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Sri Lanka Dental Journal , 2015 December (Vol:45 No:3)

Author(s): S.R. Gunawardane, H.M.R.W. Angammana, N.N. Palanage, B.M.H.S.K. Bannaheka, M.C.N. Fonseka, J.M. Jayasundara Bandara
Other formats: Abstract , PDF
Published on: Thu, 05 May 2016 17:05:11 +0530
Last updated on: Fri, 06 May 2016 10:55:29 +0530
Sri Lanka Dental Journal, 2015 December (Vol:45 No:3)

Oral health status and treatment needs among institutionalized children in the central province of Sri Lanka


Objectives: The aim of this survey was to determine “the oral health status and treatment needs among institutionalized children under the care of the Department of Probation, Central Province, Sri Lanka”.

Methods and Materials: A cross sectional study was conducted in all 36 homes of institutionalized children under the care of the Department of Probation, Central Province, Sri Lanka. Out of 36 institutions (1104 children), all the children who were above 6 years old were included in the study. An interviewer administered questionnaire was filled out for each child. Comprehensive oral examination was conducted by three calibrated examiners for each child. Every child who had been found with necessity for treatment had been treated on site or referred for special care.

Results: The prevalence of dental caries in deciduous teeth was 26.8% while 56.7% in permanent teeth. The mean DMFT (decay-missing-filled teeth index for deciduous) was 0.75±1.61 (Mean ± Standard deviation) while the mean DMFT (decay-missing-filled teeth index for permanent teeth) was 1.19±1.43. Untreated caries was dominant in both dentitions. Gingival bleeding had been present in 44.67% of the study subjects. Despite reporting a higher usage of tooth brush and tooth paste, a high percentage of bleeding gums were found in these children.

Conclusions: Institutionalized children are at a risk of developing dental problems and extremely poor in getting treated for those conditions. Care takers and administrators of these institutions have to play an important role in providing a health promoting environment and healthy lifestyle for these children.



Institutionalization is the process of placement of children in institutions, such as orphanages. These orphaned, abandoned, and maltreated children are prone to problems that persist in societies throughout the world. Although the actual number of children in residential institutions is impossible to measure accurately, estimates have ranged from 2,000,000 to more than 8,000,000 globally1,2,3. Most institutions are staffed with untrained caregivers who work rotating shifts in rather bleak material conditions. Children in institutional care may have been abandoned at birth or soon after because of poverty or parental instability. In some cases, the state may also have intervened to remove young children from their parents’ care.

Many observational studies have compared institutionalized children to non-institutionalized children. These studies present a compelling story of the negative effects of institutional care; most studies concluded that institutionalized children have developmental deficits significantly across every domain that has been examined4,5,6,7,8,9. The professionals further agreed that institutionalization is only to be used as an absolute last resort. The reason it is an absolute last resort is because of institutionalization can have extreme negative effects on children10.

Good oral health is an essential element of good general health. Although good oral health includes more than having sound teeth, many children have inadequate oral health because of active and uncontrolled caries11. Virtually everybody suffers from dental caries and periodontal diseases around the world. Dental caries is the most prevalent disease, next to the common cold among children in the global scenario12.

Oral health and general health are inevitably bound to each other. If the children develops unfavorable oral health status, they should be considered a risk group requiring special attention for planning of Dental Health Program13. Poor oral health can be associated with a number of factors, including uneven and limited access to oral health care, lack of quality measures in oral health care, inadequate health literacy, and lack of attention to oral health among primary care providers. While access has improved over time, many people including those who are most vulnerable still lack the oral health services they need. Accessing oral health care is notably difficult for certain socially marginalized communities as Institutionalized children14.

