Oral Health in Children with Hearing and Speech Impairment in Banjaluka

Aleksandra Djeri1, Irena Kuzmanović-Radman1, Milkica Grabež2, Zorislava Bajić3, Alma Prtina4, Budimka Novaković2, Slavoljub Živković5 Department of Restorative Dentistry, Dental Study Program, Faculty of Medicine, University of Banjaluka, Banjaluka, Republika Srpska, Bosnia and Herzegovina; Department of Hygiene, Faculty of Medicine, University of Banjaluka, Banjaluka, Republika Srpska, Bosnia and Herzegovina; Department of Physiology, Faculty of Medicine, University of Banjaluka, Banjaluka, Republika Srpska, Bosnia and Herzegovina; Department of Patophysiology, Faculty of Medicine, University of Banjaluka, Banjaluka, Republika Srpska, Bosnia and Herzegovina Department of Restorative Odontology and Endodontics, School of Dental Medicine, University of Belgrade, Belgrade, Serbia


INTRODUCTION
Oral health includes health of mouth, jaws, teeth, throat, and related tissues.This fact points out the great import ance of oral health in everyday life [1].The American Academy of Pediatric Dentistry (AAPD) has enabled primary and comprehensive preventive and therapeutic health care for persons with disabilities as an integral part of training in pediatric dentistry.This aims to provide the best possible care to every person, including those with special needs.AAPD defines special needs as "any physical, developmental, mental, sensory, behavioral, cog nitive, or emotional disorder or restriction that requires medical recruitment, medical interventions, and/or use of specialized services and programs.The condition may be congenital or acquired and may cause limitations in daily activities.Providing health care for people with special needs requires specialized knowledge, increased attention and adaptation to conditions that deviate from planned routine" [2].
People with disabilities have increased risk for the occurrence of oral diseases.Particularly vulnerable pa tients to develop these diseases are patients with special needs or physical disabilities who neither possess ability to understand the importance of maintaining oral health nor responsibility to take preventive actions [3].
A child with a hearing impairment can neither hear well (even with a hearing aid) nor understand speech without specific instructions.Such child cannot respond to current life demands.There are two types of hearing loss: congenital and acquired (caused by diseases) [4].Hearing impairment is often associated with speech dis orders [5].
A dentist who is dealing with a child with hearing and speech impairment must change usual therapeutic ap proach and involve parents or guardians during examina tion.Also, interventions must be implemented carefully because it is a child with special needs and requirements [6].When applying local anesthesia a dentist must be ab solutely sure that the treated area is numbed before he/she starts the procedure.Cases in which incomplete anesthe sia during restorative procedures caused regressive behav ior of children and they felt betrayed have been reported.Also, when performing an intervention in children with hearing loss dentist should take care not to obstruct pa tients' eyes with any device or objects because then their only way to communicate (eyes) is affected which can cause restless behaviour.Hyperactive and anxious chil dren sometimes need preoperative medication.General anesthesia is recommended in cases where other therapy cannot be successfully applied [6].
According to the World Health Organization (WHO), 6090% of healthy school children worldwide have caries lesions [7].The DMFT index in healthy children in USA is relatively high (3.0), in Europe it is 2.6, while the lowest value is found in African countries -1.7 [8].In Croatia, the DMFT index in healthy children is very high (6.67)[9].
Brown and Shodel [10] analyzed 32 studies about chil dren with special needs and they found out that these children had poorer oral hygiene than healthy children of their age.The study of Jain et al. [11] revealed that children with hearing and speech impairment that attend special schools had poor oral hygiene and increased need for dental treatment.The mean DMFT in these children was 2.61.As very few data about oral health in children with hearing and speech impairment is available both in the world and in our country, there was a need for re search in depth in this area.
The aim of this study was to assess oral health status and the prevalence of dental caries in children with hear ing and speech impairment attending The Center for Education and Rehabilitation of Speech and Hearing in Banjaluka.

MATERIAL AND METHODS
The study was conducted as a crosssectional study from January to April 2010 and it included 66 children of both genders, aged 318 years.
