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Effect of Health Education for Mothers about Care of Oral Health Problems on Quality of Life for Their Autistic Children

Soheir El-Sayed Mahrous Ibrahim*, Rahma Soliman Bahgat, Fatma Abdelmoniem Elhendawy

Pediatric Nursing Department, Faculty of Nursing, Tanta University, Tanta, Egypt

Abstract: Background: Autistic children present with a neuro-developmental disorder lifelong that makes them susceptible to oral diseases. The study aimed was to determine the effect of health education for mothers about the care of oral health problems on quality of life for their autistic children. Subjects and method: A convenience sampling of sixty mothers and their autistic children participated in the study. The study was conducted at the child psychiatric out-patient clinic at the Psychiatry Center of Tanta University hospital and Pediatric dental clinic faculty of dentistry, Tanta University. Three Tools were used for collection the data: structured interview schedule, an observational checklist for oral assessment, oral health-related quality of life scale. The results showed that an improvement of mothers’ knowledge and practice about the care of oral health problems after the health education implementation and improvement of quality of life for autistic children. The study concluded that the mother’s knowledge and practice about the care of oral health problems improved after the implementation of health education. Autistic children showed an improvement in their quality of life after the implementation of the health education. The study recommended that ongoing in-service educational programs must be prepared and implemented for nurses for the importance of maintaining dental health for autistic children. Education programs for the parents of maintaining their child’s oral health hygiene at home. Dental health awareness lectures and television programs designed for parents and children with different disabilities.

Keywords: health education, mothers, oral health problems, quality of life, autistic children

Received June 03, 2020; Revised July 04, 2020; Accepted July 12, 2020

Citation: Soheir El-Sayed Mahrous Ibrahim, Rahma Soliman Bahgat, Fatma Abdelmoniem Elhendawy, Effect of Health Education for Mothers about Care of Oral Health Problems on Quality of Life for Their Autistic Children. American Journal of Nursing Research, 8 (5). 524-533. January 2020. doi:10.12691/ajnr-8-5-5

1. Introduction

Autism is a developing disorder that affects behavior, in specific, social skills, communication, and daily living skills. Some autistic children also participate in restrictive and repetitive behavior as repeating phrases or words, sensory sensitivities, and heightened responses to changes in routine. Autism is a disorder of development because signs and symptoms first start to appear within the second year of life, and many appearing before the six months of life. Autism is known by a spectrum because the symptoms vary from child to another child relating to the severity and affected skills. Some children may only engagement with communication and social skills, while other children may have difficulty in all symptom areas [1].

Etiology of autism still obscure, the risk factors proposed to involve genetic, autoimmune factors, and post-encephalitic infection. Parents' education, lifestyle, and income do not appear to influence the risk of autism. Condition of oral health for autistic children may be affected by age, living conditions, and the severity of impairment. Special needs children such as autism have great limitations in the performance of oral health hygiene as a result of their potential sensory, intellectual, and motor disabilities [2,3,4].

Autistic children have difficulties with behavior, social, and language skills. These conditions make influenced children more liable to oral health problems and make their dental care complicated. Autistic children have some difficulties in daily life normal activities, as inappropriate diet and oral hygiene. Therefore, in the refusal of physical communication, the difficulty of brushing and flossing performance by the caregivers. So, it is significant to know the quality of life measures is not a substitute for determining consequences related to the disease but are adjunct to them [5,6,7,8,9,10].

Quality of life is counted as an important consequence of health care for autistic children with all abilities. There has been an obvious increase in interest and the number of instruments of oral health-related quality of life. Oral diseases may be the result of absence of adequate care, leading to oral diseases as periodontal problems and dental caries can have not only functional and physical but also psychological, economic, and social impacts. However, no such study on autistic children for whom it is severely difficult to assess the quality of life, especially children with limited or no skills of communication, and who are unable to express discomfort and pain. They greatly depend on their mothers for their daily life activities including oral and dental care and for seeking appropriate dental treatment that could have an effect on their quality of life [11].

Maintaining good oral and dental hygiene is one of the most significant things that can do for the gums and teeth. Healthy teeth not only enable to sense and look good, but they also make it possible to speak and eat appropriately. Good oral health is significant to overall well-being. Preventive daily care, such as proper flossing and brushing, will help to prevent developing the problems and remains much less painful, worried, and cost than treating conditions that have been progressed [12].

