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Dental Caries Status in Autistic Children: A Meta-Analysis

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Title: Dental Caries Status in Autistic Children: A Meta-Analysis
Language: English
Authors: Zhang, Yujian, Lin, Ling, Liu, Jianbo, Shi, Ling, Lu, Jianping
Source: Journal of Autism and Developmental Disorders. Apr 2020 50(4):1249-1257.
Availability: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 9
Publication Date: 2020
Document Type: Journal Articles
Reports - Research
Descriptors: Dental Health, Dental Evaluation, Children, Autism, Pervasive Developmental Disorders, Foreign Countries
Geographic Terms: Asia
DOI: 10.1007/s10803-019-04256-x
ISSN: 0162-3257
Abstract: The objective of this meta-analysis was to assess the dental health status of children with ASD in terms of decayed, missing, and filled permanent teeth (DMFT) and decayed, missing, and filled deciduous teeth (dmft). PubMed, Embase, psycINFO, and Cochrane library were searched for studies published until September 2018. A random-effects model was applied to estimate the pooled results. Nine studies comprising 532 children with ASD and 622 controls were included. No significant differences between children with ASD and controls were observed for DMFT and dmft in the world. Subgroup analyses revealed that children with ASD had a significantly higher dmft index than that of controls in Asia. Children with ASD have a worse dental health status than healthy children in Asia, but caution is necessary given the limited studies available for analysis.
Abstractor: As Provided
Entry Date: 2020
Accession Number: EJ1249736
Database: ERIC
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  Value: <anid>AN0142435553;aut01apr.20;2020Mar30.03:20;v2.2.500</anid> <title id="AN0142435553-1">Dental Caries Status in Autistic Children: A Meta-analysis </title> <p>The objective of this meta-analysis was to assess the dental health status of children with ASD in terms of decayed, missing, and filled permanent teeth (DMFT) and decayed, missing, and filled deciduous teeth (dmft). PubMed, Embase, psycINFO, and Cochrane library were searched for studies published until September 2018. A random-effects model was applied to estimate the pooled results.Nine studies comprising 532 children with ASD and 622 controls were included. No significant differences between children with ASD and controls were observed for DMFT and dmft in the world. Subgroup analyses revealed that children with ASD had a significantly higher dmft index than that of controls in Asia.Children with ASD have a worse dental health status than healthy children in Asia, but caution is necessary given the limited studies available for analysis.</p> <p>Keywords: Autism; Asperger; Dental health; Caries; DMFT</p> <p>Yujian Zhang, Ling Lin and Jianbo Liu contributed equally to this work.</p> <hd id="AN0142435553-2">Introduction</hd> <p>Autism spectrum disorder (ASD) is a neurodevelopmental disability characterized by deficits in reciprocal social interactions and communication as well as a restricted, stereotyped, and repetitive repertoire of interests and activities,which usually manifest early in life and may cause persistent dysfunction (American Psychiatric Association [<reflink idref="bib4" id="ref1">4</reflink>]).The 5th edition of the Diagnosticand Statistical Manual of Mental Disorders (DSM-5) has replaced the subtypes of autistic disorder (AD), Asperger's syndrome (AS), and pervasive development disorder not otherwise specified (PDD-NOS) in the previous edition (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision; DSM IV-TR) with a single diagnosis of ASD (Battle [<reflink idref="bib9" id="ref2">9</reflink>]).</p> <p>The occurrence of ASD has demonstrated an increasing trend according to the Autism Developmental Disabilities Monitoring Network in the United States; the prevalence of ASD was estimated to hit 16.8 per 1000 among 8-year-old children (1 in 59 children) in 2014 (Baio et al. [<reflink idref="bib7" id="ref3">7</reflink>]). In terms of gender difference, boys have a significantly higher prevalence of ASD than girls of the same age (26.6 per 1000 boys vs. 6.6 per 1000 girls) (Baio et al. [<reflink idref="bib7" id="ref4">7</reflink>]). In China, the prevalence of ASD was estimated to be 16.1 per 10,000 in children younger than 15 years old during 1986–2005 (Wong and Hui [<reflink idref="bib50" id="ref5">50</reflink>]). A recent meta-analysis revealed a higher prevalence of childhood autism (26.6 per 10,000 population) in mainland China, Hong Kong,and Taiwan (Sun et al. [<reflink idref="bib47" id="ref6">47</reflink>]). The fact that individuals with ASD often need assistance in many aspects of daily life due to mental and behavioral difficulties poses a major challenge for affected individuals and their families as well as society (Weintraub [<reflink idref="bib49" id="ref7">49</reflink>]). For ASD individuals with an intellectual disability, the lifetime cost was estimated to be approximately $2.4 million in the United States and £1.5 million in the United Kingdom (Buescher et al. [<reflink idref="bib11" id="ref8">11</reflink>]).