Oral health of mentally challenged Romanian athletes, still a challenge in 2018

Arina Vinereanu (1), Aneta Munteanu (2), Ioana Baltag (1), Alexandru Stănculescu (3), Daniel Popescu (4)

(1) Clinical Director Special Olympics-Special Smiles(2) Assistant lecturer, Carol Davila University of Medicine and Pharmacy, Bucharest(3) Resident in Orthodontics, Bucharest, Special Smiles volunteer(4) Private practice, Bucharest, Special Smiles volunteer


Aim: To assess the oral health situation and oral hygiene habits of Romanian Special Olympics (SO) athletes in 2018.

Methods.271 subjects aged 6 to 56 years (mean age 19.34 y, SD 9.00), were examined under field conditions, during the National SO games in 2018. Demographic data (age, gender), dental status (sound, decayed, filled, sealed, extracted) and periodontal status were individually recorded. DMF-T, restoration index RI = [F/(F+D)x100]% and Plaque Index PI (Silness and Löe) were calculated. Data were processed using SPSS 20.0.

Results.80.8% of the athletes were living with their own families. 78.2% brushed their own teeth; 10.7% were exclusively brushed by parent/caregiver; 93% had never used dental floss. 32.8 % reported to attend regular dental check-ups, ss correlated with less decay and less gingivitis (p<0.05). 7.4% of the subjects were caries free.Mean DMF-T was 8.13 [SD 5.69]. Mean RI was20.06 [SD 32.89], with significant gender differences: 14.86 for boys and 25.04 for girls (ss, p<0.05). Mean PI was 1.74 [SD 0.91]. Sealants were found in 4.4% of the examined athletes and 10% got sealants during the event.

Conclusions. Romanian SO athletes still have many unmet dental treatment needs. Access to dental care is limited and prevention is scarce. Targeted programs are needed in order to prevent oral disease, raise awareness regarding the place of oral health within the picture of general health of people with intellectual disabilities, to prevent oral disease and to improve access of mentally challenged people to effective professional oral care.

Key words: mentally challenged, oral health, Special Olympics


WHO Constitution regards health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and the enjoyment of the highest attainable standard of health as “one of the fundamental rights of every humanbeing[1]. Inseparable from general health, oral health is therefore to be considered as a right rather than as a privilege.

People with special needs are commonly reported as having an underprivileged oral health situation [2, 3, 4] while mental challenge often makes the situation even worse. There are several reasons leading to these differences. For one, systemic diseases – either syndromic or not, but often very severe – represent a very serious burden for both the affected person and the family and the various related concerns quite explicably push oral health on a secondary place. Brushing itself, as the most common and reachable preventive method for caries and periodontal disease, may be very difficult to perform in certain cases and therefore can be either unsatisfactory or even completely overlooked. Feeding habits (e.g. soft diet due to lesser or no capacity of mastication), oral breathing, medication with sugary vehicle, xerostomia, side effects of certain drugs as well as specific or non-specific oral and dental features of some diseases and syndromes are some of the factors that may induce or enhance oral pathology in people with complex general conditions [5]. Sometimes even the parents’ low level of knowledge and perception on the subject can be an aggravating factor for the oral health status of the special needs child. In addition to that, access to oral care of people with special needs can often be severely limited due to a variety of factors ranging from physical or economic barriers to practitioner’s reluctance towards treating this category of patients [6].

Material and methods

A cross-sectional study was performed on 271 SO Romanian athletes (172 male) within the age range 6 to 56 years (mean age 19.34 y [SD 9.00]), self-selected from participants in the National SO games in 2018 (Târgovişte, Romania). Adapted oral care education for athletes and caregivers was provided by volunteers (residents in Paediatric Dentistry) during the event. Dedicated booklets and special targeted educational materials developed by the Romanian National Association of Paediatric Dentistry with the support of Colgate Romania were freely distributed to parents and caregivers. Some of the athletes also benefited from professional cleanings and glass-ionomer sealants offered with the support of GC Romania and Dentex Trading Romania. Athletes were examined under field conditions, in natural light + flashlight, using dental mirror and probe [fig.1]. The following data were individually recorded:

-age, gender

-accommodation status (living with own/foster family/institutionalized)

-home oral hygiene habits (by MCQ)

-dental status (sound, decayed, filled, sealed, extracted)

-periodontal status – plaque, gingivitis.

Based on the recorded data, the following parameters were calculated:


– Restoration index RI = [F/(F+D)x100]%

– Plaque index Silness-Löe(PI).

