventable disease and dental
general anesthetic is not without morbidity
and mortality. This is of particular concern
in already compromised children. Therefore,
data on the dental health of preschool chil-
dren with disabilities can serve as a vital
component for planning appropriate oral
health care prevention programs and
informing established patterns of clinical
practice. The overall aim of this study was
to measure the dental caries at dentin level
in a sample of preschool children with dis-
abilitios in tno Popublio o roland.
METHOD AND MATERIALS
Currently, no accurate information is avail-
able on the numbers of preschool children
witn disabilitios in tno Popublio o roland.
The available data only provide an outline of
the prevalence of disabilities in young chil-
dren. Kelly et al
5
noted in their report, which
was basod on National ntollootual Disability
Databaso (NDD), tnat rogistration on tnis
database is voluntary and that an underep-
resentation of young children with an intel-
lectual disability is apparent. In their study
on how disability is measured in Ireland,
O'Donovan and Good
6
found that there is a
considerable divergence in the denition of
disability employed in research, legislation
and eligibility determination and that this
inoonsistonoy sorvos to rostriot tno oxtont to
which national data from different sources
can be compared and used.
Approximatoly 10% o onildron aro oon-
sidered to have some learning impairment,
wnilo as many as 3% maniost somo dogroo
o intollootual disability. O tnoso 3%,
approximatoly 2.7% aro oonsidorod to navo
a mild intellectual disability, whereas in total
0.3% to 0.4% o onildron aro oonsidorod to
have a moderate, severe, or profound intel-
lectual disability.
7
n an risn oontoxt, approximatoly 1,282
o 0- to 6-yoar-old prosonool onildron may
have a moderate, severe, or profound intel-
lectual disability.
8
However, a sizable num-
ber of preschool children may not yet have
been diagnosed with a disability and there-
fore remain uncounted.
Booauso o tnoso unoortaintios it was
decided to identify health service admin-
strative areas as survey regions, which are
similar in their demographic and social
composition, cover a considerable size of
the population, and are representative of
tno ovorall population. Tno Hoaltn Sorvioo
Exooutivo (HSE) is rosponsiblo or providing
health and personal social services to
ovoryono living in tno Popublio o roland
and consists of four adminstrative areas.
Basod on tno provious oonsidorations,
advioo was sougnt rom tno Small Aroa
Hoaltn Posoaron Unit (Dopartmont o Publio
Hoaltn and Primary Caro, Trinity Collogo,
Univorsity o Dublin, Dublin, roland). Also, a
dental epidemiologic study was initiated in
two HSE administrativo aroas, HSE Nortn-
East (ie, local health ofces in Cavan/
Monagnan, Loutn, and Moatn) and HSE
Soutn-East (io, looal noaltn ohoos in Carlow/
Kilkonny, Soutn Tipporary, Watorord, and
Woxord) in wnion approximatoly 18.5% o
the total population were residing.
8
Basod
on tno provious assumptions, approximato-
ly 237 prosonool onildron (0 to 6 yoars o
age) with a moderate, severe, or profound
intellectual disability were likely to reside in
the sample regions.
Pooont national risn oral noaltn survoys
in children and adults
3,9
required a data col-
lection period between 9 and 23 months.
Keeping in mind that the participants in
those surveys were known and available in
school or their homes, it was decided to
allow a data collection period for the pres-
ont study o up to 36 montns to onsuro a
high participation level. Only preschool
onildron witn disabilitios agos 0 to 6 yoars at
tno timo o tno oxamination woro solootod
as the study population. The age of the chil-
dren was dened as the chronologic age in
yoars at tno dato o tno olinioal oxamination.
Families were continuously recruited by
Enablo rolands' Early ntorvontion Sorvioos
in the two selected regions for inclusion in
the study. Enable Ireland is a voluntary ser-
vice provider that delivers disability servic-
es for children and adults on behalf of the
HSE. All amilios alroady rogistorod witn tno
Early ntorvontion Sorvioos in tno solootod
regions or who came on the register during
the study period were invited to participate
in the study.
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Four olinioal oxaminors (dontists),
inoluding tno prinoipal invostigator (DS) o
the present study, and recorders (dental
nurses) were trained and calibrated prior to
the commencement of the eldwork to
ensure reliability in the measurement indi-
ces following WHO guidelines.