It is proven that the maximum burden of all diseases rests with the underprivileged and socially deprived communities. Children from disadvantaged backgrounds have shown a high prevalence of dental caries and their utilization of dental care is significantly low. In the meantime, the provision of oral health care in developing countries like Sri Lanka is limited due to lack of adequate manpower, finance and lack of perceived need for dental care among the people. The scientific literature suggests that children from orphanages have shown a high prevalence of dental caries, gingivitis, and dental trauma. This has been associated with overcrowding, lack of adequate staff, poor oral health practices, psychological stress and improper dietary habits15,16,17,18.

The groups in most oral health surveys conducted worldwide have included primarily children, adolescents, and adults from the general population. Oral health status and dental epidemiological investigations of the socially marginalized groups such as institutionalized children is still an under-researched area both locally and globally. However, such studies are important in order to expand the level of oral health care delivery system. Therefore, the aim of this survey was to determine “the oral health status and treatment need of institutionalized children under care of the Provincial Government of the Central Province, Sri Lanka”.

Materials and Methods

The study was a cross sectional study which was conducted at 36 homes of institutionalized children. Since the Department of Probation of Central Province, Sri Lanka is the governing body and the legal guardian of all the residents of these institutions, written permission and informed consent was taken from them prior to conduct the study. Ethical approval for this study was obtained from Ethical Review Committee, Faculty of Dental Sciences, University of Peradeniya. All the children stationed at 36 institutions (1104 children), were screened and those who were above 6 years of age included to the study. Every child diagnosed to have dental or oral problems either treated on site or referred to special care. An interview based questionnaire (World Health Organization - Oral Health Questionnaire for children)19 was filled out for each child; data such as age, educational status, patterns of oral hygiene practices, dietary habits and history of professional dental care were recorded. Before commencement of the survey, clinical examiners were standardized and calibrated to ensure reliability and consistency of measurements. Comprehensive oral examination was conducted by a calibrated examiner in each child. Extraoral and intraoral examination was performed using electrical overhead light, mouth mirror, tweezers, dental explorer, gauze and wooden tongue depressor. Data were recorded according to the World Health Organization’s Basic Oral Health Survey methods using Oral health assessment form for children19. Field dental health programmes were organized at site to provide necessary dental treatment for the needy children after the clinical examination. Children who were in need of further care or special treatments were referred to Dental Teaching Hospital Peradeniya or the nearest hospital dental clinic.

Statistical analysis

Minitab version 16.00 and Microsoft Excel were used for data entry and analysis. Qualitative data were presented as frequencies and percentages, while quantitative data were presented as means and standard deviations. Kruskal-Wallis Test was used to compare the associations of dental caries indices with factor variables such as children’s perception of oral health and oral health related problems.


Out of 685 participants who had full filed the inclusion criteria, 54.01% were females and 45.99% were males. Mean age of study subjects was 11.88±4.02. Majority of children were Tamil (50.87%) followed by Sinhalese (47.39%) and Muslims (1.16%). The age of 66 children could not be accurately confirmed as they did not have birth certificates. Their age was estimated using the dental records. Mean number of teeth present was 23.87 for age group of 6-12 years and 27.39 for 13-17 years group.

Oral Health Status

The dental caries profile and gingival inflammation among the study subjects is shown in Table 1. The prevalence of dental caries in deciduous teeth was 26.86% while 56.79% in permanent teeth. The mean dmft was 0.75±1.61 (Mean±SD) while the mean DMFT was 1.19±1.43. Untreated caries was dominant in both dentitions. In males the mean DMFT was 0.88±1.79 and mean DMFT was 1.11±1.36, where as in females mean DMFT was 0.63±1.44 and mean DMFT was 1.25±1.49. Neither dmft nor DMFT showed statistically significant association with gender. Gingival bleeding had been presented in 44.67% in study subjects. Sinhala and Tamil subjects had shown higher value of dD components which is not statistically significant. Age group 6-12 years study subjects had shown higher value of dmft (1.4±2.1) while 12-13 shown vice versa for DMFT (1.5±1.1). Both relationships were statistically significant.

