Oral Health Status in Children with Autism Spectrum Disorder in Almaty, Kazakhstan

Oral Health Status in Children with Autism Spectrum Disorder in Almaty, Kazakhstan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Oral Health Status in Children with Autism Spectrum Disorder in Almaty, Kazakhstan Zhamilya Yerkibayeva, Gulzhan Yermukhanova, Korlan Saduakassova, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6682941/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: This study aimed to evaluate the oral health status and hygiene practices of children with autism spectrum disorder (ASD) in Almaty, Kazakhstan, and to assess parental awareness regardingtheir children’s oral care. Methods: The study was conducted involving 53 children aged 3 - 18 years with a confirmed ASD diagnosis, recruited from the “Autism Pobedim” rehabilitation center in Almaty. Clinical examinations assessed caries using the DMFT/dmft, CAST indices, and oral hygiene using the OHI-S index. A 36-item parental questionnaire collected information on children’s oral hygiene routines, dental care experiences, and behavioral characteristics. Results: The study revealed inadequate oral hygiene practices, with only 24.5% of children brushing their teeth twice daily. Most children relied on parental assistance for brushing. Notably, 30.2% had never visited a dentist, and among those who had, 58.5% exhibited behavioral difficulties requiring sedation, restraint, or general anesthesia. Only 39.6% of dental visits resulted in completed treatment. Dietary habits were unfavorable, with 71.7% of children consuming sweets between meals and just17% rinsing their mouths after eating. While 75.5% of parents were aware of toothpaste composition, there was limited professional guidance and a lack of adapted dental services. Conclusion: Children with ASD in Almaty showed a high prevalence of dental caries, limited independent oral hygiene, and significant challenges accessing effective dental care. These findings highlight the urgent need for specialized dental care protocols and public health strategies tailored to the needs of children with ASD in Kazakhstan. Dentistry Psychiatry autism spectrum disorder children oral health dental care Kazakhstan dental behavior management Figures Figure 1 Figure 2 Introduction The health and well-being of children and adolescents are critical indicators of a nation’s future, and oral health plays a vital role in overall health, especially during early development (El Khatib et al., 2014; Qiao et al., 2020). Dental health influences a child’s ability to eat, speak, socialize, and maintain self-esteem (Bagattoni et al., 2021). Among pediatric populations, children with functional or developmental impairments—such as those diagnosed with autism spectrum disorder (ASD)—require particular attention in this regard due to their unique behavioral and physiological profiles(Zhang et al., 2020a). ASD is a complex neurodevelopmental disorder characterized by persistent difficulties in communication and social interaction, as well as restricted, repetitive patterns of behavior, interests, or activities. The severity of ASD varies widely; some individuals can function independently, while others require lifelong care. The global prevalence of ASD has increased markedly in recent decades (Zhang et al., 2020b). According to the World Health Organization, approximately one in 100 children worldwide is affected by ASD. This rise is believed to be influenced by greater awareness, improved diagnostic practices, and changes in health policy and reporting standards ( World Health Organization (WHO). Autism Spectrum Disorders & Other Developmental Disorders: From Raising Awareness to Building Capacity; WHO: Geneva, Switzerland, 2013; Metting Report; Available Online : Https://Apps.Who.Int/Iris/Handle/10665/103312 (Accessed on 25 March 2020). , n.d.). Children with ASD often experience challenges that extend beyond their cognitive and behavioral domains, including in areas such as oral health(Shapira et al., 1989; Vishnu Rekha et al., 2012). While ASD itself does not cause direct anatomical or pathological changes in the oral cavity, the behavioral characteristics associated with the condition can significantly impair oral hygiene and complicate the delivery of dental care(Lam et al., 2020; Prynda et al., 2025) For example, sensory sensitivities may make tooth brushing uncomfortable or intolerable. Resistance to changes in routine and aversion to new experiences can result in difficulty accepting regular dental visits (Alshatrat et al., 2021; Alshihri et al., 2021; Jaber, 2011; Jaber et al., 2011). Communication impairments may prevent children from expressing oral discomfort, which can delay diagnosis and treatment (AlHumaid et al., 2020; Onol & Kirzioglu, 2018; Pi et al., 2020). A higher prevalence of dental anomalies was found in children and adolescents with delayed mental development (da Silva et al., 2024; Ibragimova et al., 2023). In addition, children with ASD often present with feeding problems, including selective or restrictive diets that increase exposure to cariogenic foods (Alshatrat et al., 2021; Loo et al., 2008). Multiple studies have shown that children with ASD are more likely to suffer from poor oral hygiene, higher rates of dental caries, and untreated dental diseases compared to neurotypical children (Bagattoni et al., 2021; Bossù et al., 2020; Ferrazzano et al., 2021). According to international data, up to 25% of children with ASD do not brush their teeth regularly, and many parents report significant difficulties in performing or supervising oral hygiene at home (Zhou et al., 2020). In clinical settings, dentists frequently face challenges such as non-cooperation, unanticipated behaviors, and the need for behavior management strategies such as physical restraint, sedation, or general anesthesia (Chauhan et al., 2025; Du et al., 2015). Moreover, these children often require additional time and staff resources, yet current health care models in many countries do not provide adequate support or reimbursement for such care (18–21). Despite the growing body of literature on ASD and oral health globally, there remains a notable lack of data specific to Central Asian countries, including Kazakhstan. While the number of children diagnosed with ASD is also increasing in Kazakhstan, the health care infrastructure—particularly dental services—may not yet be fully equipped to accommodate their needs. Limited awareness among parents and dental professionals, combined with insufficient training in special care dentistry, creates barriers to early prevention and intervention. This results in a high burden of untreated oral diseases, which may negatively affect the child’s quality of life and overall health outcomes. In this context, Kazakhstan lacks comprehensive epidemiological studies assessing oral health in children with ASD. There is an urgent need to generate data that reflects the current status of oral health in this population, as well as to identify the primary obstacles to care. Understanding the habits, challenges, and treatment experiences of children with ASD and their families is essential for designing appropriate preventive strategies and public health interventions. This study was therefore designed to investigate the dental health status of children with ASD in Almaty, Kazakhstan. The primary objectives were to evaluate the level of oral hygiene and prevalence of dental disease using clinical indices and to assess parental knowledge, behavior, and experiences regarding dental care. The study used a combination of clinical dental examinations and parent-reported surveys to gather a comprehensive picture of oral health challenges among children with ASD. This research seeks to answer three key questions: What are the clinical characteristics of oral health among children with ASD in Kazakhstan? What behavioral and systemic factors contribute to oral health deterioration in this population? And to what extent does the severity of ASD influence access to and outcomes of dental treatment? Methods Participants Children aged 3 to 18 years with a verified diagnosis of ASD, in accordance with the criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), were considered for inclusion in the study. This research had a cross-sectional descriptive design. Approval for the study was granted by the Local Ethics Committee of the S.D. Asfendiyarov Kazakh National Medical University, decision No. 8(114) dated 30.06.2021. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from the parents of children who met the inclusion criteria and agreed to participate in the study. This part of the study was conducted from September to October 2021. Measures The dental examination was carried out at the rehabilitation center for children with autism, in the presence of their parents. Disposable colorful plastic mirrors and probes were used during the examination. Oral status was assessed and recorded based on the Decayed, Missing and Filled Teeth (DMFT/dmft) criteria and the Caries Assessment Spectrum and Treatment (CAST) index. The level of oral hygiene was evaluated using the Oral Hygiene Status (OHI-S) index (I.G. Green and I.R. Vermillion, 1964), as well as by identifying dental plaque using the Qscan Plus device (AIOBIO, South Korea). Parents were surveyed to assess their knowledge regarding the oral health of children with ASD. The questionnaire consisted of 36 questions. After the examination, parents were informed about the oral health condition of their children and the need for appropriate treatment. The CAST allowed for more accurate data collection on the structure of dental caries morbidity and enabled a more detailed evaluation of the effectiveness of therapeutic and preventive measures (Leal et al., 2017) implemented in the population. The CAST index comprised ten distinct codes arranged in hierarchical order, reflecting the severity and consequences of carious lesions. It incorporated elements from previously developed systems, including ICDAS II and the pufa/PUFA index. Specifically, it adopted criteria such as p/P – advanced carious lesions, f/F – presence of a fistulous tract from an affected tooth, and components of the dmft/DMFT index, including ‘m’ for missing and ‘f’ for filled – are considered (Foros et al., 2021). The index was designed for epidemiological purposes and described the stages of dental disease progression, including the absence of carious lesions (intact surface), preventive treatment (fissure sealing), treatment