10
The trainer
(JHN), wno nad oxtonsivo oxporionoo in
oral health surveys, provided the standard
against wnion tno oxaminors woro oalibrat-
ed. The initial training and calibration pro-
gram took plaoo in Juno 2006. Tno lovol o
agroomont botwoon tno oxaminor and tno
gold standard was assessed by use of the
Kappa statistic.
11
The level of agreement
botwoon tno oxaminors and tno gold stan-
dard was calculated and showed an agree-
mont o kappa = 0.91. Follow-up training
and discussion sessions or telephone brief-
ings woro nold in rogular intorvals (approxi-
matoly ovory 6 montns) or wnon a quostion
or problem arose to ensure consistency
witn tno moasuromont indox and to addross
all issues that arose while conducting the
study.
The Trinity College Faculty of Health
Soionoos Posoaron Etnios Committoo
reviewed the protocols for training and cali-
bration o tno oxaminors in addition to tno
main study. The committee approved the
study in May 2005. Tno HSE Nortn-East
Aroa Posoaron Etnios Committoo approvod
tno study in April 2005. And tno HSE Soutn-
East Aroa Posoaron Etnios Committoo
approvod tno study in Juno 2005.
All data oollootod in tnis study woro oon-
dential. It is not possible to match the
dental health status with an individual child.
All standard oonhdontiality proooduros
were followed. Legislation covering data
protection was adhered to when collecting,
handling, and reporting on any collected
data.
All paronts/oarogivors o partioipating
children were fully informed regarding the
nature of the study and the benets of par-
ticipating at least 7 days before conducting
tno oral oxamination. At tno appointmont or
tno oral oxamination, a oonsont orm was
given to the accompanying parent/caregiv-
or. Clinioal oxaminations woro oarriod out
only in children with completed consent
forms (positive consent).
Tno olinioal oxamination took plaoo in
dontal surgorios. Tno oxaminor was soatod
noxt to tno sub|oot, wno was in a supino
position on a reclined dental chair or in the
oarogivor's lap. A singlo-uso plain moutn
mirror head with a ber optic light (cordless
DenLite Illuminated Mirror, 1 watt LED light
|Miltox]) was usod to illuminato tno moutn.
Cnildron woro only oxaminod or dontal oar-
ios tnat nad oxtondod tnrougn tno tootn
enamel and into dentin, using World Health
Organization (WHO) oxamination oritoria.
10

These criteria dictate that only dental caries
at oavitation lovol snould bo rooordod. An
additional reason to record only dental car-
ies at the cavitation level is that this level of
dental caries is considered to produce non-
ambiguous results in the present sample
population, which may have limited ability to
oooporato wnilo oonduoting tno oxamina-
tion. Tno tootn woro oxaminod wnilo wot,
and a ball-tippod CPTN (Community
Poriodontal ndox o Troatmont Nood) probo
was used to remove plaque and conrm the
diagnosis o oavitation. All data woro ool-
lected on a schematized electronic record
snoot on a tablot PC and prooossod and
analyzod using SPSS 19 (BM).
To investigate barriers to participation in
the present study, qualitative research was
employed. This qualitative analysis could
provide valuable insights into the perspec-
tives of the study population and their dif-
culties in participating in epidemiologic
rosoaron. Somistruoturod, individual intor-
views were used, because interviews can
assist respondents in speaking freely.
12
The
intorviows woro somistruoturod to allow hox-
ible data collection, so that emergent issues
oould bo oxplorod alongsido disoussion o
the key themes.
13
RESULTS
O a total o 546 oontaot dotails orwardod
or partioipation in tno study, 422 (77.3%)
children attended an individually arranged
appointment. Of these 422 attendees, 337
datasots (79.9% o tno attondoos) woro
included in the present study. Eighty-ve
datasots woro oxoludod rom tno prosont
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analysis due to insufcient/incomplete infor-
mation. Tno oxoludod onildron woro not
cooperative enough to undergo a full oral
oxamination at tno timo o tno appointmont.
