Body mass index, oral health status and OHRQoL among special health care needs children and parenting stress: a case-control study in Southern Saudi Arabia

1. Introduction

Special health care needs (SHCN) is defined by the American Academy of Pediatric Dentistry (AAPD) as any developmental, physical, mental, behavioral, sensory, cognitive or emotional mutilation that needs health care intervention, medical management, and/or use of specialized services, and may cause limitations in doing daily activities or considerable limitations in the major activities of life [1]. Additionally, SHCN children cannot comprehend, presume responsibility for, or assist with preventive oral health measures [2].

Dental caries involving permanent teeth is one of the most common diseases worldwide. Gingivitis, dental caries and periodontitis are seen among one of the eminent groups of the population; children and adolescents [3]. Among different age groups, it has been observed that overweight and obesity are common epidemics. The diseases like periodontal diseases, dental caries and obesity have almost similar features. All are of global significance, having similar risk factors such as behavioral habits like increased consumption of sugar and unhealthy health behavior; same psychosocial conditions like the support of parents and socioeconomic status [4]. All three conditions have a similar multi-factorial framework, and it has been expected that all the conditions show interactions between them. It has been advocated that dental caries and obesity are non-communicable and preventable diseases [5].

A multidimensional framework that shows being comfortable while sleeping, eating, social interactions and self-esteem, reflecting satisfactory oral health is defined as Oral health-related quality of life (OHRQoL) [6]. It has been observed that an increased prevalence rate (77–79%) of dental caries was reported in various studies done in Saudi Arabia among rationally medically-compromised and disabled children [6, 7, 8, 9, 10].

Very few studies are available to observe the impact of various socio-demographic features or BMI on the OHRQoL of special children. The appropriateness for determining OHRQoL of special children by their caregivers must be thoroughly assessed. This is especially important in cases of SHCN children when most of them are unable to provide a valid evaluation of their OHRQoL, when the children have problems in communication, or they are dependent on their parents or caregivers for maintaining oral and general health [11].

Various studies have revealed a poorer status of oral health among SHCN children as compared to healthy children [7, 8, 12, 13]. Limited studies have shown a connection between dental caries and obesity among children [14]. The impact of severity of dental caries’ on the OHRQoL of special children was not adequately assessed. Thus the present study was conducted to assess the parents’ (of healthy and disabled children) quality of life and their stress. Moreover, the study also evaluates the plaque, DMFT+df and BMI of healthy children and those with disability.

2. Materials and method

3. Results

In this study, children and their parents were used as study subjects. The data of children with 150 cases and 30 controls whose mean age was 7.52 and 8.93 years, 56% and 26.7% were male in cases and controls. The mean values of BMI, plaque and DMFT+df of both cases and controls are given in Table 1.

The comparison of mean ranks of plaque and DMFT+df shows no statistical significance between cases and controls (Table 2). The correlation between BMI and plaque & BMI and DMFT+df of cases indicates no statistically significant correlation. But there is a statistically significant correlation between plaque and DMFT+df values in cases. That is, as plaque values increase, the values of DMFT+df also increase in cases which was statistically significant (p = 0.001). A similar pattern of no correlation between BMI and plaque & BMI and DMFT+df among controls, but a statistically significant correlation between plaque and DMFT+df values in controls was found. That is, as plaque values increase, the values of DMFT+df also increase in controls (0.048) (Table 3).

The socio-demographic characteristics of parents with 150 cases and 30 controls are given in Table 4. About 61% and 70% of cases and controls were of age ≤40 years, and a higher proportion, 84.7% and 100%, were females in cases and controls. Of the 150 cases, 25 (23.3%) were ill, whereas only 3 (10%) controls were reported to be ill (Table 4).

The comparison of mean values of three factor scores of the parental Stress Index (PSI) scale, parental distress, parent-child dysfunctional interaction, difficult child, and total score between cases and controls shows statistically significant difference for the two factors (parent-child dysfunctional score and difficult child score) and total score. That is, the mean values of the parent-child dysfunctional interaction score and difficult child score of cases were statistically significantly higher than control scores (p = 0.005; p = 0.001). Also, the mean value total score of the PSI scale in parents of cases was statistically significantly higher when compared with the mean scores in parents of controls (p = 0.004) (Table 5).

The comparison of mean values of the four factors of the Quality of life scale and its total score between cases and controls showed no statistically significant difference. The mean values of the four factors and the total score of the QOL scale were not statistically significantly different across the cases and controls (Table 6).

4. Discussion

The present study is one of the few studies conducted to assess the Oral health status and BMI of children (healthy and SHCN children) and the parents’ level of stress and their OHRQoL. The mean BMI, plaque and DMFT+df values of both cases and controls were estimated and compared. The correlation between BMI and plaque & BMI and DMFT+df of cases indicated no statistically significant correlation. But there was a statistically significant correlation between plaque and DMFT+df values in cases. Similar to our study, Alwattban RR et al. [6] also found that children’s dental health and the severity of dental caries negatively impact the OHRQoL. In contrast, BMI did not have a significant impact. Alshehri et al. [20] revealed conflicting results on the relationship between BMI and dental caries in children showing a positive association.

