Oral Health Status of People with Mental Disabilities in the Municipality of Banja Luka

Introduction Oral health of mentally disabled people in Republika Srpska is on very low level. The greatest number of these persons is often edentulous or with a small number of teeth with extensive caries, high DMFT index and severe periodontal diseases. The aim of this study was to determine oral health status of people with mental disabilities in the municipality of Banja Luka. Material and Methods Study included 95 patients (45 females and 50 males), aged 15 to 45 years. The subjects were divided into two groups according to the degree of mental impairment: ICD-10 F71 (65 respondents) and F72 (30 respondents). Dental assessment included: number of present teeth, presence of caries, restorations, number of extracted teeth, presence of residual roots, fractures, presence and number of fixed restorations, gingival and plaque index. Results The mean DMFT index in patients with severe mental disability was high (17.4), while it was 12.3 in patients with mild disability. The mean value of person caries index (PCI) was 100%. In addition, the mean value of teeth caries index (TCI) in severely disabled persons was 58.1 whereas in those with mild intellectual disability it was 42.4. Average caries index (ACI) in patients with severe mental disability was 16.9 while in the group of patients with mild disability this value was 10.2. Plaque index in severely disabled people was 2.4, while in the second group (mild disability) it was 1.9. Gingival index in patients with severe mental disability was 1.8 and in mild disability group it was 1.3. Conclusion People with mental disabilities in the municipality of Banjaluka have poor oral health. They do not have habits, attitudes and behavior towards oral health.


INTRODUCTION
Oral health is an integral part of general health and dental care of persons with physical and mental disabilities is an integral part of comprehensive medical care.The number of persons with mental disabilities has been steadily growing while it has been in contrast with the development of medical care.Depending on the degree of mental disability, affected persons have impaired understanding, reasoning and independently performing daily activities and therefore they require special care provided by trained personnel [1].Due to their disability these people are not capable of self care and maintaining adequate oral hygiene.In addition to mental development they often have joined kinetic disorders (difficult moving or complete immobility) which further complicate the maintenance of oral hygiene and preservation of oral health [2].Several studies have reported poor oral health in persons with mental disabilities with dental care most often limited to tooth extraction [3][4][5][6].
Research in the world and our country have shown that this population (compared to general population) has more teeth extracted, untreated carious teeth, severe periodontal diseases, poorer oral hygiene, fewer filled teeth and frequent occurrence of xerostomia, burning and tingling in the mouth or bad breath and taste disorders [7,8,9].In their study, Nelson and Van Blaricum [10] indicated that children with severe motor and intellectual disabilities age 14-15 years had lower number of carious teeth compared to their healthy peers.Chu et al. [11] found the mean value of DMFT index in people with mental disabilities of 13.9.In one study conducted in 2004 in Serbia it was found that mentally disabled persons had significantly more untreated caries, fewer filled teeth, more extracted teeth, and significantly worse periodontal status than healthy people [12].Another study conducted in Croatia in 2007 reported that people with disabilities had significantly lower level of oral hygiene compared to healthy population [13].
Performing proper oral hygiene daily is one of the most important factors in preventing oral diseases and failure to maintain good oral health is a precondition for development and rapid progression of these diseases due to already impaired oral health in people with different disabilities [14,15].Moreover, these patients often take various medications which may also affect their oral health due to reduced salivation, increased risk for gingival inflammation that can lead to bone resorption and development of periodontal diseases further worsening their oral health [16].In most cases it is difficult to establish communi-cation (sometimes even impossible) with patients with disabilities and sometimes it is only possible to perform interventions under general anesthesia.These interventions require extensive work by the team of doctors under special conditions and often they can be performed in large centers only whereas this treatment is unavailable to people from small and underdeveloped regions [17].
The aim of this study was to determine oral health status of people with mental disabilities in the municipality of Banjaluka.

MATERIAL AND METHODS
The study included 95 patients age 15 to 45 years with mental disability, both living with their parents/guardians or residing in the institutions (Center "Zaštiti me" in Banja Luka and the Institute of Physical Medicine and Rehabilitation "Dr Miroslav Zotović" in Belgrade).According to the degree of mental impairment, all respondents were divided into two groups in regard to the ICD-10 [18].The first group consisted of 65 respondents with F71 diagnosis, and the second group consisted of 30 respondents with F72 diagnosis.Forty five females and fifty males were included in the study.The status of their oral health was assessed at the Department of Maxillofacial Surgery of the Clinical Center in Banjaluka where after all patients received their dental treatment.According to the WHO guidelines, dental mirror, probe and artificial lighting were used for the clinical assessment [19].Dental charting was performed (number of teeth, caries lesions, restorations, number of extracted teeth, remaining roots and prosthetic restorations).To assess the status of teeth, the DMFT index was used.For the assessment of the status of gingiva, Löe-Silness index was used whereas for the assessment of dental plaque Silnes-Löe index was used.All parents/guardians were informed about the purpose of the study and they signed informed consent for study participation.
All data were analyzed by standard procedures of descriptive and comparative statistics.Within the descriptive statistics the mean value and standard deviation were determined whereas for comparative statistics Kruskal-Wallis's test, Student's t test and χ 2 test were used.

RESULTS
The study included a total of 50 (52.6%)male and 45 (47.4 %) female patients.In relation to the degree of mental disability respondents were classified into two groups: the first group consisted of persons with mild intellectual disability (F71) 65 (68.4%) and the second group included persons with severe mental disability (F72) 30 (31.6%).Mixed dentition was present in 3 (3.2%)patients, and permanent dentition was present in 92 (96.8%) patients (Table 1).
