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Oral health status of children with autistic disorder in Chennai.

Introduction

Autism or autistic disorder is a severe and lifetime developmental disability that is characterised by major impairment in mutual social interactions, communication skills, and repetitive patterns of interest or behaviours [Bertrand et al., 2001]. Autism was first described in 1943 by Leo Kanner, a child psychiatrist [Kanner, 1943]. The term pervasive developmental disorder refers to the overarching group of conditions to which autism spectrum disorder belongs [Volkmar and Wiesner, 2004]. Autism spectrum disorder consists of five subtypes: (1) Autism disorder; (2) Asperger's disorder, also known as Asperger syndrome; (3) Rett's disorder; (4) Childhood disintegrative disorder; and (5) Pervasive Developmental Disorder--not otherwise specified [American Psychiatric Association, 2000].

Autism affects individuals from different ethnic backgrounds and social classes. Males are four to five times more affected than females. The Centers for Disease Control and Prevention reported the prevalence as 5.7 per 1000 (National Health Interview Survey) and 5.5 per 1000 (National Survey of Children's Health) [Centers for disease control and prevention, 2006]. They recently released a new study stating that autism now affects 1 in every 110 American children and 1 in 70 boys [Centers for disease control and prevention, 2007].

Many myths about the condition originate from the works of Kanner; for example, the cause of autism being "cold intellectual mothers, children with autism are from the upper social classes, the children are unwilling to speak and the first and only child" theories. All these myths have now been abandoned and it is clearly understood that there is always a neurobiological cause for autism [Gillberg and Coleman, 1992]. Evidence from family and twin studies suggests that it is an inherited disorder involving up to 20 interacting genes. Genes located on chromosomes 2, 7, 15, 16 and 19 have been suggested. The preponderance of males with the disorder suggests an X-linked disorder [Liu et al., 2001; Shao et al., 2002; Jamain et al., 2003]

Until recently, most scientists believed that autism is caused mostly by genetic factors. But new research indicates that environmental factors may be just as important in the development of autism. Research shows that certain children are born with a genetic vulnerability to autism that is then triggered by something in the external environment, either while the child is still in the womb or sometimes after birth. Prenatal environmental factors include taking antidepressants during pregnancy especially in the first 3 months, nutritional deficiencies early in pregnancy particularly not getting enough folic acid, complication at or shortly after birth including very low birth weight and neonatal anaemia. Research in humans and in experimental animals has supported a possible role for maternal viral infections. These microbes may act on the developing central nervous system or they may produce an inflammatory reaction in the mother, which in some way affects the foetal brain. Other examples include valproic acid and thalidomide, which, when used medically during pregnancy, include autistic behaviours in the offspring. More recent studies now suggest a potential contribution from chemical pollutants such as metals and pesticide exposures to autism. The role of environmental factors is still poorly categorised. It is not yet clear whether environmental factors act merely as precipitating agents, always requiring an underlying genetic liability, or whether they represent an essential component of a pathogenetic process where genetic liability alone does not lead to the full blown autism phenotype.

A recent study has noted that the father's age at the time of an offspring's birth influences the child's risk of developing autism [Reichenberg et al., 2006]. A study by Shelton et al. [2010] showed that while maternal age consistently increased the risk of autism, the father's age only contributed an increased risk when the father was older and the mother was under 30 years old. Among mothers over 30 years, increases in the father's age did not appear to further increase the risk of autism. A 40 year old woman's risk of having a child with autism was 50% greater than that of a woman between 25 and 29 years old [Shelton et al., 2010].

Autism can be identified in early childhood and is usually diagnosed before the age of 3 years. The diagnosis of autism is established after a thorough medical, psychological and neurological examination and four absolute criteria must be fulfilled [American Psychiatric Association, 2000].

* Severe abnormality of reciprocal social relatedness;

* Severe abnormality of communication development, often including spoken language;

* Restricted, repetitive and stereotypical patterns of behaviour, interest and imagination; and

* Early onset (before the age of 3 years).

