Parents' Dental Knowledge and Oral Hygiene Habits in Saudi Children with Autism Spectrum Disorder

Table of contents

1. Introduction

utism, or Autistic Spectrum Disorder (ASD), is a neuro-developmental disorder. It is characterized by impairments in behavioral and social interaction; language, communication, imaginative play, and a range of interests and activities Friedlander AH. 2003, Muhle R, 2004Cassel TD, 2007. ASD is not a disease, but a syndrome with multiple interacting causes; both genetic. Folstein S, Rosen 2001, Bayou N, 2008, . Landrigan would be expected to be developed enough that such impairments can be noted; typically this is around preschool age of 3 or 4 years old (APA 2000) Recently, it was reported that other social indicators such as shared smiles and direct vocalizations can be used to distinguish children as young as 12 months of age, that are at risk of developing ASD (Ozonoff et al. 2010) Due to the difficulty of diagnosing ASD cases, the prevalence of ASD is hard to establish, but is surely increasing rapidly all over the world.APA 2000. In Saudi Arabia, an extensive review of the literature revealed no specific numbers regarding diagnosed cases of autistic children reported. A rough estimate was reported in 2009 as 18 per 10,000 (Al-Salehi, Al-Hifthy, & Ghaziuddin 2009 ) While several prominent researches have been conducted from a medical point of view, the oral health and dental needs of children with ASD "specifically caries incidence studies" have been evaluated by few investigators. Previous studies conducted on this matter reported no statistical significant differences in the prevalence of fillings and caries rates in comparison to those of non-autistic individuals (Lowe O and Lindemann R. 1985, Backman, Pilebro. 1999 , Fahlvik-Planefeldt C, Herrstrom P 2001) Others reported a lower incidence of caries (Kopel HM: 1977, Karmen S, Skier I. 1985, Namal et al 2007, and A. Jaber 2011) Furthermore, previous studies showed that children with ASD showed visible plaque and different degrees of gingivitis (Lindemann and Lowe 1985, Shapira et al 1989, Murshid 2005, DeMattei et al. 2007. This might be due to the children lacking the manual dexterity needed for proper OH practices, or as a side effect of the medication used to treat their disorder. Many of the medications used to control the behavior of children with ASD or to increase their concentration and social interactions may have adverse oro-facial side effects due to their anti-cholinergic properties, including xerostomia, sialorrhea, dysphagia, sialadenitis, dysgeusia, stomatitis, gingivitis, gingival enlargement, glossitis, bruxism, edema and discoloration of the tongue .

Several studies reported a significant association between the parents' dental knowledge, routine oral hygiene practices, dietary habits, and children's oral health ( Barker JC andHorton SB 2008 &Bilal Mirza et al 2011). The standard of the children's oral hygiene correlated directly to that of their parents. Parents with better oral hygiene tended to have children with similar high standards of hygiene, and vice versa Al-Shalan, 2003, Wyne AH, 2004 Children with Autism Spectrum Disorders present a unique behavioral challenge to pediatric dentists due in part to the intrinsic communicative disability and altered sensitivities to various stimuli, Given the reported rise in the prevalence of ASD over the last 20 years, pediatric dentists can expect to be faced with the challenge of providing oral care for an increasing number of children with ASD. Increasing the parents' dental knowledge and the focus on the preventive programmers designed particularly to parents of children with ASD becomes highly significant. This can be achieved by investigating the dental knowledge of parents with ASD children. Therefore, the aim of this study was to investigate the dental knowledge of ASD children's parents and the oral hygiene practiced by ASD children.

2. Subjects and Methods

3. Questionnaire

This cross-sectional survey was approved by the Ethical Committee of Human Studies at the College of Dentistry Research Center (CDRC). A selfadministered questionnaire was formulated in simple Arabic language. To assess the questionnaire's readability, a group of 30 parents with autistic children attending the dental college at King Saud University were asked to answer the questionnaire and write their comments. Taking into consideration the comments of the pilot group of parents, a modified version of the questionnaire was distributed to parents of children diagnosed with any form of Autism or ASD. The questionnaire consisted of questions regarding the child's age, gender, and if the child was professionally diagnosed with any kind of Autistic Spectrum Disorder (ASD). In addition, it included dental questions like the sources of parents' dental knowledge, causes of dental problems, and their opinion about time of first dental visits.

