|Year : 2014 | Volume
| Issue : 2 | Page : 135-139
Oral health status and parental perception of child oral health related quality-of-life of children with autism in Bangalore, India
Richa, R Yashoda, Manjunath P Puranik
Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Bengaluru, Karnataka, India
|Date of Web Publication||17-Apr-2014|
Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Children with autism present with the physical-mental impairments and oral problems, which may have an impact on their quality-of-life (QoL). The aim of the following study was to assess oral health status and parental perception of child oral health related quality of life (OHRQoL) among children with autism. Materials and Methods: A cross-sectional study was conducted in 4-15-year-old children with autism (n = 135) and children without autism (n = 135). Oral health status was evaluated using Oral Hygiene Index-Simplified (OHI-S), its Miglani's modification for deciduous teeth, Decayed, missing and filled teeth (DMFT/dmft) and Decayed, missing and filled surface (DMFS/dmfs) indices. Parents answered the Parental-Caregivers Perception Questionnaire for assessing children's OHRQoL. Mann-Whitney U, Chi-square test and Pearson's correlation analysis were performed. Results: Mean OHI-S, DMFT, dmft scores were significantly high among children with autism (2.07 ± 0.83; 0.86 ± 1.22, 1.40 ± 2.48) when compared to children without autism (0.46 ± 0.58; 0.46 ± 1.06, 0.59 ± 1.28) respectively. Out of all domains of OHRQoL, mean score of functional limitations related to teeth problem was significantly higher among children with autism (8.87 ± 5.65) as compared to non-autism group (6.66 ± 4.97). Conclusion: Functional limitations may have a negative impact on oral health status that might influence OHRQoL.
Keywords: Autism, DMFT, oral health, perception, quality of life
|How to cite this article:|
Richa, Yashoda R, Puranik MP. Oral health status and parental perception of child oral health related quality-of-life of children with autism in Bangalore, India. J Indian Soc Pedod Prev Dent 2014;32:135-9
|How to cite this URL:|
Richa, Yashoda R, Puranik MP. Oral health status and parental perception of child oral health related quality-of-life of children with autism in Bangalore, India. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Jul 22];32:135-9. Available from: http://www.jisppd.com/text.asp?2014/32/2/135/130967
| Introduction|| |
Autism is a developmental, neuropsychiatric disorder that begins in early childhood first described in 1943 by Leo Kanner, an American child psychiatrist. Autistic disorder (AD) is a psychiatric childhood disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (EM-IV) under the section Pervasive Developmental Disorders.  The phenotype is described in three diagnostic behavioral domains: Impairments in social interactions, impairments in communication and repetitive or restrictive behaviors, with symptoms varying from mild to severe. 
There are no biological tests for autism. Its diagnosis is made in an individual between 2 and 4 years of age on the basis of the presence and extent of the three domains as mentioned earlier. , There is no cure for AD, but intensive behavioral therapy has strong beneficial effects, especially, if initiated early.  Co-morbid disorders, the effects of prescribed medications, increased or reduced saliva in the mouth, poor dietary habits, damaging oral habits such as bruxism or pica and poor oral self-care can impede adequate oral care and increase the risk of developing caries and periodontal disease in children with autism. 
Unfortunately, children with autism are almost twice as likely to have unmet oral health care needs than their peers without disabilities and represent one such population at high risk for poor oral health.  Poor oral health can lead to eating difficulties, speech impediments, oral pain, sleep disturbances, missed days of school and decreased self-esteem, ultimately resulting in a negative effect on health and quality of life (QoL).  Health-related QoL in young autistic patients has been studied extensively whereas considerably less attention has been given to the oral health related quality of life (OHRQoL) in children with autism. 
It has been consistently shown that parents can serve as proxies or judges of OHRQoL and their importance in caring for children with autism becomes even more important. 
A few studies in India have described oral health status of children with autism ,, and studies on OHRQoL of these children are lacking. Study was done to evaluate whether there was a significant difference in oral health and OHRQoL among children with autism compared to those in children without autism in Bangalore City and to plan preventive measures for these children in future.
| Materials and Methods|| |
The cross-sectional comparative study was performed for 3 months period from May 2012 to July 2012 in Bangalore City, India. Ethical approval was obtained from the Institutional Ethic Committee. The parents of all the children were informed of the nature of investigation. Prior to examination, written informed consent was obtained from the parents.
