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Table of Contents
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 122-128

Dental pain behavior of children with autism spectrum disorder at the Biruku Foundation, Bandung City

1 Faculty of Dentistry, Padjadjaran University, Indonesia
2 Department of Public Health, Faculty of Dentistry, Padjadjaran University, Indonesia
3 Department of Pediatric Dentistry, Faculty of Dentistry, Padjadjaran University, Indonesia

Date of Submission02-Jul-2022
Date of Decision04-Aug-2022
Date of Acceptance15-Aug-2022
Date of Web Publication15-Nov-2022

Correspondence Address:
Hanna Asshabirina Wanazizah
Faculty of Dentistry, Padjadjaran University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_34_22

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Background: Dental pain is one of the most common symptoms of dental and oral problems that are generally identified by verbal self-reports; however, it is difficult for children with autism spectrum disorder (ASD) who have social communication deficits. Dental pain in children with ASD can be detected by specific behavioral changes. Objective: In this study, the aim was to determine the dental pain behavior of children with ASD at the Biruku Foundation, Bandung City. Methods: The descriptive method used a cross-sectional design approach. The study sample consisted of children with ASD who were diagnosed by pediatricians as high-functioning autism (HFA) or low-functioning autism (LFA) and who were experiencing dental caries as a factor causing dental pain, which was observed by the examination of 12 children by a total sampling technique. Data collection was conducted in the form of a Dental Discomfort Questionnaire (DDQ). Results: High DDQ scores were obtained for three children (25%), a moderate DDQ score for seven children (58.3%), and a low DDQ score for two children (16.7%). The most frequent dental pain behavior displayed by children with ASD at the Biruku Foundation was increased saliva production (8.8%). Conclusion: Dental pain in children with ASD at the Biruku Foundation, Bandung City fell into the moderate category.

Keywords: Autism spectrum disorder, dental cross-sectional design, dental pain

How to cite this article:
Wanazizah HA, Susilawati S, Sasmita IS. Dental pain behavior of children with autism spectrum disorder at the Biruku Foundation, Bandung City. Sci Dent J 2022;6:122-8

How to cite this URL:
Wanazizah HA, Susilawati S, Sasmita IS. Dental pain behavior of children with autism spectrum disorder at the Biruku Foundation, Bandung City. Sci Dent J [serial online] 2022 [cited 2023 Mar 20];6:122-8. Available from: https://www.scidentj.com/text.asp?2022/6/3/122/361156

  Background Top

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social interactions, communication skills, and restricted, repetitive behavior.[1] ASD can be categorized into high-functioning autism (HFA) and low-functioning autism (LFA). Children with HFA typically develop language and cognitive skills, but suffer from social interactions and sensory and motor issues. In contrast, children with LFA typically suffer from verbal and emotional issues, reduced adaptive behavior, and deficits in social skills.[2] Around the world and in Indonesia, there is a rapid increase in the number of children detected with ASD. According to the World Health Organization (WHO), the global prevalence of ASD children is estimated to be 0,67%, representing about 16% of the entire global population of children.[3] In 2015, one in 250 children in Indonesia was estimated to have ASD.[4],[5] In 2011, 1085 children were detected with ASD in the West Java Province, and in 2007, Bandung City contributed up to 10% of the total number of ASD patients in Indonesia or ~739 patients.[6]

Meanwhile, dental caries is one of the dental and oral health problems of ASD children. A meta-analysis study revealed that currently, the prevalence of dental caries in ASD children is 60.6%.[7],[8] The high risk of dental caries in ASD children is associated with their difficulty in maintaining oral hygiene and poor eating habits, such as chewing food and high preference for cariogenic foods.[8],[9] A study reported that dental caries constitutes the main biological cause of toothache in children.[10]

