Proportion of good oral hygiene and mean value oral hygiene index among children with cerebral palsy in Africa and Asia: a systematic review and meta-analysis
Ensuring adequate oral hygiene is crucial to prevent dental issues such as gum disease from advancing into more serious health complications, ultimately enhancing overall well-being and quality of life . This importance is heightened for children with Cerebral Palsy (CP), who face unique challenges related to oral health, highlighting the critical role of good oral hygiene in safeguarding their well-being and quality of life. CP , a neurological condition impacting movement and coordination, typically emerges in early childhood, emphasizing the need for comprehensive oral care in this specific population .While CP itself doesn’t directly induce poor hygiene practices in children, the condition presents challenges stemming from weakened muscle tone and irregular alignment, complicating the establishment of regular hygiene routines for both affected children and their caregivers . Assessing oral health involves categorizing debris index score falling between 0.3 and 0.6 is termed “good,” while scores ranging from 0.7 to 1.8 are considered “fair,” and a score of 1.9 to 3.0 indicates a “poor” oral health status. Additionally, each tooth is evaluated using the Oral Health Index (OHI), graded from 0 (no plaque) to 10 (plaque present in all sections) . Encouraging personal hygiene in children with CP is essential for multiple reasons, yet there persists a notable prevalence of inadequate oral care within this population, largely due to insufficient hygiene practices and interconnected risk factors . The incidence of poor oral hygiene among children with CP is notably elevated, underscoring the urgency of tailored interventions such as Nigeria 72.13% , Cameroon 43.3% , Uganda 32.2% , and India 28% . In children with cerebral palsy, poor oral hygiene stands out as a prevalent concern, leading to oral health issues and abnormal oral behaviors . The repercussions of insufficient oral care in these children encompass difficulties in sleeping, eating, speaking, playing, and interacting with peers . Additionally, inadequate oral hygiene heightens the risk of discomfort, cardiovascular ailments, cancer, diabetes, as well as compromised nutrition and growth in children with cerebral palsy . Consequently, upholding proper oral hygiene is crucial for enhancing the overall well-being and quality of life of these children. Despite this importance, there is a lack of comprehensive research examining oral hygiene practices and the average Oral Hygiene Index (OHI-Index) values among children with cerebral palsy special in resource-constrained settings. Therefore, this systematic review and meta-analysis aim to assess the proportion of good oral hygiene and the mean OHI-Index among children with cerebral palsy in Africa and Asia. 

