Oral Health Status of Special Athletes in the San Francisco Bay Area

By Judy A. White, RDH, MPH;
Eugenio D. Beltran, DMD, MPH, MS, DrPH;
Dolores M. Malvitz, DrPH; and
Steven P. Perlman, DDS, MScD

A standardized oral health screening protocol was developed for assessing the oral health status of athletes participating in annual Special Olympics events at sites across the country. This paper reports on results at the San Francisco Bay Area Special Olympics event, where 385 athletes participated in the oral health screening. Trained dental screeners determined the presence or absence of edentulism, untreated decay, filled teeth, missing teeth, tooth injury, fluorosis and gingival signs, as well as treatment urgency. The frequency of mouth cleaning, having a mouth guard, use of tobacco, and presence or absence of pain were self-reported. Overall, child athletes 9-20 years of age had more untreated decay and substantially more missing permanent teeth than 9-20-year-old children represented in the 1986-87 National Institute of Dental Research Survey of U.S. School Children. Prevalence of missing teeth among adult athletes compared favorably with data from the Third National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System Survey. Approximately one-third of child and adult athletes were determined to need dental care. Continued use of a standardized screening protocol could allow state-specific data to be available on the oral health status of this population; trends could be tracked; and needs could be identified, with strategies developed to meet those needs.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

An estimated 7.5 million people in the United States have mental disabilities,1 yet the oral health needs of this population have not been clearly identified. Assessing these needs is an important first step in establishing strategies to maximize this population's oral health. Studies published during the past 35 years, however, suggest that characterizing the oral health needs of this group may be difficult. In these studies, people identified with mental disabilities vary considerably in the type and degree of disability, living arrangements, and lifestyle factors that affect routine self-care and access to dental care. In addition, survey design and reporting methods have differed markedly among the studies, limiting comparisons of resulting data. Also, different comparison groups have been used (e.g., institutionalized or noninstitutionalized disability groups, the general population, or groups in other countries); even designation of people with mental disabilities in the studies has varied. This review considered only studies that included non-institutionalized people with mental disabilities and made comparisons to the general population; the terms, "people with mental disabilities" or "mentally disabled" will be used.

Differences in oral disease prevalence in people with mental disabilities have occurred over time. In the 1960s and 1970s, dental caries prevalence among children and adults with mental disabilities and "physical and medical handicaps" was found to be no higher, and sometimes lower, than that of the general population.(2) Two reviews3,4 generally affirmed lower caries prevalence in both primary and permanent dentitions of mentally disabled people. Most studies reported during the 1980s5-7 found no significant difference in decayed, missing and filled teeth (DMFT) between mentally disabled and nonmentally disabled adults and children. One recent report from Singapore8 showed lower DMFT values in mentally disabled children. Analysis of the different components of the DMFT in these studies provides more information on the oral health of people with mental disabilities. Some studies(5,6,9) have reported more untreated decay (D) among mentally disabled people than among nonmentally disabled people, while others(10,11) reported less untreated decay. In the 1990s, a Swedish study(12) assessed the oral health status of mentally retarded adults living in three increasingly independent settings. Although access to care was equal and all groups demonstrated lower caries prevalence than the general population, caries levels were higher as the independence of living arrangements increased. A study in India(13) reported that children with mental disabilities had a higher caries prevalence than children without mental disabilities. A feasibility study conducted at the New Jersey Summer Special Olympic Games in 1996 found that 19 percent of screened athletes had untreated dental caries.(14)

The type and degree of dental care among people with mental disabilities have also varied with the decade and country of the published report. In the 1960 and 1970s in the United States, less treatment was found among the mentally disabled than among the general population;(3) in some cases, no previous dental care was apparent.(4) The missing (M) component of DMFT was higher for the mentally disabled than for nonmentally disabled comparison groups in the United States and other countries.(3,4) In the 1980s, a study from North Carolina(5) reported fewer missing teeth among the mentally disabled adults than among nonmentally disabled comparison groups. British reports(6,9) showed fewer fillings and higher numbers of missing teeth among the mentally disabled than the nonmentally disabled; people with slight mental disabilities had more fillings than those with moderate or profound ones, but fewer fillings than nonmentally disabled controls.(9) In the New Jersey screening,14 about one-third (32 percent) of athletes were found to have missing teeth.