Of the 337 children included in the pres-
ont analysis, 191 (56.7%) onildron woro
oxaminod in tno HSE Nortn-East and 146
(43.3%) onildron woro oxaminod in tno HSE
Soutn-East. O tnoso, 121 (35.9%) omalos
and 216 (64.1%) malos woro oxaminod.
Table 1 gives a detailed overview on the
age and disability distribution of the sam-
plo. All onildron oxaminod woro olassihod
into one of the following ve disability
groups, based on their reported medical
diagnosis: cognitive disability, physical dis-
ability, cognitive, and medically compro-
mised, medically compromised, and no
diagnosis. Tno ma|ority o onildron woro
diagnosed with a cognitive disability.
A roviow o tno data rovoalod tnat 43 o
tno onildron oxaminod woro ovor tno ago o
6 yoars. Tno oontaot dotails o tnoso onil-
dren were submitted for inclusion in the
study before their 7th birthdays, but it
appears that these children were not seen
or tno oral oxamination booro tnoir birtn-
days. Booauso tnoso onildron woro |ust
past their 7th birthdays, it was decided to
report on their dental caries levels, as well.
To investigate if there was an associa-
tion between the proportion of children with
a cognitive disability and their age, a chi-
square test of homogeneity was conducted.
To facilitate this analysis, the children were
arranged in the following three age groups:
3 yoars o ago or youngor, 4- to 6-yoar-olds,
and 7 years of age or older. They were
stratied into the following two disability
categories: children with a cognitive disabil-
ity and children with a noncognitive disabil-
ity. Table 2 demonstrates that all relevant
oolls nad an oxpootod oount o > 5. Tno
minimum oxpootod oount was 10.72. Tno
Poarson oni-squaro tost or indopondonoo
indicates no signicant association between
the three age groups and the disability cat-
ogorios (tno two-tailod valuo = .128). Tnis
suggests that the proportion of children with
a cognitive disability is not statistically sig-
nicantly different in the three age groups.
Approximatoly 74% o tno population in
tno Popublio o roland nas aoooss to huori-
dated domestic water supplies.
14
Tno onild's
parents/legal caretakers were asked wheth-
or tno onild's nomo was oonnootod to tno
piped public water supply. Fluoridation
status was classied for each child based
on tnis inormation. Approximatoly 78.6% o
tno onildron oxaminod rosidod in nomos
Table 1 Age and disability distribution (n = 337)
Disability
Age (y)
Total 1 2 3 4 5 6 7
Cognitive
n 22 19 29 42 44 33 24 213
% 6.5 5.6 8.6 12.5 13.1 9.8 7.1 63.2
Pnysioal
n 4 3 4 5 4 9 5 34
% 1.2 0.9 1.2 1.5 1.2 2.7 1.5 10.2
Cognitive and
medically compromised
n 18 6 3 5 3 2 3 40
% 5.3 1.8 0.9 1.5 0.9 0.6 0.9 11.9
Medically compromised
n 2 1 2 0 2 1 2 10
% 0.6 0.3 0.6 0.0 0.6 0.3 0.6 3.0
Not diagnosod
n 3 7 5 3 8 5 9 40
% 0.9 2.1 1.5 0.9 2.4 1.5 2.7 12.0
Total
n 49 36 43 55 61 50 43 337
% 14.5 10.7 12.8 16.3 18.1 14.8 12.8 100
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connected to the piped public water sup-
ply. This gure is slightly higher than the
national supply level.
The dental caries prevalence is pre-
sented as the mean decayed/missing/lled
teeth (dmft) for the sample stratied by age,
disability, and water uoridation level.
Table 3 demonstrates that dental caries at
dentin level was detected from 4 years of
ago. As is typioal in low-oarios populations,
the dmft values are not normally distributed
but are positively skewed with the result that
reporting the mean dmft gives an incom-
plete picture of its distribution. For this rea-
son, this study provides additional analyses
based on calculation of mean dmft levels in
onildron witn positivo (dmt > 0) sooro. Tno
analysis of mean dmft levels in children with
positivo (dmt > 0) sooros rovoalod a moan
dmft increment value of 1.14 (range in
moan dmt, 2.53 to 3.67).
