Dental awareness of the parents, dietary habits and oral hygiene of autistic children at Prince Mohammed Bin Salman Autistic Center in King Fahad Armed Forces Hospital Jeddah, Kingdom of Saudi Arabia (observational study)

1. Introduction

Autism is a lifelong neurodevelopment disability notable through significant impairment in communication skills, social interactions, and cyclic stereotypes of behaviours [1]. Leo Kanner is an American child psychologist who defined autism in 1943 [2]. Further, it has been noted by researchers that the characteristics and severity of autism differ significantly from one child to another [3, 4, 5]. This spectrum of conditions is present across all ethnic and socioeconomic groups. The spectrum encompasses Autism, Asperger Disorder (AD), and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), each displaying variations in the quantity and intensity of diagnostic traits [6]. Boys have a greater likelihood of developing Autism Spectrum Disorders (ASD) compared to girls, with a reported gender-specific epidemiology ratio of 4.6:1 for autism spectrum disorders [3]. ASD symptoms typically manifest before the age of 3 [7]. Those with ASD often exhibit significant challenges in utilizing various forms of non-verbal communication, forming social connections, sharing emotions and experiences, delayed or absent speech development, and a strong preference for routines [8]. Additionally, individuals with ASD may also experience sensory sensitivities, cognitive impairments or epilepsy [9]. All the characteristics mentioned above may hamper professionally delivered and home dental care, putting children with ASD at high risk for oral diseases, such as dental caries [10]. Autistic children may exhibit additional dental characteristics such as extensive gingivitis, delayed tooth emergence, dental injuries and misalignment of teeth [10]. These children frequently engage in detrimental oral behaviors like grinding teeth, pushing the tongue against the teeth, and biting lips [11]. The primary oral issue observed in children with autism spectrum disorder (ASD) is tooth decay [10, 11]. Early Childhood Caries (ECC) remains prevalent among children, particularly those from economically disadvantaged backgrounds [12]. Early childhood caries is “the existence of one or more tooth decays (non-cavitated or cavitated lesions), removed (due to caries), or filled tooth surfaces in any primary dentition of children under the age of six years”. Severe early childhood caries (S-ECC) is a type of dental decay that worsens over time in children, classified based on both the quantity of affected teeth and the age of the patient [12]. The presence of cavities on the smooth surfaces of teeth is a key indicator of S-ECC among children under the age of three. One contributing factor to the onset of tooth decay in these young individuals is the frequent consumption of sugary treats, often given as a reward for good behavior [13]. The breakdown of dietary sugars, the elevated level of sugar in the diet, and the continuous intake throughout the day all play significant roles in the development of cavities [14]. Alsajer et al. [15] reported that they are selective and picky eaters, as they prefer soft and sweet food, giving a chance for an increased risk of caries development in these children. Furthermore, certain children with ASD are prescribed medications that have a systemic impact on saliva production, leading to a decrease in salivary flow. This reduction can result in dry mouth, diminishing the mechanical and antibacterial properties of saliva that help wash away plaque, ultimately raising the risk of developing dental caries [16]. Additionally, individuals with autism often experience challenges in coordinating their tongue movements, leading to prolonged food retention within the oral cavity. This extended food pouching behavior can further contribute to an increased susceptibility to cavities [17].

In autistic children, the difficulty in maintaining good oral hygiene is noticeable. There are various factors that may contribute to this issue, including inconsistent brushing habits and ineffective flossing resulting from limited manual skills, insufficient guidance on dental care from parents, and challenges faced when trying to brush their children’s teeth [18]. Furthermore, the anti-convulsive and anti-psychotic medications are a significant influence on developing generalized gingivitis that affects maintaining good oral health, thus causing plaque accumulation and caries development [19]. The consistent maintenance of a child’s oral health routine is influenced by the level of parental involvement and understanding of oral hygiene practices [20]. Minervini et al. [21], demonstrated a clear correlation between parent’s knowledge and education on oral health and the positive oral hygiene habits observed in their children. Considering the various factors influencing the oral health of individuals with ASD, it is imperative to provide tailored care for this specific group. Offering ongoing education could enhance the provision of oral healthcare for these individuals. Ehsan et al. [22] found a positive correlation between educating adults on oral health and raising awareness, leading to better oral health outcomes for their children.

