Parental Oral Health Knowledge, Attitude, Practice and Caries Status of Sudanese Cerebral Palsy Children

Background: Cerebral palsy (CP) is a set of nonprogressive neuromuscular disorders due to defects in the developing fetal brain, this group of children at risk of dental caries and gingival diseases owing to dietary factors, poor oral hygiene, lack of parental knowledge concerning oral hygiene and problems related to dental management. The study aimed to assess the parental knowledge, attitude and practices of the oral health and caries status of the Sudanese Cerebral Palsy children. Methods: A cross sectional hospital based study for 123 cerebral palsy children, mean age 6.58 years at Khartoum state. Data regarding the parent oral health knowledge, attitude and practice were collected by face to face interview questionnaires and the caries status was assessed using (dmft/DMFT). Results: The majority of parents 90.2% think that good dental health is important for optimum general health, 81.3% of the children never visited dentist and whose visited dentist 95.7% due to dental problems, 60.2% heard about fluoride, 43.9% though that chocolate, backer products and soft drink cause tooth decay, 40.7% said that media is main source for oral health information. 50.4% of them responded that they can maintain a good oral health to their children. A statistically highly significant association (P=0.002) was found between mother education level and hearing about fluoride. The DMFT, MFT for primary and permanent teeth was 3.6 ± 4.64 and 2.0 ± 2.90 respectively. No significant association between age and DMFT (P=0.000). The caries prevalence in primary and permanent teeth was 57.4% and 46.3% respectively, there was significant association between knowledge level and DMFT in permanent teeth (P=0.037). Conclusion: Children with cerebral palsy had high caries prevalence and parent’s knowledge of oral health was satisfactory concerned supervision of teeth brushing and the role of oral health to the general health of their children, although it was not applying to their daily practices.


Introduction
Special health care refers to "any physical, developmental, mental, sensory, behavioural, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs". The condition may be congenital, developmental, or acquired through disease, trauma, or an environmental cause and may impose limitations on performing daily self-maintenance activities or cause substantial limitations in a major life activity [1].
Children with cerebral palsy have motor dysfunction, so normal functioning of the orofacial muscles is disturbed. Depending on the severity of the disease, individuals with CP may suffer from choking, coughing, drooling, inability to consume solid food, and difficulties in swallowing, chewing and drinking. Consequently, oral health is a significant challenge, as individuals with CP are more prone to developing caries and periodontal disease, mouth-breathers and suffer from malocclusion, skeletal class II and anterior open bite. No intraoral anomalies are unique to persons with cerebral palsy but oral conditions are more severe than the general population [3,6,7].
In 1960, McDonald discussed how pediatric medicine had changed in the previous 30 years from 90% treatment and 10% prevention to just the reverse [7]. Preventive dentistry is now the foundation on which all oral health care is built; which is depend mainly on home oral hygiene. Hence, parents with good oral health knowledge play a better role in maintaining optimal oral health for their children with CP through supervising oral hygiene and dietary habits [8].
Overall CP prevalence for the past 40 years is stable, but a modest increase in prevalence probably occurred in the last decades of the twentieth century. This increase in prevalence can be attributed to the substantial increase in the prevalence of CP per 1000 very low birth weight infants, this due to increased survival that results from new-born intensive care [9]. prevalence in children weight 1000 to 1499 g at birth was 59.18 per 1000 live births, and prevalence of CP by gestation age; before 28 weeks gestation was 111.80 per 1000 live births [10].
The estimated prevalence of cerebral palsy worldwide ranges from 0.74 to 3.6 per 1000 live births [11]. In Nigeria, the incidence was 13.1 children per year [12].
Dental caries is an infectious and communicable disease defined as localized destruction of susceptible dental hard tissues by acidic by products from bacterial fermentation of dietary carbohydrates, it is a dynamic process of demineralization and remineralization of enamel depending on salivary PH [13]. It is the most common chronic disease among children and adolescents [7].
The aims of this study were to assess the carious status and evaluate parent's oral health knowledge of children with cerebral palsy as a response to the recent increase noted in the number children with CP seeking dental care in the pediatric clinic at the faculty of Dentistry, University of Khartoum, in order to establish a proper interceptive and preventive oral health program and improve their quality of life. To the best of our knowledge, there is no such study in Sudan.