4. Subjects

The subjects of this study were recruited from three of the major autistic rehabilitation centers in Riyadh (The capital of Saudi Arabia). The centers were registered with the Saudi Autistic Society (SAS). The authorities of each center were contacted and ethical approval was obtained before distributing the questionnaires to the parents of the autistic children. The staff members in each center distributed the questionnaires to all the parents who initially agreed to answer the survey while dropping their children off at the centers and collected them back later.

5. Methods

A cover letter of invitation to participate in the study was sent with the questionnaires. The letter included an explanation of the purpose, the importance of the study, and a short introduction of the investigator. The questionnaires requested information like the child's age, gender, and if the child was professionally diagnosed with autism, semi-autism, or any kind of Autistic Spectrum Disorder (ASD). In addition, dental questions like sources of parents' dental knowledge, causes of dental problems, and their opinion about time of first dental visits. Parents were asked to answer questions in regard to the frequencies of brushing, methods and tools of oral hygiene practiced by the autistic children or their caregivers. It was thought that the distribution of the questionnaire by a 3rd person and not by the investigators would be advantageous, as the bias would be reduced if the parents answered the questionnaire away from the dentist.

The total number of questionnaires distributed was 450. The copies were distributed taking into consideration the number of children enrolled in each center and the parents' initial agreement to participate in the survey. Every family was assured of the confidentiality of the collected data and that the resultant information would be used only for research purposes. The questionnaires were distributed to all the families with the help of the staff members working in the three selected centers during the month of May in 2012. All the answered questionnaires were collected by the author. Only children who were professionally diagnosed with ASD and the completed questionnaires were included in the study. The collected data was entered in the computer using Statistical Package for Social Sciences (SPSS) software for frequencies distribution of all variables in number and percentage.

6. Results

Out of 450 questionnaires distributed, 344 were returned and with an overall response rate of 76.4%. The children's ages ranged from 3 to 14 years old (mean age ±6.4) with 75.9% males and 24.1% females.

Table 1 shows the distribution of parents' response to the source(s) of their dental knowledge. The majority of the parents (57.3%) reported that they did not receive any information about dental knowledge. Other sources were from dentists and dental personnel, and from the media (14.2% and 9.6% respectively). Regarding the parents' knowledge about etiology of dental caries, a large number of the parents (48.8%) choose irregular cleaning of the teeth as the main cause of dental caries. Hereditariness or genetic causes was given by 12.5% of the parents as the main reason of dental caries. Only 11.6% thought bacteria was the main cause. The parents were asked what age the child should have their first dental visit at. The results show that 28.2% of the parents thought dental visits were necessary only at signs of pain or dental problems. Only 2 parents thought it should be during the first year since the child's birth. Twenty-seven percent of the parents didn't know the answer. Table 2 shows the distribution of the parents' responses regarding the oral hygiene practices of their children. The data shows that 38.7% of the children were able to brush their teeth by themselves, while 61.3% needed help during tooth brushing. More than half (52.3%) of the mothers were helping their children during tooth brushing. Only a few fathers (10.2%) were involved in the brushing practices. Receiving help during brushing from home nurses, helpers and maids represented 13.4%. Only 5.8% of the parents reported irregular or no brushing of their children's teeth. The parents reported that 32.6% of their children either did not practice tooth brushing (3.8%) or brushed on an irregular basis (28.8%). The rest of the children reported brushing once or twice a day, 34.0% and 29.1% respectively. Only 4.4% of the children brushed 3 times or more. An enormous number of the parents (90.7%) reported that toothbrushes and toothpaste were the main tools used to clean their children's teeth. A few parents (8.5%) used Miswak only and only 0.9%. relied solely on water rinses or swabbing the teeth with water and cotton. Water rinse /water swab only 3(0.9)

In Saudi Arabia, the amount of consequent research on Autism Spectrum Disorders (ASD) is sorely lacking, at least from the dental aspect. While several prominent researches have been conducted from a medical point of view, far too few studies have focused on the dental, which drew forth the inspiration behind this research. The cooperation and enthusiasm of the staff in the three selected centers had a great effect on the response rate of the parents.

