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Table of Contents
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 12-19

Oral health status of people with locomotor disability in India: A systematic review

Department of Public Health Dentistry, Ragas Dental College, Chennai, Tamil Nadu, India

Date of Submission06-Oct-2020
Date of Decision08-Dec-2020
Date of Acceptance15-Jan-2021
Date of Web Publication16-Feb-2021

Correspondence Address:
Lakshmi Krishnan
Department of Public Health Dentistry, Ragas Dental College, SH102, ECR, Uthandi, Chennai - 600 119, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_40_20

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India accommodates 28.3 million disabled people. Among these, 20% are locomotor disabled (LD). Previous evidence showed that the relationship between general and oral health was high, and both were compromised in this population. Hence, evidence-based appropriate knowledge and understanding of the oral problems in this population is required to formulate policies on oral care for people with locomotor disabilities. Based on this background, the aim of the current study was to assess the prevalence of oral health status among the LD population in India. The current review generated 1.811 articles in a search using PICO in the following electronic databases: PubMed, EBSCO, Cochrane, and Google Scholar based on PICO. Based on the inclusion criteria, seven articles were selected for the final analysis. The majority of the included studies showed higher decay (3.37) and gingivitis (1.71), followed by malocclusion (54%). There were no data on adult and geriatric populations or on other oral pathologies, such as trauma, congenital malformations of the head and neck, or mucosal lesions. All articles showed a high-quality methodology. Poor oral health is prevalent among this population. However, further evaluation of other orofacial problems is required in all age groups to formulate necessary policies for the LD population of India.

Keywords: Adult, children, India, locomotor disability, oral health status

How to cite this article:
Krishnan L, Madankumar PD. Oral health status of people with locomotor disability in India: A systematic review. Sci Dent J 2021;5:12-9

How to cite this URL:
Krishnan L, Madankumar PD. Oral health status of people with locomotor disability in India: A systematic review. Sci Dent J [serial online] 2021 [cited 2023 Mar 29];5:12-9. Available from: https://www.scidentj.com/text.asp?2021/5/1/12/309544

  Background Top

According to the 2011 census in India, 2.21% of the total population were disabled; among them, about 20% were locomotor disabled (LD).[1] The Rehabilitation Council of India (RCI) states that LD is a condition in which a person is unable to perform distinctive activities such as self-movement/moving objects caused by a malfunctioning musculoskeletal or nervous system or both. The common conditions in this category are cerebral palsy (2.5%), leprosy (0.67%), muscular dystrophy (6.6%), meningocele (0.78%), meningomyelocele (0.11%), phocomelia (1.1%), and congenital dislocation of the hip (0.42%).[2]

In addition to underlying medical conditions, the evidence in the literature points to various comorbid conditions that are prevalent among persons with LD, which include joint pain, osteoarthritis, osteoporosis, low vision, fractures, stroke, chronic obstructive pulmonary disease, morning stiffness, diabetes, and heart failure in both men and women. These conditions further lead to poor health-related quality of life among this population, reflecting on negative feelings, bodily image, appearance, self-esteem, and thinking, adding to the existing psychological, emotional, and financial burden.[3] According to the social model of disability, these people face barriers in the form of poor infrastructure of the health-care system, indifferent attitudes of health-care workers, and poor knowledge on the part of health-care professionals or caregivers of disabled people, which further influences their health-care utilization pattern, leading to an increase in health burden.[4] There is adequate literature evidence to prove an association between general health well-being and oral health.[5],[6],[7]

According to evidence in the literature, people with physical, cognitive, or behavioral impairments tend to have poor oral health status and an increased tendency to periodontal disease, dental caries (untreated), and eventually tooth loss compared with the normal population. Other associated risk factors, such as age and severity of the condition, jeopardize not only their oral condition but also their daily performances.[8] This group of individuals may also not understand, assume responsibility for, or cooperate in using preventive oral health practices.[9] Moreover, the dependency of this population on others in all activities places them in an even greater disadvantaged position. The majority of the caretakers for people with disabilities often lack adequate knowledge and understanding of the value of maintaining good oral hygiene, which worsens the current scenario.[10] To address the current situation, understanding the oral health-care patterns among this population is the first step in providing them with accessible and affordable health and oral health care.

