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Oral Health-Related Quality of Life and Care Index of Children with Learning Disabilities: A Cross-Sectional Study
*Corresponding author: Dr. Priya Tomar, Department of Pediatric and Preventive Dentistry, Sri Aurobindo Dental College, Indore, Madhya Pradesh, India. tomarp603@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Tomar P, Chand B, Sontakke S. Oral Health Related Quality of Life and Care Index of Children with Learning Disabilities: A Cross-Sectional Study. doi: 10.25259/DJIGIMS_29_2025
Abstract
Objectives:
Children and adolescents with learning disabilities have higher unmet dental needs, but the quality of life provided by their parents, which can influence dental care, has not been determined.This study aims to investigate the correlation between the Care Index (CI) and the Oral Health-Related Quality of Life Index.
Material and Methods:
For this, 184 children aged 5 to 18 with learning disabilities were categorized into three groups. Dental caries assessments were conducted, and parents provided insights on quality of life using a pre-developed, validated questionnaire. Chi-square tests and regression analysis were used to compare groups and assess the correlation between the CI and the Oral Health Related Quality of Life Index.
Results:
Children with Down syndrome (DS) had the highest decayed, missing, filled teeth(DMFT) score at 14.95 ± 28.71, followed by autistic children at 12.54 ± 20.73. In terms of Oral Health-Related Quality of Life (OHRQoL), children with DS scored highest at 30.15 ± 15.81. A positive correlation was found between caries experience and OHRQoL, with caries in DS children being 2.45 times more likely to affect their OHRQoL negatively, compared to 1.20 times for autistic children.
Conclusion:
Untreated dental caries impacts oral health and social behaviour. Factors such as caries severity, caregiver education, and the child's age significantly affect the OHRQoL in children with Special Health Care Needs (SHCN). A supervised toothbrushing program with fluoridated toothpaste and topical fluoride in schools is crucial.
Keywords
Care index
Learning disabilities
Oral health related quality of life index
INTRODUCTION
Children with Special Health Care Needs (SHCN) are at a significantly higher risk of developing oral diseases due to a combination of physical, cognitive, and behavioral impairments. These challenges contribute to both unmet dental needs and difficulties in understanding and communicating oral health concerns, making them a highly vulnerable population in terms of oral health outcomes.
Traditional clinical indices such as the DMFT/dmft (decayed, missing, and filled teeth in permanent and primary dentition, respectively) are widely used to assess the prevalence and treatment of dental caries. The Care Index (CI), calculated as the proportion of filled teeth within the DMFT score (CI = F/DMF × 100), offers a measure of restorative treatment coverage. However, these indices predominantly focus on physical outcomes and fail to capture the broader psychosocial and emotional dimensions of oral health, particularly in populations with intellectual and developmental disabilities.
Oral health-related quality of life (OHRQoL) is a multidimensional concept that includes physical comfort, emotional well-being, social interactions, and self-esteem. Evaluating OHRQoL in children with SHCN is complicated due to their limited cognitive understanding and communication skills. As a result, parent-reported outcomes often serve as proxies. Studies have shown that parents of children with intellectual disabilities perceive dental caries to have a significant negative impact on their child's QoL. Despite this, clinical evaluations rarely incorporate OHRQoL assessments, and there remains a paucity of research that integrates both physical indices like DMFT and subjective measures like OHRQoL in this population. Dental caries negatively impacted the OHRQoL of children regardless of their disability,[1,2]
This study aims to address this gap by evaluating the CI and OHRQoL in children with three categories of learning disabilities. The specific objective is to explore the correlation between restorative dental care and perceived quality of life outcomes. The hypothesis is that lower CI scores, indicating higher levels of untreated disease, will be associated with poorer OHRQoL as reported by caregivers.
Given the lack of comprehensive research linking clinical and psychosocial indicators in children with SHCN, this study is both timely and essential. It seeks to provide more holistic insights into oral health outcomes and inform better-targeted dental interventions for this underserved population.
