Since pain is an inherently subjective phenomenon, it is often said that the “gold standard” for pain assessment in both children, and adults is verbal-reporting [
Reliable description of pain may be difficult for children due to their cognitive immaturity and their inability to separate pain from fear and anxiety [
Intellectual disability which affects nearly 2.5% of the population is currently defined by the American Association on Intellectual and Developmental Delay (AAIDD) as significantly subaverage intellectual functioning, existing concurrently with related limitations in two or more of certain adaptive skills including communication, self-care and social skills manifesting before the age of 18 years [
Studies show that children with disabilities have higher dental caries experience, unmet treatment needs, and prevalence of malocclusion, than those without disabilities [
This study was aimed at assessing the ability of caregivers of children with ID to evaluate the presence of dental pain through behavioral changes in their children.
This study recruited a total of 86 children among those visiting the dental clinics at the Faculty of Dentistry, and the hospital dental clinics at King Abdulaziz University (KAU), Jeddah, Saudi Arabia, during the years 2009 and 2010. Recruited children were divided into cases and controls. Cases fulfilled the following criteria. Both boys and girls ages range from birth to 16 years. A history of ID as verified by the child’s medical file or caregivers’ reporting. Child may be verbal or nonverbal. Caregivers were able to understand spoken Arabic or English. Included children could be diagnosed with medical problems other than ID.
Controls included age-matched children recruited from the dental clinics at the Faculty of Dentistry, and the hospital dental clinics at King Abdulaziz University (KAU). They basically fulfilled the same criteria only they had normal intellectual development without ID.
Before the beginning of the study, ethical approval was obtained from the Faculty of Dentistry, KAU, to conduct the study. The investigators developed a questionnaire containing a mixture of closed- and open-ended questions regarding participants’ demographical, medical, and dental data. Two investigators were calibrated to do intra- and extraoral examinations on children. Reliability of the two examiners was assessed in measuring dental caries on 10% of the sampled children with Kappa = 0.85,
Dental pain was measured using the “Dental Discomfort Questionnaire” (DDQ+) [
For each question in the DDQ+, parents’ rated the occurrence of the behavior as “never” coded as zero, “sometimes” coded as 1, or “frequently” coded as 2. A total numeric DDQ+ for each child and a mean DDQ+ for the group were calculated. Caregivers and investigators were also asked to rate the children’s dental pain on a ten-point scale where zero represented the absence of pain and ten the maximum pain imaginable [
Dental examinations were done on the dental chair with optimal lighting and intraoral mirror. Gentle removal of soft debris on teeth was done when needed without forceful use of dental explorer. Caries examination was based on the “WHO” criteria where the DFT/dft scores were measured [
The severity of dental treatment needs was determined for each child based on the following categories. None: no restorative treatment required; simple: preventative treatment required such as scaling, prophylaxis, oral hygiene instructions, topical fluoride application, or sealants; moderate: one or more teeth requiring one- or two-surface restorations; complex: one or more teeth requiring a three- or four-surface restorations, stainless steel crowns, endodontic therapy, or extractions [
The statistical analysis was done using Windows SPSS software version 15. Bivariate analyses were done to study associations between demographic, medical, and dental data and the DDQ. Regression models were also used with the main outcome variable being the average total DDQ score. The level of significance (
The study sampled a total of 86 children of which 33 were cases diagnosed with ID and 53 were healthy age-matched controls. The sample contained 44 (51.16%) males and 42 (48.84%) females. The sampled children were categorized into three age groups; birth to 6 years (
Among children with ID, 31% were perceived by their parents to have mild delays, 37.9% moderate, and 24.1% severe delays, while 6.8% of parents did not recognize the presence of delay despite the presence of a confirmed diagnosis in the child’s medical record. The majority of children with ID were diagnosed at birth (84.8%). The results showed that 97% of children with ID had other associated medical problems compared to 26.4% of healthy children (
When asked about the child’s verbal abilities, 57.6% of parents with children having ID replied that their children could speak. Among those, 74% (
Table
DFT and dft scores in healthy children and children with ID.
DFT/dft scores | Healthy children | Children with ID | Mann-Whitney test |
|
---|---|---|---|---|
DFT | 0.92 | 2.32 | 2.09 | 0.04* |
D | 0.77 | 2.04 | 2.18 | 0.03* |
F | 0.15 | 0.28 | 0.53 | 0.6 |
| ||||
dft | 8.83 | 6.81 | 2.07 | 0.04* |
d | 8.32 | 6.47 | 1.94 | 0.05* |
f | 0.36 | 0.34 | 0.03 | 0.97 |
*Statistically significant at
Caregivers’ and investigators’ reporting of children’s dental pain.
