Predictors of dental caries in children and adolescents with cerebral palsy (CP): a cross-sectional analytical study in Malaysia

Introduction

Cerebral palsy (CP) is a group of permanent movement and posture disorders that cause activity limitation due to non-progressive disturbances in the developing fetal or infant brain. It is frequently accompanied by sensory, cognitive, and communicative impairments (1). CP is the most common motor disability in childhood (2). Although non-progressive, its clinical manifestations can change over time as the brain matures (3). CP is traditionally classified by the type of functional motor impairment and topographical involvement. Functional motor impairments include spastic, dyskinetic, ataxic, or mixed; the topographic distribution is determined by the number of limbs affected, either diplegia (two lower limbs), hemiplegia (two limbs on either side), triplegia (three limbs), or quadriplegia (four limbs). These terms, however, were found to be lacking and unrepresentative of the child’s ability to function (4).

The Gross Motor Function Classification System (GMFCS) was introduced to provide clinicians and family members with a standardized way to describe the functional abilities of individuals with CP more accurately, thereby eliminating the vast heterogeneity in its description and potential miscommunication (5,6). The GMFCS uses a five-level, ordinal grading system that is reliable, valid, and stable over time (7). This system is self-explanatory, which does not require special training, making its use relatively straightforward. It covers the spectrum of children and adolescents with CP from those with almost-normal gross motor function (level I) to those who are dependent on a caregiver for all aspects of their life (level V), with meaningful distinctions between the levels (8).

Initially, the GMFCS scale presents functional descriptions for children in four age groups: 1 to 2, 2 to 4, 4 to 6, and 6 to 12 years old (5). This, however, was revised and expanded in 2007 to include the age group 12 to 18 years (9). Due to its reliability and stability across all age groups, it has been suggested that, for research involving CP populations, the GMFCS should be used as a descriptive measure (10).

Poor oral and gingival health has been reported among children with CP (11-13). This may be caused by limited motor function and impaired mental capabilities, which result in difficulties maintaining their own oral hygiene (14), coupled with the challenges their caregiver faces in performing and preserving routine dental care (15). The prevalence of dental caries among this group is generally high (16), although some studies have reported a low, non-significant difference between CP and healthy children (17,18). In Malaysia, there is a lack of studies on this issue, with fewer than five reported in the last 5 years (19,20).

The increased caries risk in children with CP has been attributed to a combination of clinical, behavioral, and socioeconomic factors, including caregiver burden and oral health practices (14,21-24). The impact of caregiver burden on maintaining optimal oral health in CP children yields conflicting findings. Despite some studies reporting a correlation between high caries experience among individuals with CP and elevated caregiver burden, and lower caregivers’ quality of life (25-27), other research concluded that dental caries was associated with the consequences of the disease itself rather than caregiver burden (28). This shows that the relative contribution of each factor remains unclear. Further, there is a lack of consensus among prior studies on the risk factors and predictors of poor oral health among this population group, warranting further investigation.

Therefore, this study aimed to determine the prevalence of dental caries among Malaysian children and adolescents with CP, assess caregiver burden, and identify predictors of caries prevalence in this group. We hypothesized that socioeconomic status, clinical characteristics, and caregiver burden significantly predict dental caries prevalence in this population. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-587/rc).

Methods

Study design and ethical approval

This was a cross-sectional analytical study. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethical Committee of the National University of Malaysia (UKM) (UKM PPI/111/8/JEP-2018-614), and the Medical Research and Ethics Committee of the Ministry of Health Malaysia [KKM/NIHSEC/P18-2014 (10)]. Written informed consent was taken from the patients’ parents or legal guardians.

Study setting, sampling and sample size calculation

Data collection was conducted at two public hospitals in Kuala Lumpur, i.e., the Pediatric Neurology Clinic of Tuanku Azizah Hospital and the Pediatric Dental Clinic at Hospital Canselor Tuanku Muhriz between March and November 2019. Purposive sampling was used to recruit participants. Based on standard recommendations for logistic regression (29), the following equations were used:

N≥50+8m[1]

where N is the sample size and m is the number of predictor variables. The sample size (N) for this study was calculated based on the expected regression analysis using seven predictor variables (m), which included patient and caregiver factors. A sample size of more than 106 participants was deemed adequate. The final number of participants was rounded up to 110 children and adolescents with CP and their respective caregivers.