MATERIAL AND METHODS
Study design and setting
This was a cross-sectional study conducted at Manovruddhi Kendra, an institution in Indore, Madhya Pradesh, India, catering to children with learning disabilities. The center was chosen due to its accessibility and willingness to participate in the study. Data collection was conducted over 3 months, from July to September 2024.
Ethical considerations
The study was approved by the Institutional Ethics Committee of Sri Aurobindo Institute of Medical Sciences, Indore, on 16th October 2024 (IEC No. SAIMS/IEC/52/2024). The research adhered to the ethical principles outlined in the Declaration of Helsinki (as revised in 2000) for research involving human participants. Informed written consent was obtained from the parents or legal guardians of all participating children. For children above 7 years of age, assent was also obtained by national ethical guidelines. Confidentiality of participant data was strictly maintained throughout the study.
Study population and sampling
A convenience sample of 183 children aged 5 to 18 years with different categories of intellectual disabilities was recruited. The sample size was calculated using G*Power software based on an effect size of 0.3, power of 0.80, and significance level of 0.05. Participants were divided into three diagnostic categories:
Children with Autism Spectrum Disorder (ASD) (n = 61)
Children with Down Syndrome (DS) (n = 61)
Children with other intellectual disabilities (n = 61)
Inclusion criteria
Children aged between 5 and 18 years.
Children with a confirmed diagnosis of intellectual disability.
Children who were cooperative and could undergo oral examination.
Parental/legal guardian consent and child assent (where applicable) obtained.
Exclusion criteria
Children with medical conditions preventing cooperation (e.g., uncontrolled seizures).
Refusal of consent by parent/guardian.
Incomplete questionnaire responses.
Oral examination procedure
Clinical oral examinations were performed on-site in classroom settings. Visual dental assessments were conducted using wooden ice cream sticks under natural daylight, following the WHO Oral Health Survey Basic Methods. The DMFT index (for primary dentition) and DMFT index (for permanent dentition) were used to record decayed, missing, and filled teeth.
Disease status was confirmed using visual-tactile criteria consistent with WHO guidelines. No radiographs or invasive diagnostic aids were employed. One trained and calibrated examiner conducted all examinations, and a research assistant recorded findings on standardized paper forms.
Calculation of CI
The CI was computed using the formula:CI = (F /(D + M + F)) × 100.This reflects the proportion of treated carious lesions via restorations.
OHRQoL assessment: Questionnaire survey
To assess OHRQoL, a pre-validated structured questionnaire was distributed to parents before the dental examination. The questionnaire evaluated three domains:
Oral symptoms (e.g., pain),
Functional limitations (e.g., difficulty eating or speaking),
Emotional and social well-being (e.g., avoidance of smiling, interaction difficulties).
Responses were rated on a 4-point Likert scale
0 – Does not bother my child
1 – Bothers my child a little
2 – Bothers my child quite a bit
3 – Bothers my child very much
Domain-specific scores were calculated by summing responses for each item. The total OHRQoL score ranged from 0 to 63, with higher scores indicating greater negative impact and poorer perceived QoL.
Statistical analysis
All data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, Version 26.0. Descriptive statistics were used to summarize demographic and clinical variables. Intergroup comparisons between diagnostic groups were performed using the Chi-square test.
A linear regression analysis was performed to evaluate the relationship between the CI and OHRQoL scores. Given that the dependent variable is continuous and affected by one or more independent variables, linear regression analysis was employed to examine these associations. A p-value < 0.05 was considered statistically significant.
RESULTS
The final sample was composed of 183 children, of whom 57% were males and 43% were females.Of these, 27% had ASD, 26% had DS, and the remaining 47% were segregated into other categories cerebral palsy, attention deficit hyperactivity disorder (CP, ADHD, Mentally Retarded).
