Oral Health Status of Hearing-Impaired Children – A cross-sectional study conducted in Karachi, Pakistan.

doi:10.21203/rs.3.rs-3588459/v1

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Oral Health Status of Hearing-Impaired Children – A cross-sectional study conducted in Karachi, Pakistan.

https://doi.org/10.21203/rs.3.rs-3588459/v1

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Background

This study aimed to assess the oral health status of hearing-impaired children in Karachi, Pakistan. It aimed to investigate specific challenges faced by this population and highlight disparities in oral health outcomes.

Methods

The study utilized a cross-sectional design and enrolled hearing-impaired children from various schools in Karachi. Data were collected through a structured questionnaire and clinical examinations. Variables examined included oral hygiene practices, plaque scores, DMFT scores, socioeconomic status, and dietary habits.

Results

Majority of participants were male (53.9%) and aged between 5–20 years. Most participants had mild (23.6%) or moderate (31.6%) hearing impairment, and the mothers had primarily received primary education (27.3%). Sign language was the primary means of communication (64.6%) with the children, and the majority belonged to the lower middle class (33.2%) and lower class (31.4%). The mean Plaque Index score was significantly higher for children with severe deafness compared to those with mild deafness (3.3 ± 1.1 vs. 2.1 ± 0.8, p < 0.05). In primary dentition, children with complete deafness had a significantly higher mean DMFT score compared to those with mild deafness (0.14 ± 0.06 vs. 0.01 ± 0.06, p < 0.05). Similarly, in permanent dentition, children with moderate deafness had a significantly higher mean DMFT score compared to those with mild deafness (0.13 ± 0.12 vs. 0.11 ± 0.07, p < 0.05). Multinomial regression analysis identified significant associations (p < 0.05) between periodontal disease, DMFT and factors such as maternal education, sociodemographic status, brushing frequency, hearing impairment level, and plaque index.

Conclusion

The study emphasizes the specific challenges and disparities in oral health faced by hearing-impaired children in Karachi, Pakistan. Socioeconomic factors, limited access to hearing aids, poor oral hygiene practices, and high sugar consumption contribute to compromised oral health outcomes. The findings underscore the need for targeted interventions, improved oral health education, and increased accessibility to dental care.

Dental Caries

hearing impairment

oral health status

periodontal diseases

plaque index

socioeconomic factors

The World Health Organisation (WHO) defines hearing impairment as the inability to hear sounds above 20 dB.⁽¹⁾ It is a global disability that is more commonly observed in developing countries. According to estimates from the World Health Organisation (WHO), 466 million individuals worldwide were estimated to have a debilitating hearing impairment in 2018. This number is expected to increase to 630 million by 2030 and to over 900 million by 2050.⁽²⁾ In Pakistan, the prevalence of hearing-impaired individuals is estimated to be approximately 7.9% of the total population, with a significant portion of these individuals being children. Recent reports from the WHO indicate that approximately 3.5 million people, particularly in middle- and low-income countries, are affected by oral diseases.⁽³⁾ Among these oral diseases, untreated caries of permanent teeth is the most widespread, followed by severe periodontitis.

Children with disabilities, including hearing impairment, face an increased risk of dental problems. This heightened risk can be attributed to various factors, such as challenges in maintaining proper oral hygiene due to cognitive disabilities. Additionally, inadequate education and training for their primary caregivers often lead to suboptimal oral hygiene practices. Limited access to dental care is another significant issue for these individuals, as their communication difficulties make it challenging to express their oral health concerns effectively.

Dental caries, a gradual loss of tooth enamel and dentin that can lead to pulpal inflammation, is typically assessed using the DMFT (Decayed, Missing, Filled, Treated) score according to WHO criteria. Globally, as per the recent statistics of the WHO, dental caries affect approximately 40% of primary teeth and 29% of permanent teeth.⁽³⁾ However, children with hearing disabilities often face difficulties in maintaining good oral hygiene; therefore, there is always an increased chance of oral health problems in these children.⁽⁴⁾

A recent meta-analysis revealed that dental caries is quite prevalent, affecting 58% of children with hearing difficulties.⁽⁵⁾ In special needs schools in India, dental caries affected 65% of kids, with an average DMFT score of 1.6 ± 1. ⁽⁶⁾ According to Azfar et al., while they were in Pakistan, 48.1% of challenged students practised adequate oral hygiene, and 51% of them had dental caries, with a mean DMFT score of 2.08 (± 2.97). ⁽⁷⁾

Periodontal disease, characterised by chronic inflammation of the tissues surrounding the teeth, has a global prevalence of approximately 19%.⁽³⁾ It exerts a higher disease burden on populations with lower socioeconomic status, income, or education. Periodontal disease is one of the main causes of tooth loss, and children with hearing impairments who may struggle with effective oral hygiene practices are at risk of developing periodontal issues at a young age.⁽⁸⁾

Various studies have indicated that children with hearing impairments have a greater incidence of periodontal disease.^{(9, 10)} However, comprehensive literature highlighting the periodontal issues of hearing-impaired children in the Pakistani population is lacking.