Data were analyzed using SPSS 20.0.

Results: 80.8% of the subjects were living with their own families; 16.2% were institutionalized, whilst the remaining 3% lived with foster families.

Most of the athletes (78.2%) brushed their own teeth, 11.1% needed help with brushing, 10.7% were exclusively brushed by parent or caregiver, 93% had never used dental floss and 32.8 % reported to attend regular dental check-ups.

The dental status of the subjects is shown in table 1.

Table 1.Dental status of the examined athletes

% subjects
Sealed during event10
Untreated decay89.2
≥ 1 extracted molar26.6

The calculated mean value for the DMF-T index was 8.13 [SD 5.69], with ss differences between genders regarding the “F” component: 0.88 in boys versus 1.85 in girls (p<0.01). Restoration index RI was 20.06 [SD 32.89], also with gender differences: 14.86 for boys and 25.04 for girls (ss, p<0.05).

The mean value for the plaque index PI was 1.74 [SD 0.91].


Most of the athletes were living with their own families and they were more likely to use electrical toothbrushes and to be assisted with brushing. Still, the use of dental floss was highly uncommon (only 7% of the subjects stated that they flossed their teeth).

Almost one third of the subjects attended regular dental check-ups. Regular visits to the dentist were positively correlated with presenceofsealants,higherRIand“F”component,lower“D”component(p<0.01),lowerPIandlessgingivitis(p<0.05).

69.7% of the athletes had RI values below or equal to 10, meaning that most of their needs for dental treatment were still unmet, while only 11.2% of the subjects had their dental treatment needs already met to a high/satisfactory degree (RI ≥ 80).

Within the international community of SO athletes, the findings of the present study are, at least in terms of DMF-T values and proportion of athletes with at least one extracted molar, comparable to results reported for various other countries, as shown in Table 2[7-12].Untreated decay seems to be more frequent in Romanian and German SO athletes, while Romanians have the worst periodontal condition. Looking on the brighter side of the matter, it is important to note that the provision of sealants during SO events is rather rare and can be regarded as a small but noticeable step forward for a better oral health situation in the future for Romanian SO athletes, bringing the overall percentage of subjects with sealants to 14.4%, but still far from the 37.7% reported for Slovenian SO athletes in 2011-2012; the corresponding figure for Romanian SO athletes reported by the same study was 3.8%, closer to the 4.3% found for Polish SO athletes [13].

Table 2.Previous reports on the oral health of SO athletes in various countries.

Previous SOSS reportsGingival signs (% subjects)Untreated decay (% subjects)Mean DMF-T1extr molar (% subjects)Sealants (% subjects)
Pakistan 2017 (Saquib)36.171.2

Trinidad Tobago 2006 (Naidu)34.645
USA 2005-2008 (Fernandez)3228

Belgium 2008 (Leroy)4422
Germany 2014 (Schüler)43.486.27.2

Italy 2008 (Dellavia)


Present study7989.28.1326.64.4 +10 During event

Previous reports[14-16] on the oral health status of Romanian enable us to assess the dynamics of the situation in time (Table 3).

Table 3.Previously reported data on the oral health of Romanian SO athletes.

200520132018 (present study)
Mean DMF-T8.158.658.13
Mean RI (%)11.921.7620.06
% Subj with RI≥80 %4.4911.2
% Subj with RI≤10 %73.257.669.7
Caries-free (%)

Data in Table 3 show that DMF-T remains relatively constant within time, while the mean values for RI have improved since 2005. The proportion of athletes that had most of their caries already treated by the time of the screening rose from 4.4% in 2005 to 11.2% in 2018. However, the percentage of athletes with highly unmet treatment needs remains very high, with almost 70% of these subjects having 10% or less of their carious lesions already taken care of by the time of the screening.

It is important to point out that in many ways, Special Olympics athletes can be regarded as “privileged among the underprivileged” within the larger community of special needs/intellectually challenged people, and that also applies to their oral health status. Though mentally challenged, SO athletes are socially integrated to a certain point, they communicate, interact and are capable to perform sports activities in an organized manner and, by being part of the Special Olympics movement, they are also more exposed to health programs such as Healthy Athletes. They are also more likely to either perform or accept oral hygiene routine and even to understand and take advantage of the adapted oral health education sessions provided as part of the Special Smiles branch of the Healthy Athletes program. Therefore, the findings of studies on SO athletes do not reflect the oral health situation of all mentally challenged people or that of the special needs population, which is unlikely to be better.