General information about the respondents, socio economic status, dental hygiene habits and frequency of dental visits were obtained using a questionnaire [12].Dental examination was performed using dental mirror, regular and proximal probe on the daylight in accordance with WHO guidelines [13].Oral examination included: number of teeth, presence of caries, restorations and number of extracted teeth.Acquired data was entered in the dental records for each patient.For the assessment of dental status, the DMFT (decayed, missing, filled) index was used.All parents/guardians were explained the pur pose of the study and they signed informed consent for the participation in research.
Statistical analysis was performed using SPSS 15.0 (frequency distribution, ANOVA, ttest).The value p<0.05 was considered statistically significant.

RESULTS
The study included 36 boys (54.55%) and 30 girls (45.45%).The average age was 10.65 years (SD 4.75).In this study the presence of deciduous, mixed and perma nent dentition was identified (Table 1).
Seven children responded that they brush their teeth three times a day or more, 34 twice a day, 21 brush their teeth once a day and 4 of respondents do not brush their teeth at all (Graph 1).
Graph 2 shows dental visits and 25.8% of children with hearing and speech impairment reported not even a single Table 2 shows the correlation between the DMFT index and gender, the living environment, who do they live with, and the age of respondents.The average DMFT value of the total sample was 7.79 (SD 4.87).Male respondents had higher DMFT index (8.50)than female (6.93), but the difference was not statistically significant (p=0.19).Respondents from rural areas had higher values of the DMFT index (8.68)than those living in urban areas (7.13), also with no statistically significant difference (p=0.20).Children who live with their parents had lower DMFT index (7.10)than children who live with foster family (9.65) or in an institution (9.50), but this difference was not statistically significant (p=0.15).The DMFT index increased with age and school age (p<0.001).
Graph 3 shows the relationship between the DMFT index and the type of dentition.This index is increasing with the appearance of permanent teeth.In deciduous teeth, the dmft index had the lowest value (4.18), while in mixed dentition it was 7.95.The highest value of this index was in children with permanent teeth (8.81).

DISCUSSION
People with special needs experience difficulties in using dental services; therefore, they rarely visit a dentist.There are three types of barriers they encounter when using dental services.The first barrier are themselves, the other barrier is dentist that provides these services, and the third one are state programs for oral health maintenance Table 2. DMFT index in children with hearing and speech disorders in relation to gender, environment they live in and whom they live with Ta be la 2. Vred no sti in dek sa KEP kod de ce s po re me ća jem slu ha i go vo ra u od no su na pol, uz rast, sre di nu u ko joj ži ve i sa kim ži ve  in people with special needs [14].In the study from UK it was shown that 63% of children with hearing impair ment had at least one problem in communication during dental visit [15].The severity of this problem increased with the severity of hearing loss.About twothirds of children (62%) stated that dentists have worn protective masks when communicating with them.The same study showed that 69% of children used sign language or some form of oral communication.These children required a quiet environment free of background noise and a good view of the speaker's face.The dentist has to put a mask during the examination, but it is recommended to take off the mask while talking to these children so they can read from lips.It is necessary that dentist inquires how that child communicates, and to respect the way of communi cation as much as possible.This points out the important role of parents at each dental examination [15].One major study that assessed oral health in institu tionalized children with special needs showed increased prevalence of poor oral health among these children com pared to healthy children, and worsen situation with age [1].In addition to communication problems, children with hearing loss often have xerostomia (dry mouth) because they breathe through the mouth and therefore increased risk of dental caries and periodontal infections [15,16].People with longterm xerostomia are susceptible to cervical and root caries as well as gingivitis.Fluoride gels with high concentrations of fluoride, available on the market, can reduce the risk of developing these condi tions.However, in these cases the priority is given to oral hygiene and teeth brushing.These patients need more close checkups for their oral hygiene monitoring [17].
