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Original Article
Dental neglect among children in Chennai
Deepa Gurunathan, Arunachalam Karthikeyan Shanmugaavel
Department of Paediatric and Preventive Dentistry, Saveetha Dental College, Chennai, Tamil Nadu, India
ABSTRACT
Background: Child dental neglect is the failure of
a parent or guardian to meet the child’s basic oral
health needs such that the child enjoys adequate
function and freedom from pain and infection,
where reasonable resources are available to family
or caregiver. Aim: The aim of the study is to
evaluate the phenomenon of dental neglect among
children in Chennai and to associate dental neglect
with oral health status of children aged 3–12 years.
Materials and Methods: This is a cross‑sectional
study involving 478 pairs of parents and children.
Dental neglect scale and a questionnaire were used to
assess the dental neglect score among parents of the
children involved in the study. Oral health status of
children was clinically assessed using oral hygiene
index, decayed, extracted, filled teeth (def(t)), pulp,
ulcers, fistula, abscess  (pufa), decayed, missing,
filled teeth (DMFT), PUFA as per the World Health
Organization criteria and pufa/PUFA index.
Student’s t‑test and one‑way ANOVA were used
appropriately for statistical analysis using SPSS
software version 20.0. Results: A significant higher
dental neglect score was reported among the parents
who reside in the suburban location  (P  <  0.001),
whose educational qualification was secondary
(P  <  0.001) and who have not availed any dental
service for >3 years (P = 0.001). A significant higher
DMFT (P = 0.003), deft (P = 0 < 0.001), pufa (P = 0.011),
and debris index (P = 0.002) scores were seen in the
higher dental neglect group. Conclusion: Child
dental neglect is seen among the parents whose
educational qualification was secondary, who reside
in the suburban location, and who have not utilized
the dental services for more than 3 years in Chennai.
This dental neglect results in poorer oral health of
children.
KEYWORDS: Children, dental neglect scale, parents
Introduction
Oral health plays a very important role in the general
well‑being of individuals, and parents’ behavior and
attitudes influence the oral health of their children.[1]
364 © 2016 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer ‑ Medknow
Address for correspondence:
Dr. Deepa Gurunathan,
Saveetha Dental College, Chennai ‑ 600 077, Tamil Nadu, India.
E‑mail: drgdeepa@yahoo.co.in
Access this article online
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DOI:
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Dental neglect is defined as parents’ persistent failure
to take precautions and provide necessary dental
treatment to maintain the child’s oral health and to
ensure their freedom from pain and infection.[2,3]
Dental neglect is seen at each and every step of life
with different reasons involved with it. Although
child dental neglect appears to be an isolated problem,
in reality, it may be an indicator of other types of
abuse.[4] In addition, children who suffer from poor
oral health are 12 times more susceptible to have lesser
activity days than those who do not.[5] Child dental
neglect leads to malnutrition which has an impact on
adulthood health.[6,7]
It is the responsibility of parents to pursue health‑related
necessities of their children. In this regard, the lack of
parent’s or guardian’s attention will have a negative
influence on the child’s oral status. Investigating
dental neglect among children would identify the
specific reason for the failure to prevent and treat
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How to cite this article: Gurunathan D, Shanmugaavel AK.
Dental neglect among children in Chennai. J Indian Soc Pedod
Prev Dent 2016;34:364-9.
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dental caries. Thereby, it provides opportunity for
the government and health care personnel to address
the issue at root level.[8] However, the World Health
Organization (WHO) has reported that neglect has to
be distinguished from factors that include poverty and
lack of dental service, implying that it can be stated as
neglect only when reasonable resources are available
to the family or caregiver.[9]
The dental neglect scale  (DNS) appears to be an
appropriate method for objectifying dental neglect. It
has satisfactory health index, can be easily measured,
apparently unaffected by the observation process, and
has to be manipulated statistically. DNS for children
assesses the extent to which a parent or caretaker cares
for the child’s teeth, receives professional dental care, and
believes oral health to be important.[10] Hence, DNS helps
to identify the reason for poor oral health in children.