Our review was guided by the following research questions: (i) what is the proportion of good oral hygiene. and (ii) what is mean value oral hygiene index among children with cerebral palsy in Africa and Asia? Searching strategies A systematic review and meta-analysis were conducted, adhering to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, in order to explore the level of good oral hygiene and the average value of the Oral Hygiene Index (OHI-index) in children with cerebral palsy residing in Asia and Africa. The PROSPERO was registered under CRD42024540182. The study utilized various databases, including PubMed, Scopus, Embase, Hinari, citation searching, and gray literature. The review utilized various search terms, such as Oral Hygiene, Oral Health, Oral Health Index, Dental Health Survey, Cerebral Palsy, Children, and Child to search across Asian and African countries. Boolean operators like “AND” and “OR” were used appropriately to combine these terms. The search was conducted from April 10 to May 01, 2023, covering all papers published up until May 01, 20,239 (Additional file 1). Eligibility criteria This review included full articles conducted among children with cerebral palsy in Africa and Asia, assessing the proportion of oral hygiene and/or the mean oral hygiene index. However, studies conducted outside these regions, lacking adequate data for assessing oral hygiene and/or the oral hygiene index, or unable to differentiate children with cerebral palsy from those with other special needs, were not included in the review. Furthermore, case reports, case series, and content from predatory journals were not taken into account. The strategies utilized to identify predatory journals includes confirming the journal’s indexing in reputable databases such as PubMed, Scopus, and Web of Science, use of predatory journal lists, seeking advice from peers and experts, and analyzing journal websites. The observational research designs (cross-sectional, cohort, and case-control) reporting on the proportion of oral hygiene and/or the mean OHI-index value among children diagnosed with cerebral palsy in Asia and/or Africa were considered. Outcome of interests The oral hygiene proportion and/or mean OHI-index value among children with cerebral palsy within Asia and Africa. Outcome measurement among children with cerebral palsy This systematic review emphasizes two main outcome variables. The primary variable involves the proportion of good oral hygiene, computed by dividing the number of children with cerebral palsy showcasing good oral hygiene by the total number of children with cerebral palsy displaying poor, fair, and good oral hygiene, and then multiplied by 100. The second outcome variable is focused on calculating the mean value of the OHI index. We utilized the Oral Hygiene Index (OHI), a well-established and validated tool employed to evaluate oral hygiene status, to maintain a standardized and comparable measure across the studies. Study selection After conducting a literature search, the retrieved articles were imported into Zotero Library, and duplicates were removed. Four reviewers (NM, DTA, ZAA, and MAZ) initially screened the titles and abstracts, and then assessed the full texts of selected papers based on predetermined eligibility criteria. The eligibility of potentially included studies was thoroughly evaluated by six authors (ESC, AK, NAT, NAG, and MAM), with any discrepancies resolved through discussions involving a third reviewer (MAS, MMG, and ECA). Data extraction The titles and abstracts of all studies were thoroughly screened using a standardized JBI data extraction format by six authors (ESC, YSK, AMD, BB, TAD, and KSC) to extract relevant data. The data extraction format included information such as primary author, continent/country, year of publication, study area, study design, sample size, prevalence, and OHI-index with 95% confidence interval or standard deviation score for each study. Any discrepancies or differences of opinion were resolved through discussion and agreement during the data extraction process. The retrieved studies were organized using the citation manager Zotero, and duplicate articles were removed. Any disagreements were resolved through a consensus meeting with other reviewers (ESC, MAZ, HSH, NAG, and SSC) to finalize the selection of studies for inclusion in the systematic review and meta-analysis. Quality assessment The Joanna Briggs Institute Critical Appraisal tool for use in JBI Systematic Reviews (JBI-MAStARI) was used to assess the trustworthiness, relevance, and results of published papers . The tool compromises eight main standards for evaluating each primary study critically. As a result, primary studies that had a score of 50% or higher were included in the systematic review and meta-analysis study. Statistical analysis The data extracted from the reviewed articles were editing, cleaning, and verification for completeness in an Excel sheet. Subsequently, the data was exported to STATA 17 software for further analysis. A meta-analysis was conducted using a random effects model to estimate the overall pooled prevalence of good oral hygiene and the mean value of the OHI-index. The heterogeneity of reported prevalence and mean value was assessed using Cochrane Q-statistics and p-values from the I 2 test. Publication bias was assessed using a funnel plot, and sensitivity analysis was performed to evaluate the impact of individual studies on the overall estimation. Additionally, subgroup analysis was conducted based on factors such as the continent of the study, study design, sample size, and year of publication. 

A systematic review and meta-analysis were conducted, adhering to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, in order to explore the level of good oral hygiene and the average value of the Oral Hygiene Index (OHI-index) in children with cerebral palsy residing in Asia and Africa. The PROSPERO was registered under CRD42024540182. The study utilized various databases, including PubMed, Scopus, Embase, Hinari, citation searching, and gray literature. The review utilized various search terms, such as Oral Hygiene, Oral Health, Oral Health Index, Dental Health Survey, Cerebral Palsy, Children, and Child to search across Asian and African countries. Boolean operators like “AND” and “OR” were used appropriately to combine these terms. The search was conducted from April 10 to May 01, 2023, covering all papers published up until May 01, 20,239 (Additional file 1). Eligibility criteria This review included full articles conducted among children with cerebral palsy in Africa and Asia, assessing the proportion of oral hygiene and/or the mean oral hygiene index. However, studies conducted outside these regions, lacking adequate data for assessing oral hygiene and/or the oral hygiene index, or unable to differentiate children with cerebral palsy from those with other special needs, were not included in the review. Furthermore, case reports, case series, and content from predatory journals were not taken into account. The strategies utilized to identify predatory journals includes confirming the journal’s indexing in reputable databases such as PubMed, Scopus, and Web of Science, use of predatory journal lists, seeking advice from peers and experts, and analyzing journal websites. The observational research designs (cross-sectional, cohort, and case-control) reporting on the proportion of oral hygiene and/or the mean OHI-index value among children diagnosed with cerebral palsy in Asia and/or Africa were considered. Outcome of interests The oral hygiene proportion and/or mean OHI-index value among children with cerebral palsy within Asia and Africa. Outcome measurement among children with cerebral palsy This systematic review emphasizes two main outcome variables. The primary variable involves the proportion of good oral hygiene, computed by dividing the number of children with cerebral palsy showcasing good oral hygiene by the total number of children with cerebral palsy displaying poor, fair, and good oral hygiene, and then multiplied by 100. The second outcome variable is focused on calculating the mean value of the OHI index. We utilized the Oral Hygiene Index (OHI), a well-established and validated tool employed to evaluate oral hygiene status, to maintain a standardized and comparable measure across the studies. 