Materials and Methods
A cross sectional hospital based study carried out at Jaafer Ibn Ouf Pediatric Teaching Hospital, Neurology Unit, Khartoum Sudan.
The inclusion criteria for the selection were; Sudanese children diagnosed from medical records as cerebral Palsy, attending Jaafer Ibn Ouf Hospital and parents or relatives of CP children attending the Hospital. Whereas, the other children; with neurological defects other than cerebral palsy, CP children with severe disabilities and uncooperative CP children were excluded from the study.
A total of 123 children aged 2 to 15 years old with a confirmed diagnosis of cerebral palsy from their medical records were included in the study. Parents' consent was first obtained, and then face to face interviews were conducted to collect personal data and information on the knowledge, attitude and practice of the parents in the doctor's office on the day of the referral clinic.
The parents' oral health knowledge, attitude and practice was measured using a modified KAP questionnaire [14]. The questionnaire was designed in English, translated into Arabic and back into English. It consisted of two parts: the first for general information such as name, age, gender of the child, and the caregiver's age and education. The second part consisted of 17 closed end questions related to knowledge, attitude and practice.
Clinical examination was conducted by the main investigator. Examination was carried out in the doctor's office under artificial lighting, with the child sitting in an up-right position in an ordinary chair or in the child's wheelchair placed in front of examiner, using sterilized gloves and an examination set. Caries was measured using the dmft/DMFT index for primary and permanent teeth, respectively, according to WHO criteria [15].
Ethical clearance was obtained from the research committee at the Faculty of Dentistry, University of Khartoum, and from the Khartoum State Ministry of Health Research Directorate. The research's purpose and objectives were explained to the parents in clear simple words, and signed informed consent was obtained from the parents before starting the oral examination.
Chi square test was applied to examine the association between categorical variables like education and hearing about fluoride, association between knowledge, attitudes and practice with caries in primary and permanent.
Analysis of Variance (ANOVA) was applied to test significant difference between age groups in dmft and DMFT.
The independent sample t-test was utilized to test if their significant difference between boys and girls in dmft and DMFT.
For all test P-value<0.05 is considered significant.

Results
A total of 123 children with cerebral palsy were included in this study, 78 boys and 45 girls. The age ranged from 2-15 years old and the mean age was 6.58 years. The majority (n=71) of children where aged 2-6. The percentage of age decrease with increase in age (Table 1). The majority of the parents were mothers aged 21 to 82 years old. Most parents had a secondary education (n=50) 40.7% ( Table 2).

Figure 1
Age of caregivers of children with cerebral palsy.
The frequency distribution of Age by taking the mean and calculate the standard deviation showed in the above Figure 1. In Table 3, Most children 87.8% brush their teeth and 80.5% of them brushed under supervision, while more than half 61.1% brushed once a day, 87.0% used manual tooth brush, Fewer used mouth wash 5.7%, 81.3%, of the children had never visited a dentist before, and of those who had visited a dentist (n=23) 10.6% within less than 12 months ago 8.1% more than 12 months. Almost these 95.7% had gone when there was a problem, and the main treatment they received was extraction and medications. The following are the answers of their parents mentioned in Table 3. More than half the parents 60.2% had heard about fluoride. Less than half 46% said that fluoride prevented tooth decay (Table 4). Regarding cariogenic food, 42.3% answered that chocolate cause's tooth decay and 43.9% said that chocolate, bakery products and soft drinks cause tooth decay shown in above Table 4. A significant association found between parents' educational level and hearing about fluoride (P=0.002) ( Table  5).  Table 6 shows that 80.2% of parents said that milk teeth don't require good care. 40.7% said that the media was their main source of information about oral health. About half 50.4% responded that they can maintain good dental health in their children by supervising their tooth brushing, reducing sugary food intake and making regular visits to a dentist. 90% of parents responded that dental health is important. showed in Table 7. No significant association between either DMFT or different age groups (p-value=0.171) or DMFT and gender (P=0.924). The most common component of DMFT (Decayed, Missing or Filled Teeth) in primary teeth was decayed and missed teeth; 57.4% and 12.0%, respectively. The filled teeth were very little 0.9% (Table 8).  Table 9 shows the total mean DMFT was 3.41 ± 3.0. A significant association between the age group and DMFT, but no significant association between gender and DMFT. The range of age group 2 to 15 years. In Table 10, the total percentage of decayed permanent teeth was 46.3%, missing were 13.0% and there were no filled teeth (Table 10). There was significant association between knowledge level and DMFT in permanent teeth (p=0.037) (Figure 2).