To investigate which teeth were actually
affected by dental caries, a dmft break-
down of the sample was computed, which
separated primary molars from primary inci-
sors and canines. This breakdown demon-
stratod tnat tno ma|ority o dontal oarios in
preschool children with disabilities occurred
in primary molars (moan dmt, 0.4, standard
doviation |SD], 1.26, rango, 8), wnoroas
primary incisors and canines remained
largoly oarios roo (moan dmt, 0.09, SD,
0.46, rango, 4). A urtnor broakdown at sur-
face level (dmfs) showed the distribution of
aootod suraoos. Tno ma|ority o suraoos
affected were occlusal surfaces in molar
teeth. Unsurprisingly, the distal surfaces of
molars were considerably less affected
Table 3 Mean dmft, SD, dmft range, percentage of caries-free children, and mean
dmft in children with dmft > 0 stratifed by age
Age (y) n Mean dmft SD Range % caries free Mean dmft in children with dmft > 0
2 85 0.0 0.0 0 100.0 --
3 43 0.0 0.0 0 100.0 --
4 55 0.58 1.45 7 81.8 3.20
5 61 0.62 1.40 6 75.4 2.53
6 50 1.1 2.12 8 70.0 3.67
7 43 0.91 1.81 8 69.8 3.00
dmt, dooayod/missing/hllod tootn, SD, standard doviation.
Table 2 Sample stratifed by disability and age group (n = 337)
Age (y)
Disability
Total Cognitive Noncognitive
3
n 97 31 128
% 75.8 24.2 100.0
Expootod n 96.1 31.9 128.0
4-6
n 129 37 166
% 77.7 22.3 100.0
Expootod n 124.6 41.4 166.0
7
n 27 16 43
% 62.8 37.2 100.0
Expootod n 32.3 10.7 43.0
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when compared with mesial, buccal, and
lingual/palatal surfaces (Fig 1).
As tno typo o disability may inhuonoo
the occurrence of dental caries in preschool
children with disabilities, it is useful to ana-
lyze caries distribution patterns in these
children according to their disability.
Table 4 demonstrates that dental caries
prevalence is higher in disability groups
that include children with a cognitive dis-
ability. Children with cognitive disabilities
appear to suffer more severely from dental
caries than their peers with a noncognitive
disability.
As botn tno ago and typo o disability
appear to inuence the occurrence of den-
tal caries in preschool children with dis-
abilities, it is useful to analyze the dental
caries distribution patterns in these chil-
dren, controlling for both age and disability.
To allow descriptive analysis and compari-
son of the data, children were arranged in
three age groups and grouped in one of two
disability categories. Table 5 demonstrates
tnat dontal oarios provalonoo (dmt > 0) in
children with a cognitive disability appears
to differ markedly from children with a non-
cognitive disability in the medium (4- to
6-yoar-olds) and oldost (. 7-yoar-olds) ago
groups. Children with a cognitive disability
appear to be more severely affected from 4
years of age when compared with children
with noncognitive disabilities.
The effect of water uoridation on dental
caries levels in preschool children with dis-
abilitios was oxaminod by uso o tno Fisnor
oxaot tost. Tno proportion o onildron witn
oarios-roo dontition (dmt = 0) was 83.4%
in children residing in homes with uoridat-
od domostio wator supplios and 87.5% in
children with nonuoridated domestic water
supplios. Tno Fisnor oxaot tost was usod to
oxamino tno assooiation botwoon onildron
witn oarios-roo dontition (dmt = 0) and
onildron witn oarios oxporionoo (dmt > 0).
The difference in dmft values between the
two groups was not considered statistically
signihoant (tno two-tailod valuo = .4683).
Booauso tno prosont study invostigatod
the dental caries levels of a section of the
child population that has not been previ-
ously systomatioally oxaminod, qualitativo
140
120
100
80
60
40
20
0
Occlusal Mesial Buccal
Molar teeth
Distal Lingual/
palatal
Mesial Buccal
Incisors and canines
Distal Lingual/
palatal
N
o
.

o
f

d
m
f
t

s
u
r
f
a
c
e
s
Fig 1 Distribution of dmft surfaces due to dental caries in the primary dentition
VOLUME 44 NUMBEP 2 FEBPUAPY 2013 165
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research has been used along with quanti-
tative methods to interpret and better under-
stand tno oomplox roality o partioipation in
this study. Qualitative methods are more
hoxiblo (io, tnoy allow groator spontanoity
and adaptation of the interaction between
researcher and the study participant). This
has obvious advantages in the present
oxploratory rosoaron sinoo partioipants aro
free to respond in their own words and the
answers were not necessarily foreseeable.
