J Dent Sci 2010;5(2):75−89

O R IGINAL ART IC L E

The oral health status and treatment needs of

institutionalized children with cerebral palsy
in Taiwan
Shun-Te Huang,1,2 Su-Ju Hurng,3 Hsiu-Yueh Liu,4 Chun-Chih Chen,4
Wen-Chia Hu,4 Yi-Chia Tai,4 Szu-Yu Hsiao1*
1
Department of Pediatric Dentistry, Chung-Ho Memorial Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan
2
Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University,
Kaohsiung, Taiwan
3
Bureau of Health Promotion, Department of Health, Executive Yuan, Taichung, Taiwan
4
School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Received: Feb 11, 2010
Accepted: May 12, 2010
KEY WORDS:
cerebral palsy;
dental health status;
dental treatment needs
Background/purpose: In this study, we investigated the dental health status of
children with cerebral palsy (CP) by determining their dental treatment needs in
terms of different grades of disability, sex, and age.
Materials and methods: In total, the dental health of 345 children with CP aged ≤ 18
years residing in institutions was examined, and their treatment needs were evalu-
ated. Stratified cluster sampling by probability proportional to size was used for
sampling. A dental examination was conducted according to the protocol criteria of
the World Health Organization. A databank was designed using Microsoft Office
Access, and SAS and JMP were used for the statistical analysis.
Results: The deft (decayed, extracted and filled primary teeth) index in 5-year-old
children with CP was 7.00 ± 6.73; the DMFT (decayed, missing and filled permanent
teeth) index of 12- and 18-year-old children with CP were 2.50 ± 3.17 and 7.42 ±
5.48, respectively. The dental treatment needs increased with increasing age and
the grade of disability. Children with a moderate grade of CP had the highest den-
tal treatment needs.
Conclusion: More decayed and missing teeth and fewer dental restorations are
common problems in children with CP, and the conditions worsen with age. The
grade of CP and having mental retardation or not also worsens their dental health.
Promoting the oral health education of parents, caregivers and nurses, strengthen-
ing prevention programs from childhood, and motivating dental practitioners to
create a dental care system for this population with disabilities are urgently
required.

*Corresponding author. Department of Pediatric Dentistry, Chung-Ho Memorial Hospital, Kaohsiung Medical University, 100,
Tzyou 1st Road, San-Ming District, Kaohsiung City 80756, Taiwan.
E-mail: syhsiao2004@yahoo.com.tw