Study population and recruitment

Children aged 4 to 16 years with a confirmed diagnosis of CP and their primary caregivers were invited to participate in this study after being briefed about the details. This age group was selected because, by approximately 4 years of age, children typically have a complete set of primary dentitions, enabling comprehensive assessment of dental caries. In addition, children in this age range are generally able to cooperate during intraoral examinations. The upper age limit of 16 years was established in accordance with the classification used in Malaysian public hospitals, where individuals up to this age are considered pediatric patients. The primary caregiver was defined as the individual primarily responsible for the child’s care and could be the parent or guardian. Information leaflets (available in Malay and English) describing the study’s purpose and data collection methods were provided to the caregivers. Children and adolescents with CP and their respective caregivers who provided written informed consent and, where appropriate, child assent were enrolled. Children and adolescents who were medically unstable or extremely uncooperative during examination were excluded.

Data collection

Dental examination

A single experienced examiner conducted all dental examinations. A Kappa test performed on 20 children demonstrated perfect intra-rater reliability (κ=1.00) (30). A systematic visual examination recording dental caries, assessed using the Decayed, Missing, and Filled Teeth (DMFT)/decayed filled teeth (dft) index, was conducted with disposable mouth mirrors and dental explorers, following World Health Organization (WHO) recommendations and guidelines (31). Each tooth was counted once, with a maximum score of 32 for permanent and 20 for primary dentition. Both DMFT and dft indices were used in cases of mixed dentition.

Dental caries prevalence (%) was calculated as the proportion of study participants with at least one carious lesion. The care index (F/DMFT or f/dft) was used to estimate the proportion of treated caries, while untreated caries was expressed as the proportion of decayed teeth. Study participants who had not already registered with dental clinics were provided with a letter for treatment and follow-up at their preferred dental clinics.

Predictor variables

To predict dental caries prevalence in children and adolescents with CP, binary logistic regression analyses were conducted. The backward stepwise (conditional) method was used to select the appropriate independent variables for inclusion. A total of seven predictor variables has been identified. Six of them were obtained through the patient’s medical records, which included GMFCS level, CP subtype (spastic, dyskinetic, mixed, or ataxic), child’s age and gender, caregiver’s education level and household income. In addition, the caregiver burden was assessed via the 22-item Malay-translated Zarit Burden Interview (MZBI). It is a self-reported, validated questionnaire graded on a five-point Likert scale ranging from 0 (never) to 4 (nearly always). This tool has been validated with a Cronbach’s alpha of 0.898 (32-35). The scores for all 22 items were then summed to yield a total burden score for each caregiver. The maximum burden score possible for a caregiver was 88. Categorization of the scores is given as: 0–20 (little or no burden); 21–40 (mild to moderate burden); 41–60 (moderate to severe burden) and 61–88 (severe burden).

Statistical analysis

Data was analyzed using IBM Statistical Package for Social Sciences (SPSS) software version 23 (IBM^® Inc. Pvt. Ltd.). Descriptive statistics were used for all variables. Normality was tested using the Shapiro-Wilk test. Variance inflation factor (VIF) values were calculated to assess multicollinearity among predictors. Binary logistic regression was performed to identify predictors of dental caries, with statistical significance set at P<0.05.

Results

Demographics

Of the 110 children with CP, 67 (60.9%) were male, with a median age of 8 [interquartile range (IQR), 5] years. Most of the group was Malay (76.4%), followed by Chinese (15.5%), Indians (7.3%), and other ethnicities (0.9%). CP types included spastic (57.3%), mixed (33.6%), and dyskinetic (9.1%); none had ataxic CP. Most of them in this group had quadriplegia (62.7%), followed by diplegia (21.8%), hemiplegia (10%), and the least were those with triplegia (5.5%). Most participants (64.6%) had severe motor dysfunction (GMFCS levels IV and V) (Table 1). Regarding the caregivers, their median age was 38 (IQR, 9) years. The majority (89.1%) were mothers. About 36.4% of families fell within the B40 (bottom 40%) income bracket. The education level of more than half (56.4%) of the caregivers was limited to the secondary level (Table 2).

Caries prevalence and care index

Many of the study participants (n=84, 76.4%) had experienced dental caries. A prevalence of 70.3% (n=26) was noted in children with primary dentition, 80.4% (n=41) in those with mixed dentition, and 77.3% (n=17) in those with permanent dentition. Table 3 shows the caries prevalence of children and adolescents in this study. The caries experience and Care Index of the study group are described in Table 4. Their median of the DMFT and dft scores were 0.0 (IQR, 3.0) and 3.0 (IQR, 5.0), respectively. A high prevalence of untreated dental caries was noted in this study population. More untreated caries were found in the primary dentition (93.9%) than in the permanent dentition (65.8%). Accordingly, the care index was low, with more restorative treatments performed on permanent dentition (20.0%) than on primary dentition (6.1%). Table 4 summarizes these findings.