Dental fluorosis was seen in 0.73% of children as 0.15% in age group 6-12 and 0.58% in age group 13-17. Dental trauma was seen in 5.84% of children and only 0.88% of them were restored. Males had shown higher prevalence of dental trauma (3.65%) whereas females had shown 2.19% which is statistically significant. Signs of dental erosions were observed in 0.58% of children and mucosal lesions (ulcers) seen in 1.61% of subjects. Dento-facial anomalies were recorded as presenting of any form of malocclusion and 5.26% of subjects found with some form of malocclusion. Majority of them (4.09%) belonged to the age group of 13-17 while 1.17% belonged to the age group of 6-12.

Table 1: Profile of dental caries & gingival bleeding by gender, ethnicity and age groups (α = 0.05)
Table 1

Own perception of oral health

Caries experience was significantly associated with own perception of oral health status of children with dmft and DMFT components (Table 2). No significant associations were found between gingival status and thhe perception of oral health. (Kruskal-Wallis Test).

Table 2: Association of own perception of oral health & caries indices (α = 0.05)
Table 2

Oral health related problems and dental caries status

Table 3 shows association of oral health related problems with dental caries indices for the study population. The DMFT indices of children have shown statistically significant association of several episodes of absenteeism from schools due to dental pain. The fact “other children make fun of my teeth” has also shown statistically significant association with both dmft and DMFT indices. (Kruskal-Wallis Test)

Table 3: Relationship between Dental Caries Indices and Oral health related problems (α = 0.05)* Proportion of children’s responses in percentage
Table 3

Dental pain and dental visits

Table 4 shows the associations between caries experience with the experience of dental pain during thhe past year and the history of recent dental visit. The d, D, dmft and DMFT components were significantly associated with the children’s experience of dental pain during the past twelve months. All caries components were higher among the children who had never seen a dentist compared to those who had seen a dentist. Although untreated caries was higher in children who had been seeing a dentist, the difference compared to the children with no dental visits was not statistically significant.

Table 4: Associations between caries experience with the dental pain experience and the history of recent dental visit
Table 4

Oral health related habits and sugar consumption

Out of 685 children 16% (110) of children stated that they never brush their teeth while 29.2% (205) once a day and 68.5% (370) twice or more. A total of 98.1%(362) children brush their teeth with a tooth brush. Considering the other cleaning aids 15% children stated the use of a chew stick to clean their teeth. Usage of toothpaste was seen in 98% of children and 44% of total sample used fluoridated toothpastes while 3.2% used herbal toothpastes. Majority of them 52.4% were not aware of their toothpaste whether it contained fluoride or not. No significant difference by oral hygiene habits was seen for the gingival status. Frequency of brushing was statistically significant with either caries indices or gingival bleeding.

As shown in Graph 1, the consumptions of sugary foods were higher in this population. Considerable number of children reported using hidden sugar very frequently as 59% as biscuits, 68.2% as milk with sugar and 84% as tea with sugar. However the use of sugary foods was not significantly associated with the dmft/DMFT indices.

Graph 1: Pattern of sugary food consumption
Graph 1

Treatment needs have been categorized accordingly WHO guidelines19 and are shown in

Table 5: Treatment needs among institutionalized children
Table 5


According to the report on voluntary residential institutions for children in Sri Lanka by UNICEF in 200720, there are 488 voluntary residential homes that provide care for children in Sri Lanka and 52 of them are for the children with disabilities. At the end of 2006, more than 19,000 children were living in these institutions, separated from their families; the approximate proportion of females is 54% and that of males is 46%20. The gender distribution of the study sample was almost identical to this as 54.01% were girls and 45.99% were boys in this study.