Our study showed lower level of oral hygiene in chil dren with hearing and speech impairment compared to healthy adolescents similarly to the study performed in 2007 in Croatia [18].About 51% of examined children in the current study, nearly 70% of healthy children in Croatia and almost 93% in Bosnia and Herzegovina, as shown in the study from 2012, brushed their teeth twice a day [18,19].Compared to 66% adolescents in Croatia who have seen dentist within one year [18] in Bosnia and Herzegovina nearly 73% have visited dentist regularly [19].In the current study only 33.3% of children have seen a dentist in the past 6 months.26% of children with hearing and speech impairment have never visited dentist compared to healthy children (about 13%) [19].
The DMFT in children with hearing and speech im pairment was 8.5 in males and 6.93 in females, but no statistically significant difference between these two groups was found.The results of the current study sig nificantly differ from results obtained in other countries: DMFT index of healthy children in US was 3.0, in Europe 2.6, while the lowest index was found in African coun tries (1.7) [8].In Croatia, the DMFT index in children is very high (6.67)[9].A study conducted among chil dren with special needs in Banjaluka (Bosnia and Her zegovina) including children age 515 years with neuro logical disorders without mental retardation, mild and moderate mental retardation showed high DMFT index (9.77)among these children [20].Jain et al. [11] reported the average DMFT index of 2.61 in children with hear ing impairment, whereas that value increased with age of children.The lowest DMFT index was found in pre school children (4.67), slightly higher value in children attending primary school (7.58), while in high school it was the highest (11.38).This can be explained by changes in their lifestyle and diet [11].One Brazilian study showed that the incidence of proximal lesions in twelve year old children can be decreased with appropriate diet and oral hygiene [21].For better oral health it is recommended to reduce intake of refined carbohydrates [22].
In the current study, correlation was observed be tween the DMFT index and types of dentition, with the lowest index value in primary teeth (4.18).The DMFT index in mixed dentition was 7.95, and in permanent 8.81.Other studies showed lower values of this index.In Croatia in 2007, a study was conducted in children with special needs, including children with cerebral palsy, mental retardation, Down syndrome, autism and hear ing and speech impairment, age 317 years.In that study the DMFT index in these children was 3.42 in deciduous and 5.24 in mixed dentition, while in healthy children it was 1.43 for deciduous and 5.1 for mixed dentition [23].Children older than 6 years can independently brush their teeth.In relation to their physical and psychological dis ability, they are in greater risk of caries.According to the WHO data, more than 60% of European countries have achieved the target maximum value of the DMFT index (3) at twelve years of age.Others, including Baltic coun tries still have high levels of the DMFT index [23,24].
There was no significant correlation between the DMFT index and the environment in which children live (town or village), or with whom they live (parents, foster care or collective).
DMFT index as main indicator of the status of teeth indicated poor dental health in children with hearing and speech impairment.Although they are physically able to maintain dental hygiene, the main obstacle is communi cation.Often, by mistake, hearing loss is associated with learning disabilities, and treated as such.In addition, these patients feel that medical personnel are compassionated, so they avoid dental visits putting their oral health at risk [25].

CONCLUSION
Children with hearing and speech impairment attending "The center for education and rehabilitation of speech and hearing" in Banjaluka showed low level of oral health.The DMFT index in these children, as one of the most import ant parameters of oral health was higher than in other European countries and countries in the region.These children should have adequate dental care with trained professionals provided.Also, it is necessary to educate children how to maintain oral hygiene involving parents, guardians and institutions in the health care program.The most optimal solution for this population would be establishment of dental offices within the institution in which children with hearing and speech impairment reside (school or collectives in which they live).In these clinics dentists could educate them about oral hygiene in order to improve their oral health.

NOTE
The research was conducted within the project No. 196 02096111209 of the Ministry of Science and Technol ogy of Republika Srpska.

