Outreach to the closed world dental service for Hong Kong … · 2016. 6. 20. · 2.7 Oral Health Education 9 2.8 Topical Fluoride Treatment 10 2.9 Oral Hygiene Instruction Poster

Title Outreach to the "closed world" dental service for Hong Kongautistic children

OtherContributor(s) University of Hong Kong. Faculty of Dentistry.

Advisor(s) Lui, JKC; Wong, AHH

Author(s) Cheung, Kai-hei, Vincent

Citation

Issued Date 2011

URL http://hdl.handle.net/10722/173747

Rights Creative Commons: Attribution 3.0 Hong Kong License

2011 Community Health Project

Outreach to the ʻClosed Worldʼ

Dental Service for Hong Kong Autistic Children

Group 4.3 Members Supervisors

Cheung Ka Hei, Vincent Prof. Edward C.M. LoCheung, Kelrie Kar Yan Dr. Jonathan K.C. LuiChow Shiu Cheuk Dr. Anthony H.H. WongHo, Stephanie Ting YanLaw Hong Yu, AnthonyLo Ka Man, CarmenMak Chun Kit, OscarSiu Ka Yu, ElsaWong Lok Wun, Mildred

Group 4.3BDS 4 Community Health Project - Outreach to the ‘Closed World’

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Table of Contents

PageAbstract 4

1. Introduction1.1 Definition of Autism 51.2 Etiology, Pathogenesis and Risk Factors 51.3 Diagnosis and Assessment 61.4 Prevalence 61.5 Dental Implication 7

2. Materials and Methods2.1 Aim of the Study 82.2 Objectives 82.3 Study Population 82.4 Recruitment of Participants 82.5 Data Collection and Activities 92.6 Clinical Examination 92.7 Oral Health Education 92.8 Topical Fluoride Treatment 102.9 Oral Hygiene Instruction Poster 102.10 Souvenir 102.11 Leaflets 102.12 Questionnaire 112.13 Data Analysis 11

3. Results3.1 Timetable of Events 123.2 Response Rate and Profile of the Participants 123.3 Oral Hygiene Condition 133.4 Dental Caries Experiences 133.5 Questionnaire 16

4. Discussion 20

5. Conclusion 24

6. Recommendations 25

7. Acknowledgements 25

8 References 27

9 Appendices 33


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AbstractBackgroundAutism is a group of neurodevelopment disorders characterised by qualitative abnormalities in reciprocal social interactions and in pattern of communication. In Hong Kong, the prevalence rate is 16.1 per 10,000. Aim & ObjectivesThe aim of this project is to provide primary dental care and oral health education to autistic children in Hong Kong. The objectives were as follows: 1) to examine the oral health status, 2) to provide oral hygiene instruction (OHI) through ‘Tell, Show, Feel, Do’, 3) to utilise a cartoon poster showing the correct toothbrushing technique and teeth models and 4) to study the acceptance of the method used to deliver oral hygiene instructions.

MethodsSixty-three autistic children aged 8 to 13 years (mean age 10.4) were selected by convenience sampling. The study comprised of a brief oral examination, toothbrushing instructions, and a questionnaire for caregivers to complete. DMFT and dmft were recorded and correct toothbrushing technique was demonstrated with the ‘Tell, Show, Feel, Do’ method and the poster. Topical fluoride varnish was applied on decayed tooth surfaces for those with given consent. Participants were advised to utilise the method taught, and to follow the poster while brushing at home. A questionnaire was distributed 2 weeks afterwards, to obtain information about the oral hygiene habit of the participants and to evaluate the acceptance of the programme. ResultsMost participants were found to have ‘fair’ (44%) to ‘poor’ (41%) oral hygiene. The mean DT and dt score found was 0.6 and both mean FT and ft was 0.2. Majority received regular annual dental check-up, with the most recent check-up being 6-12 months ago (64%). Regarding oral hygiene habits, most participants brushed their teeth twice daily (88%) but were graded with ‘poor’ toothbrushing skills (56%) by the caregivers. In addition, 80% of the participants received assistance on toothbrushing. ConclusionOral hygiene status of the autistic children in this cohort was fair to poor. Higher caries rates were found in permanent dentition compared to the general population, and most decayed teeth were untreated. It was reported from the questionnaires that most parents found the program to be meaningful, the poster was easy to follow and improvements were noted in terms of brushing technique and frequency.


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1. Introduction:

1.1 Definition of Autism

Autism is part of a group of neurodevelopmental disorder called pervasive developmental disorders, which is characterised by qualitative abnormalities in reciprocal social interactions, patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities. These qualitative abnormalities are known as pervasive features of the individual's functioning in all situations (International Classification of Diseases, 2007). From these features, autism can further be divided into three sub-categories: autistic disorder, Asperger disorder and persuasive developmental disorder-not other-wise specified (PDD-NOS).