Using tests of motor and language development at age 14 months, the research team in the centre for autism and related disorders at Kennedy Krieger Institute in Baltimore could predict autism in 70% of children ultimately diagnosed with the condition [DeNoon, 2006]. Prediction is not the same as a diagnosis but it offered these children a chance for early treatment. The earlier a child commences treatment for autism the better that child's ultimate outcome.

The impairments described above characterise an individual who has great difficulties interacting with other people, and in understanding and following instructions. In addition to these characteristics, subjects often show increased sensitivity to sounds, light, odours and colours. A majority of children with autism have a cognitive disability and about 50% of them do not achieve spoken language [Peeters and Gillberg, 1999]. The medical conditions that may occur along with autism are: learning disabilities, attention deficit hyperactivity disorder (ADHD), phenylketonuria, tuberous sclerosis, fragile X syndrome, anxiety, depression, obsessional behaviour and seizures [Bertrand et al., 2001].

Very little has been reported in the literature about the oral health needs of individuals with an autism disorder. The aim of this study was to assess the oral health status of autistic children in Chennai, India.

Materials and Methods

A cross-sectional survey was conducted in the city of Chennai using the census method, wherein all the children having autism were considered for the study. Ethical approval for this study was obtained from the Institutional Ethical Committee, Sree Balaji Dental College & Hospital and informed consent was obtained from parents of selected children. Participants were solicited from 12 special education schools, three autistic child centres and three therapy centres. Diagnosis with an autistic disorder was the selection criterion for soliciting participants from the special education schools. The diagnoses were reported initially on the survey by parents/guardians and then confirmed by the diagnosis reported in the child's school file.

A total of 483 autistic children were examined where 230 participants were from the special education schools, 198 from autistic child centres and 55 from therapy centres. Children's ages ranged from 4-16 years. Children were placed into 3 groups: primary dentition group, mixed dentition group and permanent dentition group. There were 363 boys and 120 girls.

The children were assessed for seven clinical parameters (i.e., bacterial plaque, gingivitis, dental caries, malocclusion, developmental anomalies, oral injuries and restorations). A clinical observation form was developed to record the findings of the oral assessment. Patient demographics (gender and age) were documented in the registration information. Dental treatment notes included clinical findings related to oral hygiene, dental caries, malocclusion, developmental anomalies and trauma. Existing restorations were also documented for all subjects. The oral assessment was conducted by one registered pediatric dentist who was dressed in coloured clothes. Oral examinations were carried out in the classrooms in broad daylight.

Visual inspection of generalised presence of plaque was considered as a positive result. Generalised inflammation of the gingiva was considered as gingivitis. Visual inspection was performed to record the presence of caries, restorations and crowding. The presence of excessive labio-axial inclination of the anterior teeth was considered as proclination and as anterior open bite when the anterior teeth in the maxilla did not occlude those in the mandible. It was noted as rotation when a tooth was rotated along its long axis. It was considered as enamel hypoplasia if cloudy opacities were observed on the teeth. Fraenal attachment was assessed visually and if the fraenum was attached close to the tip of the tongue, then it was considered as ankyloglossia. Presence of an extra tooth between the central incisors was considered as a mesiodens. Any loss of tooth structure in the enamel or dentine was considered as an Ellis class 1 or 2 fracture. The number of children with each of the parameters was considered.

Participants were instructed to sit in a straight-back chair. After a brief greeting, the researcher donned gloves and then stated that she needed to look in the participants' mouths. Immediately prior to each oral assessment, direct care staff members of the school were asked to give suggestions for the appropriate stimulus to prompt participants to open their mouth. If participants were uncooperative, additional approaches were used to encourage cooperation. These approaches included singing songs by the school staff; and including the parent or carers in the examination process. If necessary, parents or carers would assist by giving instructions or providing gentle restraint. The mouth mirror was used for the inspection of the occlusal and lingual surfaces of teeth. The cheeks were retracted for inspection of the facial surfaces of the teeth. If participants were compliant, the entire oral assessment was completed in approximately three minutes. A report summarising the children's oral conditions was placed in the children's medical records at the school and a copy of the same was given to the parents or care givers. Children who were in need of care were referred for dental treatment in our hospital Paediatric dental department.