Parents and responsible adults are the principal people
in the children’s development in the 1st years of life. Thus,
the interventions that are directed toward parents’ beliefs
and attitudes about oral health may be beneficial in the
prevention of oral problems such as dental caries.[11]
There are various case reports, case–control studies,
and cohort studies in the literature regarding dental
neglect in children. However, these studies have not
evaluated the complete parent’s perspective regarding
the child’s oral care.[12] Hence, the aim of this study
was to investigate dental neglect among children
in Chennai and to examine its association with key
demographic features and dental health status.
Materials and Methods
Ethical approval for the study was obtained from the
Institutional Review Board. This cross‑sectional study
was conducted for a week’s time in a book exhibition
program in Chennai. This ensured that participants
involved in the study were randomly selected from the
entire Chennai population. On the first 2  days of the
event, a pilot study which involved 100 participants
was conducted, and sample size for the main study was
calculated using  (Department of Psycholgy, University
Manheim, Germany) GPower version 3.1 based on its
result. The continuous variable was dichotomized to
find the relationship between dental neglect and caries
status. The mean decayed, extracted, filled teeth (deft)
scores for the low and high DNS groups were 2.165
and 2.981, respectively. The estimated sample size with
type I error 5% and power of a test (beta) set at 95% was
408. Considering 10% dropouts, the sample size was set
at 450. The participants included children aged from
3 to 12 years, and the questionnaire was answered by
their parents. An informed consent was obtained from
the participating parents. The parents were asked to
fill in a comprehensive questionnaire which included
demographic details, visits to dentist, and seven
questions of DNS.[10] Two calibrated dentists carried
out the oral examination in children. Children with
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2016 | Vol 34 | Issue 4 |
Gurunathan and Shanmugaavel: Need for dental care
the consent from parents to participate in the survey
were examined. Oral examination of children was
conducted using disposable mouth mirror and blunt
ball‑ended probe (0.5 mm) in natural day light. Teeth
were recorded according to the Federation Dentaire
Internationale Numbering System oral hygiene, and
dental caries status was assessed by the simplified oral
hygiene index[13] and WHO[14] criteria. Pulp, ulcers,
fistula, abscess  (PUFA)/pufa for permanent and
deciduous teeth was calculated using the pufa index to
assess the severity of untreated caries.[15]
The collected data were tabulated and subjected to
statistical analysis using   SPSS software version  20.0,
(SPSS Inc., Chicago Ill., USA)  and levels of statistical
significance were set at P <  0.05. In addition to
descriptive statistics, t‑test was used to examine
the mean DNS, deft, debris index, and pufa scores
according to sex, age, and residential address. One‑way
ANOVA was used to examine the mean DNS, deft,
debris, and pufa index scores with respect to education,
income, and dental services’ utilized pattern. Frequency
distributions of the response to DNS questions were
produced. A  median split of the DN score was used
to divide the population into two groups that is
high  (DNS  ≥17) and low  (DNS  ≤16). Then, Student’s
t‑test was used to compare the mean decayed, missing,
filled teeth (DMFT), deft, PUFA, pufa and debris scores
between the low and high dental neglect groups.
Results
A total of 478 pair of parents and children participated
in the study, of which female and male parents
were 284 and 194, respectively. The mean age of the
parents was 34.40  ±  6.54  years. Among 478 children
who participated in the study, 386 children had both
primary and permanent teeth. The remaining children
had only primary dentition. Tables  1 and 2 illustrate
the comparison of mean dental neglect, deft, debris
index, pufa, DMFT, and PUFA scores of the children
with respect to sex, age, education, domicile, income,
and last dental service utilized in years.
There was no significant difference in the mean dental
neglect score with respect to sex, age, and income.
With respect to dental neglect scores, a significant
higher dental neglect score was reported among the
people who reside in the suburban location (P < 0.001),
parents whose educational qualification was
secondary  (P  <  0.001), and those people who have
not availed any dental service for >3 years (P = 0.001).
Post hoc Tukey’s test revealed a significant difference in
the dental neglect score between the caretakers whose
educational qualification was secondary and graduate.
