ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10005-2607
International Journal of Clinical Pediatric Dentistry
Volume 16 | Issue S-1 | Year 2023

Prognostic Factors for Successful Dental Treatment in Autistic Children and Adolescents

Vishnu R Chamarthi1, Ponnudurai Arangannal2

1Department of Pediatric and Preventive Dentistry, Sathyabama Dental College and Hospital, Chennai, Tamil Nadu, India

2Department of Pediatric and Preventive Dentistry, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India

Corresponding Author: Vishnu R Chamarthi, Department of Pediatric and Preventive Dentistry, Sathyabama Dental College and Hospital, Chennai, Tamil Nadu, India, Phone: +91 9840065050, e-mail: drvishnurekha@yahoo.com

ABSTRACT

Aim: The aim of this study was to recognize and assess the prognostic factors which could predict the level of cooperation of children with autism for dental appointments.

Methods: A total of 395 parents of children with autism participated in this study. Prognostic factors of cooperation were evaluated using questionnaires. Data were collected using parent surveys by a dentist.

Statistical analysis: Statistical analyses used in the present study include the formation one way and two-way frequency tables, binomial tests, Pearson’s Chi-squared tests, Fisher’s exact test, and collation of multiple proportions tests.

Results: Autistic children meeting their own needs, cooperation for nail-clipping and haircuts, smiling frequently, using toothbrushes and toothpaste and being assisted by parents for toothbrushing, and children who brushed their teeth once a day were more cooperative with the dentist. Children who had thumb-sucking and nail-biting habits were cooperative with the dentist. Children who bit their hands appeared to be more cooperative with the dentist when compared to other self-inflicting habits.

Conclusion: This study identified ”prognostic factors” such as their cooperative ability during nail clipping, hair cutting, and ability to read, write, and meet their own needs that are answered by a parent and that may show a child’s cooperative potential.

How to cite this article: Chamarthi VR, Arangannal P. Prognostic Factors for Successful Dental Treatment in Autistic Children and Adolescents. Int J Clin Pediatr Dent 2023;16(S-1):S45–S50.

Source of support: Nil

Conflict of interest: None

Keywords: Autism, Behavior, Cooperation

INTRODUCTION

The attention to behavior guidance techniques, as appreciated by the American Academy of Pediatric Dentistry, is on ”the continuum of interaction involving the dentist and the dental team, the patient and the parent-directed toward communication and education.”1 Patients with special needs present difficulty in using these techniques.

Autism (additionally acknowledged as ”autistic disorder” and ”classic autism”) is a neurodevelopmental disturbance in which social communication, language, behavior, and cognitive functions are weakened starkly.2 Epidemiologic studies of autism reveal a prevalence of 10–20 cases of classic autism per 10,000 births.3 The male:female proportion is 3:1.4 Prevalence seems to be unassociated with race, socioeconomic position, or status of parental education.5 Interpersonal weaknesses are still obvious during infancy when the baby does not look for the attention of the caregiver and fails to embrace, produce direct eye contact, raise arms in expectation of being picked up, occupy in imitation games, signal to or reveal an object such as a toy to the parent or acknowledge to smiles or a mother’s tone.6 Young children with autism do not engage in group play but seem to be in their own world and are not able to participate in another child’s enthusiasm in a venture.7 As adolescents and young adults, they commonly continue to be oblivious to the existence and desires of others, are not able to sympathize with and perceive the world from other people’s views, and display an absence of interest in sharing their accomplishments with others; rather, they choose to occupy themselves in solitary activities than in forming friendships.

Cognitive disability is obvious in about 70% of autistic children and is extremely severe in 40%.3 Tasks in need of reasoning, explanation, consolidation, or generalization are difficult for autistic children to accomplish.