Discussion
This hospital-based cross-sectional study was conducted in order to assess the knowledge attitudes and practices of the parents of Sudanese children with cerebral palsy towards oral health, as well as dental caries in these children. The study was conducted among children attending Jaafer Ibn Ouf Pediatric Teaching Hospital in Khartoum, which is the only specialty paediatric teaching hospital in Sudan. The hospital receives all cases referred from different parts of the Sudan, and has many departments including the Neurology unit where this study was conducted.
This study assists in designing effective oral health educational programs for the parents of children with CP in order to improve oral health education/prevention programs, consequently resulting in better dental health for these children.
The response rate among respondents in this study was 100% (123 out of 123). Similar to previous study, the gender distribution of the children included in this study showed a high male to female ratio [16].
The most interesting finding in this study was that majority of children 81.3% never visited dentist before. This is in line with study done in Saudi Arabia in group of CP well as other study [18]. Of those who had visited dentist half had gone only when there was a problem like study done in Saudi in disabled children [19] and another study in Scotland [18]. The main treatment received was extraction and medication. None of the children had received prevention treatment like fluoride.
Priorities and attitudes can serve as obstacles to oral care. Parental and physician lack of awareness and knowledge may hinder an individual with CP from seeking preventive dental care. Other health conditions may seem more important than dental health, especially when the relationship between oral health and general health is not well understood [20]. The AAPD guidelines recommend making a consultation dental visit within six months or of the first tooth eruption. This should be strictly followed in children with CP [20].
In terms of knowledge about fluoride and factors causing tooth decay, more than half of the parents 60.2% heard about fluoride which was less than reported by Dana Al-Bader et al. of Saudi Disabled children they found that 92.7% of parents had heard about fluoride [19]. Less than half 46% of the parents said that fluoride prevent tooth decay. As for cariogenic food 42.3% stated that chocolate causes tooth decay, this show that the mothers were aware that sugary item likes chocolates can lead to dental caries. However, there was low awareness about the different forms of sugary items, which are harmful to the teeth. This throws the light on inadequate knowledge about the relationship between the different forms of sugar consumption and dental caries and less than half 43.9% said that (chocolate, bakery products and soft drinks) cause tooth decay this showing an overall low knowledge regarding different cariogenic food items like study in normal children by Romi Jain [14].
A great number of parents thought that good dental health was important for optimum general health which in line with studies done by Amjad in Saudia [21] and Jyoti Magoo et al. in group of Autistic children [22]. Of parents who supervised teeth brushing of their children 80.5% like study done in Brazil [16] and same as study done in group of disabled children in Saudi Arabia [19] because they are partial or total reliance on the caregiver to perform daily activities, such as feeding, mobility and general and oral hygiene.
Parents should be aware that, without their supervised to oral hygiene procedures in their children with cerebral palsy they can have serious dental consequences. Dental home cane reduces the child's risk of preventable dental/oral disease.
More than half 61.1% brush their teeth once per day like [22] which was opposite with study by Oredugba [23] and by Ferreira and their colleagues in Brazil [24]. These children will benefit from assistive devices such as electric toothbrushes and toothbrushes with large or modifying handles in this study 87.0% used manual tooth brushes for their children like [22].
Only 16 respondents 13.0% said they knew the important of the milk teeth the remaining stated that milk teeth do not require care, it fall down, which was fewer than result of Autistic children in which 71.2% of parents felts important of milk teeth [22].
Half of the responded said that they can maintain a good dental health in their children by supervising their tooth brushing, reducing sugary food intake and making regular visits to a dentist; a finding less than that reported by two study done in Saudi Arabia [19,21].
Parents or caregiver are responsible for establishing good oral hygiene at home. So dental education of parents/ caregivers is important to ensure children with CP do not jeopardize their overall health by neglecting their oral health this education mainly by dentist and mass media; newspapers, radio, television, and internet.
In our study, main source of oral health information from media like study done in normal children in India [14] this show that media influence people in their live and fewer from dentist this show that we need to incorporate oral health education in our daily clinic.
AAPD done guidelines on management of dental patients with special health care needs [20] and this should apply to Sudanese cerebral palsy children.

