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Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 396-402
Impact of oral diseases on daily activities among 12- to 15-year-old institutionalized orphan and non-orphan children in Bengaluru city: A cross-sectional analytical study

1 Department of Public Health Dentistry, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India
2 Department of Public Health Dentistry, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka, India
3 Department of Public Health Dentistry, Career Postgraduate Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India
4 Department of Public Health Dentistry, Royal Dental College and Hospital, Palakkad, Kerala, India
5 Department of Public Health Dentistry, Government Dental College, Srinagar, Jammu and Kashmir, India

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Date of Submission24-Mar-2018
Date of Decision25-Jun-2018
Date of Acceptance06-Aug-2018
Date of Web Publication06-Aug-2020


Background and Objective: As parents are the primary decision-makers of child's health, a study was conducted to assess and compare the oral health status and impact of oral diseases on daily activities among 12- to 15-year-old institutionalized orphan and non-orphan children in Bengaluru city. Materials and Methods: This cross-sectional analytical study was conducted among 210 orphans and 210 government school children living with parents. Data with regard to the impact of oral diseases on daily activities were collected by means of Child Oral Impacts on Daily Performances (C-OIDP) index, and oral health status was determined using WHO Oral Health Assessment Form 1997. Statistical Analysis: Descriptive statistics of the key variables were reported and data were analyzed using Pearson's Chi-square test, Mann–Whitney U-test, One-way analysis of variance and Step-wise multiple linear regression analysis. Statistical significance was set at P < 0.05 for this study. Results: Common oral health problems perceived by orphans and non-orphans were bleeding gums (16.8% and 12.4%) and toothache (12.7% and 13.7%), respectively. The daily performances most affected were cleaning mouth (33.3%; orphans 5.35 ± 4.22; non-orphans 7.05 ± 7.55; P = 0.000) and eating (33.1%; orphans 6.91 ± 6.09; non-orphans 7.07 ± 6.78; P = 0.003). Oral mucosal condition, dental fluorosis, dentofacial anomalies, and calculus showed significant difference among orphans and non-orphans (P = 0.000). Conclusion: C-OIDP score was high in orphans. Age, dental fluorosis, and decayed teeth were the significant factors for determining C-OIDP score. More than half of the study subjects were suffering from oral diseases which required treatment to improve their quality of life.

Keywords: India, oral health, orphanages, parents, quality of life

How to cite this article:
Pavithran VK, Murali R, Krishna M, Shamala A, Yalamalli M, Kumar A V, Raina R. Impact of oral diseases on daily activities among 12- to 15-year-old institutionalized orphan and non-orphan children in Bengaluru city: A cross-sectional analytical study. Indian J Dent Res 2020;31:396-402

How to cite this URL:
Pavithran VK, Murali R, Krishna M, Shamala A, Yalamalli M, Kumar A V, Raina R. Impact of oral diseases on daily activities among 12- to 15-year-old institutionalized orphan and non-orphan children in Bengaluru city: A cross-sectional analytical study. Indian J Dent Res [serial online] 2020 [cited 2020 Sep 23];31:396-402. Available from:

   Introduction Top

Family is the most sustained source of social contact for children.[1] United Nations Children's Fund states an orphan as a child age 0–17 years who has lost one or both parents.[2] In India, overall, 5% of children under 18 years of age are orphans (ranging from < 1% in orphan children under 2 years of age to 9% in 15 - 17 year olds).[3] Parents are often the principal decision-makers concerning child's health and their perceptions can have a major influence on children's treatment choices.[4]

Oral health-related quality of life (OHRQoL) is a multidimensional construct that includes specific indices in the subjective evaluation of functional, social, and psychosocial outcomes of oral diseases using self-reported questionnaires.[5] One of the measures developed for children is the Child Oral Impacts on Daily Performances (C-OIDP) index.[6]

In India, the child–parent relationship is seen as one of the obedience of social order more so than a right of the child. Hence, when a child is separated from parent, it is the duty of the government to provide that child with a family environment. The pattern of orphanage living is different from that of family living, as the former provides physical security, food, and shelter but is devoid of psychological assurance. Orphans form a population at risk with reference to abnormal psychosocial development that might influence the children's health behavior leading to physical health problems.[7]