The classical presentation of autism varies among the three types, and majority of the symptoms develop gradually with a regressive onset. These children begin to speak but slowly become remote and may refuse to make eye contact and stop responding to sounds over a course of a few days. However, repetitive movements may or may not develop (Volkmar et al. 2005 , Lord et al. 2004). They may also begin to regard other people as inanimate objects. Studies suggest that regression of the symptoms appears to be genetically determined (Stephanotis 2008, Werner & Dawson 2005).

As autistic children continue to grow, the ability to talk and respond usually begins again after 2 to 3 years of age. By the age of 6 to 7 they can blend into normal schools (Seltzer et al. 2004, Howlin et al. 2000), but their actions of ignoring people and avoidance of eye contact constitutes a major part of their social impairment. This forms a barrier hindering development of relationships with their families and peers.

1.2 Etiology, Pathogenesis and Risk Factors

There are different etiological theories on how autism develops but none can be confirmed. Besides having a strong genetic link, it is generally accepted that the cause is multi-factorial and thus most other theories have been discarded or abandoned. On the genetical basis, both female and male chromosomes have been confirmed. However, the father’s age at the time of offspring’s birth has been discovered to increase the child’s risk of developing autism (Reichenberg et al. 2006, Jamain et al. 2003, Shao et al. 2002, Liu et al. 2001).


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There is no accepted pathogenesis for any causative relationships for autism spectrum disorders (ASD). Nonetheless, apart from genetic factors some environmental factors are suspected to cause autism. Utero exposures of certain chemical agents, including valproic acid, thalidomide, and misoprostol, are associated with autism (Bromley et al. 2008). Additionally, studies discovered the use of assisted reproductive technologies (Knoester et al. 2007), such as infertility treatments and use of tocolytic drugs including terbutaline (Connors et al. 2005), have higher incidences of children having autism.

1.3 Diagnosis and Assessment

The diagnosis of ASD is based on the patient’s autism-specific history and clinical observation. Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observational Schedule (ADOS) are two of the specific tools commonly used for the diagnosis and assessment (Akshoomoff et al. 2006, Rutter et al. 2003, Lord et al. 2000).

For those in the high-risk groups, which include siblings of autistic children and children with developmental delay or genetic syndromes, structured instruments can be utilised for screening of ASD. These instruments include the Checklist for Autism in Toddlers (CHAT), Modified-Checklist for Autism in Toddlers (M-CHAT), Childhood Autism Rating Scale (CARS) and Social Responsiveness Scale-Parent and Teacher (SRS). However, these screening tests cannot be used to rule out or to confirm a diagnosis (Pereira et al. 2008, Charman et al. 2007, Wong et al. 2004, Baron-Cohen et al. 2000).

1.4 Prevalence

The incidence of children with ASD is approximately 4.3 to 5.5 per 10000 children in Australia (Williams et al. 2005). In North America, the prevalence is around 4.5 per 10000 (Barbaresi et al. 2005) and in the U.K., it is 8.3 per 10000 (Powell et al. 2000) which is the same as the Danish population (Lauritsen et al. 2004). In contrast, the incidence in Japan is as high as 27.2 per 10000(Honda et al. 2005) and in Hong Kong, the prevalence rate is 16.1 per 10000 (Wong & Hui 2008). The male to female ratio reported in the United States is 3.7:1 (Centres for Disease Control and Prevention 2006).


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1.5 Dental Implications

A cross-sectional study (Loo et al. 2008) stated that children with ASD had significantly lower caries prevalence than the unaffected patients. In this study, around 70% of the autistic patients were found to have caries experience compare to 86% of those in non-autistic patients. In contrast, there are studies (Marshall et al. 2010) which confirmed the validity of considering autism as an indicator of high caries risk.

In addition, some of the people with autism show deficits in motor skills which may affect their ability to carry out adequate daily plaque control independently (Hardan et al. 2003, Noterdaeme et al. 2002, Morinushi et al. 2001, Ghaziuddin & Butler 1998). Caregivers or parents should pay more attention in maintaining oral hygiene for their autistic patients.

Research has shown that many general dentists are not willing to see patients with ASD. It was found that in United States, 67% of the general dentists surveyed would not accept any adults with autism and that nearly 60% would not provide care for paediatric patients with autism (Dao et al. 2005). It is not surprising as there are problems with communications, and it is reported that 25 to 40% of these autistic children do not have verbal communication skills and those who are able to communicate may have speech that is echoic or scripted (Kopel 1977). Furthermore, ASD patients might have heightened sensory perceptions to smells, sounds and tastes, and dental procedures can irritate them and it is unsure that they are capable to cope with the demands of dental visits (Klein & Nowak 1998).


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2. Materials & Methods:

2.1 Aim of the Study

The aim of this project is to provide primary dental care and oral health education to autistic children in Hong Kong.

2.2 Objectives

The objectives of this community health project are:1. To examine the oral health status of autistic children2. To provide oral hygiene instruction through ‘Tell, Show, Feel, Do’ (TSFD), utilising a cartoon

toothbrushing instructions poster and teeth models, to autistic children3. To deliver simple dental treatment to autistic children4. To study the acceptance of the method used to deliver oral hygiene instructions by means of

a questionnaire distributed to parents or guardians of the autistic children

2.3 Study Population

The target group of this study was 8 to 13 year-old Hong Kong children with autism. It is impossible to see all autistic children due to constraints of the resources. Therefore some autism associations were contacted as convenience sampling was used.