In our study, the mean values of parent-child dysfunctional interaction score and difficult child score of cases were statistically significantly higher as compared to the mean scores of controls. The mean value total score of the PSI scale in parents of cases was statistically significantly higher when compared with the mean scores in parents of controls. Stress levels were noticeably higher in families with special needs children [21]. Children and adolescents who have high levels of stress in their parents or caregivers tend to have lower quality of life [22]. Health and oral health-related quality of life (HRQoL and OHRQoL) might deteriorate due to medical and psychological issues, as well as obstacles to receiving appropriate medical and dental care [23]. Understanding OHRQoL can help one understand the children’s oral health [24].

The mean score of parent-child dysfunction was higher in parents who had secondary school, tertiary school, and university levels of education compared to the mean scores of parents who had primary and lower levels of education. Similar to our study, Alwattban RR et al. [6] also found that the education level and occupation of the caregiver and the age group of children affected the OHRQoL of the children, where children having caregivers with no schooling or having primary education level had better OHRQoL as compared to those whose caregiver had a university degree. In another study by Chaffee et al. [25], Early childhood Oral Health Impact Scale (ECOHIS) scores were lower when advocated by less educated caregivers. This might be attributed to the fact that quality-of-life-measures are subjective in nature and show the individual’s expectations, so there is a high chance that caregivers having a lower educational-level think that dental caries is an unavoidable disease, which may not be controlled, thus causing cognitive dissonance between perceptions of caregivers’ quality-of-life and actual experiences.

On comparing the mean scores of four domains (physical domain, psychological domain, social relationship domain, and environmental domain) scale in relation to the characteristics of parents, it was found that the mean scores of physical domains were significantly higher in parents who were in the age group of ≤40 years when compared with the mean scores of parents who were in the age group of >40 years. The mean score of the social relationship domain was statistically significantly different across the four levels of parents’ educational status. Out of 4 domains of QOL, the mean scores of three domains (physical, psychological and environmental) were statistically significantly different across the four levels of parents’ job status. The mean scores of these three domains were significantly higher in parents who were housewives & students, employees and professionals when compared with the mean scores of parents who were with no job & retired. This was in accordance with the findings of Alwattban RR et al. [6] who reported that the child symptoms and function domains and the parental distress domain were affected by caries severity.

However, it has been observed that the inaccurate perception of parents of their special children’s dental health is a matter of concern, as most of the parents (90%) reported the dental health of their child as good when even the scores of caries experience of the children were not low. It is logical that children of caregivers who found their children’s dental health as poor had increased dmft/DMFT scores and were more likely to have a negative impact on their OHRQoL as compared to those caregivers who estimated their children’s dental health as good, the finding that showed a limited proportion (10%) needs to be emphasized. This reveals the need for a more reliable scale that can be used to evaluate the degree of dependence of SHCN children in the future, at least those who do not have intellectual problems, to avoid the requirement of proxy assessors to evaluate their OHRQoL.

Strengths of the study: Inclusion of SHCN children, investigating their oral health status and other parameters, including their parents in the assessment of OHRQoL and parenting stress; all variables in one research is little challenging with time-constraints. The objective element in assessment of DMFT, plaque and BMI is the strength of the research.

5. Limitations of the present study

1. A convenience sample, including children and their caregivers, was taken from a single hospital, which could have caused sampling bias.

2. The study cannot be generalized to whole population of special children.

3. It is impossible to show all SHCN categories with ease and comparatively small samples; thus, larger samples are required by using all categories of SHCN for a more specific analysis.

4. As the study was conducted on children who reported to dental setup for treatment, it might have caused an overestimation of results. Moreover, the number of males and females in cases and controls should be equal for more accuracy of the findings, due to time-constraints.

5. The study depended on care-givers’ answers, that can lead to information bias. Thus future studies should be conducted based on a scale that can be easily used and interpreted by special children to determine their OHRQoL.

6. Conclusions

The severity of dental caries, plaque accumulation, and education level of caregivers had a significant impact on the OHRQoL of the assessed population of special children; however, BMI did not show a significant relation with DMFT and plaque. The mean value of total score of the PSI scale in parents of cases was found to be statistically significantly higher when compared with the mean scores in the parents of controls.

Abbreviations

SCHN, Special Health Care Needs; OHRQoL, Oral Health related Quality of Life; DMFT, Decayed, missing, filled, teeth; PI, Plaque Index; BMI, Body mass Index; WHOQOL-BREF, World Health Organization Quality of Life Brief Version; PSI-SF, Parenting Stress Index-short format; QOL, Quality of Life; AAPD, American Academy of Pediatric Dentistry; Kgs, Kilograms; SPSS, Statistical Package for Social Sciences.

Availability of data and materials

The data are contained within this article.

Author contributions

SAeA—investigation, resources, visualization; ZMA—methodology, formal analysis, software; FAA—data curation, software, analysis; SAAR—investigation, formal analysis, visualization; RNA—investigation, resources, visualization; SAbA—visualisation, data curation, investigation; RAT—conceptualization, project-administration, supervision; TSA—validation, writing original draft, supervision; SMY—analysis, reviewing and editing, methodology; MZ—analysis, writing-review and editing, supervision. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical clearance was obtained from Institutional Ethics Committee of King Khalid University, College of Dentistry, Abha (IRB/KKUCOD/ETH/2021-22/006). Parents’/guardians’ consent was obtained prior to the start of study.

Acknowledgment

Authors would like to express their humble gratitude to King Khalid University College of Dentistry for its constant support to us for accomplishment of this research.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.