Questions to caregivers | ||||
---|---|---|---|---|
Variables | Healthy children |
Children with ID |
|
|
Do you think your child has dental pain? | No | 12 (22.6) | 6 (20.7) | 0.04 |
Yes | 41 (77.4) | 23 (79.3) | 0.84 | |
| ||||
How frequent is your child’s dental pain? | Never | 12 (22.6) | 7 (24.1) | 0.3 |
Occasionally | 27 (50.9) | 13 (44.8) | 0.86 | |
Always | 14 (26.4) | 9 (31) | ||
| ||||
How severe is your child’s dental pain?* | Mean ± SD |
|
|
0.35 |
Median | 4 | 5 | 0.73 | |
| ||||
When does pain mostly occur? | During meals | 29 (70.7) | 14 (66.7) | |
During daytime | 1 (2.4) | 0 | 0.76 | |
At night | 5 (12.2) | 3 (14.3) | 0.86 | |
Multiple occasions | 6 (14.6) | 4 (19) | ||
| ||||
Questions to investigators | ||||
Variables | Healthy children |
Children with ID |
|
|
| ||||
Do you think this child has dental pain? † | No | 5 (9.4) | 1 (3.1) | 0.4 |
Yes | 48 (90.6) | 31 (96.9) | ||
| ||||
How severe is this child’s dental pain? †† | Mean ± SD |
|
|
0.78 |
Median | 7 | 7 | 0.43 |
*Mann-Whitney
†Fisher exact test used for comparison.
††
Table
When caregivers were asked about specific behaviors related to dental pain (DDQ+) results showed that the mean DDQ+ in healthy children was
Comparison of DDQ items between healthy children and children with ID in groups with dental caries.
Items of the DDQ | Frequency | Healthy children |
Children with ID |
|
|
---|---|---|---|---|---|
Problems with brushing upper teeth | Never | 44 (83) | 24 (80) | 0.35 | 0.84 |
Occasionally | 2 (3.8) | 2 (6.7) | |||
Always | 7 (13.2) | 4 (13.3) | |||
| |||||
Problems with brushing lower teeth | Never | 44 (83) | 25 (83.3) | 0.28 | 0.87 |
Occasionally | 3 (5.7) | 1 (3.3) | |||
Always | 6 (11.3) | 4 (13.3) | |||
| |||||
Puts away something nice to eat | Never | 42 (79.2) | 20 (64.5) | 2.42 | 0.3 |
Occasionally | 3 (5.7) | 4 (12.9) | |||
Always | 8 (15.1) | 7 (22.6) | |||
| |||||
Bites with molar instead of front teeth | Never | 47 (88.7) | 26 (89.7) | 0.57 | 0.75 |
Occasionally | 1 (1.9) | 0 (0) | |||
Always | 5 (9.4) | 3 (10.3) | |||
| |||||
Chewing at one side | Never | 34 (65.4) | 26 (89.7) | 6.26 | 0.04* |
Occasionally | 2 (3.8) | 1 (3.4) | |||
Always | 16 (30.8) | 2 (6.9) | |||
| |||||
Problems chewing | Never | 37 (71.2) | 21 (72.4) | 0.02 | 0.99 |
Occasionally | 2 (3.8) | 1 (3.4) | |||
Always | 13 (25) | 7 (24.1) | |||
| |||||
Reaching for the cheek while eating | Never | 28 (52.8) | 18 (62.1) | 0.67 | 0.71 |
Occasionally | 4 (7.5) | 2 (6.9) | |||
Always | 21 (39.6) | 9 (31) | |||
| |||||
Crying at night | Never | 42 (79.2) | 22 (71) | 1.6 | 0.45 |
Occasionally | 3 (5.7) | 1 (3.2) | |||
Always | 8 (15.1) | 8 (25.8) | |||
| |||||
Crying during meals | Never | 40 (75.5) | 23 (76.7) | 5.73 | 0.06 |
Occasionally | 7 (13.2) | 0 (0) | |||
Always | 6 (11.3) | 7 (23.3) | |||
| |||||
Earache at night | Never | 51 (96.2) | 33 (100) | 1.2 | 0.55 |
Occasionally | 1 (1.9) | 0 (0) | |||
Always | 1 (1.9) | 0 (0) | |||
| |||||
Earache at daytime | Never | 52 (98.1) | 33 (100) | — | 1.00 |
Occasionally | 1 (1.9) | 0 (0) | |||
Always | 0 (0) | 0 (0) | |||
| |||||
Earache during eating | Never | 53 (100) | 33 (100) | — | — |
Occasionally | 0 (0) | 0 (0) | |||
Always | 0 (0) | 0 (0) | |||
| |||||
Excessive salivation | Never | 52 (98.1) | 25 (80.6) | — | 0.01* |
Occasionally | 0 (0) | 0 (0) | |||
Always | 1 (1.9) | 6 (19.4) | |||
| |||||
Putting hand inside mouth | Never | 47 (88.7) | 21 (70) | 11.45 | 0.003* |
Occasionally | 6 (11.3) | 3 (10) | |||
Always | 0 (0) | 6 (20) |
*Statistically significant at
Agreement between pain assessments (yes/no) by caregivers and investigators.