Caregiver burden

Most caregivers in this study reported a mild to moderate burden of caring for their child with CP (n=50, 45.4%); 36.4% (n=40) reported no burden; 18.2% (n=20) had moderate to severe burden; and none were severely burdened. The median caregiver burden score was 29 (IQR, 20.3), which falls within the mild-to-moderate burden category (category 2). This finding is summarized in Table 5.

Predictors of dental caries

Multicollinearity was not present (all VIF values <5). Logistic regression showed that GMFCS level was a significant predictor [β=3.22, odds ratio (OR) =25.01, P<0.001]. Children with severe motor impairment had 25 times higher odds of dental caries than those with mild/moderate impairment. The Wald estimate of 13.64 was significantly higher than that of the other predictors. It shows that GMFCS is the most critical predictor of dental caries prevalence in children and adolescents with CP. In addition, CP subtype (spastic vs. dyskinetic) was individually significant (β=2.36, OR =10.58, P=0.03), but the overall category was not (P=0.07). Other variables, including caregiver burden, age, gender, and income, were not significant predictors (Table 6). Our hypothesis that socioeconomic status and caregiver burden significantly predict dental caries prevalence in this population was rejected. In contrast, the impact of clinical characteristics of CP, mainly the GMFCS level, on dental caries prediction was accepted.

Discussion

The study population’s ethnic makeup closely mirrored Malaysia’s national demographic distribution. Malays made up the largest group, followed by Chinese, Indians, and other ethnic groups, in line with national census data (36).

The present study identifies spastic CP as the most prevalent subtype, followed by dyskinetic and ataxic forms (37,38). Mixed CP exhibits a variable distribution, primarily attributed to inconsistencies in classification methods. Nonetheless, several studies have reported its prevalence as second only to that of the spastic subtype (39), aligning with this research’s findings. Due to the lack of standardized criteria for classifying topographical limb involvement, international studies have documented substantial variation in prevalence estimates (39). Consistent with findings from a Brazilian cohort (40), quadriplegia emerged as the most common topographical distribution in the current study, followed by diplegia, hemiplegia, and triplegia.

Studies using CP registries from Ontario, Melbourne, and Sweden have reported the highest proportions of individuals classified as GMFCS level I, with levels II–V distributed almost equally (2,41,42). In contrast, the current study revealed a predominance of children with severe gross motor disabilities (GMFCS levels IV and V). This discrepancy is likely due to data collection occurring in tertiary care hospitals, which typically cater to individuals with more complex and severe disabilities. Such settings were considered appropriate for this study, given the availability of comprehensive medical records and access to primary caregivers. Additionally, the clinical environment facilitated oral health assessments, which would have been more challenging in community-based settings.

In this study, a primary caregiver was defined as the individual primarily responsible for the care and financial support of a child with CP. Most children were cared for by their mothers. However, some were under the care of fathers—often due to socioeconomic circumstances such as maternal employment or custody arrangements following divorce. Four children were cared for by extended family members, such as grandmothers and aunts, due to social issues affecting the nuclear family.

Socioeconomic status was assessed using two indicators: total household income and the caregiver’s level of education. Household income was dichotomized at Ringgit Malaysia (RM) 3,000 per month to differentiate between lower- and higher-income groups. This reflects the approximate income level of the bottom 40% (B40) of Malaysian households, as noted in the Eleventh Malaysia Plan (2016–2020) (43). Roughly one-third of the participants were in the lower-income group. The caregiver’s level of education was classified as primary, secondary, or tertiary. This classification aligns with the Malaysian education system and is consistent with national surveys and previous local studies (44,45).

Most caregivers participating in this research had completed only secondary education, which aligns with findings from a previous local study that included 93 children with CP in Kelantan (19). Limited educational qualifications and associated socioeconomic limitations have been linked to inadequate oral hygiene practices and increased sugar intake, both contributing to a higher risk of dental caries and periodontal disease (46,47).

The overall prevalence of caries within this population (76.4%) was somewhat lower than that found in the earlier study from Kelantan (81.7%) (19). The prevalence of caries in primary teeth (70.3%) was similar to the national average of 71.3% (48) but lower than the significantly higher rate reported in the previous Kelantan study (97.9%) (19). Conversely, the prevalence of caries in permanent teeth (77.3%) greatly surpassed the rate observed in the general Malaysian child population (33.3%) (49), highlighting the considerable and ongoing oral health challenges faced by children with CP (12,15,50). The prior Kelantan study also reported a high caries rate in permanent teeth (81.7%) (19).