Moreover, during craniofacial development, children with hearing disabilities may be more susceptible to developmental disabilities, leading to an increased risk of malocclusion of teeth. Suhani et al. reported a higher incidence of malocclusion in hearing-impaired children (79.3%) than in normal children.⁽¹¹⁾ The increased incidence of malocclusion is commonly attributed to factors such as mouth breathing, recurrent ear infections and respiratory problems that are often prevalent in these children. ⁽¹²⁾ The lack of dento-craniofacial growth leads to an increased incidence of unerupted teeth. ⁽¹³⁾

Defects in enamel formation can manifest during the stages of tooth development, leading to conditions such as enamel hypoplasia or fluorosis. These conditions result from a complex interplay of genetic and environmental factors. Notably, Khan et al. conducted a study that reported the prevalence of dental fluorosis in the Pakistani population. Their findings indicated that approximately 42.1% of males and 39.1% of females who visited a tertiary care hospital in Peshawar exhibited signs of dental fluorosis. ⁽¹⁴⁾ Another study found that hearing-impaired children are more likely to receive fluoride treatments from their dentists than children without hearing impairment.⁽¹⁵⁾ It is important to note that there is a scarcity of data to report the incidence of dental fluorosis in children with hearing impairment within the Pakistani population. All these factors indicate a dire need for research in this area to better understand the prevalence of dental diseases and their contributing factors in the Pakistani population with special needs.

The current study was implemented in three distinct special needs schools in Karachi. The main goal of the study was to determine the oral health status and treatment needs of hearing-impaired children. The findings of the current study will assist dental professionals in creating and implementing efficient treatments to prevent and treat dental issues in children with hearing impairments. Additionally, it will assist in teaching these children's parents and other caregivers how to practise better oral hygiene.

The current investigation was carried out in three different Karachi special needs schools. The Bahria University of Health Sciences' (BUHSC) Ethical Review Committee in Karachi provided ethical approval (ERC 24/2023), according to the Declaration of Helinsky. The study was conducted over a period of 6 months from April – September 2023. The technique of nonprobability purposive sampling was utilised. Students with hearing impairments only, and who had completed informed consent papers from their parents or guardians fulfilled the inclusion requirements. Students with additional disabilities, and those who were unable or unwilling to finish the oral exam fulfilled the exclusion criterion. Based on the international classification for grades of hearing impairment ⁽¹⁶⁾, the kids were split into four groups: full deafness, severe hearing impairment, moderate hearing impairment, and mild hearing impairment. A thorough oral examination was conducted utilising Williams' probe and CPITN under an artificial light source. The components of oral examination included decayed-missing-filled teeth (DMFT), gingival bleeding, periodontal pocketing, presence, or absence of plaque using the Loe and Silness plaque index⁽¹⁷⁾, malocclusion classes and enamel fluorosis using Dean’s Index. ⁽¹⁸⁾ A DMFT score of 0 is denoted as “caries-free” status, whereas "caries present" denotes a DMFT value greater than 0.

A questionnaire survey was conducted with the children in the presence of their parents or teachers. The first part consisted of demographic information such as age, gender, socioeconomic status, mother’s education level and level of hearing impairment. The second part consisted of information regarding dental visits, frequency of tooth brushing, dietary habits, use of fluoridated toothpastes and the type of toothbrush used by the children. Teachers and parents facilitated the process by use of sign language or lip reading with those children who did not use hearing aid.

Statistical Analysis

Sample size calculations

Using Open Epi, the sample size was determined with a power of 80 and a mean DMFT level of 7.58 ± 2.62 with reference to previous studies conducted in Pakistan ⁽¹⁹⁾. An estimated total of 353 participants was used, maintaining a 0.95 percent confidence range and a 0.05 percent α error. The sample size was raised to 373 participants to exclude dropouts.

Inter-examiner Reliability

Two dental house officers were trained along with the principal investigators. Inter-examiner reliability was calculated using kappa statistics, and a value of 0.83 was obtained, indicating excellent agreement between the examiners.

Reliability of questionnaire

The questionnaire was first distributed to 20 participants and was tested using Cronbach’s alpha. The questions that had an α ≥ 0.8 were included in the final version.

Statistical tests

SPSS version 27 was utilised for data analysis. To ascertain whether the data were normal, the Kolmogrov-Smirnov test was performed. We computed sociodemographic variable frequencies and percentages. The chi-square test was utilised to ascertain the questionnaire's descriptive statistics. The averages and standard deviations of the plaque index and DMFT in children with varying degrees of hearing impairment were determined using a one-way ANOVA. To determine the parameters connected to periodontal levels and DMFT in children with hearing impairments, multinomial logistic regression analysis was utilised. A statistically significant P value was defined as less than 0.05, and a 95% confidence level was employed.