Romanian Special Olympics athletes still have a lot of unmet dental treatment needs. There is little targeted prevention and mentally challenged children seldom get sealants in due time. Further development of the Special Smiles project, in terms of providing active prevention and non-invasive treatment during events, would help increase program effectiveness, not only in caries prevention but also in getting young athletes used to interact with a dental professional and in raising awareness among parents, caregivers anddental professionals.

In order to bring dentists and people with special oral care needs closer to each other, specialists from four countries (France, Italy, Turkey and Romania) are currently working together in an Erasmus+ projectaiming to help dental practitioners interested in providing treatment to this category of patients. OSCAR (Oral Special Care Academic Resources) project is putting together a digital platform where dental practitioners shall easily find practical information on how to assess and manage patients with various general diseases with impact on oral care. Structured presentations, case reports, tips and tricks and references will be held available in the attempt to overcome some of the barriers to fair access to oral care of this underserved category of population. (Project 2019-1-RO01-KA202-063820 ERASMUS+)


  1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.WHO website, 2003: http://www.who.int/about/definition/en/print.html
  2. Faulks D, Hennequin M : Evaluation of a long-term oral health program by carers of children and adults with intellectual disabilities.Spec Care Dentist. 2000 Sep-Oct; 20(5):199-208.
  3. Beange HP : Caring for a vulnerable population: Who will take responsibility for those getting a raw deal from the health care system? Med J Aust. 1996 Feb 5; 164(3):159-60.
  4. Griffiths J, Boyle S. Holistic oral care – a guide for health professionals. Sections 2-3. London: Stephen Hancocks Ltd, 2005.
  5. Scott A, March L, Stokes ML. A survey of oral health in a population of adults with developmental disabilities: Comparison with a national oral health survey of the general population. Aust Dent J. 1998;43:257–261.
  6. Dougall A, Fiske J: Access to special care dentistry, part 4. Education. Br Dent J. 2008 Aug 9;205(3):119-30. doi: 10.1038/sj.bdj.2008.652.
  7. Saquib AK, Saima A, Beenish Q: Oral health status of Special Olympics Athletes seen atIslamabad Dental Hospital. Pakistan Oral & Dental Journal 2017 April-June:37 (2)
  8. Naidu R, Percival T, Ramroop V, Prabhu SR, Perlman S. (2006). The oral health status of Special Olympics athletes in Trinidad and Tobago. Journal of Disability and Oral Health. 7. 48-52.
  9. Fernandez JBLim LJDougherty NLaSasso JAtar MDaronch M: Oral health findings in athletes with intellectual disabilities at the NYC Special Olympics. Spec Care Dentist. 2012 Sep-Oct;32(5):205-9.
  10. Leroy RDeclerck DMarks L: The oral health status of Special Olympics athletes in Belgium. Community Dent Health. 2012 Mar;29(1):68-73.
  11. Schüler IM, Kaschke I, Heinrich-Weltzien R : Special Olympics Special Smiles: Oral health care for people with special needs. EADPH 16th annual meeting, Rome 2011
  12. Dellavia CAllievi CPallavera ARosati RSforza C: Oral health conditions in Italian Special Olympics athletes. Spec Care Dentist. 2009 Mar-Apr;29(2):69-74.
  13. Fernandez Rojas C, Wichrowska-Rymarek K, Pavlic A, Vinereanu A, Fabjanska K, Kaschke I, Marks LAM: Oral health needs of athletes with intellectual disability in Eastern Europe: Poland, Romania and Slovenia. International Dental Journal 2016; 66: 113–119
  14. Vinereanu A, Luca R, Amariei C, Totolici I, Vaida L:  Oral health of special needs patients in Romania – from individual to community concern.  Oral Health and Dental Management in the Black Sea Countries, 2008, 2(24):11-14.
  15. Vinereanu A, Baltag I, Popescu D, Bratu AM, Luca R: Prevention for mentally challenged athletes: programs, preliminary outcomes, perspectives. Revista Romana de Medicina Dentara 2014, XVII(3): 74-84
  16. Vinereanu A, Ivan A, Popescu D, Bratu AM, Luca R: Oral health in a group of Romanian Special Olympics athletes. Sanatatea orala la un lot de sportivi Special Olympics din Romania. Revista Romana de Stomatologie 2014 LX(1): 30-33

Share this article:

Share on facebook
Share on whatsapp
Share on linkedin
Share on twitter
Share on email
Share on print

You might be interested:

Leave a Reply