This review included full articles conducted among children with cerebral palsy in Africa and Asia, assessing the proportion of oral hygiene and/or the mean oral hygiene index. However, studies conducted outside these regions, lacking adequate data for assessing oral hygiene and/or the oral hygiene index, or unable to differentiate children with cerebral palsy from those with other special needs, were not included in the review. Furthermore, case reports, case series, and content from predatory journals were not taken into account. The strategies utilized to identify predatory journals includes confirming the journal’s indexing in reputable databases such as PubMed, Scopus, and Web of Science, use of predatory journal lists, seeking advice from peers and experts, and analyzing journal websites. The observational research designs (cross-sectional, cohort, and case-control) reporting on the proportion of oral hygiene and/or the mean OHI-index value among children diagnosed with cerebral palsy in Asia and/or Africa were considered. 

The oral hygiene proportion and/or mean OHI-index value among children with cerebral palsy within Asia and Africa. 

This systematic review emphasizes two main outcome variables. The primary variable involves the proportion of good oral hygiene, computed by dividing the number of children with cerebral palsy showcasing good oral hygiene by the total number of children with cerebral palsy displaying poor, fair, and good oral hygiene, and then multiplied by 100. The second outcome variable is focused on calculating the mean value of the OHI index. We utilized the Oral Hygiene Index (OHI), a well-established and validated tool employed to evaluate oral hygiene status, to maintain a standardized and comparable measure across the studies. 

After conducting a literature search, the retrieved articles were imported into Zotero Library, and duplicates were removed. Four reviewers (NM, DTA, ZAA, and MAZ) initially screened the titles and abstracts, and then assessed the full texts of selected papers based on predetermined eligibility criteria. The eligibility of potentially included studies was thoroughly evaluated by six authors (ESC, AK, NAT, NAG, and MAM), with any discrepancies resolved through discussions involving a third reviewer (MAS, MMG, and ECA). 

The titles and abstracts of all studies were thoroughly screened using a standardized JBI data extraction format by six authors (ESC, YSK, AMD, BB, TAD, and KSC) to extract relevant data. The data extraction format included information such as primary author, continent/country, year of publication, study area, study design, sample size, prevalence, and OHI-index with 95% confidence interval or standard deviation score for each study. Any discrepancies or differences of opinion were resolved through discussion and agreement during the data extraction process. The retrieved studies were organized using the citation manager Zotero, and duplicate articles were removed. Any disagreements were resolved through a consensus meeting with other reviewers (ESC, MAZ, HSH, NAG, and SSC) to finalize the selection of studies for inclusion in the systematic review and meta-analysis. 

The Joanna Briggs Institute Critical Appraisal tool for use in JBI Systematic Reviews (JBI-MAStARI) was used to assess the trustworthiness, relevance, and results of published papers . The tool compromises eight main standards for evaluating each primary study critically. As a result, primary studies that had a score of 50% or higher were included in the systematic review and meta-analysis study. 

The data extracted from the reviewed articles were editing, cleaning, and verification for completeness in an Excel sheet. Subsequently, the data was exported to STATA 17 software for further analysis. A meta-analysis was conducted using a random effects model to estimate the overall pooled prevalence of good oral hygiene and the mean value of the OHI-index. The heterogeneity of reported prevalence and mean value was assessed using Cochrane Q-statistics and p-values from the I 2 test. Publication bias was assessed using a funnel plot, and sensitivity analysis was performed to evaluate the impact of individual studies on the overall estimation. Additionally, subgroup analysis was conducted based on factors such as the continent of the study, study design, sample size, and year of publication. 

