Commentary on "oral assessment of children with an autism spectrum disorder".

* DeMattei R, Cuvo A, Maurizio S. Oral assessment of children with an autism spectrum disorder. Journal of Dental Hygiene, Vol. 81, No. 3, Summer 2007.

Abstract

Purpose. The study assessed the oral health status of children with an autism spectrum disorder (ASD) to help establish the oral health needs of this population.

Methods. Oral assessments were conducted on 39 children with an ASD and 16 children with other developmental disabilities (DD), solicited from 3 different schools. Conditions assessed were bacterial plaque, gingivitis, dental caries, restorations, bruxism, delayed eruption/missing teeth, oral infection, developmental anomalies, injuries, occlusion, salivary flow, and oral defensiveness.

Results. Chi-square and Fisher's exact test of significance were used to compare groups. Young children with an ASD who resided with parents showed significantly more signs of bruxism than the comparison groups. Likewise, older children who lived at the residential school manifested significantly more gingivitis. No other significant differences existed when age and residence were considered for children with an ASD. When comparing children with ASD to those with another DD, the latter group showed significantly more oral injuries, abnormal salivary flow, and developmental anomalies. Children with an ASD displayed the following percentages for clinically visible conditions: plaque (85%), gingivitis (62%), and caries (21%). Approximately half of the children with ASD were orally defensive.

Conclusions. Children with an ASD appear to have oral conditions that might increase the risk of developing dental disease. The extent of risk is unclear and needs further investigation.

Keywords: autism, oral health, access to care, developmental disabilities, oral assessment

Summary of Key Findings of this Article

Autism spectrum disorders (ASD), which is often used synonymously with pervasive developmental disorders (PDD), is a collective term given to developmental disabilities that impair the way individuals interact and communicate with others. Autism spectrum disorder consists of five subtypes, which include autism disorder (AD), Asperger's syndrome, Rett's disorder, childhood disintegrative disorder (CDD) and pervasive developmental disorder not otherwise specified (PDD-NOS). Individuals with an ASD vary widely in abilities, intelligence and behaviors. Symptoms may include problems using and understanding language; difficulty relating to people, objects and events; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings; and repetitive body movements or behavior patterns. (1)

Asperger's syndrome is sometimes used synonymously with high-functioning autism to distinguish people on the spectrum who have a stronger command of language. Autism disorder is the most common and best studied form of the PDDs. ASDs occur in all racial, ethnic and socioeconomic groups and are four times more likely to occur in boys than girls. The Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network released data in 2007 that found approximately 1 in 150 8-year-old children in multiple areas of the United States had an ASD. (2)

In 2000, The United States Surgeon General's report on the oral health status of Americans was released, emphasizing that a "silent epidemic" of oral diseases is affecting our most vulnerable citizens, including those with special needs. Although studies have been conducted involving persons with mental retardation and other developmental disabilities, very little has been reported in the literature about the oral health needs specifically of individuals with an ASD. Although there appears to be no known autism-specific oral manifestations, oral problems might arise because of autism-related behaviors such as communication limitations, personal neglect, self-injurious behaviors, dietary habits, effect of medications, resistance to receiving dental care, hyposensitivity to pain and possible avoidance of social contact. (3)

Research Hypothesis

In this article, DeMattei, et al., investigated the oral health status of children with an ASD to identify the oral health needs of this patient population. Their goals were to (a) investigate the oral health status of all participants in the areas of plaque accumulation, gingival health, caries, restorations, bruxism, malocclusion, delayed eruption and missing teeth, oral infections, developmental anomalies, salivary flow, oral injuries and oral defensiveness; (b) determine whether there is a significant difference between the oral conditions observed in children with an ASD who reside with their parents/guardians and those who live in a residential school; (c) determine whether there is a difference between the oral conditions observed in young children with an ASD and older children with an ASD; and (d) determine whether there is a significant difference between the oral conditions observed in children with an ASD and children with other developmental disabilities (DD). This study showed that with the exception of bruxism and gingivitis, there was not a significant difference in the oral health status of children with an ASD when comparing younger children to older children or when comparing children with an ASD who resided with their parents to those who lived at the residential school. Younger children who resided with their parents showed signs of bruxism significantly more, and older children of the residential school had significantly more gingivitis than their comparison groups. The authors did indicate that bruxism is common in 13 to 26% of all children; therefore, young age rather than ASD may be the significant factor. (4)

Additionally, heavy plaque accumulation and hormonal influences are likely explanations for the high occurrence of gingivitis in the older children of the residential school. Moreover, children of the residential school may have inadequate oral care skills or may rely on caregivers who are unskilled in providing oral care to others, resulting in excessive plaque accumulation and subsequent gingivitis. Interestingly, the presence of caries and restorations in the participants (21% and 15%, respectively) was lower than what is reported for children without developmental disabilities (50%) in the Surgeon General's report. (5) Since it is unknown whether the sample used in the study is representative of the population of children with an ASD, further investigation into the caries rate of children with an ASD is warranted. Neither oral infections other than gingivitis nor developmental anomalies were reported for any children with an ASD.

Oral conditions were similar when children with an ASD were compared to those with another DD except when oral injuries, development anomalies and salivary flow were considered. Children diagnosed with a DD other than an ASD, had significantly more oral injuries, developmental anomalies and abnormal salivary flow than children diagnosed with an ASD.

Due to the increased incidence of oral defensiveness in children with an ASD, plaque accumulation was high, at 85% for all groups studied. Oral defensiveness occurred in 70% of the younger group of children (ages 2.5-5 years) with an ASD compared to 41% in older children (ages 9-21 years) with an ASD. The authors noted that the behavior and cooperation needed to complete the oral assessment for the study cannot be compared to that required for intraoral procedures involving sharp instruments, and that behavioral intervention, sedation or restraint may be necessary for more involved dental procedures.