Children in orphanages were found to have a high prevalence of dental caries, dental trauma, and gingivitis. This has been attributed to overcrowding, poor oral health practices, psychological stress, and improper dietary habits.[8] In addition, these children are underprivileged and do not receive as much care as children with parents.[9]

Thus, it can be hypothesized that the presence of oral diseases and its impact on daily activities of children would be dissimilar among orphans and non-orphans. Our null hypothesis states that there is no difference in the presence of oral diseases and its impact on daily activities of children between orphans and non-orphans.

This study was undertaken to assess and compare the oral health status and impact of oral diseases on daily activities among 12- to 15-year-old institutionalized orphan and non-orphan children in Bengaluru city.

   Materials and Methods Top

A cross-sectional analytical study was conducted in Bengaluru city, capital of Karnataka, a South Indian state that is a home for around 46 licensed orphanages.[10]

The study considered the entire orphan and non-orphan children in city as the sampling frame. Study population comprised two groups: institutionalized orphans and government school going children living with parents. Data were collected over a period of 5 months, from March 2014 to July 2014 either in orphanage or government school premises.

The study was in accordance with the ethical standards on human experiments and with Declaration of Helsinki 1975, as revised in 2000. Ethical clearance was sought from Institutional Review Board of the college where the study was conducted in Bengaluru, on 03/01/2014 (No. ACA/DCD/SYN/KCDS-B/PG/01/2012-13).

Based on the selection criteria, orphans 12–15 years of age with consent and records supported by their institutional authorities and non-orphans 12–15 years of age providing informed consent from parents/guardian of schools were included after explaining the rationale and methods involved in the study. Children having any long-standing systemic disease, physical disability, and mixed dentition were excluded. The study presents information based on STROBE Statement 2007 checklist.

One examiner (VKP) was trained and calibrated by clinically experienced faculty of the department. The examiner practiced and repeated the recordings on 20 children; intraexaminer reliability was found to be k = 0.85. Pilot study was conducted among 30 orphans and non-orphans; it confirmed the feasibility of the main study, applicability of C-OIDP index[6],[11] with minor changes in the questionnaire for effective communication, and the amount of time required for examining each subject while using WHO Oral Health Assessment Form.[12]

The sample size was determined using the formula:[13]

Previous studies[14],[15] were considered for calculating the sample size. A total sample size of 420 subjects was included with 210 children in each group. The desired power of the study (1- β) was obtained as 0.9 or 90%.

Each orphanage habitats 25–30 children in total, and among them only 13–16 children fall under the age range included in the study (12- to 15-year-olds). As a sample size of 210 orphans was to be included in the study, 40 orphanages were selected through simple random sampling technique (lottery method) from a list obtained from the Department of Women and Child Development, Government of Karnataka,[10] and approached. As the number of orphanages and the children under this age group in these institutions were minimal, Bangalore phase-wise division was ignored to achieve and include maximum orphans in the study. Among the 40, only 15 orphanages granted permission to conduct the study. Neighboring government schools in the vicinity of the orphanages were conveniently selected as the children in the orphanages were studying in these same schools thereby reducing the disparity in oral hygiene habits among orphans and non-orphans.

On the day of interview and examination, orphans present in each orphanage fulfilling the selection criteria were included in the study. An age-matched, equal number of non-orphans were selected randomly from the neighboring government schools to match both groups for sociodemographic characteristics such as area of residence or orphanage and school type to minimize selection bias. A sample of 420 was obtained from 15 orphanages and 15 government schools that granted permission across Bengaluru city.

Monthly schedule was prepared in advance, and the concerned authorities were informed regarding examination place, date, and timings. Around 18–20 subjects were interviewed and examined each day which took approximately 12–15 min per individual. Instruments and supplies used; examination area; source of light; and position of examiner, recorder, and subjects during examination were followed according to the manual.[12] Sufficient numbers of autoclaved instruments were made available on the days of examination.

