Association Between Feeding Problems and Oral Health Status in Children with Autism Spectrum Disorder

Oral Hygiene Status in Children on the Autism Spectrum Disorder

Background/Objectives: Children with autism spectrum disorder (ASD) often face challenges in maintaining oral hygiene due to sensory sensitivities, behavioral difficulties, and limited access to specialized dental care. This study aimed to assess the oral hygiene status of children with ASD and compare it with neurotypical peers. Methods: A cross-sectional study was conducted with 74 children with ASD and 74 neurotypical children. Dental exams measured oral hygiene and caries prevalence using the DMFT/dmft, Oral Hygiene Index (OHI), and Sulcus Bleeding Index (SBI). Tooth brushing frequency and dental visits were also recorded. Statistical analysis was performed using the Mann-Whitney U test and Fisher's exact test. Results: Children with ASD had significantly poorer oral hygiene and higher caries rates compared to controls. Boys with ASD had higher DMFT scores, indicating more caries. Additionally, ASD children brushed their teeth less often and had fewer dental visits. Preventive treatments were underutilized in this group despite a higher need. Conclusions: Children with ASD face notable oral health challenges, including poor hygiene, higher caries prevalence, and limited preventive care. These findings highlight the need for tailored interventions, improved parental education, and specialized dental care strategies for this population.

Level of support/commitment and behavior during mealtime and dental care negatively impact the dental caries prevalence in autistic individuals: cross-sectional study

OBJECTIVE

To verify whether factors associated with Autism Spectrum Disorder (ASD) would have impact on the dental-caries prevalence.

MATERIALS AND METHODS

All ASD-individuals receiving care in a specialized center with minimum of 4y old were recruited. Demographic, socioeconomic and behavioral characteristics, level of support/commitment (Childhood Autism Rating Scale), mealtime behavior (Brief Autism Mealtime Behavior Inventory) and medication use were answered by ASD-individual's parents. Behavior during dental care was evaluated from Frankl scale. Dental-caries prevalence was the primary outcome. Three examiners calibrated/trained collected the data. Chi-square test was used to compare the variables impact on the dental-caries prevalence.

RESULTS

61 ASD-individuals were potentially eligible, and the all parents/guardians consent to participate. Dental-caries prevalence was 42.9%, which was statistically associated with lower toothbrushing frequency, higher level of support/commitment, and worse behavior at meals and during in dental care. Dental-caries prevalence was approximately higher twice in ASD-individuals: (i) uncooperative with dental care when compared those cooperative (62% versus 32%, respectively); (ii) with severe level of support when compared to those with mild/moderate level (58% versus 28%, respectively); and (iii) with worse mealtime behavior when compared to those with better behavior (59% versus 28%, respectively). A medium statistical correlation was observed between support level and mealtime behavior (rS=0.39). The BAMBI component statistically associated with dental-caries prevalence was the food refusal (capture problem when a child rejects a presented food, crying, spitting out food).

CONCLUSION

higher required level of support, worse mealtime behavior and uncooperative profile in dental care negatively affect the dental-caries prevalence.

CLINICAL RELEVANCE

our findings provide evidence of the need of specialized, preventive and individualized dental care among ASD-individuals.

Cross-bite and oral habits among Albanian autistic children according to the stages of occlusal development

This study had two aims. First, we aimed to investigate the prevalence of ACB, PCB, and oral habits among a group of Albanian children with ASD compared with a group of children without ASD. Second, we aimed to identify the associations of ASD with ACB, PCB, and oral habits. The sample inlcuded 125 children with ASD (91 males, 34 females) from 2 special schools for children with disabilities and 2 daily residential centers in Tirana. The control group included 125 children without ASD. The relationships between categorical variables were evaluated via the chi-square test. To identify the potential risk factors for ASD, we performed binary logistic regression. No statistically significant differences were found for CB or oral habits between the primary and adolescent dentition stages. A comparison of children with ASD with CB and oral habits revealed a significant difference in the prevalence of PCB. Binary logistic regression revealed that ACB, PCB and oral habits were not associated with ASD. CB was more prevalent among children with ASD in the primary and mixed dentition stages. Oral habits were more prevalent in the mixed and adolescent dentition stages. However, ASD is not a risk factor for CB or other oral habits.

Autistic individuals have worse oral status than neurotypical controls: a systematic review and meta-analysis of observational studies

OBJECTIVE

To compare dental caries, oral hygiene, periodontal status, bruxism, malocclusion, tooth loss, and salivary alterations between autistic and typical developing individuals.