Search result Initially, 8,728 records were identified through a database search, with no results from gray literature searches. After removing 5,235 duplicates, 4,493 records were reviewed, leading to the exclusion of 2,869 articels. Subsequently, 1,624 full-text articles were evaluated for eligibility, resulting in the exclusion of 1,607 articels due to inadequate data for assessing the outcome variable and the challenge of differentiating children with cerebral palsy from those with other special needs (Fig. ). Study characteristics The analysis encompassed research conducted in nine countries across Asia and Africa spanning from 2011 to 2022. Nigeria and India had four studies each, while Saudi Arabia had three. Furthermore, Egypt, Malaysia, Cameroon, the United Arab Emirates, Uganda, and Turkey were each represented by one study. Out of the studies considered, 12 were cross-sectional and 5 were case-control studies. The sample sizes varied from 25 participants in an Indian study to 140 in a study from Saudi Arabia. (Table ). Meta-analysis The analysis of studies conducted in Asia and Africa found that most of the studies (14 out of the total) reported a good oral hygiene rate among children with cerebral palsy. Nine studies also reported the average value of the OHI-index for these children. The reported proportion for good oral hygiene varied, with the highest rate of 72.1% reported in a study from Nigeria , and the lowest rate of 5.3% also reported in Nigeria . Similarly, the mean value of the OHI-index ranged from the highest value of 5.8 reported in a study from Saudi Arabia  to the lowest value of 1.1 reported in a study from Nigeria (Study . By using a random-effects model analysis, the pooled estimate of good oral hygiene among children with cerebral palsy in Asia and Africa was found to be 21.8% (95% CI; 14.2–29.4), as shown in (Fig. ). Furthermore, the pooled mean value of the OHI-index among children with cerebral palsy in Asia and Africa, based on the random-effects model analysis, was found to be 1.9 (95%CI; 0.8–2.9), as presented in (Fig. ). The proportion of good oral hygiene among children with cerebral palsy in Africa and Asia by different categories There was substantial heterogeneity observed among the groups (I 2 = 93.2%) prompted us to analyze the level of good oral hygiene rates and the mean value of the OHI-Index among children with cerebral palsy, considering various categories for analysis. These categories included continents, year of publication, study design, and sample size. By conducting heterogeneity analysis, we were able to guide the pooling of study results and ensure the accurate interpretation of the findings in this study. The study conducted separate analyses on the proportion of good oral hygiene in Africa and Asia, showing that the estimated proportion was 33.3% (95% CI: 15.1–51.4) for Africa and 11.7% (95% CI: 7.6–15.9) for Asia, as presented in (Fig. ). Additionally, the study categorized the proportion good oral hygiene based on the study design, revealing that 22.9% (95% CI: 10.4–35.4) for case-control studies and 21.5% (95% CI: 12.6–30.4) for cross-sectional studies, as shown in (Fig. ). Furthermore, the analysis considered the difference in publication year, the proportions good oral hygiene was found to be 23.2% (95% CI: 10.1–36.3) for publications before ≤ 2015 and 20.3% (95% CI: 11.4–29.3) for publications after > 2015, as displayed in (Fig. ). Lastly, the study examined the proportion of good oral hygiene based on sample size, 28.3% (95% CI: 11.0-45.6) for sample sizes ≤ 70 and 15.8% (95% CI: 9.3–22.2) for sample sizes > 70, as presented in (Fig. ). The mean value of OHI-index among children with cerebral palsy in Africa and Asia by different categories In our analysis, we are categorizing the mean of OHI-index values for children with cerebral palsy into different stratified groups based on various criteria. The weighting process considers different factors. For instance, when examining data by continent, we find that Asia has a mean value of 1.9 with an effect size between 0.2 and 3.6, weighted at 35.8%, while Africa shows a mean value of 1.8 with an effect size ranging from 0.5 to 3.1, weighted at 64.3%. Additionally, considering study design, case-control studies have a mean value of 1.8 with an effect size from 0.4 to 3.2, representing 51.4% of the weight, whereas cross-sectional studies display a mean value of 1.9 with an effect size between 0.5 and 3.4, contributing 48.6% to the weight. Further analyses based on publication year and sample size are also conducted to understand variations in the mean OHI-index values within these groups (Table ). Publication bias Funnel plot tests were employed to assess potential bias or systematic heterogeneity in the proportion of good oral hygiene among children with cerebral palsy in Asia and Africa (Fig. ). Additionally, Funnel plot tests were utilized to evaluate any potential bias or systematic variability in the average OHI-index values among children with cerebral palsy in Asia and Africa (Fig. ). Moreover, Furthermore, sensitivity analyses employing the random effect model were conducted to the mean value OHI-index values among children with cerebral palsy (Table ). Furthermore, the sensitivity analyses utilizing the random effect model for the proportion of good oral hygiene in children with cerebral palsy are conducted, with the results of these assessments showcased (Fig. ). 