Number of carious teeth in patients with severe mental disability (13.8) was slightly higher than in patients with mild disability (10.1).This difference was statistically significant (p<0.07)(Table 2).
The number of extracted teeth (2.1) was higher in patients with severe mental disability compared to patients with mild disability (0.8) and this difference was statistically significant (p<0.02)(Table 2).
The mean number of restorations in patients with mild mental disability was 1.4, whereas in those with severe disability it was 1.5.This difference was not statistically significant (p<0.173)(Table 2).
The mean value of DMFT in patients with severe disability (17.4) was higher compared to the group with mild mental disability (12.3).This difference was highly statistically significant (p<0.001)(Table 2).
The mean value of PCI index in all patients (mild and severe disability) was 100% (Table 3).
ACI index in patients with mild intellectual disability was 10.2 while it was 16.9 in patients with severe disability.This difference was highly statistically significant (p<0.001)(Table 3).TCI index in patients with mild intellectual disability reached 42.4 while in those with severe disability it was even 58.1.This difference was highly statistically significant (p<0.01)(Table 3).
The mean GI in patients with mild intellectual disability was 1.3±0.7 while in those with severe disability it was 1.8±0.8.This difference was statistically significant (p<0.05).
The mean PI in subjects with mild mental disability was 1.9±0.6 while in patients with severe disability it was 2.4±0.6.This difference was highly statistically significant (p<0.0001).

DISCUSSION
Poor oral status in persons with mental disabilities is generally expected due to severe general condition of these patients but also frequent neglect of this aspect of their health.People with mental disabilities are not capable to independently take care of proper oral hygiene which eventually affects their oral health.They also have limited understanding or inability to understand and follow instructions and advice on the prevention measures and oral hygiene [2].In addition, people with mental disabilities often have limited access to dental treatment due to anxiety (fear of dental intervention) as well as poor financial situation of their parents and guardians who have to pay for dental interventions.There is a limited state health insurance but also low number of trained dentists to provide care to this population [20,21].
One of the factors that affect the overall oral health of this people is the possibility to perform a therapeutic procedure.Whether the traditional approach (mild forms of disability, short and simple dental interventions), treatment in sedation (difficult cooperation, more demanding dental intervention) or under general anesthesia (lack of cooperation with longer and more complex dental interventions) will be chosen for the treatment of this patients depends on the mental status and ability to communicate with this group of patients [22].
The results of the current study showed that the number of carious teeth in patients with severe degree of mental disability (13.8) was slightly higher than in those with mild impairment (10.1).Also, the number of extracted teeth (2.1) was higher in people with severe mental disability compared to those with mild disability (0.8).Patients with mild mental disability had more filled teeth compared to patients with severe disability.Great difference in the number of carious and extracted teeth between people with mild and severe disability can be explained by the fact that people with severe disability have more difficulties to adopt and learn proper techniques of oral hygiene.Depending on the degree of mental disability these patients have more or less difficulties to understand and independently perform daily activities and accordingly they require more or less care by trained personnel [1].
Several authors suggested that these people have higher prevalence of dental caries compared to healthy population [8,23] whereas severe periodontal disease reflect poor oral hygiene in these patients [24].On the other hand, there are studies that indicate caries prevalence similar in healthy subjects and people with mental disabilities [25].People with mental disabilities, especially those with severe disability, are not able to independently maintain adequate oral hygiene.People with both mental and physical disabilities, in addition to mental development often have kinetic disorders (difficult movements or completely immobile) which further complicates the maintenance of oral hygiene and preservation of oral health [2].Miller and Taylor [22] showed that physically disabled persons had more cavities than mentally disabled.They explained these results by their physical disability and inability to maintain proper oral hygiene.
The results of the current study showed that patients with severe mental impairment had high value of the DMFT index (17.4)while in mildly disabled people it was 12.3.High average value of the DMFT index indicates poor oral health of these patients which is not only caused by their inability to maintain oral hygiene but also by inadequate availability of dental care [21].
Average value of PCI index in patients with mental disabilities was 100 % suggesting that none of 95 patients included in the study had all healthy teeth.The average TCI in patients with severe mental disability was 58.1 while in mild cases it was 42.4.The mean PCI index in patients with severe mental disability reached 16.9 while it was 10.2 in mildly disabled patients.Results from the literature showed the average value of the DMFT index in mentally impaired patients in Taiwan was 14.9 [26] and Australia 14.6 [27] which is in accordance with our results.Kenkre et al. [28] reported the value of DMFT index of 12.8.Pezzementi and Fisher [29] in similar study in United States found DMFT index of 13.6.In Western Europian countries, these values were slightly higher (15.85) clearly indicating that in addition to the health care system, the development of the country or region may be one of the most important factors that influence the status of oral health [30].The results of the current study are consistent with the study by Angelillo et al. [31] conducted in Italy, who reported the mean value of DMFT index of 15.5.Similar findings were reported in the research of Lewis et al. [32] who found the average DMFT value in people with mental disabilities of 17.1.Morgan et al. [33] performed a study in the United States and included 4,732 adult patients with mental disabilities.They found the mean value of DMFT index to be 13.9 and that result is also consistent with our results.Poor oral health in persons with mental disabilities was confirmed in the study performed in Spain by Valesco et al. [34].In their study, authors found that the mean DMFT index in people with mental disabilities was 24.99.Similar values were reported in studies from Israel where Ramon et al. [35] reported the mean value of the DMFT index in people with mental disabilities of 26.74.Similar values were reported by Zusman et al. [36] in another Israel study where the average value of the DMFT index in people with mental disabilities was 23.8.