The assessment form consisted of two parts. The first part consisted of demographic information and pretested C-OIDP index[6],[14] used to assess the impacts of oral diseases on daily activities of study subjects, through guided interviews, considering eight common daily activities. Each child was asked whether he or she had faced any problem in the mouth or teeth during the past 3 months. If yes, then they were asked to tick the problems they faced and whether these problems in turn affected their daily activities. When no impact was reported, the child received a score of 0. If the child responded positively, they were asked about the frequency and severity of each impact on their daily activities[6],[14] that were scored separately based on Likert scales of 0–3 for each respectively. Finally, C-OIDP score for each individual was calculated by the multiplication of severity and frequency of each performance. A sum is made of the values obtained for the eight performances, resulting in a number from 0 to 72, which is divided by 72 and then multiplied by 100, so that the final C-OIDP score varies from 0 to 100.[6],[11],[14] The second part consisted of WHO Oral Health Assessment Form 1997 used to assess the oral health status of the subjects.[12]

Soon after oral examination, an oral health education program was conducted by the examiner for all the study subjects using audiovisual aids. The findings of the study were reported to the respective authorities of the orphanages and government schools, and the children requiring treatment were referred to our college.

Statistical analysis

Data were entered into the computer (MS-Office, Excel) and subjected to statistical analysis using SPSS version 13. Descriptive statistics of the key variables were reported. Comparison of these variables between the groups was analyzed using Pearson's Chi-square test. The mean scores of C-OIDP among two groups were evaluated using Mann–Whitney U-test. Bivariate association between each potential predictor clinical variables and C-OIDP score was assessed using one-way analysis of variance (ANOVA). To estimate the degree to which demographic and clinical variables predicted the C-OIDP score, step-wise multiple linear regression analysis was used. Non-automated backward elimination was used to select variables, with the criterion for removal being 0.05 significance on ANOVA test, and then beta coefficient, R2 (Regression coefficient), and P value were calculated. Statistical significance was set at P < 0.05 for this study.

   Results Top

Among 420 study subjects, 51% were male orphans, 49% female orphans, 50.5% male non-orphans, and 49.5% female non-orphans. In 12- and 13-year age groups, there were 52 orphans and 52 non-orphans each, respectively; in 14- and 15-year age groups, there were 53 orphans and 53 non-orphans each, respectively.

In the interview using C-OIDP index, 76.7% of orphans and 65.7% of non-orphans answered “Yes”; 23.3% of orphans and 34.3% of non-orphans answered “No” to the question “In the past three months, did you have any problem in your mouth or teeth?”

The commonly perceived oral problems by study subjects were bleeding gums, toothache, tooth position, and bad breath [Table 1]. A high prevalence of oral impacts on eating, cleaning mouth, speaking, smiling, studying, and maintaining social contact among orphans and non-orphans was noticed and it was statistically significant (P < 0.05) [Table 2].
Table 1: Prevalence of perceived oral health problems among orphans and non-orphans

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Table 2: Prevalence of Child Oral Impacts on Daily Performances among orphans and non-orphans

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The C-OIDP mean score for orphans was 3.975 ± 5.0356, and for non-orphans it was 2.855 ± 5.0524 and it was statistically significant (P = 0.00). The C-OIDP mean scores among female orphans and non-orphans were 4.823 and 2.622, respectively; among 14-year-old orphans and non-orphans, they were 3.626 and 1.838 and both were statistically significant (P = 0.003; P = 0.035, respectively).

Oral health assessment revealed a significant difference among orphans and non-orphans in conditions such as oral mucosal lesions (aphthous ulcers), dental fluorosis, dentofacial anomalies, and calculus [Table 3].
Table 3: Distribution of study subjects according to oral health status

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The mean values of caries experience among orphans and non-orphans were 0.76 ± 1.26 and 0.64 ± 1.34, respectively; it showed no statistically significant results (P = 0.370). The correlation of caries experience and the C-OIDP score in orphans showed a statistically significant positive correlation (r = 0.153; P = 0.027). However, in the non-orphans a negative correlation was observed that was statistically not significant (r = −0.045; P = 0.515).

