146

Volume 47, Number 3, September 2014

Oral health knowledge among parents of autistic child in 
Bandung-Indonesia

Yetty herdiyati nonong,1 arlette Setiawan,1 fellani danasra dewi2 and Cugati navaneetha2
1 Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Padjadjaran, Bandung - Indonesia
2 Academy of Primary and Preventive Dentistry, Faculty of Dentistry, AIMST University, Malaysia 

abstract

Background: Autistic children as well as other special needs individual demand special care given by their parents. But there 
exist limited awareness among parents in Indonesia society, especially with regard to their oral health. Purpose: The study was aimed 
to assess the oral health related knowledge, attitude and behavior of the parents; and oral health status of their autistic children in 
comparison with non-autistic children. Methods: Total of 56 children (23 autistic and 23 normal) between 7-12 years was included 
in this study. Data on parents’ knowledge, attitude, oral health practice and behavior of their children were gathered from the 
questionnaires. The oral health status of the children was recorded using deft and DMFT caries index. results: All obtained data 
were analyzed using sPss version 13 to correlate the index of the sample. It showed that caries index of autistic child was lower and 
limited oral health knowledge among parents. Conclusion: There is need of greater awareness to be spread among the population of 
Indonesia about the existing professional help for the special children and educate the parents to maintain their child’s oral health 
for a better quality of life.

Key words: Parental knowledge, autism, oral health, child, dental caries

abstrak

latar belakang: Anak autis seperti juga individu berkebutuhan khusus lainnya memerlukan perhatian khusus dari orang tuanya. 
Namun banyak keterbatasan kesadaran orang tua dalam masyarakat Indonesia, terutama berkaitan dengan kesehatan mulut anak autis 
mereka. tujuan: Penelitian ini bertujuan untuk menguji pengetahuan kesehatan gigi, perilaku orang tua dan anak mereka yang autis. 
Metode: Data pengetahuan orang tua dikumpulkan dari kuesioner dan status kesehatan mulut anak dicatat menggunakan indeks karies 
DMFT dan deft. sejumlah 56 anak (23 autis dan 23 non-autis sebagai kelompok kontrol) usia 7-12 tahun ikut serta dalam penelitian ini. 
hasil: Data yang didapatkan dianalisis menggunakan sPss versi 13 untuk mengkorelasikan indeks subjek. Hasil menunjukkan indeks 
karies anak autis lebih rendah dengan pengetahuan kesehatan mulut orang tua yang terbatas. Simpulan: Diperlukan penyebarluasan 
kesadaran yang lebih tinggi di antara populasi orang Indonesia mengenai mempertahankan status kesehatan mulut anak autis mereka 
untuk mencapai kualitas hidup yang lebih baik.

Kata kunci: Kesehatan mulut, peran orang tua, autis, karies, anak

Correspondence: Yetty Herdiyati Nonong, c/o: Departemen Ilmu Kedokteran Gigi Anak, Fakultas Kedokteran Gigi Universitas 
Padjadjaran. Jl. Sekeloa Selatan I Bandung, Indonesia. E-mail: a.suzy@unpad.ac.id, arlettesuzy@yahoo.com

Research Report



147Nonong, et al.: Oral health knowledge among parents of autistic child in Bandung-Indonesia

introduction

Autistic disorder (AD) is an organic disorder affecting 
the cerebellum and limbic system of the brain, resulting in 
behavioral and cognitive aberrations. It is characterized by 
impaired interpersonal and communication skills, limited 
attention span, hyperactivity interests, repetitive bodily 
movements and a stereotype behavioral pattern, that is 
established in the early childhood.1 Its incidence ranges 
from 0.2-1.5% across the globe,2,3 with a higher predilection 
in males (four times), but in its most oppressive form in 
females.4

In 2009, Ministry of Health in Jakarta, Indonesia 
reported the prevalence of autism as one in every 150 
children and the numbers of children diagnosed with this 
neurodevelopmental disorder are perpetually increasing. 
Yet, there exists a limited knowledge and awareness among 
parents concerning the health, habits and management of 
their children with autism including their oral health. Autistic 
individuals’ exhibit severe abnormality of reciprocal social 
relatedness and communicative incompetence prevents 
them to interact, understand and follow the instructions. 
Their sensory and auditory hyperactivity to odors, lights and 
sounds in the dental clinic stimulate them for an unpredicted 
and exaggerated response on the dental chair, making them 
uncooperative in the dental setting.1 

