Ebtissam Zakaria Murshid, BDS, MS, MPH, DrPH
College of Dentistry, King Saud University, Riyadh, KSA

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.

Autism, Autistic Syndrome (AS), Autistic Disorder (AD), Infantile Autism (IA) and Childhood Autism (CA) are different terms given to the same condition of a developmental disability. The condition was first described in 1943 by Leo Kanner, an American child psychiatrist.^1,2 Kanner reported his observations of a group of children as they expressed impaired social and behavioral interactions, verbal and nonverbal communication deficiencies, and developmental retardation.^1-3 Later, Kanner's observations were identified as an organic disorder characterized by abnormalities in the brain structure and function, especially the limbic system and cerebellum.^3-5 Recently, researchers reported that the etiology of such brain abnormalities might be due to early prenatal insult such as chromosomal abnormalities, intrauterine viral infections, and metabolic disorders suspected to play a role in the pathogenesis of this syndrome.⁴

In a recent epidemiologic study conducted in the United States, the findings show a tremendous increase in the prevalence of autism between the end of the 1980's and the beginning of the 1990's (1987-1994). The authors of the study could not determine if the observed increase in autism was due to improvements in detection, changing and broadening of diagnostic criteria or a true increase in prevalence.⁶ Other epidemiological studies of autism reported that the main age at which autism was diagnosed was 44 months, with a wide variation of the expression of symptoms among different individuals.^3,7,8 Autistic children may express mental retardation, abnormal emotional, social and linguistic development, poor muscle tone, poor coordination, as well as visual and hearing impairment.^3,9,10 Klein and other researchers reported that males are four to five times affected more than females, but more severe symptoms are exhibited in females.^{3, 8, 11-13}

As part of the multiple unknown developmental abnormalities, several studies reported that up to 70% of the children diagnosed with autism practice self injurious behavior (SIB) at some stage in their lives. This behavior is expressed as a deliberate harm to the body that may lead to serious injuries without suicidal intent. This repetitive behavior is more common in females, mentally and psychologically impaired individuals.¹⁴ It usually affects the head and neck region.^{13, 15}

Oral health and dental needs of children with autism have been evaluated by very few investigators. The studies conducted on this topic reported no statistically significant differences in the prevalence of caries, fillings, gingivitis and degree of oral hygiene in comparison with non-autistic individuals^{8, 16-18} and even a lower incidence of caries in some of the reports.^{19, 20}

Because of the widely aberrant behavior and communication impairment of children with autism, every child requires special behavior management with a great deal of patience and confidence.^8,17,21 The use of Tell-Show-Feel-Do technique with sedation or nitrous oxide was recommended in the literature to manage and treat the autistic child in routine dental settings.²¹

This study was conducted in the first center established in 1999 in Riyadh, the capital of Saudi Arabia, as indicated by the Saudi Autistic Society's official website. In Riyadh, there are about six non-profit centers that accept and offer rehabilitation services for children with autism. The center offers an intensive rehabilitation program only for children diagnosed with autism and has 20 registered children. All the children (16 males and 4 females) were included in the study. All the children had been previously examined and diagnosed medically as autistic patients according to the center's medical records. A self-administered questionnaire in Arabic was sent to 5 families to pre-test the reliability of the questions. The questionnaires included demographic information (name, age and gender of the child), child's oral hygiene practice, previous dental experience, behavior during dental examination and treatment, and habits including self injurious behavior. The habits and behavioral patterns of every child were reviewed with the children's trainer. Every family was assured of the confidentiality of the collected data and that the resultant information would be used only for the research purposes.

Files of all the children were reviewed and the medical status of each child was recorded in a special clinical examination form designed for this study. On the day of examination, each child accompanied by his/her trainer was brought to the designated examination room and was informed by his/her trainers about the procedure, and asked to cooperate with the examiner. The children were seated on an adjustable office chair or laid down flat on an exercise mattress depending on their physical condition.