Bivariate analysis revealed that among the independent clinical variables tested, only oral mucosal condition, decayed teeth, and treatment needs of the orphans were significantly associated (P = 0.00) with the dependent outcome variable (mean C-OIDP score). In non-orphans, the mean C-OIDP score was significantly associated only with oral mucosal condition (P = 0.00) and temporomandibular joint problems (P = 0.013). Oral diseases directly affected the children's daily performances thereby increasing the C-OIDP score in both orphans and non-orphans.

Multiple regression analysis was performed, and factors such as age, dental fluorosis, and decayed teeth were found to be significant in determining the C-OIDP score. R2 value (0.042) was found to be statistically significant (P < 0.001) [Table 4].
Table 4: Multiple linear regression analysis with Child Oral Impacts on Daily Performances as a dependent variable

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   Discussion Top

Oral health is an integral part of general health and affects the well-being of an individual. Orphans once recognized and institutionalized, caretakers in the orphanages become their responsible guardians thereby providing them knowledge and information regarding general and oral health maintenance.[7] The 12–15 years age group was chosen as it is the global monitoring age for dental caries for international comparisons and monitoring of disease trends.[12]

Orphans in our study seemed to have a poor OHRQoL as they experienced higher oral impact on their daily performances than non-orphans during the past 3 months. Children living in orphanages reported greater functional limitations and poor social well-being.[9]

The commonly perceived oral problems in this study were bleeding gums, toothache, tooth position, and bad breath; least perceived problem was broken permanent tooth, and similar results were observed in various other studies.[14],[15],[16],[17],[18],[19],[20],[21],[22]

Highly affected daily activities among our study subjects were eating and cleaning mouth similar to children in other countries.[11],[14],[15],[18],[19],[21],[22],[23],[24] The least affected activities were studying, sleeping, and social contact consonant to other studies[14],[15],[22],[24] suggesting that children's social performances rely more on their physical and psychological performances than adults.

The mean C-OIDP score was higher among orphans in our study. Caretakers in the orphanages were unable to provide individual attention to oral problems of all their children that affected their OHRQoL. The mean C-OIDP score in this study was low when compared with other studies in India[20] (6.5), France[23] (6.3), and Rio de Janeiro[14] (7.1) but high in comparison to 1.2 of Tanzania[25] that had the lowest one.

Female orphans had a higher mean C-OIDP score in accordance with a study where the score is higher in girls (7.7) than in boys (6.2).[14] Females are generally more sensitive to perception of their own problems and appearance than males.

Twelve-year-olds had a higher mean C-OIDP score (5.240), and the score decreased as age increased, similar to another study.[17] Younger children were psychosocially more sensitive to bodily changes than older children, and their perceptions about health gradually alter as they mature.

Prevalence of aphthous ulcers, dental fluorosis, and fractured permanent tooth was higher in our study orphans similar to other researches.[8],[26],[27],[28] This is credited to the overcrowded surroundings in the orphanages, and psychological and emotional stress these children may be undergoing in their daily life.

High prevalence of dentofacial anomalies in our study can be ascribed to the presence of malnutrition, deleterious oral habits such as mouth breathing, tongue thrusting, thumb sucking, pencil or nail biting in these orphans during childhood due to inadequate care, lack of familial support, and sense of insecurity within them. A similar distribution (66.8%) was observed among orphans in Bislapur.[29]

Calculus was higher among orphans, and bleeding on probing was higher among non-orphans in our study; Vijaya et al. and Gajic et al. showed consistent results.[24],[30] Increased calculus amid orphans may be due to improper oral hygiene practices, whereas bleeding on probing of gingiva among non-orphans may be attributed to lack of supervision and care from the parents even though good regular dental care may be affordable. Few studies reported that prevalence of gingival bleeding and calculus was higher among orphans in their studies compared with ours.[28],[31],[32]

Distribution and mean number of decayed permanent teeth were more in orphans due to their poor oral hygiene practices; lack of knowledge, supervision, and reinforcement about good oral hygiene by concerned authorities; low priority for dental care; and uncontrolled cariogenic diet regimen. Other studies showed consistent results, but their prevalence among orphans was higher compared to our study.[7],[8],[9],[26],[27],[28],[31]

Prevalence and mean number of missing and filled permanent teeth were more among non-orphans in our study as equivalent to few other studies[27],[31] and contrast to Kumar et al.[9] This may be attributed to the concern of the parents toward the treatment of their children's oral problems which was lacking in orphans as it is difficult for the institutional staff to concentrate on each child personally for their general and oral well-being.