Behavioral symptoms of people with autism, especially in young children, consist of anger, tantrums, and, as they get older, impulsiveness, anxiety, annoyance, self-assertiveness, and self-injury. Likewise, psychiatric ailments, which include anxiety disorders, mood disorders, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and schizophrenia, become more widespread during adolescence.8

The element of autism is not known, though confirmation from family and twin study researches recommends that it is an inherited disorder involving up to 20 interacting genes. Genes detected on chromosomes 2, 7, 15, 16, and 19 have been implied.9 The predominance of males with the disorder proposes an X-linked disorder.10

Children with autism are a heterogeneous group with varying capabilities to cooperate within the dental environment.11 In pediatric dentistry, communication is vital to behavior management. Therefore, the capacity to communicate with an autistic patient makes it difficult for practitioners to offer complete care in a conventional manner.12 Kamen et al. have stated that autistic patients are likely the most challenging for any dentist to treat. Repetitive body motions, echolalia, hyperactivity, and low frustration thresholds are some of the demanding situations practitioners face in treating this population.13 Furthermore, autistic patients are often unresponsive or disinterested in demonstrations of dental procedures and will struggle to put in efforts to create rapport with the dental team.14

It is essential to recognize this population’s usage of dental care in recognizing probabilities for enhancing the dental health of autistic children. The aim of this prospective study was to recognize and assess the prognostic factors which could predict the level of cooperation of children with autism for dental appointments.

MATERIALS AND METHODS

The single-subject experimental design was used for the study design. The study area included all special schools situated in Chennai. All children identified with autism spectrum disorder were included in the study. Parents of 395 children aged 4–10 years participated in the study and filled up the questionnaires. The study period was from June to December 2019.

Parents of autistic children or their legal guardians were asked to take part in this study certified by the Institutional Ethical Committee, Sree Balaji Dental College and Hospital (SBDCECM102/10). All the parents/legal guardians were invited by the dentist to participate in filling up the questionnaire in their child’s respective learning centers. Parents of children identified with autism were included if the diagnosis was confirmed by a pediatrician, medical specialist, or psychologist, which was confirmed from their medical records also. The parents/legal guardians were given a questionnaire to be filled up regarding their child’s demographic characteristics, life skill abilities, emotional outcome, oral hygiene skills, and details on the first dental appointment, if any. All these data were collected by a dentist using parent-written surveys or by questioning the parents and thereby written entries made by the dentist. All interviewees signed an informed consent prior to participating in the study. A total of 483 autistic children were observed in various special centers, but only 395 parents/guardians consented to fill up the questionnaire.

Parent-written survey questions included:

Patient demographics

Life skill abilities

Emotional outcome

Oral hygiene skills

Deleterious oral habits

Self-inflicting habits

History of a first dental appointment

The question pertaining to previous history of dental treatment was noted regarding their first dental appointment, where no dental treatment was done and only an examination of the oral cavity was performed to have uniformity in assessing their level of cooperation. The level of the child’s cooperation was noted as per their willingness to sit on the dental chair and in opening their oral cavity during their first dental visit.

Even though no part of the study was blinded, the utilization of parent surveys reduced bias by the dentist.

Deleterious oral habits and self-inflicting behavior were not included in the questionnaire at the start of the study. But some parents had reported it in the questionnaire sheet, and some parents orally stated that their child had thumb-sucking habit or that they bit themselves and asked if it could be entered in the questionnaire. So, questions related to the child having any deleterious oral habits and self-inflicting behavior were also added to the questionnaire.

The validity and reliability of the survey questionnaire were assessed using statistical tests. Parents or guardians finished the questionnaire on two different occasions that were 2 weeks apart. The time interval of 2 weeks was contemplated long enough for participants to have forgotten their feedback but not long enough for a total change to happen. Parents were not apprised of the second administration of the questionnaire in the first instance. The responses in the first administration were used in determining construct validity. Two sets of responses (i.e., the first and second administration) were used in calculating test-retest reliability. The correlation coefficient between the two sets of scores, administered two times, 2 weeks apart on the Rosenberg self-esteem scale, was +0.95. This indicated good reliability.

Correlations were made between the child’s cooperative behavior with their life skill abilities, emotional outcome, oral hygiene skills, deleterious oral habits, and self-inflicting habits.