2.4 Recruitment of Participants

In late January 2011, the General Secretary of Distinctive Learning Society, Mr. Paul Wong, was contacted, and a preliminary discussion on the feasibility of conducting an outreach oral health care service for the desired target population was held. Meetings were held with the group members, and the proposal (Appendix I) was presented. Mr Wong then sent the proposal about the planned service and the invitation letter (Appendix II) to all special needs schools in Hong Kong. Six schools/centres were interested in the project, but after careful consideration of the number of participants, four schools/centres were selected in the end. The final four schools were: Mary Rose School in Kowloon Tong, Po Leung Kuk Centenary School in Choi Wan, Evangelize China Fellowship Holy Word School in Yau Tong and Yuk Chi Resource Centre in Tuen Mun.


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Information regarding the outreach service with consent forms (Appendix III) were sent to the selected schools/centre so that they can distribute the details to potential participants. Reply slips of the consent forms were then collected by the respective schools/centre. The number of willing participants was as follows: 29 from Mary Rose School, 6 from Po Leung Kuk Centenary School, 15 from Evangelize China Fellowship Holy Word School, and 13 from Yuk Chi Resource Centre.

2.5 Data Collection and Activities

This project comprised of four components: 1) clinical oral examination, 2) oral health education, 3) free provisional dental treatment, and 4) questionnaire for the caregivers. Oral health education concentrated on toothbrushing techniques, and treatment was namely topical fluoride treatment, which was only delivered to those with signed consent from their parents or guardians.

2.6 Clinical Examination

The children underwent an intra-oral examination which assessed their dental caries using a LED light with disposable mirror. Both ‘DT’ and ‘dt’, ‘FT’ and ‘ft’ were recorded for all participants, as they are in their mixed dentition stage. The oral hygiene condition was also recorded as good, fair and poor but periodontal status was not taken into account. All clinical data was recorded on a data collection form (Appendix V). The diagnosis was recorded in the examination report (Appendix VI), notifying the parent/caregiver whether further treatment is required. In terms of work distribution, 3 members of the group worked as operators, 2 as assistants, 3 as oral hygiene instructors, 1 as the coordinator who overlooked the whole outreach event, allowing it to run as smoothly as possible.

2.7 Oral Health Education

Oral Hygiene Instruction (OHI) was delivered to the autistic children as the major component of the oral health education for this project. OHI, namely the correct toothbrushing technique, was demonstrated with TSFD method to all participants with the aid of the poster (Appendix VII). The oral hygiene instructors demonstrated on teeth model first, and then the brushing motion was demonstrated on the dorsum of the children’s hands to allow them to ‘feel’ and experience what it is like to be brushed. Under the supervision of the personnel responsible for the oral hygiene


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instructions, the children were then asked to attempt toothbrushing, utilising the method taught. Guidance was provided whenever the instructor felt that it was necessary. In order to standardise the teaching, operators were provided with a basic script (Appendix VIII).

2.8 Topical Fluoride Treatment

Duraphat (Duraflor ®, Densply), a 5% Sodium Fluoride varnish, was applied on decayed tooth surfaces with an applicator.

2.9 Oral Hygiene Instruction Poster

OHI posters (Appendix VII) with 17 cartoon diagrams drawn by the group members, depicting the concept of proper toothbrushing (i.e. angulation of the toothbrush bristles 45 degrees to the tooth surface, 10 stokes per group of teeth, brushing at buccal, lingual/ palatal and occlusal surface of both maxillary and mandibular teeth in a systematic sequence) were given to all participating children to take home. The posters were laminated, enabling them to post it up on bathroom walls, and to follow the cartoon strip step-by-step in order to to achieve proper toothbrushing. Parents or caregivers were given instructions regarding the use of the poster (Appendix IX). Extra copies of the poster were given to the schools/centres as reference and for duplication, so that they can help the children sustain and reinforce the newly learned behaviour and future distribution to other children in need.

2.10 Souvenir

Toothbrushes (Colgate®, Smile Toothbrush for age 5+, Extra Soft) and toothpastes (Oral B®, Tooth and Gum Care ) were given to the children as souvenirs.

2.11 Leaflets

Leaflets from the Department of Health regarding toothbrushing were distributed on the day questionnaires were collected. The brochures contained advice for parents and caregivers on how they could help a child with special needs in maintaining adequate oral hygiene (Appendix X). Since most of the participating organisations were schools, parents were unable to attend the program. The aim of distributing the leaflets was to provide a reference for caregivers, so that they can encourage the children to maintain their newly learned behaviour in order for it to become a daily habit. Extra leaflets were also left at the schools/centres as an information


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source for non-participants who were interested, and schools/centres were informed that extra copies can be obtained from the Department of Health.