Utilizing a convenience sample of 55 subjects, this study provides an initial effort to examine the oral health status of children with an ASD. Additional studies are needed to expand the database, determine whether children with an ASD are living with compromised oral health and determine how children with an ASD compare to other populations including typically developing children of the same age.

What Are the Implications of this Article for Clinical Practice?

The incidence of children with an ASD is on the rise; therefore, dental hygienists should be aware of the oral health needs of these individuals. This study identified oral conditions in children with an ASD that might increase the risk of developing dental disease. They include:

1) increased plaque accumulation.

2) increased bruxism in younger children (ages 2.5-5 years).

3) increased gingivitis in older children (ages 9-21 years).

4) higher level of oral defensiveness in younger children as compared to older children

Monitoring the Oral Health Status of Children with an ASD

This study assessed the oral health status of children with an ASD and helped to establish the oral health needs of this population. Although their needs do not significantly differ from the oral health needs of other children with DD, certain risk factors were identified and should be monitored during all dental visits. In addition, behavioral management techniques for children with an ASD may need to be incorporated into the dental appointment. These techniques may be necessary to improve compliance with oral care procedures so that parents, caregivers and oral health providers will have efficient and effective ways to promote oral health at home, in residential facilities and in the dental office.

Education Is the Key

Institutes of dental and dental hygiene education can play a key role in increasing access to care for children with an ASD. In addition to conducting research and providing direct care to this population, it is the responsibility of dental and dental hygiene schools to adequately train their graduates to meet the needs of children with an ASD, among other special needs populations. Historically, dental and dental hygiene programs provide minimal didactic training and clinical experience in the care of patients with special needs. (6) It is hoped that educating dental and dental hygiene students will increase the number of oral care providers who are willing to serve this population by better preparing them to address the needs of individuals with disabilities.

Glossary of Terms

Autism Spectrum Disorder: Any of the disorders included under pervasive developmental disorder that share similar patterns of behavior, including impairment in social interaction; impairment in communication; and restricted behavior, activities and interests. They are considered spectrum disorders because each individual displays a different combination of behavior from mild to severe.

Autistic Disorder: Sometimes referred to as early infantile autism or childhood autism. Children with autistic disorder have a moderate to severe range of communication, socialization and behavior problems. Many children with autism also have mental retardation.

Rett's Disorder: Also known as Rett Syndrome. This condition is diagnosed primarily in females. In children with Rett's disorder, development proceeds in an apparently normal fashion over the first 6 to 18 months at which point parents notice a change in their child's behavior and some regression or loss of abilities, especially in gross motor skills such as walking and moving. This is followed by an obvious loss in abilities such as speech, reasoning and hand use.

Childhood Disintegrative Disorder: Extremely rare disorder characterized by a clearly apparent regression in multiple areas of functioning (such as the ability to move, bladder and bowel control, and social and language skills) following a period of at least 2 years of apparently normal development. By definition, childhood disintegrative disorder can only be diagnosed if the symptoms are preceded by at least 2 years of normal development and the onset of decline is prior to age 10.

Asperger's Disorder: Also referred to as Asperger's or Asperger's syndrome. This is a developmental disorder characterized by a lack of social skills, difficulty with social relationships, poor coordination and poor concentration, and a restricted range of interests but normal intelligence and adequate language skills in the areas of vocabulary and grammar.

Pervasive Developmental Disorder Not Otherwise Specified: Condition in which individuals either (a) do not fully meet the criteria of symptoms clinicians use to diagnose any of the four specific types of PDD above, and/or (b) do not have the degree of impairment described in any of the above four PDD specific types.

Developmental Disabilities: These are a diverse group of severe chronic conditions that are due to mental and/or physical impairments that begin anytime during development up to 22 years of age and usually last throughout a person's lifetime.

Oral Defensiveness: Intense sensitivity or overreaction to certain tastes, textures, temperatures of food, or touch in or around the mouth.

References

(1.) Volkmar FR, Wiesner LA. Healthcare for children on the autism spectrum: A guide to behavioral issues. Bethesda, Md.: Woodbine House; 2004.

(2.) U.S. Department of Health and Human Services. Prevalence of the Autism Spectrum Disorders in Multiple Areas of the United States, Surveillance Years 2000 and 2002. Centers for Disease Control and Prevention, 2007.

(3.) Regn JM, Mauriello SM, Kulinski RF. Management of the autistic patient by the dental hygienist, J Pract Hyg 1999; 8: 19-23.

(4.) Negoro T, Briggs J, Plesh O, et al. Bruxing patterns in children compared to intercuspal clenching and chewing as assessed with dental models, electromyography, and incisor jaw tracing: preliminary study. J Dent Child 1998;65: 499-58.

(5.) U. S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville (MD); U. S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

(6.) Waldman HB, Perlman SP, Borg PA. Are dental hygienists prepared to meet the needs of patients with disabilities? J Pract Hyg 2003; 12:22-4.

By Michele Carr, RDH, MA

ADHA members can access the full article online by linking directly to the Journal of Dental Hygiene through the Members section of the ADHA Web site. To view journal articles, log in to the Members section of the ADHA Web site and click on the Member Resources link. Scroll down to the Journal of Dental Hygiene link, which will take you directly to a list of all the available issues online.

This column was made possible by an educational grant sponsored by Colgate Oral Pharmaceuticals.

Michele P. Carr, RDH, MA, is associate professor and director of the dental hygiene program at The Ohio State University, College of Dentistry. She is the director for seven courses in the traditional and baccalaureate degree completion program and has worked with the specials need population for the past 18 years.