Data Analysis. Data analysis was performed using statistical analysis software, SPSS version 17.0. Significance regarding the distribution between boys and girls was found using binomial test. The null hypothesis of equal proportions among children with primary, mixed and permanent dentition for each one of the conditions was tested using Chi square tests. Proportions test was used to determine the significance between boys and girls regarding their oral conditions. The null hypothesis of equal proportion was rejected if p<0.05.

Results

Data were analysed for all 483 participants with an autistic disorder. There were significantly more males (363) than females (120) (p<0.016) with a male: female ratio of 3:1. The total number of autistic children with primary dentitions were 51, in the mixed dentition 216, and in the permanent dentition 216.

Table 1 shows the data for each of the seven oral conditions in primary, mixed and permanent dentitions. The significance values were p<0.05 for all of the seven parameters investigated. Autistic children with primary dentition showed significantly more dental caries and autistic children with mixed and permanent dentition had significantly more gingivitis.

Table 2 shows the data for each of the seven oral conditions in boys and girls with primary dentition. The proportion of boys and girls having malocclusions were the same (p = 0.371), whereas the proportions were found to be different between the two gender categories for dental caries. The percentage of boys (91.66%) that had dental caries was greater than for girls (8.33%).

Table 3 shows the data for each of the seven oral conditions in boys and girls with mixed dentition. The proportion of boys and girls having dental caries was not significant (p=0.171), whereas the proportions were found to be different between boys and girls for bacterial plaque, gingivitis, malocclusion, developmental anomalies and trauma.

Table 4 shows the data for each of the seven oral conditions in boys and girls with permanent dentition. The proportion of boys and girls having traumatic injury to teeth were the same (p=0.116), whereas the proportions were found to be different between boys and girls for the following oral conditions: bacterial plaque, gingivitis, dental caries, malocclusion, developmental anomalies and restorations.

Data regarding early Childhood Caries, crowding, proclination, anterior open bite, rotation, type of developmental anomaly, type of traumatic injury and the type of restoration is shown in Table 5, which shows the number (12) of children undergoing orthodontic treatment.

Discussion

Studies of oral health conditions in children with autism are sparse. Most of the research that has been conducted has looked at children with autism spectrum disorder in developed countries [Lowe and Lindemann, 1985; Surabian, 2001]. The complicated disability itself makes clinical research difficult. This study evaluated the oral health status of autistic children with primary, mixed and permanent dentitions.

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 behaviour in this group of children. Autistic children are incapable of cooperating during dental treatment, because they typically do not tolerate exposure to foreign sounds, lights, odours and colours. In all, this makes it difficult to achieve good oral health [Saemundsson and Roberts, 1997; Medina et al., 2003].

This study showed that there was a significant difference in the oral health status of autistic children when comparing primary, mixed and permanent dentitions. Children with primary dentition showed significantly more dental caries, children with mixed dentition showed more gingivitis and children with permanent dentition also showed more gingivitis and malocclusion.

The American Academy of Pediatric Dentistry adopted a caries-risk assessment tool (CAT) for infants, children and adolescents in 2002 and revised it in 2006 to provide a means of classifying the caries risk of an individual patient at a point in time [American Academy of Pediatric Dentistry, 2007]. Using the CAT, an individual is classified as being at low, moderate or high risk for dental caries. Children with autism have a high caries-risk, according to the CAT.

Lowe and Lindemann assessed the dental needs of autistic patients and found that autistic patients had a higher caries rate in the primary dentition [Lowe and Lindemann , 1985]. Shapira et al. described the oral health and dental needs status of autistic children and found lower caries rates and severe periodontal problems. [Shapira et al., 1989]. A study on oral health in 124 Thai autistic children showed that more than half presented with poor oral hygiene and dental caries and caries may lead to early loss of teeth and subsequently to malocclusions [Tharapiwattananon, 1994]. Desai et al. also reported that dental caries rates were higher in autistic children [Desai et al., 2001].

