pain is a highly complex , dynamic , subjective experience that is useful in growing children , serving to warn them of danger and limiting exposure to additional injury .
however , untreated , acute , or recurrent or chronic pain may have significant and lifelong consequences ( both physiologically and psychologically ) .
since pain is an inherently subjective phenomenon , it is often said that the gold standard for pain assessment in both children and adults is verbal reporting [ 13 ] .
it is the only way to determine the intensity and quality of the pain present .
however , reliable description in children especially in intellectually disabled ( i d ) children is very difficult .
children with intellectual disability have an added challenge of not being able to express the pain or verbalize it .
hence , to gather pain relevant information , caregivers were interviewed regarding their children for expression of pain , experience , treatment , and coping behavior .
research shows that children with developmental disabilities generally experience more pain than the normal children due to chronic systemic conditions associated with their disability [ 46 ] .
many children have idiosyncratic behaviors such as moaning / grunting which may lead to over / underestimation of pain .
the aim of the study was to evaluate the dental pain in children with intellectual disabilities from a caregiver 's perspective .
the study was initiated after obtaining clearance from the institutional ethics committee , chettinad health city .
they were residing at vasantham institution for intellectually disabled children , mogappair , chennai , tamil nadu , india .
all the children in the control group were of normal intellectual growth as determined by their academic evaluations . 

age group ranged from 5 to 18 years.the study group has a history of intellectual disability as verified by the child 's medical file or caregivers reporting.caregivers were able to understand spoken english / tamil.the control group included children who had normal intellectual development . 
 