Statistical analyses used in the present study include the formation one way and two-way frequency tables with percentages, binomial tests, Pearson’s Chi-squared tests, Fisher’s exact test, and collations of multiple proportions tests. Graphical presentation of data was also made wherever necessary. All statistical analyses were performed using the standard statistical package IBM Statistical Package for the Social Sciences (version 24.0).

RESULTS

Over a period of 6 months, 395 parents/guardians of autistic children participated in this study by filling in the given questionnaires. The age of the children varied from 4 to 10 years. There were 315 boys and 80 girls. Among the 395 participants, there were 388 parents (383 mothers and five fathers) and seven guardians. The final sample size of the study was decreased from N = 483 to N = 395, owing to the unwillingness of the parents to fill up the questionnaires.

The demographics showed that all 395 parents/guardians stated that the child was diagnosed as autistic by a health professional. Around 4% of the parents stated that they had a family history of autism, and all 4% who were affected were the child’s twins. About 90.4% of the autistic children in this study were born full-term, and 9% were preterm children. Around 57% of the mothers had a normal delivery, 38% had a cesarean, and 4% had a forceps delivery. A total of 56% of the fathers and 90% of the mothers were below 30 years of age at the time of birth of their autistic child. A total of 3% of the fathers and 9% of the mothers were between 30 and 40 years of age. Around 41% of the fathers were above 40 years of age.

While analyzing the lifeskill abilities of autistic children, it was noted that almost 81% of the children were able to meet their own needs, like eating and wearing clothes. A total of 60 and 68% of the children could read and write. Most of the children cooperated to get their nails clipped (73%) and to get a haircut (75%).

Regarding the kind of emotion frequently displayed by the autistic child, it was noted that a majority of them smiled most of the time (47%), followed by smiling and crying (27.8%). A total of 13% of the children showed anger frequently. Frequent crying was seen in 10.1%, while only 2.8% showed that they are frightened in various instances. (Fig. 1)

Fig. 1: Emotions shown by autistic children

A total of 33% of the children had some kind of self-inflicting behavior, and 67% did not, as reported by parents. Concerning the child’s self-inflicting behavior, it was noted that a majority of children bit their hands (68%). Both hand and leg-biting were seen in 18% of the children. Around 8% of the parents reported that their children hit themselves. A total of 4% of the children bit their shoulders. Headbanging was also reported in 2% of the children (Fig. 2).

Fig. 2: Self-inflicting behavior of autistic children

In consideration of the oral hygiene skills of autistic children, it was observed that most of the children used a toothbrush (91%) and toothpaste (100%) for brushing their teeth. Very few children used an electronic toothbrush (1%), and some brushed using their fingers (7%). Most of the children were helped by their parents with tooth brushing (52%). In 17% of the children, tooth brushing was completely done by parents for the child. A total of 30% of the children brushed their teeth all on their own without any assistance from parents (Fig. 3). Majority of the children (76%) brushed their teeth only once a day, while 23% did twice a day. Only, 50% of the children did not willingly brush their teeth, and parents had to persuade them for it, while the rest (49%) showed willingness for tooth brushing.

Fig. 3: Assistance with tooth brushing

As reported by parents, only 23% of the children had a deleterious oral habit, while a majority of them did not have any oral habit. The most prevalent oral habit observed in autistic children in this study was nail-biting (12%), followed by thumb-sucking (6.8%). Bruxism and lip biting was reported in only 2% each, respectively.

It was noted that 152 autistic children had visited a dentist previously for regular dental check-ups or to get their decayed teeth filled or extracted. Recorded data by the parents showed that 13.67% of the children were uncooperative, and 24.81% were cooperative with the dentist in their first appointment.

Cooperative abilities with the dentist were associated and compared with the child’s life skill abilities, emotional outcome, oral hygiene skills, deleterious oral habits, and self-inflicting habits.

Table 1 demonstrates that autistic children who were able to meet their own needs were more cooperative with the dentist when compared to reading and writing.