©2010 Association for Dental Sciences of the Republic of China

76
Introduction
Cerebral palsy (CP) is defined as composing multiple
syndromes, which are characterized by motor im-
pairment caused by injury or damage to the devel-
oping brain prenatally, perinatally or postnatally.1,2
Children with CP are often have physical, coor-
dinative, sensory, intelligence, communication and
cognitive difficulties in performing, sensing and
memorizing self-care activities of daily living (ADLs),
such as walking, bathing, dressing, brushing the
teeth, eating, conversing, and ambulating.1,2 These
difficulties severely impact their ADLs and lead to
a deteriorated oral health status such as a high
caries rate and number of decayed teeth, low resto-
ration teeth number and rate and/or poor restora-
tive quality, and profound periodontal inflammation.
As a result, children with CP often require exten-
sive dental treatment.3−10 An investigation revealed
that the DMFS (decayed, missing and filled perma-
nent surfaces) of children with CP was 12.86 which
was significantly higher than that of normal children
at 2.87; the dental plaque index was also higher.11
De Camargo and Antunes12 reported that 49.5% of
children with CP had at least one tooth affected by
untreated caries. They have a poorer dental status
than other children of the same age and geographic
area, for both the primary and permanent dentition.
In contrast, an investigation of children with CP
showed the DMFS index was lower than that of
normal children. Children with CP, severe mental
retardation (MR), and motor disturbances had a
lower DMFS index and a higher caries-free rate than
normal children. That study proved that the dental
health status of children with CP and MR could be
better than that of children with CP but without
MR, and even better than normal children, through
the contribution of preventive strategies such as
dental health education and fluoride application.13
Another survey showed that children with CP had
a caries status similar to that of normal children.7
Nevertheless, they had fewer restorations, more ex-
tractions, less access to dental care, and poorer oral
hygiene and periodontal health. In addition, they
had more dental plaque, gingivitis, and overjets.
Furthermore, attrition of teeth of both the pri-
mary and permanent dentition was more severe.7
Pope and Curzon7 also pointed out that children
with CP and MR have more caries and missing teeth,
and fewer restorations than children with CP but
without MR.
The dental health of children with MR and those
with autism was reported to be worse than that of
the normal population in Taiwan,14,15 but the oral
health status of children with CP, considering the
complex physical, mental and sensory impairment,
has not previously been reported in Taiwan. So, we
S.T. Huang et al
do not know what the actual oral health status of
children with CP is or the dental treatment needs
they have. We wondered whether or not the dental
health status would be worse than that of normal
children.
In particular, we were concerned about the DMFT
(decayed, missing and filled permanent teeth)
index, deft (decayed, extracted and filled primary
teeth) index, and components which are usually
not described or discussed concerning the severity
of caries, and what kind of dental treatments the
observed group needs. Furthermore, evaluation of
dental treatment needs could be used to estimate
the human and financial resources in the dental
professional field, which should be provided in the
future. In order to explore the oral health status
and dental treatment needs and enhance the den-
tal care of children with CP in the future, a pro-
found awareness of the dental health status and
treatment needs of this population is essential.
The purposes of this study were to investigate the
dental health status of children with CP by sex,
age, different categories and grades of disability,
and whether or not they had MR, and their dental
treatment needs.
Materials and methods
Study population
In this study, data of 345 children ≤ 18 years old with
CP residing in institutions, whose dental health and
treatment needs were examined, were extracted
from the project “The Survey of Oral Health Status
of the People with Disabilities in Taiwan” conducted
by the Graduate Institute of Oral Health Sciences,
Kaohsiung Medical University, from December 2003
to March 2004.
Samples of this survey were selected from stu-
dents in special education schools and people re-
siding in long-term care institutes and nursing
institutes, who have permanent Taiwanese nation-
ality and are registered as a person with a disabil-
ity. Those who were living at home were excluded
from the sampling frame.
Sampling design
We used stratified cluster sampling with selection
probability proportional to size as the sampling
method. The fundamental element of the sampling
unit was by institution, and there were no restric-
tions on any single item of the 16 kinds of disabilities
listed as follows, as defined by the Ministry of In-
terior Affairs, Taiwan: vision disability, hearing mech-
anism disability, balance mechanism disability, voice
Oral status of children with CP
or speech mechanism disability, limb disability, men-
tal disability, loss of function of primary organs,
facial damage, chronic unconsciousness, senile de-
mentia, autism, chronic psychosis, multiple disabil-
ities, stubborn (difficult-to-cure) epilepsy, physical
or mental disabilities caused by infrequent disease
and confirmed by the central competent authority
in charge of health, and other disabilities confirmed
by the central competent authority in charge of
health. Sample subjects were aged 1−65 years old.
The stratification factor included geographic area
and classification of institution. The geographic dis-
tribution included four areas in Taiwan: northern
(Taipei City, Keelung City, Hsinchu City, Taipei
County, Ilan County, Taoyuan County, and Hsinchu
County), central (Taichung City, Miaoli County,
Taichung County, Changhua County, Nantou County,
and Yunlin County), southern (Kaohsiung City, Chiayi
City, Tainan City, Chiayi County, Tainan County,
Kaohsiung County, Pingtung County, and Penghu
County), and eastern (Hualien County and Taitung
County). The professional statistical software, JMP
5.0, provided the exploratory data analytical tool,
which was a cluster analysis for sorting ages and
kinds of disability into groups to solve classifica-
tion problems. In each geographic stratum, char-
acteristics of the institutions were divided into
three strata: institutions/schools for residents who
have only one kind of disability, institutions/schools
for the residents who have two or more kinds of
disability, and institutions/schools for the residents
who have MR or multiple disabilities). There were
5790 people with disabilities extracted from the
population of people with disabilities residing in in-
stitutions in Taiwan. Among these, the dental health
status and treatment needs of 355 children with CP
≤ 18 years residing in institutions for the disabled
were analyzed and are presented in this study. Some
samples were excluded from this study because of
uncooperative behavior during the dental exami-
nation. There were 345 children with CP examined,
for a completion rate of 97.2%.
Investigative tools
The dental examination form and rules followed
the Oral Health Surveys—Basic methods,16 which is
published by the World Health Organization. The
dentition status and treatment needs were also re-
corded from dental charts as per the World Health
Organization criteria. All examiners received con-
sistent training for the dental examination. Oral
examinations were carried out by well-trained den-
tists, who were evaluated prior to the survey and
achieved acceptable interexaminer agreement with
a kappa score exceeding 0.8. A pilot study was car-
ried out to ensure reproducibility of the evaluation
77
of dental health and treatment needs by inter- and
intra-reexamination of 10 children during 1 day.
The same team of examiners performed all dental
examinations and evaluations for dental treatment
needs. These dental examinations included demo-
graphic information of the children with CP, their
dental health status, and treatment needs of the
primary and permanent dentition. The deft/DMFT
and defs/DMFS indices are general indicators to
express the amount of dental caries in an individual,
and is considered reliable. DMFT (decayed, missing
and filled teeth) and DMFS (decayed, missing, filled
surfaces) refer to the permanent dentition, with
MT denoting missing teeth and FT filled teeth. For
the primary dentition, the indices are deft (decayed,
extracted and filled teeth) and defs (decayed, ex-
tracted and filled surfaces), with dt, et and ft denot-
ing decayed teeth, extracted teeth and filled teeth,
respectively. For the mixed dentition, the indices
are deft + DMFT and defs + DMFS, with the decayed
teeth denoted by dt + DT, missing teeth by et + MT
and filled teeth by ft + FT.
No radiographs were utilized to detect dental
caries because of the difficulties of achieving sat-
isfactory radiographic images and acquiring coop-
erative behavior from these participators. So all
data reflect clinical findings only; dental examina-
tions were performed under good lighting condi-
tions, using a plain disposable mirror.
When the dental examination was completed, in-
structions about dental hygiene were given to the
children and their parents, caregivers, and staff at
the institutions. By doing so, we intended to influ-
ence the adoption of recommended behaviors for
dental hygiene.
Data analysis and statistical
methods
We used Microsoft Office Access (Microsoft, Redmond,
WA, USA) to design the databank, then loaded the
data obtained from the oral examinations into the
databank. After checking and amending the data,
we used SAS version 8.2 statistical software (SAS
Institute, Cary, NC, USA) and JMP version 5.0 (SAS
Institute) to run the statistical analysis. We analyzed
the dental health status and treatment needs of the
samples examined, which demonstrated a trend dom-
inating each group. Descriptive statistics including
the mean, standard deviation and frequency distri-
bution were calculated for each group. Categorical
variables were compared using Pearson χ2 test and
are presented as proportions. Numerical variables
were examined by t test, analysis of variance, and
nonparametric tests according to the nature of the
variables studied, with the level of significance set
at P < 0.05.
78
Results
Demographic data of children with CP
There were 206 males (59.7%) and 139 females
(40.3%) in the present study. The average age was
11.5 years. By age group, the 13- to 18-year-old
group contained 175 children (50.7%), who com-
prised the highest percentage of the sample. By
the grade of disability, severe CP accounted for
the largest percentage with 163 children (47.2%).
Among these children with CP, 200 children (58.0%)
had MR and 145 (42.0%) children did not (Table 1).
Dental health status of children with CP
The mean deft index of children with CP ≤ 6 years old
was 4.50 ± 5.39, and the mean prevalence of caries
was 62.79%. Males showed a higher deft index (4.96 ±
5.54) than females (3.95 ± 5.22). Children with mod-
erate CP had the highest deft index (5.15 ± 6.04) and
number of decayed teeth (4.69 ± 5.60), but showed
no statistical significance (P = 0.1560 and P = 0.6348,
respectively). The dental health status of children
with CP either with or without MR showed no sta-
tistically significant difference (all P > 0.05), but
the former had more extracted teeth (Table 2).
The dental health status of the primary teeth
of 2- to 12-year-old children with CP showed that
5-year-old children had the highest deft index at
7.00 ± 6.73 and the most decayed teeth at 5.85 ±
6.60. Both indices significantly statistically decreased
with increasing age after 5 years of age (all P <
0.0500). The 6-year-old group had the highest caries
prevalence (84.61%), but after that, caries preva-
lence decreased with age (Table 3, Fig. 1).
The deft + DMFT index and caries prevalence of
the 7- to 12-year-old group were 3.92 ± 3.96 and
75.00%, respectively. Females had a higher deft +
DMFT index (4.76 ± 4.52) than males (3.34 ± 3.45).
Children with moderate CP had almost the highest
deft + DMFT index (5.86 ± 5.90), number of dt + DT
(5.00 ± 4.86), and filling rate (56.98%), and the
fewest et + MT (0.29 ± 0.49) or ft + FT (0.57 ± 1.13),
but only the number of ft + FT of children with CP
showed a statistically significant increase with the
severity of disability (P = 0.0001). Children with CP
but without MR had more dt + DT (2.90 ± 3.29) than
those children with CP and MR (2.02 ± 3.46), but
there was no statistical significance (P = 0.0500)
(Table 4).
The DMFT index and caries prevalence rate of
the 13- to 18-year-old-children group were 5.56 ±
4.90 and 84.00%, respectively. Females had a higher
DMFT index (6.17 ± 5.10) than males (5.19 ± 4.76).
Children with moderate CP had the highest DMFT in-
dex at 6.11 ± 5.34 and showed statistical significance
S.T. Huang et al
Table 1. Distribution of demographic characteristics
of children with cerebral palsy (n = 345)
Variable n (%)
Sex
Male 206 (59.7)
Female 139 (40.3)
Age group
≤ 6 years old 86 (24.9)
7−12 years old 84 (24.3)
13−18 years old 175 (50.7)
Severity of disability
Moderate 55 (15.9)
Severe 163 (47.2)
Profound 127 (36.8)
Mental retardation
No 145 (42.0)
Yes 200 (58.0)
(P = 0.0045) compared with children with severe and
profound CP. Children with profound CP had the
highest number of MT (0.70 ± 1.56). The number of
FT of children with CP and MR was 1.70 ± 2.95,
which was statistically significantly higher than that
of children with CP but without MR (1.60 ± 2.46;
P = 0.0469) (Table 5).
Regarding the dental health status of the per-
manent teeth of children 6−18 years old, besides
filling rate, all indices significantly statistically in-
creased with increasing age (all P < 0.0500). Children
at 18 years old with CP had the highest DMFT index
(7.42 ± 5.48), number of filled teeth (2.53 ± 3.20),
and caries prevalence rate (90.90%), and these were
statistically significant (P < 0.0001, P = 0.0024, and
P < 0.0001, respectively) (Table 6, Fig. 2).
Treatment needs of children with CP
By age group, most of the treatment needs increased
with age (Tables 7 and 8). In terms of the need for
dental restorations, there were 164 children (47.5%)
and 1.51 teeth which needed one surface filling and
100 children (29.0%) and 0.82 teeth that needed
two surface fillings. There were 60 (17.4%) and 38
children (11.0%) that needed an extraction and pulp
restoration, respectively. Among the variables of the
dental treatment needs by age, the 13- to 18-year-
old group showed the statistically significantly high-
est treatment needs for one surface filling, pulp
therapy, restoration, and extraction (all P < 0.0500),
but the need for three surface fillings and crown
construction did not show statistical significance.
By the severity of disability, children with moder-
ate CP had the highest treatment needs compared
Table 2. Oral health status of the primary dentition by age of children ≤ 6 years old with cerebral palsy*