Dental pain is one of the most common symptoms of dental and oral problems that can affect the quality of life in children, such as difficulty in sleeping, eating, concentrating, and participating in activities, absence from school, low academic achievement, impaired growth, and digestive problems.[11],[12],[13],[14] In several countries, the prevalence of dental pain in children ranges from 5% to 33%.[13] According to FDI World Dental Federation and the WHO, one of the Goals for Oral Health 2020 is the reduced occurrence of dental pain.[12] Generally, dental pain is a subjective experience that is easiest identified by explicitly describing it by verbal self-report,[15] but it is difficult for ASD children who suffer from social communication deficits.[16] Delays in the development of spoken language, inability to synchronize dialogue with context, difficulty articulating objectives and following norms in conversation, as well as the development of nonverbal communication behavior, make it difficult for ASD children to express their emotions and feelings, including when they experience dental pain.[17]

Children with ASD depend on their parents to recognize and manage their pain and discomfort.[18] Parents frequently find it difficult to understand the experience as ASD children cannot express and explain the specific area of pain, resulting in delayed pain management.[19],[20],[21],[22] Raposa reported that behavioral changes in ASD children might be a symptom of dental pain.[20],[23] Such specific behavior can serve as a warning indicator for parents to recognize dental pain in ASD children and treat it as early as possible before it causes more severe dental and oral problems.

The Biruku Foundation, which is located at Senam St. I No.8 Arcamanik, Bandung City, is an active foundation that provides a center for learning and therapy for ASD children. Based on the findings of an examination conducted in 2019, the dental and oral health conditions of ASD children at the Biruku Foundation revealed a poor to fair plaque index, which is one of the risk factors for dental caries that causes dental pain in ASD children.,[24]

Currently, studies detailing the dental pain behavior of children with ASD have not been conducted in Indonesia, particularly in Bandung City, to the best of our knowledge. In this study, the behavior of ASD children with dental pain at the Biruku Foundation, Bandung City, is described.

  Materials and Methods Top

In this study, a cross-sectional design approach was employed in this descriptive study. The sampling method included a total sampling technique with a total sample of 12 children. The inclusion criteria were ASD children diagnosed by a pediatrician as either high-functioning autism (HFA) or low-functioning autism (LFA) and who experienced dental caries as identified by a dental caries examination based on the caries severity index. The exclusion criteria were ASD children accompanied by other developmental disorders and parents who refused informed consent. This study was conducted in January 2022, and ethical approval was received from Padjajaran University Research Ethics Commission with number 1068/UN6.KEP/EC/2021.

In this study, an informed consent form, research questionnaires, basic dental tools, and personal protective equipment, as well as analysis tools of SPSS, Microsoft Excel, and Microsoft Word, were used. Whether dental pain caused certain behaviors in ASD children was investigated on the basis of the Dental Discomfort Questionnaire (DDQ) completed by their parents. DDQ is a measuring instrument whose validity and reliability are tested for assessing the behaviors that occur more frequently in ASD children experiencing dental pain. The DDQ questionnaire contained 11 questions to be answered by the parents of children with ASD due to their limitations and inability to complete the questionnaire. The answers were measured on a 3-point Likert scale: never, sometimes, and often. Dental pain behavior was categorized on the basis of the total score of the DDQ questionnaire.

The research procedure started by explaining the aims of the study and the procedure for providing informed consent to the prospective respondents. Next, the researcher distributed an informed consent form, containing a consent statement to participate in the study. Information of the children from the prospective respondents who agreed to participate in this study, including name, age, gender, ASD diagnosis, and address, was recorded. The dental caries data of ASD children were collected by conducting a dental examination, and the results were recorded on the caries examination result sheet. Subsequently, respondents were invited to objectively complete a research questionnaire. The frequency distribution was used to process the research data, which were presented in the form of tables, figures, and descriptive narratives.