Although two reviews(3,4) noted generally poor oral hygiene among people with mental disabilities, results were mixed when their level of oral hygiene was compared to that of the general population.(2) Brown and Schoedel(2) noted a higher prevalence of gingivitis among the mentally disabled than comparison groups, as well as correlation with poor oral hygiene. Three reviews(2-4) reported studies with high prevalence of periodontal disease in the mentally disabled; one(4) discussed contributing factors and noted mixed results in correlating levels of oral hygiene and periodontal disease. More recent studies have found poor oral hygiene among mentally disabled adults and children, whether or not compared to the nonmentally disabled.(9-11,15,16)

In summary, surveys generally report more missing and fewer filled teeth among the mentally disabled than among the general population as well as worse oral hygiene, more inflammation or gingivitis, and more periodontal involvement than in the general population. During the past 35 years, the oral health status of noninstitutionalized mentally disabled adults and children seems to have changed from being approximately equal to or slightly better than that of the general population in the 1960s and 1970s, to demonstrating more decayed teeth (but similar total DMFT) in the 1980s. Reports from the 1990s are few and mixed. Differences in survey design, reporting methods, and comparison groups -- added to differences in the disabilities -- make characterizing the oral health needs of people with mental disabilities a difficult task that produces contradictory results.

Special Olympics allows people with mental disabilities to compete in athletic events: More than 450,000 people participate in Special Olympics events in the United States each year. All special athletes must have been diagnosed as having mental retardation or a significant developmental disability that interferes with their ability to function;18 athletes have varying levels of mental disability, as well as other disabilities. Although there is no upper age limit for participation, athletes must be at least 8 years old. Athletes come from all ethnic, racial, social, educational, and economic backgrounds.

Screening, as used in oral epidemiology, is an intraoral assessment and uses a simplified visual-only procedure to estimate the oral health status of a sample of the population and their treatment needs. Screenings are practical, rapid and non-intrusive. Recently, a standardized screening method has been shown to provide valid information (in terms of sensitivity, specificity, and predictive value) when assessing the oral health status of population samples.(17) This method was adapted and pilot-tested among athletes participating in annual area or statewide Special Olympics events in New Jersey, California, and Massachusetts. When the standardized method is extended to other sites, state-specific and aggregated data can be used to characterize the oral health needs of these athletes and to make comparisons over time and among population groups with varying characteristics. This paper reports findings from use of the standardized screening method among participating athletes at the San Francisco Bay Area pilot site (June 1997).

Methods

The Special Olympics Special Smiles site coordinator in San Francisco arranged for the recruitment, scheduling, and training of volunteer dental screeners, recorders, registrars, and oral hygiene educators. Dental professionals from the community and from area dental and dental hygiene schools participated. The Division of Oral Health at the Centers for Disease Control and Prevention developed the case definitions, screening protocol, all training materials, and the data form; CDC also trained the dental examiners, oversaw screenings at the sites, and compiled and analyzed the data. Screenings took place from 9 a.m. to 4 p.m. under a tent prepared by Special Olympics Special Smiles on-site personnel, located in the Olympic Village. Registrars at the tent entrance interviewed the athletes and recorded self-reported data on age, sex, dental history (frequency of cleaning the mouth [asked in this way to include all types of adaptive devices and including, but not limited to, brushing], having a mouth guard, and use of tobacco [chewed or smoked]).