MATERIAL AND METHODS

Observational studies presenting clinical measures of oral outcomes between autism spectrum disorder (ASD) individuals and controls. EMBASE, LILACS, PubMed, PsycINFO, Scopus, Web of Science, Google Scholar, and ProQuest were searched up to June 26, 2023. Pairs of reviewers independently conducted study selection, data extraction, and assessments of methodological quality and certainty of evidence. Meta-analyses of standardized mean differences (SMD) and risk ratio (RR) were performed.

RESULTS

A total of 47 studies comprising 6885 autistic individuals were included in the review. Autistic individuals had significantly higher severity of dental-caries experience in primary teeth (SMD 0.29, 95%CI 0.02, 0.56), of dental plaque presence (SMD 0.59, 95%CI 0.24, 0.94), and of gingivitis (SMD 0.45, 95%CI 0.02, 0.88). Autistic individuals showed higher probability of occurrence of gingivitis (RR 1.34, 95%CI 1.08, 1.66,), bruxism (RR 4.23, 95%CI 2.32, 7.74), overjet (RR 2.16, 95%CI 1.28, 3.64), overbite (RR 1.62, 95%CI 1.02, 2.59), crossbite (RR 1.48, 95%CI 1.02, 2.13), and openbite (RR 2.37, 95%CI 1.46, 3.85), when compared to neurotypical individuals. Most estimates showed a small effect size with very low certainty of evidence.

CONCLUSION

Autistic individuals show worse oral health status than controls.

CLINICAL RELEVANCE

The findings reported herein can help to build health policies to better serve autistic individuals including prevention actions and access to specialized dental care.

Food selectivity and neophobia in children with autism spectrum disorder and neurotypical development: a systematic review

CONTEXT

Individuals with autism spectrum disorder (ASD) have common eating problems, including food refusal, dietary restrictions, and behavioral problems during eating.

OBJECTIVE

The aim of this systematic review was to find more clear evidence on the relationship between food selectivity or food neophobia (FN) and ASD in children up to age 14 years. The PECO-based question was: Are food selectivity and FN behaviors more prevalent in children with ASD than in children with neurotypical development (NTD)?, in which the P is children, E is ASD, C is children with NTD, and O is food selectivity and FN.

DATA SOURCES

Clinical studies in the databases PubMed, Embase and Web of Science, comparing children with ASD and those with NTD, were reviewed from October 1966 to October 2021.

STUDY SELECTION AND DATA EXTRACTION

A total of 122 studies were analyzed for summary reading, and only 17 of these were included in the descriptive qualitative analysis. In 9 studies, the analysis of food selectivity was performed via a questionnaire.

RESULTS

The results showed that children with ASD are more selective than those with NTD. Four studies evaluated FN through scales; however, only 2 found higher levels of FN in the ASD group than in children with NTD. The sensory profile was measured using questionnaires in 9 studies, and we found that altered sensory processing is more common in children with ASD.

CONCLUSION

Children with ASD present greater food selectivity than children with NTD. However, the occurrence of FN was higher in only 50% in which FN was investigated, which points to a need for studies that compare FN between siblings with ASD and those with NTD in the same family nucleus. In addition, atypical oral sensitivity seems to be a sensory characteristic most related to eating disorders.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021247880.

Saliva based diagnostic methodologies for a fast track detection of autism spectrum disorder: A mini-review

Autism spectrum disorder (ASD) is considered a complicated neurodevelopment disorder with rising prevalence globally. ASD is characterized by a series of events including varying degrees of defects in communication, learning, and social interaction which is accompanied by stereotypical behavioral patterns. Despite extensive research, the current diagnosis for ASD is complex and almost solely based on the behavioral assessments of the suspected individuals. The multifactorial etiopathology of this disease along with the diversity of symptoms among different individuals adds to the current intricacies for accurate prognosis of ASD. Hence, there exists a dire need for biologically relevant biomarkers for an early diagnosis and for tracking the efficacy of therapeutic interventions. Until recently, among various biofluids, saliva has gained increasing interest for biomarker identification, the advantages include the non-invasive nature and ease of sample handling. This mini-review aims to provide a succinct summary of recent literature on saliva-based diagnostic modalities for ASD, examine various studies that highlight the potential use of proteomic and/or RNA-based biomarkers. Finally, some conclusive perspectives of using the salivary system for ASD mechanistic details and diagnosis are also discussed.