  Results Top

From a total population of 15 persons, only 12 subjects were involved in this study. The other 3 subjects did not meet the inclusion criteria as they were included in the free caries category (did not have dental caries). [Table 1] shows the distribution of research respondents based on their characteristics:
Table 1: Distribution of research respondents based on characteristics

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The research respondents were divided into three age groups: Three children aged 6–11 years (25%), three children aged 12–16 years (25%), and six children aged 17–25 years (50%). Based on gender, 10 boys (83.3%) and 2 girls (16.7%) were present. Based on the severity of dental caries, three children (25%) were included in the severe category, five children (41,7%) in the moderate category, and four children (33,3%) in the mild category. With respect to the ASD diagnosis of these children, six children (50%) were categorized into HFA candidates, and six children (50%) were classified as LFA candidates.

According to the age group, respondents with high DDQ scores were most likely to be in the age group of 17–25 years with two children (16,7%), those with intermediate DDQ scores were most likely to be in the age group of 12–16 years with three children (25%), and the others with the lowest DDQ scores were most likely to be in the age group of 17–25 years with two children (16,7%). [Figure 1] shows the distribution of DDQ scores according to the age group.
Figure 1: Distribution of the DDQ scores according to age group

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Based on gender, 2 children (16,7%) out of 10 male respondents exhibited high DDQ scores, 6 children (50%) had intermediate DDQ scores, and 2 children (16,7%) exhibited low DDQ scores. Of the two female respondents, one child (8.3%) had a high DDQ score, while the other one (8.3%) had an intermediate DDQ score. None of the female respondents had low DDQ scores. [Figure 2] shows the distribution of DDQ scores according to gender.
Figure 2: Distribution of the DDQ scores according to gender

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According to the severity of caries, two (16.7%) respondents with severe caries had high DDQ scores, four (33.3%) respondents with moderate caries had intermediate DDQ scores, and two (16.7%) respondents had low DDQ scores, with mild caries severity. [Figure 3] provides an overview of the DDQ score distribution based on caries severity levels.
Figure 3: Distribution of the DDQ scores by caries severity levels

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The respondents were divided into two categories based on their ASD diagnosis: HFA and LFA. Six children were diagnosed with HFA, with one child (8,3%) having a high DDQ score, three children (25,0%) having intermediate DDQ scores, and two others (16,7%) having low DDQ scores. From the LFA type, two children (16,7%) had high DDQ scores, and four children (33,3%) had intermediate DDQ scores, while no children with LFA had low DDQ scores. [Figure 4] shows the distribution of DDQ scores based on the ASD diagnosis.
Figure 4: Distribution of DDQ scores based on ASD diagnosis

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From the respondents’ responses to the questionnaire, the most common dental pain behavior displayed by ASD children at the Biruku Foundation was increased saliva production, with a total score of 35 (8,8%), while the least common was sobbing at night while sleeping, with a total score of 23 (5,8%). The total score for completing the DDQ questionnaire from 12 research respondents was 304, with an average score of 25,33. [Figure 5] shows the distribution of dental pain behavior of ASD children at the Biruku Foundation.
Figure 5: Distribution of dental pain behavior of ASD children at the Biruku Foundation

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The overall distribution of DDQ scores from 12 research respondents revealed that three children (25%) had high DDQ scores, seven children (58,3%) had intermediate DDQ scores, and two children (16,7%) had low DDQ scores.

  Discussion Top

The study’s results demonstrated that male respondents outnumber females by a ratio of 5:1 [Table 1]. This result was consistent with that reported by Jody, et al. (2021), where the majority of research respondents at the Biruku Foundation were reported to be male, with a male-to-female ratio of 5:1.[25] This result was consistent with that reported in the study by the Center for Disease Control and Prevention (CDC, 2014) in that the prevalence of ASD in children is higher in males than in females.[26]

[Figure 1] shows the distribution of DDQ scores of ASD children based on age, as defined by Ministry of Health of Republic of Indonesia (Departemen Kesehatan Republik Indonesia/Depkes RI) in 2009. The results revealed that the highest and lowest DDQ scores correspond to the age group of 17–25 years. This result is related to that reported by Hadjikhani, et al. in that the biological age of ASD children does not impact perceptions and mindsets, including understanding behavioral responses to a pain stimulus.[27] Previously, Rattaz (2013) reported that the behavioral response of ASD children to pain stimuli does not alter significantly after 3 years as it does in normal children.[28] This result indicates that ASD children exhibit specific deficits in interpreting a behavioral response to pain stimuli, which is not related to age.

