Factors Associated with the Caregivers' Perception of the Oral Health of Individuals with Cerebral Palsy

Objective: To evaluate factors associated with the caregivers’ perception of the oral health of children and adolescents with cerebral palsy. Material and Methods: A cross-sectional study was carried out with 80 children and adolescents with cerebral palsy aged 2-18 years, registered at a reference institution and their respective caregivers. Caregivers provided socioeconomic, systemic and health perception and access to dental services data. A calibrated researcher (Kappa=0.75-0.98) performed oral examinations using DMF-T, dmf-t, dental trauma, gingival bleeding index, community periodontal index, malocclusion index and the dental aesthetic index. The Poisson Regression was used ( α =0.05). Results: According to the caregivers’ perception, the oral health reports of children and adolescents with cerebral palsy considered good and poor was 73.8% and 26.3%, respectively. The poor oral health perception is associated with the presence of dental caries in anterior teeth (PR 1.34, 95% CI=1.11-1.63) and bleeding during tooth brushing (PR 1.20, 95% CI=1.04-1.40). Conclusion: Children and adolescents with cerebral palsy who presented lesions of caries in the anterior teeth and gingival bleeding during tooth brushing, more frequently, had poor oral health by their caregivers.


Introduction
Cerebral Palsy (CP) is defined as a set of movement and posture developmental disorders resulting from a non-progressive injury that occurred in the brain during the fetal or infantile period [1]. This motor disorder presents a global prevalence of 2.11 to 1000 live births [2], which increases according to the decrease in socioeconomic status [3]. In addition, individuals with CP present motor disorders that can be accompanied by changes in sensation, cognition, communication, behavior, and perception [1,4]. These changes limit self-care functions, such as feeding and oral hygiene [4,5].
In this context, caregivers are responsible for making decisions and carrying out the daily activities related to the general and oral health of children and adolescents with CP [6]. However, despite the fact that the people with CP have a high frequency and severity of oral problems compared to those without CP [7,8], caregivers are more concerned with the general health than the oral health of these individuals, due to the complexity imposed by this disorder [9]. Moreover, the alterations present in individuals with CP generate an inability to verbalize emotions and anguishes [10]; thus, the caregivers seek oral health care, mostly, due to pain [11].
In this perspective, the caregivers' perception of the oral health of children and adolescents with CP is essential and may influence the oral hygiene frequency [12], as well as the search for access and use of dental services [11,12]. Studies [13][14][15][16] indicate that socioeconomic factors, such as family income [14][15][16], and clinical conditions, such as toothache due to dental caries [13], pain during dental eruption [16], dental caries [14,15], malocclusion [15] and need for dental treatment [14], influence the caregivers' perception of the oral health of children and adolescents. However, there is a lack of studies that assess the caregivers' perception of the oral health of people with CP and their factors associated. Therefore, the present study aimed to evaluate factors associated with the caregivers' perception of the oral health of children and adolescents with CP.

Study Population
A cross-sectional study of inductive approach with statistical comparative procedure and intensive direct observation technique through clinical interview and clinical examination [17] was carried out at the Association of Parents and Friends of Children and Adolescents with Special Needs in the city of Campina Grande, Paraíba, Brazil from February to April 2014. The Association of Parents and Friends of Children and Adolescents with Special Needs is a philanthropic nongovernmental organization created on September 1, 1982. In addition, this philanthropic nongovernmental organization of Campina Grande is a reference institution in the performance of therapeutic activities and social integration for individuals with CP; however, it does not offer dental care for the users.
The population was composed of 97 children and adolescents aged 2-18 years with a clinical diagnosis of cerebral palsy (ICD-10 G80), and their respective primary caregivers. It was considered as the primary caregiver of children and adolescents with CP, those responsible for making decisions and carrying out the daily activities of these individuals, who were 18 years of age or older [6]. The refusal to participate in the study and non-attendance for the clinical examination, after three successive attempts, was considered as a loss.
Thus, of the total of 97 patients, three refused to participate, and 14 did not attend the clinical examination after three attempts (17 patients lost), resulting in 80 participants (response rate: 82.5%). Among these participants, 59 were children (2 to 12 years), and 21 were adolescents (13 to 18 years). The classification of participants in children or adolescents was based on individuals' dentition [18]. Participants with deciduous and mixed dentition (up to 12 years old) were considered as children while those with permanent dentition (from 13 years) were considered adolescents [18].