One study conducted in Bosnia and Herzegovina in 2009 which included 70 patients from the institution for mentally handicapped people in Visegrad, age 30 to 55 years, reported poor oral health in 90% of patients, 4.3% of patients had satisfactory condition whereas in 5.7% of patients the examination was not possible [37].Another study conducted in Serbia which examined 114 patients with mental disability from 22 to 71 years of age reported high value of DMFT index of 20.95.The largest portion of the index were extracted teeth (63.76%), then carious teeth (33.48%) and the least number was for filled teeth (2.76%) [38].
According to the data from literature, inadequate nutrition has shown great impact on increased incidence of dental caries in this population [39].Stanfield [40] in his research concluded that increased incidence of caries in people with mental disabilities was result of excessive consumption of food rich in sugar.
Results of the current study confirmed that people with mental disabilities have poor oral hygiene.All 95 respondents in our study had dental plaque.Plaque index was 2.1 and most of them (56.8%)showed moderate amount of plaque.In addition, gingival index of the respondents was 1.5.Only 4% of patients had healthy gingiva while most of them had moderate inflammation (52%) indicating low level of oral hygiene.Our results are consistent with the findings obtained by Moraru et al. [41] in their study conducted in Romania.They reported plaque present in 90%, calculus in 80% while only 3% of respondents had healthy periodontium.As many as 97% showed gingivitis, supragingival (53%) and subgingival calculus (36%) and 11% showed subgingival and occlusal calculus.
Research conducted by McCreadie et al. [42] in the UK showed that 75% of hospitalized patients with schizophrenia regularly maintained oral hygiene.In his reaserach, Hede [43] showed that only 55% of hospitalized patients with psychiatric disorders brushed their teeth.Research in India has indicated poor oral health in people with mental disabilities [44].Out of 250 respondents, 30% of them had shallow and deep periodontal pockets, indicat-ing the need for complex periodontal therapy.Angelillo et al. [31] in their research reported 11.1% edentulous persons with mental disabilities, whereas Tang et al. [45] reported 6.6% of edentulous patients.Moraru et al. [41] in their study found that 25% of respondents had complete dentition while 3% were edentulous.In accordance with these findings are the results of Savić-Stanković et al. [39], who reported that only three of 114 respondents had crowns and bridges.These complex dental interventions that require multiple visits can be completed only in special institutions with increased concern and involvement of the therapist as well as family members [46].Another research conducted in Serbia also showed that 20% of psychiatric patients were edentulous [47].
Preventive dental education is the most important treatment strategy against oral and dental diseases in people with mental disabilities.Oral health of these people can be improved by implementing preventive health programs and education in oral health.Every preventive program requires substantial modification to meet requirements of this population [19,48,49].

CONCLUSION
Patients with severe mental disability showed higher DMFT index compared to patients with mild disability.None of respondents had all healthy teeth (PCI=100%).ACI and TCI were also higher in people with severe mental disability than in people with mild disability.Gingival health and oral hygiene were poorer in severely disabled patients then in mildly impaired patients as confirmed by GI and PI.
People with mental disabilities do not have habits, attitudes and behavior towards oral health.It is necessary to organize preventive health education programs to maintain and improve their oral health.

KRATAK SADRŽAJ