of caries (restoration), enamel and dentin lesions, pulp involvement, abscess or fistula formation, and tooth extraction (Table 1). Each tooth surface was assessed visually, without the use of compressed air to dry the surface, which was a significant advantage in epidemiological studies where dental units or portable air supplies were often unavailable. The inclusion of Code 8 (tooth extracted due to caries) allowed for comparison of CAST results with the dmft/DMFT index. Additionally, the inclusion of Codes 6 and 7, which described clinical symptoms of carious complications, enabled comparisons with the pufa/PUFA index(Gudipaneni et al., 2022). Description of survey data The parents who participated in the study were asked to complete a structured questionnaire in Google Forms, which was designed to collect data for the assessment of oral health in children with ASD. The questionnaire included items on socio-demographic characteristics, such as the child’s age, gender, and whether the parents had received any special training related to ASD. The survey consisted of two main sections: Assessment of Oral Health Status – this section included questions regarding the presence of dental problems, frequency of tooth brushing, who performs the brushing, whether the child had received dental treatment, and any difficulties encountered during dental visits. Child Development Characteristics – this section focused on developmental information, including the age at which the child was diagnosed with ASD. Statistical Analysis All collected data were processed and analyzed using Microsoft Excel and IBM SPSS Statistics version 26.0. Descriptive statistics were employed to summarize demographic characteristics and survey responses. Categorical variables, such as brushing frequency, type of toothpaste used, and frequency of dental visits, were expressed as absolute values (n) and percentages (%). Quantitative data, such as age, were assessed using measures of central tendency, including means and standard deviations, where appropriate. Comparative analysis was conducted to examine relationships between oral hygiene behaviors and dental service utilization. The Chi-square test was used to assess associations between categorical variables, including frequency of brushing and incidence of dental treatment or behavioral challenges during dental visits. The significance level of p < 0.05 was considered statistically significant. Missing or incomplete data entries were excluded from individual item analyses but were accounted for in overall sample size reporting. All analyses were conducted in accordance with the study’s cross-sectional design and aimed at identifying trends relevant to oral health outcomes among children with autism spectrum disorder. Results This study included 53 children diagnosed with autism spectrum disorder (ASD), aged between 3 and 18 years (mean age: 8.26 ± 3.68 years), who attended a rehabilitation center in Almaty, Kazakhstan. Of the participants, 84.9% (n = 45) were male and 15.1% (n = 8) were female. The age of the children varied, with a wide representation across early childhood, middle childhood, and adolescence. The average number of decayed teeth (Decayed) was 3.85 ± 1.60, ranging from 1 to 8. The number of missing teeth (Missing) varied from 0 to 2, with a mean of 0.38 ± 0.63. The number of filled teeth (Filled) ranged from 0 to 4, with an average of 0.91 ± 1.20. The mean DMFT/dmft index was 5.13 ± 2.05, with a minimum value of 2, a maximum of 10, and a median of 5. The CAST analysis showed that most patients had various degrees of dental lesions. The average values were: CAST 3 (superficial caries) – 1.53 ± 0.72, CAST 4 (deep caries) – 1.55 ± 1.03, CAST 5 (complicated caries) – 0.68 ± 0.78. Other CAST categories were significantly less frequent. All age groups (primary dentition 3–5 years – OHI-S 4.2 ± 0.15, mixed dentition 6–11 years – OHI-S 3.95 ± 0.13, permanent dentition 12–18 years – OHI-S 4.15 ± 0.14) showed poor or very poor oral hygiene levels (see Table 2). The worst hygiene indicators were observed in the permanent bite group. All dentition stages demonstrated unsatisfactory oral hygiene levels. A progressive deterioration of hygiene indicators was noted: From 4.2 (milky bite) to 4.15 (permanent bite). Parental responses to the survey indicated that oral hygiene practices among children with ASD were inconsistent and often inadequate. Only 24.5% (n = 13) of children brushed their teeth twice a day, whereas 41.5% (n = 22) brushed once a day, and 22.6% (n = 12) brushed only several times a week or occasionally. Notably, 11.3% (n = 6) of children rarely or never brushed their teeth. When asked who performs tooth brushing, 56.6% (n = 30) of children did so with parental assistance, 28.3% (n = 15) were brushed solely by parents, and only 3.8% (n = 2) brushed independently. Six children (11.3%) did not brush their teeth at all. Most children (64.2%, n = 34) used children’s toothpaste, while 24.5% (n = 13) used toothpaste formulated for adults. A small proportion (3.8%, n = 2) used natural-based products, and another 3.8% used both children’s and adult toothpaste. Two children (3.8%) did not use toothpaste. Regarding awareness of toothpaste ingredients, 75.5% (n = 40) of parents reported checking the composition of toothpaste, whereas 24.5% (n = 13) did not. The majority of respondents (52.8%, n = 28) replaced their child’s toothbrush every three months, while 37.7% (n = 20) did so every six months. Only 3.8% (n = 2) changed toothbrushes annually, and 5.7% (n = 3) monthly. Despite the availability of electric toothbrushes, only one child (1.9%) used one. Information about oral hygiene was obtained primarily through the internet or social networks (49.1%, n = 26), followed by dental visits (22.6%, n = 12). However, 15.1% (n = 8) of parents had no information at all on how to properly brush their child’s teeth. A total of 69.8% (n = 37) of children had been examined or treated by a dentist, while 30.2% (n = 16) had never visited one. Among those who had visited a dentist, the most common reason was dental problems such as caries or plaque (37.7%, n = 20), followed by acute dental pain (24.5%, n = 13). Only 7.5% (n = 4) reported routine check-ups. Sixteen parents (30.2%) had never sought dental care for their child. When asked about the last dental visit, 22.6% (n = 12) had last visited over a year ago, while 20.8% (n = 11) visited six months ago. Smaller numbers had visited within the past four months. More than half of respondents (58.5%, n = 31) reported significant problems during dental visits, including severe fear, restlessness, and the need for general anesthesia. As a result, only 39.6% (n = 21) of children were successfully treated. Among those treated, 13 children required interventions such as physical restraint (n = 7), general anesthesia (n = 5), or sedation (n = 6). A total of 11 children (20.8%) had previously undergone dental procedures under general anesthesia. Dental treatment was conducted in state clinics for 41.5% (n = 22) of respondents and in private clinics for 28.3% (n = 15); the remainder (30.2%, n = 16) had not received treatment. Parents reported various ways they recognized dental issues in their children. The most common signs included putting fingers in the mouth or touching the cheeks (28.3%, n = 15), visible cavities (15.1%, n = 8), and complaints of pain (15.1%, n = 8). A small number of parents noticed swelling or eating difficulties, while 9.4% (n = 5) reported no dental problems. Only 17% (n = 9) of children rinsed their mouths after meals, and 71.7% (n = 38) consumed sweets between meals. Of these, 24.5% (n = 13) consumed sweets daily or more often. Regarding the age at which oral care began, most parents initiated brushing at age three (28.3%, n = 15), followed by age two (17.0%, n = 9) and age one (15.1%, n = 8). However, 9.4% (n = 5) had never started oral care. When asked about challenges and improvements in dental care, parents emphasized the need for treatment under anesthesia or sedation (18.9%, n = 10), a more individualized approach (13.2%, n = 7), improved access and financial support (11.3%, n = 6), and better training for dental professionals (7.5%, n = 4). Some of the results described above are visually represented in Fig. 1 , which includes bar charts illustrating key indicators of oral hygiene practices. Additionally, a heat map was conducted to show the relationship between tooth brushing frequency and the likelihood of visiting a dentist (Fig. 2 ). These visualisations provided a clearer understanding of the patterns and correlations within the dataset, particularly highlighting the association between inadequate oral hygiene and reduced dental care utilization among children with ASD. Discussion The results of this study highlight the significant challenges in maintaining oral health among children with autism in Kazakhstan. Despite a relatively high awareness of oral hygiene among parents, the implementation of effective oral care practices remains inconsistent. Most children required assistance with brushing, and a substantial proportion had never received dental care, which may contribute to the observed prevalence of dental issues. The mean DMFT/dmft index of 5.13 ± 2.05 was found to be higher than that reported in studies conducted in Italy by Bagattoni et al. (2021), where values of 3.00 ± 1.2 (primary dentition) and 2.3 ± 1.8 (permanent dentition) were observed in children with ASD (Bagattoni et al., 2021). Similarly, in the Turkish study by Oda et al. (2021), a lower mean DMFT/dmft score of 4.75 ± 3.66 was reported, although the overall caries prevalence (81.9%) was comparable to that seen in the present cohort (Oda et al., 2021). Poor oral hygiene was consistently observed across all dentition stages in this study, with mean OHI-S scores exceeding 3.9, indicating poor or very poor hygiene. These findings align with those of Ferrazzano et al. (2020), who in a systematic review highlighted poor oral hygiene, limited cooperation during oral care, and dietary factors as major contributors to caries and periodontal disease in children with ASD (Ferrazzano et al., 2021). In study using the mobile application “Marzhan tis”, a high prevalence of superficial (CAST 3: 1.53 ± 0.72) and deep caries (CAST 4: 1.55 ± 1.03) was observed, consistent with the advanced lesion profiles described by Bossù et al. (2020), who reported that 66.38% of ASD children had caries, and over 79% had signs of gingivitis (Bossù et al., 2020) . It has been noted that sensory