Malocclusion characteristics amongst individuals with autism spectrum disorder: a systematic review and meta-analysis

BACKGROUND

To estimate the prevalence of malocclusion in individuals with autism spectrum disorders (ASD) and to assess the relationship between ASD and malocclusion.

METHODS

We searched electronic databases including PubMed, Scopus, Web of Science, Cochrane, Embase, SciELO LILACS, Proquest, OpenGrey and Google Scholar. There were no language or publication dates restrictions. Two researchers independently performed selection, data extraction and quality assessment. Quality assessment and risk of bias were evaluated through the Newcastle-Ottawa scale and ROBINS-E tool. Meta-analyses using random effect models were used to estimate pooled measures of prevalence of malocclusion characteristics in individuals with ASD and pooled odds ratio (OR) on the relationship between ASD and malocclusion characteristics. Subgroup meta-analyses were conducted according to children and adolescents, history of orthodontic treatment, and occurrence of other syndromes and medical conditions.

RESULTS

Searching identified 5549 papers with 238 were selected for full assessment. Eighteen cross-sectional studies were included according to inclusion criteria. Of them, eleven studies were considered of moderate quality. A judgement of critical risk of bias occurred for thirteen studies. The most prevalent malocclusion characteristics in individuals with ASD were crowding (33%; 95% CI 22 to 44%) and increased maxillary overjet (39%; 95% CI 23 to 54%). Individuals with ASD had higher odds of Angle's Class II (OR 1.92; 95% CI 1.36 to 2.72), Angle's Class III (OR 2.33; 95% CI 1.29 to 4.23), open bite (OR 1.96; 95% CI 1.21 to 3.16), and increased maxillary overjet (OR 1.53; 95% CI 1.06 to 2.21) than individuals without ASD.

CONCLUSIONS

Angle's Class II, Angle's Class III, anterior open bite and increased maxillary overjet were more prevalent in individuals with ASD than those without ASD. Further high-quality studies are needed.

Autistic spectrum disorder children and adolescents' oral health characteristics - scoping review

This study aimed to conduct a scoping review to know children and adolescents' main oral health concerns with Autism Spectrum Disorder (ASD) and thus identify any oral characteristic that stands out, aiming at preventive and interceptive clinical conduct. A search was performed in the three electronic databases and the gray literature; in September 2021. A total of 562 studies were identified, and after applying the eligibility criteria, 73 articles were included in the synthesis of this scoping review. The mean decayed, lost, and restored teeth index (DMFT/dfmt) ranged from 0 to 12.37; the mean DMFT index (permanent dentition) from 0.06 to 6.2; and the average dmft index (deciduous dentition) ranged from 0.29 to 9.91. The mean simplified oral hygiene index (OHIS) ranged from 0 to 3.4; gingival index (GI) from 0.29 to 2; and plaque index (PI) from 0.005 to 3.15. Plaque prevalence was 25.9% to 90%; dental calculus from 4.7% to 59.41%; gingivitis from 36.7% to 100%. Bruxism was 10.3% to 73%, and dental trauma was 4.7% to 100%. This disparity in the results shows the heterogeneity of this population, with different degrees of socio-behavioral impairment, which can directly influence oral hygiene and the consequent accumulation of biofilm.

Autism Spectrum Disorders and Malocclusions: Systematic Review and Meta-Analyses

Studies heretofore have shown inconsistent results on the link of ASD to malocclusion. Herein, we aimed to compare the prevalence of malocclusion among children and adolescents with ASD compared with non-ASD healthy counterparts through a systematic review. The electronic search focused on five databases, PubMed, Web of Science, EMBASE, LILACS, and OpenGrey until January 2022, and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO No. CRD42022298023). Observational and intervention studies that compared occlusion characteristics of ASD individuals under 18 years old with healthy controls were included. Pairwise random effects meta-analyses of odds ratio (OR) were performed. Methodological quality was assessed by using the Joanna Briggs Institute Critical Appraisal Checklist for cross-sectional studies. A total of thirteen studies were included for qualitative analysis, and seven for quantitative analysis. The results presented a great heterogeneity and moderate risk of bias; thus, it was not possible to state that there is a risk of malocclusion in individuals with ASD. Future studies should be carried out with strict criteria in the choice of samples, control group, and diagnosis of malocclusion in order to meet the necessary requirements for greater methodological quality.

Food selectivity, nutritional inadequacies, and mealtime behavioral problems in children with autism spectrum disorder compared to neurotypical children

OBJECTIVE

To evaluate body composition, nutritional status through food selectivity and degree of inadequate intake, and mealtime behavior in children with autism spectrum disorder (ASD) compared to neurotypical children.