[Figure 2] shows the distribution of the DDQ scores of ASD children based on gender, indicating that male respondents have the highest DDQ scores. The study’s results contradict the theory reported by Zagni, et al. (2016); in his study, compared to males, females tended to be more sensitive to pain response because estradiol and progesterone, which exert a pronociceptive effect.[29],[30] This disparity can be related to the significantly different numbers of male and female respondents.

[Figure 3] shows the distribution of the DDQ scores of ASD children based on the severity of caries as measured by the caries severity index (CSI) measuring instrument. The results revealed that children with high DDQ scores are more likely to experience severe caries. Similar to this study, Boeira, et al. (2012) reported that the severity of caries affected perceptional and behavioral responses to dental pain that occurs more frequently. The results of this study were also in accordance with that reported by Pranati T and Jeevanandan (2020), who stated that high DDQ scores were more commonly found in subjects with dental caries with or without pulp involvement, because exposed dentinal tubules caused more intense pain and elicited more severe behavioral reactions.[14]

[Figure 4] shows the distribution of DDQ scores in ASD children based on their ASD diagnosis. The results revealed that ASD children with type LFA have the highest DDQ scores. This result was in agreement with that conducted by Li J, et al. (2014), who revealed that ASD children with LFA exhibited a worse deficit in social communication skills than ASD children with HFA.[31] ASD children with LFA have difficulty understanding and verbalizing the pain they are experiencing; thus, they frequently express it through behavioral changes.

In several studies, communication deficits in ASD children have been associated with neurobiological disorders.[32] A study stated that since infancy and toddlerhood, ASD individuals exhibit pathological growth in the frontal and temporal lobes, which play a key role in the communication process.[32] Several studies using diffusion tensor imaging (DTI) reported that the ASD group of individuals exhibits reduced white matter in the superior longitudinal fasciculus connecting Broca’s and Wernicke’s areas that play a role in mapping sound to articulation compared with that of the neurotypical control group.[32]

According to [Figure 5], increased salivation was the most common behavior shown by ASD children suffering from dental pain caused by dental caries. Rahayu, et al. (2018) reported that the presence of an infection or inflammation in the oral cavity can stimulate the increased production of saliva from the salivary glands, which occurs under the influence of the autonomic nervous system; this result indicates that it cannot be controlled consciously.[33] Besides bacterial infections, drug consumption is another factor that affects the production amount of saliva.[33] Bassokou, et al. (2009) reported that the salivary flow rate of ASD children was greater than that of normal children because ASD children take drugs to control certain symptoms, such as antidepressants to control anxiety and selective serotonin release inhibitors (SSRIs) to treat hyperactivity symptoms.[34]

According to the data processing results, from a total of 12 respondents, DDQ scores of ASD children at the Biruku Foundation were predominantly in the intermediate category (58,7%). This study exhibited several limitations, including the dental pain measurement tool of DDQ, which was responded primarily by parents’ observations instead of ASD children, thus permitting disparities of pain perception among parents and children of ASD. Moreover, the study only focused on only one aspect of pain, i.e., dental pain caused by dental caries.

  Conclusion Top

In this study, dental pain in ASD children at the Biruku Foundation, Bandung City, lies in the moderate category. Further research is suggested to use a dental pain measurement tool that can be answered objectively and directly by the ASD children and investigate factors that affect dental pain behavior of ASD children other than dental caries.

Financial support and sponsorship

This research was supported by Academic Leadership Grant Universitas Padjadjaran.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]


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