Oral health status, dental needs, habits and behavioral attitude towards dental treatment of a group of autistic children in Riyadh, Saudi Arabia
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SAUDI DENTAL JOURNAL SAUDI DENTAL JOURNAL SAUDI DENTAL JOURNAL 132 Oral health status, dental needs, habits and behavioral attitude towards dental treatment of a group of autistic children in Riyadh, Saudi Arabia Ebtissam Zakaria Murshid, BDS, MS, MPH, DrPH The purpose of the study was to obtain baseline information regarding the oral health status, dental needs, habits and behavioral attitudes towards dental treatment of a group of autistic children attending a rehabilitation center in Riyadh, Saudi Arabia. A self-administered questionnaire in Arabic was completed by the parents of each child involved and was reviewed with the children’s trainers. Extra-oral and intra-oral examinations were performed in 20 autistic children with a mean age of 9.6 years. The parents of all the 20 children (16 males and 4 females) responded to the questionnaires. Extra-oral examination showed that 14 (70%) children showed different signs of trauma due to habits and also expression of temporary madness. Intra-oral assessment showed poor oral hygiene (80%) and generalized gingiva. The mean DMFT score was 1.6 and 7.25, and mean dmft score for males and females was 3.62 and 1.0, respectively. Regarding the behavioral attitude to dental treatment, 56.25% of the children were definitely negative, 31.25% were negatively behaved and only 12.5 % reacted positively towards the dental examination. The following conclusions were made: Oral health status of the examined autistic children did not show statistically significant differences from the international groups reported in previous studies. Autistic children in the present study showed similar behavior and habits as other autistic children around the world. INTRODUCTION of such brain abnormalities might be due to early prenatal insult such as Autism, autistic syndrome (AS), autistic chromosomal abnormalities, intrauterine disorder (AD), infantile autism (IA) and viral infections, and metabolic disorders childhood autism (CA) are different terms suspected to play a role in the given to the same condition of a pathogenesis of this syndrome.4 developmental disability. The condition In a recent epidemiologic study was first described in 1943 by Leo Kanner, conducted in the United States, the an American child psychiatrist.1,2 Kanner findings show a tremendous increase in reported his observations of a group of the prevalence of autism between the end children as they expressed impaired social of the 1980’s and the beginning of the and behavioral interactions, verbal and 1990’s (1987-1994). The authors of the nonverbal communication deficiencies, study could not determine if the observed and developmental retardation.1-3 Later, increase in autism was due to Kanner’s observations were identified as improvements in detection, changing and an organic disorder characterized broadening of diagnostic criteria or a true by abnormalities in the brain structure increase in prevalence. 6 Other and function, especially the limbic epidemiological studies of autism reported system and cerebellum. 3-5 Recently, that the main age at which autism was researchers reported that the etiology diagnosed was 44 months, with a wide variation of the expression of symptoms Received 1 April 2005; Revised 13 June 2005 Accepted 20 August 2005 Address reprint requests to : Assistant Professor Ebtissam Zakaria Murshid Department of Preventive Dental Sciences P.O. Box 60169, Riyadh 11545, KSA College of Dentisty, King Saud University, Riyadh, KSA Email : emurshid@ksu.edu.sa Saudi Dental Journal, Volume 17, No. 3, September - December 2005
133 ORAL HEALTH STATUS AND BEHAVIOURAL ATTITUDE among different individuals.3,7,8 Autistic and distribution of Saudi autistic children children may express mental retardation, is available in brochures and flyers abnormal emotional, social and linguistic published by various autistic development, poor muscle tone, poor rehabilitation centers and the Saudi coordination, as well as visual and hearing Autistic Society which was established in impairment. 3,9,10 Klein and other 2003. These brochures provide definitions researchers reported that males are four and some medical characteristics of this to five times affected more than females, group of children with no information but more severe symptoms are exhibited about their oral health status or dental in females.3, 8, 11-13 needs. Recently, Yazbak reported that the As part of the multiple unknown estimated number of autistic children in developmental abnormalities, several Saudi Arabia was 42,500.22 However, no studies reported that up to 70% of the reference was made as to how this children diagnosed with autism practice estimate was obtained. The purpose of self injurious behavior (SIB) at some stage this study was to obtain baseline in their lives. This behavior is expressed information regarding the oral health as a deliberate harm to the body that may status, dental needs, habits, and lead to serious injuries without suicidal behavioral attitudes to dental treatment intent. This repetitive behavior is more of a group of children diagnosed with common in females, mentally and autism in a non-profit autistic psychologically impaired individuals.14 It rehabilitation center in Riyadh, Saudi usually affects the head and neck Arabia. region.13, 15 Oral health and dental needs of METHODS AND MATERIALS children with autism have been evaluated by very few investigators. The studies This study was conducted in the first conducted on this topic