Table 1: Association between life skill abilities and cooperation with the dentist
Cooperation for dental treatment Fisher’s exact test/Chi-square test
Uncooperative Cooperative
Life skills Ν % Ν % Chi-square value p-value
Yes fully 46 85.19 80 81.63
The child is able to meet his/her own needs 0.068
Only partially 5 9.26 3 3.06 5.389
[nonsignificant (NS)]
No 3 5.56 15 15.31
The child is able to read Yes 35 64.81 52 53.06 0.175
1.965
(NS)
No 19 35.19 46 46.94
The child is able to write Yes 38 70.37 67 68.37 0.856
0.065
(NS)
No 16 29.63 31 31.63

Table 2 verifies that autistic children who cooperated with nail-clipping and haircut were equally cooperative with the dentist.

Table 2: Association between nail clipping and haircut and cooperation with the dentist
Cooperation for dental treatment
Uncooperative Cooperative
Child’s cooperation Uncooperative Cooperative Uncooperative Cooperative Fisher’s exact test
Ν % Ν % Ν % Ν % Chi-square value p-value
Cooperation of child for nail clipping 13 24.07 41 75.93 27 27.55 71 72.45 0.217 0.703 (NS)
Cooperation of child for a haircut 17 31.48 37 68.52 26 26.53 72 73.47 0.421 0.574 (NS)

Table 3 verifies that children who frequently smiled were more cooperative with the dentist when compared to children who frequently showed other emotions like crying, anger, and frightened.

Table 3: Association between emotions and cooperation with the dentist
Kind of emotions the child generally shows Cooperation for dental treatment Pearson’s Chi-squared test
Uncooperative Cooperative
Ν % Ν % Chi-square value p-value
Smiling 32 59.26 42 42.86
Smiling and crying 16 29.63 32 32.65 0.186
Crying 2 3.70 12 12.24 6.180 (NS)
Anger 10 10.20
Frightened 0 0.00 2 2.04

Table 4 signifies that children who used toothbrushes and toothpaste for brushing their teeth, children who were helped by their parents with tooth brushing, and children who brushed their teeth once a day were more cooperative with the dentist.

Table 4: Association between oral hygiene skills and cooperation with the dentist
Cooperation for dental treatment Fisher’s exact test/Pearson’s Chi-squared test
Oral hygiene skills Uncooperative Cooperative
Ν % Ν % Test value p-value
The child knows the importance of toothbrushing Yes 12 22.22 28 28.57 0.724 0.446 (NS)
No 42 77.78 70 71.43
The child willingly says “yes” to tooth brushing Yes 25 46.30 44 44.90 0.027 1.000 (NS)
No 29 53.70 54 55.10
Finger 2 3.70 8 8.16
The tool used for brushing Toothbrush 51 94.44 88 89.80 1.141 0.565 (NS)
Electronic toothbrush 1 1.85 2 2.04
The material used for brushing Paste 51 94.44 93 94.90 0.014 1.000 (NS)
Powder 3 5.56 5 5.10
Only parent 8 14.81 15 15.31
Person doing brushing Only child 15 27.78 29 29.59 0.078 0.962 (NS)
Parent with child 31 57.41 54 55.10
Number of times brushed Once a day 42 77.78 75 76.53 0.031 1.000 (NS)
Twice a day 12 22.22 23 23.47

Table 5 suggests that children who had thumb-sucking and nail-biting habits tended to be more cooperative with the dentist rather than those having bruxism and lip-biting.

Table 5: Association between oral habits and cooperation with the dentist
Cooperation for dental treatment Pearson’s Chi-squared test
Uncooperative Cooperative
Deleterious habits of the child Ν % Ν % Chi-square value p-value
Thumb-sucking 2 40.00 8 30.77
Bruxism 0 0.00 1 3.85 0.909 0.823 (NS)
Nail-biting 3 60.00 14 53.85
Lip-biting 0 0.00 3 11.54

Table 6 reveals that children who had a self-inflicting habit like hand biting were more cooperative with the dentist than those compared with other self-inflicting habits.