Caries
deft index dt et ft Filling rate
Variable n prevalence
Oral status of children with CP

Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P % P % P

Age (yr)
≤6 86 4.50 ± 5.39 3.59 ± 4.85 0.35 ± 1.58 0.56 ± 1.82 62.79 16.21
Sex
Male 47 4.96 ± 5.54 0.3906 3.94 ± 4.73 0.4743 0.38 ± 1.97 0.8279 0.64 ± 2.14 0.6564 61.70 0.8211 11.20 0.2575
Female 39 3.95 ± 5.22 3.18 ± 5.02 0.31 ± 0.95 0.46 ± 1.35 64.10 22.53
Severity of disability
Moderate 13 5.15 ± 6.04 0.1560 4.69 ± 5.60 0.6348 0.08 ± 0.28 0.2875 0.38 ± 1.12 0.7504 61.54 0.9863 5.89 0.5655
Severe 44 4.89 ± 5.48 3.57 ± 4.55 0.61 ± 2.17 0.70 ± 2.22 63.64 15.49
Profound 29 3.62 ± 5.01 3.14 ± 5.03 0.07 ± 0.37 0.41 ± 1.38 62.07 22.22
Mental retardation
No 44 4.16 ± 4.86 0.5512 3.64 ± 4.69 0.9330 0.09 ± 0.47 0.1344 0.43 ± 1.40 0.5174 61.36 0.7824 15.75 0.9237
Yes 42 4.86 ± 5.93 3.55 ± 5.06 0.62 ± 2.20 0.69 ± 2.18 64.29 16.71
Physical handicap
Left hand 15 5.00 ± 6.12 0.5079 4.55 ± 5.99 0.5817 0.35 ± 1.09 0.5079 0.10 ± 0.45 0.4705 70.00 0.2786 7.69 0.4187
Right hand 4 5.80 ± 4.60 5.40 ± 4.10 0.00 ± 0.00 0.40 ± 0.89 80.00 4.55
Both hands 19 5.16 ± 5.77 4.72 ± 5.59 0.21 ± 0.92 0.16 ± 0.55 72.00 6.95

*Significance determined by the Wilcoxon/Kruskal-Wallis rank-sums tests. deft = sum of dt, et and ft; dt = number of primary decayed teeth; et = number of primary missing teeth;
ft = number of filled primary teeth; SD = standard deviation.
79
80 S.T. Huang et al