</p> <p>It remains contentious whether there is a difference in the oral health status between individuals with and without ASD. One study found that dental caries were more frequent in children with ASD compared to their healthy siblings (50% vs. 22.2%) (Suhaib et al. [<reflink idref="bib46" id="ref9">46</reflink>]), while another study argued that ASD individuals were less likely to have dental caries and had lower decayed, missing, and filled permanent teeth (DMFT) scores compared to non-ASD individuals (Loo et al. [<reflink idref="bib28" id="ref10">28</reflink>]). A significantly lower DMFT index/decayed, missing, and filled deciduous teeth (dmft) index has been found in children with ASD compared to children without ASD (Fakroon et al. [<reflink idref="bib19" id="ref11">19</reflink>]). Similarly, the results from another study suggested that although maintaining good oral hygiene is more difficult for children with ASD, they were more likely to be caries-free than their normally developed counterparts (Sarnat et al. [<reflink idref="bib39" id="ref12">39</reflink>]).</p> <p>It has been established that one's oral health status has a direct impact on their general health (Shangase et al. [<reflink idref="bib41" id="ref13">41</reflink>]). However, there is a lack of consensus in terms of the knowledge and attitudes toward oral health care and intervention among health care providers for children with ASD (Murshid [<reflink idref="bib33" id="ref14">33</reflink>]). A recent meta-analysis revealed that the prevalence rates of dental caries and periodontal disease in children and young adults with ASD were 60.6% and 69.4%, respectively, which are higher than the Healthy People 2010 dental caries targets of 11% and 51% for children younger than 5 years old and adolescents aged 15 years old, respectively (da Silva et al. [<reflink idref="bib13" id="ref15">13</reflink>]).The DMFT and dmft indices are the primary criteria for evaluation of oral and dental health, describing the number of decayed, missing, and filled permanent and deciduous teeth, respectively. DMFT and dmft are commonly used surrogates for caries experience and reflect the oral hygiene status in epidemiological studies (Fakroon et al. [<reflink idref="bib19" id="ref16">19</reflink>]); however, no meta-analysis has been conducted to evaluate the association of the DMFT/dmft indexwith ASD. The present study provided a meta-analysis of the DMFT/dmft index from oral health surveys among children with ASD and those without ASD as controls, aiming to assess the oral health condition in this specific population vulnerable to oral diseases and to provide evidence for strengthened public health efforts with regard to the prevention and treatment of oral disease in the ASD population.</p> <hd id="AN0142435553-3">Materials and Methods</hd> <p></p> <hd id="AN0142435553-4">Search Strategy</hd> <p>The PubMed,Embase,psycINFO,and Cochrane databases were searched from January 1997 to September 2018.The search terms were as follows: 'Autistic Disorder', 'autism spectrum disorder','Asperger syndrome', 'autis*', 'pervasive developmental disorder', 'ASD', 'oral health', 'dental health', 'dental care', 'dental caries', 'teeth loss', 'decayed teeth', 'DMF index', and 'DMFT'.</p> <p>The PICO (Population, Interventions, Comparisons, and Outcomes) framework was used to develop the inclusion criteria for the meta-analysis as follows (Schardt et al. [<reflink idref="bib40" id="ref17">40</reflink>]): (<reflink idref="bib1" id="ref18">1</reflink>) study design case–control study; (<reflink idref="bib2" id="ref19">2</reflink>) diagnosis: diagnosis of autism based on the criteria defined by the Diagnostic and Statistic Manual of Mental Disorders or the International Statistical Classification of Diseases and Related Health Problems (ICD); (<reflink idref="bib3" id="ref20">3</reflink>) oral health-related parameters included: DMFT and/or dmft index. The exclusion criteria were as follows: (<reflink idref="bib1" id="ref21">1</reflink>) patients only with poor oral hygiene but not with caries or other lesions; (<reflink idref="bib3" id="ref22">3</reflink>) letter, systematic review, or summary; (<reflink idref="bib4" id="ref23">4</reflink>) repeated report; (<reflink idref="bib5" id="ref24">5</reflink>) the control group was not defined, had unknown diagnostic criteria, or did not exist.