Children with autism are often cited as having certain behaviours / life factors which may lead to an increased risk for dental caries. Among these behaviours / life factors are a preference for soft / sweet foods, poorer masticatory abilities, pouching of food, poor oral hygiene, requiring help with tooth brushing, and medications causing xerostomia [Shapira et al., 1989]. The most commonly prescribed class of medication was anti-psychotic drugs used to manage symptoms of irritability, agitation, self-injurious behaviour, aggression, repetitive behaviours, delusions and hallucinations. One of the orofacial adverse effects of these medications includes xerostomia, which is an increased risk factor for caries. Gingivitis also is stated to be an adverse effect of anti-psychotic drugs [Friedlander et al., 2006]. Methamphetamine is therapeutically used by individuals with autistic disorder. Rampant caries is a characteristic finding in methamphetamine abusers [Shaner et al., 2006].

Parents frequently avoid taking their autistic children for routine dental examinations because of the children's fear of dental procedures. As a result, children with autism have a high prevalence of carious lesions, poor oral hygiene and more periodontal disease [Starks et al., 1985]. Oral problems might arise because of autism-related behaviours such as communication limitations, personal neglect, self-injurious behaviours, resistance to receiving dental care, hyposensitivity to pain and possible avoidance of social contact [Rean et al., 1999].

Poor oral hygiene should also be considered a risk indicator for caries. Poor oral hygiene has been reported in autistic children, and they have also shown a higher rate of periodontal diseases and dental caries [Lowe and Lindemann, 1985; Fahlvik-Planefeldt and Herrstrom, 2001; Onyeaso, 2003; Friedlander et al., 2006; American Academy of Pediatric Dentistry, 2007].

Suwannee et al. showed that autistic children had significantly poorer oral hygiene and significantly more periodontal problems and that the percentages of spacing, reverse overjet, open bite and class II molar relationship tendencies were higher in children with autism [Suwannee et al., 2010]. These orthodontic problems may be related to these patient's deviant behaviours, such as finger sucking, biting finger nails/ foreign objects, or self extraction of teeth [Fombonne, 2003]. Fahlvik-Planefeldt and Herrstrom stated that handicapped children, including those with autistic disorders may need more dental care and frequently more orthodontic treatment [Fahlvik-Planefeldt and Herrstrom, 2001].

It is not surprising to find a significantly higher incidence of gingivitis in the mixed and permanent dentition of autistic children. Heavy plaque accumulation and hormonal influences are likely explanations for the high occurrence of gingivitis in autistic children. Moreover, children 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. The consequence of developing dental diseases as a result of constant plaque accumulation over time is of concern in autistic children. The risk of developing oral disease is increased when children resist daily oral hygiene as well as professional oral care procedures. In the US Surgeon General's report, the presence of restorations was lower than reported for children without developmental disabilities [US Surgeon General's report., 2000].

The male: female ratio of 3:1 that was observed in our study was consistent with previously reported sex ratios of 3.7:10 [Centers for disease control and prevention, 2006] and 4.3:1 [Fombonne, 2003] in the autism spectrum disorder group. As the gender distribution was not equal in our study, our findings show more distribution of the oral conditions in boys than in girls, except for trauma which was seen more in girls than in boys. The reason that trauma was seen more in girls than in boys could be that a greater number of girls had proclined anterior teeth.

It is appropriate to consider the methodological weaknesses and in this study, the same person performed all clinical examinations and evaluations. This may not be methodologically ideal, since it precludes blinding, but it was a prerequisite for the study in this group of subjects since autistic children are very dependent on routines and continuity in treatment. Difficulties in clinical examination also meant that the measurement of plaque could not be performed according to standard methods using disclosing solution and calculation of plaque indices. The methods applied must be considered a compromise, but are nevertheless valid.

Conclusions

Autistic children with primary dentition showed higher levels of dental caries. Children with mixed dentition had significantly more gingivitis. Children with permanent dentition had significantly more gingivitis and malocclusion when compared to other oral conditions. It is suggested that children with autism receive special care so their oral hygiene as well as their dental aesthetics are improved.

References

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American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition, 2000.

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C.Vishnu Rekha *, P. Arangannal *, H. Shahed **

* Department of Pediatric Dentistry, Sree Balaji Dental College & Hospital, Chennai, India. ** Department of Periodontics, Yenepoya Dental College & Hospital, Mangalore, India.