Athletes were free to take part in the screening as they passed through the Olympic Village with their teams and coaches.
Before the clinical portion of the screening began, each athlete was asked to consent to the screening, and whether he or she was experiencing pain inside the mouth. Then screeners sequentially determined the presence or absence of the following:

* Edentulism;
* One or more primary or permanent teeth with untreated decay;
* One or more primary or permanent filled teeth;
* One or more permanent missing teeth (excluding premolars);
* Tooth injuries/sequelae;
* Two or more permanent homologous teeth with signs of dental fluorosis (Dean's mild or worse); and
* Gingival signs (moderate color and texture/contour changes surrounding three or more permanent teeth).

Precise, specific criteria (case definitions) for each condition were adapted from the National Institute of Dental Research diagnostic criteria.(19) The screening protocol was adapted from Beltrán et al.(17) and included using a flashlight and tongue blade to visually inspect the entire mouth rather than assess individual teeth or surfaces. Gloves were used and masks were available. Finally, from reported pain and observed clinical conditions, screeners evaluated treatment urgency, assigning one of three categories: maintenance, nonurgent, or urgent. That information was recorded on a "dental report card" and given to the athlete, with a gift bag that included a toothbrush and toothpaste.

Case definitions were sent to the screeners prior to the event. Training sessions for screeners were held on site before the screenings began and repeated as screeners were scheduled throughout the day. A total of 25 screeners were trained at this event. Each session included use of a manual, models, and posters to review case definitions, followed by an exercise with a question-and-answer period. Recorders were given a sheet of instructions and paired with a dental screener. Because the main focus of the one-day Special Olympics event is participation in physical activity, and screenings often occurred between events, athletes were not asked to participate in measures of intra- and interexaminer reliability for this pilot project.

Self-reported and clinical data recorded on paper forms at the site were entered into a customized Epi-Info program; data analysis was completed in SAS,(20) which calculated the percentages of athletes in the sample with each oral health indicator by age group. Results were compared to the 1986-87 NIDR Survey of United States School Children,21 Healthy People 2000 progress data22 calculated from phase one of the Third National Health and Nutrition Examination Survey, the 1993-94 California Oral Heath Needs Assessment,(23) and data from the 1995 Behavioral Risk Factor Surveillance System Survey (BRFSS).(24) To compare findings with those of the 1986-87 NIDR children's survey, the NIDR dataset was reanalyzed (with appropriate weighting and design effects) to obtain similar epidemiologic estimators as those obtained in this study. For example, because the Special Olympics Special Smiles protocol excluded premolars in the assessment of missing teeth due to caries, these teeth were excluded from the analysis of the NIDR dataset.

Results

Approximately 1,100 athletes participated in the Special Olympics event in the San Francisco Bay Area. Of an estimated 700 who came to the Olympic Village (the remainder competed at remote sites), 385 (55 percent) participated in the oral health screening. Most (67 percent) participants were male and ranged from 9 to 60 years of age, with a median age of 27; 107 (28 percent) were children 9-20, and 271 (72 percent) were adults 20-49. Because of their small number, seven athletes 50 or older were not included in the analyses; screening data are presented for 378 participants. To allow comparisons with existing data, nine 20-year-old athletes are included both in the 9- through 20-year-old group and in the 20- through 49-year-old group.

Table 1 presents findings for children and adults on self-reported information. Overall, 72 percent reported cleaning their mouths at least daily (63 percent of children and 75 percent of adults), and 9 percent reported intraoral pain on the day of the Special Olympics event (12 percent of children and 8 percent of adults). Few athletes (10 percent) said they had mouthguards, and few reported smoking (4 percent) or chewing (1 percent) tobacco.

Table 2 displays the percentages of child athletes by oral health indicator and age group. Overall, 15 percent had one or more missing permanent teeth and 29 percent had untreated decay. Among 15- through 17-year-olds, however, these values were 20 percent and 34 percent, respectively. Analysis of NIDR survey data found that among U.S. children aged 9-20, 3 percent had at least one missing permanent tooth, and 23 percent had untreated decay.21 About one-third (34 percent) of those screened in California at the Special Olympics needed dental care: 12 percent required urgent care and 22 percent, nonurgent. Among 9- through 11-year-olds, however, 21 percent were judged to need urgent care. Findings for other indicators and for specific age groups are noted in Table 2.