UVOD
Oral no zdra vlje ob u hva ta zdra vlje usta, vi li ce, zu ba, gr la i pri pa da ju ćih tki va.Ta či nje ni ca uka zu je na ve li ki zna čaj zdra vlja ovih or ga na u sva ko dnev nom ži vo tu [1].Ame rič ka aka de mi ja pe di ja trij ske sto ma to lo gi je (Ame ri can Aca demy of Pe di a tric Den ti stry -AAPD) omo gu ći la je da pri mar na i obim na pre ven tiv na i te ra pij ska zdrav stve na za šti ta oso ba s po seb nim po tre ba ma bu de in te gral ni deo spe ci ja li za ci je iz deč je sto ma to lo gi je.Ti me se na sto ji obez be di ti naj bo lja mo gu ća ne ga sva koj oso bi, pa i oso ba ma s po seb nim po tre ba ma.AAPD de fi ni še po seb ne po tre be kao "bi lo ko ji fi zič ki, raz voj ni, men tal ni, sen zor ni, bi hej vi o ral ni, kog ni tiv ni ili emo ci o nal ni po re me ćaj ili ogra ni če nje ko je zah te va me di cin sko an ga žo va nje, zdrav stve ne in ter ven ci je i/ili upo tre bu spe ci ja li zo va nih uslu ga ili pro gra ma.Sta nje mo že bi ti uro đe no ili ste če no, a mo že iza zva ti ogra ni če nja u sva ko dnev nim ak tiv no sti ma.Zdrav stve na za šti ta oso ba s po seb nim po tre ba ma zah te va spe ci ja li zo va na zna nja, po ve ća nu pa žnju, pri la go đa va nje sta nju ko je od stu pa od pred vi đe ne ru ti ne." [2] Kod oso ba s po seb nim po tre ba ma po ve ćan je ri zik od bo le sti oral nog apa ra ta.Na stan ku ovih bo le sti na ro či to su pod lo žni pa ci jen ti s po seb nim po tre ba ma ili fi zič kim ne do sta ci ma ko ji ni su spo sob ni da raz u me ju zna čaj odr ža va nja hi gi je ne usta i zu ba, ni ti da pre du zmu od go vor nost za pre ven tiv no de lo va nje u oču va nju svo ga zdra vlja [3].
De te s ošte će njem slu ha je ono ko je ne ma do volj no do bar sluh (čak i sa slu šnim apa ra tom) da raz u me go vor bez po seb nih in struk ci ja.Ta kvom de te tu ču lo slu ha ne mo že da od go vo ri na sva ko dnev ne zah te ve ži vo ta.Po sto je dva ti pa ošte će nja slu ha: kon ge ni tal no (uro đe no) i ste če no (uzro ko va no ne kim bo le sti ma) [4].Ošte će nje slu ha je če sto udru že no s po re me ća jem go vo ra [5].
Sto ma to log ko ji je sve stan za vi sno sti de te ta s ošte će nim slu hom i go vo rom od ro di te lja (sta ra te lja) mo ra pro me ni ti svoj uobi ča je ni te ra pij ski pri stup, te od mah pri pre gle du uklju či ti i ro di te lje u či tav pro ces.In ter ven ci je se mo ra ju re a li zo va ti pa žlji vo s ob zi rom na to da je u pi ta nju de te s po seb nim po tre ba ma i zah te vi ma [6].Pri pri me ni lo kal ne ane ste zi je sto ma to log mo ra bi ti pot pu no si gu ran da je ona de lo va la pre ne go što poč ne sa dru gim pro ce du ra ma.Za be le že ni su i slu ča je vi u ko ji ma je ne pot pu na ane ste zi ja pri re sta u ra tiv nim za hva ti ma do ve la do re gre si je u po na ša nju tog de te ta, pri če mu se ono ose ti lo iz da nim, što je na kra ju do ve lo i do ote ža ne sa rad nje s njim.Pri li kom iz vo đe nja in ter ven ci ja kod de ce s ošte će njem slu ha sto ma to log tre ba da vo di ra ču na o tome da pa ci jen to ve oči ne bu du za klo nje ne ne kim apa ra tom ili pred me tom, jer je ta da je di no sred stvo ko mu ni ka ci je s oko li nom (oči) ugro že no, te to kod de te ta mo že iza zva ti bur nu re ak ci ju.Kod hi pe rak ti ve i vr lo ner vo zne de ce ne ka da je neo p hod no po seg nu ti za pre me di ka ci jom.Op šta ane ste zi ja se pre po ru ču je ka da se dru gi ob li ci le če nja po ka žu ne u spe šnim [6].