This study aims to report baseline information about the dental awareness of the parents and dental health of a group of autistic children in King Fahad Armed Forces Hospital, Jeddah. This information was necessary for quality improvement in the hospital. It helped design effective educational programs for autistic children and their parents to improve their quality of life and general health through better oral care.

2. Materials and methods

3. Results

4. Discussion

Autism is a severe public health issue in many countries [24]. Children diagnosed with ASD typically exhibit significant challenges in social interaction, communication deficits, repetitive behaviors and motor skill impairments, along with medication-induced dry mouth, a preference for sugary foods and food hoarding [25]. These factors collectively impact the provision of home dental care by healthcare givers, leading to an increased susceptibility for oral health issues, notably dental caries, among children with ASD [26]. Advanced educational programs and specialized behavioral therapy can lead to significant improvements in a child’s condition, promoting enhanced self-care practices and ultimately, better oral health. As a result, parental involvement and awareness play a crucial role in enhancing the oral health of their children [27]. The study aimed to collect baseline data about the patients diagnosed with autism from Prince Mohammed bin Salman Center at King Fahad Armed Forces Hospital, Jeddah, Kingdom of Saudi Arabia. This information played a crucial role in enhancing the quality of care provided at the hospital. Utilizing these findings, tailored educational initiatives were developed for both children with autism and their parents, aiming to enhance their overall well-being and oral health through improved oral hygiene practices. Additionally, the surveys were presented in straight forward Arabic language. The total number of samples was 72. All the families were assured that all the data and the results would be confidential.

According to the data, the majority of the patients (86.1%) were male, consistent with a recent prevalence study conducted in Riyadh, Saudi Arabia, which indicated a higher proportion of males compared to females [28]. According to the Centers for Disease Control and Prevention reports, the number of males diagnosed with autism was 3.4 times higher than that of females [29]. According to Bagattoni et al. [30], the oral health of children is influenced by the educational background of their parents. They found a correlation between parents with higher levels of education and lower rates of cavities, as well as better oral hygiene practices. In our study, the parents scored 34% for mothers and 55% for fathers with high school education, but none were significant. ASD-specific parental stress, which tends to escalate when there is more than one child diagnosed with autism [31], is identified as a significant factor influencing oral health. These parents often experience high levels of stress, fatigue, and feelings of being overwhelmed by the various obstacles they confront. These challenges can result in ineffective parenting practices, impacting not only the individual child but also posing potential risks to family dynamics, potentially leading to marital issues such as divorce [32]. For example, they might neglect their child’s oral health because they are becoming overloaded with the child’s general health difficulties [33].

Moreover, behavioral and lifestyle issues experienced by children with autism can significantly impact their oral health by increasing the risk of tooth decay [26]. Included in these behaviors/lifestyles are the following: (1) favoring sweet and soft foods; (2) inadequate oral hygiene habits; (3) medication use. Our research findings align with previous studies, indicating a strong inclination towards consuming soft diet and sweet treats, utilizing sweet food as a form of reward, and exhibiting a tendency to pocket food in the oral cavity due to insufficient tongue coordination [13, 15, 17, 30]. 86.1% preferred soft drinks; many studies correlate the high soft drink consumption by autistic children [13, 21]. Moreover, the use of the medication as an anti-psychotic and anti-depressant drug was also a common factor in caries progression due to its’ reduced salivary flow effect [34].

In terms of oral hygiene habits, many children with autism face challenges due to limited manual dexterity and physical impairments that can impact their ability to brush their teeth effectively [18]. Similarly to findings from previous research, our study revealed that these children rely on their mothers to assist with brushing [20]. The research also indicated that the children typically used a toothbrush once a day, consistent with earlier studies [13, 29, 32]. Moreover, the earlier examiners [4, 30] pointed out that autistic children are sensitive to taste. In our study, the parents stated that their children (79.2%) refused toothpaste due to its taste, which might explain why these children were brushing only once a day.