8
deft index

0.0021
P
Filling rate
7 dt
6 et

20.71
31.79
38.18
37.50
42.85
77.14
73.33
27.50
0.00
0.00
0.00
5 ft

% 4

deft = sum of dt, et and ft; dt = number of primary decayed teeth; et = number of primary missing teeth; ft = number of filled primary teeth; SD = standard deviation.
< 0.0001 3
P
prevalence

2
Caries

1
20.00
50.00
50.00
71.42
84.61
73.30
54.54
46.66
50.00
30.76
16.66
0
%

2 3 4 5 6 7 8 9 10 11 12
Age (yr)
< 0.0001

Fig. 1 Oral health status of the primary dentition by age

P

of children ≤ 12 years old with cerebral palsy.

with those with severe and profound CP; however,

ft

0.00 ± 0.00
0.00 ± 0.00
0.00 ± 0.00
0.78 ± 2.15
1.42 ± 2.73
1.33 ± 2.35
1.00 ± 2.04
1.13 ± 2.47
1.60 ± 2.91
0.30 ± 0.63
0.08 ± 0.28
Mean ± SD

only the needs of more than three surface fillings

and extraction were highly needed and were statis-
Table 3. Oral health status of the primary dentition of children aged 2−12 years old with cerebral palsy

tically significant (P = 0.0170 and P = 0.0107, respec-

tively). Among children with a handicap of the limbs,
those with a right-hand handicap had the highest
< 0.0001

treatment needs for each variable, but only pulp

P

therapy treatment, restoration and extraction were

statistically significant (P = 0.0097 and P = 0.0327,
respectively) (Tables 7 and 8).
et

0.00 ± 0.00
0.00 ± 0.00
0.00 ± 0.00
0.35 ± 1.08
0.96 ± 2.70
Mean ± SD

−
−
−
−
−
−

Discussion

Dental health status of children £ 18 years

< 0.0001

old with CP
P

Among the population of the present study, 15.9%,

47.2%, and 36.8% of the children had moderate,
dt

severe and profound CP, respectively. We found no

0.80 ± 1.78
3.44 ± 4.85
3.25 ± 4.67
5.85 ± 6.60
3.19 ± 4.03
2.60 ± 3.52
1.27 ± 2.10
1.00 ± 1.77
0.40 ± 0.96
0.30 ± 1.10
1.04 ± 3.32
Mean ± SD

people with mild disabilities in our study (Table 1).

In fact, it is unusual to find cases of mild CP in
institutions in Taiwan; de-institutionalization is a
trend for the health care of people with disabilities
worldwide, and children with mild CP have better
< 0.0001

self-care abilities, more community activities, and

P

fewer disadvantages in mental, physical and sen-

deft index

sory impairment in general, so they can live with

their families without institutional care. In our study,
0.80 ± 1.78
3.44 ± 4.85
3.25 ± 4.67
7.00 ± 6.73
5.57 ± 5.43
4.53 ± 3.70
2.36 ± 2.61
2.66 ± 3.43
2.30 ± 3.77
0.84 ± 1.51
1.16 ± 3.54
Mean ± SD

higher ratios of children with severe and profound

CP were resident in institutions owing to their dif-
ficulties and disadvantages in handling their daily
activities.
There were statistical significant increases in
18
21
14
26
15
11
14

12
24
5

8
n

the DMFT index, DT, MT, and FT by age in each age

group (Table 6). No statistical significance was found
Age
(yr)

for any single dental health status item by sex in

10
11
12
2
3
4
5
6
7
8
9

any age group (Tables 2, 4 and 5). In the present

Table 4. Oral health status of mixed dentition of children aged 7−12 years old with cerebral palsy

DMFT + deft Caries Filling

dt + DT et + MT ft + FT
Variable n index prevalence rate
Oral status of children with CP

Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P % P % P

Age (yr)
7−12 84 3.92 ± 3.96 2.35 ± 3.40 0.43 ± 1.09 1.14 ± 2.09 75.00 38.09
Sex
Male 50 3.34 ± 3.45 0.1055 2.24 ± 2.97 0.7333 0.36 ± 0.75 0.4877 0.74 ± 1.55 0.0317 70.00 0.1890 28.35 0.0726
Female 34 4.76 ± 4.52 2.50 ± 4.00 0.53 ± 1.46 1.74 ± 2.62 82.35 49.22
Severity of disability
Moderate 7 5.86 ± 5.90 0.4037 5.00 ± 4.86 0.2185 0.29 ± 0.49 0.9127 0.57 ± 1.13 0.0001 85.71 0.7977 56.98 0.1555
Severe 50 3.74 ± 3.66 2.34 ± 3.46 0.42 ± 1.20 0.98 ± 1.79 74.00 39.33
Profound 27 3.74 ± 3.95 1.67 ± 2.56 0.48 ± 1.01 1.59 ± 2.71 74.07 46.03
Mental retardation
No 31 4.58 ± 3.95 0.2036 2.90 ± 3.29 0.0500 0.55 ± 1.50 0.8091 1.13 ± 1.80 0.4179 80.65 0.5097 32.16 0.2508
Yes 53 3.53 ± 3.94 2.02 ± 3.46 0.36 ± 0.76 1.15 ± 2.27 71.70 42.32
Physical handicap
Left hand 32 5.50 ± 4.69 0.1251 2.56 ± 3.27 0.2439 0.53 ± 1.05 0.0421 2.41 ± 3.89 0.2819 81.25 0.3839 44.24 0.3485
Right hand 12 7.17 ± 5.52 4.83 ± 4.45 0.33 ± 0.78 2.00 ± 3.49 91.67 22.92
Both hands 44 5.95 ± 4.92 3.18 ± 3.72 0.48 ± 0.98 2.30 ± 3.75 84.09 37.90

DMFT + deft = sum of dt + DT and ft + FT; dt + DT = number of primary and permanent decayed teeth; et + MT = number of primary and permanent missing teeth; ft + FT = number of primary
and permanent filled teeth; SD = standard deviation.
81
 82

Table 5. Oral health status of the permanent dentition of 13- to 18-year-old children with cerebral palsy*

