Background
Methods
Searches
Inclusion criteria
Study selection
Data extraction
Data extracted
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Study characteristics (title, reference, author(s) and year of publication);
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○ Methodology (Characteristics of data collection (e.g. data collectors, part of a regular epidemiological programme etc.); caries data collection system, and threshold for caries diagnosis (e.g. D2, D3 etc.);
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Year of data collection;
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Participant inclusion and exclusion criteria;
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Participant demographic information:
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○ Age groups were recorded. As the upper age limit for childhood varies geographically and between cultures, all groups were included up to the age of 19. Note was taken of the age group and range included in each study; and
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○ The type of disability was recorded as reported and decisions made around the appropriateness of grouping different disabilities together.
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○ Number of participants and whether or not a sample size was calculated.
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○ Study setting (country, region, national/ local/ international, and clinical setting).
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Outcome data for caries levels; and CI and RI.
Data synthesis and meta-analysis
Risk of bias assessment (ROB)
Results
Searching/ screening results
Study | Reason for Exclusion |
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Areias et al., 2011 [34] | No quantifiable measure of DMFT/dmft - descriptive only. |
Altun et al. 2010 [35] | Included children with physical disabilities as well as learning disabilities and data could not be separated. |
Areias et al., 2012 [36] | This seems to be the same group or a repeat study dataset of Areias et al., 2013. This was not clear as it’s not detailed in the paper, but it included the same population of exactly the same age. DMFT and dmft were different but because of duplicate sampling, even if not the same dataset, we excluded. |
Chadha et al., 2012 [37] | No comparison group |
Bakarcic et al., 2009 [38] | Not all children in the study population have a learning disability |
Fahlvik-Planefeldt et al., 2001 [39] | Index for caries recording/detection system not specified, no DMFT/dmft data |
Fuertes-Gonzales et al., 2014 [40] | This study included adults (age range 2–37 years) and did not allow for extraction of age groups. |
Fung et al., 2008 [41] | Data collection through questionnaire (no clinical examination carried out) |
Lowe et al., 1985 [42] | This study included adults (age range 3–30 years) and did not allow for extraction of age groups. |
Macho et al., 2013 [43] | This study included adults (age range 2–26 years) and did not allow for extraction of age groups. |
Mattila et al., 2001 [44] | No learning disabled children in the study population. |
Oredugba et al., 2007 [45] | This study included adults and did not allow for extraction of age groups for DMFT/dmft indices |
Pollard et al., 1992 [46] | No learning disabled children in the study population. |
Purohit et al., 2010 [47] | Not all children in the study population have a learning disability |
Radha et al., 2016 [48] | Errors in study authors’ conclusions from dataset: Table 10 shows CLD to have a lower caries experience than CNLD group, however the discussion and conclusion sections state the opposite to be true. |