Braun (Brown) i Šo del (Sho del) [10] su ana li zi ra li 32 stu di je de ce s po seb nim po tre ba ma i po ka za lo se da ta kva de ca lo ši je odr ža va ju hi gi je nu usta u od no su na dru gu de cu istog uz ra sta.Stu di ja Džej na (Jain) i sa rad ni ka [11] je po ka za la da je kod de ce s ošte će njem slu ha i go vo ra ko ja su po ha đa la spe ci jal nu ško lu oral na hi gi je na lo ša, te da je po ve ća na i po tre ba za sto ma to lo škim in ter ven ci ja ma.Sred nja vred nost in dek sa KEP kod te de ce bi la je 2,61.Ka ko je vr lo ma lo po da ta ka o oral nom zdra vlju de ce s ošte će njem slu ha i go vo ra u sve tu, pa i kod nas, ja vi la se po tre ba za is tra ži va njem u ovoj obla sti.
Cilj ra da je bio da se pro ve re sta nje zu ba i pre va len ci ja ka ri je sa kod de ce s ošte će njem slu ha i go vo ra ko ja po ha đa ju Cen tar za obra zo va nje i vas pi ta nje i re ha bi li ta ci ju go vo ra i slu ša nja u Ba nja lu ci.

MATERIJAL I METODE RADA
Is tra ži va nje je iz ve de no kao stu di ja pre se ka od ja nu a ra do apri la 2010.go di ne, a ob u hva ti lo je 66 de ce oba po la, uz ra sta od tri go di ne do 18 go di na.
Op šti po da ci o is pi ta ni ci ma, nji ho vom so ci o e ko nom skom sta tu su, na vi ka ma odr ža va nja hi gi je ne zu ba i usta i uče sta lo sti po se ta sto ma to lo gu do bi je ni su upit ni kom [12].Sto ma to lo ški pre gled je oba vljen po mo ću sto ma to lo škog ogle dal ce ta, sto ma to lo ške pra ve i aprok si mal ne son de pri dnev noj sve tlost u skla du s uput stvom SZO [13].Sto ma to lo škim pre gle dom su utvr đe ni: broj zu ba, po sto ja nje ka ri je sa, po sto ja nje is pu na i broj iz va đe nih zu ba.Do bi je ni po da ci su upi sa ni u sto ma to lo ške kar to ne sva kog de te ta.Za pro ce nu sta nja zu ba ko ri šćen je in deks KEP (K -zub za hva ćen ka ri je som; E -eks tra ho van zub; P -plom bi ran zub).Svi ro di te lji (sta ra te lji) upo zna ti su sa svr hom is tra ži va nja i svo jim pot pi som su po tvr di li do bro volj ni pri sta nak za uče šće de ce u stu di Sta ti stič ka ob ra da po da ta ka je vr še na u pro gra mu SPSS 15.0 (di stri bu ci je fre kven ci je, ANO VA, Stu den tov ttest).Sta ti stič ki zna čaj nom sma tra la se vred nost p<0,05.
Na pi ta nje o na vi ci pra nja zu ba, se dam is pi ta ni ka je od go vo ri lo da zu be pe re naj ma nje tri pu ta dnev no, 34 je re klo da ih pe re dva pu ta dnev no, 21 is pi ta nik je na veo da zu be pe re sa mo jed nom dnev no, dok su če ti ri is pi ta ni ka od go vo ri la da ni ka da ne pe ru zu be (Gra fi kon 1).
Na gra fi ko nu 2 pri ka za na je po sled nja po se ta sto ma to lo gu, gde se uoča va da čak 25,8% de ce s ošte će njem slu ha i go vo ra ni ka da ni je bi lo kod zu ba ra i da 21,2% de ce ni je bi lo kod sto ma to lo ga u po sled njih go di nu da na.