Dentist reporting of presence of pain | Parent-reporting of presence of pain | |||
---|---|---|---|---|
Healthy children | Children with ID | |||
No | Yes | No | Yes | |
|
|
|
|
|
No | 5 (41.7) | 0 | 1 (20) | 0 |
Yes | 7 (58.3) | 41 (100) | 4 (80) | 23 (100) |
Kappa | 0.53 | 0.29 | ||
|
0.0001* | 0.03* |
*Statistically significant at
The analysis looked at the correlation between the average DDQ+ and the DFT/dft scores. The results showed a significant positive correlation in healthy children between the DDQ+ and DFT score (Spearman rho = 0.47,
The association between caregivers’ perception of the presence of dental pain and the complexity of dental treatment needs was evaluated (Table
Association between dental treatment needs and caregivers’ ability to recognize presence of pain.
Does child have pain (question to caregiver)? | |||||
---|---|---|---|---|---|
Type of subject | Child’s dental treatment needs | No | Yes | Total | Kendall’s tau-b |
|
|
||||
Healthy children | Non/simple | 0 (0) | 0 (0) | 0 (0) | |
Moderate | 4 (33.3) | 2 (4.9) | 6 (11.3) | 0.38 | |
Complex | 8 (66.7) | 39 (95.1) | 47 (88.7) | 0.06 | |
Total | 12 (100) | 41 (100) | 53 (100) | ||
| |||||
Children with ID | Non/simple | 3 (50) | 0 (0) | 3 (10.3) | |
Moderate | 2 (33.3) | 1 (4.3) | 3 (10.3) | 0.79 | |
Complex | 1 (16.7) | 22 (95.7) | 23 (79.3) | 0.003* | |
Total | 6 (100) | 23 (100) | 29 (100) |
*Statistically significant at
The regression model with the DDQ+ as the outcome variable did not show any of the predictors (gender, mother’s education or occupation, father’s education, child’s medical condition, and medication intake) to be significant.
Reliable description of pain is generally difficult in children, and more so in those with ID due to their cognitive immaturity, lack of verbal skills, and their demonstration of idiosyncratic behaviors [
Due to communication difficulties, children with ID often depend on their parents and caregivers in discerning the presence of pain. A study by Hennequin et al. in 2003 showed that parents had more difficulties recognizing pain in children with Down syndrome than healthy children [
Our results show that the DFT score was significantly higher in children with ID whereas the dft was higher in healthy children. This was surprising as children with ID seemed to have more caries risk factors such as associated medical conditions and intake of medications. Our assumption is that children with ID had both higher DFT and dft scores compared to healthy children. However, because of their often uneasy behavior in dental settings, it is can be difficult to provide them with good quality dentistry which may at times make extractions a common treatment. Because our calculations of the DFT/dft scores did not include the missing teeth component, we may have underestimated the actual caries severity (dft score) in children with ID. This underestimation was not seen in the DFT score because children in our sample were mostly 6–12 years old and may not have had extractions of permanent teeth yet.
Our data indicate that caregivers can recognize pain-related behaviors in children with ID such as excessive salivation and putting hands inside the mouth more often. This finding is in accord with previous research and indicates that parents become experts in their children’s behavior; hence there are useful tools to healthcare providers in making diagnoses [
This study had some limitations which can be addressed in future studies. Some of these limitations included the lack of a professional assessment of the level of intellectual disability. The investigators evaluated the medical histories of all children from their medical records. However, a professional psychological assessment of their level of disability was not always present. Future research in this area can be modified to include only children with professional psychological assessment and to stratify the analysis by level of intellectual disability.
Based on the investigators findings from this research, the following can be concluded. There is no significant difference in the general display of dental pain-related behaviors among healthy children and those with ID. Children with ID display more salivation and putting hands inside the mouth in response to dental pain. The more severe the carious process the more the child will display pain-related behaviors. Caregivers of children with ID who had complex dental treatment needs were more able to detect dental pain in their children compared to those of healthy children.
This project was funded by the Deanship of Scientific Research (DSR), King abdulazizi University, Jeddah, under Grant no. (019-9/429). The authors, therefore, acknowledge with thanks the DSR technical and financial support.