Currently, India is facing a revolutionary change in the health-care delivery system based on an increasing number of programs and schemes that focus on the health of the disabled population. Among them, only one insurance scheme, Niramaya, has a provision for preventive dental care. A SWOT analysis performed by Krishnan et al.[11] showed that oral care was not a priority, and future opportunities of integrating primary health with oral health were promising. Poor infrastructure and inadequate accountability in public–private partnerships have proven to threaten the delivery of oral care services among this disadvantaged population. The authors concluded that there was an urgent need to evaluate current schemes and bring about an appropriate integrated health and oral health system for the differently abled.[11]

Although some publications have reported the most prevalent oral and dental pathologies in this group, up-to-date evidence-based research is required, which could be obtained by a systematic review of the existing literature.[5],[6],[7],[8] The findings of the present systematic review provide an appropriate platform to make decisions regarding national policies for oral care, which would further improve dental care services for people with locomotor disability (LD) across India, making the dream of inclusive dental care a reality in the near future. Hence, based on this background, this systematic review was conducted to assess the oral health status among the people with LD in India.

  Materials and Methods Top


The current study is a qualitative/descriptive systematic review that adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify, evaluate, and summarize all relevant research findings. The protocol for this review has been submitted to the PROSPERO registry (the number is yet to be assigned).

Eligibility criteria

The following PICO was used to search articles in the electronic databases:

P I (C) O analysis:

  • POPULATION – Patients with locomotor/movement disability
  • INTEREST – Oral health status
  • COMPARISON – Not applicable
  • OUTCOME – Oral health status.

Inclusion criteria

  • Studies that assessed the oral health status of patients with LD as their primary or secondary aim
  • Studies that assessed oral health status in terms of dental caries/gingivitis/periodontitis/dental trauma injuries/malocclusion.

No restriction was made on age group, and articles published in the past 15 years were included.

Cross-sectional, cohort studies, qualitative studies, clinical trials, longitudinal studies, and comparative studies were searched.

Exclusion criteria

  • Studies that reported oral health perception or oral health-related quality of life
  • Studies that reported oral health status in a subjective manner using questionnaires
  • Reviews, editorials, books, expert opinions, and case series
  • Studies that required translation into the English language.

All the studies were sorted based on title and abstract. The full texts of the articles that met the eligibility criteria were read. A complete hand search using the references in the selected articles was done. A hand search of journals focusing on disability and oral health was performed, but it did not yield useful results.

Search strategy

Articles were included within the timeframe from January 2004 to December 2019 in the selected electronic databases. A detailed search strategy using the Medical Subject Headings (MeSH) terms was developed for MEDLINE, and it was modified to search other databases. Initially, the search terms “oral health status” and “oral health care” separated by the Boolean operator OR were input, followed by the terms “movement” and “locomotor disability” separated by the Boolean operator OR. The third set included the terms “children,” “adults,” and “adolescent” separated by the Boolean operator OR. All these search terms were joined by the Boolean operator AND. Data searches were done in October 2019 and again in December 2019. Bibliographies of included articles were analysed to ensure complete search. The duplication of articles was identified using zotero software version 5.0. Mason university. Created in 2006. [Table 1] depicts the search applied in MeSH terms and search words used in each database.
Table 1: The search terms used

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Study selection

Two authors (LK and MK) were independently involved in screening the selected articles based on the eligibility criteria. The selection of articles for the review was completed by the two authors without disagreement regarding their inclusion. Using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. IBM Corp. Released 2012, the inter-rater agreement between the authors was recorded as 0.83, which was acceptable.

Data extraction

The findings of the final seven selected articles were tabulated in the following format: first author name, year of publication of the article, study population, method of obtaining relevant information (assessment tool), results/primary outcome [Table 2].
Table 2: The characteristics of the study

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Quality assessment of the included studies

The methodological quality of the final selection of articles was performed using the Newcastle–Ottawa Scale because they were cross-sectional in nature. The scale uses selection, comparability, and outcome as categories for scoring, which were the following: a maximum score of 5 points for group selection, 2 points for compatibility, and 3 points for outcome. These scores were recorded to determine the methodological quality of the included studies. The higher the score, the higher the quality of the study. There was no available tool to assess the risk of bias in the cross-sectional studies. Based on our review objective, the sample representativeness and assessment tool used were the criteria chosen to determine the risk of bias across the studies, which were computed using Review Manager (RevMan) [Computer program]. Version 5.4, The Cochrane Collaboration, 2020.