reported no center established in 1999 in Riyadh, the statistically significant differences in the capital of Saudi Arabia, as indicated by the prevalence of caries, fillings, gingivitis Saudi Autistic Society’s official website. and degree of oral hygiene in comparison In Riyadh, there are about six non-profit with non-autistic individuals8, 16-18 and centers that accept and offer even a lower incidence of caries in some rehabilitation services for children with of the reports.19, 20 autism. The center offers an intensive Because of the widely aberrant rehabilitation program only for children behavior and communication impairment diagnosed with autism and has 20 of children with autism, every child registered children. All the children (16 requires special behavior management males and 4 females) were included in the with a great deal of patience and study. All the children had been previously confidence. 8,17,21 The use of Tell-Show- examined and diagnosed medically as Feel-Do technique with sedation or autistic patients according to the center’s nitrous oxide was recommended in the medical records. A self-administered literature to manage and treat the autistic questionnaire in Arabic was sent to 5 families child in routine dental settings.21 to pre-test the reliability of the questions. The An extensive review of the literature questionnaires included demographic revealed no specific numbers regarding information (name, age and gender of the diagnosed cases of autistic children in child), child’s oral hygiene practice, previous Saudi Arabia. Most of the estimated dental experience, behavior during dental infor m a t i o n a b o u t t h e p r e v a l e n c e examination and treatment, and habits Saudi Dental Journal, Volume 17, No. 3, September - December 2005
MURSHID 134 including self injurious behavior. The (e.g. ulcer, abscess). Oral hygiene was habits and behavioral patterns of every recorded as good, fair or poor according to child were reviewed with the children’s the Simplified Oral Hygiene Index (OHI- trainer. Every family was assured of the S).25 confidentiality of the collected data and The collected data were entered in the that the resultant information would be computer using Statistical Package for used only for the research purposes. Social Sciences (SPSS version 10) Files of all the children were reviewed software for frequency distribution of all and the medical status of each child was variables. recorded in a special clinical examination A report of each child’s oral health and form designed for this study. On the day dental needs as well as any special of examination, each child accompanied instructions to improve the oral hygiene by his/her trainer was brought to the of the child was sent to the parents. designated examination room and was informed by his/her trainers about the RESULTS procedure, and asked to cooperate with the examiner. The children were seated on an adjustable office chair or laid down flat The parents of all the 20 children, 16 on an exercise mattress depending on (80%) males and 4 (20%) females with a mean age of 9.6 years participated in the their physical condition. study. Results of the extra oral During the examination procedure, the assessment, types of habits, trauma and “Tell–Show–Feel and Do” technique was injuries as well as the given reasons are used with all the children. Extra-oral shown in Table 1. Out of the 20 examined examination included any scars, trauma children, 14 (70%) showed signs of to the head and neck, hands and fingers. trauma. The injuries varied from Intra-oral examination of the soft and hard scratches to one case of burned fingers. tissues was done under flash light and Five males and one female had no signs regular room light using disposable gloves, of trauma or injuries in the examined mouth mirror, explorer and sterilized areas (Table 1). gauze to clean and dry the teeth. Sound, Injuries to the head region were decayed, missing and filled teeth were recorded in 6 (30%) of the children (4 males recorded in the dental chart following the and 2 females) and it was due to self head WHO criteria.23 banging on the walls and furniture, and The gingival status was evaluated hitting by bare hands or with objects according to the gingival index of Loe and during stressful moments or as Silness (1963) which varied between mild expression of temporary madness and (slight changes in color and texture) to discomfort. Three other children (15%) moderate gingivitis (redness, edema, and showed signs of scratches on the sides of bleeding on pressure).24 No probing or their faces due to head banging and hair pocket depth measurement was conducted pulling. to evaluate the periodontal health due to The most common trauma was recorded the difficult behavior of the children. in the hands and fingers, as 15 (75%) of Gingival status was recorded as the children (11 males and 4 females) generalized or localized gingival showed different degrees of injuries. The inflammation depending on the amount reasons given were repeated self biting of gingival redness and bleeding during habit and touching hot beverages or food. the examination. The examination also A 10-year old male had shown signs of included any intra-oral soft tissue findings localized gum recession in the upper Saudi Dental Journal, Volume 17, No. 3, September - December 2005