A total of 135 participants with autism attending various special schools and 135 children from regular schools (children without autism group) between the age group of 4 and 15 years were recruited.
For children with autism, inclusion criteria was diagnosis of autism (based on records) and exclusion criteria were oral prophylaxis in the last 6 months; suffering from other diseases known to influence dental caries or the severity of periodontal disease such as Down's syndrome and diabetes and undergoing antibiotic medication. For children without autism, medically fit (based on records) children were included and subjects undergoing antibiotic or anti-inflammatory therapy or had undergone such therapy in the previous 6 months were excluded.
Parents were asked to fill the structured proforma that included information on the child's chronological age, socio-economic status, oral hygiene practices, oral habit history, dietary habits, medical and dental history. Parental perception was assessed using a pre-validated 31-item Parental/caregiver perception questionnaire of child OHRQoL (Parental-Caregivers Perception Questionnaire). It included four domains-oral symptoms, functional limitations, emotional well-being and social well-being related to teeth problems. It consisted of six items in oral symptoms domain; eight items in functional limitations domain; seven items in emotional well-being domain; and 10 items in social well-being domain. Parents rated the items on the four-point Likert scale ranging from zero (does not bother my child) to three (Bothers my child very much).  Questionnaire was administered in local language after ensuring linguistic reliability by back translation method.
Training and calibration of principal examiner (R) was carried before the start of the study. Both children with and without autism were examined at their schools, seated on a comfortable chair, under natural light using sterile instruments which included mouth mirror, explorer and cotton pellets. Oral health status was assessed by using Oral Hygiene index-Simplified (OHI-S) given by Greene and Vermillion,  its modification for deciduous teeth by Miglani et al.,  DMFT/dmft and DMFS/dmfs indices. ,
Data was entered into a database (Microsoft Office Excel 2007). Statistical analyses was performed by using statistical software SPSS 16.0, SPSS Inc.,Chicago,USA. The results were analyzed using Mann-Whitney U, Chi-square test and Pearson's correlation tests. Cohen's Kappa statistic was used to test intrarater reliability in assessment of indices (k = 0.94).
| Results|| |
[Table 1] depicts that there were more males (108) than females (27) with male:female ratio 4:1 within the children with autism group. Within the comparison group, there were 79 males and 56 females. Among the three age groups, maximum children were present in 8-11 years age group. According to modified Kuppuswamy socio-economic status, most of the children belonged to upper and upper-middle classes. 
Seventy two (53.3%) with autism and 75 (55.6%) without autism children had visited the dentist. Among them, 45 (62.5%) children with autism and 38 (50.7%) without autism visited in last 1 year. Most of children with autism (97%) were using the toothbrush for cleaning their teeth. Among them 34 children were using powered toothbrushes.
[Table 2] shows that among self-inflicting trauma habits, biting lips, biting extremities and hair pulling were significantly associated with children with autism. Some children had more than one type of habit.
|Table 2: Comparison of autism and non autism group with self — infl icting habits history|
Click here to view
Mean OHI-S, DMFT, dmft, DMFS and dmfs score was found be significantly higher among children with autism (2.07 ± 0.83; 0.86 ± 1.22, 1.40 ± 2.48, 0.9 ± 1.33, 2.65 ± 6.32) as compared to the comparison group (0.46 ± 0.58; 0.46 ± 1.06, 0.59 ± 1.28, 0.59 ± 1.40, 1.13 ± 2.81) respectively as shown in [Table 3].
|Table 3: Mean oral hygiene scores and caries prevalence in the autism and non-autism group|
Click here to view
[Table 4] presents significantly higher OHRQoL score among children with autism. Out of all domains of OHRQoL, mean score of functional limitations related to teeth problem was significantly higher among children with autism as compared to children without autism (P < 0.05).
[Table 5] shows weak correlation was observed between variables of oral health status and domains of OHRQoL among autism and comparison group, although showed significance for some variables only.
|Table 4: Mean domain scores of OHRQoL in the autism and non autism group|
Click here to view
|Table 5: Correlation between variables of oral health status and domains of OHRQoL among autism and non-autism group|
Click here to view
A significant correlation was found between DMFT and oral symptoms in children with autism. All the domains correlated with dmft significantly except social well-being although the correlation was weak in children with autism whereas only functional limitations and emotional well-being correlated with dmft in children without autism. Similarly, emotional well-being significantly correlated with DMFS in children without autism whereas oral symptoms and functional limitations significantly correlated with dmfs in children with autism.
| Discussion|| |
Oral health related research is scarce in children with autism. The most of the research has focused on children with autism spectrum disorder in developed countries.  To the best of our knowledge, there are only three published studies which describe oral health status of children with autism in India. ,, This cross-sectional comparative study was conducted to identify the oral problems and to assess parental perception of OHRQoL of children with autism and to compare this with that of a group of unaffected children.