Uvod Oral no zdra vlje oso ba ome te nih u men tal nom raz vo ju u Re pu bli ci Srp skoj je na ve o ma ni skom ni vou.Naj ve ći broj ovih oso ba je če sto bez zu ba ili s ma lim bro jem zu ba, s eks ten ziv nim akut nim ka ri je som, vi so kim vred no sti ma in dek sa KEP i iz ra že nim obolje nji ma pot por nog apa ra ta zu ba.Cilj ovog ra da je bio da se utvr di sta nje oral nog zdra vlja oso ba ome te nih u men tal nom raz vo ju ko je ži ve na pod ruč ju op šti ne Ba nja Lu ka.Ma te ri jal i me to de ra da Is tra ži va njem je ob u hva će no 95 is pi ta ni ka (45 žen skog i 50 mu škog po la), sta ro sne do bi od 15 do 45 go di na.Is pi ta ni ci su svr sta ni u dve gru pe pre ma ste pe nu men tal nog ošte će nja, ko je je pre ma De se toj re vi zi ji Me đu na rod ne kla si fika ci je bo le sti svr sta no u ka te go ri je F71 (ume re na du šev na za o sta lost, 65 is pi ta ni ka) i F72 (te ška du šev na za o sta lost, 30 is pi ta ni ka).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, broj iz va đe nih zu ba, po sto ja nje za o sta lih ko re no va, broj frak tu ra, broj fik snih na dok na da, te gin gi val ni i plak in deks.Re zul ta ti Sred nja vred nost in dek sa KEP kod is pi ta ni ka s te škim ste pe nom ome te no sti u men tal nom raz vo ju bi la je ve o ma vi so ka -17,4, dok je kod is pi ta ni ka ume re nog ste pe na du šev ne za o sta lo sti bi la 12,3.Pro seč na vred nost ka ri jes-in dek sa oso be (Kio) bi la je 100%.Pro seč na vred nost ka ri jes-in dek sa zu ba (Kiz) kod te ško ome te nih bo le sni ka bi la je 58,1, a kod onih s ume re nim ste pe nom men tal ne ome te no sti 42,4.Sred nja vred nost ka ri jes-in dek sa pro se ka (Kip) kod oso ba s te škim ste pe nom men tal ne ome te no sti bi la je 16,9, dok je u dru goj gru pi ta vred nost bi la 10,2.Vred nost plak-in dek sa kod te ško ome te nih bi la je 2,4, a kod bo le sni ka ume re ne du šev ne za o sta lo sti 1,9.Vred nost gin gi val nog in dek sa kod is pi ta ni ka s te škim ste pe nom men tal ne ome te no sti bi la je 1,8, a u dru goj gru pi 1,3.Za klju čak Oso be ome te ne u men tal nom raz vo ju ko je ži ve na pod ruč ju op šti ne Ba nja Lu ka ima ju lo še sta nje usta i zu ba.Ove oso be ne ma ju od go va ra ju će zdrav stve ne na vi ke, zna nja i po na ša nje u ve zi s oral nim zdra vljem.Ključ ne re či: oso be ome te ne u men tal nom raz vo ju; ka ri jes; KEP; Kio; Kip; Kiz UVOD Oral no zdra vlje je neo dvo ji vi deo op šteg zdra vlja čo ve ka, a stoma to lo ško zbri nja va nje uop šte, pa i oso ba s te le snim i psi hič kim ošte će nji ma, sa stav ni je deo sve o bu hvat nog me di cin skog zbrinja va nja.Broj oso ba ome te nih u men tal nom raz vo ju se po ve ćava i u su prot no sti je sa ste pe nom raz vo ja zdrav stve ne za šti te.U za vi sno sti od ste pe na men tal ne ome te no sti, oso ba ma ome te nim u men tal nom raz vo ju je ugro že no raz u me va nje, ra su đi va nje i sa mo stal no oba vlja nje sva ko dnev nih ak tiv no sti, pa im je u skladu s tim po treb na ve ća bri ga od stra ne struč nog oso blja [1].Zbog svog hen di ke pa, ove oso be ni su spo sob ne da sa mo stal no bri nu o hi gi je ni usta i zu ba i na od go va ra ju ći na čin odr ža va ju oral nu hi gi je nu.Oso be s te škim ste pe nom po re me ća ja psi ho fizič kog raz vo ja če sto po red men tal nih ima ju i te ške po re me ća je mo to ri ke (te ško po kret ni, pot pu no ne po kret ni), što do dat no ote ža va odr ža va nje oral ne hi gi je ne i oču va nje zdra vlja usne duplje [2].Ne ko li ko stu di ja je za be le ži lo lo še sta nje oral nog zdravlja oso ba ome te nih u men tal nom raz vo ju, a u sto ma to lo škom zbri nja va nju naj če šće je pri mje nji va na eks trak ci ja zu ba [3][4][5][6].
Is tra ži va nja u sve tu i kod nas su po ka za la da ova po pu la ci ja, u po re đe nju s op štom po pu la ci jom, ima vi še eks tra ho va nih zuba, ma nje plom bi ra nih zu ba, vi še ne sa ni ra nih zu ba s ka ri je som, ve ću ras pro stra nje nost obo lje nja pa ro don ci ju ma, znat no ni ži nivo oral ne hi gi je ne i če šću po ja vu su vo će usta, ža re nja i pec ka nja u usnoj du plji, od no sno za da ha iz usta i po re me ća ja ču la uku sa [7,8,9].Is tra ži va nja Nel so na (Nel son) i Van Bla ri ku ma (Van Bla ri cum) [10], ra đe na u Sje di nje nim Ame rič kim Dr ža va ma, po ka za la su da obo le la de ca, po seb no ona s te škim mo tor nim i men tal nim hen di ke pom, uz ra sta 14-15 go di na, ima ju ma nje ka ri je sa u od no su na nji ho ve zdra ve vr šnja ke.Ču (Chu) i sa radni ci [11] su na Taj va nu utvr di li da je pro seč na vred nost in dek sa KEP oso ba ome te nih u men tal nom raz vo ju 13,9.U is tra ži va njima ko ja su ura đe na u Sr bi ji 2004.go di ne utvr đe no je da mental no ome te ne oso be ima ju znat no vi še ne sa ni ra nog ka ri je sa, ma nje plom bi ra nih zu ba i vi še eks tra ho va nih zu ba, dok je sta nje pa ro don ci ju ma bi lo znat no go re u od no su na zdra ve oso be [12].Is tra ži va nja ura đe na u Hr vat skoj 2007.go di ne su po ka za la da su oso be s po te ško ća ma u raz vo ju ima la zna čaj no lo ši ji ni vo oral ne hi gi je ne u po re đe nju sa zdra vim is pi ta ni ci ma [13].