The most important role of the nurse in an autistic child is education. The parents and siblings need to be educated on various aspects of autism and oral health problems include symptoms, treatment opportunities, expected and potential outcomes, and available support resources. A nurse must be skilled in screening children attending their care who probably could have autistic characteristics. The nurse should be proficient in finding out strategies by which an individual patient and their family are benefited. Encourage by giving positive reinforcement to the child and the primary caregivers. Implement nursing interventions to decrease anxiety and pain to promote the quality of care. They have a key role in relieving anxiety by providing information. Must take appointments for regular follow up visits and enumerate the problems/improvement of the child [13,14].

2. Aim of the Study

The study was conducted to determine the effect of health education for mothers about the care of oral health problems on quality of life for their autistic children.

3. Subjects and Method

This is quasi-experimental research design. The study was conducted at; Child Psychiatric out-patient clinic at Psychiatry Center of Tanta University Hospital and Pediatric dental clinic Faculty of Dentistry, Tanta University.

3.1. Subjects

Sample: A convenient sample of sixty mothers and their autistic children who were attended the previously mention setting for oral health management. The sample size was based on the following parameters confidence level error level 5% type I error 0.05 and power of test 95%. Children having the following criteria; both sexes, aged from 6-12 years, Autistic children with oral health problems, and Free from chronic disease.

3.2. Three Tools Were Used to Collect Data

Tool I: Structured interview schedule: It consisted of three parts: Part one: Sociodemographic data of the studied children: the form covered the personal data of the studied children such as their age, sex, birth order, family number, and residence. And also, characteristics of the mother such as age, education level, and occupation. Part two: included knowledge of mothers with their autistic children about oral health problems such as the importance of oral health, type, number, importance of teeth, the definition of dental problems, common dental problems, and its contributing factors, and the pattern of dental care. Scoring system of mothers with their autistic children knowledge was as follows: Correct and completely answer was scored (two), correct and incompletely answer was scored (one), and don't know or incorrect answer was scored (zero). Score for mothers with their autistic children knowledge was calculated and classified as follows: Less than 65% were considered poor knowledge, from 65 to less than 75% were considered fair, and from 75 to 100% were considered good. Part three: It covered the oral assessment of autistic children schedule, which includes: a history of the children’s dental health condition, age at an eruption of the first milky teeth, eruption pattern, number of teeth, type of feeding, favorite foods, habits of brushing and health condition of the child and dental problem, teeth attrition, occlusion, and oral infections, developmental anomalies, oral soft and hard tissue injuries.

Tool II: Observational checklist for oral assessment: It consisted of two parts: Part I: Observational checklist for the assessment of dental health condition. Caries assessment was done using the Decay-Missing-Filled (DMF) index for permanent and decay-missing-filled (dmf) index for primary teeth [15] DMF index: it was used to permanent dentition and was indicated the total teeth number or surfaces which are decayed, missing, or filled in the autistic child. The index was applied to teeth specifically, and it was called the DMFT index, scores per individual ranged from zero to twenty eight or thirty two, depending on include the third molars in the scoring. Calculating Decay-Missing-Filled (DMF) index: not counted teeth were unerupted teeth, supernumerary teeth or congenitally missing teeth, teeth removed for any reasons other than caries, and primary teeth engaged in the permanent dentition. Third molars counting was optional. When a carious lesion (s) and restoration were present, the tooth was recorded as a D. As soon as teeth have been extracted as a result of caries, recorded as an M. Once a temporary or permanent filling was present, and when a filling was defective but not decayed, counted as an F. The decay-missing-filled (dmf) Index: used to the primary dentition. The experience of caries for autistic child was indicated the total teeth number or surfaces which were decayed, missing, or filled. The dmft index indicates the number of influenced teeth in the primary dentition.

Gingival and periodontal assessment index [16] was done to assess periodontal status by assessing loss of attachment, probing depths, recession, mucogingival involvement, bleeding, teeth mobility, bone level, and gum appearance.

Gingivitis and Plaque Grading [17]: Plaque Index (PI): Plaque was a sticky deposit on teeth in which bacteria proliferate. PI 0 - No plaque observable, PI 1 - Less than 1/3 of the surface of the buccal tooth covering by scattered plaque , PI 2 - Between 1/3 and 2/3 of the buccal tooth surface covering by plaque, and PI 3 - Greater than 2/3 of the surface of buccal tooth covering by plaque. Calculus Index (CI): Calculus was mineralized material on the surface of tooth. The calculus index indicates to the calculus amount on a tooth. CI 0 - No calculus observable, CI 1 - Less than 1/3 of the surface of the buccal tooth covering by scattered calculus, CI 2 - Between 1/3 and 2/3 of the buccal tooth surface covering by calculus with minimal subgingival deposition, and CI 3 - Greater than 2/3 of the surface of buccal tooth and extending sub-gingivally covering by calculus. Gingival Index (GI): is the assigned number to appoint a gingival inflammation degree. GI 0 - Normal and healthy gingival with non-inflamed margins and sharp, GI 1 - No bleeding on probing, edema at free gingival and marginal gingivitis with minimum inflammation, GI 2 - Bleeding upon probing, moderate gingivitis with a broader band of inflammation, and GI 3 -Advanced gingivitis with clinically inflammation reaching the junction of mucogingival usually with ulceration.