2.12 Questionnaire

A questionnaire was designed and distributed to the parents or guardians 2 weeks after the date of the outreach, in order to assess the oral hygiene habits of the children before and after the study (Appendix XI). Items of the questionnaire include:

a) Number of dental check-ups per yearb) Most recent visit to the dentistc) Number of times of toothbrushing per day before participating in this projectd) Child’s oral hygiene status before participating in this project, as rated by the parent/guardiane) Child’s attitude towards brushing before participating in this project, as rated by the parent/

guardianf) Child’s brushing technique before participating in this project, as rated by the parent/guardiang) Whether or not the parent/guardian usually assists with toothbrushingh) Whether or not the child has previous exposure to oral hygiene educationi) Child’s snacking frequency per dayj) Whether or not the child is enrolled in School Dental Care Servicesk) Number of times of toothbrushing per day after participating in this projectl) Child’s oral hygiene status after participating in this project, as rated by the parent/guardianm) Child’s attitude towards brushing after participating in this project, as rated by the parent/

guardiann) Child’s brushing technique after participating in this project, as rated by the parent/guardiano) Overall benefit of the study towards autistic childrenp) Any extra opinions/suggestions regarding the project

2.13 Data analysis

The data from the questionnaires and charting sheets were entered into Microsoft Excel 2007 and proof-read. The data were then analysed using SPSS 17-0 (SPSS Inc., Chicago, USA). Chi-square test was used to study various independent variables. The cut-off point for statistical significance was set at 0.05.


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3. Results:

3.1 Timetable of Events

Date: Location Event

24/01/2011 Distinctive Learing Society at North Point

Meeting with General Secretary of Distinctive Learning Society, Mr. Paul Wong

(Preliminary discussion)

03/03/2011 Mary Rose SchoolProvide service; distribution of OHI posters, souvenirs, and questionnaires

24/03/2011 Mary Rose SchoolQuestionnaires collected and leaflets distributed

30/03/20111) Po Leung Kuk Centenary School

2) Evangalize China Fellowship Holy Word School

Provide service; distribution of OHI posters, souvenirs, and questionnaires

09/04/2011 Yuk Chi Resource CentreProvide service; distribution of OHI posters, souvenirs, and questionnaires

29/04/2011 Evangalize China Fellowship Holy Word SchoolQuestionnaires collected and leaflets distributed

06/05/2011 Yuk Chi Resource CentreQuestionnaires collected and leaflets distributed

08/05/2011 Po Leung Kuk Centenary SchoolQuestionnaires collected and leaflets distributed

3.2 Response Rate and Profile of the Group

A total of 67 local autistic Chinese children agreed to participate the program, with 6.0% (4) failing to attend the scheduled dental check up. Among the sixty-three participants who attended the check-up, 18.5% (10) were females and 81.5% (53) were males. The subjects ranged in age from 8 to 13 years, resulting in a mean age of 10.4 (SD = 1.2). However, one participant was uncooperative (1.5%) and thus clinical data could not be obtained from that participant (Table 1).


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CharacteristicCharacteristic Statistic

Gender Male 53

Gender Female 10

Mean Age (SD)Mean Age (SD) 10.4 (1.2)

Mean DT (SD)Mean DT (SD) 0.6 (0.9)

Mean dt (SD)Mean dt (SD) 0.6 (1.5)

Mean FT (SD)Mean FT (SD) 0.2 (0.5)

Mean ft (SD)Mean ft (SD) 0.2 (0.5)

Table 1. Demographic characteristic and dental caries status of the participants who underwent clinical examination

3.3 Oral Hygiene Condition

At the dental check-up, 12.7 % (8) of the subjects was rated ‘good oral hygiene’, 44.4% (28) with ‘fair oral hygiene’, and the remaining 41.3% (26) had ‘poor oral hygiene’.

3.4 Dental Caries Experiences

All subjects are in their mixed dentition stage. The DT scores ranged from 0 to 3, with a mean DT score of 0.6 (SD=0.9). More than half of participants (62.9%, 39) had no caries in their permanent dentition, but 21% (13) had a DT score of 1, 9.7% (6) had a DT score of 2 and 6.5% (4) had a DT score of 3.


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Fig. 3.1 Distribution of DT scores of the subjects

For primary dentition, the dt scores ranged from 0 to 10, producing a mean dt score of 0.6 (SD= 1.5). Majority of the participants (80.6%, 50) had a dt score of 0, 3.2% (2) had a score of 1, 8.1% (5) had a score of 2, and 6.5% (4) had a score of 3. Only one participant (1.5%) had a dt score of 10.

Fig. 3.2 Distribution of dt scores of the subjects


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The FT scores recorded had a range of 0 to 2, and the mean was 0.2 (SD 0.5). Most of the participants (85.5%, 53) had a FT score of 0, 8.1% (5) had a score of 1 and 6.5% (4) had a score of 2.

Fig. 3.3 Distribution of FT scores of the subjects

The ft scores for primary teeth also ranged from 0 to 2, thus also with a mean score of 0.2 (SD =0.5). Majority of the participants (87.1%, 54) had a ft score of 0, 6.5% (4) had a ft score of 1, and 6.5% (4) had a ft score of 2.