Table 1

Demographics of the study participants
Variables	Frequency (N)	Percentage (%)
Gender
Males	201	53.9
Females	172	46.1
Age
5–10 years	116	31.1
11–15 years	153	41
16–20 years	104	27.9
Status of hearing impairment
Mild	88	23.6
Moderate	118	31.6
Severe	109	29.2
Deafness	58	15.5
Mother's level of education
None	43	11.5
Primary Education	102	27.3
Middle School	61	16.4
High School	48	12.9
Graduate	87	23.3
Postgraduate	32	8.6
Means of communication
Sign language	241	64.6
Lip reading	41	10.9
Child used hearing aid	91	24.3
Socioeconomic status
Lower class	117	31.4
Lower middle class	124	33.2
Upper middle class	80	21.4
High class	52	13.9

Table 1 shows the descriptive statistics for the study participants, including gender, age, status of hearing impairment, mother's level of education, means of communication, child used hearing aid, and socioeconomic status. The majority of the participants were male (53.9%) and aged between 5–20 years old, with most participants in the 11–15 years age group (41%). The participants had a variety of levels of hearing impairment, with most participants having mild (23.6%) or moderate (31.6%) hearing impairment. Most of the mothers had primary education (27.3%), followed by graduate education (23.3%). Sign language was the primary means of communication (64.6%) with the children. The majority of the children belonged to the lower middle class (33.2%) and lower class (31.4%).

Table 2

Descriptive statistics of the questionnaire
Question	Level of hearing impairment				p-value
	Mild	Moderate	Severe	Complete Deafness
	N (%)	N (%)	N(%)	N (%)
How much sugary food do you consume per day?
Sometimes	40 (24.0)	49 (29.3)	52 (31.1)	26 (15.6)	0.87
Once a day	22 (28.6)	26 (33.8)	19 (24.7)	10 (13.0)
Twice a day	15 (18.8)	29 (36.3)	24 (30.0)	12 (15.0)
Three or more	11 (22.4)	14 (28.6)	14 (28.6)	10 (20.4)
What type of sugary food do you consume?
Milk with sugar	28 (22.2)	47 (37.3)	34 (27.0)	17 (13.5)	0.03*
Juice	20 (25.0)	20 (25.0)	25 (31.3)	15 (18.8)
Soft drinks	8 (22.2)	9 (25.0)	12 (33.3)	7 (19.4)
Candies & Chocolates	21 (23.6)	23 (25.8)	32 (36.0)	13 (14.6)
Others	11 (26.2)	19 (45.2)	6 (14.3)	6 (14.3)
Do you brush your teeth?
Yes	79 (23.4)	108 (32.0)	98 (29.0)	53 (15.7)	0.96
No	9 (25.7)	10 (28.6)	11 (31.4)	5 (14.3)	0.96
How often do you brush your teeth?
Never	11 (22.0)	15 (30.0)	17 (34.0)	7 (14.0)	0.002*
2–3 times per week	4 (17.4)	6 (26.1)	8 (34.8)	5 (21.7)
Once a day	39 (28.3)	41 (29.7)	34 (24.6)	24 (17.4)
Twice a day	34 (21.0)	56 (34.6)	50 (30.9)	22 (13.6
What type of brush do you use?
Manual	101 (23.1)	134 (30.6)	131 (29.9)	72 (16.4)	0.65
Electric Brush	23 (28.4)	24 (26.9)	20 (24.7)	14 (17.3)
Others (Miswak etc)	8 (30.8)	8 (30.8)	6 (23.1)	4 (15.4)
Do you brush after meals?
Never	52 (24.9)	64 (30.6)	55 (26.3)	38 (18.2)	0.28
Sometimes	50 (25.1)	60 (30.2)	62 (31.2)	27 (13.6)
Always	30 (21.9)	42 (30.7)	40 (29.2)	25 (18.2)
Have you ever been to a dentist?
Yes	60 (24.3)	87 (35.2)	58 (23.5)	42 (17.0)	0.04*
No	72 (24.2)	79 (26.5)	99 (33.2)	48 (16.1)	0.04*
Have you experienced toothache within last one year?
Yes	60 (24.0)	79 (31.6)	64 (25.6)	47 (18.8)	0.34
No	72 (24.4)	87 (29.5)	93 (31.5)	43 (14.6)	0.34
Do you use flouride based toothpaste?
Yes	73 (83.0)	212 (89.8)	282 (86.2)	224 (96.6)	0.03*
No	10 (11.4)	14 (5.9)	33 (10.1)	8 (3.4)
Don't know	5 (5.7)	10 (4.2)	12 (3.7)	0 (0.0)

Chi-square test was applied. *p-value at 5% was significant.

The questionnaire's descriptive data for children with varying degrees of hearing impairment are displayed in Table 2. The percentage of children in each group that answered the questions differently was compared using chi-square testing.

There was a statistically significant difference in the type of sugary foods that children consumed. Children with severe deafness were more likely to consume milk with sugar (37.3%) than children with mild deafness (22.2%).

A statistically significant difference in how often children brushed their teeth. Children with severe deafness were more likely to brush their teeth never (34.0%) or 2–3 times per week (34.8%) than children with mild deafness (22.0% and 17.4%, respectively).

A statistically significant difference was observed in dental visits. Children with severe deafness were less likely to have ever been to a dentist (23.5%) than children with mild deafness (24.3%). The use of fluoridated toothpaste was also observed more in children with severe deafness (96.6%).