Pra vil no i sva ko dnev no odr ža va nje oral ne hi gi je ne je je dan od naj va žni jih fak to ra pre ven ci je na stan ka obo lje nja usta i zuba, a nje no neo dr ža va nje zna ča jan pred u slov raz vo ja, ali i br zog na pre do va nja ovih obo lje nja usled već na ru še nog oral nog zdravlja ovih oso ba [14,15].Osim to ga, ovi pa ci jen ti če sto uzi ma ju i dru ge le ko ve, ko ji ta ko đe mo gu da uti ču na nji ho vo oral no zdra vlje (sma nju ju lu če nje plju vač ke, iza zi va ju za pa lje nje de sni, do vo de do re sorp ci je ko sti ju i po ja ve pa ra don to pa ti je) i ti me dodat no po gor ša va ju svo je oral no sta nje [16].U ve ći ni slu ča je va s ta kvim pa ci jen ti ma se vr lo te ško us po sta vlja kon takt (po ne kad je ne mo gu će po sti ći ga), pa im je ne kad te ško i po mo ći osim in ter ven ci jom u op štoj ane ste zi ji.Iz vo đe nje ova kve in ter ven ci je obič no zah te va ve li ko an ga žo va nje ti ma le ka ra i po seb ne uslo ve, a če sto se mo že re a li zo va ti sa mo u ve li kim cen tri ma, te su oso be iz ma njih i ne raz vi je nih sre di na u ozbilj nom pro ble mu [17].
Cilj ovog ra da je bio da se utvr di sta nje oral nog zdra vlja osoba ome te nih u men tal nom raz vo ju na pod ruč ju op šti ne Ba nja Lu ka.

MATERIJAL I METODE RADA
U is tra ži va nje je uklju če no 95 is pi ta ni ka ome te nih u men tal nom raz vo ju sta ro sne do bi od 15 do 45 go di na.Ono je ob u hva ti lo oso be ko je ži ve kod ro di te lja, od no sno sta ra te lja i oso be sme štene u spe ci ja li zo va nim usta no va ma (Cen tar "Za šti ti me" u Ba njoj Lu ci i Za vod za fi zi kal nu me di ci nu i re ha bi li ta ci ju "Dr Mi ro slav Zo to vić" u Be o gra du).Is pi ta ni ci su, pre ma ste pe nu men tal nog ošte će nja, na osno vu De se te re vi zi je Me đu na rod ne kla si fi kaci je bo le sti (MKB-10) [18], svr sta ni u dve gru pe.Pr vu gru pu či ni lo je 65 is pi ta ni ka sa di jag no zom F71 (ume re na du šev na za o sta lost), a dru gu 30 is pi ta ni ka sa di jag no zom F72 (te ška dušev na za o sta lost).Is tra ži va nje je ob u hva ti lo 45 oso ba žen skog i 50 oso ba mu škog po la.Sta nje zu ba je utvr đe no na Kli ni ci za mak si lo fa ci jal nu hi rur gi ju Kli nič kog cen tra u Ba njoj Lu ci, gde je ura đe na i sa na ci ja zu ba ovih bo le sni ka.Za pre gled su ko ri šće ni sto ma to lo ško ogle dal ce, son da i ve štač ko osve tlje nje u skla du s uput stvi ma Svet ske zdrav stve ne or ga ni za ci je [19].Pri pre gle du je po pu njen sto ma to lo ški kar ton (broj zu ba, po sto ja nje ka ri jesa, po sto ja nje is pu na, broj iz va đe nih zu ba, za o sta li ko re no vi u vi li ca ma i even tu al no po sto ja nje pro te tič kih na dok na da).Za pro ce nu sta nja zu ba pri me njen je in deks KEP.Za pro ce nu sta nja gin gi ve ko ri šćen je gin gi val ni in deks po Lou-Sil ne su (Löe-Sil nes), a pri su stvo den tal nog pla ka je utvr đe no pri me nom in dek sa po Sil nes-Lou (Sil nes-Löe).Svi ro di te lji, od no sno sta ra te lji bi li su upo zna ti sa svr hom is tra ži va nja i svo jim pot pi som su po tvrdi li pri sta nak za uče šće bo le sni ka u ovom is pi ti va nju.
Svi do bi je ni po da ci su ob ra đe ni stan dard nim de skrip tiv nim i kom pa ra tiv nim sta ti stič kim me to da ma.U okvi ru de skrip tiv ne sta ti sti ke od re đe na je sred nja vred nost sa stan dard nom de vija ci jom, a u okvi ru kom pa ra tiv ne sta ti sti ke pri me nje ni su Kraskal-Vo li sov (Kru skal-Wal lis) test, Stu den tov t-test i χ 2 -test.
Eks tra ho va nih zu ba kod is pi ta ni ka s te škim ste pe nom mental ne ome te no sti bi lo je 2,1, a u dru goj gru pi is pi ta ni ka 0,8 (Tabe la 2).I ova raz li ka je bi la sta ti stič ki zna čaj na (p<0,02).
Ana li za do bi je nih po da ta ka je po ka za la da je kod osoba ume re nog ste pe na men tal ne ome te no sti sred nja vred nost plom bi ra nih zu ba bi la 1,4, a kod oso ba s te škim ste pe nom 1,5 (Ta be la 2).Ova raz li ka ni je bi la sta ti stič ki zna čaj na (p<0,173).
Sred nja vred nost in dek sa KEP kod oso ba s te škim ste pe nom men tal ne ome te no sti bi la je 17,4, a u gru pi is pi ta ni ka ume re nog ste pe na 12,3 (Ta be la 2).Ova raz li ka je bi la vi so ko sta ti stič ki zna čaj na (p<0,001).
Pro seč na vred nost ka ri jes-in deksa oso be (Kio) bi la je 100% i kod is pi ta ni ka s te škim i kod onih s ume re nim ste pe nom omete no sti u men tal nom raz vo ju (Ta be la 3).