Part II: Observational checklist for assessing the actual children's practices related to the technique of teeth. It was adopted from the American Dental Association (ADA) [18] to assess autistic child’s practices regarding the technique of teeth. It includes: Using fluoridated toothpaste and a soft brush. Pay attention to the tooth part next to the line of the gum, back teeth and areas which around fillings, bridges, crowns or partial dentures which hard-to-reach. Thoroughly clean each section as follows: clean the outer/cheek-side surfaces of the upper teeth, clean the inner/tongue-side surfaces of the upper teeth, clean the chewing surfaces and then repeat for the lower teeth. For removing odor-producing bacteria, brush from back to front the tongue. Scoring system for autistic child’s practice was as follows: Not done was scored (zero), done correctly and incomplete was scored (one), and correctly done and complete was scored (two). Total score of autistic child’s practice was calculated and classified as follows: less than 65% were considered unsatisfactory practice and from 65% to 100% were considered satisfactory practice.

Tool III: Oral health-related quality of life scale: it was adopted by Slade [19] and modified by the researcher after the literature reviewing to assess the effect of oral health on quality of life. It Consisted of 14 points of the autistic child life which include the following: feel the tense of taste worsened, painful aching in the mouth, unable to eat any food, speech disorder, feeding problems, self-confidence, unsatisfactory diet, diet interferes with meals, embarrassment, difficult to relax, always worry, irritable, feel that unsatisfactory life, unable to function work and difficult to do daily activity. Responses were made on five points type of Likert scale indicating a problem’s frequency as: (4) = very often, (3) = fairly often, (2) = occasionally, (1) = rarely, and (0) = never. The total score of oral health-related quality of life scale was a summation of all individual items scores were 56 and, it was calculated and classified as follows: From 60% to 100% was considered the poor quality of life. Less than 60% was considered the good quality of life.

3.3. Method

This study was accepted by Research Ethical Committee of Faculty of Nursing, Tanta University at (TUH) 5-6-2018. Oral consents were obtained from mothers and their autistic children to engage in the study after explaining the aim of the study and their right to withdraw from the study at any time and without providing a reason. The tools were offered to a jury of five experts in the field of pediatric nursing to check content clarity, validity, relevance, comprehensiveness, understanding, applicability, and ease for implementation. Content validity index was 98.9%. To assess reliability, the tools of the study were tested and the value of Cronbach's alpha coefficient was equal 0.892. A pilot study carried out on ten mothers with their autistic children to test the tools for its applicability, clarity, feasibility and the required modification was made. Pilot study excluded from the study total sample.

3.4. Implementation of the Study

1-Assessment phase: It was done by the researcher for all study subjects to assess the studied mothers and their autistic children who meet the inclusion and exclusion criteria of this study. Firstly, met psychiatric and dentistry doctors and nurses to clarify the purpose and the educational intervention of the study to gain their cooperation after taking permission from related authorities. Children who meet the inclusion criteria of the studied sample were interviewed by the researcher and their parents in the waiting area. The mothers were asked about their characteristics, socio-demographic of the children, knowledge about oral health problems, and oral assessment of autistic children to answer the question of tool one. Afterward, the researcher explained to the mother how to make the oral assessment for their autistic children and how to practice the technique of teeth (tool two). And then discuss to the mothers the scale of quality of life-related to oral health and how to apply this scale (tool three).

2- Planning phase: Based on reviewing the literature the researcher developed the educational intervention according to mothers’ education needs and expected outcomes criteria were formulated, different methods and materials for educational intervention were used including PowerPoint presentations, small lectures, and group discussion.