In this study, the insufficiency in the distribution of oral hygiene instructions and dental awareness by dentists or dental personnel and dental institutions was reflected in the parents' responses. Only small number of parents received direct oral hygiene instructions from dentists, and even fewer parents received information from other sources like professional dental brochures and the media. Similar findings of shortages in the distribution of oral hygiene instructions was reported by parents of healthy children, or parents of children with different disabilities from the same city. ) the parents reported that they had received dental instructions directly from dentists at an early age. An explanation of this discrepancy could be the differences in the nature of the children's conditions. CP and DS are two conditions that are easily diagnosed at or about the time of birth, so parents usually are educated about their children's condition and the importance of an early intervention in regards to different health aspects before they leave the maternity and delivery ward. However, in the case of autistic children, the child looks absolutely normal at birth. "ASD cases usually diagnosed by the age of 2 years or older" (APA 2000, WHO 1992, Stone W et al 1999, Moore. V, Goodson S 2003, Amendah, D. et al 2011) In addition, Autism is considered to be a relatively new condition when compared to CP or DS, so parents with autistic children might be more occupied with the urgency of the medical, behavioral and training condition of their children than the dental condition.

Dental literature define caries as the most common multi-factorial disease of the human race. . Parents in this study showed substantial deficiencies in their dental knowledge, which was clearly reflected in their responses regarding the cause of dental caries. A large number of parents attributed the cause of dental caries to improper tooth brushing only. The role of bacteria was chosen by a very small number of parents in this study, and similar studies conducted with parents of healthy children This could be due to autism being considered a genetic and/or hereditary disorder, making parents believe that the two are correlated. Some studies point out that autism is a genetic disorder and many characteristics of the disease are still inexplicable, parents may believe that genetics may cause victim-blaming or victimshaming. These responses merely highlight the necessity of raising awareness about these controversial topics. Parents should be better educated by medical personnel on the procedures that follow the successful diagnosis of autism, or any signs of ASDs in children, so that they may seek dental advice from professionals well-acquainted with these disorders and sufficiently equipped to handle these children (e.g. pediatric dentists).

While the American Academy of Pediatric Dentistry (American Academy of Pediatric Dentistry: www.aapd.org), calls for the first dental visit to be by one year of age, a large number of the participating parents believed dental visits should be an option only in the case of pain or dental problems. Similar responses were reported by mothers of children with Down's syndrome (Al-Hussyeen 2006). Unfortunately, only two parents in this study thought their children should visit a dental clinic during their first year of age and many others chose the ages 3-6 to do so. Similar findings of delaying first dental visits were reported by other studies conducted in the same area (AlShalan et al. 2002, Al-Bader 2006, Al-Hussyeen A 2006, Wyne 2007). The delay in performing dental visits could be due to many reasons such as; the difficulty in managing the behavior of ASD children, or the unavailability of specialist clinics to treat children with Autism. Parents were likely unaware that dentists specializing in pediatric dentistry are trained in and capable of managing patients with different medical conditions and special needs. The lack of simple language brochures explaining the wide selection of behavioral management techniques that can be used in dentistry can be linked to this response. Cooperation between the different dental service providers in designing and distributing brochures customized for children with special needs is essential. Furthermore, a list of pediatric dentists and clinics Volume XIV Issue II Version I Year ( ) J should be sent to the SAS website and different rehabilitation centers to convey this information to the parents and increase their dental awareness.

Most of the children in the present study needed help during tooth brushing, which given the nature of disorder (wherein physical impairments or poor manual dexterity skills are counted amongst the characteristics of autism) was to be expected. (AAP 2000, Vivian Nordian, Ch Gillberg 1996, NIH 2008, Amendah, D.et al .2011) Another expectation was the large number of mothers helping during brushing. The mothers' role and enthusiasm in regards to their disabled children's oral health was acknowledged in many studies (Petersen PE 1995,Al-Tamimi S. 1998, Al-Hussyeen 2006, Hulya Bilgin, Leyla Kucuk 2010, ) It is also worth noting that most Saudi families are in the habit of hiring live-in help, usually nannies or maids, to help care for their children and perform household chores. Therefore it makes sense that some of the participant children were helped by their caretakers as well. It is important to highlight that the number of fathers assisting during tooth brushing was not particularly high. This could be due to the fact that most of the fathers in Saudi society are the main source of their families' income, and mothers usually are the ones caring for the children and homes.