135 ORAL HEALTH STATUS AND BEHAVIOURAL ATTITUDE children showed that, 16 (80%) of the children (14 males and 2 females) had poor oral hygiene. Only 4 (20%) of the children (2 females and 2 males) showed fair oral hygiene and none had good oral hygiene (Table 2). The gingival status was evaluated and the results showed that all the children had mild generalized gingivitis. Four of the males and two of the females showed gingival dryness and redness in the upper front areas which could be due to mouth breathing and/or open bite (Table 2). Two males and two females were considered as having fair oral hygiene. The trainers as well as the parents reported that these children do not mind brushing their teeth and sometimes they are able to brush by themselves. Difficulty in practicing oral hygiene was reported by the trainers and parents in males more than females and in the older age group (9 years and above). Four males and 2 females had clear protrusion of the upper jaw associated with a mouth breathing anterior region due to repeated picking habit. The results are illustrated in Table with his nail. Another male reported that 2. he had a habit of pinching himself and the The hard tissue assessment showed others when he was angry. Two of the that thirteen children (65%) had multiple females and one male children showed decayed and untreated teeth (49 signs of ulcers in the lips and tongue permanent and 27 primary). Only 6 regions which were difficult to diagnose children (30%) had fillings in their teeth as either traumatic or aphthous ulcers (6 permanent and 10 primary), and five (Table 1). children (25%) showed no signs of clinical The parents of the 6 (30%) children with decay or fillings. The mean DMFT score no signs of trauma reported that their was 1.6 and 7.25, whereas, the mean children do not practice self injury habits. On the other hand, four of the males expressed their anger with peculiar repetitive hand movements and hyperactivity without hurting themselves or the others. The rest of the children had repeated habits which were similar to those of normal children such as nail biting, grinding of teeth at night (Table 1). The soft tissue assessment which included evaluation of oral hygiene and gingival status of the participating Saudi Dental Journal, Volume 17, No. 3, September - December 2005
MURSHID 136 dmft was 3.62 and 1.0 for the males Regarding the behavior of the children and females, respectively. The overall during the dental examination (Table 5), means DMFT was 2.75 and the dmft was the results show that 9 (45%) of the 3.1(Table 3). children were definitely negative, 8 (40%) were negatively and 3 (15 %) reacted positively to dental examination according to the modified behavioral scale of Frankl and Wright.26 The children showed a great a mount of fear towards the dental team and a great resistance to the clinical examination which was observed more in the males than in the females. Parents’ responses to the questionnaire regarding dental visits (Table 4) indicated that 13 (65%) of the children had been to a dental clinic and had history of treatment and follow up while 7 (35%) other children did not make any previous dental visits. Six of the thirteen families who went for dental appointments had tried several times but they faced great difficulty with their children and only minimum or no treatment could be The use of “Tell-Show-Feel and Do” performed under regular dental setting. technique was not effective with the This made the parents hesitant to take majority (85%) of the children even with their children to the subsequent the trainers’ help and the introductory appointments. Only seven children had visit of the team members to the center managed to receive dental treatment, four before the day of the clinical examination. were treated under General anesthesia The children were brought to the room and 3 children were treated under local with their trainers and each one of them anesthesia with nitrous oxide and was informed by his/her trainers about physical restraint. The parents of the the procedure and asked to cooperate. seven (35%) children who had never been During the clinical examination, the to a dental clinic attributed this to their children were resisting and fighting, children’s difficult behavior and lack of refusing to open their mouths. Only 3 compliance even during homecare. This children (2 males and one female) showed led the parents to believe that nobody could positive behavior and they were willing to manage to treat their children and so they open their mouths for only short periods depended on home dental care only. of time without too much resistance. Saudi Dental Journal, Volume 17, No. 3, September - December 2005
137 ORAL HEALTH STATUS AND BEHAVIOURAL ATTITUDE group showed more males registered in the center than females, which might reflect the higher prevalence of autism in males as it was reported in other studies around the world.3,12 With regard to self injurious behavior, the findings are in agreement with the findings of Lindemann that most of the children practice self injuries behavior (SIB) which DISCUSSION range from self-pinching or scratching to severe self-biting or head banging.27 None The need for baseline information of the children in the present study regarding the oral health status of showed severe SIB to the extent of that children with autism in Saudi Arabia is reported by Medina et al group, where a 4 becoming clearly essential. The published year old autistic girl used to self extract information through the Saudi Autism her own primary teeth.13 Only one male Society and the different rehabilitation in this study showed a history of picking centers regarding these children was not his gum in the upper canine area and enough to provide a clear perspective which caused a mark but without major about the oral health status of children damage similar to the case reported by with autism in Saudi Arabia. This Johnson.28 particular autistic center was chosen