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Fig. 3.4 Distribution of ft scores of the subjects

3.5 Questionnaire

A total of 63 questionnaires were distributed to parents or guardians of all the participants via the schools and the Yuk Chi Resource Centre. 18% (11) of them failed to complete the questionnaire. From the completed questionnaires, the following information was obtained: a) background information of the participants, b) oral health behaviour of the participants before the project, c) oral health behaviour of the participants after the project, and d) overall comments on the project.

a) Background information

The participants ranged from 8 to 13 years old, resulting in a mean age of 10.6 (SD=1.2). Among those who completed the questionnaire, 19.2% (10) were females, 78.8% (41) were males, and one who omitted the question. For the degree of autism, 55.8% (29) of the participants were reported to be ‘mild’, 32.7% (17) reported ‘moderate’ and 9.6% (5) reported ‘unknown’. b) Oral health behaviour before the project:

Only 5.8% (3) of the participants were said to have received less than one dental check-up per year, the majority (84.6%, 43) had received one dental check-up per year and 9.6% (5) had


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received two or more dental check-ups per year. There was only 1.9% (1) of the participants who never visited a dentist before. Most of the participants (30.8%, 16) reported their most recent check-up to be 6 to 12 months ago, with 61.5% (32) reported to have received the check-up within 6 months. There was 7.7% (4) of the participants who had their last dental check-up more than 12 months ago.

In terms of daily toothbrushing frequencies, the majority (71.2%, 37) brushed their teeth twice a day, and a quarter of the participants (25%, 13) only brushed once daily. It is found that 1.9% (1) of them brushed less than once per day while another 1.9 %(1) brushed more than twice per day. For the toothbrushing technique, most participants (57.7%, 30) were rated to have ‘poor’ brushing skills, 36.5% (19) for ‘fair’, and only 5.8% (3) for ‘good’. In addition, 86.5% (45) had received assistance on toothbrushing from their caregivers. Snacking habits were also investigated and it was noted that 3.8% (2) had no snaking habits, 44.2% (23) snacked once per day, 28.8% (15) snacked twice per day, and the remaining (23.1%, 12) snacked more than 3 times per day.

Majority of the parents graded their children’s oral hygiene condition to be as ‘fair’ (57.7%, 30) before the project commenced. The remaining 7.7% (4) were marked as good, and 34.6% (18) were thought to have ‘poor’ oral hygiene. It was also noted that 17.3% (9) of the participants had a ‘good’ attitude towards toothbrushing, 51.9% (27) had a ‘fair’ attitude, and 30.8% (16) had a ‘poor ‘attitude.

In addition, most participants (63.5%, 33) said that they had received oral hygiene instruction from other sources prior to this program (Fig.3.5). No statistical significant difference was found between those who are rated ‘mild’ and ‘moderate’ in terms of autism (p>0.05, Chi-square test).


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Fig. 3.5 Percentage and number of subjects according to their ways of receiving oral hygiene education before the project

Almost all participants are currently (98.1%, 51) enrolled in the Student Dental Care Service scheme, provided by the Department of Health, Hong Kong. Only one participant (1.9%) claimed that he or she has never been enrolled in the SDCS scheme.

c) Oral health behaviour after the project

Among those who completed the questionnaires, majority (86.5%, 45) brushed their teeth twice a day and 9.6% (5) of the participants brushed once daily. 1.9% (1) brushed less than once per day while another 1.9 %(1) brushed more than twice per day.

After the project, those who reported ‘poor’ brushing skills reduced to 34.6% (18), with 51.9% (27) rated ‘fair’ and 13.5% (7) as ‘good’ (Table 2). There was a statistically significant improvement in terms of subjects’ brushing technique from the parents/guardians’ point of view (p<0.001, McNemar test). No statistical significant difference was found between those who are rated ‘mild’ and ‘moderate’ in terms of autism (p>0.05, Chi-square test).


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After the programmeAfter the programmeAfter the programmeAfter the programme

Before the programme Good Fair Poor Total

Good 3 0 0 3

Fair 4 14 1 19

Poor 0 13 17 30

Total 7 27 18

Table 2. Parents/Guardians’ rating of the autistic children brushing technique before and after the programme

Majority of the parents also noted positive attitude changes in their children towards daily toothbrushing after the project. It was recorded that 19.2% (10) had a ‘good’ attitude towards toothbrushing, 57.7% (30) had a ‘fair’ attitude, and only 23.1% (12) had a ‘poor’ attitude (Table 3). In terms of toothbrushing attitude, there was no statistically significant difference in scores for toothbrushing attitude before and after the project (p=0.273, McNemar Test). No statistical significant difference was found between those who are rated ‘mild’ and ‘moderate’ in terms of autism (p>0.05, Chi-square test) .