DISKUSIJA
Lo še sta nje usta i zu ba du šev no za o sta lih oso ba uglav nom je oče ki va no zbog te škog op šteg sta nja ovih bo le sni ka, ali i če stog za ne ma ri va nja ovog aspek ta nji ho vog zdra vlja.Oso be ome te ne u men tal nom raz vo ju ni su spo sob ne da sa mo stal no bri nu o pravil noj hi gi je ni usta i zu ba, što se vre me nom od ra ža va i na op šte sta nje nji ho vog oral nog zdra vlja.Pro blem odr ža va nja oral ne hi gi je ne po sle di ca je sma nje nog raz u me va nja ili ne mo guć no sti da raz u me ju i pra te uput stva i sa ve te u ve zi s me ra ma pre venci je [2].Ovi bo le sni ci naj če šće ima ju ogra ni čen pri stup sto mato lo škom le če nju zbog uz ne mi re no sti (strah od sto ma to lo ške in ter ven ci je), ali i ne do stat ka fi nan sij skih sred sta va ko ji ma bi ro di te lji ili sta ra te lji pla ća li uslu ge sto ma to lo ga.Osim to ga, nepo sto ja nje dr žav nog si ste ma ži vot nog osi gu ra nja ko ji bi po krio sto ma to lo ške uslu ge, od no sno ne do vo ljan broj sto ma to lo ga ko ji su sprem ni da pru že ne gu ovoj vr lo ra nji voj po pu la ci ji, ta ko đe su zna ča jan pro blem u zbri nja va nju [20,21].
Je dan od fak to ra ko ji uti če na op šte sta nje oral nog zdra vlja ovih bo le sni ka je ste i mo guć nost re a li za ci je te ra pij skih po stupka.Da li će se ona oba vi ti na kon ven ci o na lan na čin (lak ši ob li ci hen di ke pa, krat ke i jed no stav ne sto ma to lo ške in ter ven ci je), u se da ci ji (ote ža na sa rad nja, du že sto ma to lo ške in ter ven ci je) ili op štoj ane ste zi ji (iz o sta nak sa rad nje, ve ći broj za hva ta i slo ženi je sto ma to lo ške in ter ven ci je) umnogome za vi si od men tal nog sta nja i mo guć no sti ko mu ni ka ci je te ra pe u ta s ovom gru pom pa ci je na ta [22].
Re zul ta ti na šeg is tra ži va nja po ka zu ju da je broj zu ba za hvaće nih ka ri je som kod oso ba s te škim ste pe nom men tal ne omete no sti (13,8) bio ne što ve ći ne go kod oso ba ume re nog ste pe na (10,1).Ta ko đe je bi lo vi še eks tra ho va nih zu ba (2,1 pre ma 0,8).Ana li za do bi je nih po da ta ka je po ka za la da je kod oso ba ume renog ste pe na men tal ne ome te no sti sred nja vred nost plom bi ra nih zu ba bi la ne što ma nja ne go kod te že obo le lih is pi ta ni ka (1,4 pre ma 1,5).Ve li ka raz li ka u bro ju ka ri o znih i eks tra ho va nih zu ba u od no su na ste pen men tal ne ome te no sti ob ja šnja va se či nje ni com da oso be s te škim ste pe nom za o sta lo sti te že usva ja ju i uče pra vil nu teh ni ku odr ža va nja oral ne hi gi je ne.Kod njih je vi še ugro že no raz u me va nje, ra su đi va nje i sa mo stal no oba vljanje sva ko dnev nih ak tiv no sti, pa im je u skla du s tim po tre ban i ve ći ste pen bri ge od stra ne struč nog oso blja, od no sno zah te va ju tu đu ne gu [1].
Is tra ži va nja ne kih auto ra po ka zu ju da ove oso be ima ju veću pre va len ci ju ka ri je sa u po re đe nju sa zdra vim is pi ta ni ci ma [8,23], a da su pa ro don tal na obo lje nja ve o ma iz ra že na usled neo dr ža va nja oral ne hi gi je ne [24].Me đu tim, ima i na la za ko ji po ka zu ju da je pre va len ci ja ka ri je sa slič na kod zdra vih i du ševno za o sta lih oso ba [25].Oso be ome te ne u men tal nom raz vo ju, na ro či to one s te škim ste pe nom za o sta lo sti, ni su spo sob ne da sa mo stal no bri nu o hi gi je ni usta i zu ba i na ade kva tan na čin odr ža va ju oral nu hi gi je nu.Oso be s te škim ste pe nom po re meća ja psi ho fi zič kog raz vo ja če sto po red men tal nih ima ju i te že po re me ća je mo to ri ke (te ško su po kret ni ili ne po kret ni) [2], što do dat no ote ža va odr ža va nje oral ne hi gi je ne i oču va nje zdra vlja usne du plje.Is tra ži va nja Mi le ra (Mil ler) i Tej lo ra (Taylor) [24] po ka za la su da fi zič ki hen di ke pi ra ne oso be ima ju vi še ka ri je sa od men tal no hen di ke pi ra nih.To su ob ja sni li nji ho vim fi zič kim ošte će njem i sla bi jom mo guć no šću odr ža va nja hi gi je ne usta i zu ba.
