Oral Health Status, Oral Health Behaviors, and Oral Health Care Utilization among Persons with Disabilities in Saudi Arabia

Various studies have indicated that persons with special needs may face several barriers to dental treatment, which increases the prevalence of oral diseases in this population. Moreover, these studies suggested that Saudis with special needs have a higher prevalence of oral diseases, such as dental caries and periodontal disease. The aim of this review is to synthesize evidence regarding the current status, trends in oral health behaviors, and oral health care utilization among these individuals, as well as to assess the quality of the literature. Furthermore, this review seeks to recommend directions for future research and oral health care policymaking. An electronic search was conducted using the following databases and registers: PubMed/Medline, Embase, ISI Web of Science, Scopus, ClinicalTrials.gov, and CENTRAL. Gray literature, which included conference proceedings and unpublished literature, was searched via the library services and Google/Google Scholar, and the quality of studies was assessed using the AXIS scale for cross-sectional studies. A total of 38 studies were included in this review, with the majority of the studies graded as ‘low’. Within the limitations of this study, it can be concluded that individuals with special needs have limited access to oral health care, poor oral health status, and a general lack of awareness in regard to oral health. Therefore, nationwide surveys should be carried out to ascertain the actual extent of the oral inequities among individuals with special needs.


Introduction
The contemporary concept of disability is that individuals with disabilities are differently abled persons who have a different capacity to perform functions [1]. Disability can be apparent, such as physical and sensory, or intellectual and cognitive. It usually affects a person's movement, vision, thinking, hearing, learning, speech, communication, memorizing, and social interactions [2,3]. The World Health Organization (WHO) and World Bank 2011 reports have stated that 15% of the global population is living with some form of disability, of which a majority (80%) belongs to the developing world [4]. It has been indicated that persons with special needs may face several barriers to dental treatment, which increases the prevalence of oral diseases in this population [5]. Individuals with special needs have poor oral health and face oral inequity more frequently than those without disabilities [6]. Additionally, developmental disorders, such as Down syndrome, may alter immune responses, making the individual more susceptible to periodontal disease and peri-implantitis [7]. Efforts have been made internationally to educate and train dentists to treat individuals with special needs [8]. In Saudi Arabia, it has been estimated that 2.9% of the total population have an extreme form of disability [9]. Moreover, studies suggest that Saudis with special needs have a higher prevalence of oral disease, such as dental caries and periodontal disease [10]. prior to validation. A qualitative meta-analysis was not feasible due to the heterogeneity of the studies.

Quality Assessment
The quality of the studies was determined by using the critical appraisal tool to assess the quality of cross-sectional studies (AXIS) [18]. Briefly, various aspects of introduction, methodology, results, discussion and other sections of studies were assessed. Any disagreements were solved by discussion.

Results of the Literature Search
The initial literature search resulted in 1657 items. After the removal of 1200 items, the titles and abstracts of 457 articles were read to determine eligibility. Ultimately, the full texts of 53 research articles were downloaded for potential inclusion. Of these, 15 articles were excluded and are listed in Supplementary Table S1, along with the reasons for their exclusion (Supplementary Table S1). Therefore, 38 studies were included in this review [10][11][12][13][14]. No additional studies were found upon hand searching or searching the gray literature. The inter-examiner reliability (Kappa) score was calculated as 0.89. The literature search process is presented in Figure 1.
Three studies showed a significantly higher prevalence of gingival inflammation and dental caries in children with special needs (ASD, hearing impairment, and visual impairment) [28][29][30] and that children with visual impairment, hearing impairment, and cerebral palsy are more likely to experience dental trauma [20,33,40]. Moreover, there was a higher need for orthodontic treatment in patients with Down syndrome (66-81.9%) due to Class III malocclusions [19,22,23,43]. Children with intellectual disabilities had a higher prevalence of dental caries than children with blindness or deafness [24], and people with intellectual disabilities and cerebral palsy had a higher risk and prevalence of dental caries, compared to people with other physical or mental disabilities [25].
-Oral health behavior: Overall, there was a low frequency of tooth brushing (less than twice a day) and flossing among the participants [11,[25][26][27]30,31,34,35,50]. When dietary habits were studied, sugar consumption was high and was associated with a high caries rate [12,25,27,42]. In one study, sugar consumption was low and this was associated with the overall positive parental attitude towards oral health [39]. One study showed that obesity may act as a co-factor in aggravating the dental caries prevalence in children with special needs [42]. In the studies included, there was variability in the brushing habits of persons with disabilities. Murshid et al. observed that up to 60% of participants with ASD could not brush their teeth by themselves [27] and 85.2% needed help during brushing [12]. Moreover, there were statistically significant differences between those with and without visual impairment in terms of tooth brushing (p = 0.043) [29], whilst two studies did not find significant differences in brushing habits among persons with and without disabilities [30,50]. In another study, nearly 50% of caregivers or parents helped their children with disabilities with brushing, but this did not have a statistically significant effect on periodontal disease or plaque accumulation. Plaque accumulation and gingival inflammation were significantly associated with reduced brushing practices (=0.004 and <0.0001, respectively) [39]. Ashour et al. observed that dental caries prevalence decreased with the use of fluoridated dentifrice [25].