Rai et al., 2012 [50] | Index for caries recording/detection system not specified, no DMFT/dmft data |
Rekha et al. 2012 [51] | No DMFT/dmft data given, only caries prevalence |
Ruiz et al., 2018 [52] | This study included adults (age range 4–20 years) and did not allow for extraction of age groups. |
Sarnat et al., 2016 [53] | Index for caries recording/detection system not specified, no DMFT/dmft data |
Shaw et al., 1985 [54] | Dataset includes disabled children from a very wide group also no consistency between children’s ages in the study group and control group. |
Suhaib et al., 2017 [55] | No quantifiable measure of DMFT/dmft - descriptive only. |
Subramanium et al., 2011 [56] | No comparison group |
Weckwerth et al., 2016 [57] | Errors in study authors’ conclusions from dataset calculations; Table 1 demonstrates incorrect results for the CI calculations in the permanent dentition for both groups 1 and 2. |
Study characteristics
Study designs and sampling
Study settings
Disability status and subgrouping
Non-participation and representativeness of participating groups
Caries assessment; examiners, recording indices and thresholds
Size of participant groups
All learning disability groups (n = 20 studies with DMFT data and 16 with SD data) | |||||||||
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Study | Number of participants | Ages | DMFT data | ||||||
CLD | CNLD | CLD DMFT (sd) | CNLD DMFT (sd) | CLD CIa | CNLD CIa | CLD RIb | CNLD RIb | ||
Total for all 3 Groups | 1819 | 2157 | 1–18 | ||||||
Mean (sd) | 72.76 (±47.31) | 86.28 (±64.56) | 2.31 (±1.97) | 2.51 (±2.14) | 0.12 (±0.12) | 0.18 (±0.27) | 0.15 (±0.14) | 0.28 (±0.33) |
Down syndrome (permanent teeth; n = 11 studies) | ||||||||||
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Study | Number of participants | Ages | DMFT data | |||||||
CLD | CNLD | CLD DMFT (sd) | CNLD DMFT (sd) | CLD CI | CND CI | CLD RI | CNLD RI | Reason no DMFT data included | ||
Al Habashneh 2012 [15] | 103 | 103 | 12–16 | 3.32 (3.77) | 4.59 (4.21) | |||||
AlSarheed 2015 [17] | 93 | 99 | 7–15 | 2.66 (3.09) | 3.11 (2.58) | 0.18 | 0.18 | 0.22 | 0.19 | |
Areias 2013 [18] | 45 | 45 | 6–18 | 1.02 (2.42) | 1.84 (3.13) | 0.16 | 0.02 | 0.27 | 0.04 | |
Cogulu 2006 [65] | 73 | 70 | 7–12 | 0.92 | 4.26 | |||||
86 | 86 | 10–13 | 1.30 (0.30) | 1.70 (0.40) | ||||||
Davidovich 2010 [21] | 70 | 32 | 1–9 | 3.37 (0.56) | 5.90 (0.8) | |||||
Hashizume 2017 [25] | 61 | 52 | 6–14 | 0.36 (1.00) | 0.40 (0.92) | |||||
Lee 2004 [61] | 19 | 41 | 8–17 | DMFS only | ||||||
Mathias 2011 [27] | 69 | 69 | 1–7 | 2.20 (6.30) | 3.40 (8.10) | |||||
Stabholz 1991 [63] | 32 | 30 | 8–13 | DMFS only | ||||||
Subramaniam 2014 [29] | 34 | 34 | 7–12 | 1.68 (0.69) | 1.84 (1.12) | |||||
Subgroup Total | 685 | 661 | ||||||||
Mean (sd) | 62.27 (±26.97) | 60.09 (±26.90) | 1.87 (±1.08) | 2.49 (±1.42) |
Participant ages
Autism (permanent teeth; n = 8 studies) | ||||||||||
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Study | Number of participants | Ages | DMFT data | |||||||
CLD | CNLD | CLD DMFT (sd) | CNLD DMFT (sd) | CLD CI | CNLD CI | CLD RI | CNLD RI | Reason no DMFT data included | ||
Al-Maweri 2014 [16] | 42 | 84 | 5–16 | 2.00 (2.18) | 1.27 (1.77) | 0 | 0.02 | 0.04 | 0.03 | |
Bhandary 2017 [19] | 30 | 30 | 6–12 | 0.37 (0.62) | 0.37 (0.56) | 0 | 0.19 | 0 | 0.35 | |
Du 2014 [49] | 257 | 257 | 3–7 | 0.10 | 0.09 | 0.11 | 0.09 | dmfs only | ||
El Khatib 2014 [22] | 100 | 100 | 3–13 | 3.40 (4.54) | 3.50 (3.63) | |||||
Fakroon 2014 [23] | 50 | 50 | 3–14 | 0.22 (0.08) | 1.15 (0.27) | 0.1 | 0.06 | 0.1 | 0.07 | |