Caries
DMFT index DT MT FT Filling rate
Variable n prevalence

Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P % P % P

Age (yr)
13−18 175 5.56 ± 4.90 3.43 ± 4.24 0.47 ± 1.16 1.66 ± 2.76 84.00 32.80
Sex
Male 109 5.19 ± 4.76 0.2036 2.94 ± 3.75 0.0423 0.46 ± 1.26 0.8091 1.79 ± 3.01 0.4179 82.57 0.5097 35.86 0.2508
Female 66 6.17 ± 5.10 4.23 ± 4.88 0.50 ± 0.98 1.44 ± 2.28 86.36 28.09
Severity of disability
Moderate 35 6.11 ± 5.34 0.0045 3.66 ± 4.58 0.4756 0.40 ± 0.81 0.0426 2.06 ± 2.53 0.4719 82.86 0.0036 36.89 0.5764
Severe 69 5.81 ± 4.05 3.80 ± 3.59 0.28 ± 0.70 1.74 ± 2.87 88.41 28.69
Profound 71 5.04 ± 5.43 2.96 ± 4.66 0.70 ± 1.56 1.38 ± 2.76 80.28 34.96
Mental retardation
No 70 5.56 ± 4.46 0.4939 3.50 ± 3.86 0.4756 0.46 ± 1.19 0.0826 1.60 ± 2.46 0.0469 85.71 0.4191 85.71 0.5764
Yes 105 5.56 ± 5.20 3.38 ± 4.50 0.49 ± 1.14 1.70 ± 2.95 82.86 83.81
Physical handicap
Left hand 32 5.50 ± 4.69 0.3665 2.56 ± 3.27 0.0470 0.53 ± 1.05 0.5025 2.41 ± 0.67 0.3610 81.25 0.4056 44.24 0.1668
Right hand 12 7.17 ± 5.52 4.83 ± 4.45 0.33 ± 0.78 2.00 ± 1.09 91.67 22.92
Both hands 44 5.95 ± 4.92 3.18 ± 3.72 0.48 ± 0.98 2.30 ± 3.75 84.09 37.90

*Significance determined by the Wilcoxon/Kruskal-Wallis rank sum tests. DMFT = sum of DT, MT and FT; DT = number of permanent decayed teeth; MT = number of permanent missing teeth;
FT = number of permanent filled teeth;SD = standard deviation.
S.T. Huang et al
Oral status of children with CP 83

8 DMFT index

0.1717
P
Filling rate
7 DT
6 MT

DMFT = sum of DT, MT and FT; DT = number of permanent decayed teeth; MT = number of permanent missing teeth; FT = number of permanent filled teeth; SD = standard deviation.
FT

50.00

12.50
25.00
56.25
37.48
45.04
28.61
46.69
30.07
17.65
35.97
0.00
% 5
0
< 0.0001 4

3
P
prevalence

2
Caries

1
13.33
54.54
57.14
62.50
66.66
66.66
82.60
82.35
76.66
85.71
85.00
90.90
3.84

0
%

6 7 8 9 10 11 12 13 14 15 16 17 18
Age (yr)
0.0024

Fig. 2 Oral health status of the permanent dentition by

P

age of children ≤ 12 years old with cerebral palsy.

FT

0.00 ± 0.00
0.13 ± 0.51
0.00 ± 0.00
0.21 ± 0.80
0.25 ± 0.70
0.83 ± 1.26

1.56 ± 3.04
1.12 ± 2.60
1.96 ± 3.23
1.48 ± 2.35
1.12 ± 2.07
2.53 ± 3.20
0.70 ± 1.19
Mean ± SD

study, the DMFT index, deft index, and number of

decayed teeth were inversely proportional to the
Table 6. Oral health status of the permanent dentition of 6- to 18-year-old children with cerebral palsy

grade of disability. From 7 to 12 years old, the num-

ber of missing teeth increased with an increasing
severity of disability. However, the average num-
0.0038

bers of dt + DT, et + MT, and ft + FT were 2.35, 0.43

P

and 1.14 teeth, respectively. Apparently, this indi-

cates that children with CP have more decayed
MT

teeth and fewer filled teeth, and the dental health

0.00 ± 0.00
0.00 ± 0.00
0.00 ± 0.00
0.07 ± 0.65
0.25 ± 0.70
0.08 ± 0.28
0.41 ± 0.88
0.04 ± 0.20
0.41 ± 0.72
0.43 ± 0.81
0.37 ± 0.97
1.03 ± 2.96
0.73 ± 1.31
Mean ± SD

worsens with the severity of CP.

In the present study, there was no statistical
significant difference recognized by severity, with
or without MR or physical handicaps, in children
with disabilities in the ≤ 6-year-old group (Table 2).
< 0.0001

In the 7- to 12-year-old group, there was a statisti-

P

cally significant increase in et + MT with physical

handicap (Table 4). In the 13- to 18-year-old group,
there was a statistically significant decrease in the
DT

0.07 ± 0.39
0.26 ± 1.03
1.00 ± 1.26
1.71 ± 2.01
1.50 ± 2.32
1.00 ± 2.04
1.37 ± 2.35
2.08 ± 2.69
1.87 ± 2.72
2.30 ± 3.77
3.68 ± 3.91
4.76 ± 4.90
4.31 ± 5.07

DMFT index and increase in the MT by severity of

Mean ± SD

disability and DT by physical handicap (Table 5).