the study group has a history of intellectual disability as verified by the child 's medical file or caregivers reporting .
the nature of the study was explained and the investigators assisted them in filling the questionnaire . to assess
the change in behavior in intellectually disabled children during tooth ache , a dental discomfort questionnaire ( ddq+ ) was developed .
the questionnaire was drafted after extensive interviews with parents or caregivers of children with pain by versloot et al .
a lot of questions relating to the behavior of intellectually disabled children were added to the ddq+ .
the questionnaire was filled during the interviews by the caregivers with the help of the investigators .
the questions were tabulated and the caregivers had to select the most appropriate option that explained the occurrence of pain / discomfort in children .
( scored as one ) , and  always  ( scored as two ) . a total numeric mean for each child and a mean of the ddq+ for the group
caregivers and investigators were also asked to rate the child 's dental pain on a ten point scale where  zero  represented the absence of pain and  ten  the maximum pain imaginable .
the scale was converted to an ordinal scale with never , mild , moderate , and severe categories .
mild pain was when the rating was between 1 and 3 , moderate was between 4 and 7 , and severe pain was between 8 and 10 .
the caries examination was based on the  who  criteria according to which the dmft / dft ( decayed , missing , and filled teeth ) indices were scored . a frank cavitation which is a break of 0.5  mm or more into enamel
any teeth filled with any restoration except sealants were considered as  filled  teeth .
student 's t - test , degree of freedom , mean and standard deviation , and chi - square test were analyzed .
the sample investigated in this study was a total of 236 children , out of which 111 were intellectually disabled children and 125 were healthy children .
the dmft and dft scores of the sample investigated were tabulated ( table 1 ) .
the difference in the number of filled teeth between the study and control group was negligible .
the investigators put forward questions describing the specific behavioral pattern of the children experiencing dental pain .
these questions were presented to the caregivers in order to find out the perception of dental pain between the control and study group and whether it was comparable .
the behavioral pattern which was specifically exhibited by the children during dental pain was documented as per the caregiver 's perception .
outcome of the tabulation in this study showed that i d children had problems in brushing teeth especially the upper teeth and it was statistically significant ( p = 0.00 ) .
the other significant change during pain included biting with the molar instead of the other teeth ( p = 0.001 ) .
most of the i d children reached for the cheek region while eating , a behavioral change depicting vague dental pain which they were unable to express otherwise . typically developing children
reported ear pain at night ( p = 0.014 ) , during daytime ( p = 0.02 ) , and a few while eating ( p = 0.01 ) . in the entire study , excessive salivation in i
d children during dental pain ( p = 0.00 ) was one of the most important behavioral changes observed by the caregivers . adding to this , the other significant behavioral change was the habit of placing their hand or objects inside the mouth ( p = 0.00 ) ( table 2 ) .
according to the international association for study of pain ( iasp ) , pain is defined as  an unpleasant sensory and emotional experience associated with actual or partial tissue damage . 
a reliable description of such pain is generally difficult in children and even more challenging in i d children .
intellectual disability is defined as mental retardation or impairment in the areas of development or cognitive activities .
intellectual disability is  a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior , which covers many everyday social and practical skills .
dental problems are more common in people with special needs , sometimes not only because of the disability itself but also because of inadequate oral health care .
these special children required special health care approaches as they had very poor oral hygiene . according to research and the literature , these children had physical , mental , sensory , behavioral , cognitive , emotional , and chronic medical conditions which required health care beyond the usual measures and which involved specialized knowledge , increased awareness , attention , and accommodation .
information about pain in children with cognitive impairment was always insufficient and less reliable for a dentist [ 1113 ] . to gather any data related to pain the investigators or health care provider had to rely on the caregiver 's perception depending on the level of cognitive impairment , and pain coping and expression varied in these special children .
the identification and interpretation of dental pain in severe cognitive communication and motor impairments were challenging .
we concluded that there is a high incidence of dental pain and treatment needs that are not catered to . in spite of parents and caregiver 's educational qualifications , dental pain
is rarely understood and treated ; this was due to the other major chronic systemic illnesses the children undergo .
hence , dental pain in children goes unnoticed often and they are not brought to the dentist for routine checkup .
mostly caregivers identify dental pain based on the i d children change in behavior and bring it to the notice of the healthcare provider .
hence , mostly i d children reach the dentist in an acute state of pain leaving very few options to save the teeth .
the data outcome of this study indicates that i d children have problem in brushing upper and lower teeth .
this was because of fear and anxiety amongst intellectually disabled children in placing a foreign object into their mouth .
children should be trained patiently to overcome these problems which require a dentist 's and a caregiver 's cooperation .
reaching for cheek while eating and earache at night or during meals were also common behavioral changes during dental pain .
the caregivers should understand these signs and bring the children to the dentist immediately because the pain expressed in such manner is mostly of acute nature .
most of the i d children had excessive salivation and the habit of placing their hand or objects inside the mouth during dental pain .
according to researches , an increase in dental caries causes more dental pain which leads to these pain related behavior .
so caregivers and dentists have to work mutually to recognize specific changes in behavioral pattern .
though this study was done based on research articles specializing on pediatric dentistry and cognitive impairment in children , it still had a number of limitations which include lack of professional assessment of i d children .
future studies including the comparison between different degrees of intellectual disability could further provide more specific conclusions .
intellectually disabled children had more problems in brushing upper teeth and exhibited the habit of reaching for the cheek while eating .
the prevalence of reporting dental pain was more in typically developing children than in intellectually disabled children .
 
 aim . children with developmental disabilities generally experience more pain than the normal children . 
 description of pain is generally difficult in children and more so in children with intellectual disabilities . 
 the study aimed at evaluating dental pain in children with intellectual disabilities . methods . 
 the survey was carried out in an institution caring for intellectually disabled children to determine the oral health status and the treatment needs of the special kids . 
 236 children were surveyed out of which the test group is comprised of 111 intellectually disabled children and the control group had 125 normal children with age ranging between five to eighteen years . 
 a questionnaire was presented to the caregivers to elaborate about dental pain in their wards using the dental discomfort questionnaire ( ddq+ ) . 
 the children were examined for dental caries and periodontal status based on the who indices for oral hygiene status . 
 result . 
 results revealed a statistically significant difference between intellectual disability and brushing , chewing , and earache . 
 the frequency of reporting dental pain was lesser in the intellectually disabled group . 
 conclusion . 
 children with intellectual disability tended to report dental pain of any nature with lesser frequency than typically developing peers . 
 they also faced greater difficulty in brushing and chewing . 
1. Introduction
2. Materials and Methods
3. Results
4. Discussion
5. Conclusion