Two hundred and fifty mothers of children with Down's syndrome participated in this study.  These children were attending three institutions which provided education to children with mental disabilities in Riyadh, Saudi Arabia.

In these institutions, children attended from 7:00 a.m. to 2:00 p.m. for educational purposes only.  They bring their food and snacks from their homes and there are no preventive dental programs available in any of the institutions.  The data for this study was obtained through a self-administered questionnaire.  The questionnaire was tested on a group of parents who did not participate in the main study and appropriate modifications were made. 

The aim of the study was explained to the mothers and confidentiality of the provided information was assured by an explanatory letter sent to each mother.  The following areas were covered in the questionnaire: 

• Demographic information such as age, sex, nationality of the child.

• Socioeconomic status such as educational level and occupation of mothers.  Three categories of education were defined including illiterate, high school or less and university education.  With regard to the occupation,¹⁶ five categories were defined including higher professions (doctor, dentist, pharmacist, lawyer, engineer), intermediate professions (teacher, accountant, government employee, journalist, translator), laborer (cook, nanny, housekeeper), retired and housewife.

• Dental visit practices including previous child's visit to a dentist, age of the child when first seen by dentist, his/her behavior during the dental visit and the frequency of dental visits.

• Mothers' oral health knowledge which included causes of dental caries, causes of bad mouth breath, ways of keeping the mouth and teeth healthy, effect of fluoride on dental health, causes of gingival disease and source of any dental information.
  

All the information was entered into a computer utilizing FoxPro program for windows.  Statistical Package for Social Sciences (SPSS version 10) was utilized for all the statistical computations.  Frequency distribution was used for the descriptive analysis and Chi-square test at 5% significance was used for the statistical relationship between the variables.

Socio-Demographic Background

Out of the two hundred and fifty questionnaires distributed, two hundred and twenty-five questionnaires were returned giving a response rate of 90%.  The age of the children ranged from one to 19 years with a mean age of 7.24 ± (SD 4.11).  The mean age of male children was 7.27 ± (SD 4.08) and 7.20 ± (SD 4.17) for the females (Table 1).  The majority of the children (91%) were Saudis.

With regards to the mothers' occupation, around 29% of the mothers had an intermediate profession, whereas 68.5% were housewives or retired and therefore not working.  Due to the high percentage of non-working mothers, only two categories (working and non-working) were used when the occupational status of the mother was related to various mothers' responses.

More than half of the children (57.4%) visited the dentist and more than one-third of them (71.9%) visited the dentist at the age of 4-6 years or earlier.  Nearly 70% of the children visited the dentist only when they had pain.  About half of the children (52.5%) were cooperative during the dental appointment (Table 3).

Table 4 shows that no statistically significant differences (P>0.05) were found between mothers with different educational levels and occupational status in relation to the child's visit to the dentist.  Regarding the child's age at the first dental visit, statistically significant differences were observed between children of mothers with different educational levels, as a higher percentage of children (36.5%) of mothers with university education was found to make their dental visit at an earlier age (1-3 years old) compared to only 6.3% of children of illiterate mothers (P=0.030).  No statistically significant differences, however, were observed between the child's age at the first dental visit in relation to mothers occupational status (P>0.05).

For frequency of dental visits, children of mothers in all educational levels were found to visit the dentist only when in pain (P>0.05).  A higher percentage (76.2%)  of children of non-working mothers were found to make their dental visits only when in pain compared to 59.1% of children of working mothers, and this difference was found to be statistically significant (P=0.025).  A higher percentage (65.7%) of children of mothers with high school or less were reported to be cooperative during dental appointment compared to other children and this difference was found to be statistically significant (P=0.014).  However, no statistically significant difference was seen between the child's cooperation level during dental appointment in relation to the mother's occupational status (P>0.05) as shown in Table 4.

Mothers' Oral Health Knowledge

Bacteria was selected to be the main cause of dental caries by the majority of mothers (97.8%) as shown in Table 5.  No statistically significant differences were found between the mothers of different educational levels or occupational status regarding their response to the causes of dental caries (P>0.05) as shown in Table 6.

Not brushing teeth and gingival inflammation were recognized by the same percentage (92% - 91.1%, respectively) of mothers as possible causes of bad mouth breath followed by about 85% of mothers who regarded dental caries as a possible reason for bad mouth breath.  Statistically significant differences were observed between mothers with university education and those in other educational levels regarding the responses about the relationship of dental caries and bad mouth breath (P<0.01).  No statistically significant differences were noted, however, in the answers of causes of bad mouth breath between mothers based on their occupational status (Table 6).  With level was compared (P=0.007) but not for mothers' occupational status (P>0.05).

Table 5 shows the responses of mothers when they were asked about the cause of presence of blood on the toothbrush and Table 6 presents the relationship of mothers' responses and their educational levels and occupational status.  The majority of mothers (92.4%) realized that blood on toothbrush might be a sign of gingival inflammation.  More illiterate mothers (10.7%) stated that they did not know the reason for the presence of blood on toothbrush as compared to mothers in other educational levels and the difference was found to be statistically significant (P=0.045).  In addition, more of the non-working mothers (4.2%) stated that they did not know the reasons for the  presence of blood on the toothbrush as compared to the working mothers but the difference was not found to be statistically significant (P>0.05).

Tables 7 and 8 present the source of mothers' dental knowledge.  Sixty percent of mothers received their information from the dentist, whereas only 8.9% received their information from relatives and friends.  Nearly half of the mothers with university education and half of the working mothers stated that they received their information from magazines and newspapers as compared to mothers in other educational levels and non-working mothers and these differences were found to be statistically significant (P<0.001). 

The oral health practices of non-institutionalized Down's syndrome is not well-reported in Saudi Arabia as well as in the other parts of the world.⁵

This study showed that some practices regarding dental visits appeared satisfactory such as commencing time of dental visits, and age at first dental visits.  The practices seen in this study were  different from those reported by Randell  et al.⁵ in U.S.A.

Data showed that a high percentage of children visited the dentist only when they were in pain especially children of non-working women as compared to other children. This may suggest a lack of awareness of the value of oral disease prevention among the mothers.  Another possible reason is that the mothers were too occupied with other general health problems and daily basic needs to consider dental visits a high    Although the overall mothers' knowledge of oral health was considered to be satisfactory, more dental health education is needed with respect to the importance of dental visits, role of fluoride and causes and symptoms of gingival inflammation.

• The majority of the children had visited the dentist and most of them made their first visit at an age younger than 6 years, however, nearly three quarters of the children visited the dentist only when in pain.
• Sugar reduction, tooth brushing and dental visits were regarded by the mothers as effective methods of caries prevention. 
• The effect of fluoride on dentition was recognized by less than half of the surveyed mothers and a high proportion of them were mothers with high educational levels.

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