During the examination procedure, the "Tell-Show-Feel and Do" technique was used with all the children. Extra-oral examination included any scars, trauma to the head and neck, hands and fingers. Intra-oral examination of the soft and hard tissues was done under flash light and regular room light using disposable gloves, mouth mirror, explorer and sterilized gauze to clean and dry the teeth. Sound, decayed, missing and filled teeth were recorded in the dental chart following the WHO criteria.²³

The gingival status was evaluated according to the gingival index of Loe and Silness (1963) which varied between mild (slight changes in color and texture) to moderate gingivitis (redness, edema, and bleeding on pressure).²⁴ No probing or pocket depth measurement was conducted to evaluate the periodontal health due to the difficult behavior of the children. Gingival status was recorded as generalized or localized gingival inflammation depending on the amount of gingival redness and bleeding during the examination. The examination also included any intra-oral soft tissue findings (e.g. ulcer, abscess). Oral hygiene was recorded as good, fair or poor according to the Simplified Oral Hygiene Index (OHI-S).²⁵

The collected data were entered in the computer using Statistical Package for Social Sciences (SPSS version 10) software for frequency distribution of all variables.

A report of each child's oral health and dental needs as well as any special instructions to improve the oral hygiene of the child was sent to the parents.

The parents of all the 20 children, 16 (80%) males and 4 (20%) females with a mean age of 9.6 years participated in the study. Results of the extra oral assessment, types of habits, trauma and injuries as well as the given reasons are shown in Table 1. Out of the 20 examined children, 14 (70%) showed signs of trauma. The injuries varied from scratches to one case of burned fingers. Five males and one female had no signs of trauma or injuries in the examined areas (Table 1).

Injuries to the head region were recorded in 6 (30%) of the children (4 males and 2 females) and it was due to self head banging on the walls and furniture, and hitting by bare hands or with objects during stressful moments or as expression of temporary madness and discomfort. Three other children (15%) showed signs of scratches on the sides of their faces due to head banging and hair pulling.

The most common trauma was recorded in the hands and fingers, as 15 (75%) of the children (11 males and 4 females) showed different degrees of injuries. The reasons given were repeated self biting habit and touching hot beverages or food. A 10-year old male had shown signs of localized gum recession in the upper anterior region due to repeated picking with his nail. Another male reported that he had a habit of pinching himself and the others when he was angry. Two of the females and one male children showed signs of ulcers in the lips and tongue regions which were difficult to diagnose as either traumatic or aphthous ulcers (Table 1).

The parents of the 6 (30%) children with no signs of trauma reported that their 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 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 habit. The results are illustrated in Table 2.

The hard tissue assessment showed that thirteen children (65%) had multiple decayed and untreated teeth (49 permanent and 27 primary). Only 6 children (30%) had fillings in their teeth (6 permanent and 10 primary), and five children (25%) showed no signs of clinical decay or fillings. The mean DMFT score was 1.6 and 7.25, whereas, the mean dmft was 3.62 and 1.0 for the males and females, respectively. The overall means DMFT was 2.75 and the dmft was 3.1(Table 3).

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 performed under regular dental setting. This made the parents hesitant to take their children to the subsequent appointments. Only seven children had managed to receive dental treatment, four were treated under General anesthesia and 3 children were treated under local anesthesia with nitrous oxide and physical restraint.    The parents of the seven (35%) children who had never been to a dental clinic attributed this to their children's difficult behavior and lack of compliance even during homecare. This led the parents to believe that nobody could manage to treat their children and so they depended on home dental care only.

Regarding the behavior of the children during the dental examination (Table 5), the results show that 9 (45%) of the 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.   

The need for baseline information regarding the oral health status of children with autism in Saudi Arabia is becoming clearly essential. The published information through the Saudi Autism Society and the different rehabilitation centers regarding these children was not enough to provide a clear perspective about the oral health status of children with autism in Saudi Arabia. This particular autistic center was chosen because of many reasons.  It was the first established center especially for autistic children in Riyadh, the geographic location in the middle of Riyadh the capital is suitable, and for the availability of different rehabilitation facilities, special education certified trainers, and the range of the children's age groups in addition to the principal trainers and parents' cooperation, the choice of the center was appropriate.