Initially, 8,728 records were identified through a database search, with no results from gray literature searches. After removing 5,235 duplicates, 4,493 records were reviewed, leading to the exclusion of 2,869 articels. Subsequently, 1,624 full-text articles were evaluated for eligibility, resulting in the exclusion of 1,607 articels due to inadequate data for assessing the outcome variable and the challenge of differentiating children with cerebral palsy from those with other special needs (Fig. ). 

The analysis encompassed research conducted in nine countries across Asia and Africa spanning from 2011 to 2022. Nigeria and India had four studies each, while Saudi Arabia had three. Furthermore, Egypt, Malaysia, Cameroon, the United Arab Emirates, Uganda, and Turkey were each represented by one study. Out of the studies considered, 12 were cross-sectional and 5 were case-control studies. The sample sizes varied from 25 participants in an Indian study to 140 in a study from Saudi Arabia. (Table ). 

The analysis of studies conducted in Asia and Africa found that most of the studies (14 out of the total) reported a good oral hygiene rate among children with cerebral palsy. Nine studies also reported the average value of the OHI-index for these children. The reported proportion for good oral hygiene varied, with the highest rate of 72.1% reported in a study from Nigeria , and the lowest rate of 5.3% also reported in Nigeria . Similarly, the mean value of the OHI-index ranged from the highest value of 5.8 reported in a study from Saudi Arabia  to the lowest value of 1.1 reported in a study from Nigeria (Study . By using a random-effects model analysis, the pooled estimate of good oral hygiene among children with cerebral palsy in Asia and Africa was found to be 21.8% (95% CI; 14.2–29.4), as shown in (Fig. ). Furthermore, the pooled mean value of the OHI-index among children with cerebral palsy in Asia and Africa, based on the random-effects model analysis, was found to be 1.9 (95%CI; 0.8–2.9), as presented in (Fig. ). 

There was substantial heterogeneity observed among the groups (I 2 = 93.2%) prompted us to analyze the level of good oral hygiene rates and the mean value of the OHI-Index among children with cerebral palsy, considering various categories for analysis. These categories included continents, year of publication, study design, and sample size. By conducting heterogeneity analysis, we were able to guide the pooling of study results and ensure the accurate interpretation of the findings in this study. The study conducted separate analyses on the proportion of good oral hygiene in Africa and Asia, showing that the estimated proportion was 33.3% (95% CI: 15.1–51.4) for Africa and 11.7% (95% CI: 7.6–15.9) for Asia, as presented in (Fig. ). Additionally, the study categorized the proportion good oral hygiene based on the study design, revealing that 22.9% (95% CI: 10.4–35.4) for case-control studies and 21.5% (95% CI: 12.6–30.4) for cross-sectional studies, as shown in (Fig. ). Furthermore, the analysis considered the difference in publication year, the proportions good oral hygiene was found to be 23.2% (95% CI: 10.1–36.3) for publications before ≤ 2015 and 20.3% (95% CI: 11.4–29.3) for publications after > 2015, as displayed in (Fig. ). Lastly, the study examined the proportion of good oral hygiene based on sample size, 28.3% (95% CI: 11.0-45.6) for sample sizes ≤ 70 and 15.8% (95% CI: 9.3–22.2) for sample sizes > 70, as presented in (Fig. ). 

In our analysis, we are categorizing the mean of OHI-index values for children with cerebral palsy into different stratified groups based on various criteria. The weighting process considers different factors. For instance, when examining data by continent, we find that Asia has a mean value of 1.9 with an effect size between 0.2 and 3.6, weighted at 35.8%, while Africa shows a mean value of 1.8 with an effect size ranging from 0.5 to 3.1, weighted at 64.3%. Additionally, considering study design, case-control studies have a mean value of 1.8 with an effect size from 0.4 to 3.2, representing 51.4% of the weight, whereas cross-sectional studies display a mean value of 1.9 with an effect size between 0.5 and 3.4, contributing 48.6% to the weight. Further analyses based on publication year and sample size are also conducted to understand variations in the mean OHI-index values within these groups (Table ). 