  Results Top

Search results

In total, 1181 articles were generated in our initial search of PubMed, EBSCO, Cochrane, and Google Scholar. PubMed yielded 223 articles, the EBSCO database yielded 76 articles, Cochrane yielded 669 articles, and Google Scholar yielded 253 articles. The PRISMA 2009 guidelines regarding article selection are shown in the flowchart in [Figure 1].
Figure 1: PRISMA flowchart

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Finally after the screening process, seven out ten articles were selected. No productive results were obtained from the bibliographic or hand search. Hence, the same seven articles were considered in the final review. Among the three excluded articles, two had reported only on oral health-related quality of life, and one article reported only self-reported awareness on oral facial conditions. All the studies included had been based on cross-sectional designs.

A low risk of bias was determined among the studies that were assessed using the Modified Newcastle–Ottawa Scale. [Figure 2] shows the quality assessment and the risk of bias across the seven articles included in the review study.
Figure 2: The quality assessment performed for the included studies using Review Manager (RevMan) [Computer program]. Version 5.4, The Cochrane Collaboration, 2020

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Main findings

All studies reported the oral health status of persons suffering from any one LD as described by the RCI. Two studies reported only the decayed, missing, and filled status,[12],[13] and two studies reported the calculus debris status.[14],[15] One study reported only orthodontic findings;[16] other studies reported both dental caries and calculus debris status.[17],[18]

Assessment tool

All seven studies used a validated measurement tool to assess the oral health status of people with LD in India. The Decayed, Missing, and Filled Teeth (DMFT) Index, Simplified Oral Hygiene Index (OHI-S), Community Periodontal Index (CPI), and Dental Aesthetic Index (DAI) were used to measure oral health status quantitatively. Among the seven studies, four measured dental caries status in terms of the DMFT Index, the Care Index, and the Restorative Index. Debris and calculus status were obtained using the OHI-S, the Simplified Debris Index, and the Simplified Calculus Index. One study conducted by Nayak et al.[16] assessed orofacial abnormalities in terms of the DAI. The periodontal status of the population was assessed using the CPI.

All assessment tools were subjected to pilot testing to assess their feasibility in this special population. Inter-rater bias was eliminated by calibrating the examiner, and the reliability of the outcome was assessed using kappa statistics, the values of which ranged from 0.7 to 0.9, which were in good agreement.

Study population

The sample sizes of the included studies ranged between 100 and 800, and the age groups ranged from 3 to 20 years. Most studies (five of seven) assessed only pediatric patients 15 years of age. The ages of the study population were defined in all studies, but none used random sampling due to a decrease in the quality of the sample representation.

Of the included studies, two studies by Tak et al.[15] and Nagarajappa et al.[12] focused on a poliomyelitis population, whereas Shivakumar et al.,[18] Gardens et al.,[17] and Chand et al.[13] had conducted their studies on a sample of children with cerebral palsy. The remaining two studies were based on an entire disability population, in which 9.7% and 17.9%, respectively, represented physical disability.[14],[16] The case definition of the study population was explicit in all the included studies except Nayak et al.[16] and Rao et al.,[14] who used the ill-defined term “physical disability” to indicate LD.

Dental caries status

Four of the seven studies assessed dental caries status in the study population using the DMFT Index. Higher DMFT (4.80) and DFT scores (9.17) were shown in Shivakumar et al.[18] Similar DEFT scores (0.33) were recorded by Nagarajappa et al.[12] and Chand et al.[13] Gardens et al.[17] reported higher DFT scores (3.95) than DMFT scores (2.21).