15
All paronts/oarogivors o prosonool onil-
dren with disabilities registered with the
Early ntorvontion Sorvioos woro oontaotod,
but those who refused to participate in the
present study were contacted by letter in
Table 4 Mean dmft, SD, dmft range, percentage of caries-free children, and mean
dmft in children with dmft > 0 stratifed by disability
Disability n
Mean
dmft SD Range
% caries
free
Mean dmft in children with dmft >
0
Cognitive 213 0.61 1.59 8 81.7 3.33
Pnysioal 34 0.21 0.91 5 94.1 3.50
Cognitive and medi-
cally compromised
40 0.45 1.22 5 85.0 3.00
Medically compro-
mised
10 0.20 0.63 2 90.0 2.00
Not diagnosod 40 0.18 0.50 2 87.5 1.40
dmt, dooayod/missing/hllod tootn, SD, standard doviation.
Table 5 Total number of children, percentage of caries-free children, number of
children with dmft>0, dmft range, mean dmft in children with dmft>0,
standard deviation stratifed by age group and disability group
Age (y) Cognitive disability Noncognitive disability
3 n total 97 31
% oarios roo 100.0 100.0
n (dmt > 0) 0 0
Pango -- --
Moan dmt > 0 -- --
SD -- --
4-6 n total 129 37
% oarios roo 72.9 86.5
n (dmt > 0) 35 5
Pango 7 4
Moan dmt > 0 3.26 2.20
SD 2.09 1.64
7 n total 27 16
% oarios roo 63.0 81.2
n (dmt > 0) 10 3
Pango 7 1
Moan dmt > 0 3.40 1.67
SD 2.32 0.58
dmt, dooayod/missing/hllod tootn, SD, standard doviation.
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Sagheri et al
January 2009 asking i tnoy wisnod to par-
ticipate in nonresponse analysis. Ten par-
ents/caregivers initially responded, followed
by another three. Individual interviews were
arranged by the principal investigator and
took plaoo in lato January 2009. Ono paront
withdrew from participation since her child
had died between the initial consent and
sonodulod intorviow. All intorviows took
botwoon 40 minutos and 2 nours, dopond-
ing on what the parent/caregiver wanted to
discuss. These interviews took place in
sominar rooms in HSE primary oaro oontors.
All paronts/oarogivors woro ully inormod
regarding the nature of the interviews and
the benets of participating before signing
a oonsont orm (positivo oonsont). All par-
ents/caregivers were from a wide range of
age, educational, and socio-economic
baokgrounds. Somo paronts/oarogivors
nad ono onild witn disabilitios, otnor paronts
had two or three children with disabilities.
All partioipating paronts/oarogivors
identied the demands on their resources
as the main obstacle. Oral health care was
generally a low priority for them, and par-
ticipation in an oral health care research
pro|oot witnout immodiato gain was out o
the question because of these competing
daily demands. Wrangling with health care
services to obtain medical, child develop-
mental, and family support for their child
was initially of greater concern than their
onild's oral noaltn. Conhdonoo appoarod to
be an issue, which may constrain parents/
caregivers from attendance, perhaps fears
oonoorning dovaluing tnoir porsonal oxpori-
ences by other nondental professionals. It
became apparent that a large burden of
care is placed on mothers, although the
parents interviewed appeared to have sup-
portive partners and a supportive family
network. However, some parents appeared
surrounded by the pervasive negativity of
some professionals. This disabling attitude
on the part of some professionals gave par-
onts littlo nopo or tnoir onild's uturo, and
this may further disable them and their chil-
dren by affecting their willingness to engage
with services. The daily demands of caring
for a child with disabilities means that most
paronts aro tiod to a day-to-day oxistonoo,
and the greater the level of impairment, the
nignor tno numbor o domands. Somo par-
ents/caregivers interviewed were perform-
ing the role of an intensive care nurse, giv-
ing intravonous in|ootions, vontilating tnoir
onild, using pulso oximotors, doaling witn
incontinence, dressing open wounds,
administering medication, and waking
throughout the night to tend to their child.
