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ORIGINAL ARTICLE |
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| Year : 2007 | Volume
: 25
| Issue : 2 | Page : 97-102 |
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Do autistic children have higher levels of caries? A cross-sectional study in Turkish children
Necmi Namal1, Hayriye Ertem Vehit2, Selcuk Koksal3
1 Department of Public Health, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
2 Department of Family Health, Child Health Institute, Istanbul, Turkey
3 Department of Public Health, Cerrahpasa Medical Faculty, Istanbul, Turkey
Correspondence Address:
Necmi Namal
Atakoy 9-10, Kisim D-20, C-D.21 34750, Istanbul
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-4388.33457
 Abstract | | |
The aim of this study is to assess whether the dental caries experience is higher in children with an autistic disorder (AD) than in normal children. Three schools for autistic children and three standard elementary schools in Istanbul, Turkey, were included in a cross-sectional study. Subjects were orally examined. Socio-demographic information and data about their oral care habits were obtained from their parents from records. Sixty-two children with AD and 301 children without AD were examined. Their ages varied between 6 and 12 years. Children with AD compared to those without AD had lower experience of caries. Logistic regression analysis of DMFT showed that the dental status was positively affected in younger children (OR = 15.57; 95% CI 7.62, 31.80), children from families with high income (OR = 5.42; 95% CI 2.31, 12.75), children brushing teeth regularly (OR = 2.01, 95% CI 1.10, 3.68), children consuming less sugar (OR = 5.01; 95% CI 2.57, 9.76) and in those with AD (OR=3.99; 95% CI 1.56, 10.19). Children with AD had better caries status than children without AD at younger ages.
Keywords: Autism, dental caries, risk factors
How to cite this article:
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 |
How to cite this URL:
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 [serial online] 2007 [cited 2021 Apr 15];25:97-102. Available from: https://www.jisppd.com/text.asp?2007/25/2/97/33457 |
| Introduction | |  |
Over the past decade, autism has emerged as a major public health concern in many countries. Although known for more than 50 years as one of the most severe childhood neuropsychiatric disorders, it was thought to be quite rare. [1] Individuals with autism have impairments in social interaction and communication and exhibit some repetitive, often self-stimulatory behaviors. [2]
Most of the epidemiologic data on autism prevalence come from studies of autistic disorder (AD). Through the 1990s, the most commonly accepted estimates of the overall population prevalence of autistic disorder are in the range of 5-13 per 10,000. The prevalence in males is three to four times than in females. [2],[3] Recent estimates suggest that the prevalence is higher than reported in the 1990s. A recent study conducted in the United Kingdom reported a prevalence rate of 16.8 per 10,000 children for autistic disorder. [4] Even higher prevalence rates are reported in the US. There the rate is 34/10,000. [5] In Turkey, the prevalence of the children with AD is approximately 12/10,000. [6] These studies indicate that AD is a relatively common disability and as a behavioral problem, should not be overlooked when considering risk for dental caries, a multifunctional disease that is also affected by behavior. [7],[8]
It is known that individuals with AD may have less learning abilities than healthy individuals. [9],[10] This may affect their oral hygiene. [11],[12] Some researchers maintain that individuals with AD tend to have a strong affinity for sweets. [13],[14] The abuse of methamphetamine, which is therapeutically used by individuals with autistic disorder, has been reported to be related with dental caries. [15]
The question that the present study addresses is "Do children with autistic disorder have higher levels of caries experience?" There are few publications dealing with dental conditions of children with AD and most of the research on them is in developed countries. [16],[17] Desai et al., [18] reported that dental caries rates were higher in autistic children than others, whereas De Moor and Martens [19] found that there were no differences in dental caries between the autistic and non-autistic populations. [18],[19] Similarly, Fahlvik et al., [20] compared autistic Swedish children between the ages of 3 and 19 years with a non-autistic population and found that their dental status was similar. Whilst Shapira et al. [21] reported that there were no differences overall in dental caries levels between autistic and non-autistic children. They did find that older autistic people had lower DMFT values than non-autistic individuals of the same age. [21]
Though many factors influence an individual's dental caries risk, [22] there is not enough evidence to show whether AD is a risk factor for caries. Because there are relatively few studies on dental status and risk factors for caries in children with AD and the findings vary, this study was planned with the objective to assess whether the dental caries experience is higher in children with an AD than in normal Turkish children.