DISKUSIJA
Oso ba ma s po seb nim po tre ba ma ote ža no je ko ri šće nje sto ma to lo ških uslu ga, te one ret ko po se ću ju zu ba ra.Po sto je tri vr ste pre pre ka na ko je na i la ze pri li kom ko ri šće nja sto ma to lo ških uslu ga.Pr vu ba ri je ru pred sta vlja ju oni sa mi, dru gu či ne sto ma to lo zi ko ji pru ža ju te uslu ge, a tre ću dr žav ni pro gra mi za odr ža va nje oral nog zdra vlja ovih oso ba [14].U Ve li koj Bri ta ni ji je ura đe na stu di ja ko ja je po ka za la da je 63% de ce s ošte će njem slu ha ima lo bar je dan pro blem u ko mu ni ka ci ji pri li kom po se te sto ma to lo gu i da se te ži na tog pro ble ma po ve ća va sa te ži nom ošte će nja slu ha [15].Oko dve tre ći ne de ce (62%) je iz ja vi lo da je sto ma to log no sio ma sku pri ko mu ni ka ci ji s nji ma.Ista stu di ja je po ka za la da se 69% de ce slu ži je zi kom zna ko va ili ne kim ob li kom usme ne ko mu ni ka ci je.Ta kva de ca zah te va ju ti hu sre di nu, bez po za din skih zvu ko va, i do bar po gled na li ce go vor ni ka.Sto ma to log mo ra da no si ma sku to kom pre gle da, ali je do volj no da je ski ne pri li kom obra ća nja de te tu, ka ko bi ono mo glo da či ta s usa na.Pri pre gle du neo p hod no je da se sto ma to log ras pi ta na ko ji na čin de te ko mu ni ci ra, te da po štu je ta kav na čin sa rad nje ko li ko je to mo gu će.To uka zu je na ve li ku ulo gu ro di te lja pri sva kom pre gle du kod zu ba ra [15].
Jed na od ve ćih stu di ja ko ja je is pi ti va la oral no zdra vlje de ce s po seb nim po tre ba ma ko ja su sme šte na u po seb ne usta no ve po ka za la je da je po ve ća na pre va len ci ja lo šeg zdra vlja usta i zu ba ta kve de ce u od no su na zdra vu de cu, te da se si tu a ci ja po gor ša va sa uz ra stom [1].Osim pro ble ma u ko mu ni ka ci ji, de ca s ošte će njem slu ha če sto ima ju kse ro sto mi ju (su vo ća usta) jer di šu na usta, a ti me i po ve ćan ri zik od po ja ve ka ri je sa i pe ri o don tal nih in fek ci ja [15,16].Oso be sa du go traj nom kse ro sto mi jom pod lo žne su na stan ku ka ri je sa zub nog vra ta i ko re na, te gin gi vi ti su.Flu o rid ni ge lo vi s vi so kom kon cen tra ci jom flu o ri da ko ji se mo gu na ći na tr ži štu sma nju ju ri zik od po ja ve ovih sta nja.Ipak, pred nost se u ta kvim slu ča je vi ma da je sa ve ti ma o odr ža va nju hi gi je ne usta i zu ba i na či ni ma či šće nja zu ba.Ta kvi pa ci jen ti se mo ra ju če šće ja vlja ti na kon trol ne pre gle de, da bi se pra ti lo ka ko odr ža va ju hi gi je nu usne du plje [17].