Table 6: Association between self-inflicting habits and cooperation with the dentist
Cooperation for dental treatment Pearson’s Chi-squared test
Uncooperative Cooperative
Kind of self-inflicting behavior Ν % Ν % Chi-square value p-value
Hand biting 15 68.18 13 52.00
Hand and leg biting 3 13.64 7 28.00
Head banging 1 4.55 0 0.00 3.566 0.468 (NS)
Hitting themselves 1 4.55 3 12.00
Shoulder biting 2 9.09 2 8.00

DISCUSSION

The defining features of autistic disorder exhibit a variety of challenges and a lifespan of situational stresses to children with autism and their parents.15 A dental appointment is among the usual activities where the autistic child may reveal misbehavior. This study attempted to identify prognostic factors for uncooperative behavior. Definite key questions asked prior to the dental appointment may be helpful in evaluating cooperative ability and, consequently, in identifying appropriate behavior guidance schemes for each autistic child.

Only examination of the oral cavity was considered in this study to have uniformity in assessing if the children were cooperative or uncooperative with the dentist.

Children who were not able to meet their own needs and were not able to read and write were more likely to be uncooperative with the dentist.

Children who were not able to sit for a haircut or who required persuading were more uncooperative with the dentist. Both dentistry and haircuts involve handling the head by an adult with instrumentation that is unfamiliar to a child’s daily activities. This is in accordance with the study done by Marshall et al.11

The emotional status of a child could also be a factor in knowing the level of cooperation in the dental setting, and this factor in this study showed that children who smile often are more cooperative with the dentist than children showing anger, fear, and those who cry.

In this study populace, a large percentage of parents assisted with tooth brushing. Children of parents who helped with tooth brushing, especially those children whose parents were the only toothbrushers, were uncooperative with the dentist. This is in similarity to Marshall et al’s. study.11

The other oral hygiene skills considered in this study were the willingness of the child to tooth brushing, the tool and material used for tooth brushing, and the frequency of tooth brushing. This study exhibited that children who willingly said yes to tooth brushing and children who used toothbrushes and toothpaste were more cooperative with the dentist. Only three children used electronic toothbrushes, and two of them were cooperative with the dentist. This level of cooperation can be ascribed to the fact that tooth brushing involves getting a tool into the child’s mouth, and tools being used in the dental clinic are also being used in the child’s mouth. In essence, a high level of cooperation with the dentist was observed in those autistic children where some kind of tool like a toothbrush is being put into their mouth and, similarly, dental tools being introduced into their oral cavity while doing the dental treatment.

In parallel, this study showed that children who had thumb-sucking and nail-biting were more cooperative with the dentist rather than with bruxism. This persistently shows that they are more comfortable with something in their oral cavity.

Among the children observed having self-inflicting behavior, children who bit their hand were more cooperative with the dentist than those with other self-inflicting habits like head banging and shoulder biting.

No single evaluation technique is completely precise in predicting a child’s behavior response to dental treatment. This study recognized certain ”prognostic factors” or questions that are readily replied to by a parent or caregiver, and that may designate a child’s cooperative capacity.

Limitations

The cooperativeness of the child noted in this study solely depended on the parent’s opinion and was not done by the dentist since the level of cooperativeness in this study was based on the previous first dental appointment.

CONCLUSION

Evaluating the autistic child’s capacity to cooperate may be attained by considering these prognostic factors prior to the appointment. These prognostic factors include autistic children meeting their own needs, cooperation for nail-clipping and haircuts, smiling frequently, using toothbrushes and toothpaste and being assisted by parents for toothbrushing, and children who brushed their teeth once a day were more cooperative with the dentist. Children who had thumb-sucking and nail-biting habits were more cooperative with the dentist when compared to other oral habits. Children who bit their hands appeared to be more cooperative with the dentist when compared to other self-inflicting habits.

Practical implementation for this study may comprise asking these questions during a new patient’s appointment consultation. This would contemplate more appropriate adjustments in the dental environment. These questions could also be asked to returning patients to support in gauging the autistic child’s behavioral development.

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