Heterogeneous proclamation has been reported in the 
literature concerning oral health status and dental needs of 
autistic children and young adults. Where studies in the 80s-
late 90s have found the prevalence of caries and periodontal 
disease to be of no difference compare with non-autistic 
individuals,5-6 contradicted to some studies in recent years 
that have evidenced comparatively lower prevalence of 
caries in children with ASD.8,9 It is well established that 
health related practices are derived from the norms, goals, 
values and behaviors of the family members/parents, who 
contribute to their children’s healthy lifestyle habits.10-11 

Therefore this study was aimed to determine the oral health 
related knowledge, attitude and behavior of the parents; and 
oral health status of their autistic children.

materials and methods

This two-phased study was conducted at Bandung, West 
Java, Indonesia. Ethical clearance was obtained from Health 
Research Committee, Universitas Padjadjaran, Indonesia. 
Total of 56 children and their parents were included for 
this project. Twenty-three children with AD were selected 
randomly from three institutions. Besides the diagnosed of 
autism, all children were medically healthy and were not 
on any therapeutic drugs. Similarly, the number, age and 
gender matched counterparts were chosen from one private 
elementary school. All the children were aged between 7-
12 years. In the first phase of the study, parents of all the 
children participants were informed about the study purpose 
and procedures; and all the parents were provided with 12-

itemed questionnaire to elicit the knowledge, attitude, Oral 
hygiene practice and behavioral habits in their children. In 
the second phase, informed consent was obtained from the 
parents to conduct oral examination on minor children using 
dental diagnostic instruments (single use disposable plain 
mouth mirror, blunt probe, tweezers), light source (flash 
light) and personal protective attire (disposable surgical 
gown, masker, gloves) under cotton roll isolation, to record 
deft and/ DMFT index for primary and permanent dentition 
respectively.

The questionnaire for the parents targeted on the 
following concern; knowledge (awareness in tooth brushing 
and fluoridated toothpastes), attitude (previous experience 
of toothache, toothache management, reason for not seeking 
professional care), oral hygiene practice (frequency, 
timing, and parental assistance of tooth brushing activity), 
behavior (preference and frequency of sweetened food, 
pocket money to buy food from venders at school, 
frequency of those foods). While, the dental examinations 
was performed in the classroom by a single examiner in a 
conventional method using FDI tooth numbering system; 
scoring decayed, extracted missing and filled tooth index 
(deft) for primary teeth; and Decayed, Missing, and Filled 
tooth index (DMFT) for permanent teeth was done using 
WHO caries criteria.12 

results

Among the children participants in this study, 20 were 
males and 3 were females in both autistic and control 
groups. In each group, six children ranged from 7-9 years 
and seventeen children ranged from 10-12 years. All the 
parent samples involved in this study responded completely 
for the survey questionnaire and their reports are illustrated 
in Table 1.

It was fortunate to know that most of the parents for 
autistic children (82.60%) and normal children (60.86%) 
knew about fluoridated toothpaste. Table 1 also identified 
that majority of normal children (82.61%) have self 
awareness to brush their teeth. In contrast most of parent 
for autistic children claimed that their children were assisted 
for the routine oral hygiene practice. 

More than 2/3 (69.56%) of the autistic children were 
previously experienced with episodes of toothache and 
56.52% of them was seeking the treatment from dentist, 
but 39.13% of the children were medicated by the parents 
themselves. It was described by 56.52% of the parents of 
autistic children that, it was unnecessary to get a professional 
helped for child’s toothache. In contrast, all the children 
in the control group had pervious experience of toothache. 
Though majority of parents did self-medication (47.82%) 
to their children, considerable proportion (43.47%) of them 
incurred dentist’s advice and treatment. Cost and the fear 
of dentist were the main reasons among the control group 
for not obtaining professional consultation for toothache 
in their children.



148 Dent. J. (Maj. Ked. Gigi), Volume 47, Number 3, September 2014: 146–152

table 1. Parental report on knowledge, attitude, oral health practice and behavior between autistic and normal children