Calibration and Training Process
Prior to data collection, the examiner was calibrated. The calibration had the participation of a dentist and a specialist in pediatric dentistry, which was considered the gold standard. The process had theoretical and clinical stages. In the theoretical stage, the criteria for the diagnosis of dental caries, periodontal changes, malocclusion, and trauma were discussed. In the clinical stage, 40 children and adolescents without neurological impairment were examined in a pre-school and in a public school. At the end, inter and intra-examiner kappa values of 0.75-1.00 were obtained.

Data Collection
Data collection was performed by a single examiner and a scorer. Initially, information about the location of CP and the type of neuromuscular dysfunction were obtained from the institution's medical records.
According to the anatomical location of the involved limbs, CP was classified in tetraparesis, diparesia, or hemiparesis [4,19]. In tetraparesis, the four limbs are equally compromised; in diparesia, the lower extremities are more compromised, compared to the upper extremities; while in hemiparesis there is exclusive involvement of one side of the body [4,19]. According to the type of neuromuscular dysfunction, CP was subdivided into spastic, extrapyramidal, ataxic, or mixed [4,19].
Spastic neuromuscular dysfunction is characterized by increased muscle tone, tendon reflexes, tremors, and weakness [4,19]. Extrapyramidal is characterized by continuous and uncontrollable movements of limbs [4,19]. The ataxic is characterized by the presence of voluntary tremors and compromised balance and motor coordination [4,19]. Finally, the mixed is the combination of the other cases [4,19].
Soon after, face-to-face with the caregiver, a clinical file was filled out in a service room of the institution. This clinical file included information about demographic and socioeconomic characteristics (sex, children's age, caregiver's schooling, monthly family income according to the minimum wage in Brazil), caregiver's perception regarding general and oral health of patients with CP, access to dental service (time of the last visit to dentist) and systemic (medication use). Then, after supervised tooth brushing, clinical exams were performed with the patient sitting in a wheelchair or a traditional chair. The examiner used a light emitting-diode (LED) lamp attached to the head, flat dental mirrors, periodontal probes (Community Periodontal Index -CPI, Trinity Ind. Com. Ltda, São Paulo, SP, Brazil), mouth openers, wooden spatulas, and disposable gauzes.
Oral exams were performed by calibrated examiner with registration of DMF-T, dmf-t records [18], gingival bleeding index in the age group of 2-6 years [20], adapted for use of four index teeth [21], community periodontal index in the age group of 7-18 years in six index teeth [18,22], malocclusion index [23] and dental aesthetics index [23].
In the general clinical examination, the ability to communicate of the children and adolescent with CP, which is classified as normal, mild, moderate or severe disability, was observed [24]. The normal ability to communicate is characterized by the absence of difficulty in using speech [24]. The mild deficiency in communication ability is characterized by the presence of difficulty in the use of speech; however, the individual can speak [24]. The moderate deficiency in communication ability refers to the lack of use of speech to communicate [24]. Finally, the severe deficiency in the ability to communicate is characterized by a lack of communication [24].

Statistical Analysis
In the data analysis, descriptive statistics were performed for sample characterization. After categorization, the bivariate and multivariate Poisson regression analysis with robust variance (p<0.05) was used to determine the association between independent variables (socioeconomic, general health perception, systemic and oral ones) and the dependent variable (oral health perception). In the multivariate regression model, which used a hierarchical approach [25], were
According to the caregivers' perception, the frequency of oral health for children and adolescents with CP considered good and poor was 73.8% and 26.3%, respectively. For the multivariate model, we incorporated the independent variables that presented p<0. 20

