Open Access

Original Article

Occurrence of oral habits among preschool

children with Autism Spectrum Disorder
Fares S. Al-Sehaibany1
ABSTRACT
Objective: To determine occurrence of oral habits among Saudi preschool children with autism spectrum
disorder (ASD) and compare it with healthy preschool children.
Methods: This study was conducted over a 14-months period in Riyadh, Saudi Arabia. The sample consisted
of two groups; a study group (SG) of 150 ASD children, and a control group (CG) of age- and gender-matched
150 healthy children. The parents of the children in both the groups were administered a questionnaire that
included questions about the children’s demographic information and previous or persistent oral habits.
Results: The prevalence of oral habits was higher (87.3%) among the SG children as compared to CG
children (49.3%). The most prevalent oral habit among the SG was bruxism (n = 82; 54.7%), followed by
object biting (n = 67; 44.7%) and mouth breathing (n = 40; 26.7 %). Among the CG; the most prevalent oral
habit was mouth breathing (n = 40; 26.7%) followed by nail biting (n=18; 12%) and object biting (n = 7;
4.7%). The prevalence of bruxism, object biting, thumb sucking and tongue biting was significantly (p<0.05)
higher in the SG than the CG.
Conclusions: The prevalence of oral habits was higher in the ASD group children than the healthy children.
KEYWORDS: Autism spectrum disorder, Oral habits, Preschool children.
doi: https://doi.org/10.12669/pjms.335.13554
How to cite this:
Al-Sehaibany FS. Occurrence of oral habits among preschool children with Autism Spectrum Disorder. Pak J Med Sci.
2017;33(5):1156-1160. doi: https://doi.org/10.12669/pjms.335.13554
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION In addition to self-injurious behaviors such as

hitting with bare hands, banging their heads on
Autism or autism spectrum disorder (ASD) is a walls and furniture, and pricking or pinching;3
group of neurodevelopmental disorders that may oral habits including bruxism, tongue thrusting,
affect children at an early age.1 In Saudi Arabia, the lip biting, and pica (eating objects and substances
reported prevalence of ASD was 18 per 10,000 live such as gravel, or pens) have been reported among
births in 2009.2 children with ASD.4 These habits may contribute to
significant dental problems such as soft tissue injury,
1. Fares S. Al-Sehaibany, BDS, DMSc, tooth loss, tooth wear, increased overjet, anterior
Associate Professor, open bite, and posterior crossbite.5 Furthermore,
Department of Pediatric Dentistry and Orthodontics, these habits are associated with skeletal and
College of Dentistry, King Saud University,
Riyadh, Saudi Arabia. dentoalveolar deformation. The severity of
deformation is related to the frequency and
Correspondence:
duration of the habit, and should be evaluated by
Dr. Fares S. Al-Sehaibany,
Associate Professor,
pediatric dentists.6 An assessment of the prevalence
Department of Pediatric Dentistry and Orthodontics, of various oral habits among children with ASD
College of Dentistry, King Saud University, and comparison non-ASD children would provide
P.O. Box 60169, Riyadh 11545,
Saudi Arabia. the necessary information regarding the habits in
E-mail: [email protected] these groups and the problems associated with the
* Received for Publication: July 24, 2017 oral habits. Studies investigating the prevalence of
* Accepted for Publication: * September 5, 2017 oral habits among children with ASD are relatively