Smoking and Substance Abuse
Only two studies explored the effect of smoking on the oral health of persons with disabilities [30,50], and one study found a significantly higher prevalence of periodontal disease in cigarette smokers [50]. No other type of substance abuse was studied.
-Oral health care attendance and barriers: A study showed that 26.3% of children with special needs have never visited a dentist [13], and the most prevalent reasons for this included: the inability or difficulty of the children to adjust to the environment of the dental clinic (43.4%), parents being too busy with providing medical care to their children (30.1%), and inaccessibility of dental clinics (26.5%). In another study, it was observed that 51.3% of individuals with disabilities had not seen a dentist for more than a year and 84.7% visited a dentist only for emergency treatment. Fear of the dentist was found to be the most common factor impeding dental care to persons with disabilities (52.1%), followed by cost (48.7%), inability to sit in the dental chair (28.2%), transportation issues (26.9%), distance (18.5%), and the lack of skill of the dentist (16.5%) [11]. In other studies, only 28.2% of children with ASD had visited the dentist and this was only in cases of an emergency [26,27]. Al-Qahtani et al. found that 40% of the included sample size of children with disabilities had never visited the dentist before [30]. Two studies also showed that almost half (46.6% to 49.2%) of the participants had never visited the dentist [12,35], and Alsheri et al. found that dental pain was the main reason for visiting a dental clinic [10]. Common barriers to dental care stated by caregivers included distance, transportation difficulties, unsuitable clinic environment care, medical issues, lack of medical insurance or coverage, previous bad experience at the dental clinic, and lack of time [44,51].