3- Implementation phase: The researcher attended 9:30 am or 10.00 am till 1.00 pm every Monday and Tuesday in the previously mentioned settings to collect the data and meet the mothers and their autistic children in the waiting area. The researcher met the study subjects individually or in groups from two mothers with their autistic children according to the availability of them. Health education was implemented by the researcher for the study subjects using interactive lectures, video presentations, and booklets. They attended the four sessions. First session: focused on the introduction about the importance of oral health, the importance of teeth, normal dentition, number of teeth, and type of teeth. Second session: focused on the pattern of dental care, type of feeding, the definition of dental problems, and contributing factors of dental problems in autistic children and common problems. Third session: focused on the technique of teeth brushing. Fourth session: focused on oral health impact on health-related quality of life. Each session time was ranged from thirty to sixty minutes. It was accomplished on four successive days for each mother or group of them per day.

4- Evaluation phase: Health education was evaluated before, immediately, and after one month from health education implementation using constructed tool (I) part II and tool (II) part II. and the implementation of the scale of quality of life before, after one month from health education application and three months later using constructed tool (III). The data was collected through a period of eight months from the beginning of December 2018 to July 2019.

3.5. Statistical Analysis

The collected data were prepared, tabulated, and analyzed statistically by using SPSS software (Statistical Package for the Social Sciences, version 25, SPSS Inc. Chicago, IL, USA). For quantitative data, calculated the mean, standard deviation, and range. For qualitative data, using Chi-square test (χ²) for a comparison between two groups or more. F value (ANOVA test) used to comparison the parametric data among more than two means. Pearson’s coefficient (r) used for correlation between variables. Kruskal-Wallis (X² value) used to a comparison of non-parametric data among more than two means. Significance was accepted at P <0.05 for the clarification of the results of significance tests [20].

4. Result

I- Sociodemographic data of children; Table 1: as regards the age, it was evident that half of the children (50.0%) had from six to less than eight years and slightly more than one-third of them (35.0%) had from eight to less than ten years with the mean age 8.063 ± 1.55 years. Concerning sex, it was clear that 63.3% of the autistic children were males and 36.7% of them were females.

II- Sociodemographic characteristics of mothers; Figure 1: regarding the age, it was observed that less than two-thirds of them (60.0%) aged from 20-<30 years while 6.7% aged ≥40 with the mean age of 27.916 ± 6.41 years. As regards the education level, 30.0% of mothers completed their university education and more than half of them (55.0%) had secondary education while 6.7% of them were read and write and 8.3% of them had preparatory education. Regarding their occupation, less than two-thirds of them (63.3%) housewives while 36.7% of them were working.

III- Levels and mean total scores of mothers’ knowledge about oral health of their autistic children; Table 2: explains the percentage distribution of levels and mean total scores of mothers’ knowledge about the oral health of their autistic children and changes of scores after the health education. It was observed that the majority of mothers (98.3%) had poor knowledge before the health education implementation while the majority of them (93.3%) and (90.0%) had a good knowledge immediately after and one month after the health education implementation respectively.

IV- Oral assessment of autistic children; Table 3: clarifies the mean score of caries assessment of autistic children. It was found that the mean scores of decayed (d) teeth of autistic children in the study was 0.366±0.636, the mean of extracted (e) teeth of autistic children in our study were 0.316±0.567 and the mean decayed, extracted, filled teeth (deft) value of the autistic children was 0.683± 0.812. Whereas the mean of Decayed (D) teeth of autistic children was 0.900 ± 0.933, the mean score of Missing (M) teeth of autistic children was 0.200 ± 0.443, the mean of Filled (F) teeth of autistic children was 0.366 ± 0.581 and the mean score of Decayed, Missing and Filled teeth (DMFT) of the autistic children was 1.466 ± 1.126.

V- Mothers’ practice of autistic children related technique of teeth; Table 4: explains the percentage distribution of levels and mean scores of total mothers’ practice related to the technique of teeth and changes of scores after the health education. It was found that the majority of mothers (98.3%) had unsatisfactory practice before the health education implementation while all of them (100.0%) and most of them (80.0%) had satisfactory practice immediately and after one month from the health education implementation respectively. The total mean scores of mothers’ practice was 3.62±4.09, 18.82±1.20, and 14.97±5.78 before, immediate and one month after health education implementation respectively.

VI- Oral health related to the quality of life of autistic children; Table 5: explains the percentage distribution of total levels and mean scores of autistic children's oral health-related to their quality of life and changes in scores after health education. It was found that all of the mothers (100.0%) their autistic children had poor quality of life before the health education implementation compared by the majority of them (93.3%) and three-quarters of them (75.0%) one month and three months after the health education implementation respectively. Also, it was found that the total mean scores of total quality of life for autistic children was 41.50 ± 3.74, 39.30 ± 4.09, and 37.40 ± 3.92 before, one month, and three months after the health education implementation respectively.