Caries prevalence in children with CP
The total mean dmft and DMFT in the present study was found to be 3.6 ± 4.64 and 2.0 ± 2.90 respectively. No significant association between dmft/DMFT and gender, contrary to findings reported by Nouf Al-Hammad et al. [25] and Maria Teresa et al. [26] there was significant association between DMFT and different age group (P-value=0.000); a finding similar like study by Ana Carolina et al. [16] they mentioned that these may be attributed to the fact that children with CP may experience delays in the chronology of tooth eruptions due to nutritional reasons as studied by Pope and Curzon [18].
Studies conducted in Arab countries showed higher caries indices, United Arab Emirates (UAE), [27] and in Saudi Arabia [25].
The dental caries experience in this study was found to be high, similar to results to global studies done in Brazil, [28][29][30] New York and China, Nigeria and South Africa respectively [31,32], a recent study done in Albania show high prevalence of caries. The mean deft and DMFT index was 3.4 ± 3.5 and 4.9 ± 4.6, respectively [33].
Some studies found no difference in the caries index between normal children and children with CP [17,18] and study done in adults by Miriam in 2008 [34].
Contrary to our findings, Nelsen in case control study in Denmark showed that the caries rate of the CP-group was significantly lower than that of control group [35] a study in Brazil, the author mentioned that the children evaluated were not representative to all children with CP, but only of those who look for treatment in a reference center and they may possess better oral health due to enhanced parental attention and/or fewer difficulties in controlling oral conditions [36].
The prevalence of dental caries in children with CP was, as expected very high. Risk factors such as present of infantile reflexes (rooting, suckle-swallow, biting and gagging) would explain this [37], as well as side effects of drugs and recurrent hospitalization [38], high salivary osmolality [39], soft diet intake [40], high frequency of carbohydrate intake, autocleaning inability; all this factor contributing to difficulty in maintaining adequate oral hygiene.
The association of dental caries with the caregiver's educational level approves the statement that the caregiver's low educational level increases the probability of dental caries [28] this is clarifying by Caregivers with high educational level have better health knowledge and positive attitudes towards oral health [41].
The most common components of DMFT in primary and permanent teeth was decayed teeth 57.4%, 46.3% respectively, similar to study done by Oredugba [23] and [19,20,42] missing component in primary and permanent teeth was 12.0%, 13.0% respectively and there was fewer filled teeth, this show that there is sever unmet preventive and restorative dental treatment needs and this was mentioned in literatures [43].
It is an unhappy fact of life that oral health care comes far down in the list of priorities where parents of CP children are concerned. This is possibly due to the fact the cerebral palsy condition itself is of major concern and oral health care is forgotten. Thus, the results of the present study draw attention to a portion of the population that requires special care regarding their oral health through treatment and orientation this preventing possible harm and complication and avoiding local, systemic, psychological and social complications stemming from inadequate oral health. Considering the previously mentioned carries risks, unmet dental treatment need and barriers to access to dental services in the CP individuals therefor there is a need for public oral health programs with multidisciplinary services for this population as well as for all individuals with disabilities.

Conclusion
Parents' knowledge of oral health was satisfactory in most areas. lack of knowledge about the oral health of their Cerebral Palsy children.
The most interesting finding was that most of the cerebral palsy children never visited the dentist Those who's visited dentist half of them gone when there is a problem.
A great number of parents know the important of good dental health to optimum general health. The main source of oral health information from media minimal from dentist.
Cerebral palsy children had high caries prevalence and more prevalence of decayed teeth than other component of decayed, missing and fill teeth.

Recommendations
Children with cerebral palsy are at risk of dental caries and gingival diseases due to dietary factors, poor oral hygiene, lack of parental knowledge regarding oral hygiene and problems related to dental management (involuntary movement and lack of cooperation). Therefore, continuous dietary supervision and assistance in maintaining good oral hygiene are obligatory because these children are partially or totally reliant on their caregivers to perform daily activities [4].