This indicates that dental health is impacted by the
severity of disability, whether combined with MR and
physical impairment by aging. A survey comparing
< 0.0001

the dental health among four levels of MR in greater

detail classified the CP population as educable,
P

trainable, with MR and behavioral problems, and

DMFT index

with MR and severe physical handicaps. The total

DMFT index of children and young adults with MR
0.07 ± 0.39
0.40 ± 1.12
1.00 ± 1.26
2.00 ± 2.03
2.00 ± 2.13
1.92 ± 2.27
2.50 ± 3.17
3.69 ± 3.46
3.43 ± 3.81
4.70 ± 4.66
5.54 ± 4.18
7.08 ± 6.49
7.42 ± 5.48
Mean ± SD

was 12.78 and significantly differed from those peo-

ple with MR and behavioral problems (P < 0.0010);
the number of MT was 10.70 for the educable group
compared with 5.52 for the group with MR and se-
vere physical handicaps. Total treatment needs were
32
26
15
11
14

12
24
23
16
30
35
39
8
n

3.32 for restorations and 0.61 for extractions on

average. Participants at institutions with dental clin-
Age
(yr)

ics had higher mean DMFT, DT, MT, and FT values

10
11
12
13
14
15
16
17
18
6
7
8
9

(all P < 0.0500) compared with those at institutions

 84

Table 7. Status of dental treatment needs by percentage of children with cerebral palsy

No. of surface filling

Pulp and Crown
Extraction
restoration (no. of teeth)
Variable n 1 2 ≥3

n (%) P n (%) P n (%) P n (%) P n (%) P n (%) P

Total 345 164 (47.5) 100 (29.0) 36 (10.4) 38 (11.0) 60 (17.4) 10 (2.9)
Age (yr)
≤6 86 35 (40.7) 0.0239 29 (33.7) 0.0479 10 (11.6) 0.2705 11 (12.0) 0.0088 9 (10.5) 0.0223 3 (3.5) 0.3393
7−12 84 34 (40.5) 22 (26.2) 5 (6.0) 6 (7.1) 11 (13.1) 2 (2.4)
13−18 175 95 (54.3) 49 (28.0) 21 (12.0) 21 (12.8) 40 (22.9) 5 (2.9)
Severity of disability
Moderate 55 32 (58.2) 0.1678 18 (32.7) 0.5396 10 (18.2) 0.0326 8 (14.6) 0.6207 14 (25.5) 0.0489 1 (1.8) 0.1292
Severe 163 78 (47.9) 49 (30.1) 16 (9.8) 18 (11.0) 24 (14.7) 6 (3.7)
Profound 127 54 (42.5) 33 (26.0) 10 (7.9) 12 (9.4) 22 (17.3) 3 (2.4)
Mental retardation
No 145 73 (50.3) 0.2977 49 (33.8) 0.0424 14 (9.7) 0.9068 19 (13.1) 0.6405 24 (16.6) 0.8720 4 (2.8) 0.6461
Yes 200 91 (45.5) 51 (25.5) 22 (11.0) 19 (9.5) 36 (18.0) 6 (3.0)
Physical handicap
Left hand 72 34 (47.2) 0.2206 17 (23.6) 0.2474 10 (13.9) 0.8364 7 (9.7) 0.0500 11 (15.3) 0.0123 1 (1.4) 0.3485
Right hand 21 11 (52.4) 8 (38.1) 3 (14.3) 7 (33.3) 5 (23.8) 1 (4.8)
Both hands 57 26 (45.6) 17 (29.8) 7 (12.3) 5 (8.8) 9 (15.8) 0 (0)
S.T. Huang et al
Table 8. Status of dental treatment needs of children with cerebral palsy

No. of surface filling

Pulp and Crown
Extraction
Oral status of children with CP

restoration (no. of teeth)

Variable n 1 2 ≥3

Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P Mean ± SD P

Total 345 1.51 ± 2.29 0.82 ± 1.77 0.20 ± 0.74 0.28 ± 1.33 0.44 ± 1.44 0.04 ± 0.28
Age (yr)
≤6 86 1.17 ± 1.85 0.0131 1.31 ± 2.33 0.0117 0.31 ± 1.05 0.1019 0.60 ± 2.42 0.0311 0.21 ± 0.83 0.0765 0.07 ± 0.45 0.5339
7−12 84 1.12 ± 1.80 0.68 ± 1.36 0.07 ± 0.30 0.17 ± 0.77 0.33 ± 1.11 1.12 ± 1.80
13−18 175 1.87 ± 2.62 0.65 ± 1.58 0.20 ± 0.69 0.17 ± 0.52 0.61 ± 1.77 0.03 ± 0.17
Severity of disability
Moderate 55 1.51 ± 2.03 0.3262 1.07 ± 2.36 0.0170 0.36 ± 0.99 0.7045 0.36 ± 1.14 0.7217 0.73 ± 2.15 0.0107 0.04 ± 0.27 0.4676
Severe 163 1.66 ± 2.35 0.93 ± 1.82 0.17 ± 0.64 0.20 ± 0.70 0.37 ± 1.28 0.04 ± 0.19
Profound 127 1.32 ± 2.31 0.57 ± 1.34 0.17 ± 0.73 0.34 ± 1.90 0.41 ± 1.25 0.05 ± 0.37
Mental retardation
No 145 1.66 ± 2.38 0.4559 1.09 ± 2.07 0.1210 0.18 ± 0.68 0.1914 0.25 ± 0.84 0.6020 0.30 ± 0.79 0.2764 0.03 ± 0.16 0.9458
Yes 200 1.41 ± 2.22 0.63 ± 1.48 0.21 ± 0.78 0.30 ± 1.59 0.55 ± 1.76 0.05 ± 0.34
Physical handicap
Left hand 72 1.50 ± 2.21 0.6165 0.64 ± 1.46 0.1255 0.25 ± 0.85 0.9535 0.43 ± 2.41 0.0097 0.28 ± 0.74 0.0327 0.01 ± 0.12 0.3511
Right hand 21 1.57 ± 1.89 1.29 ± 1.85 0.24 ± 0.70 0.71 ± 1.38 0.76 ± 2.02 0.05 ± 0.22
Both hands 57 1.44 ± 2.16 0.84 ± 1.65 0.26 ± 0.94 0.49 ± 2.70 0.30 ± 0.78 0.00 ± 0.00
85
86 S.T. Huang et al