Finally, parental care is critical in achieving children’s best oral health care [25]. Our study showed that parents need to be more educated about the first dental visit and the importance of having it as early as possible, as most parents bring their children when there is pain. This finding is consistent with previous research conducted on children with various disabilities [35, 36]. Additionally, the data revealed that parents should be educated on the importance of conducting regular dental check-ups for their children at home; 38.9% of the parents admitted that they infrequently inspect their children’s teeth at home. Past studies have highlighted a discrepancy in parental awareness of appropriate oral hygiene habits and routines, indicating a necessity for improved awareness regarding their children’s routine dental appointments [37, 38, 39].

Furthermore, 84.7% responded “yes” to the idea that oral health wellness can affect the general oral health of children. Similarly, multiple research studies have demonstrated the direct correlation between oral health and overall well-being. Oral diseases serve as a gateway for various pathogens to enter the bloodstream and bones, triggering a pro-inflammatory state that may result in severe systemic illnesses [40]. Castilho et al. [41] emphasized the significance of parental oral hygiene practices and their impact on the dental well-being of their offspring, consequently enhancing their quality of life.

Lastly, 59.7% changed their toothbrush every three months, which agreed with the authors’ recommendation about changing the toothbrush’s period, as the chance of bacterial accumulation that causes gingivitis increases more after three months of toothbrush use [42, 43].

It is essential to highlight some limitations of the present report. First, the sample size is small; it was explained that the data collection was in 2021; still, in that year, we had COVID-19, and the people were not compliant with dental appointments unless there was an emergency, which may affect the validity of the findings. Secondly, the completion of the questionnaire by parents may introduce response bias, and the cross-sectional design of the study implies the presence of associations rather than causal relationships. Additionally, the utilization of a self-developed questionnaire with a limited number of inquiries could potentially introduce bias into the research outcomes. Future studies incorporating a larger sample size, sufficient statistical power, and a more extensive range of questions adopted from existing literature or experts could enhance the validity of the results and mitigate bias. Longitudinal designs are also required to confirm the validity of the findings and explore potential causal relationships that affect the dental caries and poor oral health of autistic children.

5. Conclusions

Most parents and caretakers knew well about children’s oral hygiene, but this knowledge was not reflected in their attitudes and practices. Regular oral health promotion education programs, with stress on dietary practices and other preventive measures, are necessary to promote this knowledge among parents and caretakers.

Enhanced cooperation among dentists and various healthcare professionals, including psychiatrists, pediatricians and other specialists serving autistic children, is essential. This collaboration should prioritize addressing parental stress and challenges, assisting families in establishing appropriate boundaries between the autistic child and other family members. We need to conduct more awareness programs in the hospital for the pediatricians about early dental referral once the child is diagnosed with autism and emphasize the importance of early prevention and intervention.

Educate all dental providers to be proactive! Remind them of the importance of early prevention and, thus, less harm. Motivate the dentist to use Positive Behavioral Support (PBS) to provide the appropriate service to the autistic patient in a way that improves their quality of life and fulfils their needs by learning new skills without any unnecessary restriction.

Abbreviations

AD, Asperger Disorder; PDD-NOS, Pervasive Developmental Disorder-Not Otherwise Specified; ASD, Autism Spectrum Disorders; ECC, Early childhood caries; S-ECC, Severe early childhood caries; PBS, Positive Behavioral Support; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology.

Availability of data and materials

The data presented in this study are available on reasonable request from the corresponding author.

Author contributions

RA, BA, AS and MA—conceptualized and designed the research study. RA, BA and AS—performed the research, as well as interpreted the data; wrote the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This is descriptive, cross-sectional study was carried out following the guidelines of E Von Elm, “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE statement) and was approved through the pathway of the Research and Ethics Committee at King Fahad Armed Forces Hospital, Jeddah, with reference ethical number REC370. The consent forms were obtained from the parents or legal guardians of autistic children visiting the dental clinic or Prince Mohammed Bin Salman autistic center in King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia and have obtained their informed consent.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.