| Materials and Methods | | |
Ethical approval for this study was obtained from the Ethics Committee of the Cerrahpasa Medical School of the University of Istanbul and informed consent was obtained from parents of selected children. The study was carried out in Fatih, Gaziosmanpasa and Kagithane districts of Istanbul. A total of 363 students were included (62 autistic children and 301 non-autistic children). Data for children with AD were collected from three schools, one autistic child center and two elementary schools offering private classes to autistic children. Schools were selected randomly. Data for normal children without AD were obtained by randomly selecting three elementary schools in the same districts.
The socio-demographic data used in the survey were obtained from the existing files of the students. Oral hygiene and sweet consumption data for children without AD were obtained from the children. Oral hygiene and sweet consumption data for children with AD were obtained from their parents and their teachers.
The individuals who brushed their teeth at least once a day were classified as regular brushers and those brushing less than once a day were classified as irregular brushers. Individuals consuming foods containing sugar once a day or more (including between meals) were classified as "frequent sugar eaters" and individuals consuming less (sugar) than the amounts mentioned above were classified as "infrequent sugar eaters." Monthly income for an average low-income family varied between TL 250 ($150) and TL 500 ($300). Monthly income for an average high-income family was over TL 500 ($300+). [23]
Oral examinations of children without AD were carried out in the classrooms with the help of a dental mirror and explorer under daylight or, where necessary, by using a portable source of light. Oral examinations for children were performed by a dentist in a well-lit environment with the aid of their schoolteacher. One examiner performed all examinations. The dental disease experience for permanent teeth was measured in terms of the number of decayed, extracted, missing and filled teeth (DMFT). WHO criteria for caries detection were used. [24] According to the dental caries levels, children with "0" DMFT value were coded as one group and children with "1 or higher" DMFT were considered as another group. The logistic regression analyses were performed according to the designated codes.
In addition to descriptive statistics, both univariate and multivariate analyses were done. Univariate analyses and logistic regression analyses were performed for all variables. Logistic regression using SPSS software was done to identify significant risk factors for DMFT. In addition to 'p' values, the Chi-square, Odds ratio (OR) and its 95 percent confidence internal were computed.
| Results | | |
The mean age of the children attending the study (n = 363) was 9.32 ± 1.68 years. The ages varied between 7 and 12 years. As many as 50.1% of the children were boys. Forty-three children were 12-year-old (11.8%), 60 were 11-year-old (16.5%), 70 were 10-year-old (19.3%), 68 were 9-year-old (18.7%), 41 were 8-year-old (11.3%) and 81 were 7-year-old (22.3%). A total of 62 (17.1%) of the 363 individuals had AD. All the children with AD were aged between 7 and 12 years. There were 22 seven-year-old (35.5%), 9 eight-year-old (14.5%), 14 nine-year-old (22.6%), 8 ten-year-old (12.9%), 4 eleven-year-old (6.5%), 5 twelve-year-old (8.1%). A greater proportion of boys had AD than girls, 46 (25.3%) of the 182 males having AD as compared to 16 (8.9 %) of the 181 females.
More than half of the mothers of the children had received a low level of education or no education at all (85.4%). Additionally, approximately one-sixth of the mothers (14.6%) had received schooling for 9 years or more. More than half of the fathers of the children had received a low level of education or no education at all (71.1%). Approximately one-third of the fathers (28.9%) had received schooling for 9 years or more. Approximately one-fifth of the families (20.1%) had a high family income. As many as 29.8% of the children brushed their teeth once or more than once a day regularly.