Comparing the dental neglect and the oral health status,
a higher DMFT  (1.17) and debris index  (1.21) scores
were seen in the children whose parents’ educational
qualification was secondary. Similarly, a higher debris
index  (1.20) score was reported in children who live
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Gurunathan and Shanmugaavel: Need for dental care

Table 1: Comparison of the mean dental neglect scale, decayed, extracted, filled teeth, debris index and pulp,
ulcers, fistula, abscess scores with respect to the demographic status
n Mean DNS score P Mean deft P Mean debris index P Mean pufa P
Sex
Male 194 18.26 0.16 2.72 0.61 0.96 0.21 0.67 0.06
Female 284 17.67 2.60 1.07 0.90
Age (years)
20-29 115 17.47 0.44 2.57 0.70 0.91 0.32 0.83 0.73
30-39 255 18.12 2.74 1.08 0.85
40-50 108 17.89 2.53 1.05 0.72
Education
Secondary 201 18.88 <0.001** 2.40 0.08 1.21 0.001* 0.81 0.30
Higher 102 17.87 2.54 0.84 0.61
secondary
Graduate 151 16.46 2.96 0.95 0.92
Postgraduate 24 19.04 3.29 0.65 0.96
Address
Urban 214 16.94 <0.001* 2.55 0.42 0.81 <0.001** 0.87 0.41
Suburban 264 18.70 2.73 1.20 0.76
Income
<5000 102 17.86 0.88 2.43 0.07 1.05 0.51 0.67 0.02*
5000-10,000 208 17.92 2.91 1.08 1.01
10,000-15,000 102 18.16 2.69 0.91 0.70
>15,000 66 17.58 2.09 0.99 0.55
Services
1 161 16.81 0.001* 2.882 <0.001** 1.12 <0.001** 1.04 0.53
2 112 18.25 3.184 0.90 0.93
3 205 18.84 2.185 0.52 1.06
*P<0.05 significant, **P<0.001 highly significant. P value calculated using either Student’s t‑test or one‑way ANOVA. DNS: Dental neglect scale, deft: Decayed,
extracted, filled teeth, PUFA: Pulp, ulcers, fistula, abscess

in the suburban areas. In addition, higher mean dental
neglect score  (18.12) was seen in the parents age
group of 30–39 which corresponds to the higher mean
deft  (2.74), DMFT  (1.12), pufa  (0.85), PUFA  (0.29),
and debris index  (1.08) scores. A  higher deft  (2.91),
pufa (1.01), DMFT (1.10), and debris index (1.08) scores
were reported by parents whose monthly income
ranges between 10,000 and 15,000 and whose mean
dental neglect score was 17.92. In the dental services
utilized, a higher mean deft (3.184), DMFT (1.33), and
debris index  (0.90) scores were reported among the
parents who have not utilized the services for 2 years.
The descriptive statistics for the response distribution
in percentage to the dental neglect questions are
shown in Table  3. With respect to items 1, 2, 5, and
7 questions given in the table, around 40%–70% of
the people have responded saying “somewhat yes,”
which means that the child is maintaining his/her
home dental care by brushing the teeth regularly and
also receives the care from the dental office. Around
37% of them responded that they somewhat do not
say no to the dental care needed for the child. In item
4, around 34% of the parents responded that the child
definitely does not neglect the dental care needed for
them. Regarding parental control of snacking between
the meals, around 33% reported that they are not able
to control the snacking habits of the children, while
another 33% reported that they can somewhat control
the child’s between‑meals snacking habit.
Figure  1 shows the comparison of the DMFT, deft,
PUFA, pufa, and the debris index score between the
higher dental neglect and the lower dental neglect
groups. A  significant higher DMFT  (P  =  0.003),
deft  (P  =  0  <  0.001), pufa  (P  =  0.011), and debris
index (P = 0.002) scores were seen in the higher dental
neglect group when compared with the lower dental
neglect group.
Discussion
There is very scarce literature regarding the estimate
of child dental neglect worldwide. Assessing child
dental neglect among caretakers offers a linkage
between dental health and socioeconomic factors,
attitude toward dental health, and acceptability
to dental treatment which have hitherto received
less attention.[10] Literature states that early lesions
progress to cavity in 2–3  years and these cavities
can further give rise to symptoms such as pain and
swelling, which are also considered to be features
of neglect.[16] A systematic review[16] suggested that
salient features of dental neglect include failure to
seek or delay in seeking dental treatment, to comply
with treatment plan, and failure to implement

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Gurunathan and Shanmugaavel: Need for dental care

basic oral care. Hence, in this study, in addition to
recording the caries status, the severity of caries
was also evaluated  (PUFA and pufa),[15,17] which
interprets the degree of failure to seek dental
treatment.
influence dental care and the oral health of a child.