Table 3: Clinical parameters of Hearing-impaired children
Variables	Hearing impairment status				p-value
	Mild deafness Mean ± SD	Moderate deafness Mean ± SD	Severe deafness Mean ± SD	Compete deafness Mean ± SD
Plaque Index	2.1 ± 0.8	1.7 ± 0.9	3.3 ± 1.1	2.3 ± 1.3	0.008*
DMFT
Primary dentition	0.01 ± 0.06	0.01 ± 0.06	0.02 ± 0.07	0.14 ± 0.06	< 0.001**
Permanent dentition	0.11 ± 0.07	0.13 ± 0.12	0.11 ± 0.05	0.11 ± 0.07	< 0.001**

ANOVA was applied to calculate mean values.

*p-value was significant at 5%.

**p-value was significant at 1%.

Table 3 shows the mean and standard deviation of the Plaque Index and decayed, missing, and filled teeth (DMFT) scores for children with different levels of hearing impairment. The mean Plaque Index score for children with mild deafness (2.1 ± 0.8) was significantly lower than the mean Plaque Index score for children with severe deafness (3.3 ± 1.1). The mean DMFT score for children with mild deafness in the primary dentition (0.01 ± 0.06) was significantly lower than the mean DMFT score for children with complete deafness (0.14 ± 0.06). This suggests that children with complete deafness may be at increased risk for tooth decay in the primary dentition.

The mean DMFT score for children with moderate deafness in the permanent dentition (0.13 ± 0.12) was significantly higher than the mean DMFT score for children with mild deafness (0.11 ± 0.07). This suggests that children with moderate deafness may be at increased risk for tooth decay in the permanent dentition.

Table 4

Multinomial logistic regression analysis for the periodontal parameters of hearing-impaired children
Variable			B	S.E.	Wald	df	p-value	Odd’s Ratio	95% C.I.
Periodontal Status									L	U
Mild	Mother’s level of education	Graduate Education	-1.068	.543	5.869	1	0.049	0.344	0.119	0.996
	Socio-demographic status	Upper Middle Class	-2.112	0.762	7.688	1	0.006	0.121	0.027	0.538
	Frequency of brushing	Twice a day	-2.395	0.865	7.675	1	0.006	0.091	0.017	0.496
Moderate	Mother’s level of education	Graduate education	-1.927	0.619	9.690	1	0.002	0.146	0.043	0.490
Moderate	Mother’s level of education	Postgraduate	-2.726	0.912	8.941	1	0.003	0.065	0.011	0.391
Severe	Mother’s level of education	Secondary education	3.828	1.460	6.872	1	0.009	4.597	2.627	8.043
	Level of hearing impairment	Severe deafness	3.750	1.510	6.169	1	0.013	0.024	0.001	0.453
	Socio-demographic status	Lower class	3.947	1.725	5.234	1	0.022	5.177	1.760	15.253
	Frequency of brushing	Twice a day	-2.307	1.150	4.027	1	0.045	0.100	0.010	0.948
	Frequency of brushing	Thrice a day	-4.073	1.623	6.297	1	0.012	0.017	0.001	0.410
	Plaque Index	2	5.949	2.712	4.812	1	0.028	3.8341	1.884	7.798
DMFT
Decayed teeth	Gender	Males	-0.85	0.319	7.074	1	0.008	0.428	0.229	0.8
	Level of hearing impairment	Severe deafness	0.958	0.422	5.139	1	0.016	1.672	0.386	3.172
	Mother’s level of education	High school education	-4.105	0.622	4.36	1	< 0.001	0.016	0.053	1.056
	Mother’s level of education	Graduate	-3.22	0.611	2.777	1	< 0.001	0.040	0.012	1.324
	Frequency of brushing	twice a day	-1.38	0.509	7.418	1	0.006	0.25	0.092	0.678
	Brushing after meals	Never	1.28	0.6	4.552	1	0.033	3.599	1.11	11.672
	Enamel Fluorosis	Very Mild	2.264	0.765	8.76	1	0.003	9.622	2.149	43.093
	Enamel Fluorosis	Mild	1.399	0.723	3.747	1	0.053	4.051	0.983	16.702
Missing teeth	Sociodemographic status	Lower middle class	-1.628	0.763	4.559	1	0.033	0.196	0.044	0.875
	Sociodemographic status	Upper middle class	-2.24	0.541	1.721	1	< 0.001	0.106	0.037	0.306
	Frequency of brushing	Nil	2.465	1.596	1.98	1	< 0.001	5.709	2.498	13.055
	Type of malocclusion	Class 2 div II	2.051	1.410	21.155	1	< 0.001	8.012	5.056	12.692
Filled teeth	Sociodemographic status	High class	1.808	0.607	8.886	1	0.003	6.1	1.858	20.030
	Level of hearing impairment	Mild deafness	0.890	0.422	4.437	1	0.03	2.43	1.064	5.571
	Frequency of consumption of sugary foods	Three or more than three times a day	-1.063	0.48	4.808	1	0.028	1.345	0.133	2.893

Multinomial Logistic regression analysis. Reference S.E. – Standard Error, C.I. – Confidence Interval, L – Lower bound, U – Upper bound. *p-value less than 5%, **p-value less than 1%.