</p> <hd id="AN0142435553-5">Outcomes</hd> <p>The primary outcomes of interest were the DMFT/dmft indices. The normal maximum numbers of deciduous and permanent teeth are 20 and 32, respectively; therefore, the corresponding maximum dmft and DMFT index scoresare 20 and 32, respectively, and the minimum scores are 0. The following outcomes were extracted if available: numbers of missing permanent teeth (MT) and deciduous teeth (mt), numbers of decayed permanent teeth (DT) and deciduous teeth (dt), and numbers of filled permanent teeth (FT) and deciduous teeth (ft).</p> <hd id="AN0142435553-6">Data Extraction</hd> <p>Two authors conducted the study selection process independently using the inclusion and exclusion criteria; discrepancies were resolved through discussion. For each study, the following information was recorded: author, year of publication, region and country, sample size, range of ages, and outcomes of interest.</p> <hd id="AN0142435553-7">Quality Assessment</hd> <p>Quality assessments of the included studies were performed using the Newcastle–Ottawa scale (NOS) (Peterson et al. [<reflink idref="bib36" id="ref25">36</reflink>]).This rating scale has a maximum score of 8 and consists of 8 items as follows: (<reflink idref="bib1" id="ref26">1</reflink>) adequate definition of cases; (<reflink idref="bib2" id="ref27">2</reflink>) case representativeness; (<reflink idref="bib3" id="ref28">3</reflink>) selection of controls; (<reflink idref="bib4" id="ref29">4</reflink>) definition of controls; (<reflink idref="bib5" id="ref30">5</reflink>) controlling for potential confounding factors or other factors; (<reflink idref="bib6" id="ref31">6</reflink>) assessment of exposure; (<reflink idref="bib7" id="ref32">7</reflink>) same method of ascertainment for cases and controls; and (<reflink idref="bib8" id="ref33">8</reflink>) nonresponse rate. Studies were considered to be of very high (NOS scores of 0–3), high (scores of 4–6), or low (scores of 7–9) risk of bias (Lo1† [<reflink idref="bib27" id="ref34">27</reflink>]).</p> <hd id="AN0142435553-8">Statistical Analysis</hd> <p>For continuous variables, weighted mean difference (WMD) ± standard deviation (SD) was calculated for outcome comparison, along with 95% confidence intervals (CIs) for effect size. A random-effects model was used for meta-analysis. For subgroup analysis, studies were categorized as Asian or non-Asian, based on the country of the studied population, and random-effects meta-analyses by subgroups were performed. Publication bias was evaluated with funnel plots and Egger's test. <emph>P</emph> values less than 0.05 were considered statistically significant.</p> <hd id="AN0142435553-9">Results</hd> <p></p> <hd id="AN0142435553-10">Characteristics of the Included Studies</hd> <p>Figure 1 shows the flow chart of the study selection procedure. Of 533 articles identified from the database search, 244 were from PubMed, 261 were from Embase and psycINFO, and 28 were from Cochrane library. After removing duplicates, title and abstract screening was conducted and 106 articles were selected for full-text review. After excluding 83 articles lacking relevant outcomes, 11 articles lacking healthy controls (Altun et al. [<reflink idref="bib3" id="ref35">3</reflink>]; Awasthi et al. [<reflink idref="bib6" id="ref36">6</reflink>]; Dias et al. [<reflink idref="bib16" id="ref37">16</reflink>]; Gace et al. [<reflink idref="bib20" id="ref38">20</reflink>]; Jaber et al. [<reflink idref="bib23" id="ref39">23</reflink>]; Kalyoncu and Tanboga [<reflink idref="bib24" id="ref40">24</reflink>]; Marshall et al. [<reflink idref="bib30" id="ref41">30</reflink>]; Morales-Chavez [<reflink idref="bib32" id="ref42">32</reflink>]; Shapira et al. [<reflink idref="bib42" id="ref43">42</reflink>]; Slayton [<reflink idref="bib43" id="ref44">43</reflink>]; Subramaniam and Gupta [<reflink idref="bib45" id="ref45">45</reflink>]), and 3 articles providing data lacking standard deviation (Loo et al. [<reflink idref="bib28" id="ref46">28</reflink>]; Namal et al. [<reflink idref="bib34" id="ref47">34</reflink>]; Vajawat and Deepika [<reflink idref="bib48" id="ref48">48</reflink>]), a total of 9 studies comprising 532 patients with ASD and 622 controls were included in the meta-analysis (Al-Maweri et al. [<reflink idref="bib2" id="ref49">2</reflink>]; Bassoukou et al. [<reflink idref="bib8" id="ref50">8</reflink>]; Bhandary and Hari [<reflink idref="bib10" id="ref51">10</reflink>]; El Khatib et al. [<reflink idref="bib18" id="ref52">18</reflink>]; Fakroon et al. [<reflink idref="bib19" id="ref53">19</reflink>]; Jaber [<reflink idref="bib22" id="ref54">22</reflink>]; Onol and Kirzioglu [<reflink idref="bib35" id="ref55">35</reflink>]; Qiao et al. [<reflink idref="bib37" id="ref56">37</reflink>]; Yashoda and Puranik [<reflink idref="bib51" id="ref57">51</reflink>]). Table 1 shows the details of the nine studies included in this meta-analysis. As shown by NOS assessment in Table 2, all of the included studies had a NOS score greater than 7, indicating a low risk of bias.