DNS is an ideal instrument for assessing behavior and
attitude toward oral health. As well, it is a good tool
for population surveys that are aimed at identifying
vulnerable groups to dental care.[18‑20]

The caretakers who responded to the questionnaire The median DNS score among parents in Chennai
were mostly mothers of the children.  Hence, it helped is 17.9, indicating mediocre oral health care for
us to know the complete home and professional children  (out of possible range: 6–30). This is higher
dental care the child receives as the child is mostly than those of parents in Australia[10] which can be
with the mother during the preschool and even after due to the availability of dental services and cultural
the child starts to go to school. DNS was used in the differences between the places of study. This higher
present study to associate various factors that could dental neglect scores are associated with poorer oral
health as seen in previous reports[10,21] Since there is
Table 2: Comparison of the mean decayed, missing, no available printed literature regarding the dental
filled teeth and pulp, ulcers, fistula, abscess scores neglect score of parents of young children, a direct
with respect to the demographic status comparison between the studies is difficult. The
children in this study with higher dental neglect score
n Mean P Mean P
had a statistically significant higher caries and debris
DMFT PUFA
index when compared to children with lower dental
Sex
neglect score as seen in Australia.[10] The present
Male 165 0.86 0.39 0.21 0.41
study showed that the dental neglect score is higher
Female 221 1.01 0.27
in caregivers aged above 30 years. The importance of
Age (years)
oral health might not have been as a lifestyle practice
20-29 74 0.62 0.09 0.18 0.40
for elder people in this population. However, we
30-39 221 1.12 0.29 see that the present younger generation parents are
40-50 91 0.80 0.20 more toward the maintenance of good oral health
Education similar to results obtained by Shamta Sufia et  al.[22]
Secondary 173 1.17 0.03* 0.17 0.17
Higher secondary 80 1.08 0.38
Graduate 112 0.60 0.28
Postgraduate 21 0.52 0.19
Address
Urban 173 1.11 0.15 0.24 0.90
Suburban 213 0.824 0.25
Income
<10,000 77 0.72 0.39 0.27 0.19
10,000-15,000 168 1.10 0.20
15,000-20,000 85 0.80 0.20
>20,000 56 1.02 0.43
Last services
utilized (years)
1 139 0.67 0.008** 0.30 0.28
2 82 1.33 0.14 Figure 1: Comparison of DMFT, deft, pufa, PUFA, and debris index
3 165 0.76 0.25 between higher dental neglect and lower dental neglect groups.
*P<0.05 significant, **P<0.001 highly significant. P value calculated using *P  <  0.05 significant, P value calculated using Student’s t‑test.
either Student’s t‑test or one‑way ANOVA. DMFT: Decayed, missing, filled DMFT  =  Decayed, missing, filled teeth, deft  =  decayed, extracted,
teeth, PUFA: Pulp, ulcers, fistula, abscess filled teeth, PUFA = Pulp, ulcers, fistula, abscess

Table 3: Response distribution to the dental neglect scale questions in percentage

Item No Neutral Yes
Definitely Somewhat Somewhat Definitely
Your child maintains his/her home dental care 3.96 (19) 10.0 (48) 0.8 (4) 64.7 (310) 20.4 (98)
Your child receives the dental care he/she should 5.2 (25) 11.6 (56) 4.3 (21) 69.1 (331) 9.6 (46)
Your child needs dental care, but you put it off 22.3 (107) 37.7 (181) 5.63 (27) 21.0 (101) 13.1 (63)
Your child needs dental care, but he/she puts it off 34.1 (164) 28.8 (138) 7.7 (37) 20.7 (99) 8.5 (41)
Your child brushes as well as he/she should 5.2 (25) 8.3 (40) 5.4 (26) 55.5 (266) 25.4 (122)
Your child controls between meal snacking as well as he/she should 33.1 (159) 24.2 (116) 3.5 (17) 32.9 (158) 6 (29)
Your child considers his/her dental health to be important 16.2 (78) 17.3 (83) 11.0 (53) 42.5 (204) 12.7 (61)

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Gurunathan and Shanmugaavel: Need for dental care
This is a positive aspect that the trend of importance
of oral health is getting rooted into the society.[23,24]
The mean dental neglect score among the mothers is
high suggestive of requirement of dental education as
mothers are important role models transferring values,
norms, and attitude to their children.[24]
The results of the present study showed that the parents
having income <15,000 and who have done secondary
education showed lesser levels of positive dental
attitudes which is similar to studies done by Freeman
et  al. and Williams et  al.[25,26] Hence, there is a greater
probability for the occurrence of oral diseases among
children of low‑income mothers,[24] which is in contrary
to the result of AlGahnim et al.,[27] where it was stated
that income does not play a role in attitude toward
oral health. In the present population, it was observed
that untreated caries resulting in pulpal involvement is
seen in lower income group of population. However,
the parents who have postgraduate education showed
higher dental neglect in the study. This result might
be misleading as only few postgraduate parents were
involved in the study.