Variable name
Autistic children Normal children

n % n %

Demographic:
Sex

 Male
 Female

Age
 7 – 9 years
 10-12 years

20
3

6
17

86.96
13.04

26.09
73.91

20
3

6
17

86.96
13.04

26.09
73.91

Question Item:
Knowledge

Heard of Fluoridated toothpastes
 Yes
 No 

Awareness in tooth brushing
 Told by parent
 Self awareness

Attitude
Experience in toothache

Yes
No

Managing Toothache
Leave it

Take some medication
Went to a dentist

Reason didn’t go for a dentist
Scared
Lazy

Unnecessary
No pain

Cost

19
4

-
-

16
7

1
9
13

5
1
12
4
1

82.60
17.39

-
-

69.56
30.43

4.34
39.13
56.52

21.73
4.34
52.17
17.39
0.00

14
9

4
19

23
0

2
11
10

6
1
3
7
6

60.86
39.13

17.39
82.61

100
0.00

8.69
47.82
43.47

26.08
4.34
13.04
30.43
26.08

Oral hygiene practice 
Frequency of tooth brushing

Once
Twice
Thrice

Timing of Tooth Brushing
Before taking a bath

After meal & before bath
During take a bath & before sleeping

After meal & before sleeping
 Take a bath, After meal, before sleep

Assisting in brushing teeth
 Yes
 No

Behavior
Pocket money to buy food from venders

Yes
No

Frequency of buying food from venders at school in one week
Once

2-3times
Everyday

Never
If parent gave the money

0
15
8

9
1
8
3
2

17
6

-
-

-
-
-
-
-

0.00
65.22
34.78

39.13
4.35
34.78
13.04
8.70

73.91
26.09

-
-

-
-
-
-
-

2
19
2

6
2
8
5
2

-
-

20
3

3
8
4
0
8

8.70
82.61
8.70

26.09
8.70
34.78
21.74
8.70

-
-

89.96
13.04

13.04
34.78
17.39
0.00
34.78



149Nonong, et al.: Oral health knowledge among parents of autistic child in Bandung-Indonesia

Variable name
Autistic children Normal children

n % n %

Sweet consumption
Yes
No

Frequency sweet consumption
Once
Twice

Thrice and more

19
4

10
1
12

82.60
17.39

43.47
4.34
52.17

14
9

11
8
4

60.86
39.13

47.82
34.78
17.39

table 2. deft and DMFT Index in the study samples

No Sex Age
Autistic children Normal children

def-t DMF-T def-t DMF-T

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

M
M
M
M
M
M
M
M
M
M
F
F
M
M
M
M
M
M
F
M
M
M
M

7
8
8
8
8
9
10
10
10
10
10
11
11
11
11
11
11
11
12
12
12
12
12

0
2
7
3
1
3
1
2
7
0
2
0
0
0
8
4
2
4
0
0
2
6
0

0
1
0
2
2
4
3
1
1
2
1
1
5
1
1
0
4
2
0
0
3
0
2

5
6
8
7
10
8
5
4
4
5
4
0
0
4
6
2
0
4
3
0
0
0
0

3
1
3
0
1
0
2
2
4
2
4
5
7
0
1
3
4
0
4
5
2
5
1

TOTAL 28 36 85 52

table 3. Mann-Whitney test for the comparison for def-t index between autistic children and normal children

d e f def-t D M F DMF-T

Mann-Whitney U
Wilcoxon W

Z
Asymp. Sig. (2-tailed)

228.500
504.500
 -.876
 .381

141.000
417.000
 -3.087
 .002

264.500
540.500

 .000
 1.000

197.500
473.500
 -1.503
 .133

221.000
497.000
 -.979
 .328

264.500
540.500

 .000
 1.000

241.500
517.500
 -1.430
 .153

185.500
461.500
 -1.767
 .077

sig: < p =0.05; *0.77/2 = 0,039 (2-tailed)



150 Dent. J. (Maj. Ked. Gigi), Volume 47, Number 3, September 2014: 146–152

It was claimed by the parents of autistic children that 
65.22% of them brushed twice a day and 34.78% brushed 
three times a day. While greater percentage (82.61%) of 
the control group brushed two times per day. More than 
1/3 (34.78%) of the study population in each of the group 
practiced their routine habit of brushing during bathing time 
in the morning and prior to sleeping in the night. However 
majority (39.13%) of the autistic children brushed before 
bathing hours and 73.91% of them were assisted by the 
parents during the daily ritual of brushing. All the children 
in the control group brushed themselves.

According to the parents, 82.60% of the autistic children 
showed their favourism towards sweet food and 52.17% of 
them consumed sweetened food three or more times a day. 
On the contrary, though 60.86% of normal children carved 
for sweetened food, their snacking frequency was only once 
a day in 47.82% and two times in a day among 34.78%. 
The parents of normal children were questioned regarding 
pocket money given to the children to buy food from 
venders. This was to identify the possibility of unhealthy 
food consumption, which in turn could increase caries 
index. Ninety precent of the normal children were given 
pocket money and 34.78% bought food from the venders 
during school hours, for 2-3 times in a week. However, 
autistic children were very selective in their food preference 
and were forbidden to buy meals from the venders without 
parents’ knowledge. 