Even though a large number of the parents in this study didn't receive any dental information or oral hygiene instructions, most of them brushed their children's teeth once or twice a day. This could be considered largely adequate on their part, especially if we take into consideration the territorial outlook most ASD children have when it comes to their privacy. Friedlander 2003, Klein and Nowak 1999, Marshall et all 2007, , Hulya Bilgin, Leyla Kucuk 2010, Murshid 2011. Fortunately, only a fractional percentage of the parents never brushed for their children. Similar regular oral hygiene practices were reported by different authors, who collected their data from parents of children with different disabilities living in the same area. (Al-Bader et al 2006, Al-Hussyeen,2006, Wyne 2007 ) The use of toothbrushes and toothpaste was reported with the majority of the parents of this study and many other similar studies conducted in the same area (Al-Bader et al 2006, Wyne 2007). Luckily, only a few of the parents in this study used water rinsing and cotton swabs only. Fewer parents still reported the use of the traditional and cultural tool known as Miswak to brush their children's teeth. Miswak is a natural tree branch taken from the Salvadora persica tree (a wooden stick) commonly used for brushing teeth in Arabian Countries and other parts of the world. The benefits of Miswak to the gums and teeth were touched upon by the World Health Organization. (T. al-Khateeb, D. O'Mullane, H. Whelton, M. Sulaiman 1991, WHO 2000, Ezoddini-Ardakani 2010) A small percentage of the parents in this study were using Miswak with their children. Similar findings were reported by parents of children with cerebral palsy in Riyadh. (Wyne 2007) This could be due to the difficulties in controlling the stick during brushing especially in cleaning the back teeth.

In general, the data collected in this study shows that most of the parents seemed to understand the importance of oral hygiene practices. A positive attitude in brushing the children's teeth was shown by the mothers participating in the study. The lack of circulation of dental information by professional dental personnel and dental institutions was clearly reflected in the parents knowledge of the causes of dental caries and the time of first dental visits and regular checkups. It is noteworthy to mention that a child with ASD may not be able to overlook and accept changes in his or her expected environment; most of them may become particularly defensive and obsessive about the variation. (Bogdashina, 2003). The difficulties in controlling and dentally treating children with ASD have been mentioned in a variety of studies. (Klein and Nowak 1999, Friedlander 2003, Marshall et all 2010, Murshid 2011) Therefore, obviously preventing dental problems in this group of children is more convenient than treating them. Parents should be informed that preventing plaque formation is the key to reducing dental caries and gingival diseases. This can be achieved by mechanical removing of plaque materials, reducing the refined carbohydrate diet intake, fluoride applications and regular dental check-ups.

7. Limitations

The questionnaire and data collection methods in this study may have certain limitations. For example, the educational level and socioeconomic status of the participants were not included though this could affect the results. To overcome these shortcomings, future studies are recommended. With the limitation of this study, it can be concluded that:

8. Conclusions

? There is lack of dental knowledge amongst the participating parents of children with ASD in this study, especially in regards to causes of dental caries, and the appropriate time of a child's first dental visit. ? Parents of children with ASD showed satisfactory oral hygiene practices.

9. Recommendations

? The need for professional dental health awareness lectures, brochures, educational television and radio advertisements, and programs designed especially for children with different disabilities becomes obvious.