</p> <p>Graph: Fig. 1 Flow chart of the study selection procedure</p> <p>Characteristics of the studies included in the meta-analysis</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Author (year of publication)</p></th><th align="left"><p>Location</p></th><th align="left"><p>Sample size (ASD/control)</p></th><th align="left"><p>Age (years)</p></th><th align="left"><p>Outcomes</p></th></tr></thead><tbody><tr><td align="left"><p>Qiao (<xref ref-type="bibr" rid="bibr37">2018</xref>)</p></td><td align="left"><p>Shanghai, China</p></td><td align="left"><p>26/26</p></td><td align="left"><p>7–14</p></td><td align="left"><p>DMFT</p></td></tr><tr><td align="left"><p>Fakroon (<xref ref-type="bibr" rid="bibr19">2015</xref>)</p></td><td align="left"><p>Libya</p></td><td align="left"><p>50/50</p></td><td align="left"><p>3–14</p></td><td align="left"><p>DMFT, dmft</p></td></tr><tr><td align="left"><p>Jaber (<xref ref-type="bibr" rid="bibr22">2011</xref>)</p></td><td align="left"><p>Dubai and Sharjah, UAE</p></td><td align="left"><p>61/61</p></td><td align="left"><p>6–16</p></td><td align="left"><p>DMFT, dmft</p></td></tr><tr><td align="left"><p>El Khatib (<xref ref-type="bibr" rid="bibr18">2014</xref>)</p></td><td align="left"><p>Alexandria, Egypt</p></td><td align="left"><p>100/100</p></td><td align="left"><p>3–13</p></td><td align="left"><p>DMFT, dmft</p></td></tr><tr><td align="left"><p>Onol and Kirzioglu (<xref ref-type="bibr" rid="bibr35">2018</xref>)</p></td><td align="left"><p>Turkey</p></td><td align="left"><p>63/111</p></td><td align="left"><p>6–14</p></td><td align="left"><p>DMFT</p></td></tr><tr><td align="left"><p>Yashoda (<xref ref-type="bibr" rid="bibr51">2014</xref>)</p></td><td align="left"><p>Bangalore, India</p></td><td align="left"><p>135/135</p></td><td align="left"><p>4–15</p></td><td align="left"><p>DMFT, dmft</p></td></tr><tr><td align="left"><p>Bassoukou et al. (<xref ref-type="bibr" rid="bibr8">2009</xref>)</p></td><td align="left"><p>Sao Paulo,Brazil</p></td><td align="left"><p>25/25</p></td><td align="left"><p>3–14</p></td><td align="left"><p>DMFT, dmft</p></td></tr><tr><td align="left"><p>Al-Maweri (<xref ref-type="bibr" rid="bibr2">2014</xref>)</p></td><td align="left"><p>Sana, Yemen</p></td><td align="left"><p>42/84</p></td><td align="left"><p>5–16</p></td><td align="left"><p>DMFT, dmft</p></td></tr><tr><td align="left"><p>Bhandary (<xref ref-type="bibr" rid="bibr10">2017</xref>)</p></td><td align="left"><p>Mangalore, India</p></td><td align="left"><p>30/30</p></td><td align="left"><p>6–12</p></td><td align="left"><p>DMFT</p></td></tr></tbody></table> </ephtml> </p> <p>Quality assessment of the studies included in the meta-analysis</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Author</p></th><th align="left"><p>Year</p></th><th align="left"><p>1</p></th><th align="left"><p>2</p></th><th align="left"><p>3</p></th><th align="left"><p>4</p></th><th align="left"><p>5</p></th><th align="left"><p>6</p></th><th align="left"><p>7</p></th><th align="left"><p>8</p></th><th align="left"><p>Total quality score</p></th></tr></thead><tbody><tr><td align="left"><p>Yashoda</p></td><td align="left"><p>2014</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>8</p></td></tr><tr><td align="left"><p>Qiao</p></td><td align="left"><p>2018</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p>Onol</p></td><td align="left"><p>2018</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>8</p></td></tr><tr><td align="left"><p>Bhandary</p></td><td align="left"><p>2017</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p>Fakroon</p></td><td align="left"><p>2015</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p>El Khatib</p></td><td align="left"><p>2014</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p>Jaber</p></td><td align="left"><p>2011</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p>Bassoukou</p></td><td align="left"><p>2009</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left" /><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>7</p></td></tr><tr><td align="left"><p>Al-Maweri</p></td><td align="left"><p>2014</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>★</p></td><td align="left"><p>9</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0142435553-11">Meta-analysis</hd> <p>Figure 2 summarizes the meta-analyses comparing children with ASD and controls for the following outcomes: DMFT/dmft index, DT/dt, MT/mt, and FT/ft.