processing difficulties, commonly reported in children with ASD, may explain avoidance of routine oral care. In line with prior work by Qiao et al. (2020), who linked sensory hypersensitivity to increased risk of halitosis and food impaction, the high mean number of decayed teeth (3.85 ± 1.60) in the current study likely reflects resistance to brushing and infrequent dental visits (Qiao et al., 2020). Only a minority of children were reported to receive regular dental care, echoing findings from Oda et al. (2021) and Suhaib et al. (2019), where dental visit rates and daily brushing habits were notably low among ASD cohorts (e.g., only 9.6% brushed twice daily in the Turkish sample, and 62.7% had never visited a dentist (Oda et al., 2021); 8.6% brushed twice daily in Pakistan, and 82.7% required brushing assistance (Suhaib et al., 2019)). Parental involvement and education have also been emphasized in previous literature as modifiable factors. Suhaib et al. (2019) highlighted a strong link between maternal education and oral hygiene practices, and a similarly high proportion (82.7%) of ASD children in their study required assistance with brushing (Suhaib et al., 2019). In our cohort, inconsistent parental practices were also observed, suggesting that targeted caregiver education and behavioral interventions could serve as effective strategies for improving oral health outcomes. Taken together, these findings reinforce the importance of early preventive strategies tailored to the ASD population. Sensory-adapted dental protocols, visual aids, and structured caregiver training should be prioritized. Despite regional and cultural differences, the evidence indicates that the barriers to oral care in ASD are consistent globally and must be addressed through interdisciplinary, individualized approaches. Behavioral and communication barriers present equally significant challenges. Abstract instructions about proper brushing techniques often do not translate into effective practice for children with ASD. The global review by Lam et al. (2020) highlights that while ASD itself does not directly increase the risk of caries, these behavioral and hygiene challenges can lead to poorer outcomes. Visual supports, such as step-by-step picture guides, video modeling, and social stories, can effectively bridge this gap by providing clear and predictable routines(Lam et al., 2020). Additionally, the dental environment can be overwhelming for children with ASD due to its unfamiliarity and unpredictability, necessitating modifications like quiet waiting areas and structured appointment schedules. Systemic gaps in dental care provision exacerbate these individual challenges. Many dental professionals lack training in ASD-specific care techniques, and traditional dental settings often do not accommodate sensory needs. This creates a cycle where negative experiences reinforce dental avoidance. Addressing the issue requires multifaceted interventions at both individual and systemic levels. Early and gradual introductions to the dental environment, through "happy visits" that focus solely on acclimation, can build positive associations before treatment needs arise. Home-based interventions should incorporate occupational therapy strategies to systematically address sensory aversions, utilizing tools like vibrating toothbrushes or flavored floss to increase tolerance. At the policy level, healthcare systems must prioritize accessible dental care for children with Autism Spectrum Disorder (ASD). This should include insurance coverage for extended behavioral management appointments, interdisciplinary care models that integrate dental professionals with ASD specialists, and mandatory training in neurodiversity-affirming care practices for dental students. Schools and community programs can further support these efforts by incorporating oral hygiene education into existing special education curricula and providing visual supports in classroom settings. Several critical questions remain for future research. Longitudinal studies are necessary to evaluate the long-term impact of sensory-adapted dental interventions. Additionally, further exploration is needed to assess the effectiveness of these approaches across various cultural contexts and socioeconomic backgrounds. Research should also investigate the relationship between ASD-related dietary preferences and caries risk, as many children with ASD have specific food preferences that may affect their oral health. Poor cooperation during dental procedures is a well-documented problem among children with ASD, and our data confirm this. Nearly 60% of parents reported major difficulties during dental visits, often requiring sedation, general anesthesia, or physical restraint. These findings are consistent with international literature, which emphasizes the heightened behavioral challenges faced by this population during oral examinations and treatments. Dietary habits also play a critical role in oral health, with over 70% of children consuming sweets between meals and only a minority rinsing their mouths afterward. Selective eating, common in children with ASD, can limit exposure to protective dietary elements and increase cariogenic risk. Access to dental care was another significant issue. Many parents reported long wait times, difficulty finding qualified professionals, and inadequate accommodations for sensory sensitivities. Furthermore, a lack of specialized training among general dentists may result in reduced willingness or ability to treat children with special needs. This is compounded by the absence of financial incentives for longer or more complex procedures in this patient population. Notably, while many parents demonstrated an interest in proper dental care—as reflected by checking toothpaste composition and replacing brushes regularly—knowledge gaps persist. A sizeable portion of respondents relied on the internet rather than professional advice for information, and nearly one in six had no guidance on oral hygiene practices. Overall, the study underscores a pressing need for targeted oral health education, caregiver support, and systemic improvements in dental service accessibility and training. Developing specialized programs tailored to the behavioral and sensory profiles of children with ASD is essential to improving oral health outcomes in this vulnerable group. Conclusion The findings of this study reveal significant oral health challenges among children with autism spectrum disorder (ASD) in Almaty, Kazakhstan. The majority of children demonstrated inadequate oral hygiene practices, high consumption of cariogenic foods, and limited independent oral care skills. A substantial proportion had never received professional dental care, and those who had often encountered serious behavioral barriers, including fear, sensory sensitivity, and communication difficulties, which complicated both diagnosis and treatment. Children with autism are considered at high risk for dental caries due to their selective dietary habits and difficulties with oral hygiene routines, such as tooth brushing, which are often hindered by deficits in motor coordination. Parents expressed a general awareness of the importance of oral health, yet many lacked professional guidance or access to appropriately trained dental specialists. The study also highlights the structural limitations within the healthcare system, including a shortage of adapted services and insufficient training of dental professionals in managing children with special needs. Given the high burden of untreated dental conditions and the multifactorial barriers to care, there is a clear and urgent need for targeted oral health education for parents, the integration of behaviorally sensitive dental practices, and the development of specialized training programs for dental providers. Establishing multidisciplinary, autism-friendly dental services and improving access to preventive care can significantly enhance the oral health and overall quality of life of children with ASD in Kazakhstan. In conclusion, improving oral health outcomes for children with ASD requires a comprehensive approach that addresses sensory, behavioral, and systemic barriers. Through clinical adaptations, caregiver education, and policy reforms, we can create an oral healthcare system that meets the unique needs of neurodiverse children. Future efforts should concentrate on developing evidence-based, scalable interventions and ensuring their implementation across diverse care settings to achieve equitable oral health for all children with ASD. Declarations Acknowledgments To the Ministry of Science and Higher Education of the Republic of Kazakhstan References AlHumaid, J., Gaffar, B., AlYousef, Y., Alshuraim, F., Alhareky, M., & El Tantawi, M. (2020). Oral Health of Children with Autism: The Influence of Parental Attitudes and Willingness in Providing Care. TheScientificWorldJournal , 2020 (101131163), 8329426. Ovid MEDLINE(R) . https://doi.org/10.1155/2020/8329426 Alshatrat, S. M., Al-Bakri, I. A., Al-Omari, W. M., & Al Mortadi, N. A. (2021). Oral health knowledge and dental behavior among individuals with autism in Jordan: A case-control study. 