Discussion
Children and adolescents with CP present motor disorders that make them dependent on caregivers for daily activities [1]. This makes it essential to know the caregivers' perception of the oral health of these children and adolescents, as well as the factors associated, in order to qualify the oral care performed on these individuals.
In this study, 26.3% of caregivers considered the oral health of children and adolescents with CP as poor. However, lower frequencies were observed in research conducted in English children with different levels of physical disabilities, medical histories, and behavioral problems [26]. Thus, these children may have worse general health conditions [26] than the participants in the present study. The higher impairment of the general health may concern more the caregivers than the oral health problems, influencing the perception of oral health [9]. In contrast, in another study [12], 66.2% of the children and adolescents with CP-related epilepsy had their dental status classified as bad according to the caregivers' perception. This high frequency of poor oral health is due to the presence of epilepsy, which increases in sixfold-higher odds of having oral health classified as bad [12].
In our study, the poor perception of oral health of children and adolescents with CP, according to caregivers, was associated with the presence of caries lesion in anterior teeth. This result corroborates the Brazilian study in children without disabilities [15], which suggests that the oral condition needs to be evident to the caregivers perceive [13]. In addition, when oral problems involve clinical discomfort and impairment of eating, aesthetics, and communication, the health and general well-being of the people are greatly affected [16], which may influence the perception.
Clinical manifestations of dental caries are primary markers of oral health impairment [13].
However, the visualization of oral problems can be impaired [26] due to the presence of involuntary movements, pathological oral reflexes, spasticity of mastication muscles, lack of cooperation and mouth opening limitation [26,27]. This compromises the caregivers' perception of oral health of children and adolescents with CP. On the other hand, when the caries lesion in the cavitated form is located in the anterior teeth, it becomes more visible. This is due to the impairment of aesthetics and function, which causes discomfort and difficulty to feed [13,15] and, consequently, may reflect on the negative caregivers' perception of the oral health of children and adolescents with CP.
In discordance, a study carried out in Brazil [13] concluded that the presence of dental caries lesion in the anterior teeth was not a factor associated with the poor perception of the caregivers about the oral health of children. However, the caregivers' perception of the oral health of children was associated with dental caries when toothache was present [13], which also evidences the oral complaint in question and, consequently, influences perception.
Bleeding during tooth brushing was also associated with the poor perception of the caregivers about the oral health of children and adolescents with CP. In the literature, the research that assessed the associated factors with the caregivers' perception of the oral health of children did not include in the data analysis the variable bleeding during tooth brushing, preventing this result can be compared with other studies. However, the presence of bleeding during tooth brushing has been described as a factor associated with negative self-perception of oral health [27]. Therefore, although periodontal changes are asymptomatic [28], the bleeding during tooth brushing becomes an alert for the presence of an oral problem, contributing to the caregivers perceive the poor oral health status of children and adolescents with CP.
However, this study has some limitations, such as a cross-sectional design that only Moreover, the oral health classification, that is according to the caregivers' perception may not be consistent with which would be reported by children and adolescents. However, it was observed that caregivers were reliable substitutes for the children regarding oral health perception due to the similarity found between oral health classification of children reported by caregivers and children themselves [29]. Given the above, longitudinal and case-control studies should be conducted, with a larger sample and selection criteria similar to previous studies, allowing comparisons.
Considering that caregivers are responsible for home oral health care of children and adolescents with CP [6,30], they need to be trained. Capacitation can be elaborated based on the factors associated with the perception of the oral health of this population since this reflects the difficulties found by the caregivers to identify the oral health problems of these individuals.
Therefore, the training should guide and motivate caregivers to perform better home oral health care, as well as encourage the search for access to professional oral health care for these children and adolescents.
Although the Brazilian Federal Government has created the National Plan for the Rights of Persons with Disabilities -Living Without Limits, which acts in the dental care of people with disabilities [31], the actions of this plan in the state of Paraíba face difficulties of the process. In primary care, most dentists did not have access to the training course to assist people with disabilities. In part of the Dentistry Specialty Centers, the service does not show resolving, and the demand continues to be suppressed. Finally, in the high complexity, demand is not supported and is often not offered. In addition, there is no insertion of dental offices in institutions for the rehabilitation of people with disabilities in the state. In this perspective, the results of this study can assist in the qualification of the oral health care network for people with disabilities and in the elaboration of an action plan focused on the formation in permanent health education, centered on the caregiver and the problematization of oral health care for people with disabilities.

Conclusion
Children and adolescents with cerebral palsy who had dental caries lesions in anterior tooth and gingival bleeding during dental brushing, more frequently, had their oral health considered poor by their caregivers. Therefore, it is suggested that for the caregivers to perceive the oral health of the children and adolescents with cerebral palsy as bad, it is necessary the presence of visible oral injuries. From this perspective, it is necessary to train caregivers to identify the dental caries lesion and indicators of poor oral hygiene in their initial stages. Thus, caregivers will be able to seek early the professional oral health care, as well as improve the home oral health care performed in children and adolescents with cerebral palsy, in order to restore the oral health of these individuals.
interpreted data. MMDM and AMRC were the major contributors in writing the manuscript. All authors contributed significantly to the writing of the manuscript and revised it critically for important the intellectual content. All authors read and approved the final manuscript.
Financial Support: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil (CAPES) -Finance Code 001.

Conflict of Interest:
The authors declare no conflicts of interest.