</p> <p>Graph: Fig. 2 Forest plots of the meta-analyses of the association between dental caries parameters (DMFT/dmft, DT/dt, MT/mt, FT/ft, and dft) and ASD</p> <hd id="AN0142435553-12">DMFT/dmft/dft</hd> <p>DMFT index as the outcome measure was evaluated in 9 studies comprising 532 children with ASD and 622 controls. The DMFT index scores of the children with ASD were not significantly different from those of the controls (WMD = 0.43; 95% CI − 0.34 to 1.2; <emph>P</emph> = 0.273). In 6 studies comprising 413 children with ASD and 455 controls, the dmft index was measured, and the pooled results showed no significant difference in the dmft index between children with or without ASD (WMD = 0.25; 95% CI − 0.31 to 0.81; <emph>P </emph>= 0.385). In 2 studies comprising 93 children with ASD and 141 controls, the decayed filled teeth (dft)scoreswere provided and were not significantly different between the groups (WMD = 0.43; 95% CI − 0.02 to 0.87; <emph>P </emph>= 0.06).</p> <hd id="AN0142435553-13">DT/dt</hd> <p>In 4 studies included for the meta-analysis of DT in association with ASD, no significant difference was found in the mean scores of DT between 185 children with ASD and 275 controls in the pooled analysis (WMD = 0.25; 95% CI − 0.46 to 0.97; <emph>P</emph> = 0.486). These 4 studies also provided mean scores of dt, and the pooled results showed no significant difference of dt between children with and without ASD (WMD = 0.33; 95% CI − 0.17 to 0.83; <emph>P</emph> = 0.19).</p> <hd id="AN0142435553-14">MT/mt</hd> <p>Four studies calculated the mean MT scores; in the meta-analysis including 185 children with ASD and 275 controls, no obvious difference in MT was found between the groups (WMD = 0.01; 95% CI − 0.06 to 0.08; <emph>P</emph> = 0.83). The pooled results of 2 studies comprising 92 children with ASD and 134 controls showed that the mean mt score for the ASD children was not significantly different from that for the controls (WMD = 0.33; 95% CI − 0.17 to 0.83; <emph>P</emph> = 0.19).</p> <hd id="AN0142435553-15">FT/ft</hd> <p>In the meta-analysis including 185 children with ASD and 275 controls from 4 studies, the FT scores of the ASD children were not significantly different from those of the controls (WMD = − 0.08; 95% CI − 0.24 to 0.08; <emph>P</emph> = 0.31). The pooled results from these 4 studies involving 185 children with ASD and 275 controls showed that the ft scores between the children with ASD and the controls were not significantly different (WMD = − 0.20; 95% CI − 0.79 to 0.39; <emph>P</emph> = 0.51).</p> <hd id="AN0142435553-16">Meta-analysis of Subgroups</hd> <p>Figure 3 shows the subgroup meta-analysis comparing children with ASD and controls in terms of the dmft index, grouped based on the country of the studied population into two categories: Asia and non-Asia. Of the 6 studies for the dmft index, 3 studies were conducted in Asian populations and included 238 children with ASD and 280 controls; the other 3 studies were conducted in non-Asian populations and included 175 children with ASD and 175 controls. In the pooled Asian population, children with ASD had a significantly higher dmft index score than the controls (WMD = 0.64; 95% CI 0.34 to 0.94; <emph>P </emph>< 0.01), while no difference was observed in studies conducted in non-Asiancountries (WMD = − 0.68; 95% CI − 1.87 to 0.51; <emph>P</emph> = 0.26).</p> <p>Graph: Fig. 3 Forest plots of the subgroup meta-analyses ofthe dmft index in association with ASD by country of the studied population</p> <hd id="AN0142435553-17">Sensitivity Analysis</hd> <p>As shown in Figures S1 and S2, sensitivity analysis revealed that the study by Fakroon et al. (Fakroon et al. [<reflink idref="bib19" id="ref58">19</reflink>]) was the main cause of heterogeneity in the meta-analysis of the DMFT/dmft index. After excluding this study, compared with the controls, children with ASD had a significantly higher DMFT (WMD = 0.61; 95% CI 0.19 to 1.02) and dmft (WMD = 0.55; 95% CI 0.33 to 0.78).</p> <hd id="AN0142435553-18">Publication Bias</hd> <p>Figures S3 and S4 show the funnel plots depicting the risk of publication bias for the DMFT index and dmft index, respectively. Both funnel plots appear to be asymmetrical, and subsequent Egger's tests found evidenceof apublication bias for the DMFT index (<emph>P</emph> = 0.029) and the dmft index (<emph>P</emph> = 0.01).