In the present study, a significant difference was
observed in the dental neglect scores among parents
residing in the suburban areas (P < 0.001) in comparison
with parents of urban areas. This is essentially due to
lesser awareness of oral health, availability, and usage
of dental services.[28] Hence, the oral hygiene status and
caries status are poorer when compared to children
from urban areas.
The dental neglect among children is higher whose
parents’ last dental visit was before 2 and 3 years and
symptom driven which is similar to the findings in South
Australia.[10] The dental neglect is reflected in the poor
oral health  (debris index  0.90) of these children with
significantly higher caries prevalence and untreated
carious lesions  (deft  [3.184] and DMFT  [1.33]). This
suggests that the knowledge of parents regarding
oral health and utility of dental services is limited as
the frequency of dental visits suggests the oral health
awareness among parents.[29]
It was observed in the present population that 34.1% of
respondents  showed indifference to take professional
dental care. Parents who avoid bringing their children to
scheduled dental appointments and previous negative
experiences for the child indicate the development
of risk for dental caries in 5‑year‑old children.[23] In
addition, parents who do not give importance to their
own dental treatment will not take their child to dental
examination.[30,31] Although 70% of the parents in the
present study state that their children brush their teeth,
the oral hygiene status of children does not indicate
it. There exists a disparity between the observed tooth
brushing habit and that reported by mothers. Hence,
the response of the parents regarding brushing has to
be taken with caution.[32] Although more than half of
368 Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2016 | Vol 34 | Issue 4 |
the parents in the study population thought that they
gave good home care to their children, the oral health
status did not support their view. This was similar to
a study done in Texas where it has been observed that
parents perceived that their children “took care” of
their teeth while the children reported that they had
not given importance.[33]
In the studied population, parents were not confident
about their control over the in‑between meal snacking
habit of their children. As well, the parents assumed
that it is the responsibility of the child rather than
themselves in terms of dietary habits. However,
childhood dietary habits constitute an important factor
in the etiology and progression of dental caries. Hence,
guidance from parents is not only associated with good
oral habits but also in the rational consumption of
sugar.[34] In addition, Ferreira[35] also found that carious
activity was higher in those patients who began tooth
brushing without parental supervision and who began
to consume sucrose before the 1st year of life and who
eat in‑between the main meals. Similarly, the results
of the present study indicate that the oral health and
the caries status in children were poor whose parents
showed negligence toward good brushing and
snacking habit.
Conclusion
Dental neglect is present among parents of Chennai
city. Education and domicile play an important role
in the parent’s knowledge and attitude toward good
dental care. Hence, it is essential to identify the parents
and children who are at risk of lesser oral care and
initiate measures targeted to their needs.
Limitations
The limitation of the present study is that the
observations regarding dental neglect among parents
was seen in a limited area. A  multicentric study in
Chennai can help us to have an overall view regarding
child dental neglect. As well, dental screenings were
carried out under natural light using a community
periodontal probe and a mouth mirror. Use of
radiographs might be helpful to associate DNS and
dental caries experience.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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