Figure 1.
Knowledge and Oral Hygiene Habits in Saudi Children with Autism Spectrum Disorder II.
Figure 2.
Note: Author : Associate Professor in the Department of Pediatric Dentistry and Orthodontics College of Dentistry, King Saud University Riyadh,
Figure 3.
Figure 4. Table 1 :
1
Question Parents' Response NO (%)
Parents' sources of No information was received 197 (57.3)
dental knowledge Information received from Dentist/dental personal 49 (14.2)
Information received from media 33 (9.6)
Information received from folds and brochures 19 (5.5)
Information received from friends, relativities 10 (2.9)
Multiple resources 36 (10.5)
Reason for teeth Irregular cleaning 168 (48.8)
decay Multiple reasons 59 (17.15)
Hereditary/ Genetics 43 (12.5)
Don't know 44 (12.8)
Bacteria 40 (11.6)
Consuming food high in sugar 35 (10.1)
Time of first dental visit Only in case of pain or dental problems 97 (28.2)
Don't know 94 (27.3)
From 3-6 years 65 (18.9)
After 6 years 46 (13.4)
From 1-3 years 40 (11.6)
During the first year 2 (0.6)
Figure 5. Table 2 :
2
Question Parents' Response NO (%)
ASD child's ability to brush Yes 133 (38.7)
his/her teeth by his/her-self No 211 (61.3)
Children's help during tooth Mother 180 (52.3)
brushing Children are able to brush by themselves 133 (38.7)
Father 35 (10.2)
Maid, helper, home nurse 46 (13.4)
More than one person 55 (16.0)
Siblings 9 (2.6)
No or irregular brushing 19 (5.8)
Frequencies of tooth Never brushing 13 (3.8)
brushing practiced by The Children Irregular brushing Brushing once per day 99 (28.8) 117 (34.0)
Figure 6.
Parents' Dental Knowledge and Oral Hygiene Habits in Saudi Children with Autism Spectrum Disorder Parents' Year 2014 Parents' Year 2014 Year 2014
Volume XIV Issue II Version I V.
( ) J ( D D D D ) J ( D D D D ) J
VI.
VII.
Note: © 2014 Global Journals Inc. (US) Year ( ) J Volume XIV Issue II Version I © 2014 Global Journals Inc. (US)
1

Appendix A

Appendix A.1 Acknowledgment

The author would like to address her thanks to all the staff members and the directors of all the three centers for their help in distributing and collecting the questionnaires of this study. The author also would like to thank all the parents who agreed to complete the questionnaires of the study and for Mr. Ibrahim Abu-AlHassan for his help with the data entry and analysis.