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Oral health status and dental needs of autistic children and young adults. Journal of Investigative and Clinical Dentistry , 2 (1), 57–62. Ovid MEDLINE(R) . https://doi.org/10.1111/j.2041-1626.2010.00030.x Lam, P. P., Du, R., Peng, S., McGrath, C. P., & Yiu, C. K. (2020). Oral health status of children and adolescents with autism spectrum disorder: A systematic review of case-control studies and meta-analysis. Autism , 24 (5), 1047–1066. https://doi.org/10.1177/1362361319877337 Leal, S. C., Ribeiro, A. P. D., & Frencken, J. E. (2017). Caries Assessment Spectrum and Treatment (CAST): A Novel Epidemiological Instrument. Caries Research , 51 (5), 500–506. https://doi.org/10.1159/000479042 Loo, C. Y., Graham, R. M., & Hughes, C. V. (2008). The caries experience and behavior of dental patients with autism spectrum disorder. Journal of the American Dental Association (1939) , 139 (11), 1518–1524. Ovid MEDLINE(R) . https://doi.org/10.14219/jada.archive.2008.0078 Makkar, A., Indushekar, K. R., Saraf, B. G., Sardana, D., & Sheoran, N. (2019). A cross sectional study to evaluate the oral health status of children with intellectual disabilities in the National Capital Region of India (Delhi-NCR). Journal of Intellectual Disability Research , 63 (1), 31–39. https://doi.org/10.1111/jir.12553 Oda, G., Karayagmurlu, A., Dagli, I., Aren, G., & Soylu, N. (2021). Oral Health Status in Children with Autism Spectrum Disorder: A Cross Sectional Study from Turkey. Psychiatry and Behavioral Sciences , 11 (3), 186. https://doi.org/10.5455/PBS.20210321075312 Onol, S., & Kirzioglu, Z. (2018). Evaluation of oral health status and influential factors in children with autism. Nigerian Journal of Clinical Practice , 21 (4), 429–435. Ovid MEDLINE(R) . https://doi.org/10.4103/njcp.njcp_41_17 Pi, X., Liu, C., Li, Z., Guo, H., Jiang, H., & Du, M. (2020). A Meta-Analysis of Oral Health Status of Children with Autism. The Journal of Clinical Pediatric Dentistry , 44 (1), 1–7. Ovid MEDLINE(R) . https://doi.org/10.17796/1053-4625-44.1.1 Prynda, M., Pawlik, A. A., Emich-Widera, E., Kazek, B., Mazur, M., Niemczyk, W., & Wiench, R. (2025). Oral Hygiene Status in Children on the Autism Spectrum Disorder. Journal of Clinical Medicine , 14 (6), 1868. https://doi.org/10.3390/jcm14061868 Qiao, Y., Shi, H., Wang, H., Wang, M., & Chen, F. (2020). Oral Health Status of Chinese Children With Autism Spectrum Disorders. Frontiers in Psychiatry , 11 , 398. https://doi.org/10.3389/fpsyt.2020.00398 Shapira, J., Mann, J., Tamari, I., Mester, R., Knobler, H., Yoeli, Y., & Newbrun, E. (1989). Oral health status and dental needs of an autistic population of children and young adults. Special Care in Dentistry : Official Publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry , 9 (2), 38–41. Ovid MEDLINE(R) . https://doi.org/10.1111/j.1754-4505.1989.tb01022.x Suhaib, F., Saeed, A., Gul, H., & Kaleem, M. (2019). Oral assessment of children with autism spectrum disorder in Rawalpindi, Pakistan. Autism , 23 (1), 81–86. https://doi.org/10.1177/1362361317730299 Vishnu Rekha, C., Arangannal, P., & Shahed, H. (2012). Oral health status of children with autistic disorder in Chennai. European Archives of Paediatric Dentistry : Official Journal of the European Academy of Paediatric Dentistry , 13 (3), 126–131. Ovid MEDLINE(R) . https://doi.org/10.1007/BF03262858 World Health Organization (WHO). Autism Spectrum Disorders & Other Developmental Disorders: From Raising Awareness to Building Capacity; WHO: Geneva, Switzerland, 2013; Metting Report; Available online: Https://apps.who.int/iris/handle/10665/103312 (accessed on 25 March 2020). (n.d.). Zhang, Y., Lin, L., Liu, J., Shi, L., & Lu, J. (2020a). Dental Caries Status in Autistic Children: A Meta-analysis. Journal of Autism and Developmental Disorders , 50 (4), 1249–1257. Ovid MEDLINE(R) . https://doi.org/10.1007/s10803-019-04256-x Zhang, Y., Lin, L., Liu, J., Shi, L., & Lu, J. (2020b). Dental Caries Status in Autistic Children: A Meta-analysis. Journal of Autism and Developmental Disorders , 50 (4), 1249–1257. https://doi.org/10.1007/s10803-019-04256-x Zhou, N., Wong, H. M., & McGrath, C. (2020). Social story-based oral health promotion for preschool children with special healthcare needs: A 24‐month randomized controlled trial. Community Dentistry and Oral Epidemiology , 48 (5), 415–422. https://doi.org/10.1111/cdoe.12554 Tables Тable 1 CAST codes and description Characteristic Code Description Sound 0 No visible evidence of a distinct carious lesion is present Sealant 1 Pits and/or fissures are at least partially covered with a sealant material Restoration 2 A cavity is restored with an (in)direct restorative material Enamel 3 Distinct visual change in enamel only; a clear caries-related discolouration is visible, with or without localised enamel breakdown Dentine 4 Internal caries-related discolouration in dentine; the discoloured dentine is visible through the enamel, which may or may not exhibit a visible localised breakdown 5 Distinct cavitation into dentine; the pulp chamber is intact Pulp 6 Involvement of the pulp chamber; distinct cavitation reaching the pulp chamber, or only root fragments are present Abscess/fistula 7 A pus-containing swelling or a pus-releasing sinus tract related to a tooth with pulpal involvement Lost 8 The tooth has been removed because of dental caries Other 9 Does not match with any of the other descriptions Т able 2 Comparative Analysis of OHI-S index Parameter Milky bite Changeable bite Permanent bite Mean index value 4.2 3.95 4.15 Standard deviation ±0.15 ±0.13 ±0.14 Hygiene level Poor Poor Very poor Additional Declarations The authors declare no competing interests. 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ASD\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6682941/v1/43ad0d2cbd85de8d531cd929.png"},{"id":83292089,"identity":"77cdadff-2165-4179-a63c-db504ec58d16","added_by":"auto","created_at":"2025-05-22 13:15:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":90799,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHeat map showing the relationship between frequency of tooth brushing and dental visits among children with ASD\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6682941/v1/61976336ef2b7d96da31ed91.png"},{"id":83293640,"identity":"6f74fb1f-9ceb-41e5-bb18-bf860f40450e","added_by":"auto","created_at":"2025-05-22 13:23:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1075044,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6682941/v1/34454b09-5e07-45bc-a2cf-6e436750fc9c.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eOral Health Status in Children with Autism Spectrum Disorder in Almaty, Kazakhstan\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e The health and well-being of children and adolescents are critical indicators of a nation\u0026rsquo;s future, and oral health plays a vital role in overall health, especially during early development (El Khatib et al., 2014; Qiao et al., 2020). Dental health influences a child\u0026rsquo;s ability to eat, speak, socialize, and maintain self-esteem (Bagattoni et al., 2021). Among pediatric populations, children with functional or developmental impairments\u0026mdash;such as those diagnosed with autism spectrum disorder (ASD)\u0026mdash;require particular attention in this regard due to their unique behavioral and physiological profiles(Zhang et al., 2020a).\u003c/p\u003e \u003cp\u003eASD is a complex neurodevelopmental disorder characterized by persistent difficulties in communication and social interaction, as well as restricted, repetitive patterns of behavior, interests, or activities. The severity of ASD varies widely; some individuals can function independently, while others require lifelong care. The global prevalence of ASD has increased markedly in recent decades (Zhang et al., 2020b). According to the World Health Organization, approximately one in 100 children worldwide is affected by ASD. This rise is believed to be influenced by greater awareness, improved diagnostic practices, and changes in health policy and reporting standards (\u003cem\u003eWorld Health Organization (WHO). Autism Spectrum Disorders \u0026amp; Other Developmental Disorders: From Raising Awareness to Building Capacity; WHO: Geneva, Switzerland, 2013; Metting Report; Available Online\u003c/em\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eHttps://Apps.Who.Int/Iris/Handle/10665/103312\u003c/span\u003e\u003cspan address=\"http://Https://Apps.Who.Int/Iris/Handle/10665/103312\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e \u003cem\u003e(Accessed on 25 March 2020).\u003c/em\u003e, n.d.).\u003c/p\u003e \u003cp\u003eChildren with ASD often experience challenges that extend beyond their cognitive and behavioral domains, including in areas such as oral health(Shapira et al., 1989; Vishnu Rekha et al., 2012). While ASD itself does not cause direct anatomical or pathological changes in the oral cavity, the behavioral characteristics associated with the condition can significantly impair oral hygiene and complicate the delivery of dental care(Lam et al., 2020; Prynda et al., 2025) For example, sensory sensitivities may make tooth brushing uncomfortable or intolerable. Resistance to changes in routine and aversion to new experiences can result in difficulty accepting regular dental visits (Alshatrat et al., 2021; Alshihri et al., 2021; Jaber, 2011; Jaber et al., 2011). Communication impairments may prevent children from expressing oral discomfort, which can delay diagnosis and treatment (AlHumaid et al., 2020; Onol \u0026amp; Kirzioglu, 2018; Pi et al., 2020). A higher prevalence of dental anomalies was found in children and adolescents with delayed mental development (da Silva et al., 2024; Ibragimova et al., 2023). In addition, children with ASD often present with feeding problems, including selective or restrictive diets that increase exposure to cariogenic foods (Alshatrat et al., 2021; Loo et al., 2008).\u003c/p\u003e \u003cp\u003eMultiple studies have shown that children with ASD are more likely to suffer from poor oral hygiene, higher rates of dental caries, and untreated dental diseases compared to neurotypical children (Bagattoni et al., 2021; Boss\u0026ugrave; et al., 2020; Ferrazzano et al., 2021). According to international data, up to 25% of children with ASD do not brush their teeth regularly, and many parents report significant difficulties in performing or supervising oral hygiene at home (Zhou et al., 2020). In clinical settings, dentists frequently face challenges such as non-cooperation, unanticipated behaviors, and the need for behavior management strategies such as physical restraint, sedation, or general anesthesia (Chauhan et al., 2025; Du et al., 2015). Moreover, these children often require additional time and staff resources, yet current health care models in many countries do not provide adequate support or reimbursement for such care (18\u0026ndash;21).\u003c/p\u003e \u003cp\u003eDespite the growing body of literature on ASD and oral health globally, there remains a notable lack of data specific to Central Asian countries, including Kazakhstan. While the number of children diagnosed with ASD is also increasing in Kazakhstan, the health care infrastructure\u0026mdash;particularly dental services\u0026mdash;may not yet be fully equipped to accommodate their needs. Limited awareness among parents and dental professionals, combined with insufficient training in special care dentistry, creates barriers to early prevention and intervention. This results in a high burden of untreated oral diseases, which may negatively affect the child\u0026rsquo;s quality of life and overall health outcomes.