Na še is tra ži va nje je po ka za lo da su hi gi jen ske na vi ke pra nja zu ba kod de ce s ošte će njem slu ha i go vo ra na ni žem ni vou u od no su na po dat ke is tra ži va nja ko je je 2007.go di ne ura đe no na zdra vim ado le scen ti ma u Hr vat skoj [18].Na i me, re zul ta ti na še stu di je su po ka za li da 51% de ce zu be pe re dva pu ta dnev no, dok je u Hr vat skoj to či ni lo sko ro 70% zdra ve de ce [18], a u Bo sni i Her ce go vi ni 2012.go di ne 93% [19].U po re đe nju sa 66% hr vat skih ado le sce na ta ko ji su kod sto ma to lo ga bi li u pro te klih go di nu da na [18], u Bo sni i Her ce go vi ni njih sko ro 73% re dov no ide kod zu ba ra [19], dok je u na šem is tra ži va nju po ka za no da je sa mo tre ći na de ce bi la kod sto ma to lo ga u po sled njih šest me se ci.Sto ma to lo ga ni kad ni je po se ti lo 26% de ce s ošte će njem slu ha i go vo ra, što je sko ro du plo vi še u od no su na zdra vu de cu (oko 13%) [19].
In deks KEP de ce s ošte će njem slu ha i go vo ra bio je 8,5 kod is pi ta ni ka mu škog po la, a 6,93 kod žen skog, ali ova raz li ka iz me đu dve po sma tra ne gru pe ni je bi la sta ti stič ki zna čaj na.Re zul ta ti stu di je znat no od stu pa ju od na la za u ne kim dru gim ze mlja ma: ta ko je, na pri mer, vred nost in dek sa KEP zdra ve de ce u SAD bi la 3,0, u Evro pi 2,6, a u afrič kim ze mlja ma 1,7 [8].Kod de ce u Hr vat skoj vred nost in dek sa KEP je bi la vr lo vi so ka -6,67 [9].U Ba nja lu ci je ura đe no is tra ži va nje ko je je ob u hva ti lo de cu s po seb nim po tre ba ma uz ra sta 5-15 go di na ko ja su ima la ne u ro lo ške po re me ća je bez men tal ne re tar da ci je i de cu ko ja su ima la bla gu ili ume re nu men tal nu re tar da ci ju.Re zul ta ti stu di je su po ka za li vi sok in deks KEP, či ja je vred nost bi la 9,77 [20].Džejn i sa rad ni ci [11] su kod de ce s ošte će njem slu ha iz ra ču na li pro seč nu vred nost in dek sa KEP od 2,61, ko ja se sa uz ra stom de ce po ve ća va la.I u stu di ji ura đe noj na de ci s ošte će njem slu ha i go vo ra utvr đe na je sta ti stič ki zna čaj na po ve za nost uz ra sta de ce i po ra sta vred no sti in dek sa KEP.Naj ni ža vred nost je bi la kod de ce pred škol skog uz ra sta (4,67), ne što ve ća kod de ce ko ja su po ha đa la osnov nu ško lu (7,58), dok je kod sred njo ško la ca bi la naj vi ša (11,38).To se ob ja šnja va pro me na ma na či na ži vo ta i is hra ne [11].Is tra ži va nje bra zil skih auto ra je po ka za lo da se in ci den ci ja aprok si mal nih le zi ja kod dva na e sto go di šnja ka mo že sma nji ti od go va ra ju ćom is hra nom i oral nom hi gi je nom [21].Za po bolj ša nje oral nog zdra vlja pre po ru ču je se sma nje ni unos ra fi ni sa nih uglje nih hi dra ta u dnev nim ob ro ci ma [22].
U na šem is tra ži va nju uoče na je po ve za nost in dek sa KEP i vr ste den ti ci je, pri če mu je vred nost ovog in dek sa bi la naj ni ža kod mleč nih zu ba (4,18).Kod me šo vi te den ti ci je ona je bi la 7,95, a kod stal ne 8,81.Re zul ta ti dru gih stu di ja po ka zu ju ni že vred no sti ovog in dek sa.U Hr vat skoj je 2007.ura đe no is tra ži va nje na de ci s po seb nim po tre ba ma, ko je je ob u hva ti lo de cu s ce re bral nom pa ra li zom, men tal nom re tar da ci jom, Da u no vim sin dro mom, auti zmom i ošte će njem slu ha i go vo ra, uz ra sta 3-17 go di na.U toj stu di ji vred nost in deks KEP kod mleč ne den ti ci je bi la je 3,42, a kod me šo vi te 5,24, dok je kod zdra ve de ce iz no si la 1,43 za mleč nu i 5,1 za me šo vi tu den ti ci ju [23].De ca sta ri ja od šest go di na su sa mo stal ni ja i sa ma pe ru zu be.U po gle du nji ho ve fi zič ke i psi ho lo ške one spo so blje no sti, kod njih je ve ći ri zik za na sta nak ka ri je sa.Pre ma po da ci ma SZO, vi še od 60% evrop skih ze ma lja po sti glo je cilj mak si mal ne vred no sti in dek sa KEP (3) već kod de ce uz ra sta od dva na est go di na.U dru gim ze mlja ma, uklju ču ju ći i bal tič ke, i da lje se be le ži vi sok ni vo in dek sa KEP [23,24].