VII- Relation among levels of total scores of mothers’ knowledge and practice related to the technique of teeth; Figure 2: presents the relation among levels of total scores of mothers’ knowledge and practice related to the technique of teeth before, immediate and one month after health education. It was showed that the majority of mothers (98.3%) had a poor knowledge and unsatisfactory practice and 1.7% of them had good knowledge and satisfactory practice before health education. The majority of mothers (98.3%) had good knowledge and satisfactory practice and 1.7% of them had fair knowledge and satisfactory practice immediately after the health education. And less than three-quarters of mothers (71.7%) had good knowledge and satisfactory practice, 18.3% of them had good knowledge but unsatisfactory practice one month after the health education.

Figure 3 shows correlation among total scores of mothers’ knowledge and practice related to the technique of teeth. It was clarified that there were a positive but not statistically significant difference in correlation between levels of total scores of mothers’ knowledge and practice related to the technique of teeth before, immediate, and one month after health education where (P=0.683, 0.957, and 0.236 respectively).

Table 6 presents the relationship among total mothers’ knowledge and practice scores and their socio-demographic data before, immediate, and one month after health education. It was clarified that there was a statistical significant difference among scores of total mothers’ knowledge and their age after one month of the health education implementation where (P=0.038). The same table clarifies that there was no statistical significant difference among total mothers’ practice scores with their socio-demographic data immediately and after one month of the health education implementation (P-value < 0.05).

Table 1. Percentage distribution of autistic children regarding sociodemographic characteristics

Figure 1. Sociodemographic characteristics of the studied mothers

Table 2. Percentage distribution of levels and total mean scores of mothers’ knowledge about the oral health of their autistic children

Table 3. Mean score of caries assessment of autistic children

Table 4. Percentage distribution of levels and mean scores of total mothers’ practice related to the technique of teeth

Table 5. Percentage distribution and mean scores of autistic children oral health related to their quality of life

Table 6. Relation between total mothers’ knowledge and total practice scores and their socio-demographic data

Figure 2. Relation between levels of total mothers’ knowledge and total practice related to the technique of teeth

Figure 3. Correlation among total scores of mothers’ knowledge and practice related to the technique of teeth

5. Discussion

Autistic children often have problems with emotional, social, and communication skills. They might repeat certain actions and might not want to change in their regular activities. The risk for oral health disease is identified to increase in autistic children. Reports from parents of autistic children have shown that the children suffer from a diversity of oral symptoms, daily life problems, and concerns that assign to the autistic child’s oral health and have an impact on the family’s and child’s quality of life [21].

This study concentrated on determining the effectiveness of the health education to the mothers about the care of oral health problems on quality of life to their autistic children at the Child Psychiatric out-patient clinic at the Psychiatry Center of Tanta University Hospital and Pediatric dental clinic Faculty of Dentistry, Tanta University. The result of this study clarified that two-thirds of the autistic children were males, indicating a higher prevalence of this disorder between males. A possible reason that males are genetically susceptible to having any form of disabilities as opposed to females. AlMaweri [22] who was in the same direction with this result and stated that most of autistic children were males, referred this to increase the fetal testosterone level which may potentially affect the chromosomes and genes.

In addition to Gonçalves [23] who observed in their study that there was a high prevalence of autistic children, three-quarters of them were male compared to one quarter were females, which suggested that there are changes between the male brain functioning more systematic and female brain functioning more empathetic. Therefore, autism could be a hypermasculinization brain and one of its reasons may be the early exposure to androgens like testosterone, which affecting behavior and brain development. This would clarify the higher prevalence in males.

The findings of the current study clarified that more of half of the children’s mothers were secondary education and about one-third of them were post-graduate universities. Regarding their job, about two-thirds of them not working. This may be regarding the caring challenges for autistic children, since they may require constant care and supervision. Mothers with low educational background about oral hygiene maybe not able to access the proper aids of oral hygiene and the facilities of health care. Also, they may deficit awareness about the importance of oral health and its appropriate care. This result was incompatible with Nassar [24] who stated in their study the children of working mothers had a good chance for the best Improvement. The working mothers had a good chance to contact with their colleagues who simplify the exchange of concepts about child care.

Concerning mothers’ knowledge about the oral health problems of their autistic children, the results revealed that the majority of mothers were good knowledge after the health educational implementation while the majority of them were poor knowledge before the program. There was a statistical significant difference in total mother’s knowledge scores after immediate and one month after than before the health education intervention. This finding may be a result of good communication with the mothers during the program and the effect of the teaching methods and materials which were used in the program.