Table 4 shows the results of the multinomial regression analysis of periodontal disease and DMFT. Periodontal status was kept as a dependent variable. Of the eleven independent variables that were tested, the mother’s level of education, sociodemographic status, frequency of brushing, level of hearing impairment, and plaque index showed a significant association with the presence of periodontal disease in hearing-impaired children. People with higher levels of maternal education, higher sociodemographic status, and more frequent brushing are less likely to have periodontal disease, while people with severe deafness and a Plaque Index of 2 are more likely to have periodontal disease.

The results suggest that a high level of maternal education is less likely to be associated with periodontal disease. For mothers who have "Graduate Education" compared to other education levels, the odds of having "Mild" and “Moderate” periodontal disease are reduced by a factor of 0.344 (95% C.I. o.119-0.996) and 0.146 (95% C.I. 0.043–0.490), respectively. The odds of having "severe" periodontal disease were increased by a factor of 4.597 (95% C.I. 2.627–8.043) for individuals with mothers having a secondary education compared to those with other education levels. Similarly, children belonging to the upper middle class status were less likely to have “mild” periodontal disease (odds ratio: 0.121, 95% C.I. 0.027–0.538), and the odds of having “severe” periodontal status are increased by a factor of 5.177 (95% C.I. 1.760-15.253) for individuals with low sociodemographic status. Brushing more frequently “twice a day” reduces the odds of having mild periodontitis by a factor of 0.091 (95% C.I. 0.017–0.496) Individuals who brush their teeth more frequently “twice a day” (odd’s ratio: 0.100 95% C.I. 0.010–0.948) or “thrice a day” (odd’s ratio: 0.017 95% C.I. 0.001–0.410) are more likely to have severe periodontitis. A higher plaque index also indicates that the odds of having severe periodontitis are increased by a factor of 3.8341 (95% C.I. 1.884–7.798) compared to those who had low levels of plaque index.

Analysis of DMFT indicates that the odds of having decayed teeth are reduced by a factor of 0.428 (95% C.I. 0.229-0.8) in males compared to females. Similarly, severe deafness increased the odds of decayed teeth by a factor of 1.672 (95% C.I. 0.386–3.172). Individuals with mothers having at least high school and graduate education have reduced odds of having decayed teeth by a factor of 0.016 (95% C.I. 0.053–1.056) and 0.040 (95% C.I. 0.012–1.324). The frequency of brushing twice a day reduces the risk of dental caries by a factor of 0.25 (95% C.I. 0.092–0.678), while those who never brush after meals have an increased odds of having caries by a factor of 3.599 (95% C.I. 1.11-11.672). Individuals with very mild fluorosis are at higher risk of having decayed teeth (odds ratio: 9.622, 95% C.I. 2.149–43.093), while mild fluorosis increases the risk of decayed teeth by a factor of 4.051 (95% C.I. 0.983–16.702).

The frequency of having missing teeth is reduced in hearing-impaired children belonging to lower- and upper-middle-class families (odds ratio: 0.196, 95% C.I. 0.044–0.875 and 0.106, 95% C.I. 0.037–0.306, respectively). Children who never brush their teeth have increased odds of missing teeth by a factor of 5.709 (95% C.I. 2.498–13.055). Type II div. 2 malocclusion type increases the odds of having missed teeth by a factor of 8.012 (95% C.I. 5.056–12.692).

Children belonging to higher class had higher odds of having filled teeth (odd’s ratio: 6.1, 95% C.I. 1.858-20.0.30). A mild level of deafness is also a factor in increasing the odds of having filled teeth (odd’s ratio: 2.43, 95% C.I. 1.064–5.571). Children who consumed sugary foods three or more times a day numbered 1.345 (95% C.I. 0.133–2.893) times more likely to have filled teeth than children who consumed sugary foods less than three times a day.

Figure 1 is a pie chart showing that the frequency of malocclusion in hearing-impaired children is highest for class II malocclusion, followed by class I malocclusion, anterior crowding, class III malocclusion, rotated teeth, crossbite, and class II division II malocclusion. The percentages are 38.7%, 16.6%, 10.2%, 7.8%, 7.5%, 5.9%, and 3.6%, respectively.

Figure 2 shows a bar graph of the prevalence of periodontal status among hearing-impaired children. The graph shows that the prevalence of severe periodontitis is highest among children with moderate deafness (52.5%), followed by severe hearing impairment. followed by children with moderate hearing impairment (50.5%) and children with mild hearing impairment (47.7%). The prevalence of severe periodontitis is low among hearing-impaired children. Mild periodontitis is prevalent among children with mild hearing impairment (47.7%), followed by children with complete deafness (36.2%).

Figure 3 is a pie chart that shows the distribution of the prevalence of enamel fluorosis among deaf children in India. A total of 16.6% of the participants had normal teeth. A total of 13.9% of the participants had very mild enamel fluorosis. A total of 18.8% of the participants had mild enamel fluorosis. A total of 16.6% of the participants had moderate enamel fluorosis. A total of 21.2% of the participants had severe enamel fluorosis. A total of 13.9% of the participants had questionable enamel fluorosis.