\u003c/p\u003e \u003cp\u003eIn this context, Kazakhstan lacks comprehensive epidemiological studies assessing oral health in children with ASD. There is an urgent need to generate data that reflects the current status of oral health in this population, as well as to identify the primary obstacles to care. Understanding the habits, challenges, and treatment experiences of children with ASD and their families is essential for designing appropriate preventive strategies and public health interventions.\u003c/p\u003e \u003cp\u003eThis study was therefore designed to investigate the dental health status of children with ASD in Almaty, Kazakhstan. The primary objectives were to evaluate the level of oral hygiene and prevalence of dental disease using clinical indices and to assess parental knowledge, behavior, and experiences regarding dental care. The study used a combination of clinical dental examinations and parent-reported surveys to gather a comprehensive picture of oral health challenges among children with ASD.\u003c/p\u003e \u003cp\u003eThis research seeks to answer three key questions: What are the clinical characteristics of oral health among children with ASD in Kazakhstan? What behavioral and systemic factors contribute to oral health deterioration in this population? And to what extent does the severity of ASD influence access to and outcomes of dental treatment?\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eChildren aged 3 to 18 years with a verified diagnosis of ASD, in accordance with the criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), were considered for inclusion in the study.\u003c/p\u003e\n \u003cp\u003eThis research had a cross-sectional descriptive design. Approval for the study was granted by the Local Ethics Committee of the S.D. Asfendiyarov Kazakh National Medical University, decision No. 8(114) dated 30.06.2021. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from the parents of children who met the inclusion criteria and agreed to participate in the study. This part of the study was conducted from September to October 2021.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThe dental examination was carried out at the rehabilitation center for children with autism, in the presence of their parents. Disposable colorful plastic mirrors and probes were used during the examination. Oral status was assessed and recorded based on the Decayed, Missing and Filled Teeth (DMFT/dmft) criteria and the Caries Assessment Spectrum and Treatment (CAST) index. The level of oral hygiene was evaluated using the Oral Hygiene Status (OHI-S) index (I.G. Green and I.R. Vermillion, 1964), as well as by identifying dental plaque using the Qscan Plus device (AIOBIO, South Korea).\u003c/p\u003e\n\u003cp\u003eParents were surveyed to assess their knowledge regarding the oral health of children with ASD. The questionnaire consisted of 36 questions. After the examination, parents were informed about the oral health condition of their children and the need for appropriate treatment.\u003c/p\u003e\n\u003cp\u003eThe CAST allowed for more accurate data collection on the structure of dental caries morbidity and enabled a more detailed evaluation of the effectiveness of therapeutic and preventive measures (Leal et al., 2017) implemented in the population. The CAST index comprised ten distinct codes arranged in hierarchical order, reflecting the severity and consequences of carious lesions. It incorporated elements from previously developed systems, including ICDAS II and the pufa/PUFA index. Specifically, it adopted criteria such as p/P \u0026ndash; advanced carious lesions, f/F \u0026ndash; presence of a fistulous tract from an affected tooth, and components of the dmft/DMFT index, including \u0026lsquo;m\u0026rsquo; for missing and \u0026lsquo;f\u0026rsquo; for filled \u0026ndash; are considered (Foros et al., 2021).\u003c/p\u003e\n\u003cp\u003eThe index was designed for epidemiological purposes and described the stages of dental disease progression, including the absence of carious lesions (intact surface), preventive treatment (fissure sealing), treatment of caries (restoration), enamel and dentin lesions, pulp involvement, abscess or fistula formation, and tooth extraction (Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003eEach tooth surface was assessed visually, without the use of compressed air to dry the surface, which was a significant advantage in epidemiological studies where dental units or portable air supplies were often unavailable.\u003c/p\u003e\n\u003cp\u003eThe inclusion of Code 8 (tooth extracted due to caries) allowed for comparison of CAST results with the dmft/DMFT index. Additionally, the inclusion of Codes 6 and 7, which described clinical symptoms of carious complications, enabled comparisons with the pufa/PUFA index(Gudipaneni et al., 2022).\u003c/p\u003e\n\u003ch3\u003eDescription of survey data\u003c/h3\u003e\n\u003cp\u003eThe parents who participated in the study were asked to complete a structured questionnaire in Google Forms, which was designed to collect data for the assessment of oral health in children with ASD. The questionnaire included items on socio-demographic characteristics, such as the child\u0026rsquo;s age, gender, and whether the parents had received any special training related to ASD.\u003c/p\u003e\n\u003cp\u003eThe survey consisted of two main sections:\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cspan\u003e\u0026nbsp;Assessment of Oral Health Status \u0026ndash; this section included questions regarding the presence of dental problems, frequency of tooth brushing, who performs the brushing, whether the child had received dental treatment, and any difficulties encountered during dental visits.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChild Development Characteristics \u0026ndash; this section focused on developmental information, including the age at which the child was diagnosed with ASD.\u003cbr\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eAll collected data were processed and analyzed using Microsoft Excel and IBM SPSS Statistics version 26.0. Descriptive statistics were employed to summarize demographic characteristics and survey responses. Categorical variables, such as brushing frequency, type of toothpaste used, and frequency of dental visits, were expressed as absolute values (n) and percentages (%). Quantitative data, such as age, were assessed using measures of central tendency, including means and standard deviations, where appropriate.\u003c/p\u003e\n \u003cp\u003eComparative analysis was conducted to examine relationships between oral hygiene behaviors and dental service utilization. The Chi-square test was used to assess associations between categorical variables, including frequency of brushing and incidence of dental treatment or behavioral challenges during dental visits. The significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\n \u003cp\u003eMissing or incomplete data entries were excluded from individual item analyses but were accounted for in overall sample size reporting. All analyses were conducted in accordance with the study\u0026rsquo;s cross-sectional design and aimed at identifying trends relevant to oral health outcomes among children with autism spectrum disorder.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study included 53 children diagnosed with autism spectrum disorder (ASD), aged between 3 and 18 years (mean age: 8.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68 years), who attended a rehabilitation center in Almaty, Kazakhstan. Of the participants, 84.9% (n\u0026thinsp;=\u0026thinsp;45) were male and 15.1% (n\u0026thinsp;=\u0026thinsp;8) were female. The age of the children varied, with a wide representation across early childhood, middle childhood, and adolescence.\u003c/p\u003e \u003cp\u003eThe average number of decayed teeth (Decayed) was 3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60, ranging from 1 to 8. The number of missing teeth (Missing) varied from 0 to 2, with a mean of 0.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63. The number of filled teeth (Filled) ranged from 0 to 4, with an average of 0.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20.\u003c/p\u003e \u003cp\u003eThe mean DMFT/dmft index was 5.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05, with a minimum value of 2, a maximum of 10, and a median of 5.\u003c/p\u003e \u003cp\u003eThe CAST analysis showed that most patients had various degrees of dental lesions. The average values were: CAST 3 (superficial caries) \u0026ndash; 1.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72, CAST 4 (deep caries) \u0026ndash; 1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03, CAST 5 (complicated caries) \u0026ndash; 0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78. Other CAST categories were significantly less frequent.\u003c/p\u003e \u003cp\u003eAll age groups (primary dentition 3\u0026ndash;5 years \u0026ndash; OHI-S 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15, mixed dentition 6\u0026ndash;11 years \u0026ndash; OHI-S 3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13, permanent dentition 12\u0026ndash;18 years \u0026ndash; OHI-S 4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14) showed poor or very poor oral hygiene levels (see Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eThe worst hygiene indicators were observed in the permanent bite group. All dentition stages demonstrated unsatisfactory oral hygiene levels. A progressive deterioration of hygiene indicators was noted: From 4.2 (milky bite) to 4.15 (permanent bite).\u003c/p\u003e \u003cp\u003e Parental responses to the survey indicated that oral hygiene practices among children with ASD were inconsistent and often inadequate. Only 24.5% (n\u0026thinsp;=\u0026thinsp;13) of children brushed their teeth twice a day, whereas 41.5% (n\u0026thinsp;=\u0026thinsp;22) brushed once a day, and 22.6% (n\u0026thinsp;=\u0026thinsp;12) brushed only several times a week or occasionally. Notably, 11.3% (n\u0026thinsp;=\u0026thinsp;6) of children rarely or never brushed their teeth. When asked who performs tooth brushing, 56.6% (n\u0026thinsp;=\u0026thinsp;30) of children did so with parental assistance, 28.3% (n\u0026thinsp;=\u0026thinsp;15) were brushed solely by parents, and only 3.8% (n\u0026thinsp;=\u0026thinsp;2) brushed independently. Six children (11.3%) did not brush their teeth at all.