Amin [25] who was in the same direction with this result and stated that a significant improvement was noticed in knowledge of the parents after the workshop. Mean knowledge scores increased significantly after the workshop. In addition to Choi and Ahn [26] who observed in their study that participant mothers in oral health workshops showed significantly increased in the knowledge and improved their behavior more than mothers in control group who received oral health information only through pamphlets.

On the other hand, Abd Allah [27] who disagree with this result as on determining dental knowledge of parents before and after the educational program implementation, results released that there was no statistically significant difference among answers of caregivers before or after the educational program; for instance, when they were asked around the oral health effect on general health, the importance of brushing teeth, and the effect of sweets on teeth.

The findings of the current study clarified that the mean scores of decayed, extracted, filled teeth (deft) for primary and permanent teeth of the autistic children indicated an occurrence of caries prevalence in children with autism. This could be due to autism-related behaviors as personal neglect, self-injurious behaviors, communication limitations, effects of medications, resistance to receiving dental care, dietary habits, possible avoidance of social contact, and hyposensitivity to pain. Naidoo and Singh [28] were in the same direction with this result who found that a high incidence of dental caries in autistic children. A high caries index between autistic children in the study could be referred to as their excessive eating of sweets and poor oral hygiene. The component of decay was a major part of both deft and DMFT indices, representing a higher proportion of untreated dental caries and a greater require for treatment.

On the other hand, Nonong [29] disagreed with these results and reported that the caries experience recorded using deft/DMFT index clarifies that autistic children had a lesser incidence of caries than normal children. El Khatib [30] also showed lower amounts of caries in autistic children, the oral status of the 62 autistic children was evaluated and it was found that these children had lower Decayed, Missing, Filled teeth (DMFT) values, but they had more missing permanent teeth.

Concerning mothers’ practice related to the technique of teeth, the result of the current study showed that the majority of them had unsatisfactory practice before the health education, while most of them had satisfactory practice one month after the health education implementation. This can be explained by the mother’s full communication and co-operation to formal implementation of training guideline and the effect of the teaching methods and materials which were used in the training guideline.

Doichinova [31] who mentioned that results were consistent with these results who reported that the results showed that improvement of oral hygiene practice in autistic children after the program as compared to the baseline status of children before the program. Murshid [32] who mentioned that the same direction with this result who found that there was a statistical significant difference in the pattern response of brushing the tooth, where more than half of autistic children who brushing the tooth irregularly at the time of the dental book receiving were reduced to one third after using of the dental book.

Concerning the autistic children oral health-related to their quality of life assessment, the result of the current study revealed that there was an improvement in the quality of life of autistic children after the health education implementation compared by before the health education. This evidence by a statistically significant difference between autistic children's oral health-related to their quality of life before and after health education. This could be mainly attributed to the prevalence of dental caries and DMFT index observed. Also, these results may be explained by toothache in autistic children was the most commonly reported symptom before the health education. Refusing certain foods, difficulties to relax, and irritability as a result of tooth pain were the most commonly reported daily life problems. This result in the same direction with Alaki [33] who mentioned that autistic children displayed poorer OHRQOL status at all the parts of the OHRQOL measure. Also, the result was supported by Abanto [34] who mentioned that educational intervention was appeared overall effectiveness score and significant in all terms of scale of oral health-related quality of life.

The current study revealed also that there was a positive but not statistical significant difference in correlation between levels of total mothers’ knowledge and total practice related to the technique of teeth before, immediate, and one-month after the health education. This result was incongruent with Murshid [35] who found that there is deficit of dental knowledge among the participating parents of autistic children in the study, particularly in the appropriate first time of a child’s dental visit and regarding causes of dental caries, and parents of autistic children presented satisfactory oral hygiene practices.

The results of the present study showed that there was no statistical significant difference between mother’s knowledge and practice and to their demographic data except between the age of mothers and their knowledge after one month of the health education implementation. Kotha [36] whose results were consistent with the results of the present study as they stated that certain factors like mother’s and father’s education and their income were considered less important. Though the results are not significant (mother’s education P-value equal 0.3, father’s education P-value equal 0.6). On the other hand, Kotha and Alghanim [37] who disagreed with this result and stated that there was a statistical significant difference in the relationship between the demographic factors with the means of oral health care factors as parental knowledge, dietary and hygiene practices.

6. Conclusion

Regarding the findings of the current study, it is concluded that there an improvement in mothers’ knowledge and practices about oral health problems after implementation of the health education. Autistic children showed an improvement in their quality of life after the implementation of the health education. There was a significant statistical difference in total mother’s knowledge, practice scores, and gross quality of life scores of autistic children before and after the health education.