Appendix B

  1. , Publication 2008. p. . National Institutes of Health. Autism fact sheet. National Institute of Neurological Disorders and Stroke
  2. Oral hygiene practices and dietary habits among children with Down's syndrome in Riyadh, Saudi Arabia. A A Al-Hussyeen , Al-Sadhan Sa . Saudi Dent J 2006. 18 p. .
  3. The pathophysiology, medical management, and dental implications of autism. A H Friedlander , J A Yagiela , V I Paterno , M E Mahler . Journal of the California Dental Association 2003. 31 p. .
  4. Oral health knowledge, attitude and practices by parents of the children attending KSUCD clinics. A H Wyne , A N Chohan , F H Al-Rowily , B M Shehri . Pakistan Oral and Dental Journal 2004. 24 (2) p. .
  5. Attitude of parents of disabled children toward dental visits in Riyadh, Saudi Arabia. A H Wyne . Odontostomatol Trop 2007. 30 p. .
  6. Use of M-CHAT for a multinational screening of young children with autism in the Arab countries. A Seif Eldin , D Habib , A Noufal , S Farrag , K Bazaid , M Al-Sharbati , H Badr , S Moussa , A Essali , N Gaddour . International Review of Psychiatry 2008. 20 p. .
  7. Infants and Toddlers with Autism Spectrum Disorder: Early Identification and Early Intervention. B A Boyd , S L Odom , B P Humphreys , A M Sam . Journal of Early Intervention 2010. 32 p. .
  8. Visual pedagogy in dentistry for children with autism. B Backman , C Pilebro . ASDC Journal of Dentistry for Children 1999. 66 p. .
  9. Fertility and abortion rates in the United States. B E Hamilton , S J Ventura . International Journal of Andrology 1960-2002. 2006. 29 p. .
  10. Faisal Izhar, Ayyaz Ali Khan , Oral health attitudes, knowledge, and behavior amongst high and low socioeconomic school going children in lahore. Bilal Abdul Qayum Mirza , Ayma Syed . Pakistan Pakistan Oral & Dental Journal 2011. p. .
  11. Dental care of autistic children within the non-specialized Public Dental Service. C Fahlvik-Planefeldt , P Herrstrom . Swedish Dental Journal 2001. 25 p. .
  12. The epidemiology of autism spectrum disorders. C J Newschaffer , L A Croen , J Daniels , E Giarelli , J K Grether , S E Levy , D S Mandell , L A Miller , J Pinto-Martin , J Reaven , A M Reynolds , C E Rice , D Schendel , G C Windham . Annual Review of Public Health 2007. 28 p. .
  13. The caries experience and behavior of dental patients with autism spectrum disorder. C Loo , R Graham , C Hughes . J Am Dent Assoc 2008. 139 p. .
  14. The caries experience and behavior of dental patients with autism spectrum disorder. C Y Loo , R M Graham , C V Hughes . J Am Dent Assoc 2008. 139 p. .
  15. Oral health knowledge and sources of information in parents of Saudi disabled children. D Al-Bader , L Al-Athel , A Wyne , A Chohan . Pakistan Oral & Dental Journal 2006. (26) p. .
  16. The economic costs of autism: A review. D Amendah , S D Grosse , G Peacock , D S Mandell . Autism spectrum disorders, D Amaral, D Geschwind, & G Dawson (ed.) (Oxford
    ) 2011. p. . Oxford University Pres
  17. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 2000. Washington: American Psychiatric Association. p. . (4th ed)
  18. , Diagnostic Descriptions , Guidelines . 1992. Geneva, Switzerland World Health Organization.
  19. Dental needs and status of autistic children: results from the national survey of children's health. D Kopycka-Kedzierawski , P Auinger . Pediatr Dent 2008. 30 (1) p. .
  20. Dental needs and status of autistic children: results from the National Survey of Children's Health. D T Kopycka-Kedzierawski , P Auinger . Pediatr Dent 2008. 30 (1) p. .
  21. Oral health status, dental needs habits and behavioral attitude towards dental treatment of a group of autistic children in Riyadh, Saudi Arabia. E Z Murshid . Saudi Dental Journal 2005. 17 (3) p. .
  22. Efficacy of Miswak (salvadora persica) in preventing dental caries Health, Ezoddini-Ardakani . 2010. 2 p. .
  23. The autistic child in dental practice. H M Kopel . ASDC Journal of Dentistry for Children 1977. 42 p. .
  24. Raising an Autistic Child. Hulya Bilgin , Leyla Kucuk . Perspectives From Turkish Mothers Journal of Child and Adolescent Psychiatric Nursing 2010. 23 (2) p. 92.
  25. An ethnographic study of Latino preschool children's oral health in rural California: Intersections among family, community, provider and regulatory sectors. J C Barker , S B Horton . BMC Oral Health 2008. 8 p. 8.
  26. Cooperation predictors for dental patients with autism. J Marshall , B Sheller , B J Williams , L Mancl , C Cowan . Pediatr Dent 2007. 29 (5) p. .