Treatment needs for dentition status are higher in orphans compared with counterparts, similar to another study.[27] Dental caries experience among orphans in Bengaluru city reflects their poor accessibility to dental care and that there was no sign of preventive dental treatment; therefore, the need for oral healthcare is critical.

Caries experience was higher among orphans in our study in contrast to another study.[9] Studies have shown a mean decayed, missing and filled teeth (DMFT) in orphan children as 2.06,[8] 3.56;[7] and in school children as 1.77,[8] 1.02[19] which was higher in comparison with this study. These comparisons show that caries experience among the orphan and non-orphans in Bengaluru city is comparatively lower than their counterparts around the world.

A positive correlation between C-OIDP score and caries experience among orphans suggests that their oral problems had a higher impact on daily activities or poorer OHRQoL similar to a Brazilian study.[14] However, the negative correlation among non-orphans suggests that their poor caries status had less impact on their daily activities because they were aware that their parents would be proactive in providing them dental consultation soon.

Children with aphthous ulcers had higher C-OIDP score. Although ulcers remain for a short duration, their effects such as pain, interference in eating, and difficulties in cleaning the mouth can be the reasons for this significant association in accordance to other studies.[14],[23]

Age, dental fluorosis, and decayed teeth were found to be associated with C-OIDP. Dental caries was a strongly associated factor with C-OIDP[9],[14],[17] as it could influence the children's OHRQoL through dental pain leading to limitations in oral functioning and by casting its effects on emotional and social roles of the children.

The study results have therefore been generalized to orphan and non-orphans in India as well as in foreign countries assuring a good external validity.

Limitations of the study

As simple random sampling was used to select subjects from neighboring schools, gender could not be matched accurately. However, orphans and non-orphans were completely matched for age and other sociodemographic characteristics such as area of residence or orphanage and school type, which is a positive representation.

As this study includes questionnaire to collect information on the impact of oral diseases, there is a chance of interviewer bias and social desirability bias incorporated into it.

Lack of temporality is an inherent limitation in a cross-sectional study. Hence in future, longitudinal studies are needed to assess the perceptions of OHRQoL among orphans and non-orphans over time.


  • Health education programs must be conducted targeting primary caregivers and supporting staff of orphanages to create awareness of the prominence of oral healthcare and its role in OHRQoL of an individual
  • Staff in orphanages ought to be trained by dentists to help the children take care of their oral cavity and the same must be supervised and reinforced effectively by these caregivers
  • Orphans must be encouraged to take good responsibility of their own oral health at an early age which helps them in improving preventive dental behavior and attitudes, which is beneficial lifelong
  • Government should focus on providing orphans with regular dental check-ups in the orphanages and also appoint dentists to follow up and treat these children as needed at affordable expenses.

   Conclusion Top

The C-OIDP score was high in orphans. Age, dental fluorosis, and decayed teeth were the significant factors for C-OIDP score, that is, older age subjects and children with dental fluorosis and decayed teeth had higher effect of these oral impacts on their daily activities. More than half of the study subjects were suffering from oral diseases which required attention to prevent further disabilities in their daily performances.


Sincere thanks to Dr. Dinta Kakkad, Dr. Punith Shetty, Dr. Preethi Nagdev, Dr. Roomani Srivastav, Dr. Zaharunnissa and Dr. Divya Saikumar for helping in data collection and for providing an all round support throughout the research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. Varsha K Pavithran
Assistant Professor, Division of Public Health Dentistry, Rajah Muthiah Dental College & Hospital, Annamalai University, Chidambaram - 608 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_260_18

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