7. Recommendations

The following recommendations are suggested regarding the findings of the current study:

1. Ongoing in-service educational programs should be prepared and implemented for nurses at the special needs centers for the importance of maintaining dental health and dental check-ups for autistic children

2. Education programs for the parents about the harms of using sweets and substitute it with other rewards for behavior modification and involving them in the task of maintaining their child’s oral health hygiene at home.

3. Dental health awareness lectures and television programs designed essentially for parents and children with various disabilities.

4. Education about the impact of oral health problems on quality of life for autistic children in the basic curriculum for nursing students.

References

[1]   | Kasari C, Brady N, Lord C, Tager-Flusberg H. Assessing the minimally verbal school-aged child with autism spectrum disorder. Autism Research. 2013; 6(6): 479-493.
[2]   | Karimi P, Mousavi S, Karahmadi M. Environmental factors influencing the risk of autism. Journal of research in medical sciences. 2017; 22(1): 27.
[3]   | Alkhabuli J, Essa E, Al-Zuhair A, Jaber A. Oral health status and treatment needs of children with special needs. Pesquisa Brasileira em Odontopediatria e Clínica Integrada. 2019; 19(1): e4877.
[4]   | Bassam S, Tork H. Education Program for Mothers of Children with Autism Spectrum Disorder: Mothers and Child Outcomes. American Journal of Nursing Research. 2019; 7 (6): 1046-1056.
[5]   | Al-Sufyani G, Al-Maweri S, Al-Ghashm A, Al-Soneidar W. Oral hygiene and gingival health status of children with Down syndrome in Yemen: A cross-sectional study. Journal of International Society of Preventive and Community Dentistry. 2014; 4(1): 82-86.
[6]   | Suhaib F, Saeed A, Gul H, Kaleem M. Oral assessment of children with autism spectrum disorder in Rawalpindi, Pakistan. International Journal of Research and Practice. 2019; 23(1): 81-86.
[7]   | Park K, Park’s. Text Book of Preventive and Social Medicine. 23rd ed. M/S India: Banarsidas Bhanot Co., 2015; 608.
[8]   | Khudhair A, Jassim S. The Knowledge of Autistic Children's Mothers Regarding Autism in Basra City. American Journal of Nursing Research. 2018;6 (5): 296-298.
[9]   | Blomqvist M, Bejerot S, Dahllöf G. A cross-sectional study on oral health and dental care in intellectually able adults with an autism spectrum disorder. BioMed Central Oral Health. 2015; 15(1): 81.
[10]   | Russell G, Rodgers L, Ukoumunne O, Ford T. Prevalence of parent-reported ASD and ADHD in the UK: Findings from the Millennium Cohort Study. Journal of Autism and Developmental Disorders. 2014; 44(1): 31-40.
[11]   | Sun L, Wong H, McGrath c. The factors that influence oral health-related quality of life in 15-year-old children. Health and Quality of Life Outcomes. 2018; 16(1): 19.
[12]   | Rudenko A, Prevention of hygiene-related oral disorders. In: Krinsky D. Berardi R, Ferreri S. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association. 2012.
[13]   | Petersen P, The World Oral Health Report 2003: Continuous improvement of oral health in the 21st century-the approach of the WHO Global Oral Health Program. Community Dentistry and Oral Epidemiology. 2013; 31(11): 3-23.
[14]   | Appukuttan D. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, Cosmotic and Investigational Dentistry. 2016; 8(1): 35-50.
[15]   | Chattopadhyay A. Oral Health Epidemiology: Principles and Practice.Sudbury, Jones and Bartlett Publishers. 2011. Available at: https://www.dentalcare.com/en-us/professional-education/ce courses/ ce368/ epidemiology-the-dmf-index
[16]   | Dhingra K, Vandana K. Indices for measuring periodontitis, International Dental Journal. 2011; 61(1): 76-84.
[17]   | Bellows J. The Oral Assessment, Treatment and Prevention protocol, Periodontal Examination — Gingivitis and Plaque Grading 2015. Available at: http://www.oralatp.com.
[18]   | American Dental Association, Oral health worksheet, Tooth Brushing. Journal of Dental Hygiene. 2012; 85(2): 7-12, Available at: https://www.mouthhealthy.org/en/az-topics/b/brushing-your-teeth.