The current study assessed the oral health status of hearing-impaired children enrolled in various schools across Karachi, Pakistan. Existing research has consistently demonstrated that individuals with disabilities, including hearing impairment, are more susceptible to dental caries and periodontal conditions due to the challenges they face in maintaining good oral hygiene.^{(20, 21)} In this context, this study sought to shed light on the specific oral health challenges faced by this population in the Karachi region.

In this study, most of the participants were males, and a significant number of participants fell within the age group of 11–15 years, which also aligns with the data of previous studies that state that hearing impairment is most prevalent in children of this age range.⁽²²⁾ The study also investigated the distribution of hearing impairment levels, where moderate and mild hearing impairments were the most common. A striking observation in this study was a lower percentage of participants using hearing aids (24.3%) compared to other research studies where the range typically falls between 30 and 40%.⁽²³⁾ This discrepancy may be attributed to the study location in a developing country where limited accessibility to hearing aids might pose challenges for hearing-impaired children.

Another significant variation was the higher percentage of participants hailing from a lower socioeconomic status (31.4%), contrasting with findings from other studies, which typically report figures between 20–25%.⁽²⁴⁾ This discrepancy may be linked to the socioeconomic conditions prevailing in the study's context, reflecting the impact of regional disparities and the financial constraints experienced by families in this developing nation.

Although no significant difference was observed in the consumption of sugary food per day, the majority of the children consumed sugar more than once a day. Likewise, findings from the study revealed that most of the students preferred taking milk with sugar. With respect to the frequency of brushing teeth, most of the students brushed once or twice daily. Another study conducted in Pakistan reported a higher frequency of hearing-impaired children brushing their teeth twice a day. ⁽⁷⁾ Tugeman et al.'s findings showed that hearing-impaired children brushed less frequently than children with normal hearing.⁽²⁵⁾ These findings are consistent with a prior Chinese study that highlights the need for increased oral disease prevention, particularly for hearing-impaired individuals.⁽²⁶⁾ Moreover, most of the students reported never visiting the dentist for dental examination. These findings are consistent with a previously conducted study by Suma et al., where most of the individuals had never been to the dentist.⁽²⁷⁾ This may be because Pakistan is a developing nation with persistent problems and a financial crisis, making it challenging for parents to take care of their children's needs while also making regular dental check-ups. Last, most of the respondents answered using a fluoridated toothpaste for brushing their teeth, which is a good sign.

An examination of the research participants' plaque scores demonstrated that individuals with severe deafness had higher levels of plaque scores. These results are consistent with previous research studies that found moderate to extensive plaque deposition in the majority of subjects.⁽²⁸⁾ This suggests that a child's ability to practice proper dental hygiene was significantly impaired. The DMFT score in primary dentition was highest in individuals suffering from complete deafness, while the DMFT score in permanent dentition was nearly similar for individuals suffering from different levels of deafness. The DMFT observed in our study was noted to be significantly less than that reported by Jain et al.⁽²⁹⁾ Another study conducted in the UK also revealed a higher DMFT score compared to our findings.⁽³⁰⁾ However, as stated by Jain et al.,⁽²⁹⁾ because the attention of parents is placed on the illness of hearing-impaired children, the dental health status is often overlooked, which could be the reason for the compromised dental status of the study participants.

The ability to remove plaque from teeth could be achieved by an individual who is physically skilled and who understands the intent of the procedure. It goes without saying that maintaining good dental hygiene would be much harder for individuals with disabilities than for healthy people. Those with hearing impairment cannot comprehend and learn the skill of oral hygiene practices since they are unable to perceive and respond to the instructions that are provided to them. Likewise, findings from the current study revealed that the periodontal status of our study participants was moderately affected.⁽³¹⁾ These findings are comparable to a prior study where more than 70% of hearing-impaired individuals suffered from compromised periodontal health.⁽⁹⁾

Individuals with hearing impairment face communication issues that impede them from receiving oral health education. Effective cleaning of teeth can be particularly difficult, as the dentist is unable to use sign language to communicate with them. Therefore, more frequent visits are needed to promote healthy dental hygiene practices.⁽⁹⁾ This is consistent with the findings of Champion and Holt, who found that almost two-thirds of HI children from the National Deaf Children's Society in the UK had trouble conversing with nurses or dentists. Nonetheless, in a peaceful setting, lip reading and oral conversation were feasible.⁽³²⁾

The multinomial regression analysis underscores the significance of various factors in determining oral health outcomes in hearing-impaired children. The role of maternal education and socioeconomic status in oral health disparities has been well documented in recent research. For instance, a study found that children from lower socioeconomic backgrounds are more likely to experience periodontal issues and dental caries, which is consistent with the findings in this study.⁽³³⁾ Similarly, research by Naidu et al. emphasised the impact of maternal education on children's oral health, highlighting the importance of maternal knowledge and resources in promoting good oral hygiene practices. ⁽³⁴⁾

The protective effect of regular tooth brushing and its association with reduced odds of periodontal disease and dental caries in this study is in line with the broader understanding of the pivotal role of oral hygiene practices. Research has consistently emphasised the preventive impact of tooth brushing in maintaining oral health.⁽³⁵⁾