Postal address: Dr.C.Vishnu Rekha, Sree Balaji Dental College and Hospital, Velachery Main Road, Pallikaranai, Chennai-600100, Tamilnadu, India.

Email: drvishnurekha@yahoo.com
Table 1. Number (%) of autistic children for the seven
oral parameters investigated for primary, mixed and
permanent dentitions

Oral                Primary       Mixed        Permanent
condition          dentition     dentition     dentition
                      (%)           (%)           (%)

Bacterial Plaque    3 (1.39)    102 (47.22)   111 (51.39)
Gingivitis          3 (1.04)    144 (50)      141 (48.96)
Dental caries      24 (12.31)    90 (46.15)    81 (41.54)
Malocclusion        3 (1.92)     42 (26.92)   111 (71.15)
Developmental       0 (.00)      15 (41.67)    21 (58.33)
  anomalies
Trauma              0 (.00)      18 (75)        6 (25)
Restorations        0 (.00)      12 (30.77)    27 (69.23)

Oral                  Chi-         Sig.
condition            Square
                     Value

Bacterial Plaque     87.6639       .000
Gingivitis          119.3258       .000
Dental caries        32.3890       .000
Malocclusion         85.9294       .000
Developmental        16.7926       .000
  anomalies
Trauma               21.9679       .000
Restorations         15.5429       .000

Table 2. Oral conditions of autistic children (boys
& girls) with primary dentition

Oral condition      Boys (%)    Girls (%)   Z value   Sig.

Bacterial Plaque    3 (100)     0 (.00)        --     --
Gingivitis          3 (100)     0 (.00)        --     --
Dental Caries      22 (91.66)   2 (8.33)     4.382    .000
malocclusion        2 (66.67)   1 (33.33)     .612    .371
Developmental
  anomalies         0 (.00)     0 (.00)        --     --
Trauma              0 (.00)     0 (.00)        --     --
Restorations        0 (.00)     0 (.00)        --     --

Table 3. Oral conditions of autistic children
(boys & girls) with mixed dentition

Oral condition       Boys (%)    Girls (%)    Z value   Sig.

Bacterial Plaque   79 (77.45)    23 (22.55)    6.634    .000
Gingivitis        132 (91.67)    12 (8.33)    18.091    .000
Dental Caries      65 (72.22)    25 (27.77)    1.663    .171
malocclusion       37 (88.10)     5 (11.90)    7.624    .000
Developmental      12 (80)        3 (20)       2.905    .000
  anomalies
Trauma              3 (16.67)    15 (83.33)    3.795    .000
Restorations       12 (100)       0 (.00)        --     --

Table 4. Oral conditions of autistic children
(boys & girls) with permanent dentition

Oral condition       Boys (%)    Girls (%)    Z value   Sig.

Bacterial Plaque   97 (87.39)    14 (12.61)   11.865    .000
Gingivitis        133 (94.33)     8 (5.67)    22.752    .000
Dental Caries      47 (58.02)    34 (41.97)    4.813    .000
malocclusion       96 (86.49)    15 (13.51)   11.244    .000
Developmental      17 (81)        4 (19)       3.612    .000
  anomalies
Trauma              1 (16.67)     5 (83.33)    2.191    .116
Restorations       21 (77.78)     6 (22.22)    3.472    .000

Table 5. Distribution of malocclusion, developmental
anomalies, trauma and restorations in autistic children

Condition        Description          Primary   Mixed   Permanent
malocclusion
                 Crowding                0       21        51
                 Proclination            3       15        42
                 Anterior open bite      0        3         0
                 Rotation                0        3         6
                 Under orthodontic       0        0        12
                   treatment
Developmental
anomalies        Enamel hypoplasia       0       12        15
                 Fusion                  0        3         0
                 Ankyloglossia           0        0         3
                 Mesiodens               0        0         3
Trauma
                 Ellis class 1           0       12         3
                 Ellis class 2           0        6         3
Restorations
                 Preformed               0        3        18
                   metal crowns
                 Glass ionomer           0        9         9
                   cement
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Author:Rekha, C. Vishnu; Arangannal, P.; Shahed, H.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:9INDI
Date:Jun 1, 2012
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