Mean decayed, missing, filled (DMF) scores and CI of different groups have been summarized in Table 1.
| Variable | Condition | Mean±SD | P-value |
|---|---|---|---|
| D | Autism | 1.22±1.32 | 0.03* |
| Down syndrome | 1.73±1.22 | ||
| Others | 0.94±1.69 | ||
| Total | 1.33±1.42 | ||
| M | Autism | 0.14±0.61 | 0.5 |
| Down syndrome | 0.20±0.40 | ||
| Others | 0.08±0.28 | ||
| Total | 0.15±0.46 | ||
| F | Autism | 0.42±0.81 | 0.2 |
| Down syndrome | 0.48±0.89 | ||
| Others | 0.20±0.83 | ||
| Total | 0.39±0.85 | ||
| DMFT | Autism | 1.77±1.63 | 0.01* |
| Down syndrome | 2.42±1.62 | ||
| Others | 1.11±1.81 | ||
| Total | 1.84±1.74 r | ||
| CI | Autism | 14.95±28.71 | 0.17 |
| Down syndrome | 12.54±20.73 | ||
| Others | 5.00±20.82 | ||
| Total | 11.46±24.48 |
P-values were calculated using One-way ANOVA. DMFT: Decayed, missing, filled teeth, CI: Care index and 0.03 p-value is statistically significant. *represents significance.
DMF score of Downs children came to be the highest with a score of 2.42±1.62 . Mean score of 14.95 (±28.71) noted for CI of autistic children, which was recorded tobe the highest, followed by Down syndrome with 12.54±20.73.
OHRQoL scores of the three groups have been summarized in Table 2.
| Condition | OHRQoL (Mean±SD) | P-value |
|---|---|---|
| Autism | 16.27±10.50 | 0.05* |
| Down syndrome | 30.15±15.81 | |
| Others | 8.01±4.29 |
The p-value was calculated using One-way ANOVA to compare mean OHRQoL scores among the three groups. The result (p = 0.05*) indicates a statistically significant difference among the groups at the 5% level (p < 0.05). OHRQoL: Oral health related quality of life
With regards to OHRQoL, Down syndrome had the highest index values, 30.15±15.81, while the other category had the lowest, 8.01±4.29.
Table 3 depicts the correlation between caries experience and OHRQoL, which came out to be positive, in which caries in Down’s children is 2.45 times likely to affect a child’s OHRQoL, whereas caries in Autistic children is 1.20 times likely to have negative effects on a child’s OHRQoL.
| Condition | Mean±SD | Odd’s ratio |
|---|---|---|
| Autism | 1.77±1.63 | 1.20 |
| Down syndrome | 2.42±1.62 | 2.45 |
| Others | 1.11±1.81 | 1.00 |
DMFT: Decayed, missing, filled teeth, OHRQoL: Oral health related quality of life SD: Standard deviation
DISCUSSION
This research was carried out to assess the relationship between the CI and the OHRQoL Index, specifically the effect of treated dental caries on different aspects of the health index in children with learning disabilities.
This cross-sectional study evaluated the oral health status, CI, and OHRQoL in children with various types of learning disabilities, such as ASD, DS, and other intellectual disabilities.
The findings revealed significant differences in caries experience (DMFT scores), CI, and OHRQoL outcomes across the groups.
Children with DS exhibited the highest mean DMFT score (2.42 ± 1.62), followed by children with Autism (1.77 ± 1.63) and those categorized under other disabilities (1.11 ± 1.81). The elevated caries experience among DS may be attributed to multiple factors, such as hypotonia, delayed eruption of teeth, altered immune responses, reduced salivary flow, and challenges in performing oral hygiene effectively.[3].
On the contrary, caries experience for children with DS and those without the syndrome wasnot different based on the results of this study.[4]
According to Morishima et al.[5], numerous features of saliva in individuals with DS have been documented, such as reduced secretion, heightened oxidative stress, and increased levels of secretory IgA. All these elements are likely to influence the salivary microbiome, and since children with DS show higher concentrations of IgA compared to their counterparts, which is essential in protecting against dental caries by inhibiting bacterial adhesion, they demonstrate lower rates of caries.