\u003c/p\u003e \u003cp\u003eMost children (64.2%, n\u0026thinsp;=\u0026thinsp;34) used children\u0026rsquo;s toothpaste, while 24.5% (n\u0026thinsp;=\u0026thinsp;13) used toothpaste formulated for adults. A small proportion (3.8%, n\u0026thinsp;=\u0026thinsp;2) used natural-based products, and another 3.8% used both children\u0026rsquo;s and adult toothpaste. Two children (3.8%) did not use toothpaste. Regarding awareness of toothpaste ingredients, 75.5% (n\u0026thinsp;=\u0026thinsp;40) of parents reported checking the composition of toothpaste, whereas 24.5% (n\u0026thinsp;=\u0026thinsp;13) did not. The majority of respondents (52.8%, n\u0026thinsp;=\u0026thinsp;28) replaced their child\u0026rsquo;s toothbrush every three months, while 37.7% (n\u0026thinsp;=\u0026thinsp;20) did so every six months. Only 3.8% (n\u0026thinsp;=\u0026thinsp;2) changed toothbrushes annually, and 5.7% (n\u0026thinsp;=\u0026thinsp;3) monthly. Despite the availability of electric toothbrushes, only one child (1.9%) used one.\u003c/p\u003e \u003cp\u003e Information about oral hygiene was obtained primarily through the internet or social networks (49.1%, n\u0026thinsp;=\u0026thinsp;26), followed by dental visits (22.6%, n\u0026thinsp;=\u0026thinsp;12). However, 15.1% (n\u0026thinsp;=\u0026thinsp;8) of parents had no information at all on how to properly brush their child\u0026rsquo;s teeth. A total of 69.8% (n\u0026thinsp;=\u0026thinsp;37) of children had been examined or treated by a dentist, while 30.2% (n\u0026thinsp;=\u0026thinsp;16) had never visited one. Among those who had visited a dentist, the most common reason was dental problems such as caries or plaque (37.7%, n\u0026thinsp;=\u0026thinsp;20), followed by acute dental pain (24.5%, n\u0026thinsp;=\u0026thinsp;13). Only 7.5% (n\u0026thinsp;=\u0026thinsp;4) reported routine check-ups. Sixteen parents (30.2%) had never sought dental care for their child.\u003c/p\u003e \u003cp\u003eWhen asked about the last dental visit, 22.6% (n\u0026thinsp;=\u0026thinsp;12) had last visited over a year ago, while 20.8% (n\u0026thinsp;=\u0026thinsp;11) visited six months ago. Smaller numbers had visited within the past four months. More than half of respondents (58.5%, n\u0026thinsp;=\u0026thinsp;31) reported significant problems during dental visits, including severe fear, restlessness, and the need for general anesthesia. As a result, only 39.6% (n\u0026thinsp;=\u0026thinsp;21) of children were successfully treated. Among those treated, 13 children required interventions such as physical restraint (n\u0026thinsp;=\u0026thinsp;7), general anesthesia (n\u0026thinsp;=\u0026thinsp;5), or sedation (n\u0026thinsp;=\u0026thinsp;6). A total of 11 children (20.8%) had previously undergone dental procedures under general anesthesia.\u003c/p\u003e \u003cp\u003eDental treatment was conducted in state clinics for 41.5% (n\u0026thinsp;=\u0026thinsp;22) of respondents and in private clinics for 28.3% (n\u0026thinsp;=\u0026thinsp;15); the remainder (30.2%, n\u0026thinsp;=\u0026thinsp;16) had not received treatment. Parents reported various ways they recognized dental issues in their children. The most common signs included putting fingers in the mouth or touching the cheeks (28.3%, n\u0026thinsp;=\u0026thinsp;15), visible cavities (15.1%, n\u0026thinsp;=\u0026thinsp;8), and complaints of pain (15.1%, n\u0026thinsp;=\u0026thinsp;8). A small number of parents noticed swelling or eating difficulties, while 9.4% (n\u0026thinsp;=\u0026thinsp;5) reported no dental problems.\u003c/p\u003e \u003cp\u003eOnly 17% (n\u0026thinsp;=\u0026thinsp;9) of children rinsed their mouths after meals, and 71.7% (n\u0026thinsp;=\u0026thinsp;38) consumed sweets between meals. Of these, 24.5% (n\u0026thinsp;=\u0026thinsp;13) consumed sweets daily or more often. Regarding the age at which oral care began, most parents initiated brushing at age three (28.3%, n\u0026thinsp;=\u0026thinsp;15), followed by age two (17.0%, n\u0026thinsp;=\u0026thinsp;9) and age one (15.1%, n\u0026thinsp;=\u0026thinsp;8). However, 9.4% (n\u0026thinsp;=\u0026thinsp;5) had never started oral care.\u003c/p\u003e \u003cp\u003eWhen asked about challenges and improvements in dental care, parents emphasized the need for treatment under anesthesia or sedation (18.9%, n\u0026thinsp;=\u0026thinsp;10), a more individualized approach (13.2%, n\u0026thinsp;=\u0026thinsp;7), improved access and financial support (11.3%, n\u0026thinsp;=\u0026thinsp;6), and better training for dental professionals (7.5%, n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e \u003cp\u003eSome of the results described above are visually represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which includes bar charts illustrating key indicators of oral hygiene practices. Additionally, a heat map was conducted to show the relationship between tooth brushing frequency and the likelihood of visiting a dentist (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These visualisations provided a clearer understanding of the patterns and correlations within the dataset, particularly highlighting the association between inadequate oral hygiene and reduced dental care utilization among children with ASD.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study highlight the significant challenges in maintaining oral health among children with autism in Kazakhstan. Despite a relatively high awareness of oral hygiene among parents, the implementation of effective oral care practices remains inconsistent. Most children required assistance with brushing, and a substantial proportion had never received dental care, which may contribute to the observed prevalence of dental issues.\u003c/p\u003e \u003cp\u003eThe mean DMFT/dmft index of 5.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05 was found to be higher than that reported in studies conducted in Italy by Bagattoni et al. (2021), where values of 3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 (primary dentition) and 2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 (permanent dentition) were observed in children with ASD (Bagattoni et al., 2021). Similarly, in the Turkish study by Oda et al. (2021), a lower mean DMFT/dmft score of 4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66 was reported, although the overall caries prevalence (81.9%) was comparable to that seen in the present cohort (Oda et al., 2021).\u003c/p\u003e \u003cp\u003ePoor oral hygiene was consistently observed across all dentition stages in this study, with mean OHI-S scores exceeding 3.9, indicating poor or very poor hygiene. These findings align with those of Ferrazzano et al. (2020), who in a systematic review highlighted poor oral hygiene, limited cooperation during oral care, and dietary factors as major contributors to caries and periodontal disease in children with ASD (Ferrazzano et al., 2021). In study using the mobile application \u0026ldquo;Marzhan tis\u0026rdquo;, a high prevalence of superficial (CAST 3: 1.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72) and deep caries (CAST 4: 1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03) was observed, consistent with the advanced lesion profiles described by Boss\u0026ugrave; et al. (2020), who reported that 66.38% of ASD children had caries, and over 79% had signs of gingivitis (Boss\u0026ugrave; et al., 2020) .\u003c/p\u003e \u003cp\u003e It has been noted that sensory processing difficulties, commonly reported in children with ASD, may explain avoidance of routine oral care. In line with prior work by Qiao et al. (2020), who linked sensory hypersensitivity to increased risk of halitosis and food impaction, the high mean number of decayed teeth (3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60) in the current study likely reflects resistance to brushing and infrequent dental visits (Qiao et al., 2020). Only a minority of children were reported to receive regular dental care, echoing findings from Oda et al. (2021) and Suhaib et al. (2019), where dental visit rates and daily brushing habits were notably low among ASD cohorts (e.g., only 9.6% brushed twice daily in the Turkish sample, and 62.7% had never visited a dentist (Oda et al., 2021); 8.6% brushed twice daily in Pakistan, and 82.7% required brushing assistance (Suhaib et al., 2019)).\u003c/p\u003e \u003cp\u003eParental involvement and education have also been emphasized in previous literature as modifiable factors. Suhaib et al. (2019) highlighted a strong link between maternal education and oral hygiene practices, and a similarly high proportion (82.7%) of ASD children in their study required assistance with brushing (Suhaib et al., 2019). In our cohort, inconsistent parental practices were also observed, suggesting that targeted caregiver education and behavioral interventions could serve as effective strategies for improving oral health outcomes.\u003c/p\u003e \u003cp\u003eTaken together, these findings reinforce the importance of early preventive strategies tailored to the ASD population. Sensory-adapted dental protocols, visual aids, and structured caregiver training should be prioritized. Despite regional and cultural differences, the evidence indicates that the barriers to oral care in ASD are consistent globally and must be addressed through interdisciplinary, individualized approaches.\u003c/p\u003e \u003cp\u003eBehavioral and communication barriers present equally significant challenges. Abstract instructions about proper brushing techniques often do not translate into effective practice for children with ASD. The global review by Lam et al. (2020) highlights that while ASD itself does not directly increase the risk of caries, these behavioral and hygiene challenges can lead to poorer outcomes. Visual supports, such as step-by-step picture guides, video modeling, and social stories, can effectively bridge this gap by providing clear and predictable routines(Lam et al., 2020). Additionally, the dental environment can be overwhelming for children with ASD due to its unfamiliarity and unpredictability, necessitating modifications like quiet waiting areas and structured appointment schedules.\u003c/p\u003e \u003cp\u003eSystemic gaps in dental care provision exacerbate these individual challenges. Many dental professionals lack training in ASD-specific care techniques, and traditional dental settings often do not accommodate sensory needs. This creates a cycle where negative experiences reinforce dental avoidance. Addressing the issue requires multifaceted interventions at both individual and systemic levels. Early and gradual introductions to the dental environment, through \"happy visits\" that focus solely on acclimation, can build positive associations before treatment needs arise. Home-based interventions should incorporate occupational therapy strategies to systematically address sensory aversions, utilizing tools like vibrating toothbrushes or flavored floss to increase tolerance.