The findings related to dietary habits, sugary food consumption, and the likelihood of having filled teeth resonate with the broader consensus on the impact of diet on oral health. Recent research studies have highlighted the relationship between high sugar intake and dental caries, underscoring the importance of dietary choices in oral health.⁽³⁶⁾

The results regarding missing teeth and malocclusion types emphasise the multifaceted nature of oral health, with significant associations in line with research on these aspects. For instance, a study by Ravaghi et al. explored the associations between malocclusion and tooth loss, supporting the idea that malocclusion types can impact oral health outcomes. ⁽³⁷⁾

The strengths of the study include its sample representation, as the researchers enrolled hearing-impaired children from various schools in Karachi, Pakistan, increasing the likelihood of a diverse and representative sample. Focusing on a specific population of hearing-impaired children, the study addresses their unique oral health challenges and emphasises the need for targeted interventions. By comparing their findings with previous research, the study provides a valuable context and contributes to existing knowledge. The use of multinomial regression analysis enhances the understanding of the factors influencing oral health outcomes in this population.

However, the study's generalizability is limited since it was conducted only in Karachi and focused on a specific population. The cross-sectional design restricts the ability to establish causal relationships or assess changes over time. Reliance on self-reported data introduces the potential for bias. The lack of a control group limits comparison with hearing children without impairments, therefore a causal relationship could not be developed.

Future studies in this direction should consider longitudinal study designs to track changes over time. Comparative analysis with control groups would provide valuable insights. Intervention studies are also recommended to evaluate the effectiveness of targeted oral health education program and accessibility to dental care. Implementing these recommendations will contribute to developing policies for improving oral health outcomes among hearing-impaired children.

In conclusion, the study on the oral health status of hearing-impaired children in this study revealed significant challenges and gaps. These children faced difficulties in maintaining good oral hygiene, leading to higher susceptibility to dental issues. Socioeconomic factors, such as lower socioeconomic status and limited accessibility to hearing aids, contributed to the observed disparities. Poor oral hygiene practices, high sugar consumption, and limited dental visits were prevalent. The study emphasised the importance of oral health education, regular tooth brushing, and improved access to dental care for this population. Addressing these factors is crucial in promoting better oral health outcomes among hearing-impaired children.

Availability of Data and Materials:

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Ethical Approval and consent to participate:

The study received ethical approval from the Ethical Review Committee of Bahria University Health Sciences Campus, Karachi Ref. No. ERC 24/2023 dated 31^st March 2023. Informed consent was obtained from all study participants and their (legal) guardians. All experiments were performed in accordance with relevant guidelines and regulations as prescribed by the Declaration of Helinsky.

Consent for publication

Not Applicable.

Competing Interests

The authors declare no competing interests.