In this study, male to female ratio was 4:1; this might reflect the higher prevalence of autism in males which concurs with the previously reported literature. ,,,,, More biased prevalence in males could be the effect of high level of fetal testosterone and potential genetic/chromosomal effects. 
The socio-economic status was assessed according to the modified Kuppuswamy's socio-economic scale. It is an important tool in hospital and community based research in India. This scale takes account of education, occupation and income of the family to classify study groups in to high, middle and low socioeconomic status.  Earlier reports have suggested that children with autism usually belong to high social class distribution.  This study observed 66.7% of children with autism in upper socio-economic class.
Self-inflicting behavior is most distressing event for children with autism. Habit of hitting, banging, biting, pricking, pinching and grinding were observed in 70% of children with autism.  In the present study, these habits specially biting lips, biting extremities, hair pulling were significantly associated with autistic group when compared to the non-autistic group and were found to be present in 61.4% of children with autism. Some children presented with more than one type of self-injurious habit.
For autistic children, school is the best place of examination, since they are used to this environment. A change of location for dental examination would probably provoke negative behavior in this group of children. Prior to each oral health assessment of children with autism, care takers were asked to give suggestions for the appropriate stimulus for participants to open their mouth. If participants were uncooperative, additional approaches were used such as involvement of the parents or care takers in the examination process and singing songs by the care taker. 
It has been observed in the previous literature that poor oral hygiene in children with autism can be attributed to decreased frequency of rinsing/swishing combined with the lack of interest in oral hygiene ,,, pouching of food in the mouth for a longer time,  lack of the necessary manual dexterity of children with autism, which result in inadequate tooth brushing. ,, All children with autism could not brush independently and needed assistance, motivation and supervision.  Hence, these changes could also be related to difficulties that parents encountered when they brushed the children's teeth. In the present study also, most of children with autism had poor oral hygiene compared with the comparison group.
Children with autism are often cited as having certain behaviors/life factors which may lead to an increased risk for dental caries. These are poorer masticatory abilities and medications causing xerostomia as Methamphetamine,  medication in the form of sweet syrup solution and the poor oral hygiene practices. Caries prevalence among children with autism was high compared to children without autism, although this caries level is considered low according to the World Health Organization classification. This finding agrees with the findings of Jaber MA and Murshid EZ , whereas earlier studies reported lower caries prevalence. ,,,, Further research is required to assess the role of these factors in the development of dental caries.
The importance of oral health cannot be underestimated; oral health has an impact on an individual's overall health as well as QoL. Dental practitioners should be able to serve the need of individuals diagnosed with autism as this population is continuing to grow. This study shows that OHRQoL score is significantly higher in children with autism as compared to children without autism. It may have a negative impact on oral health.
In the present study, functional limitation was significantly higher among the children with autism compared to children without autism. This could be related to self-inflicting habits and eating disorders which are predominantly seen among this group. This is in contrast to study by Pani SC et al. where all other domains showed significant differences except the oral symptoms domain. This can perhaps be attributed to the fact that parents may feel inclined to feel more sympathetic towards the disability of the child.  Correlation between oral health status and all domains of OHRQoL was weak in both groups.
This study has a few limitations. Parents answered the questionnaire which may not clearly reflect children's feeling and conditions. Second, only special schools for children with autism were considered since these children not attending special schools were beyond the scope of the study.