Jaber 2011 [26] | 61 | 61 | 6–16 | 1.60 (0.64) | 0.60 (0.29) | |||||
Namal 2007 [58] | 62 | 301 | 7–12 | 1.74 | 2.41 | 0.04 | 0.06 | 0.05 | 0.06 | |
Yashoda 2014 [30] | 135 | 135 | 4–15 | 0.86 (1.22) | 0.46 (1.06) | |||||
Subgroup Total | 737 | 1018 | ||||||||
Mean (sd) | 92.13 (±74.74) | 127.25 (±99.65) | 1.10 (±0.69) | 1.01 (±0.70) |
Mixed Learning Disability Groups (permanent teeth; n = 6 studies) | ||||||||||
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Study | Number of participants | Ages | DMFT data | |||||||
CLD | CNLD | CLD DMFT (sd) | CNLD DMFT (sd) | CLD CI | CND CI | CLD RI | CNLD RI | Reason no DMFT data included | ||
33 | 53 | 3–13 | 0.12 | 0.84 | DFT only | |||||
Forsberg 1985 [24] | 100 | 103 | 12–17 | 7.20 (6.10) | 9.00 (4.00) | |||||
Jokic 2007 [59] | 80 | 80 | 3–17 | 6.39 | 4.76 | |||||
Moreira 2012 [28] | 76 | 89 | mean 8.9 | 5.20 (5.75) | 1.50 (2.10) | |||||
Palin 1982 [60] | 58 | 58 | 9–10 | no M or DMFS | ||||||
Pope 1991 [62] | 50 | 95 | 3–18 | 2.94 | 2.27 | 0.36 | 0.82 | 0.43 | 0.82 | |
Subgroup Total | 397 | 478 | ||||||||
Mean (sd) | 66.17 (±23.92) | 79.67 (±20.24) | 5.43 (±1.85) | 5.20 (±2.79) |
All learning disability subgroups (primary teeth; n = 9 studies with dmft data) | |||||||||
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Study | Number of participants | Ages | dmft/deft data | ||||||
CLD | CNLD | CLD dmft / deft (sd) | CNLD dmft / deft (sd) | CLD CIa (sd) | CNLD CIa (sd) | CLD RIa (sd) | CNLD RIa (sd) | ||
Total for all 3 Groups | 1819 | 2157 | |||||||
Mean (sd) | 72.76 (±47.31) | 86.28 (±64.56) | 2.34 (±1.37) | 2.25 (±1.39) | 0.15 (±0.14) | 0.06 (0.06) | 0.15 (±0.14) | 0.04 (±0.01) |
Down syndrome (primary teeth; n = 11 studies) | ||||||||||
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Study | Number of participants | Ages | dmft/deft data | |||||||
CLD | CNLD | CLD dmft / deft (sd) | CNLD dmft / deft (sd) | CLD CI | CNLD CI | CLD RI | CNLD RI | Reason no DMFT data included | ||
Al Habashneh 2012 [15] | 103 | 103 | 12–16 | No dmft/deft data | ||||||
AlSarheed 2015 [17] | 93 | 99 | 7–15 | No dmft/deft data | ||||||
Areias 2013 [18] | 45 | 45 | 6–18 | No dmft/deft data | ||||||
Cogulu 2006 [65] | 73 | 70 | 7–12 | No dmft/deft data | ||||||
86 | 86 | 7–9 | 2.40 (0.60) | 1.70 (0.30) | ||||||
Davidovich 2010 [21] | 70 | 32 | 1–9 | No dmft/deft data | ||||||
Hashizume 2017 [25] | 61 | 52 | 6–14 | 1.84 (3.67) | 0.98 (1.39) | |||||
Lee 2004 [61] | 19 | 41 | 8–17 | No dmft/deft data | ||||||
Mathias 2011 [27] | 69 | 69 | 1–7 | No dmft/deft data | ||||||
Stabholz 1991 [63] | 32 | 30 | 8–13 | No dmft/deft data | ||||||
Subramaniam 2014 [29] | 34 | 34 | 7–12 | 2.69 (1.62) | 2.90 (1.60) | |||||
Subgroup Total | 685 | 661 | ||||||||
Mean (sd) | 62.27 (±26.97) | 60.09 (±26.90) | 2.31 (±0.43) | 1.86 (±0.97) |
Autism (primary teeth; n = 8 studies) | ||||||||||
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Study | Number of participants | Ages | dmft/deft data | |||||||
CLD | CNLD | CLD dmft / deft (sd) | CNLD dmft / deft (sd) | CLD CI | CNLD CI | CLD RI | CNLD RI | Reason no DMFT data included | ||
Al-Maweri 2014 [16] | 42 | 84 | 5–16 | 5.23 (2.34) | 4.06 (2.98) | 0.05 | 0.10 | |||
Bhandary 2017 [19] | 30 | 30 | 6–12 | No dmft/deft data | ||||||
Du 2014 [49] | 257 | 257 | 3–7 | No dmft/deft data | ||||||
El Khatib 2014 [22] | 100 | 100 | 3–13 | 3.53 (4.57) | 3.56 (3.86) | |||||
Fakroon 2014 [23] | 50 | 50 | 3–14 | 1.13 (1.84) | 2.85 (3.32) | 0.25 | 0.02 | 0.25 | 0.03 | |
Jaber 2011 [26] | 61 | 61 | 6–16 | 0.80 (0.20) | 0.30 (0.30) | |||||
Namal 2007 [58] | 62 | 301 | 7–12 | No dmft/deft data | ||||||