Although the CI was highest among children with Autism (14.95 ± 28.71), followed by DS (12.54 ± 20.73), the overall restorative care rates remained low across all groups. This indicates that despite the existence of dental needs, treatment uptake was less than optimal, potentially due to behavioral challenges, financial obstacles, a shortage of specialized dental services, and limited awareness among caregivers. Our results do not align with the research carried out by Hegde et al.[6] which indicated that most autistic children exhibited poor or fair oral hygiene. Poor oral hygiene in children with autism is attributed to low powers of concentration and a limited cognitive ability.Autistic children with primary and mixed dentition showed a higher caries index.[7] Notably, children with Autism often require more behavior management strategies, sedation, or hospital-based dental care, complicating timely intervention.
One of the explanations provided for the rising prevalence of dental caries among this demographic is the regular consumption of sugar-laden medications and reliance on a caregiver for consistent oral hygiene, reduced clearance of foods from the oral cavity, impaired salivary function, preference for carbohydrate-rich foods, a liquid or puréed diet, and oral aversions.[6]
The research conducted by Ningrum et al. focused on the DMFT index in children with intellectual disabilities or ASD. Their findings established a correlation between the prevalence of dental caries and the average DMFT scores across different countries, underscoring the importance of a comprehensive and fair treatment approach to uphold oral health in children with special needs, particularly in countries with high DMFT rates.[8]
The findings of research done by Ikehara et al. [9] indicate that children with ASD experience significantly lower OHRQOL across various dimensions when compared to their neurotypical counterparts. It was found that self-esteem, depressive symptoms, and social support have a substantial effect on OHRQOL, where increased depressive symptoms are associated with diminished OHRQOL, while elevated self-esteem is related to improved self-perception. Furthermore, social support played a crucial role in moderating OHRQOL, underscoring the importance of fostering supportive environments for children with ASD.
Consistent with caries experience, the OHRQoL scores were also poorest in DS children (30.15 ± 15.81), indicating that poor oral health status significantly impacts daily functioning, emotional well-being, and social interaction. Conversely, children with “other” disabilities demonstrated better OHRQoL outcomes (8.01 ± 4.29) alongside lower caries experience. In their recent study, Aljameel et al [10] found that oral health significantly affected the quality of life of both children with DS and their families, especially in emotional and social domains.Mothers reported stronger impacts on family functioning and emotions compared to the children’s self-perception.
In a study by Vanessa dos Santos Viana and colleagues,[11] researchersfound a low prevalence of dental caries and satisfactory oral hygiene between children and adolescents with autism, and a positive association between mothers’ education and better scores of children’s OHRQoL. Patyal N and colleagues[12] investigated the impact of dental carious lesions on the OHRQoL of preschool children and their families. This was evaluated using the Odia version of the Early Childhood Oral Health Impact Scale (ECOHIS). The study revealed that the presence of carious lesions significantly disrupted family routines and caused emotional distress, including feelings of frustration, anxiety, and sleep disturbances among caregivers. Most mothers had to take time off work, and parents reported a greater impact on family life (22.76%) compared to the impact on children (17.8%).A study by Carolina Schwertner et al.[13] suggests that caregivers of children with DS have similar oral health and QOL compared to caregivers of children without DS.
Regression analysis revealed a positive correlation between caries experience and OHRQoL. Children with DS were found to be 2.45 times more likely to experience a negative impact on OHRQoL related to caries, while those with Autism were 1.20 times more likely, compared to others. These findings reinforce the notion that dental caries is not merely a clinical condition but a multidimensional health issue affecting physical comfort, emotional status, and social integration.[14]
Overall, this study underscores the urgent need for integrated oral health programs targeting children with learning disabilities. Preventive strategies such as regular dental screenings, fluoride applications, caregiver education, and early intervention are critical. Moreover, interdisciplinary collaboration among dentists, pediatricians, speech therapists, and special educators can play a pivotal role in improving oral health outcomes and enhancing the quality of life of these vulnerable children.