</p> <hd id="AN0142435553-19">Discussion</hd> <p>The purpose of this study was to evaluate the true dental health status among children with ASD using the DMFT/dmft index. This is of great necessity, because previous studies reported inconsistent results (da Silva et al. [<reflink idref="bib13" id="ref59">13</reflink>]; Fakroon et al. [<reflink idref="bib19" id="ref60">19</reflink>]; Loo et al. [<reflink idref="bib28" id="ref61">28</reflink>]; Sarnat et al. [<reflink idref="bib39" id="ref62">39</reflink>]; Suhaib et al. [<reflink idref="bib46" id="ref63">46</reflink>])and it was estimated that 15.1% of children with ASD had unmet dental needs according to data from the 2009 to 2010 National Survey of Children with Special Health Care Needs (McKinney et al. [<reflink idref="bib31" id="ref64">31</reflink>]).</p> <p>Our meta-analysis revealed that children with ASD were not significantly different from healthy controls in terms of the DMFT/dmft index. This finding may be due to many factors affecting the oral health status. A recent meta-analysis reported a higher prevalence of dental caries in individuals with ASD compared with general population, with both children and adult population included (da Silva et al. [<reflink idref="bib13" id="ref65">13</reflink>]). Since dental health status can change with age, to minimize the possible confounding effect of age, our meta-analysis was conducted to include studies in children only. In a cross-sectional survey conducted in Pakistani children, children with ASD were reported to have a higher incidence of caries compared with their healthy siblings (Suhaib et al. [<reflink idref="bib46" id="ref66">46</reflink>]). In a retrospective study conducted in a university hospital in Boston, the medical charts of children with ASD were reviewed along with patients without ASD; the results showed that children with ASD had lower DMFT scores than the controls (Loo et al. [<reflink idref="bib28" id="ref67">28</reflink>]).Since only patients with a dental visit were included in the analysis, the possibility that those without a dental visit had a different pattern may not be excluded. In fact, it has been reported that individuals with ASD have an increased difficulty making dental appointments than those without ASD (Delli et al. [<reflink idref="bib14" id="ref68">14</reflink>]). The inconsistency between studies may also be due to factors related to family, including food culture and dietary habits, patterns in parental rearing, parental health perception, and socioeconomic status of the family (Adair et al. [<reflink idref="bib1" id="ref69">1</reflink>]; Loo et al. [<reflink idref="bib28" id="ref70">28</reflink>]; Suhaib et al. [<reflink idref="bib46" id="ref71">46</reflink>]).</p> <p>In this meta-analysis, a random-effects model was used because of heterogeneity between the included studies. Given that the region of the studied population likely contributed to the heterogeneity, we conducted subgroup analysis by Asia or non-Asia, and the results showed evidence of variation between subgroups. In the Asian population, children with ASD had a significantly higher dmft index than the controls, but such a difference was not observed in the non-Asian population. Although the reason remains largely unknown, this variation may be partially explained by differences between western and eastern cultures in terms of dietary habits, patterns of dental visits, and awareness of the importance of physical exercise (Adair et al. [<reflink idref="bib1" id="ref72">1</reflink>]; Arora et al. [<reflink idref="bib5" id="ref73">5</reflink>]; Kumanyika [<reflink idref="bib26" id="ref74">26</reflink>]).</p> <p>Many attempts have been made to explain the oral health issues related to ASD.It has been reported frequently that children with ASD experience atypical sensory processing and more food selectivity compared with typically developing children, resulting in less food variety in children with ASD; consequently, nutritional inadequacies or deficiencies may occur (Chistol et al. [<reflink idref="bib12" id="ref75">12</reflink>]; Kotha et al. [<reflink idref="bib25" id="ref76">25</reflink>]; Sarnat et al. [<reflink idref="bib39" id="ref77">39</reflink>]). For example, children with ASD have significantly lower levels of serum 25-OHD, a surrogate of vitamin D status; this makes them vulnerable to health risks including oral health problems (Saad et al. [<reflink idref="bib38" id="ref78">38</reflink>]). Sensory processing difficulties in children with ASD pose a great challenge to oral care both at home and during dental visits (Stein et al. [<reflink idref="bib44" id="ref79">44</reflink>]). Besides, children with autism have a slightly but significant lower salivary pH compared to that of healthy children (Diab et al. [<reflink idref="bib15" id="ref80">15</reflink>]), but conflicting results exist (Bassoukou et al. [<reflink idref="bib8" id="ref81">8</reflink>]). Altered gut microbiota as well as salivary and dental microbiota have been