Good 9 0 0 9

Fair 1 23 3 27

Poor 0 7 9 16

Total 10 30 12

Table 3. Parents/Guardians’ rating of the autistic children attitude towards toothbrushing before and after the programme

It was also noted that many of the parents had noticed improvement of the oral hygiene of their


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child after the project. Most parents graded the oral hygiene condition of their children as ‘fair‘ (69.2%, 36), 15.4% (8) were marked as ‘good’, and 15.4% (8) were thought to have poor oral hygiene (Table 4). There is a statistically significant improvement in terms of subjects’ oral hygiene status from the parents/guardians’ point of view (p<0.001, McNemar test). No statistical significant difference was found between those who are rated ‘mild’ and ‘moderate’ in terms of autism (p>0.05, Chi-square test).



Good 4 0 0 4

Fair 4 26 0 30

Poor 0 10 8 18

Total 8 36 8

Table 4. Parents/Guardians’ rating of the autistic children’s oral hygiene before and after the programme

d) Overall comments on the project

It was noted that the outreach program was meaningful, and the oral hygiene instructions and aids were helpful. 96.2% (48) of the respondents claimed that the program was beneficial for their children. In the opinions/suggestions section, it was noted that the parents and the guardians of the participants requested for regular oral health care and oral health education especially targeted for the autistic children.

4. Discussion

When comparing the decayed teeth (DT) scores of this study to the Hong Kong Oral Health Survey conducted in 2001, a higher score (0.60; SD=0.9) was obtained than those reported for 12 year-old children in the Survey (0.1). When comparing the dt scores, the values were lower in this study (0.55; SD=1.5) than those reported for 5 year-old children in the Survey (2.1). However, theoretically the DT scores of this study should have lower values due to the fact that


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the Survey was conducted using children subjects of 12 year-old but this study incorporated DT scores of children aged 8 to 13. The subjects in this study are generally younger than those who were included in the Survey. Most of the cohort of this present study only had their permanent teeth recently, meaning that it is less likely for newly erupted permanent teeth to already be carious. Although it is unclear whether these autistic children are more prone to caries, the higher DT scores may be implying the possibility that this cohort possesses more undiagnosed or untreated caries than those of a similar age in the general public. A probably reason for this may be associated with the difficulty in managing this group of patients. Although the association with autism and increased caries risk has been reported in more recent years (Marshall et al. 2010, Ivancić Jokić N et al. 2007), the idea has also been refuted by numerous studies in the past (Namal et. al 2007, Shapira et al. 1989, Lowe & Lindermann 1985). This therefore suggests that the issue remains controversial, and similar to caries risk for the general public, the cause in increased risk is possibly multi-factorial.

Fig 4.1 Bar graph comparing the mean DT, dt, FT and ft values obtained from this cohort, compared to those from the Oral Health Survey 2001


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In terms of filled teeth (ft), the ft scores reported in this study (0.2; SD=0.5) and the Survey (0.2) were similar, yet again it should be taken into account that the subjects in the Survey were 5 year old children, indicating that the children in this study would have less primary teeth to contribute to the ft score . In contrast, the mean FT score obtained (0.2; SD=0.5) was less than that reported in the Survey (0.6), thus reflecting a possible problem that these children are not receiving the treatment they require despite being enrolled in the Student Dental Care Service scheme organised by the Department of Health of Hong Kong. It would be fair to assume that this phenomenon is also because of difficulties in patient management or patient uncooperativeness, which is supported by studies such as Lowe and Lindermann (1985). Nelson et al. (2011) also supported this phenomenon by showing that a significant number of children with special health care needs (20% of the participants in the study) had unmet dental needs despite majority (90%) had visited the dentist in the past year. It was also reported that these patients had more aversions and treatment complications due to their medical conditions.

In relation to caries, other possible reasons for increased caries risk were also investigated. Snacking habits of the cohort in this study were examined using the questionnaire distributed to the parents or guardians of the children. There was no significant increase in habitual snacking as most (56.0%; 14) snacked only once daily. Therefore, snacking habits may not be the major factor affecting the increased findings of untreated caries and filled teeth for these autistic children. Studies have shown that sometimes there can be no direct correlation between caries experience and snacking habits, such as those with various degrees of fluorosis (Makhanu et al. 2009), despite various studies showing a significant positive association between the two factors (Johansson et al. 2010, Hashim et al. 2009).

The scores for missing teeth (MT and mt) have been excluded because it was not known if the missing of teeth was due to exfoliation or extraction.

Observing the oral hygiene of these autistic children, it can be seen that most of the children have fair (44.4%; 28) to poor (41.3%; 26) oral hygiene conditions. The difference between the group with poor oral hygiene and the group with fair oral hygiene was not significantly greater, with only the minority having what was considered to be good oral hygiene (12.7 %; 8). Although this study showed no strong direct correlation between oral hygiene and caries, as with the study conducted by Rehman et al. (2008), the data nonetheless provides good overall picture of the oral condition of these children and indicating a lack of proper self-maintenance of their oral health. A likely reason for this is the short attention span and insufficient knowledge of proper toothbrushing technique, leading to inadequate toothbrushing, since most parents reported that


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their children can perform toothbrushing by themselves. However, as it is already given that the autistic child would have more difficulties in performing proper toothbrushing than a child of the same age without special needs, even though they may have the best oral hygiene than those with mental retardation (Altun et al. 2010). Even though most parents or caregivers reported that they do assist the child with toothbrushing, the possibility that even the parents or caregivers are finding it difficult to perform assisted toothbrushing, or that they have improper knowledge in toothbrushing technique themselves cannot be disregarded (Altun et al. 2010, Martens 1984).