As an oral health status reflected by the caries index 
showed in Table 2. Three autistic children were completely 
free from carious attack (0). The caries experience recorded 

using deft/DMFT index illustrates that autistic children had 
lesser caries incidence than normal children. In autistic 
individuals deft was 28 and DMFT were 36; in contrast to 
85 deft and 52 DMFT in normal healthy children. 

Mann-Whitney test performed to determine the 
significance between the deft index in autistic and normal 
children showed no statistical difference except for the index 
“e” (extracted primary teeth), which shows the difference 
as very significant (P = 0.002 with 95% confidence level). 
Similarly, the DMFT index between autistic children and 
normal children showed statistical significant difference (p 
= 0.039 with 95% confidence level) (Table 3.).

Chi-square test was performed to correlate the parent’s 
reply of the questionnaire and caries index in the samples. 
The DMFT Index in autistic children and parental practice 
of oral hygiene with regard to the timings of brushing (31.83 
> 21.03); and parental attitude towards managing toothache 
(23.14 > 12.59) for their autistic children were significant 
correlated. Whereas for deft index in the control group 
and the parental attitude with regard to their reasoning for 
not consulting the dentist (26.91 > 26.29) for their child’s 
toothache problem (cost, fear of dentist and unreasonable 
cause) was significant (Table 4). 

Contingency Coefficient would be the most appropriate 
measure of association between the two variables. The 
calculated value for this statistics suggests association of 
timing of tooth brushing with DMFT in autistic children 
(0.762), displaying strong correlation. Likewise, strongest 
correlation in normal children was the reason for not 
sending their children to the dentist when their child’s 
experienced toothache with deft (0.734). 

table 4. Correlation among the questionnaires with def-t and DMF-T index

Question Item

Autistic children Normal children

def-t DMF-T def-t DMF-T

χ2 χ2table C χ
2 χ2table C χ

2 s2table C χ
2 χ2table C

Frequency of tooth brushing 6.744 7.815 0.476 2.196 7.815 0.295 4.81 15.51 0.416 4.784 12.59 0.415

Timing of tooth brushing 9.044 21.03 0.531 31.83 21.03 0.762 7.124 26.29 0.486 10.76 21.03 0.565

Assisting in brushing teeth 2.579 7.815 0.318 4.110 7.815 0.389 - - - - - -

Awareness in tooth brushing - - - - - - 2.930 9.49 0.336 2.229 7.815 0.297

Heard of Fluoridated toothpastes 6.034 7.815 0.456 1.369 7.815 0.237 5.317 9.488 0.433 6.809 7.815 0.478

Pocket money to buy food from 
venders at school

- - - - - - 9.334 9.49 0.537 0.993 7.815 0.203

Frequency of buying food from 
venders at school in one week

- - - - - - 12.66 21.03 0.596 6.625 16.92 0.473

Experience in toothache 1.746 7.815 0.266 3.598 7.815 0.368 - - - - - -

Managing toothache 2.973 12.59 0.338 23.14 12.59 0.708 5.882 15.51 0.451 13.92 12.59 0.614

Reason didn’t go for a dentist 11.19 16.92 0.572 5.691 16.92 0.445 26.91 26.29 0.734 6.202 21.03 0.461

Sweet consumption 6.034 7.815 0.456 1.369 7.815 0.237 5.317 9.488 0.433 6.809 7.815 0.478

Frequency sweet consumption 3.925 7.815 0.382 0.901 7.815 0.194 10.58 15.51 0.561 6.202 12.59 0.461

Note: Chi square: χ2 ; Contingency Coefficient: C ; Correlation significant: χ2 > χ2table 



151Nonong, et al.: Oral health knowledge among parents of autistic child in Bandung-Indonesia

discussion

Psychosocial, neurobiological and emotional disorder 
of autism presents with pathognomonic behavioral pattern 
and preference in the victim patients. They exert extreme 
and distinct sensitivity to varying environmental factor and 
are dependents for their routine activities. Perhaps, they 
are not devoid of dental disease and through a good oral 
care an optimum oral health can be achieved. However, 
this greatly depends on the knowledge and attitude of the 
parents, guardians or the caretakers of these patients. A 
systematic assessment of varied parental factors that could 
influence the overall oral health of the children is very much 
of a necessity to undertake the schemes and, therefore to 
provide a comprehensive dental health in all the children 
uniformly. 