without clinics. Shapira et al.10 further pointed out
that high dental morbidity and significant oral health
differences are caused by behavioral problems, age,
and dental clinic status. Those results indicate that
the dental health status of children with disabilities
are affected by the factors of age, disease severity,
and the presence of MR and physical handicaps,
which are highly related to and impact the clean-
ing ability, dental hygiene, and dental treatment
accessibility of this group.
In the present study, the dental health status of
children with CP between those with and those
without MR did not show a statistically significant
difference in any age group except for a lower FT
found to be statistically significant in the 13- to 18-
year-old group (P = 0.0469; Table 5). However, Pope
and Curzon7 reported that children with CP and MR
had more decayed teeth and missing teeth and fewer
filled teeth. In this study, we found that the chil-
dren with CP with a right-hand handicap had the
highest DT compared with those with other manual
handicaps. This may have been due to poor motor
skills, and the fact that most people are right-
handed. The DMFT index had a tendency to decrease
with the severity of disability, and it is reasonable
to presume that the teeth of children with CP are
brushed by their parents or caregivers, because they
cannot care for their own oral health. That is why the
most helpless children with poor manual dexterity
tend to have the best oral hygiene.15,17
A significantly higher DMFS index and plaque
index for children with CP and with their permanent
dentition of both sexes was reported compared with
normal children.13 A similar report emphasized that
none of the children with CP had a healthy perio-
dontium, and they had a higher percentage of un-
treated caries, but a lower percentage of filled
teeth, compared with 66.3% of normal children who
had a healthy periodontium. Meanwhile, children
with CP had a significantly higher percentage of
extracted teeth (10.6%) than normal children (4.1%).6
Another survey reported that the caries prevalence
rate of children and adolescents with CP was 49.5%,
which was higher than the normal population of
the same age range.12
When compared with a survey of normal chil-
dren, the present study showed that the DMFT
index of 12-year-old children with CP was 2.50,
which was lower than that of the national survey
for Taiwanese children at 2.58,18 and also lower than
that of children with MR at 3.97.15 Numbers of DT
of children with CP, normal children, disabled chil-
dren, and children with MR aged 12 years were
1.37, 1.15, 1.95, and 2.79, respectively.15,18,19 The
filling rate at 37.48% was lower than that of nor-
mal children at 60.01%.18 The lower DMFT index of
children with CP does not mean that they have a
better oral status, because they have more unre-
stored caries. The DMFT index of 18-year-old chil-
dren with CP was 7.42, which was higher than that
of normal children at 4.86 and children with MR at
7.35.15,18 The filling rate was 35.97%, which was
lower than that of normal children at 64.20%
(Table 9).18 The reason could be that parents, car-
egivers, and nurses might not brush the teeth of
children with CP when they get older, and the chil-
dren might have their own opinion against the au-
thority of their parents and caregivers. Comparing
the above research15,18,19 and our results, we found
that the dental health status of children with CP
had a common consistency of poorer dental health,
more decayed teeth and extracted teeth or miss-
ing teeth, and fewer filled teeth, compared with
normal children of the same age.
The caries-free rate was reported to be higher
in 6- to 7-year-old children with CP than in children
with MR or vision problems, but it promptly de-
creases with age and worsens in 14- to 15-year-old

Table 9. Comparison of the oral health status of children aged 12−18 years old with cerebral palsy (CP) and
mental retardation (MR)

DT MT FT

Age Chen & Present Chen & Present Chen & Present
Huang19 Liu15 Huang19 Liu15 Huang19 Liu15
(yr) Huang18 study Huang18 study Huang18 study

Normal Disabled CP MR Normal Disabled CP MR Normal Disabled CP MR

12 1.15 1.95 1.37 2.79 0.12 0.39 0.41 0.37 1.31 0.80 0.70 0.82
13 1.79 2.63 2.08 3.89 0.20 0.35 0.04 0.51 1.79 1.10 1.56 1.28
14 2.02 2.66 1.87 2.74 0.16 0.39 0.41 0.40 2.06 1.68 1.12 1.98
15 1.99 3.79 2.30 5.28 0.22 0.58 0.43 0.83 2.32 1.84 1.96 1.98
16 1.75 4.38 3.68 5.03 0.19 0.57 0.37 0.62 2.78 2.10 1.48 2.29
17 1.63 4.43 4.76 4.53 0.22 0.63 1.03 1.03 3.30 2.17 1.12 2.10
18 1.58 4.19 4.31 4.10 0.14 0.69 0.73 0.88 3.14 2.57 2.53 2.36
Oral status of children with CP 87

children.20 In this study, the average DMFT index of
children with CP at 6−15 years old was lower than
that of children with MR;18 we noted that the DMFT
index of children with CP was lower in 6−11 year
olds, and higher in 12−15 year olds than values of
children with MR. The main reason for the increase
in the DMFT index as children with CP age is due to
rapid increases in the numbers of DT and FT. We
found the same tendency in our study, i.e., the
better dental health status and proper restoration
in young children with CP contrasted with a worse
dental health status with aging, especially charac-
terized by a high decay rate, low restoration, and
poor dental hygiene. This indicates that the dental
health status is almost the same among children
with CP, MR, and others disabilities, and even nor-
mal children. A better dental health status can be
achieved because of few opportunities to obtain
sweet foods owing to their immobility and possibly
closer attention from their parents. If these chil-
dren with CP do not receive sufficient, proper, and
early general and dental health intervention and
care, once they grow up, their disabilities such as the
severity, combined with MR, physical impairment
and dental accessibility, will become progressively
worse and act as confounding factors to threaten
their dental health status.
Comparisons among the dental health of our
study on CP and those on autism14 and mentally
retarded15 children in Taiwan showed that CP chil-
dren 3−18 years old had a lower DMFT index (0.03,
1.71, and 5.56) in each single (3- to 6-year-old, 7-
to 12-year-old, and 13- to 18-year-old) age group
than did children with MR (0.35, 2.87, and 7.29)
and autism (0.36, 2.67, and 5.75) for the compara-
tive age groups. Also, children with CP also showed
a lower caries prevalence rate and higher filling rate
compared with MR and autistic children. The fact
that children with CP had a better dental health
status than children with MR and autism indicates
that the cognitive, intelligent, and behavioral abil-
ities may play more important roles than physical
disabilities in regulating dental health as children
with disabilities get older.
Vignehsa et al.3 described how most of the dif-
ferences in the prevalence and severity of dental
conditions assessed among these studied groups
were not significant after they examined children
with various disabilities. However, in comparison
with normal school children, disabled children had
higher levels of disease and received less dental
attention. Kozak5 demonstrated a worse dental and
periodontal status and poorer oral hygiene in chil-
dren with MR. The prevalence of caries in mentally
retarded children was 100%.
Maiwald and Engelkensmeier21 proposed a dif-
ferent prospective by emphasizing the importance
of long-term interventions of dental hygiene and
reported that the caries prevalence of children with
MR was nearly the same as for children without MR,
a result similar to what we found in the present
study. The authors agreed that the degree of treated
teeth in the group of mentally retarded children
was low,21 which showed the same tendency as our
research. Another survey emphasized similar dental
caries experiences in disabled and normal groups,
but children with disabilities had more extracted
and unrestored teeth, and fewer and poorer-quality
restorations than normal children.7
Although there were few differences in caries
prevalence when comparing children with disabili-
ties and normal children, the provision of dental
care showed significant differences; children with
disabilities received less restorative treatment.
There were also significantly poorer levels of oral
hygiene and a greater prevalence of periodontal
disease in children with disabilities attending spe-
cial schools. The author further emphasized that the