As many as 21.0% of the mothers of the children with AD and 37.1% of the fathers of the children with AD had 9 years or more education. More than half of the families of the children with AD had a high family income (69.4%). As many as 22.6% of the children with AD failed to brush their teeth regularly and 30.6% consumed junk food containing sugar.
The overall mean DMFT, D, M and F scores were 2.29, 2.07, 0.11 and 0.13 respectively. The mean DMFT, D, M and F scores in children without AD group were 2.41, 2.27, 0.02 and 0.14 respectively and in those with AD, the corresponding scores were 1.74, 1.08, 0.56 and 0.06 respectively. [Table - 1] shows the percentage of children with AD compared to those without AD according to the variables studied. A lower percentage of children with AD were caries free than with caries experience (41.9% vs. 58.1%).
[Table - 2] shows the percentage of children with any experience of caries (DMFT) by age, gender, mother's education, father's education, family income, brushing, sweet consumption and being with AD. About 70.5% of children had "any" experience of caries. A meaningful difference is observed between age and DMFT level arising from the increase in age (51.1-91.9%) ( P < 0.05). The percentage of boys with any experience of caries (65.9%) was statistically significant as compared to females (75.1%) ( P < 0.05). "Any" experience of caries in the high-family-income group was 46.6% and statistically lower than that in the low-family-income group (76.6%) ( P < 0.05). The variations in brushing between groups were statistically significant ( P < 0.05). Whilst nearly one-half of caries-free children brushed their teeth regularly, in the other group one-fourth (24.7%) did so. "Any" experience of caries in children with frequent consumption of junk food containing sugar was 79.6% and statistically higher than that in children with infrequent consumption of junk food containing sugar (50.4%) ( P < 0.05). The children with AD had lower experience of caries than the non-autistics (58.1%, 73.1%). This difference was statistically significant ( P < 0.05). The following variables did not show a significant association with "any" experience of caries: mother's education level and father's education level.
The outcome of the conditional logistic regression model for "any" experience of caries prevalence is presented in [Table - 3]. The 10 to 12 year old group had 15.57 times greater experience of caries than the 7 to 9 year old age group ( P = 0.000, OR = 15.57, 95% CI for OR = 7.62-31.80). The low family income group had 5.42 times greater experience of caries than the high family-income group ( P = 0.000, OR = 5.42, 95% CI for OR = 2.31-12.75). Children who brushed their teeth irregularly had 2.01 times more experience of caries compared to the children who brushed their teeth regularly ( P = 0.024, OR = 2.01, 95% CI for OR = 1.10-3.68). The children consuming junk food containing sugar frequently had 5.01 times greater experience of caries compared to children who infrequently consumed such food ( P = 0.000, OR = 5.01, 95% CI for OR = 2.57-9.76). A child without AD had 3.99 times the odds of having any experience of caries than autistics ( P = 0.004, OR = 3.99, 95% CI for OR = 1.56-10.19). No other covariate was significantly associated with the outcome.
| Discussion | | |
This cross-sectional study suggests that AD is not a risk factor for dental caries experience among 7 to 12 year old Turkish children in Istanbul. Before considering the implications of this finding, it is appropriate to consider the methodological weaknesses and strengths of the study. The children without autistic disorder were in state schools, where education is free of charge and were representative of the dental experience level within Istanbul. Less than 1% of the children of that age in Turkey get education in paid private schools. The educational and income levels of families of the children in private schools are most probably far higher than those of the families of children in state schools, the latter being the average of the majority of the working population. Only 400-500 out of the 80,000 children with autistic disorder are able to get education in schools. [6] The children with autistic disorder in our study population have been selected from that group which gets education. In other words, these children may be defined as having special care by their families. Since there is no satisfactory data regarding methamphetamine abuse, which is reported to influence dental caries, this variable has not been used in this study.