suggested to occur in children with ASD, compared with typically developing children (Inoue et al. [<reflink idref="bib21" id="ref82">21</reflink>]; Qiao et al. [<reflink idref="bib37" id="ref83">37</reflink>]). Other factors proposed to affect the oral and dental health of individuals with ASD are adverse oral habits related to increased caries including pouching food in the mouth and consuming sugary foods between meals (Kotha et al. [<reflink idref="bib25" id="ref84">25</reflink>]). Poor oral hygiene is frequently observed in children with ASD because of less frequent tooth-brushing and toothpaste use related to reduced manual dexterity (Du et al. [<reflink idref="bib17" id="ref85">17</reflink>]; Sarnat et al. [<reflink idref="bib39" id="ref86">39</reflink>]). Individuals with ASD need more assistance from caregivers and dental professionals to keep up with their dental health, but their uncooperative behavior at home and during dental care may impede their efforts (Loo et al. [<reflink idref="bib28" id="ref87">28</reflink>]; Mansoor et al. [<reflink idref="bib29" id="ref88">29</reflink>]). Among children with ASD, those with intellectual or communication difficulties have shown a worse scenario of unmet dental needs likely due to their uncooperative behavior (McKinney et al. [<reflink idref="bib31" id="ref89">31</reflink>]), which was further confirmed by a subsequent study reporting a five fold likelihood of noncooperation at dental health screening of ASD patients with reduced cognitive function (Du et al. [<reflink idref="bib4" id="ref90">4</reflink>]). Therefore, children with ASD may be at higher risk of developing dental disease and may be underestimated with regard to dental problems.</p> <p>Our study faced several limitations. First, since most of the included studies did not organize their data by the severity of ASD, it was impossible to explore the relationship between the oral health status and the type of ASD symptoms, thus limiting the generalizability of the results to the ASD population. Second, our meta-analysis included studies covering an age range of 3–16 years old. A heterogeneity in the oral health status with age has been observed, with more caries in older children. (Bassoukou et al. [<reflink idref="bib8" id="ref91">8</reflink>]; Jaber [<reflink idref="bib22" id="ref92">22</reflink>]; Namal et al. [<reflink idref="bib34" id="ref93">34</reflink>]). Subgroup analysis by age was not conducted in this study due to the lack of age stratification data. In terms of the source of patients, it was reasonable to assume that the oral status of children in an institution can be kept in better condition because of the accessibility of professional dental care. But a survey found no significant difference in the DMFT index between ASD patients residing in an institution compared to those living at home (Loo et al. [<reflink idref="bib28" id="ref94">28</reflink>]). Moreover, parents of children with ASD have been reported to have better dental knowledge than the general population (Du et al. [<reflink idref="bib17" id="ref95">17</reflink>]). In our meta-analysis, most studies investigated children with ASD in an institution or special school, except for one study on non-institutionalized children (Bassoukou et al. [<reflink idref="bib8" id="ref96">8</reflink>]) and another study with an undescribed source of participants (Qiao et al. [<reflink idref="bib37" id="ref97">37</reflink>]). Because of the disproportionate distribution of noninstitutionalized and institutionalized patients in the pooled data, subgroup analysis by the source of participants was not conducted. Another limitation of this study was related to the reliability and completeness of the DMFT/dmft index as indictors for the oral health status. Children with ASD are reported to have more periodontal issues with treatment needs compared with typically developing children (Fakroon et al. [<reflink idref="bib19" id="ref98">19</reflink>]). Therefore, our results of no obvious difference in the DMFT/dmft index do not necessarily indicate that children with ASD do not require more dental needs. More studies assessing oral health problems including gingivitis, periodontitis, dental plaque, and stones in individuals with ASD are expected. Because of these limitations, our results should be considered as preliminary.