CONCLUSION
Our study revealed a significant correlation between dental caries experience, CI, and OHRQoL in children with learning disabilities. Children with DS had the highest caries prevalence and the poorest OHRQoL, indicating a substantial impact of untreated dental issues on their overall well-being. Autistic children, despite showing the highest CI, still reflected a need for improved restorative care. The findings highlight that dental caries extends beyond clinical implications, influencing emotional, social, and functional aspects of a child’s life. There is a pressing need for inclusive, preventive oral health programs, increased caregiver awareness, and accessible dental services to enhance the quality of life for children with SHCN. Establishing school-based supervised brushing programs and regular fluoride applications may significantly contribute to reducing the oral disease burden in this population.
Ethical approval:
The research/study was approved by the Institutional Review Board at Sri Aurobindo Institute of Medical Sciences, approval number SAIMS/IEC/52/2024, dated 16th October 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil
References
- Oral health-related quality of life according to dental caries severity, body mass index and sociodemographic indicators in children with special health care needs. J Clin Med. 2021;10:4811.
- [CrossRef] [PubMed] [Google Scholar]
- Oral health-related quality of life in children attending university special needs and paediatric dental clinics in Trinidad and Tobago: A parental perspective. Acta Odontol Scand. 2025;84:43009.
- [CrossRef] [PubMed] [Google Scholar]
- The incidence of dental caries in children with Down syndrome: A systematic review and meta-analysis. Dent J. 2022;10:205.
- [CrossRef] [PubMed] [Google Scholar]
- Dental caries in children with Down syndrome and associated factors. RGO Rev Gaúch Odontol. 2021;69:e20210044.
- [CrossRef] [Google Scholar]
- Salivary microbiome in children with Down syndrome: A case-control study. BMC Oral Health. 2022;22:438.
- [CrossRef] [PubMed] [Google Scholar]
- Analysis of dental caries experience and parents' perception of the oral health status of children with autism spectrum disorders from South India. Med J Bakirkoy. 2024;20:189-95.
- [CrossRef] [Google Scholar]
- Oral health assessment of children with autism spectrum disorder in special schools. Int J Clin Pediatr Dent. 2021;14:548-53.
- [CrossRef] [PubMed] [Google Scholar]
- The oral health inequities between special needs children and normal children in Asia: A systematic review and meta-analysis. Healthcare. 2021;9:410.
- [CrossRef] [PubMed] [Google Scholar]
- Influence of self-esteem on health-related quality of life in children and adolescents with autism spectrum disorders. Psychiatry Clin Neurosci Rep. 2025;4:e70079.
- [CrossRef] [PubMed] [Google Scholar]
- Oral health-related quality of life of children with Down syndrome and their families: A cross-sectional study. Children. 2021;8:954.
- [CrossRef] [PubMed] [Google Scholar]
- Parental caregivers' perceptions of oral health-related quality of life in children with autism spectrum disorder. J Dent Health Oral Disord Ther. 2020;11:132-7.
- [CrossRef] [Google Scholar]
- Impact of caries experience on the oral health-related quality of life of pre-school children and their families in an Indian city: An evaluative study. Indian J Dent Res. 2024;35:136-9.
- [CrossRef] [PubMed] [Google Scholar]
- Oral health status and quality of life of the parental caregivers of children with Down syndrome: A case-control study. J Intellect Disabil. 2023;27:238-49.
- [CrossRef] [PubMed] [Google Scholar]
- Correlation of untreated dental caries and oral health-related quality of life amongst school children: A cross-sectional study. J Pharm Bioallied Sci. 2024;16(Suppl 4):S4003-5.
- [CrossRef] [PubMed] [Google Scholar]