Ana li zom po ve za no sti in dek sa KEP i sre di ne u ko joj de ca ži ve (se lo ili grad) ni je utvr đe na sta ti stič ki zna čaj na raz li ka, kao ni kod po ve za no sti in dek sa KEP i sa tim s kim de ca ži ve (s ro di te lji ma, u hra ni telj skoj po ro di ci ili u ko lek ti vu).
In deks KEP, kao glav ni po ka za telj zdra vlja zu ba, uka zu je na lo še zdra vlje zu ba de ce s ošte će njem slu ha i go vo ra.Iako su oni fi zič ki spo sob ni da odr ža va ju hi gi je nu zu ba i usne šu plji ne, osnov nu pre pre ku u to me či ni ko mu ni ka ci ja.Če sto se ošte će nje slu ha po gre šno ve že s po re me ća jem uče nja, te se ta kva de ca ta ko i tre ti ra ju.Osim to ga, oni ne ka da ose ća ju da ih i me di cin sko oso blje sa ža lje va, pa su nji ho ve po se te sto ma to lo gu ret ke, či me je i nji ho vo oral no zdra vlje ugro že no [25].

ZAKLJUČAK
De ca s ošte će njem slu ha i go vo ra ko ja po ha đa ju Cen tar za obra zo va nje i vas pi ta nje i re ha bi li ta ci ju go vo ra i slu ša nja u Ba nja lu ci vr lo su lo šeg oral nog zdra vlja.In deks KEP, je dan od naj va žni jih pa ra me ta ra oral nog zdra vlja, kod ove je de ce mno go ve ći u od no su na de cu iz osta lih evrop skih i ze ma lja u re gi o nu.Nji ma bi za to tre ba lo omo gu ći ti od go va ra ju ću sto ma to lo šku uslu gu s ob u če nim pro fe si o nal ci ma, ko ja će im bi ti pri stu pač ni ja.Ta ko đe, neo p hod na je edu ka ci ja ove de ce o odr ža va nju hi gi je ne i nje nom zna ča ju, ali i uklju či va nje ro di te lja, sta ra te lja i usta no va u pro gram nji ho ve zdrav stve ne za šti te.Op ti mal no re še nje za ovu po pu la ci ju bi lo bi osni va nje sto ma to lo ških am bu lan ti u sa sta vu usta no va u ko ji ma de ca s ošte će njem slu ha i go vo ra bo ra ve (ško le ili ko lek ti vi u ko ji ma ži ve).U ta kvim am bu lan ta ma sto ma to lo zi bi vr ši li edu ka ci ju o odr ža va nju hi gi je ne usta i zu ba, či me bi se una pre di lo oral no zdra vlje ove de ce.

NAPOMENA
Is tra ži va nje je re a li zo va no u okvi ru pro jek ta br.196020961 11209 Mi ni star stva na u ke i teh no lo gi je Re pu bli ke Srp ske.

Figure 2 .Figure 3 .
Figure 2.Last dental visit of respondents Gra fi kon 2. Ras po de la is pi ta ni ka pre ma po sled njoj po se ti sto mato lo gu

Figure 1. Frequency of brushing teeth Gra fi kon 1. Uče
sta lost pra nja zu ba dental visit while 21.2% of children had not visited dentist in the past year.