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 Fares S. Al-Sehaibany

rare. Therefore, the aim of the present study was to prevalent among 131 (87.3%) of the SGchildren
determine occurrence of oral habits among Saudi and 74 (49.3%) of the CG children. There were no
preschool children with ASD and compare it with gender differences in both the groups, so combined
healthy preschool children. data are presented. The prevalence of oral habits for
the SG and CG children is shown in Fig.1. The most
METHODS
prevalent oral habit among the SG was bruxism
The study protocol and consent form were (54.7%), followed by object biting (44.7%) and
approved by the Research and Ethical Committee of mouth breathing (26.7 %). Among the CG, the most
Human Studies at the College of Dentistry Research prevalent oral habits were mouth breathing (26.7%)
Center (PR 0024), in King Saud University, Riyadh, followed by nail biting (12%) and object biting
Saudi Arabia. The sample consisted of 150 SG (4.7%). The prevalence of bruxism, object biting,
children (3-6 years old) and 150 age- and gender- thumb sucking and tongue biting was significantly
matched CG children.The SG was recruited from (p<0.05) higher in the SG than the CG.
three ASD centers randomly selected from a list The duration (hours per day) of various oral
of ASD centers obtained from the Saudi Ministry habits in the SG and CG is shown in Table-I. Half
of Education. Three kindergartens were also of the children (50%) in the SG showed a bruxism
randomly selected from a list of kindergartens duration of more than one hour, while no child in
provided by the ministry. A letter explaining the the CG showed a bruxism duration of more than
objectives of the study and informed consent forms one hour. Similarly, higher number of children
were sent to the parents of the selected children in the SG showed reported object biting duration
through the kindergarten principals. Parents who (n=29) and tongue biting duration (n = 10) of
agreed to participate in the study received a self- more than one hour daily than the CG (n=6 and 0,
administered questionnaire for completion. respectively).
The study was conducted over a 14-month period The pattern of oral habits (while asleep, awake
between September 2014 and October 2015. The or both) for the SG and CG children are shown in
questionnaire was derived from the oral habits Table-II, A majority in the SG reported bruxism
guidelines of the American Academy of Pediatric while awake (69.5%). Similarly, majority of the
Dentistry6 and was translated from English to Arabic children in the SG reported object biting while
by a certified bilingual translator. The questionnaire awake (97%). Whereas all of the CG children with
asked about the child’s gender, date of birth, bruxism and object biting reported performing the
medical history, previous history of orthodontic
habits while awake.
treatment, and previous or current oral habits. A
test-retest was performed to verify the consistency
and reliability of the questionnairein parents of 15
SG and 15 CG children not participating in the main
study.
The data obtained from the questionnaires were
manually entered into the computer using Statistical
Package for the Social Sciences software package
(IBM, SPSS version 20, Chicago, IL, USA) and
analyzed using a significance level of P<0.05. The
statistical analyses included frequency distribution,
cross-tabulation, Fisher’s exact test, and Pearson’s
Chi-square test to compare the two groups.
RESULTS
The age of the children in each group ranged
between 3-6 years with a mean age of 4.7 ± 0.8 years Fig.1: The prevalence of oral habits in the SG and CG.
for SG and 4.4 ± 0.6 years for CG. In each group SG: study group, CG: control group,
the number of males (n=109; 73%) was significantly TS: thumb sucking, PS: pacifier sucking,
(p<0.001) higher than females (n=41; 27%), the TB: tongue biting, LB: lip biting, OB: object biting,
male:female ratio was 2.7:1. Oral habits were NB: nail biting, MB: mouth breathing, BX: bruxism.

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 Oral habits among autistic children

Table-I: The duration per dayof oral habits in the SG and CG.
Oral Habit Group Duration P value
≤ 1 hr. n (%) >1 - 3 hrs. n (%) > 3 - 6 hrs. n (%) > 6 hrs. n (%)
TS SG 11 (64.6) 2 (11.8) 2 (11.8) 2 (11.8) < 0.001
CG 0 (0.0) 4 (80.0) 0 (0.0) 1 (20.0)
PS SG 0 (0.0) 2 (100.0) 0 (0.0) 0 (0.0) < 0.001
CG 0 (0.0) 3 (100.0) 0 (0.0) 0 (0.0)
TB SG 2 (16.7) 1 (8.3) 8 (66.7) 1 (8.3) < 0.001
CG 4 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)
LB SG 4 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) < 0.001
CG 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
OB SG 38 (56.7) 27 (40.3) 2 (3.0) 0 (0.0) < 0.001
CG 1 (14.3) 6 (85.7) 0 (0.0) 0 (0.0)
NB SG 14 (93.3) 1 (6.7) 0 (0.0) 0 (0.0) < 0.001
CG 0 (0.0) 17 (94.4) 1 (5.6) 0 (0.0)
MB SG 1 (2.5) 26 (65.0) 3 (7.5) 10 (25.0) < 0.001
CG 3 (7.5) 30 (75.0) 2 (5.0) 5 (12.5)
BX SG 41 (50.0) 26 (31.7) 12 (14.6) 3 (3.7) < 0.001
CG 3 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)
SG: study group, CG: control group, TS: thumb sucking, PS: pacifier sucking, TB: tongue biting,
LB: lip biting, OB: object biting, NB: nail biting, MB: mouth breathing, BX: bruxism.