Children with autism are usually treated by comprehensive multidisciplinary approach including psychologist, neurologist, psychiatrist, speech therapist and physiotherapist. However, we would like to recommend involvement of dentists in the multidisciplinary approach. Dentist may serve an important role in the integration of oral health care into the day to day life of the child, training as well as education of parents and care givers and regular preventive professional oral health care. This can contribute to good oral hygiene and better OHRQoL of children with autism.
| Conclusion|| |
Higher caries prevalence and poor oral hygiene may have negative impact on OHRQoL of children with autism compared to children without autism. Sustained training and education of parents and caregivers can make a difference in the oral health of children with autism in a long run to improve their OHRQoL.
| Acknowledgment|| |
We would like to thank special schools participated in the study (Apoorva Centre for Autism, Shristi Special Academy, Academy for Severe Handicaps and Autism (ASHA) and Deepika School, Bengaluru). We would like to thank the children and families who participated in this research. A Special thanks to Mr. Javali for statistical analysis of our research work.
| References|| |
|1.||Klein U, Nowak AJ. Characteristics of patients with autistic disorder (AD) presenting for dental treatment: A survey and chart review. Spec Care Dentist 1999;19:200-7. |
|2.||Rada RE. Controversial issues in treating the dental patient with autism. J Am Dent Assoc 2010;141:947-53. |
|3.||Stein LI, Polido JC, Mailloux Z, Coleman GG, Cermak SA. Oral care and sensory sensitivities in children with autism spectrum disorders. Spec Care Dentist 2011;31:102-10. |
|4.||Stein LI, Polido JC, Najera SO, Cermak SA. Oral care experiences and challenges in children with autism spectrum disorders. Pediatr Dent 2012;34:387-91. |
|5.||Pani SC, Mubaraki SA, Ahmed YT, Alturki RY, Almahfouz SF. Parental perceptions of the oral health-related quality of life of autistic children in Saudi Arabia. Spec Care Dentist 2013;33:8-12. |
|6.||Vishnu Rekha C, Arangannal P, Shahed H. Oral health status of children with autistic disorder in Chennai. Eur Arch Paediatr Dent 2012;13:126-31. |
|7.||Subramaniam P, Gupta M. Oral health status of autistic children in India. J Clin Pediatr Dent 2011;36:43-7. |
|8.||Rai K, Hegde AM, Jose N. Salivary antioxidants and oral health in children with autism. Arch Oral Biol 2012;57:1116-20. |
|9.||Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Measuring parental perceptions of child oral health-related quality of life. J Public Health Dent 2003;63:67-72. |
|10.||Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13. |
|11.||Miglani DC, Beal JF, James PM, Behari SA. The assessment of dental cleanliness status of the primary dentition using a modification of the simplified oral hygiene index (OHIS-M). J Indian Dent Assoc 1973;45:385-8. |
|12.||Klein H, Palmer, CE, Knutson JW. Dental status and dental needs of elementary school children. Public Health Rep 1938;53:751-65. |
|13.||Grubbel AO. A measurement of dental caries prevalence and treatment service for deciduous teeth. J Dent Res 1944;23:163-8. |
|14.||Patro BK, Jeyashree K, Gupta PK. Kuppuswamy's socioeconomic status scale 2010-the need for periodic revision. Indian J Pediatr 2012;79:395-6. |
|15.||Jaber MA. Dental caries experience, oral health status and treatment needs of dental patients with autism. J Appl Oral Sci 2011;19:212-7. |
|16.||Loo CY, Graham RM, Hughes CV. The caries experience and behavior of dental patients with autism spectrum disorder. J Am Dent Assoc 2008;139:1518-24. |
|17.||Klein U, Nowak AJ. Autistic disorder: A review for the pediatric dentist. Pediatr Dent 1998;20:312-7. |
|18.||Murshid EZ. Oral health status, dental needs, habits and behavior attitude towards dental treatment of a group of autistic children in Riyadh. Saudi Arabia. Saudi Dent J 2005;17:132-9. |
|19.||Baron-Cohen S, Lombardo MV, Auyeung B, Ashwin E, Chakrabarti B, Knickmeyer R. Why are autism spectrum conditions more prevalent in males? PLoS Biol 2011;9:e1001081. |
|20.||Altun C, Guven G, Akgun OM, Akkurt MD, Basak F, Akbulut E. Oral health status of disabled individuals attending special schools. Eur J Dent 2010;4:361-6. |
|21.||Orellana LM, Silvestre FJ, Martínez-Sanchis S, Martínez-Mihi V, Bautista D. Oral manifestations in a group of adults with autism spectrum disorder. Med Oral Patol Oral Cir Bucal 2012;17:e415-9. |
|22.||Namal N, Vehit HE, Koksal S. Do autistic children have higher levels of caries? A cross-sectional study in Turkish children. J Indian Soc Pedod Prev Dent 2007;25:97-102. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]