In this study, the facts that make DMFT "0" i.e., caries-free condition have been found to be young age, high family income, regular brushing, infrequent sweet consumption and being children with AD.
Age is commonly considered to be an important factor that influences dental caries experience in children. The higher the age, the higher the dental caries. [25] In this study, the 10-12 years age group had 15.57 times greater caries experience compared to the 7-9 years age group. The results of the present study agree with these findings of Eronal et al., [25] The children of parents with high income levels were reported to have more dental caries. [26] In this study, the low family income group had 5.42 times greater caries experience compared to the high family income group. While the results of the study are not compatible with those of the study by Holan et al., [26] they are compatible with those of the study by Schultz et al. [27] In this study, "brushing frequency" influenced dental caries-free levels in permanent teeth. Children who brushed their teeth irregularly had 2.01 times greater there caries experience compared to children who brushed teeth regularly. The results of the present study agree with the findings of Dominguez-Rojas et al ., [28] however, they do not agree with those of Olmez et al., [29] Children who frequently consumed junk food containing sugar had 5.01 times greater caries experience compared to children who consumed such food infrequently. [7]
The dental caries experience in permanent teeth of children with AD was lower than in those of the children without AD. Children without AD had 3.99 times the odds of having any experience of caries compared to the autistics. This result differs from that of Desai et al., [18] who found that children with AD had higher levels of dental caries; and from that of De Moor and Martens [19] and Lowe and Lindemann, who found no differences in dental caries between the autistic and non-autistic populations. [17]
These study results showed that children with AD had better dental status of permanent teeth at younger ages. The reasons were consumption of less sugar by children with AD at younger ages and the care by their more highly educated mothers who brushed their child's teeth, a finding that emphasizes the importance of mothers of children with AD in dental care. [30]
Children with AD had more missing permanent teeth than did the children without AD. The 'permanent filled teeth' levels were higher in children without AD than in the others. The results of the study show that tooth extraction is preferred to tooth restoration in children with AD compared to children without AD. This might probably be because of the difficulty of treating children with AD. It is reported that level of dental treatment is lower in children with AD. [20] Numerous studies have reported that children with AD have more unmet dental needs and are difficult to treat. These results are compatible with those of Desai et al . [18],[20],[31] Consequently, children with AD are more often treated under general anesthesia. For example, Klein and Nowak found that comprehensive dental care was done under general anesthesia in 37% of a group of autistic children. [14]
In Japan, where there has been an improvement of the dental status of children with AD, the decline was attributed to several factors such as the qualitative and quantitative improvements in treatment of caries, more regular visits to dental clinics, improved daily oral hygiene and change in dietary patterns. [32]
Studies commonly survey one or few factors related to DMFT. Most studies utilize bivariate relationships of risk indicators. In this study, several risk indicators have been taken into account. The simultaneous impact of age, gender, education of mother and father, the frequency of brushing teeth, the frequency of sugar eating as well as having AD was also evaluated.
The logistic regression analysis of DMFT representing the dental caries and outcome in permanent teeth showed that younger age, a child of high-family-income, brushing teeth regularly, consuming less sugar and having AD are factors that led to less caries experience.
In a study on individuals with AD in Israel, the DMFT in individuals with AD was lower than the other individuals' DMFT. (21) This study found that adults without AD compared to individuals with AD consumed more sugar and had inadequate oral hygiene. This conclusion regarding DMFT agrees with this study's conclusions. [21]
Children with AD had better dental caries status than children without AD at younger ages. The main reason for this is that the parents of autistic children controlled their sweet consumption.
| Acknowledgment | | |
The authors would like to thank Prof. Aubrey Sheiham (Department of Epidemiology and Public Health, University College London, UK) for his help in editing the manuscript.
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[Table - 1], [Table - 2], [Table - 3]
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