Table 3 displays the percentages of adult athletes by oral health indicator and age group. Overall, 34 percent had one or more missing teeth, and 18 percent had untreated decay. Among adults aged 25-29, however, 29 percent had one or more untreated decayed teeth. More than half of adults aged 40 or older had at least one missing molar or anterior tooth. More than one-third (36 percent) of adult athletes needed dental care: 7 percent urgent and 29 percent nonurgent. Findings for other indicators and for specific age groups are noted in Table 3.

Discussion

Although preliminary and based on a convenience sample and small numbers, California screening data suggest that the prevalence of missing permanent teeth among child special athletes may be five times that found for school children represented in the 1986-87 NIDR survey (15 percent vs. 3 percent).(21) While these values reflect overall comparisons, individual age groups may fare far worse. For example, 20 percent of special athletes in two age groups (9-11 and 15-17) were found to have missing molars or anterior teeth. In the younger age group, still likely to have mixed dentitions, many of these missing teeth probably are first permanent molars, and the consequences of early loss of these important teeth will continue for the remainder of their lives.

When prevalence of missing teeth among adults is considered, participating athletes compared favorably with recent adult data. Among athletes aged 35-44 years, the 41 percent found to have at least one missing molar or anterior tooth were comparable to the 40 percent of Californians in that age group who responded (in a 1995 telephone survey conducted for the state health agency) that they had lost one or more teeth because of dental decay or periodontal disease.(24) Both values remain well less than the 68 percent of this age group found to have one or more missing teeth in a 1988-91 clinical examination conducted on a nationally representative sample.(22) Given the differences in data collection and sample selection methods for these three reports, however, comparisons require caution. In a self-report format,(24) recall can be poor: Respondents may underestimate or overestimate their own tooth loss. In addition, this current screening considered only loss of molars and anterior teeth; those criteria avoided bias from misclassifying teeth removed for orthodontic purposes but probably underestimated slightly -- and to an unknown degree -- actual prevalence of missing teeth.

Among athletes aged 9-20 who participated in this screening, the prevalence of untreated decay was 26 percent higher than that calculated for U.S. school children of those ages in 1986-87 (29 percent vs. 23 percent).(21) When these current findings are compared with data reported for the 1993-94 California Oral Health Assessment,(23) the prevalence of untreated decay among adolescents appears to be lower -- 34 percent of athletes aged 15-17 vs. 45 percent of children aged 15 in the state. These figures are substantially higher than both the objective established for untreated decay by Healthy People 2000 (15 percent) and the 1992 progress value (24 percent).(22)

Several factors suggest caution with all these comparisons. First, the prevalence of untreated decay for athletes in this study is based on only 37 people aged 15-17, while the California needs assessment included 898 10th-graders, and the NIDR survey examined 2,771 adolescents aged 15 (representing 3.5 million in the United States). Second, samples were chosen in different ways. Athletes were volunteers, while schools attended by participants in the California assessment were chosen by established characteristics. NIDR sample selection used a complex, three-stage method employing random selection and permitting generalization to all U.S. schoolchildren. Third, because this current screening used a visual-only assessment, reported prevalence of untreated decay was more likely to underestimate the true figure than would California or NIDR data, which are based on a tactile -- as well as visual -- examination. Finally, athletes came largely from Northern California; thus, the characteristics of that region (e.g., urban or rural location, water fluoridation status, access to dental treatment) affected findings to an unknown degree.