Re zul ta ti na šeg is tra ži va nja po ka zu ju da je kod is pi ta ni ka s te škim ste pe nom ome te no sti u men tal nom raz vo ju sred nja vred nost in dek sa KEP bi la ve o ma vi so ka (17,4), dok je kod ispi ta ni ka ume re nog ste pe na za o sta lo sti bi la 12,3.Vi so ka sred nja vred nost in dek sa KEP uka zu je na lo še sta nje oral nog zdra vlja ovih bo le sni ka ko je ni je uzro ko va no sa mo nji ho vom ne mo gućno šću odr ža va nja oral ne hi gi je ne, već i neo d go va ra ju ćom i nedo volj nom sto ma to lo škom za šti tom [23].
Pro seč na vred nost Kio kod svih is pi ta ni ka na še stu di je bi la je 100%, što zna či da od 95 is pi ta ni ka ni je dan ni je imao zdra ve zu be.Pro seč na vred nost Kiz kod is pi ta ni ka s te škom du šev nom za o sta lo šću bi la je ve ća ne go kod is pi ta ni ka dru ge gru pe (58,1 pre ma 42,4).Pro seč na vred nost Kip ta ko đe je bi la ve ća kod ovih bo le sni ka ne go kod is pi ta ni ka ume re ne du šev ne za o stalo sti (16,9 pre ma 10,2).U skla du s ovim re zul ta ti ma su i po da ci iz li te ra tu re, ko ji go vo re da su vred no sti in dek sa KEP kod ovih bo le sni ka na Taj va nu bi le 14,9 [26], a u Austra li ji 14,6 [27].Kenkre (Ken kre) i sa rad ni ci [28] su u svo jim is tra ži va nji ma u In di ji do bi li vred no sti in dek sa KEP od 12,8.Pe ze men ti (Pez ze men ti) i Fi še ro va (Fis her) [29] su ura di li slič no is tra ži va nje u SAD i do bi li vred no sti in dek sa KEP od 13,6.U za pad no e vrop skim zemlja ma te vred no sti su bile ne što ve će (15,85), što ne dvo smi sleno upu ću je na to da, osim sa mog si ste ma zdrav stve ne za šti te, i raz voj ze mlje, od no sno re gi o na mo že bi ti zna ča jan fak tor sta nja oral nog zdra vlja bo le sni ka [30].
Re zul ta ti na šeg is tra ži va nja sa gla sni su s re zul ta ti ma studi je An dže li la (An ge lil lo) i sa rad ni ka [31], ko ja je ura đe na u Ita li ji, gde je sred nja vred nost in dek sa KEP bi la 15,5.Sli čan na laz po ka zu ju i is tra ži va nja Lu i sa (Le wis) i sa rad ni ka [32] u Ve li koj Bri ta ni ji, gde je pro seč na vred nost in dek sa KEP oso ba ome te nih u men tal nom raz vo ju bi la 17,1.Mor gan (Mor gan) i sa rad ni ci [33] su u SAD, u stu di ji ko ja je ob u hva ta la 4.732 od ra sla is pi ta ni ka ome te na u men tal nom raz vo ju, utvr di li da je sred nja vred nost ovog in dek sa 13,9, što je ta ko đe u skla du s na šim re zul ta ti ma.Da je lo še sta nje usta i zu ba oso ba ome te nih u men tal nom raz vo ju po tvr đu ju i na la zi iz Špa ni je, gde su Va lesko (Va le sco) i sa rad ni ci [34] u svo jim is tra ži va nji ma utvr di li da je sred nja vred nost in dek sa KEP kod ovih oso ba 24,99.Slič ne na la ze do bi li su u Izra e lu Ra mon (Ra mon) i sa rad ni ci [35], u či jem je is tra ži va nju sred nja vred nost in dek sa KEP kod oso ba ome te nih u men tal nom raz vo ju bi la 26,74, kao i Zu sman (Zu sman) i sa rad ni ci [36], ko ji su do bi li vred no sti od 23,8.
Is tra ži va nje ura đe no u Bo sni i Her ce go vi ni 2009.go di ne obu hva ti lo je 70 že na sta rih iz me đu 30 i 55 go di na ko je su bi le sme šte ne u Do mu za men tal no hen di ke pi ra ne oso be u Vi še gra-du [37].Ve o ma lo še sta nje oral nog zdra vlja za be le že no je kod 90% is pi ta ni ca, kod 4,3% že na sta nje je bi lo za do vo lja va ju će, a kod 5,7% ni je bi lo mo gu će ura di ti pre gled.Is tra ži va nje ura đe no u Sr bi ji, gde je pre gle da no 114 is pi ta ni ka ome te nih u men talnom raz vo ju sta ro sne do bi od 22 do 71 go di ne, po ka za lo je loš na laz in dek sa KEP kod njih (20,95) [38].Utvr đe no je naj vi še eks tra ho va nih zu ba (63,76%), zu ba za hva će nih ka ri je som bi lo je 33,48%, dok je naj ma nje bi lo plom bi ra nih zu ba (2,76%).
Pre ma re zul ta ti ma broj nih stu di ja, ve li ki uti caj na po ve ća nu in ci den ci ju ka ri je sa kod ovih bo le sni ka ima i ne pra vil na is hrana [39].U pri log to me go vo re i re zul ta ti is tra ži va nja Sten filda (Stan fi eld) [40], ko ji je za klju čio da je po ve ća na in ci den ci ja ka ri je sa kod oso ba ome te nih u men tal nom raz vo ju po sle di ca pre te ra nog je de nja hra ne bo ga te še će rom.