[19]   | Slade G. Oral health-related quality of life: Assessment of oral health-related quality of life. In: Inglehart M, Bagramian R, editors. Oral Health-Related Quality of Life. Illinois: Quintessence Publishing Co. Inc; 2002.
[20]   | Dawson B, Trapp R. Reading the medical literature: Basic & Clinical Biostatistics. Lange Medical Book/ McGraw - Hill. Medical Publication Division, New York. 3rd ed., Ch. 7-9, PP 161-218 and Ch. 13, PP 305-314, 2001.
[21]   | Morales-Chávez M. Oral health assessment of a group of children with autism disorder. Journal of Clinical Pediatric Dentistry. 2017; 41(2): 147-149.
[22]   | Al-Maweri S, Halboub E, Al-Soneidar W, Al-Sufyani G. Oral lesions and dental status of autistic children in Yemen: A case-control study. Journal of International Society of Preventive and Community Dentistry. 2014; 4(3): 199-203.
[23]   | Gonçalves J, Moreira E, Rauen M, Rossi A, Borgatto A. Associations between caries experience, nutritional status, oral hygiene, and diet in a multigenerational cohort. Pediatric Dentistry. 2016; 38(3): 203-211.
[24]   | Nassar N, Dixon G, Bourke J, Bower C, Glasson E, de Klerk N. Autism spectrum disorders in young children: Effect of changes in diagnostic practices. International Journal of Epidemiology. 2019; 38(5): 1245-1254.
[25]   | Amin M, Nyachhyon P, Elyasi M, Al-Nuaimi M. Impact of an oral health education workshop on parents’ Oral health knowledge, attitude, and perceived behavioral control among african immigrants. Journal of Oral Diseases. 2014: 2014(1): 1-7.
[26]   | Choi H, and Ahn H. Effects of mothers involved in dental health program for their children, Journal of Korean Academy of Nursing. 2012; 42(7): 1050-1061.
[27]   | AbdAllah E, Metwalli N, Badran A. Effectiveness of a one-year oral health educational and preventive program in improving oral health knowledge and oral hygiene practices of a group of Autistic Egyptian children and their caregivers. Future Dental Journal. 2018; 4(1): 23-29.
[28]   | Naidoo M, Singh S. The Oral health status of children with an autism Spectrum disorder in KwaZulu-Nata, South Africa, BioMed Central Oral Health. 2018; 18(1):165.
[29]   | Nonong Y, Setiawan A, Dewi F, Navaneetha C. Oral health knowledge among parents of an autistic child in Bandung-Indonesia. Dental journal. 2014; 47(3): 146-152.
[30]   | El Khatib A, El Tekeya M, El Tantawi M, Omar T. Oral health status and behaviors of children with autism spectrum disorder: A case-control study. International Journal of Pediatric Dentistry. 2014; 24(2): 314323.
[31]   | Doichinova L, Gateva N, Hristov K. Oral hygiene education of special needs children. Part 1: children with an autism spectrum disorder, Biotechnology and Biotechnological Equipment. 2019; 33(1): 748-755.
[32]   | Murshid E. Effectiveness of a preparatory aid in facilitating oral assessment in a group of Saudi children with autism spectrum disorders in Central Saudi Arabia. Saudi Medical Journal. 2017: 38(5): 533-540
[33]   | Alaki S, Khan J, El Ashiry E. Parental Perception of Oral Health-Related Quality of Life in Children with Autism. American-Eurasian Network for Scientific Information Journal. Advances in Environmental Biology. 2016; 10(12): 213-221.
[34]   | Abanto J, Ortega A, Raggio D, Bönecker M, Mendes F, Ciamponi A. Impact of oral diseases and disorders on oral-health-related quality of life of children with cerebral palsy, Special Care Dentistry Association and Wiley Periodicals. 2014; 34(2):56-63.
[35]   | Murshid E. Parents’ Dental Knowledge and Oral Hygiene Habits in Saudi Children with Autism Spectrum Disorder. Global Journal of Medical Research. 2014; 14(2): 11-18.
[36]   | Kotha S, AlFaraj N, Ramdan T, Alsalam M, Al Ameer M, Almuzin Z. Associations between Diet, Dietary and Oral Hygiene Habits with Caries Occurrence and Severity in Children with Autism at Dammam City, Saudi Arabia. Open Access Macedonian Journal of Medical Sciences. 2018; 6(6): 1104-1110.
[37]   | Kotha S, Alghanim A. The Influence of Oral Health Knowledge on Parental Practices among the Saudi Parents of Children Aged 2-6 Years in Riyadh City, Saudi Arabia, Journal of International Society of Preventive and Community Dentistry. 2018; 8(6): 565-571.