These variations may signify regional differences in oral health practices, socioeconomic conditions, and exposure to water fluoridation (48,49,51). Specifically, the state of Kelantan has the highest mean dft of 7.45 compared to the other states in Malaysia (48) for 5-year-olds. The low Care Index and the high number of untreated caries observed in this study highlight limited access to or use of dental services, especially among younger children. This concern is not just for children with special needs. A national survey shows that 64.9% of 5-year-olds need dental care for their primary teeth (48). Healthy children also rely on parents/caregivers or other adults to take them to dental appointments. Furthermore, CP children depended entirely on their caregivers, not only for accessing oral health care services but also for their daily oral hygiene routines (52). On the other hand, dental issues in children with CP can lead to serious health problems that may harm their well-being and quality of life. In addition, caregivers often focus more on medical issues rather than on oral health (53). These findings align with previous local studies and underscore the urgent need for targeted approaches to improve oral health care delivery for this vulnerable group (15,19).

The Oral Health Division of the Ministry of Health Malaysia currently runs an outreach dental program for children and adolescents with CP who attend community-based rehabilitation (CBR) centres (15). These services usually include routine dental check-ups, fluoride treatments, and other preventive care. However, evidence on the effectiveness of these initiatives remains limited, and it is unclear whether they have successfully addressed barriers to dental care access for this population. Additionally, the current study did not confirm whether the participating children were enrolled in or attended CBR centres, which limits the ability to assess how these programs affected their oral health outcomes.

Although caregiver burden was common, it was not a statistically significant predictor of caries risk in this study, consistent with findings from studies conducted in Brazil and other countries (25,50). The diversity in caregiver experiences suggests that factors such as psychological resilience and social support may mitigate the impact of caregiving stress on health outcomes.

Among all variables assessed, GMFCS level emerged as the most significant predictor of dental caries, corroborating evidence from studies in Nigeria, India, and Bangladesh (17,18,21). Severe motor dysfunction is known to exacerbate feeding difficulties, reduce oral clearance, and increase dependence on fermentable carbohydrates—factors conducive to caries development (8,12,14). As children with CP grow and their body weight increases, mobility limitations may create transportation barriers. At the same time, the scarcity of wheelchair-accessible dental facilities further diminishes their access to regular dental care (54). This might explain the higher prevalence of caries in secondary dentition in the study population compared to the national average. Furthermore, challenges related to behavioral issues, communication difficulties, and the need for specialized equipment or sedation may deter both caregivers and dental professionals from seeking routine care (54).

In contrast, CP subtype was not a statistically significant predictor in this study, consistent with the findings of De Camargo et al. (55). Nevertheless, it yielded the second-highest Wald score, with children with spastic CP demonstrating 10.6 times greater odds of caries than those with the dyskinetic subtype. This finding contrasts with another study that reported higher mean caries scores in individuals with mixed CP than in those with spastic or ataxic CP (56).

Given the functional heterogeneity within each CP subtype, it is posited that subtype classification may not be the most reliable indicator of caries risk. Furthermore, the absence of a standardized classification framework for CP subtypes complicates cross-study comparisons and limits the reliability of related findings (42). In contrast, the GMFCS provides a more objective, function-based metric for evaluating risk of oral disease in this population (13,57).

It should be noted that this study did not encompass all behavioral and dietary risk factors, as the focus remained on CP-specific predictors—an acknowledged limitation. Additionally, purposive sampling from tertiary hospitals likely skewed the sample towards more severe cases, thereby limiting the generalizability of the results. This study also did not assess the oral health literacy of the caregivers, which may have contributed to the caries experience in the study population. Future studies should be designed as multicentre CBR centres to better represent the population of children and adolescents with CP. It is essential to measure caregiver oral health literacy, as it significantly affects daily oral care habits and service use. Studies that assess customized education programs, adaptive oral hygiene methods, and other targeted strategies would help identify effective ways to improve outcomes. Long-term studies will provide valuable insights into changes in oral health as children grow and their needs evolve. Lastly, future research should examine how nutrition and feeding habits impact the risk of caries and overall oral health.

Conclusions

This study demonstrates that children and adolescents with CP continue to experience a high burden of dental caries and significant unmet treatment needs. On average, caregivers experience mild to moderate burden and severe motor impairment (GMFCS levels IV to V) is the sole predictor of caries risk. These findings support the use of the GMFCS classification as a practical and clinically meaningful tool for stratifying caries risk in this population. Strengthening targeted preventive strategies, ensuring early dental care, and implementing regular oral health checks, with support from pediatricians, rehabilitation teams, and pediatric dental providers, are crucial for improving oral health outcomes for children and adolescents with CP.

Acknowledgments

We would like to thank the Directors of the respective hospitals and the hospital staff for their support and assistance throughout this study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-587/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-587/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-587/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-587/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethical Committee of the National University of Malaysia (UKM) (UKM PPI/111/8/JEP-2018-614), and the Medical Research and Ethics Committee of the Ministry of Health Malaysia [KKM/NIHSEC/P18-2014 (10)]. Written informed consent was taken from the patients’ parents or legal guardians.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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