In spite of all these factors, if the prevalence of missing teeth truly is higher among child special athletes than that found in the NIDR child survey (and the magnitude of the difference suggested it), conjecture remains the only way to explain this finding. Do children with mental disabilities have greater or reduced access to dental care than did cohorts of such children 20-30 years ago, when institutionalization may have been more common? Would regular dental attention provided through an institution ensure that incipient disease is found and treated, thus reducing the need for removal of teeth (and affecting the prevalence of missing teeth among current adults)? Have current efforts to mainstream or deinstitutionalize made dental care more or less available to people with mental disabilities? If the latter, has reduced availability resulted in less frequent visits and thus more limited treatment options? Or do adults with mental disabilities with their own earned incomes have better access to care? Have changes in diet and supervision of self-care associated with less regimented living arrangements affected levels of disease and thus treatment outcomes? How might changes in Medi-Cal policies on covered services affect the prevalence of missing teeth and untreated decay among children and adults?

There are no firm answers to these -- and many other -- questions arising from the data. In this screening, athletes were not asked about their most recent dental visit or their eligibility for Medi-Cal dental services; it was thought that many responses would be unreliable and that a parent or guardian would need to provide such information. Certainly, missing teeth reflect the lack of timely dental care in the past; untreated decay and reported intraoral pain suggest current deficiencies. Associations among specific oral health indicators, as well as their relation to the receipt of dental services, remain important topics for future investigations.

Even so, the current findings raise issues for discussion regarding preventive and treatment services for people with mental disabilities. For example, more than one-third (36 percent) of the child athletes and more than one-fourth (25 percent) of the adults reported that they did not clean their mouths at least once per day. Since this group of people with mental disabilities is considered to be high-functioning, one might expect that these values would be higher among lower-functioning people with mental disabilities. The importance of oral hygiene procedures should be reinforced wherever possible, particularly during appointments for dental care. Any instruction should include group home managers and other guardians to encourage appropriate supervision of recommended procedures and reinforcement of their importance at home. Further, the preventive benefits of early and regular dental attention -- before problems arise -- should be stressed with athletes, guardians, and group home managers. Primary preventive measures such as dental sealants and chemotherapeutic rinses should be used when individual evaluations determine that people with mental disabilities are at elevated risk of dental caries and periodontal diseases.

Conclusions

Although interpretations of the data presents difficulties and limitations, they represent the first California-specific information on the oral health needs of people with mental disabilities who participated in Special Olympics. The findings regarding missing teeth and untreated dental decay indicate that these athletes had a substantial unmet need for dental preventive and treatment services. Approximately one-third of child and adult athletes were judged to need dental care. If the standardized screening protocol and case definitions are repeated in future screenings at Special Olympics events, trends in oral health indicators can be tracked and answers sought to questions about the effect of policy changes on the oral health needs of this subset of people with mental disabilities. In addition, further analysis of the data or comparisons among Special Olympics sites may reveal associations that could prove useful in characterizing the oral health needs of special athletes, in developing public policies or privately sponsored programs to meet those needs, or in monitoring their levels of risk for oral diseases.

Acknowledgment

Special thanks to Christine E. Miller, RDH, MHS, MA, the University of the Pacific School of Dentistry and support staff, especially Stephen Meany and Jacqueline Ramos; Dr. Ariane Terlet; the Berkeley Dental Society; all who participated in screening at the site; and everyone at the Centers for Disease Control and Prevention who participated in preparing the paper, especially Stuart Lockwood, DMD, MPH, and Susan Griffin, PhD.

Authors

Judy A. White, RDH, MPH, is a fellow in the Division of Oral Health at the Centers for Disease Control and Prevention in Atlanta.
Eugenio Beltrán, DMD, MPH, MS, DrPH, is an oral epidemiologist in the Division of Oral Health at the CDC.
Dolores M. Malvitz, DrPH, is the acting director for the Division of Oral Health at the CDC.
Steven P. Perlman, DDS, MScD, is an associate clinical professor of pediatric dentistry at the Boston University Goldman School of Dental Medicine and the founder and clinical director of Special Olympics, Special Smiles in Boston.


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To request a printed copy of this article, please contact/Judy A. White, RDH, MPH, Centers for Disease Control and Prevention, Division of Oral Health, 4770 Buford Hwy NE, M.S. F-10, Atlanta, GA 30341-3717.