Gingival and periodontal conditions

Two studies (Rao et al.[14] and Tak et al.[15]) exclusively measured oral hygiene and periodontal status using the OHI-S and CPI Indices. Gardens et al.[17] and Shivakumar et al.[18] assessed gingival and periodontal conditions using the CPI Index. Rao et al.[14] compared oral hygiene status among different dentitions in which permanent dentition showed a higher OHI-S score (2.77). Tak et al.[15] showed a mean OHI-S score of 1.72, and the majority of the population had a higher mean sextant score for two values (2.33). Gardens et al.[17] and Shivakumar et al.[18] represented their CPI scores in terms of percentages, which were 48% and 19% of score 2 values, respectively.

Orofacial abnormalities

Only one study by Nayak et al.[16] assessed dentofacial abnormalities using the DAI, which showed that the majority of the population (54.4%) had minor or no abnormalities.

Oral hygiene practices

All studies reported poor dental attendance in the previous 6 months–1 year. The majority of the participants used a toothbrush and toothpaste to clean, but all studies showed that most LD participants used supervised toothbrushing techniques, indicating their increased level of dependence. Five of seven studies reported an increase in snacking between meals among the study participants. Among the included studies, Nayak et al.[16] reported the increased prevalence of deleterious habits, such as mouth breathing, tongue thrusting, and thumb sucking among this population.

  Discussion Top

The purpose of this descriptive systematic review was to assess the oral health status of the people with LD in India. Although this review was intended to analyze age groups to 75 years, there were no data on adult and geriatric populations. The search was restricted to India because in recent years the national has developed a national oral health policy which has reached its second draft stage. Despite such efforts, inclusion of people with disability stands left out. There has been a tremendous change in oral health patterns among the population.[11] Hence, in a pioneering step, a deeper understanding of the oral health burden through a systematic literature analysis would provide a platform for stakeholders to devise and modify appropriate policies across India.

Although our initial search yielded 1118 articles, only seven articles were considered for the final review. In the past 15 years, the first article was published in 2005, whereas the next article was published in 2012, indicating a gap of almost a decade. This gap corroborates the lack of quality evidence regarding the oral health status of the people with LD in India.

In the present review study, the search strategy was performed according to the PRISMA guidelines, which yielded a set of seven analytical cross-sectional studies with outcomes on the oral health status of the people with LD, especially the pediatric age group, which indicated the lack of data on the adult and geriatric population. Among the included studies, three were conducted in Udaipur city, one in Chennai city, one in Bangalore city, one in Maharashtra, and one in Indore.

The trend in oral health status has shown improvement over time across the globe, yet India faces a huge dental disease burden among its residents. In particular, higher prevalence is seen in specific populations, which are mainly referred to as risk groups.[19] Among the risk populations are people with LD who show inequalities in oral and general health.[20]

Despite numerous health schemes, oral health still occupies a back seat.[11] Increased untreated dental caries, increased gingival bleeding, and calculus were seen among the study participants of the included studies, in addition to poor oral hygiene practices and decreased dental attendance. Studies on other oral findings, such as oral-mucosal lesions, traumatic injury, tooth hypoplasia, and congenital tooth abnormalities, were not found in any of the included studies.[20] Furthermore, the minority of the population who had accessed dental services had used only secondary or tertiary care rather than primary care.

Overall, the findings of this study suggest huge variations in the population characteristics. Lacunae exist in the data on adult and geriatric populations; no data were found on dental trauma, congenital abnormalities, or oral-mucosal lesions. Based on the evidence revealed in the current literature review, we conclude that an increased decay component and an increased calculus component exist among LD patients in India.

During the study, a few limitations were encountered. One such limitation was high heterogeneity in the sample used in this review study; hence, caution should be used in extrapolating the current results to other contexts. Moreover, because all the reviewed studies used cross-sectional designs, the pooled evidence was of low quality.

  Conclusion Top

The present review showed an increase in the prevalence of dental caries and gingival conditions, followed by malocclusion among the LD population in India. The seven studies included in the review focused on the pediatric population. Because of gaps in the data on adult and geriatric populations, there is scant evidence about the oral health burden among the LD population in India, which negatively affects dental clinicians as well as oral health policy stakeholders. Henceforth, to obtain further comprehensive evidence of the oral health status of the LD population in India, research on adult and geriatric populations focusing on other dental problems is warranted. These studies would further facilitate the concerned governmental bodies in framing new schemes and policies that consider the key factor of oral health.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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