DMFT index Caries prevalence Filling rate

Chen & Present Chen & Present Chen & Present

Huang19 Liu15 Huang19 Liu15 Huang19 Liu15
Huang18 study Huang18 study Huang18 study

Normal Disabled CP MR Normal Disabled CP MR Normal Disabled CP MR

2.58 3.14 2.50 3.97 37.30 69.43 66.66 73.68 60.01 35.93 37.48 25.29
3.78 4.09 3.69 5.68 52.17 74.84 82.60 85.11 55.17 33.15 45.04 25.40
4.23 4.72 3.43 5.12 54.12 83.87 82.35 95.24 55.92 39.12 28.61 35.06
4.52 6.22 4.70 8.09 57.80 85.76 76.66 93.83 54.89 34.25 46.69 27.59
4.72 7.05 5.54 7.95 51.94 90.08 85.71 94.50 60.77 34.71 30.07 33.07
5.14 7.24 7.08 7.66 50.69 90.50 85.00 97.52 65.77 36.13 17.65 27.47
4.86 7.44 7.42 7.35 50.79 91.04 90.90 93.59 64.20 39.17 35.97 31.36
88
type of disability also significantly affected the
periodontal problems; insufficient and improper
brushing of the teeth by children with MR causes
them to have the poorest levels of oral hygiene and
the greatest periodontal treatment requirements.9
Children and adolescents with disabilities show
worse dental health, fewer restorations, and poorer
hygiene compared with normal children and ado-
lescents in most studies. This indicates that chil-
dren with disabilities are a minority group lacking
medical and social care regarding oral prevention,
dental treatment, transport, and caregiver and even
economic support. Moreover, once sufficient and
proper knowledge, tools and techniques are offered
to them and their caregivers, and dentists offer
proper dental care service, their dental health sta-
tus could be the same as that of normal children at
the same age. One study showed that the dental
health of children with profound CP can be improved
to an acceptable status, with a low DMFS of 3.5,
comparable to normal children, through effective
preventive strategies.13
In the present study, we still can see that dis-
parities may be caused by the disabilities, and pre-
vention and dental treatment programs still need
to be reinforced in spite of efforts by government
authorities and dental professionals.
Dental treatment needs of children
£ 18 years old with CP
In our study, the treatment needs of children with
CP statistically significantly increased with age for
each single dental health item. Children with mod-
erate CP had the highest treatment needs compared
with children with severe and profound CP. They
had significantly more teeth requiring more than
three surface fillings and extraction. There was still
a tendency for higher dental treatment needs in the
items of one and two surface fillings in children
with moderate CP. Children with severe and pro-
found CP had fewer and lighter dental treatment
needs, because many of their daily life activities,
such as taking food and teeth brushing, mostly de-
pend on parents or caregivers. They have fewer
chances to take sweet food by themselves, and their
teeth are mostly brushed by their parents or car-
egivers. So, it is not surprising that they have fewer
and lighter dental treatment needs compared with
children with moderate CP (Tables 7 and 8).
In a further analysis of our study, children with
CP and MR have more dental treatment needs than
children with CP but without MR, with statistically
significantly greater needs for two surface fillings,
and greater tendencies in the items of one and two
surface fillings and extractions. A status of MR in
children with CP impacts the cognition, memory, and
S.T. Huang et al
their toothbrushing behavior, causing their dental
health to be worse (Tables 7 and 8).
CP is the most common childhood physical dis-
ability characterized by involuntary, uncontrolled
movements of the arms, hands, legs or feet. As
manual dexterity, reflected by the child’s motor
skills, is an important factor in achieving optimal
oral hygiene, among children with one or two hand
handicaps, the right-handed handicapped had the
highest treatment needs for each variable, but
only pulp therapy, restoration, and extraction were
statistically significant (Tables 7 and 8). In general,
most children use their right hand as the active
one to brush their teeth; children with right-hand
impairment may have more difficulty brushing than
those with left-hand impairment, which leads to
poor dental health. Children with both-hand impair-
ment often have severe or profound disabilities,
resulting in much greater difficulty in brushing their
teeth and performing their daily life activities, in-
cluding dental care, and cannot care for themselves
independently, so their daily life activities includ-
ing dental care are often handled by caregivers,
which leads to a tendency for better oral health
than right-hand-impaired children (Tables 2, 4 and 5).
Conclusion
Children with CP have a lower DMFT index than do
normal children, but are characterized with higher
numbers of decayed and missing teeth and a
smaller number of filled teeth. The fewer filled
teeth number and lower rate are confounded by
age, severity of disability, the presence of MR, and
the severity of physical impairment.
The dental health of children with CP is better
than that of children with autism or MR, and the
dental health status of children with CP and MR
showed statistically significant lower FT in the 13-
to 18-year-old group. This indicates that the sever-
ity of disability, and the cognitive, intelligence, and
behavior abilities may play more-important roles
than physical disability in regulating the dental
health of children with CP.
Earlier preventive measures, and professional
and regular dental care within the framework of
dedicated prophylactic and therapeutic programs
for patients with CP are required, because they are
a high-risk group for dental caries.5,11
These services should be provided especially for
preschool children to have early intervention be-
fore their dental health deteriorates.8
Certainly, advanced training and long-term con-
tinuing education programs are recommended for
dental professionals and staff of institutions to en-
hance their dental health awareness.10
Oral status of children with CP
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