\u003c/p\u003e \u003cp\u003eAt the policy level, healthcare systems must prioritize accessible dental care for children with Autism Spectrum Disorder (ASD). This should include insurance coverage for extended behavioral management appointments, interdisciplinary care models that integrate dental professionals with ASD specialists, and mandatory training in neurodiversity-affirming care practices for dental students. Schools and community programs can further support these efforts by incorporating oral hygiene education into existing special education curricula and providing visual supports in classroom settings.\u003c/p\u003e \u003cp\u003eSeveral critical questions remain for future research. Longitudinal studies are necessary to evaluate the long-term impact of sensory-adapted dental interventions. Additionally, further exploration is needed to assess the effectiveness of these approaches across various cultural contexts and socioeconomic backgrounds. Research should also investigate the relationship between ASD-related dietary preferences and caries risk, as many children with ASD have specific food preferences that may affect their oral health.\u003c/p\u003e \u003cp\u003ePoor cooperation during dental procedures is a well-documented problem among children with ASD, and our data confirm this. Nearly 60% of parents reported major difficulties during dental visits, often requiring sedation, general anesthesia, or physical restraint. These findings are consistent with international literature, which emphasizes the heightened behavioral challenges faced by this population during oral examinations and treatments.\u003c/p\u003e \u003cp\u003eDietary habits also play a critical role in oral health, with over 70% of children consuming sweets between meals and only a minority rinsing their mouths afterward. Selective eating, common in children with ASD, can limit exposure to protective dietary elements and increase cariogenic risk.\u003c/p\u003e \u003cp\u003eAccess to dental care was another significant issue. Many parents reported long wait times, difficulty finding qualified professionals, and inadequate accommodations for sensory sensitivities. Furthermore, a lack of specialized training among general dentists may result in reduced willingness or ability to treat children with special needs. This is compounded by the absence of financial incentives for longer or more complex procedures in this patient population.\u003c/p\u003e \u003cp\u003eNotably, while many parents demonstrated an interest in proper dental care\u0026mdash;as reflected by checking toothpaste composition and replacing brushes regularly\u0026mdash;knowledge gaps persist. A sizeable portion of respondents relied on the internet rather than professional advice for information, and nearly one in six had no guidance on oral hygiene practices.\u003c/p\u003e \u003cp\u003eOverall, the study underscores a pressing need for targeted oral health education, caregiver support, and systemic improvements in dental service accessibility and training. Developing specialized programs tailored to the behavioral and sensory profiles of children with ASD is essential to improving oral health outcomes in this vulnerable group.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study reveal significant oral health challenges among children with autism spectrum disorder (ASD) in Almaty, Kazakhstan. The majority of children demonstrated inadequate oral hygiene practices, high consumption of cariogenic foods, and limited independent oral care skills. A substantial proportion had never received professional dental care, and those who had often encountered serious behavioral barriers, including fear, sensory sensitivity, and communication difficulties, which complicated both diagnosis and treatment. Children with autism are considered at high risk for dental caries due to their selective dietary habits and difficulties with oral hygiene routines, such as tooth brushing, which are often hindered by deficits in motor coordination.\u003c/p\u003e \u003cp\u003eParents expressed a general awareness of the importance of oral health, yet many lacked professional guidance or access to appropriately trained dental specialists. The study also highlights the structural limitations within the healthcare system, including a shortage of adapted services and insufficient training of dental professionals in managing children with special needs.\u003c/p\u003e \u003cp\u003eGiven the high burden of untreated dental conditions and the multifactorial barriers to care, there is a clear and urgent need for targeted oral health education for parents, the integration of behaviorally sensitive dental practices, and the development of specialized training programs for dental providers. Establishing multidisciplinary, autism-friendly dental services and improving access to preventive care can significantly enhance the oral health and overall quality of life of children with ASD in Kazakhstan.\u003c/p\u003e \u003cp\u003eIn conclusion, improving oral health outcomes for children with ASD requires a comprehensive approach that addresses sensory, behavioral, and systemic barriers. Through clinical adaptations, caregiver education, and policy reforms, we can create an oral healthcare system that meets the unique needs of neurodiverse children. Future efforts should concentrate on developing evidence-based, scalable interventions and ensuring their implementation across diverse care settings to achieve equitable oral health for all children with ASD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eTo the Ministry of Science and Higher Education of the Republic of Kazakhstan\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlHumaid, J., Gaffar, B., AlYousef, Y., Alshuraim, F., Alhareky, M., \u0026amp; El Tantawi, M. (2020). Oral Health of Children with Autism: The Influence of Parental Attitudes and Willingness in Providing Care. \u003cem\u003eTheScientificWorldJournal\u003c/em\u003e, \u003cem\u003e2020\u003c/em\u003e(101131163), 8329426. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2020\u0026gt;. https://doi.org/10.1155/2020/8329426\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlshatrat, S. 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A., \u0026amp; Omar, T. (2014). Oral health status and behaviours of children with Autism Spectrum Disorder: A case\u0026ndash;control study. \u003cem\u003eInternational Journal of Paediatric Dentistry\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(4), 314\u0026ndash;323. https://doi.org/10.1111/ipd.12067\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrazzano, G. F., Salerno, C., Bravaccio, C., Ingenito, A., Sangianantoni, G., \u0026amp; Cantile, T. (2021). Autism spectrum disorders and oral health status: Review of the literature. \u003cem\u003eEuropean Journal of Paediatric Dentistry\u003c/em\u003e, \u003cem\u003e1\u003c/em\u003e, 9\u0026ndash;12. https://doi.org/10.23804/ejpd.2020.21.01.02\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForos, P., Oikonomou, E., Koletsi, D., \u0026amp; Rahiotis, C. (2021). Detection Methods for Early Caries Diagnosis: A Systematic Review and Meta-Analysis. \u003cem\u003eCaries Research\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e(4), 247\u0026ndash;259. https://doi.org/10.1159/000516084\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGudipaneni, R. K., Alkuwaykibi, A. S., Ganji, K. K., Bandela, V., Karobari, M. I., Hsiao, C.-Y., Kulkarni, S., \u0026amp; Thambar, S. (2022). Assessment of caries diagnostic thresholds of DMFT, ICDAS II and CAST in the estimation of caries prevalence rate in first permanent molars in early permanent dentition\u0026mdash;A cross-sectional study. \u003cem\u003eBMC Oral Health\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 133. https://doi.org/10.1186/s12903-022-02134-0\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbragimova, R., Yermukhanova, G., Yessirkepov, A., Xetayeva, G., \u0026amp; Yerkibayeva, Z. (2023). Relationship between pathogenic factors and the prevalence of temporomandibular joint dysfunctions in children. \u003cem\u003eThe Saudi Dental Journal\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(1), 103\u0026ndash;109. https://doi.org/10.1016/j.sdentj.2022.12.007\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaber, M. A. (2011). Dental caries experience, oral health status and treatment needs of dental patients with autism. \u003cem\u003eJournal of Applied Oral Science : Revista FOB\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(3), 212\u0026ndash;217. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2010 to 2011\u0026gt;. https://doi.org/10.1590/s1678-77572011000300006\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaber, M. A., Sayyab, M., \u0026amp; Abu Fanas, S. H. (2011). Oral health status and dental needs of autistic children and young adults. \u003cem\u003eJournal of Investigative and Clinical Dentistry\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(1), 57\u0026ndash;62. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2010 to 2011\u0026gt;. https://doi.org/10.1111/j.2041-1626.2010.00030.x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLam, P. P., Du, R., Peng, S., McGrath, C. P., \u0026amp; Yiu, C. K. (2020). Oral health status of children and adolescents with autism spectrum disorder: A systematic review of case-control studies and meta-analysis. \u003cem\u003eAutism\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(5), 1047\u0026ndash;1066. https://doi.org/10.1177/1362361319877337\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeal, S. C., Ribeiro, A. P. D., \u0026amp; Frencken, J. E. (2017). Caries Assessment Spectrum and Treatment (CAST): A Novel Epidemiological Instrument. \u003cem\u003eCaries Research\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(5), 500\u0026ndash;506. https://doi.org/10.1159/000479042\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoo, C. Y., Graham, R. M., \u0026amp; Hughes, C. V. (2008). The caries experience and behavior of dental patients with autism spectrum disorder. \u003cem\u003eJournal of the American Dental Association (1939)\u003c/em\u003e, \u003cem\u003e139\u003c/em\u003e(11), 1518\u0026ndash;1524. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2008 to 2009\u0026gt;. https://doi.org/10.14219/jada.archive.2008.0078\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakkar, A., Indushekar, K. R., Saraf, B. G., Sardana, D., \u0026amp; Sheoran, N. (2019). A cross sectional study to evaluate the oral health status of children with intellectual disabilities in the National Capital Region of India (Delhi-NCR). \u003cem\u003eJournal of Intellectual Disability Research\u003c/em\u003e, \u003cem\u003e63\u003c/em\u003e(1), 31\u0026ndash;39. https://doi.org/10.1111/jir.12553\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOda, G., Karayagmurlu, A., Dagli, I., Aren, G., \u0026amp; Soylu, N. (2021). Oral Health Status in Children with Autism Spectrum Disorder: A Cross Sectional Study from Turkey. \u003cem\u003ePsychiatry and Behavioral Sciences\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(3), 186. https://doi.org/10.5455/PBS.20210321075312\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnol, S., \u0026amp; Kirzioglu, Z. (2018). Evaluation of oral health status and influential factors in children with autism. \u003cem\u003eNigerian Journal of Clinical Practice\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(4), 429\u0026ndash;435. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2018\u0026gt;. https://doi.org/10.4103/njcp.njcp_41_17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePi, X., Liu, C., Li, Z., Guo, H., Jiang, H., \u0026amp; Du, M. (2020). A Meta-Analysis of Oral Health Status of Children with Autism. \u003cem\u003eThe Journal of Clinical Pediatric Dentistry\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(1), 1\u0026ndash;7. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2020\u0026gt;. https://doi.org/10.17796/1053-4625-44.1.1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrynda, M., Pawlik, A. A., Emich-Widera, E., Kazek, B., Mazur, M., Niemczyk, W., \u0026amp; Wiench, R. (2025). Oral Hygiene Status in Children on the Autism Spectrum Disorder. \u003cem\u003eJournal of Clinical Medicine\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(6), 1868. https://doi.org/10.3390/jcm14061868\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQiao, Y., Shi, H., Wang, H., Wang, M., \u0026amp; Chen, F. (2020). Oral Health Status of Chinese Children With Autism Spectrum Disorders. \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 398. https://doi.org/10.3389/fpsyt.2020.00398\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapira, J., Mann, J., Tamari, I., Mester, R., Knobler, H., Yoeli, Y., \u0026amp; Newbrun, E. (1989). Oral health status and dental needs of an autistic population of children and young adults. \u003cem\u003eSpecial Care in Dentistry : Official Publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(2), 38\u0026ndash;41. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;1988 to 1995\u0026gt;. https://doi.org/10.1111/j.1754-4505.1989.tb01022.x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuhaib, F., Saeed, A., Gul, H., \u0026amp; Kaleem, M. (2019). Oral assessment of children with autism spectrum disorder in Rawalpindi, Pakistan. \u003cem\u003eAutism\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 81\u0026ndash;86. https://doi.org/10.1177/1362361317730299\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVishnu Rekha, C., Arangannal, P., \u0026amp; Shahed, H. (2012). Oral health status of children with autistic disorder in Chennai. \u003cem\u003eEuropean Archives of Paediatric Dentistry : Official Journal of the European Academy of Paediatric Dentistry\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(3), 126\u0026ndash;131. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2012\u0026gt;. https://doi.org/10.1007/BF03262858\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eWorld Health Organization (WHO). Autism Spectrum Disorders \u0026amp; Other Developmental Disorders: From Raising Awareness to Building Capacity; WHO: Geneva, Switzerland, 2013; Metting Report; Available online: Https://apps.who.int/iris/handle/10665/103312 (accessed on 25 March 2020).\u003c/em\u003e (n.d.).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, Y., Lin, L., Liu, J., Shi, L., \u0026amp; Lu, J. (2020a). Dental Caries Status in Autistic Children: A Meta-analysis. \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(4), 1249\u0026ndash;1257. Ovid MEDLINE(R)\u0026thinsp;\u0026lt;\u0026thinsp;2020\u0026gt;. https://doi.org/10.1007/s10803-019-04256-x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, Y., Lin, L., Liu, J., Shi, L., \u0026amp; Lu, J. (2020b). Dental Caries Status in Autistic Children: A Meta-analysis. \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(4), 1249\u0026ndash;1257. https://doi.org/10.1007/s10803-019-04256-x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou, N., Wong, H. M., \u0026amp; McGrath, C. (2020). Social story-based oral health promotion for preschool children with special healthcare needs: A 24‐month randomized controlled trial. \u003cem\u003eCommunity Dentistry and Oral Epidemiology\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e(5), 415\u0026ndash;422. https://doi.org/10.1111/cdoe.12554\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eТable 1 CAST codes and description\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCode\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo visible evidence of a distinct carious lesion is present\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSealant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePits and/or fissures are at least partially covered with a sealant material\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRestoration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA cavity is restored with an (in)direct restorative material\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEnamel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistinct visual change in enamel only; a clear caries-related discolouration is visible, with or without\u0026nbsp;\u003c/p\u003e\n \u003cp\u003elocalised enamel breakdown\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDentine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInternal caries-related discolouration in dentine; the discoloured dentine is visible through the enamel,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ewhich may or may not exhibit a visible localised breakdown\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistinct cavitation into dentine; the pulp chamber is intact\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePulp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInvolvement of the pulp chamber; distinct cavitation reaching the pulp chamber, or only root fragments\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eare present\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbscess/fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA pus-containing swelling or a pus-releasing sinus tract related to a tooth with pulpal involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe tooth has been removed because of dental caries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDoes not match with any of the other descriptions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eТ\u003c/strong\u003e\u003cstrong\u003eable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eComparative Analysis of OHI-S index\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMilky bite\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChangeable bite\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermanent bite\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean index value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026plusmn;0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHygiene level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery poor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Asfendiyarov Kazakh National Medical University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"autism spectrum disorder, children, oral health, dental care, Kazakhstan, dental behavior management","lastPublishedDoi":"10.21203/rs.3.rs-6682941/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6682941/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eThis study aimed to evaluate the oral health status and hygiene practices of children with autism spectrum disorder (ASD) in Almaty, Kazakhstan, and to assess parental awareness regardingtheir children’s oral care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e The study was conducted involving 53 children aged 3 - 18 years with a confirmed ASD diagnosis, recruited from the “Autism Pobedim” rehabilitation center in Almaty. Clinical examinations assessed caries using the DMFT/dmft, CAST indices, and oral hygiene using the OHI-S index. A 36-item parental questionnaire collected information on children’s oral hygiene routines, dental care experiences, and behavioral characteristics.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e The study revealed inadequate oral hygiene practices, with only 24.5% of children brushing their teeth twice daily. Most children relied on parental assistance for brushing. Notably, 30.2% had never visited a dentist, and among those who had, 58.5% exhibited behavioral difficulties requiring sedation, restraint, or general anesthesia. Only 39.6% of dental visits resulted in completed treatment. Dietary habits were unfavorable, with 71.7% of children consuming sweets between meals and just17% rinsing their mouths after eating. While 75.5% of parents were aware of toothpaste composition, there was limited professional guidance and a lack of adapted dental services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/em\u003e Children with ASD in Almaty showed a high prevalence of dental caries, limited independent oral hygiene, and significant challenges accessing effective dental care. These findings highlight the urgent need for specialized dental care protocols and public health strategies tailored to the needs of children with ASD in Kazakhstan.\u003c/p\u003e","manuscriptTitle":"Oral Health Status in Children with Autism Spectrum Disorder in Almaty, Kazakhstan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-22 13:15:24","doi":"10.21203/rs.3.rs-6682941/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b23d8568-26e2-425e-94c3-7098e7f5d53f","owner":[],"postedDate":"May 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48653490,"name":"Dentistry"},{"id":48653491,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-05-22T13:15:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-22 13:15:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6682941","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6682941","identity":"rs-6682941","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}