The results of the gingival status of the because of many reasons. It was the first children showed that all the children had established center especially for autistic generalized gingivitis which could be children in Riyadh, the geographic location related to many reasons such as the in the middle of Riyadh the capital is irregular brushing habits because of the suitable, and for the availability of difficulties the trainers and the parents different rehabilitation facilities, special encountered when they brushed the education certified trainers, and the children’s teeth. It could also be due to range of the children’s age groups in lack of the necessary manual dexterity of addition to the principal trainers and autistic children during brushing by parents’ cooperation, the choice of the themselves, which made their tooth center was appropriate. brushing inefficient. Furthermore, the The history of scars and trauma findings of this study reflect poor dental obtained during the clinical examination awareness, a lack of dental education and was cross-checked with the parents’ deficiency in receiving oral hygiene response for any possible findings of child instructions from dental staff. Care-givers abuse or child neglect. The results showed need to know the different techniques that all the scars or signs of trauma were and materials of tooth brushing with due to repeated self injuries according to emphasis on behavior modification to the parents’ report which was in harmony control the behavior of the children as well with the trainer’s response. as diet control and regular dental visits. The results of this study showed Another possible explanation of the some similarities and differences in presence of generalized gingivitis might oral health status, dental needs and be the side effects of medications used behavior of this group of Saudi autistic to control the manifestations of children when compared to other autistic autism. Examples are hyperactivity children around the world. The studied (methylpheniadate), repetitive behaviors Saudi Dental Journal, Volume 17, No. 3, September - December 2005
MURSHID 138 (fluoxetine, sertraline, and pimozide) and The difficulties in controlling children aggressive behaviors (lithium, valproate). with autism were reflected in the results Although, the long term effects of of the previous dental experience where instituting these medications in young nitrous oxide, physical restrain and children remain unknown, it is reported general anesthesia were used to control that these antidepressants inhibit certain the children’s behavior. The findings also metabolic pathways and certainly have show that most of the children had different side-effects.29 It is essential that negative to definitely negative reaction to every dentist dealing with autistic the examination which was conducted children should be familiar with the within an area familiar to them and manifestations of the condition and its among their trainers. Our findings were associated features and should be familiar in agreement with other studies with the used medications to evaluate any conducted in the western world by Klein possible side effects that may cause and Backman.3, 8 untoward orofacial and systemic reactions Therefore, it is important to obtain as or precipitate adverse interaction with much information as possible about every dental therapeutic agents. Even for the case of autism. A careful review of the four children who were reported to be medical and dental history, the behavior cooperating with the daily brushing they of the child during the clinical had generalized gingivitis because they examination and the behavior of the child were brushing only once a day and 3 of in general are essential. More studies them had protrusion and incompetent lips. should be conducted about children with This made them mouth breathers causing autism in Saudi Arabia. The studies gingival inflammation especially in the should include the rest of the upper anterior areas. rehabilitation centers around the country Regarding the caries prevalence of this to provide better information regarding autism in the Kingdom. group of children, the results showed that the mean dmf, and DMF for all the subjects were 3.1 and 2.75, respectively. This level CONCLUSIONS of dental caries is considered moderate according to the WHO classification.23 It The findings of this study are limited to would not be accurate to compare the one rehabilitation Center in Riyadh and to results of the male and female subjects the convenient sample size; consequently separately due to the small number of the results should be interpreted female subjects in the study, but accordingly. Therefore, within the limits of comparing the results of all the subjects the present study design, the following with other studies conducted with different conclusions could be made: groups of healthy children in Riyadh (dmft = 5.0) area show a lower caries prevalence • The oral health status of the autistic in the autistic study group.30 This finding children did not show significant would be in agreement with Karmen and differences from the international groups reported in the previous Kopel findings who reported lower caries studies. prevalence in autistic children. 19, 20 However, the differences observed in • The autistic children in this study caries prevalence can not be generalized showed similar repetitive behavior and because of the convenience sample of self injuries habits as other autistic children. children reported around the world. Saudi Dental Journal, Volume 17, No. 3, September - December 2005
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