  27. Oral health status and dental needs of an autistic population of children and young adults. Spec Care Dent, J Shapira , J Mann , I Tamari , R Mester , H Knobler , Y Yoeli , E Newbrun . 1989. 9 p. .
  28. The knowledge and practices of oral hygiene methods and attendance pattern among school teachers in Riyadh, Saudi Arabia. K Almas , T M Al-Malik , Al-Shehri Ma , N Skaug . Saudi Med J 2003. 24 (10) p. .
  29. Dental caries experience, oral health status and treatment needs of dental patients with autism Journal of applied oral science, M A Jaber . 2011. p. 19.
  30. How well does early diagnosis of autism stand the test of time? Follow-up study of children assessed for autism at age 2 and development of an early diagnostic service. Moore Vgoodson , S . 10.1111/dmcn.1996.38.issue-4/issuetoc. Autism 2003. p. .
  31. Autism: an overview of genetic aetiology. N Bayou , R Ahlem , B Béchir Helayem , M Chaabouni , H . Tunis Med 2008. 86 p. .
  32. Do autistic children have higher levels of caries? A cross-sectional study in Turkish children, N Namal , H E Vehit , S Koksal . 2007. Indian Soc Pedod Prev Dent. 25 p. .
  33. Sensory Perceptual Issues in Autism and Asperger Syndrome, O Bogdashina . 2003. London, UK: JK Publishing. p. 84.
  34. Assessment of the autistic patient's dental needs and ability to undergo dental examination. O Lowe , R Lindemann . ASDC Journal of Dentistry for Children 1985. 52 p. .
  35. What causes autism? Exploring the environmental contribution. P J Landrigan . Current Opinion in Pediatrics 2010. 22 p. .
  36. Oral assessment of children with an autism spectrum disorder. R Demattei , A Cuvo , S Maurizio . J Dent Hyg 2007. 81 (3) p. 65.
  37. The genetics of autism, R Muhle , S V Trentacoste , I Rapin . 2004. 113 p. .
  38. Oral health situation of schoolchildren, mothers and schoolteachers in Saudi Arabia. S Al-Tamimi , P E Petersen . Int Dent J 1998. 48 (3) p. .
  39. Genetics of autism: complex aetiology for a heterogeneous disorder. S E Folstein , B Rosen-Sheidley . Nature Reviews Genetics 2001. 2 p. .
  40. Dental management of the autistic child. S Karmen , J Skier . Special Care in Dentistry 1985. 5 p. .
  41. Autism in Saudi Arabia: presentation, clinical correlates and comorbidity. S M Al-Salehi , E H Al-Hifthy , M Ghaziuddin . Transcult Psychiatry 2009. (2) p. .
  42. A prospective study of the emergence of early behavioral signs of autism. S Ozonoff , A M Iosif , F Baguio , Cook , Ic , M M Hill , T Hutman , S J Rogers , A Rozga , S Sangha , M Sigman , M B Steinfeld , G S Young . J Am Acad Child Adol Psychiatry 2010. (3) p. .
  43. Susan L Santangelo Paternal age increases the risk for autism in an Iranian population sample. Mol Autism Roksana Sasanfar, 1,2 Stephen A Haddad, 2 Ala Tolouei, 3 Majid Ghadami, 4 Dongmei Yu (ed.) 2010. 1 (2) .
  44. Al-Khamis A M, Parents' attitude towards children's first dental visit in the College of Dentistry. T A Al-Shalan , B A Al-Musa . Saudi Arabi Saudi Med J 2002. 23 (9) p. .
  45. Saudi parent's knowledge of and attitude toward the prevention of dental caries. T A Al-Shalan . Saudi Dental Journal 2003. 15 (1) p. .
  46. Early social and emotional communication in the infant siblings of children with autism spectrum disorders: an examination of the broad phenotype. T D Cassel , D S Messinger , L V Ibanez , J D Haltigan , S I Acosta , A C Buchman . Journal of Autism and Developmental Disorder 2007. 37 p. .
  47. Sulaiman Periodontal treatment needs among Saudi Arabian adults and their relationship to the use of the Miswak Community Dent. Health, T Khateeb , D O'mullane , H Whelton , M . 1991. 8 p. .
  48. Characteristics of patients with autistic disorder (AD) presenting for dental treatment: a survey and chart review. Spec Care Dent, U Klein , A J Nowak . 1999. 19 p. .
  49. autism spectrum disorders in children with physical or mental disability or both. ii: screening aspects. Viviann Nordin , Christopher Gillberg . Developmental Medicine & Child Neurology 1996. 38 (4) p. .
  50. Consensus statement on oral hygiene. Who . Int Dent J 2000. p. 139.
  51. World Health Organization, the ICD-10 Classification of Mental and Behavioral Disorders: Clinical 39. Stone WLLee EBAshford LBrissie JHepburn SLCoonrod EEWeiss BH Can autism be diagnosed accurately in children under 3 years?. J Child Psychol Psychiatry 1999. 40 p. .
  52. Murtomaa : Influence of mothers' oral health knowledge and attitudes on their children's dental health. Z Saied-Moallemi , J I Virtanen , F Ghofranipour , F , H . European Archives of Paediatric Dentistry 2008. 9 (2) p. .
Notes
1
© 2014 Global Journals Inc. (US)
Home 
Date: 2014-01-15