These daily demands made the invitation to
a dontal oxamination as part o tno prosont
study a low priority.
DISCUSSION
There is currently no accurate information
on the numbers of preschool children with
disabilitios in tno Popublio o roland avail-
able. However, the sampling method
employed in the present study aimed to
provide a comprehensive picture of the
dental health levels of preschool children
with disabilities in two health service admin-
istrativo aroas. Novortnoloss, it oan not bo
veried beyond doubt that a representative
sample had been drawn and any general-
ization has to be treated with caution.
To fully understand dental caries preva-
lence in preschool children with disabilities,
it is useful to put the ndings of the present
study in oontoxt witn data rom tno gonoral
population. However, oral epidemiologic
data in young children are available for only
5-year-old children. Comparison of the
present results with the ndings from the
last national child oral health survey
3

revealed that dental caries prevalence in 5
year olds with disabilities was lower (dmft
0.6, 75.4% oarios-roo) wnon oomparod
with the general child population (dmft 1.3,
63.1% oarios-roo) wno rosidod in nomos
connected to the public water supply.
The dental caries levels in preschool
chldren with disabilties demonstrated that
onildron agod 3 yoars or youngor oxnibitod
no dental caries at dentin level. This is an
important nding since this establishes that,
or oxamplo, sovoro orms o nursing bottlo
caries or early childhood caries appeared
not to affect the population surveyed. This is
in clear contrast to the general population,
in which various studies have found an
increased prevalence of nursing bottle car-
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QUI NTESSENCE I NTERNATI ONAL
Sagheri et al
ies

in children younger than 3 years of
age.
16,17
This absence of dental caries at
dentin level at an early age will positively
inhuonoo tnoso onildron's dovolopmont,
because severe dental pain would affect
their daily life. It has been shown that early
onildnood oarios advorsoly aoot a onild's
development, especially body weight and
height.
18
Furthermore, the present study showed
no difference in dental caries levels between
children residing in homes with uoridated
domestic water supplies and children with
nonuoridated domestic water supplies,
which may indicate that the high level of
care for these children may inuence the
development of dental caries and vindi-
cates the observation that these children
show unique dental health patterns, which
differentiates them from the general child
population.
However, the data revealed that from the
age of 4, dental caries at dentin level was
detected, which increased in the older age
groups. Sinoo tno dovolopmont o dontal
caries in the dentition is a slow process, this
criterion fails to identify early signs of dental
caries and therefore the prevention of the
development of dental caries has to com-
mence before it has been detected at the
level of dentin. Current dental health policy
in tno Popublio o roland
14
generally recom-
mends advising parents/caregivers not to
use toothpaste when brushing their chil-
dron's tootn until tnoy aro 2 yoars o ago.
Prior to tnis ago, paronts/oarogivors aro
advisod to brusn tnoir onildron's tootn witn
a toothbrush and tap water. However, the
Forum on Fluoridation
14
did recommend
that professional advice should be sought
on the use of uoride toothpaste in children
considered to be at high risk of developing
dental caries younger than 2 years of age.
This part of the recommendation should be
strengthened and claried for the popula-
tion oxaminod in tnis study and snould
become better known by oral health profes-
sionals in tno Popublio o roland.
Marinho et al
19
found, in their review on
effectiveness and safety of uoride tooth-
pastes in the prevention of caries in chil-
dren and adolescence, that the benets of
uoride toothpastes are rmly established.
Howovor, oonoorn nas boon oxprossod tnat
dental uorosis, enamel defects caused by
tno onronio ingostion o oxoossivo amounts
of uoride during the period of tooth forma-
tion (up to 6 yoars o ago), is inoroasing in
both uoridated and nonuoridated com-
munities, and the early use of uoride tooth-
pastes by young children may be a risk
factor.
20-22
. However, Wong et al
23
found in
their systematic review on topical uoride
as a potential cause of dental uorosis in
children that most of the available evidence
focuses on mild uorosis. Furthermore, they
found only weak, unreliable evidence that
starting the use of uoride toothpaste in
children less than 12 months of age may be
associated with an increased risk of uoro-
sis.