Yashoda 2014 [30] | 135 | 135 | 4–15 | 0.40 (2.48) | 0.59 (1.28) | |||||
Subgroup Total | 737 | 1018 | ||||||||
Mean (sd) | 92.13 (±74.74) | 127.25 (±99.65) | 2.42 (±1.90) | 2.27 (±1.73) |
Mixed Learning Disability Groups (primary teeth; n = 6 studies) | ||||||||||
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Study | Number of participants | Ages | dmft/deft data | |||||||
CLD | CNLD | CLD dmft / deft (sd) | CNLD dmft / deft (sd) | CLD CI | CNLD CI | CLD RI | CNLD RI | Reason no DMFT data included | ||
33 | 53 | 3–13 | 0.05 | 0.04 | No dmft/deft data | |||||
Forsberg 1985 [24] | 100 | 103 | 3–11 | 2.00 (2.90) | 3.30 (2.80) | |||||
Jokic 2007 [59] | 80 | 80 | 3–17 | No dmft/deft data | ||||||
Moreina 2012 [28] | 76 | 89 | mean 8.9 | No dmft/deft data | ||||||
Palin 1982 [60] | 58 | 58 | 9–10 | No dmft/deft data | ||||||
Pope 1991 [62] | 50 | 95 | 3–18 | No dmft/deft data | ||||||
Subgroup Total | 397 | 478 | ||||||||
Mean (sd) | 66.17 (±23.92) | 79.67 (±20.24) | 2.00 | 3.30 |
Caries experience in the permanent teeth for CLD compared to CNLD (DMFT)
Caries experience in the primary dentition for CLD compared to CNLD (dmft)
Care, and restorative indices (permanent teeth)
Care index and restorative index (primary teeth)
Narrative reports of unmet dental need
Study | Disability for CLD group | Relative level of unmet dental need in CLD compared with CNLD | Narrative text on dental care provided for caries |
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Down | Higher for CLD | DS children receive less treatment of the deciduous dentition - this may be due to the delay in eruption of the teeth when examined alongside non-DS children of a similar age. | |
El Khatib 2014 [22] | Autism | Higher for CLD | In the primary dentition, children with ASD had more untreated caries. In the mixed stage, ASD children with ASD had less filled teeth than children without ASD. |
Jaber 2011 [26] | Autism | Higher for CLD | Autistic children receive 60% less treatment. |
Palin 1982 [60] | Range of conditions | Higher for CLD | In comparison with the healthy, the retarded children are not given enough dental care with respect to their treatment need. |
Stabholz 1991 [63] | Down | Higher for CLD | Authors hypothesise that because treating those with DS and MR (institutionalised) is more expensive, more complex and requires more specialised personnel, only a small proportion of their needs are met. |
Forsberg 1985 [24] | Range of conditions | Lower for CLD | The severely mentally retarded children had been offered dental care to the same extent as healthy children |
Quality assessment
Assessment of publication bias
Discussion
Conclusions
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1. Overall, there was no evidence that children with learning disabilities have different levels of dental caries in their permanent or primary dentition, to children without learning disabilities.
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2. When the types of disabilities were separated out, there was evidence of lower levels of dental caries in children with Down syndrome in the permanent dentition, however, this could be linked to delayed tooth eruption. There was no evidence of a difference for children with autism or mixed learning disabilities.
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3. There is some evidence of a difference in the amount and type of dental care provided for CLD based on quantitative (using the care and restorative indices) and narrative data, but this is sparse and this area should be strengthened by better reporting of datasets.