In this pilot study, the behavioural management method of ‘Tell, Show, Feel, Do’ instead of the usual ‘Tell, Show, Do’, as suggested by De Moor and Martens (1984), was utilised when teaching the participants proper toothbrushing technique. A poster with cartoon flow diagrams, designed by the researchers, and teeth models were used as teaching aids in order to allow the child to have better visualisations and a ‘feel’ of what toothbrushing is like. The idea of the poster was based on the study conducted by Pilebro and Bäckman B. (2005) where a poster with a flow diagram of photos was used, and its use was reported to be a success. As observed by the researchers, the children found strong interest in the cartoon drawings and the tooth model used for teaching, thus acting as wonderful tools used for attracting the child’s attention as well. In addition, behavioural modifications such as positive reinforcement and modelling were also used by the operators, which have been indicated effective by Burkhard (1985). The poster was then taken home by all participants so that they were able to follow the steps whilst toothbrushing at home. From the questionnaire analysis, the responses from parents or caregivers indicated that the aids were useful and valuable (95.7%; 22). Although a significant improvement in brushing technique was observed, it seems that attitude towards toothbrushing was difficult to modify, since behaviour is always hard to change in a short duration of time. In order for attitude to be modified, a longer behaviour reinforcement period may be required.

All the data mentioned above highlighted a potential problem with management of special needs patients such as those autistic children involved in this study, making both detail examination and execution of treatment difficult for the dentist. Therefore, this results in the continuous suffering of these patients from oral diseases. Although there is yet to conduct a study regarding the association between poor oral health and its affect on quality of life for autistic children in Hong Kong, the survey carried out in Massachusetts (Nelson et al. 2011) indicated that unmet dental needs have an impact on the children’s quality of life.

Throughout the study, several problems were encountered. Firstly, the student operators lacked clinical experience in paediatric dentistry and, most importantly, skills in managing special needs


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patients such as those autistic children involved in this study. It is known that in Hong Kong, specialist training in this field mainly relies on paediatric dentists, and the Special Needs Patient Clinic in the Discipline of Paediatric Dentistry of the University of Hong Kong. In European countries such as United Kingdom, Special Needs dentistry is an independent discipline and there are specialist training courses for postgraduates. Simple courses for oral health care workers to enrich their skills in management for special needs patients are also available. Brazil also recognises this field as a Specialty with masters and PhD courses (Mugayar et al. 2007). In other countries, both Australia and Japan acknowledge this discipline with master courses, diplomas, or fellowship awards (Nunn 2006). Most Bachelor of Dentistry curriculums still do not involve special emphasis and practical sessions on management of special needs patients. Hence, difficulties were encountered when instructing the children to sit still, open their mouths, or even respond to simple questions (e.g. “what is your name?”). Therefore, it is common for general practitioners, not just in Hong Kong, to refer such cases to specialists (Fahlvik-Planefeldt & Herrström 2001) and parents have difficulties finding a dentist willing to provide care due to child’s medical diagnoses (Nelson et al. 2011).

Secondly, it appears that autistic children seemed most cooperative when they were accompanied by their parents or guardians. This was observed from the outreach visit to Yuk Chi Resource Centre in Tuen Mun, compared to the other visits that were done without the presence of parents or caregivers in a school environment. It is believed that these children are less anxious in a familiar environment, without the presence of many dental equipment, and thus outreach visits are deemed to be very beneficial for a large range of reasons (Lo et al. 2004).

Lastly, the study cohort sample is small and confined to the local population. The sample may not be an adequate representation of autistic children, which makes generalising the results of this pilot study inappropriate. It was difficult to contact and access a group of children with just autism, as there is no specific organisation or committee for this group, unlike other special needs groups. Therefore, the conclusions that can be drawn may only be used as reference purposes for further investigations in this field.

5. Conclusion

In conclusion, from the results of this study, it can be seen that the oral hygiene status of the autistic children is fair to poor. They tend to have higher caries rate in permanent dentition


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compared to the general population, and most of the decayed teeth were untreated. Topical fluoride treatment was delivered to these patients.

Oral hygiene instruction was given utilising the ‘Tell, Show, Feel, Do’ method and with the additional aid of a cartoon oral hygiene instruction poster. Most of the participants’ parents or caregivers reported the oral health education to be useful, and participants showed improvement in the perceived oral hygiene status and the toothbrushing technique.

6. Recommendations

In terms of recommendations, it is suggested that a larger scale survey on autistic children to be conducted in order to further explore the oral health condition of these children. In addition, it is believed that training for management of special needs patients for dental students or dentists would be beneficial for both patients and dentists in the future. On the community level, the government and non-governmental organisations in Hong Kong, together with dental professionals, should seek ways to provide more oral health care and oral health education for the special needs group and their care providers.