It is generally recommended that chil-
dron youngor tnan 6 yoars o ago snould bo
supervised when brushing their teeth and
that no more than a pea-sized amount of
toothpaste with a uoride concentration of
1,000/1,100 ppm F snould bo usod to
reduce the risk of developing dental uoro-
sis.
14
Therefore, a balanced consideration
between the benets of topical uorides in
dental caries prevention in this specic
group of the child population who almost
witnout oxooption will navo tnoir tootn
brushed for them and the risk of the devel-
opment of uorosis has to be made. It
would be reasonable to suggest that pre-
school children with disabilities as a group
will have their risk of developing dental car-
ies reduced, if toothpaste with a uoride
oonoontration o 1,000/1,100 ppm F is usod
when the rst teeth appear in the oral cavity,
rather than delaying the start of toothpaste
use until these children have reached the
age of 2.
However, this revised strategy of dental
caries prevention needs to be embedded in
a widor oonoopt o oaro. Tno Amorioan
Aoadomy o Podiatrios
24
developed the
concept of the medical home and recom-
mended that the medical care of infants,
children, and adolescents ideally should be
accessible, continuous, comprehensive,
family centered, coordinated, compassion-
ate, and culturally effective. It should be
delivered or directed by well-trained physi-
cians who provide primary care and help to
manage and facilitate essentially all aspects
o podiatrio oaro." Furtnormoro, tno Amorioan
168 VOLUME 44 NUMBEP 2 FEBPUAPY 2013
QUI NTESSENCE I NTERNATI ONAL
Sagheri et al
Aoadomy o Podiatrios statod in 2003
25
that
pediatric primary dental care needs to be
delivered in a similar manner. This concept,
the dental home, is a specialized primary
dental care provider within the framework of
the medical home.
25
Tno Amorioan
Aoadomy o Podiatrio Dontistry rohnod tnis
concept and dened it as an ongoing rela-
tionship between the dentist and the patient,
inclusive of all aspects of oral health care
delivered in a comprehensive, continuously
accessible, coordinated, and family-cen-
tered way. Establishment of a dental home
begins no later than 12 months of age and
includes referral to dental specialists when
appropriate.
26
This concept of a dental
home may well be used as a template and
adapted to local needs and levels of avail-
able resources. Furthermore, Kagihara et
al
27
idontihod in tnoir study on paronts'
views on common barriers to dental servic-
es for children with disabilties recommen-
dations to improve access to dental care
and the establishment of a dental home,
various issues that were similar to the prob-
loms oxprossod by tno partioipants o tno
nonresponse analysis of the present study.
For that reason, the establishment of a den-
tal home may address those barriers to
dental services for children with disabilties.
Poorring a onild or a dontal noaltn oxami-
nation by a dentist who provides care for
inants and young onildron 6 montns ator
the rst tooth erupts or by 12 months of age
ostablisnos tno onild's dontal nomo and
provides an opportunity to implement pre-
ventive oral health habits that meet each
onild's uniquo noods and promisos to koop
the child free from dental or oral disease.
CONCLUSION
Evidence from the present study demon-
strated that the prevalence of dental caries
in preschool children with disabilities in
Ireland is low when compared with the gen-
oral population, and an ad|ustmont o our-
rent oral health prevention practice may
lead to a further reduction in the prevalence
of dental caries in this section of the child
population. Tnoso ad|ustmonts snould
include the concept of establishing a den-
tal home: that is, the inclusion of preschool
onildron witn disabilitios rom 6 montns ator
the rst tooth erupts or by 1 year of age
(whichever comes rst) in a routine oral
heath care program with regular oral health
oxaminations and risk assossmont. Tno
recall intervals between routine oral health
oxaminations snould bo basod on ostab-
lished and tested guidelines
28
and adapted
to looal oonditions. Also, huoridatod tootn-
paste with a uoride concentration of
1,000/1,100 ppm F snould bo usod wnon
the rst teeth appear in the oral cavity in all
preschool children with disabilities.
ACKNOWLEDGMENTS
The staf of the HSE North-East and HSE South-East den-
tal services, the children and their parents are thanked
for their assistance in this study.
This study was funded by the Health Research Board
(HRB). HRB Grant Reference: RP/2004/115. The funders
had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
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