Funnel plot tests were employed to assess potential bias or systematic heterogeneity in the proportion of good oral hygiene among children with cerebral palsy in Asia and Africa (Fig. ). Additionally, Funnel plot tests were utilized to evaluate any potential bias or systematic variability in the average OHI-index values among children with cerebral palsy in Asia and Africa (Fig. ). Moreover, Furthermore, sensitivity analyses employing the random effect model were conducted to the mean value OHI-index values among children with cerebral palsy (Table ). Furthermore, the sensitivity analyses utilizing the random effect model for the proportion of good oral hygiene in children with cerebral palsy are conducted, with the results of these assessments showcased (Fig. ). 

The study assesses the good oral hygiene and mean oral hygiene index among children with cerebral palsy in Asia and Africa. It discovered that only about one-fifth of these children upheld good oral hygiene practices in these regions, indicating a significant deficiency in essential oral health care among this vulnerable population. Additional analyses revealed differences in proportion of oral hygiene between Africa and Asia, as well as variations in study aspects like methodologies, publication dates, and sample sizes. The review will enrich the existing knowledge base concerning oral health among children with CP, offering crucial insights for healthcare providers, policymakers, and researchers striving to enhance oral health outcomes in Asia and Africa. These findings have the potential to guide the formulation of targeted interventions, preventive measures, increasing awareness, and providing education to address the distinct challenges encountered by children with CP in these regions. Moreover. the findings of proportion of good oral hygiene and the mean value of the OHI-index varied across the group in the review. Therefore, it is advisable that healthcare providers, public health entities, caregivers, parents, researchers, and policymakers thoroughly take into account the subgroup results in oral hygiene proportions and OHI index among children with cerebral palsy across various demographic categories. This thorough strategy will improve our understanding of the consequences of oral health outcomes in this vulnerable population. The proportion of good oral hygiene was low among children with cerebral palsy in Asia and Africa. Additionally, oral hygiene index was more prevalent among children with cerebral palsy. In this review, oral hygiene among children with cerebral palsy in Asia and Africa was similar to the global rate in Italy  and Brazil . However, the mean OHI-index reported in this review was higher than studies from Albania , while the prevalence of good oral hygiene and the mean OHI-index were lower compared to studies conducted in Brazil  and Croatia . The study’s outcomes emphasize the critical need to tackle oral health disparities among children with cerebral palsy in the regions. Recognizing potential limitations in healthcare resources, especially in African region, timely preventive measures and treatments are essential to uphold good oral hygiene and prevent the onset of more severe health complications, ultimately improving the well-being and quality of life of these vulnerable populations. The significant variability observed among the groups (I 2 = 93.2%) prompted further analysis of proportion oral hygiene and the mean OHI-Index among children with cerebral palsy across diverse categories. The study aimed to aid in consolidating research findings for accurate interpretation through this analysis. Notable differences in proportion of good oral hygiene and mean OHI-Index values were identified in Africa and Asia, further explored based on study design, publication year, and sample size. The observed discrepancies may be attributed to differences in sampling size, study conditions, study time, and participant characteristics. Additionally, variations in oral health knowledge, perception, cultural background, and practices could also contribute to the differences . This review assessed the proportion good oral hygien and OHI index in Africa and Asia, possibly being the first study to do so, supported by strong data collection and in-depth subgroup analyses. However, limitations include restricted generalizability, potential publication bias, reliance on study quality, and the exclusive concentration on children with cerebral palsy in Asia and Africa. Furthermore, the review was confined to quantitative observational studies, excluded research that did not differentiate between various special needs, and it did not investigate the factors that affect oral hygiene among children with cerebral palsy in Asia and Africa. 

This review suggested that the proportion of good oral hygiene among children with cerebral palsy appears insufficient in Asia and Africa. With just one-fifth exhibiting good oral hygiene, it is advisable to strengthen interventions and support programs in both regions to enhance oral hygiene in this vulnerable population. Further research better to focus on identifying potential factors and conducting qualitative investigations to comprehend the perspectives of children and caregivers on oral hygiene within these regions. 

Below is the link to the electronic supplementary material. Supplementary Material 1 