Re zul ta ti na šeg is tra ži va nja su po ka za li da du šev no za o sta le oso be ima ju lo še na vi ke u po gle du odr ža va nja oral ne hi gi je ne.Me đu 95 is pi ta ni ka ni je bi lo ni jed nog bez den tal nog pla ka.Proseč na vred nost PI bi la je 2,1, a naj vi še bo le sni ka ima lo je umere nu ko li či nu den tal nog pla ka (56,8%).Pro seč na vred nost GI bi la je 1,5.Zdra va gin gi va utvr đe na je kod sve ga 4% is pi ta ni ka, a naj vi še ih je ima lo ume re nu in fla ma ci ju (52%), što uka zu je na ni zak ni vo odr ža va nja oral ne hi gi je ne.Na ša za pa ža nja su u skla du s na la zi ma Ru mun ke Mo ra ru o ve (Mo ra ru) i nje nih sa rad ni ka [41], ko ji su za be le ži li plak kod 90% is pi ta ni ka, ka menac kod 80%, dok je sve ga 3% is pi ta ni ka ima lo zdrav pa ro dont.Čak 97% njih ima lo je gin gi vi tis, 53% su pra gin gi val ne kon kremen te, 36% sub gin gi val ne kon kre men te i 11% sub gin gi val ni i oklu zal ni ka me nac.
Stu di ja Me kri di ja (McCre a die) i sa rad ni ka [42] u Ve li koj Bri ta ni ji po ka za la je da je 75% ho spi ta li zo va nih oso ba sa shi zofre ni jom re dov no odr ža va lo hi gi je nu usta i zu ba.He de (He de) [43] je u svom is tra ži vač kom ra du po ka zao da sa mo 55% lju di s psi hi ja trij skim po re me ća ji ma ko ji bo ra ve u bol ni ci re dovno pe re zu be.Is tra ži va nja ura đe na u In di ji uka zu ju na lo še oral no zdra vlje oso ba ome te nih u men tal nom raz vo ju [44].Na i me, od 250 is pi ta nih bo le sni ka, kod 30% su usta no vlje ni plit ki i du bo ki pa ro don tal ni dže po vi, što uka zu je na po tre bu za kom plek snom pa ro don tal nom te ra pi jom.An dže li lo i sa rad ni ci [31] su u svo jim is tra ži va nji ma uka za li na 11,1% be zu bih osoba ome te nih u men tal nom raz vo ju, dok ih je u is tra ži va nji ma Tan ga (Tang) i sa rad ni ka [45] bi lo 6,6%.Mo ra ru o va i sa rad ni ci [41] su u svo joj stu di ji uoči li da je 25% is pi ta ni ka ima lo pu nu den ti ci ju, dok je 3% bi lo bez zu ba.U skla du s ovim na la zi ma su i re zul ta ti Sa vi će ve i sa rad ni ka [39], ko ji na vo de da su sa mo tri is pi ta ni ka od 114 ima la fik sne na dok na de.Na i me, ova ko slo že na sto ma to lo ška in ter ven ci ja, ko ja zah te va vi še po se ta stoma to lo gu, mo gu ća je sa mo u po seb noj usta no vi i uz po ve ća nu bri gu i an ga žo va nje te ra pe u ta i čla no va po ro di ce [46].Is tra živa nja ra đe na u Sr bi ji isto ta ko po ka zu ju da 20% psi hi ja trij skih bo le sni ka ne ma zu be [47].
Pre ven tiv na sto ma to lo ška edu ka ci ja je osno va stra te gi je leče nja bo le sti usta i zu ba oso ba ome te nih u men tal nom raz vo ju.Nji ho vo oral no zdra vlje se mo že po bolj ša ti pre ven tiv nim sto mato lo škim pro gra mi ma i edu ka ci jom u obla sti oral ne zdrav stve ne za šti te.Ali sva ki pre ven tiv ni pro gram za una pre đe nje oral nog zdra vlja u ovoj obla sti zah te va mo di fi ka ci ju u zna čaj nom stepe nu, ka ko bi se mo gao pri la go di ti po tre ba ma ove po pu la ci je [19,48,49].

ZAKLJUČAK
Kod bo le sni ka s te škom du šev nom za o sta lo šću usta no vlje ne su ve će vred no sti in dek sa KEP u po re đe nju sa is pi ta ni ci ma ume re nog ošte će nja u men tal nom raz vo ju.Ni je dan is pi ta nik ni je imao sve zdra ve zu be (Kio=100%).Vred no sti Kip i Kiz su ta ko đe bi le ve će kod oso ba s te žim ste pe nom ome te no sti u men tal nom raz vo ju ne go kod oso ba sa bla gim in va li di te-tom.Zdra vlje gin gi ve i oral na hi gi je na su isto ta ko bi li lo ši ji kod njih ne go kog ume re no hen di ke pi ra nih, što po tvr đu ju i vred nost GI i PI.
Oso be ome te ne u men tal nom raz vo ju ne ma ju od go va ra ju će zdrav stve ne na vi ke, zna nja i po na ša nje u ve zi s oral nim zdravljem.Neo p hod no je or ga ni zo va ti pre ven tiv ne zdrav stve no vaspit ne pro gra me, ka ko bi se po bolj ša lo, oču va lo i una pre di lo nji ho vo oral no zdra vlje.

Table 2 .
DMFT index and degree of mental disability in adult re-