Discussion
Children and young adults with disability and special education needs are known to have poorer oral health and greater unmet dental needs, compared to that of the general child population [52]. In addition to receiving high-quality clinical care, improving the oral health of people with disabilities necessitates that they have adequate access to dental care. Before recommending solutions, an awareness of the obstacles that people with disabilities face when trying to access dental treatment is required.
The government of Saudi Arabia has planned to modernize health care by 2030. The main aim of this agenda is to promote healthy lives. An action plan specifically for the aforementioned program is the "Health Sector Transformation Program" [53]. Its goal is to improve the accessibility of health care services to the entire population and deliver people-centered services by providing quality services along with disease prevention and promotion [54]. Therefore, the goal of this systematic review is to summarize and analyze the literature that has been published, focusing on oral health care (including the barriers, access, and utilization of oral health services) among people with special needs in Saudi Arabia. Additionally, this study also aims to describe the current oral health status of people with disabilities.
This study observed that the majority of research participants had poor oral hygiene practices and were dependent on caretakers to maintain proper oral hygiene and access oral health care services. As a result, caregiver training and education should be considered to support preventative approaches to oral disease [55]. Previous studies have indicated that training health care workers to treat individuals with special needs improves their ability to provide health care and may improve outcomes, when compared to those providers with no such training [56].
Over the last few decades, there have been significant advances in medical care for persons with special needs, leading to greater life expectancy. Therefore, oral health provisions for people with special needs need to be tailored and made accessible. Dental care is recognized as an integral component of the basic health requirements of children and adults with special needs [57]. Globally, one in every ten individuals live with disability, and the majority lack access to dental care [58]. Although disability in Saudi Arabia is a major concern, both socially and economically, there is very limited literature available to analyze the situation in detail [59].
Over the years, approximately 4-8% of Saudi Arabia's population has become disabled, but only a small percentage receives proper health care services [44]. In Saudi Arabia, according to the General Authority for Statistics, 2.9% of the population is living with an extreme form of disability [9]. Therefore, there is a need a for comprehensive guidelines and policy to make dental care accessible for Saudis with special needs. Results from this review suggest that there are several gaps in the research that need to be overcome to achieve this goal. Arguably the biggest deficiency in the literature concerning dental care of the Saudi population with special needs, is the lack of nationallevel surveys assessing access to dental care, oral health status, and knowledge of caregivers [60,61]. This is indicated by more than two-thirds of studies being conducted in one city, Riyadh [10,11,[13][14][15][19][20][21][22][23][24][25][26][27][28]32,33,35,38,46,49]. Participants from smaller cities and towns need to be studied to gauge a more representative view of the national situation. The lack of representation is shown by the majority of studies conducted in single institutions. Furthermore, the majority of the studies that did carry out multi-center surveys, did not include individuals with special needs from mainstream schools. Since special needs schools are more likely to provide an oral and systemic health care regimen personalized to the disabilities of the patient, the outcomes of the studies could have been influenced. Future studies should include both individuals with special needs living or studying in specialized institutes and those studying in mainstream schools.
An important observation made in this review are the barriers and difficulties faced by individuals with special needs in receiving dental care. Surveys in rural areas would reveal additional data regarding issues, such as distance and lack of dental clinics. Furthermore, more detailed studies should be conducted regarding the skills of general dental practitioners in treating individuals with special needs. We also recommend establishing continuing education or specialist programs that train dentists in special care dentistry. A glaring omission in the literature is a lack of studies focusing on adults with special needs, with only three studies [34,38,50] focusing on adults. With increasing age, psychomotor issues, lack of parental assistance, and poor oral hygiene, adults with special needs are expected to have a higher prevalence of periodontal disease and dental caries, which can add to the difficulties encountered by these individuals. Therefore, specialized dental programs aimed at adults with special needs should be initiated.
There are several recommendations that could be made to attempt to improve the oral health care of individuals with special needs in Saudi Arabia. Firstly, there needs to be specialized training programs in special care dentistry. Similar training for dental therapists, hygienists and assistants should be conducted. The oral health care for children with special needs should be accessible. One way to do this would be to create mobile dental hygiene services that can visit special needs centers. Oral health education programs need to be implemented in special needs centers and among children with special needs in mainstream schools. Dental outreach programs focusing on the population with special needs should be mandated among dental students. Doing so may not only make dental care accessible for patients but also familiarize future clinicians with providing dental care to these patients. Special care dentistry should be emphasized in the dental curriculum, dental offices and clinics should be designed appropriately to cater for people with special needs (focus on ramps and elevators for ease of access), and conscious sedation should be available and used where appropriate. To date, there has not been a guideline published in regard to the provision of general anesthesia or conscious sedation to patients with special needs and disabilities.
The included studies had several limitations. As shown in the quality assessment results, the majority of the studies were graded as 'low'. The majority of the studies did not have a control group comparing the oral health issues of individuals with special needs to those without them. Furthermore, the majority of the studies failed to carry out randomization of the included sample size. Additionally, due to ethical reasons, it is difficult to blind patients, participants, or caregivers. Therefore, performing randomized controlled trials would be considered unethical, which adds a further limitation to future studies. The authors plan to conduct systematic reviews, focusing on oral health status in Saudi individuals with specific disabilities and special needs.

Conclusions
Within the limitations of this study, it can be concluded that individuals with special needs have limited access to oral health care, poor oral health status, and a general lack of awareness about oral health. Furthermore, the differences in the age and overall health of individuals with special needs make it difficult to present an overall assessment of oral health behaviors and oral health care utilization among persons with disabilities in Saudi Arabia. Standardized nationwide surveys should be carried out to ascertain the actual extent of the oral inequities among individuals with special needs.