The time length (in years) of the oral habits in biting (64.6%) and thumb sucking (64.6%) for more
the SG and CG children is shown in Table-III. A than two years. The time length of all the oral habits
majority in the SG had bruxism for more than one in the majority of CG children, was more than one
year (82.9%). Similarly, majority of the children in year.
the SG had the habits of tongue biting (100%), object
Table-III: The time length (in years) of
Table-II: The pattern of oral habits in the SG and CG. oral habits in the SG and CG.
Oral Group Pattern P value Oral Group Time Length P value
Habit While asleep While awake Both Habit < 1 yr. 1 - 2 yrs. > 2 yrs.
n (%) n (%) n (%) n (%) n (%) n (%)
TS SG 2 (11.8) 11 (64.6) 4 (23.6) < 0.001 TS SG 3 (17.7) 3 (17.7) 11 (64.6) < 0.001
CG 0 (0.0) 0 (0.0) 5 (100.0) CG 0 (0.0) 5 (100.0) 0 (0.0)
PS SG 0 (0.0) 0 (0.0) 2 (100.0) 0.480 PS SG 0 (0.0) 2 (100.0) 0 (0.0) 0.480
CG 2 (66.7) 0 (0.0) 1 (33.3) CG 1 (33.3) 2 (66.7) 0 (0.0)
TB SG 1 (8.3) 1 (8.3) 10 (83.4) < 0.001 TB SG 0 (0.0) 0 (0.0) 12 (100.0) < 0.001
CG 3 (75.0) 1 (25.0) 0 (0.0) CG 1 (25.0) 2 (50.0) 1 (25.0)
LB SG 1 (25.0) 0 (0.0) 3 (75.0) < 0.001 LB SG 1 (25.0) 1 (25.0) 2 (50.0) < 0.001
CG 0 (0.0) 0 (0.0) 0 (0.0) CG 0 (0.0) 0 (0.0) 0 (0.0)
OB SG 0 (0.0) 65 (97.0) 2 (3.0) < 0.001 OB SG 4 (5.9) 20 (29.5) 43 (64.6) < 0.001
CG 0 (0.0) 7 (100.0) 0 (0.0) CG 2 (28.6) 5 (71.4) 0 (0.0)
NB SG 0 (0.0) 15 (100.0) 0 (0.0) < 0.001 NB SG 2 (13.3) 8 (53.4) 5 (33.3) < 0.001
CG 0 (0.0) 18 (100.0) 0 (0.0) CG 0 (0.0) 14 (77.8) 4 (22.2)
MB SG 25 (62.5) 3 (7.5) 12 (30.0) < 0.001 MB SG 2 (5.0) 23 (57.5) 15 (37.5) < 0.001
CG 8 (20.0) 2 (5.0) 30 (75.0) CG 3 (7.5) 21 (52.5) 16 (40.0)
BX SG 9 (11.0) 57 (69.5) 16 (19.5) < 0.001 BX SG 14 (17.1) 46 (56.1) 22 (26.8) < 0.001
CG 0 (0.0) 3 (100.0) 0 (0.0) CG 0 (0.0) 0 (0.0) 3 (100.0)
SG: study group, CG: control group, TS: thumb sucking, SG: study group, CG: control group, TS: thumb sucking,
PS: pacifier sucking, TB: tongue biting, PS: pacifier sucking, TB: tongue biting,
LB: lip biting, OB: object biting, NB: nail biting, LB: lip biting, OB: object biting, NB: nail biting,
MB: mouth breathing, BX: bruxism. MB: mouth breathing, BX: bruxism.

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 Fares S. Al-Sehaibany

DISCUSSION Pediatric dentists can expect to face the challenge

of providing preventive dental care to an increasing
The present study has provided important
number of children with ASD.16 A reduced oral
baseline information on the occurrence of oral
health-related quality of life as perceived by the
habits in a group of Saudi preschool children with
parents of Saudi children with ASD has been
ASD. Development of dental occlusion is strongly
documented.17 This could be attributed to fact that
influenced by environmental factors such as oral
the parents are overwhelmed by the medical and
habits. Early diagnosis and successful treatment of
behavioral problems of their ASD children, resulting
oral habits is pivotal in the development of occlusal
in lower priority to dental health.18 Therefore, the
harmony and function.7 Therefore, intervention
provision of preventive dental care and increasing
leading to oral habits cessation should be initiated
dental health knowledge of the parents of ASD
as early as possible.
children is of vital importance.
There are several reasons why the children with
ASD receive limited oral health care including CONCLUSIONS
preventive care. These reasons include lack
of knowledge and experience regarding ASD The most prevalent oral habit in the SG was
among dental professionals and a low priority for bruxism, whereas the most prevalent oral habit in
preventive oral health care on part of the parents.8,9 the CG was mouth breathing. The prevalence of
A better understanding of the behavioral effects bruxism, object biting, thumbs sucking and tongue
of ASD and existing oral habits may help dental biting was higher in the SG than in the CG.
practitioners deliver preventive oral health care
ACKNOWLEDGEMENTS
empathetically and appropriately.10
The present study found that bruxism was the The author thanks Dr. Ala Aljubour, postgraduate
most prevalent oral habit in the SG. Furthermore, student, Department of Pediatric Dentistry and
the duration and time length of bruxism were Orthodontics, College of Dentistry, King Saud
higher in the SG. Studies have reported that University, for her assistance in the distribution
bruxism is a common habit among children with of the questionnaires. The author also extends his
ASD.11 Bruxism in children with special healthcare appreciation to the College of Dentistry Research
needs may result in excessive wear of dentition,
Center and Deanship of Scientific Research at King
and temporomandibular joint (TMJ) pain.12 The use
Saud University, Saudi Arabia, for funding this
of splints or behavioral modification techniques
study.
to treat bruxism may be limited in children with
ASD due to their poor intellectual skills and Declaration of interest: None.
communication difficulties.13 Intraoral appliances,
such as splints, may become an aspiration hazard Source of funding: This study was funded by the
for children with ASD.12 Therefore, pharmacological College of Dentistry Research Center and Deanship
treatment has been recommended ranging from of Scientific Research at King Saud University,
injection of botulinum toxin to the use of central Saudi Arabia (PR 0024).
nervous system medication.12,14
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