</p> <p>In conclusion, our meta-analysis suggests that children with ASD have a worse dental health status than typically developing children in the Asian population, but such a difference was not observed in non-Asian countries. Most current studies on this topic were cross-sectional; thus, further well-designed cohort studies are warranted to verify the findings. Furthermore,studies that stratify data by age, sex, severity of ASD, region, source of subjects, and other possible confounding factors related to the family environment and socioeconomic status of the parents are required. Future studies with more information regarding factors affecting ASD are needed for accurate estimation of the oral health status in individuals with ASD and for proper recommendations to improve the overall health of the ASD population.</p> <hd id="AN0142435553-20">Acknowledgements</hd> <p>This work was funded Sanming project of medicine in Shenzhen (No. SZSM201612079), Shenzhen Science and Technology Innovation Committee (JCYJ20160429185235132).</p> <hd id="AN0142435553-21">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0142435553-22"> <title> References </title> <blist> <bibl id="bib1" idref="ref18" type="bt">1</bibl> <bibtext> Adair PM, Pine CM, Burnside G, Nicoll AD, Gillett A, Anwar S, Young DW. Familial and cultural perceptions and beliefs of oral hygiene and dietary practices among ethnically and socio-economicall diverse groups. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Dental Caries Status in Autistic Children: A Meta-Analysis
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Zhang%2C+Yujian%22">Zhang, Yujian</searchLink><br /><searchLink fieldCode="AR" term="%22Lin%2C+Ling%22">Lin, Ling</searchLink><br /><searchLink fieldCode="AR" term="%22Liu%2C+Jianbo%22">Liu, Jianbo</searchLink><br /><searchLink fieldCode="AR" term="%22Shi%2C+Ling%22">Shi, Ling</searchLink><br /><searchLink fieldCode="AR" term="%22Lu%2C+Jianping%22">Lu, Jianping</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. Apr 2020 50(4):1249-1257.
– Name: Avail
  Label: Availability
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  Data: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 9
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2020
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Dental+Health%22">Dental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Dental+Evaluation%22">Dental Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Asia%22">Asia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10803-019-04256-x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0162-3257
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The objective of this meta-analysis was to assess the dental health status of children with ASD in terms of decayed, missing, and filled permanent teeth (DMFT) and decayed, missing, and filled deciduous teeth (dmft). PubMed, Embase, psycINFO, and Cochrane library were searched for studies published until September 2018. A random-effects model was applied to estimate the pooled results. Nine studies comprising 532 children with ASD and 622 controls were included. No significant differences between children with ASD and controls were observed for DMFT and dmft in the world. Subgroup analyses revealed that children with ASD had a significantly higher dmft index than that of controls in Asia. Children with ASD have a worse dental health status than healthy children in Asia, but caution is necessary given the limited studies available for analysis.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2020
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1249736
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1249736
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      – Type: doi
        Value: 10.1007/s10803-019-04256-x
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 9
        StartPage: 1249
    Subjects:
      – SubjectFull: Dental Health
        Type: general
      – SubjectFull: Dental Evaluation
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Pervasive Developmental Disorders
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Asia
        Type: general
    Titles:
      – TitleFull: Dental Caries Status in Autistic Children: A Meta-Analysis
        Type: main
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      – PersonEntity:
          Name:
            NameFull: Zhang, Yujian
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            NameFull: Lin, Ling
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            NameFull: Liu, Jianbo
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            NameFull: Shi, Ling
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            NameFull: Lu, Jianping
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            – D: 01
              M: 04
              Type: published
              Y: 2020
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              Value: 50
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            – TitleFull: Journal of Autism and Developmental Disorders
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