Young children in institutional care have often been abandoned at birth or soon after because of poverty or parental instability. In some cases, the state may have intervened to remove young children from their parents’ care. Most of the time children are found with no previous records. In this scenario, sometimes children are missing their birth records and other medical records. This could attribute to a problem of taking care of children and making them vulnerable to medical conditions such as congenital diseases or hypersentivity reactions15. This has been observed in the study population as 66 children were unable to confirm their age due to loss of birth records. Dental age was estimated for them using the erupted dentition and necessary referrals were made to get through process of obtaining a birth certificate.

Though there are studies that suggested relationships between ethnicity and oral health status,16 it was not considered here since the most of the children had been living under the same roof from their birth. National oral health survey - 2003 findings indicated that mean number of teeth present in age group 12 years old was 24.96 while that of 15 years old was 27.80. The study population represented consistent findings as 23.87 for age group of 6-12 years and 27.39 for 13-17 years. The national figures for mean tooth loss in permanent dentition were 0.07 and 0.17 respectively for 12 years and 15 years. Though it was not constant, the findings observed in this study were 0.01 and 0.08 respectively. Neither dmft nor DMFT has shown significant correlation with gender but both were significantly associated with age.

The relatively low mean DMFT found in this study and the prevalence of dental caries in permanent dentition in both age groups was in line with those figures found in the national oral health survey. Considering the socially marginalized life style in this population, it might be expected to have a higher DMFT. The result indicates that the oral health status among institutionalized children is even better than that of the children of general population. This may be due to direct supervision from supervisors of institutions and guided schedules for oral hygiene practices such as brushing. Though this result presented as the entire children population, depending on the quality status of the children’s homes, it is reported within a few homes, 110 children not brushing at all.

Dental fluorosis was seen in 0.73% of children which is not consistent with the national figure. The reduced number may be due to the presence of a relatively low concentration of fluoride of water resources in the study area17. Children with fluorosis might have migrated from the fluoride rich areas. Traumatic injuries to the teeth were dominant in males than females as they actively participated in physical activities and sports. The low percentage of treated teeth may reflect the loss of parental care. Malocclusions were presented in 5.26% of children and none of them were receiving any form of treatment. This fact also can be attributed to the loss of parental care as the care takers tend to seek treatments only for the conditions causing dental pain. Majority of conditions which does not involve dental pain had been neglected due to limited resources and time of the guardians.

A significantly higher number of children stated tooth brushing at least twice daily in this sample. At the same time an extraordinary high prevalence of gingival bleeding was observed in the clinical investigation (44.67%). This inconsistency could be explained by either over reporting of tooth brushing or simply reflecting a lack of tooth brushing skills. While the tooth brushing technique may be inadequate to the vast majority of the children, they may still gain some caries preventive effect of such practice when using toothpaste with appropriate level of fluoride thus explaining the lower caries indices.

The survey revealed a significant correlation between information on untreated dental caries and the subjective evaluation of own oral health. Due to the progressive development course of untreated caries the experience of pulp-involvement and pain is relatively common in spite of the harmlessly looking DMFT level. Untreated caries and caries indices were highly associated with tooth ache and absenteeism from schools due to dental pain was experienced significantly. A significant relationship found in the fact that “other children make fun of my teeth” stating that these children were subjected to psychological harassments by their friends due to poor oral health.

Experience of the dental pain was significantly associated with all components of the caries indices (d, D) and untreated caries components (d, D) were higher among the children who had never seen a dentist compared to those who had seen a dentist. Findings suggested that regular dental care had reduced the dental pain related problems since it had been associated with daily life functions and oral health related to the quality of life.


The present study reveals lower level of dental caries while having higher prevalence of periodontal problems. Despite reporting higher usage of tooth brush and tooth paste, high percentage of bleeding gums were found in these children and this could be attributable to improper tooth brushing techniques and lack of individual supervision.


This research was supported by Sri Lanka Dental Association Research Grant 2014 and Wedasara Foundation Research & Publication Unit. We thank Department of Probation and Child Care, Central Province, Sri Lanka for their greater support and assistance.


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