The history of scars and trauma obtained during the clinical examination was cross-checked with the parents' response for any possible findings of child abuse or child neglect. The results showed that all the scars or signs of trauma were due to repeated self injuries according to the parents' report which was in harmony with the trainer's response.

The results of this study showed some similarities and differences in oral health status, dental needs and behavior of this group of Saudi autistic children when compared to other autistic children around the world. The studied 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 range from self-pinching or scratching to severe self-biting or head banging.²⁷ None of the children in the present study showed severe SIB to the extent of that reported by Medina et al group, where a 4 year old autistic girl used to self extract her own primary teeth.¹³²⁸ Only one male in this study showed a history of picking his gum in the upper canine area and which caused a mark but without major damage similar to the case reported by Johnson.

The results of the gingival status of the children showed that all the children had generalized gingivitis which could be related to many reasons such as the irregular brushing habits because of the difficulties the trainers and the parents encountered when they brushed the children's teeth. It could also be due to lack of the necessary manual dexterity of autistic children during brushing by themselves, which made their tooth brushing inefficient. Furthermore, the findings of this study reflect poor dental awareness, a lack of dental education and deficiency in receiving oral hygiene instructions from dental staff. Care-givers need to know the different techniques and materials of tooth brushing with emphasis on behavior modification to control the behavior of the children as well as diet control and regular dental visits. Another possible explanation of the presence of generalized gingivitis might be the side effects of medications used to control the manifestations of autism. Examples are hyperactivity (methylpheniadate), repetitive behaviors (fluoxetine, sertraline, and pimozide) and aggressive behaviors (lithium, valproate). Although, the long term effects of instituting these medications in young children remain unknown, it is reported that these antidepressants inhibit certain metabolic pathways and certainly have different side-effects.²⁹ It is essential that every dentist dealing with autistic children should be familiar with the manifestations of the condition and its associated features and should be familiar with the used medications to evaluate any possible side effects that may cause untoward orofacial and systemic reactions or precipitate adverse interaction with dental therapeutic agents. Even for the four children who were reported to be cooperating with the daily brushing they had generalized gingivitis because they were brushing only once a day and 3 of them had protrusion and incompetent lips. This made them mouth breathers causing gingival inflammation especially in the upper anterior areas.

Regarding the caries prevalence of this 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 of dental caries is considered moderate according to the WHO classification.²³  It would not be accurate to compare the results of the male and female subjects separately due to the small number of female subjects in the study, but comparing the results of all the subjects with other studies conducted with different groups of healthy children in Riyadh (dmft = 5.0) area show a lower caries prevalence in the autistic study group.³⁰ This finding would be in agreement with Karmen and Kopel findings who reported lower caries prevalence in autistic children.^{19, 20} However, the differences observed in caries prevalence can not be generalized because of the convenience sample of children.

The difficulties in controlling children with autism were reflected in the results of the previous dental experience where nitrous oxide, physical restrain and general anesthesia were used to control the children's behavior. The findings also show that most of the children had negative to definitely negative reaction to the examination which was conducted within an area familiar to them and among their trainers. Our findings were in agreement with other studies conducted in the western world by Klein and Backman.^{3, 8}

Therefore, it is important to obtain as much information as possible about every case of autism. A careful review of the medical and dental history, the behavior of the child during the clinical examination and the behavior of the child in general are essential. More studies should be conducted about children with autism in Saudi Arabia. The studies should include the rest of the rehabilitation centers around the country to provide better information regarding autism in the Kingdom.

The findings of this study are limited to one rehabilitation Center in Riyadh and to the convenient sample size; consequently the results should be interpreted accordingly. Therefore, within the limits of the present study design, the following conclusions could be made:

• The autistic children in this study showed similar repetitive behavior and self injuries habits as other autistic children reported around the world.

Table 1.  Findings of extra-oral examination in the participating autistic children 

( * Self Injuries Behavior (SIB), ** Others Injuries Behavior (OIB)) 

Table 2. Gingival status, oral hygiene and anterior occlusion of the participating children 

 

Table 3.  Distribution of DMFT and dmft according to age group and gender

Table 4.  Autistic children's' previous dental experiences in relation to age and gender

Table 5.  Autistic children's behavior during dental examination (Wright, 1975)