7. Acknowledgements

We would like to express our sincere gratitude to our supervisors, Dr. Anthony H.H. Wong and Dr. Jonathan K.C. Lui, for their continuous support and guidance throughout the project. Special thanks to Professor Edward C.M. Lo for organising and helping us with the necessary equipment for this project.

We would also like to acknowledge the following organisations and their staff for their generous support during this project. Without their help, the project would not have been possible.

• Mr. Wong and the Distinctive Learning Society

• Mary Rose School

• Po Leung Kuk Centenary School

• Evangelize China Fellowship Holy Word School


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• Yuk Chi Resource Centre

• Colgate-Palmolive Company

• Procter & Gamble Hong Kong Ltd.


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9. Appendices

I. Proposal to Distinct Learning Society (English)II. Invitation to Participating Schools/Centres (English)III. Notice and Consent Reply Slip (English)IV. Equipment List V. Data Collection FormVI. Dental Check-up Report for Parents (English)VII. Oral Hygiene Instruction Poster (for Toothbrushing)VIII. Oral Hygiene Instructions Script for Teaching of Toothbrushing (for Operators)IX. Instructions to Parents Regarding Use of Oral Hygiene Instruction Poster (for Toothbrushing)X. Leaflet from Department of Health Regarding How Parents Can Help with Oral Health

Maintenance for Children with Disabilities (Chinese)XI. Questionnaire for Caregivers (Chinese and English)


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Appendix I: Proposal to Distinct Learning Society (English)


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Appendix II: Invitation to Participating Schools/Centres (English)


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Appendix III: Notice and Consent Reply Slip (English)

Notice:Date: / / 2011

Dear Parent/Guardian,

The Faculty of Dentistry at University of Hong Kong is now conducting a project, Outreach to the ‘Closed World’, which aims to help autistic children enhance their oral health and related maintenance knowledge. Participating children will be provided a complimentary basic dental check-up, and one-to-one oral hygiene maintenance instructions. We sincerely hope that you can help us with this project. Details of the project are as follows:

Date: / / 2011 ( )Time: Location: Fee: FREE

If you have any queries or concerns, feel free to contact us at 90657745.

Thank you for your kind attention.

----------------------------------------------------------- please cut -------------------------------------------------------

REPLY SLIP:

I agree / disagree my son/daughter ( name:_____________ class:___________) to participate in the Outreach to the ‘Closed World’ project, organised by the Faculty of Dentistry, University of Hong Kong which will be held on / / 2011.

I allow my child to have:□ Basic dental check-up and one-to-one oral hygiene instructions only.□ Basic dental check-up, one-to-one oral hygiene instructions, and fluoride treatment if it is required.

Parent/Guardian’s Signature:________________ Date: ________________


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Appendix IV: Equipment List

Item Quantities

Disposable Gown 1 pack

Mask 1 box

Glove 1 box of size XS2 boxes of size S

Fluoride Varnish (NaF) 2 tubes

Microbrush / Applicator 70

Dappen Dishes 70

Disposable Mirror Head 70

LED Mirror Handles 3 sets

Gauze 1 pack

Paper Towel 3 rolls

Alcohol Spray 2 bottles

Clipboards 3

Plastic Bags 2 rolls

Hand/Table Mirrors 3

OHI Teeth Models 3 sets

OHI Posters (laminated) 80

Data Collection Forms 70

Questionnaire 70

Report form for parents 70

Toothbrush (souvenirs) 70

Toothpaste (souvenirs) 70


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Appendix V: Data Collection Form


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Appendix VI: Dental Check-up Report for Parents (English)


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Appendix VII: Oral Hygiene Instructions Poster (for Toothbrushing)


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Appendix VIII: Oral Hygiene Instructions Script for Teaching of Toothbrushing (for Operators)


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Appendix IX: Instructions to Parents Regarding Use of Oral Hygiene Instructions Poster (for Toothbrushing)

Instructions Sheet for the OHI poster 指引:

1. 請將此海報貼於洗手間的當眼處。

2. 請家長鼓勵你的子女一邊刷牙一邊觀看並學習海報上的刷牙方法。

3. 請家長鼓勵你的子女養成早晚刷牙的習慣。

4. 建議家長每天替你的子女補刷一次牙齒。

Instructions Sheet for the OHI poster:

1. Please paste this poster in an eye-catching position in the lavatory.

2. Please encourage your child to watch and follow the brushing method on the poster while

toothbrushing.

3. Please encourage your child to brush habitually twice a day, in the morning and before going

to bed.

4. It is strongly recommended for you to help your child to re-brush once everyday.


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Appendix X: Leaflet from Department of Health Regarding How Parents Can Help with Oral Health Maintenance for Children with Disabilities (Chinese)


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Appendix XI: Questionnaire for Caregivers (Chinese and English)


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Documents

Outreach to the closed world dental service for Hong Kong … · 2016. 6. 20. · 2.7 Oral Health Education 9 2.8 Topical Fluoride Treatment 10 2.9 Oral Hygiene Instruction Poster