The change in food habits and current trend in food 
consumption pattern demonstrates its inclination towards 
frequent and refined carbohydrates. This has reported higher 
incidence of dental caries in the literature and the autistic 
children are not exempted from this. It is demonstrated in 
the literature that higher priority caries risk group for all 
between 11-14 years.13 Year 12 being the average age is 
the important in conducting the survey as it is the age at 
which the child leaves the schools, from where the reliable 
source of samples can be obtained from and also this is the 
highest priority risk group.14-16

It was well established in this study that the parents 
of both groups were knowledgeable with the beneficial 
effect of fluorides in the toothpastes. Though majority of 
the normal children were aware of tooth brushing and its 
benefit, there were not affirmative about the correct method 
of brushing which could have increased the caries index. 
Considering the fact that the autistic children have problems 
with fine motor control and were assisted by their parents 
for the routine oral hygiene practice, a thorough and correct 
procedure has to be known by the parents. 

It is concluded in the literature that significant predictors 
of children’s favorable habits were parents’ favorable 
attitudes towards controlling their children’s tooth brushing 
and sugar snacking habit.17 Autistic children being highly 
sensitive to taste and food consistency, early introduction to 
good food and oral hygiene habits may play a role in “oral 
perception” of the child with communicative disorder.13 It 
was observed in this study that the frequency of brushing 
was more in autistic children than the normal children with 
a majority of them practicing their brushing during bathing 
and prior to sleeping. This was in similarity with the normal 
children. However in three-fourth (73.91%) of the autistic 
children, brushing was assisted by the parents, while all 
the children in the control group brushed themselves, 
without any parental guidance, assistance or supervision. 
This may affect the overall oral hygiene of the child to a 
considerable extent, as the manual dexterity of the children 
is still immature in the earlier years of development and 
improves over time gradually, therefore affecting the oral 
hygiene index of the study sample. 

This study was also an effort to understand the beliefs 
and attitudes of parents towards dentists and dental health. 
Based on the children’s oral health status, it was evident that 
the behavior of parents was comparably different in both 
the groups. Though all the samples in the control group had 
experienced toothache, greater proportion of their parents 
(47.82%) self-medicated their children. This was in contrast 
to the autistic children group, where half (56.52%) of them 
seeked the professional help and the quantity of parents 
doing self medication were comparably less (39.13%), 
while Only 4.34% ignored the child’s complain about 
toothache. This reflects the care and concern of the parents 
of autistic children, despite their limited knowledge about 
oral health. This corroborates the requirement of specially 
training dental professionals for treating these children and 
their parents. 

Diverse reasons were attributed in this study by the 
parents for avoiding dental treatment and the reasons being 
the fear of dentist, cost issue, ignoring the complaint and 
not considering the problem as real serious; and therefore 
managing toothache by parents themselves was apathetic. 
Though major percentage of parents of autistic children 
found it was unnecessary to seek professional help for their 
child’s dental problem, none worried about the cost. But 
more than 25% of the parents of normal children considered 
cost as one of the major issue to avoid dentist. This was 
followed by the fear of dentist in children preventing 
them from professional care, thus projecting care from an 
expertised specialist, who can formulate structured timings 
and space for better patient management.18

Regarding the behavior of samples to their food habits, 
in this study autistic group preferred sweeter food and 
increased frequency of consumption in comparison with 
their control group; They also postulating lower deft/ 
DMFT index, which was independent of the parents attitude 
and knowledge, while only ‘extracted’ primary teeth index 
showed significance difference in both the study sample. 
This indicates that the severity of the dental disease that 
needed extraction, implying the severity of the disease. 
However, there difference in the DMFT index between the 
groups reflected statistically significant difference, which 
in concordance recent studies.8,9,18-20

The study culminates the caries experience in 
autistic children as less in comparison with their normal 
counterparts and was independent of the parents’ behavior, 
knowledge, practice and attitude. Yet, there are needs 
moulding and modulation in parental attributes that can 
be achieved by schemed professional training by the 
general dentist or by the specialists and/ or experts in the 
fields of managing challenging children. It concluded that 
there is need of greater awareness to be spread among the 
population in Indonesia about the existing professional help 
for the special children and educate the parents to maintain 
their oral health for betterment. A greater effort has to be 
implemented for community dental services with optimum 
and timely parental education and follow up. 



152 Dent. J. (Maj. Ked. Gigi), Volume 47, Number 3, September 2014: 146–152

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