Organization WH. International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of disease, published in accordance with resolution WHA29. 35 of the Twenty-ninth World Health Assembly, May 1976: World Health Organization; 1980.
Organization WH. Addressing the rising prevalence of hearing loss. 2018.
Organization WH. Global oral health status report: towards universal health coverage for oral health by 2030. Regional summary of the African Region: World Health Organization; 2023.
Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngologica Italica. 2016;36(5):386.
Bhadauria US, Purohit B, Agarwal D, Priya H. Dental caries status in individuals with hearing difficulties: a systematic review and meta‐analysis. Special Care in Dentistry. 2023;43(1):9-16.
Sandeep V, Kumar M, Vinay C, Chandrasekhar R, Jyostna P. Oral health status and treatment needs of hearing impaired children attending a special school in Bhimavaram, India. Indian journal of dental research. 2016;27(1):73.
Azfar M, Khan I, Quershi S, Zia N, Abid K. Oral health status among hearing and speech impaired children of karachi, Pakistan. JPDA. 2008;27:181-5.
Craig MH, Scott JM, Slayton RL, Walker AL, Chi DL. Preventive dental care use for children with special health care needs in Washington's Access to Baby and Child Dentistry program. The Journal of the American Dental Association. 2019;150(1):42-8.
Jnaneswar A, Subramaniya GB, Pathi J, Jha K, Suresan V, Kumar G. Assessment of dental caries and periodontal status in institutionalized hearing impaired children in Khordha District of Odisha. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2017;35(3):203-8.
Tefera AT, Girma B, Adane A, Muche A, Awoke Ayele T, Getahun KA, et al. Oral Health Status of Hearing-Impaired Students Attending Special Need Schools in Amhara Region, Ethiopia: A Cross-Sectional Study. Clinical, Cosmetic and Investigational Dentistry. 2022:19-35.
Suhani RD, Suhani MF, Muntean A, Mesaros M, Badea ME. Deleterious oral habits in children with hearing impairment. Clujul Medical. 2015;88(3):403.
Singh A, Agarwal A, Aeran H, Dhawan P. Oral Health & Quality of Life in preadolescents with hearing impairment in Uttarakhand, India. Journal of oral biology and craniofacial research. 2019;9(2):161-5.
Peláez AN, Mazza SM. Need for orthodontic treatment according to severity of malocclusion in adult patients. Odontoestomatología. 2015;17(26):12-23.
Khan F, Ajmal A, Shawana M, Khurshid AA, Ahmed J. Prevalence of Dental Fluorosis amongst patients attending the tertiary care hospital, Peshawar, Pakistan: Prevalence of Dental Fluorosis amongst Patients. Pakistan BioMedical Journal. 2022:55-9.
Pareek S, Nagaraj A, Yousuf A, Ganta S, Atri M, Singh K. Effectiveness of supervised oral health maintenance in hearing impaired and mute children-A parallel randomized controlled trial. Journal of International Society of Preventive & Community Dentistry. 2015;5(3):176.
Olusanya BO, Davis AC, Hoffman HJ. Hearing loss grades and the International classification of functioning, disability and health. Bulletin of the World Health Organization. 2019;97(10):725.
Löe H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. Acta odontologica scandinavica. 1963;21(6):533-51.
Dean HT. The investigation of physiological effects by the epidemiological method. Fluorine and dental health. 1942:23-31.
Khan I, Zia N, Abid K. Oral Health Status Among Hearing and Speech Impaired Children of Karachi, Pakistan. Oral Health. 2018;27(04).
Hulland S, Sigal MJ. Hospital‐based dental care for persons with disabilities: a study of patient selection criteria. Special Care in Dentistry. 2000;20(4):131-8.
Swain SK, Choudhury BK, Sahu MC. Dental problems among hearing-impaired children: Our experiences at a tertiary care teaching hospital in eastern India. Pediatria Polska-Polish Journal of Paediatrics. 2018;93(3):199-202.
Haile LM, Kamenov K, Briant PS, Orji AU, Steinmetz JD, Abdoli A, et al. Hearing loss prevalence and years lived with disability, 1990–2019: findings from the Global Burden of Disease Study 2019. The Lancet. 2021;397(10278):996-1009.
Schmucker C, Kapp P, Motschall E, Löhler J, Meerpohl JJ. Prevalence of hearing loss and use of hearing aids among children and adolescents in Germany: a systematic review. BMC Public Health. 2019;19(1):1-10.
Davis AC, Hoffman HJ. Hearing loss: rising prevalence and impact. Bulletin of the World Health Organization. 2019;97(10):646.
Tugeman H, Rahman N, Yusoff A, Daud M. Oral health knowledge, practice and dental plaque maturity status of hearing-impaired children. Sains Malaysiana. 2016;45(5):761-8.
Wei H, Wang Y-L, Cong X-N, Tang W-Q, Wei P-M. Survey and analysis of dental caries in students at a deaf–mute high school. Research in developmental disabilities. 2012;33(4):1279-86.
Suma G, Das UM, Akshatha B. Dentition status and oral health practice among hearing and speech-impaired children: A cross-sectional study. International journal of clinical pediatric dentistry. 2011;4(2):105.
Manohar PS, Subramaniam P. Oral health-related quality of life and oral hygiene of children and adolescents with hearing impairment. International Journal of Clinical Pediatric Dentistry. 2022;15(3):311.
Jain M, Bharadwaj SP, Kaira LS, Bharadwaj S, Chopra D, Prabu D, Kulkarni S. Oral health status and treatment need among institutionalised hearing-impaired and blind children and young adults in Udaipur, India. A comparative study. Oral Health Dent Manag. 2013;12(1):41-9.
Shaw L, Maclaurin ET, Foster TD. Dental study of handicapped children attending special schools in Birmingham, UK. Community dentistry and oral epidemiology. 1986;14(1):24-7.
Waldron C, Nunn J, Phadraig CMG, Comiskey C, Guerin S, van Harten MT, et al. Oral hygiene interventions for people with intellectual disabilities. Cochrane Database of Systematic Reviews. 2019(5).
Champion J, Holt R. Dental care for children and young people who have a hearing impairment. British dental journal. 2000;189(3):155-9.
de Abreu MHNG, Cruz AJS, Borges-Oliveira AC, Martins RdC, Mattos FdF. Perspectives on social and environmental determinants of oral health. International Journal of Environmental Research and Public Health. 2021;18(24):13429.
Naidu RS, Nunn JH. Oral health knowledge, attitudes and behaviour of parents and caregivers of preschool children: implications for oral health promotion. Oral Health Prev Dent. 2020;18(1):245-52.
Pérez-Portilla T, Ortíz-Benitez DL, Lucas-Rincón SE, Canseco-Prado G, Delgado-Pérez VJ, Scougall-Vilchis RJ, et al. The Importance of Toothbrushing and Oral Hygiene in Maintaining Oral Health. 2023.
Chi DL, Scott JM. Added sugar and dental caries in children: a scientific update and future steps. Dental Clinics. 2019;63(1):17-33.
Ravaghi V, Baker SR, Benson PE, Marshman Z, Morris AJ. Socioeconomic variation in the association between malocclusion and oral health related quality of life. Community Dental Health. 2019;36(1):17-21.

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Oral Health Status of Hearing-Impaired Children – A cross-sectional study conducted in Karachi, Pakistan.

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