METHOD

A cross-sectional case-control study was carried out in 144 children (N = 55 with ASD; N = 91 with neurotypical children) between 6 and 18 years of age. Body composition, nutritional intake, food consumption frequency (FFQ), and mealtime behavior were evaluated.

RESULTS

Results showed a greater presence of children with a low weight (18.4% ASD vs. 3.20% comparison group) and obesity (16.3% ASD vs. 8.6% comparison group) in the ASD group for body mass index (BMI) categories (p = .003; number needed to take [NNT] = 8.07). The presence of obesity in ASD children compared to the comparison group was even higher when considering the fat component (47.5% ASD vs. 19.4% comparison group, p = .002; NNT = 10.3). ASD children had greater intake inadequacy (50% ASD vs. 22% comparison group, p = .014; NNT = 3.58), high food selectivity by FFQ (60.6% ASD vs. 37.9% comparison group, p < .037; NNT = 4.41), and more eating problems (food rejection, limited variety, disruptive behavior), compared to neurotypical children (p = .001).

CONCLUSION

Children with ASD showed an unbalanced body composition toward both underweight and obesity, a greater degree of inadequate intake, high food selectivity as indicated by their consumption frequency, and more disturbed eating behavior than children with neurotypical development. We suggest monitoring nutritional inadequacies and implementing nutritional strategies to expand the variety of foods children with ASD consume.

Potential of Salivary Biomarkers in Autism Research: A Systematic Review

The diagnostic process for autism spectrum disorders (ASD) is based on a behavioral analysis of the suspected individual. Despite intensive research, no specific and valid biomarker has been identified for ASD, but saliva, with its advantages such as non-invasive collection, could serve as a suitable alternative to other body fluids. As a source of nucleic acid of both human and microbial origin, protein and non-protein molecules, saliva offers a complex view on the current state of the organism. Additionally, the use of salivary markers seems to be less complicated not only for ASD screening but also for revealing the etiopathogenesis of ASD, since enrolling neurotypical counterparts willing to participate in studies may be more feasible. The aim of the presented review is to provide an overview of the current research performed on saliva in relation to ASD, mutual complementing, and discrepancies that result in difficulties applying the observed markers in clinical practice. We emphasize the methodological limitations of saliva collection and processing as well as the lack of information regarding ASD diagnosis, which is critically discussed.

Eating Behaviors and Diet Quality in Chinese Preschoolers with and without Autism Spectrum Disorder: A Case-Control Study

OBJECTIVES

To compare mealtime behaviors and diet quality in Chinese preschoolers with autism spectrum disorder (ASD) and typically developing preschoolers in Hong Kong.

STUDY DESIGN

This case-control study included a community sample of 65 families with preschoolers with ASD aged 3-6 years and 65 families with typically developing preschoolers matched for age and sex. Preschoolers' eating behaviors were assessed using the Brief Autism Mealtime Behaviour Inventory and the Preschoolers' Eating Behaviour Questionnaire (CPEBQ). Preschoolers' usual diet and nutrient intake were assessed using a validated food frequency questionnaire. Diet quality and diversity were generated using the Chinese Children Dietary Index total score and diet variety score. Between-group differences in various scales and dietary variables were examined using multivariate linear or logistics regression models adjusting for baseline demographic differences.

RESULTS

Compared with the typically developing group, the ASD group had greater scores in the Brief Autism Mealtime Behaviour Inventory food refusal domain (P < .001), the CPEBQ food fussiness (P = .001) and eating habit (P = .001) domains, and lower CPEBQ exogenous eating score (P = .003) and initiative eating score (P < .001). The Chinese Children Dietary Index total score (P = .001) and diet variety score (P = .005) and intake of soy and soy products (P = .001) were lower in the ASD group compared with the typically developing group.

CONCLUSIONS

Preschoolers with ASD showed more eating and mealtime problems, and lower diet quality and diversity than their typically developing counterparts. Our findings highlight the need for regular monitor and early identification of mealtime behavioral and nutrition problems among preschoolers with ASD.

Dietary Sugar Exposure and Oral Health Status in Children with Autism Spectrum Disorder: A Case-control Study

This case-control study compared dietary sugar exposure and oral health status between children with and without Autism Spectrum Disorder (ASD), aged 5-12 years (n = 136, each). Data regarding socio-demographics, child's oral hygiene practices and behavior, diet-related behavior, oral habits and dental trauma were obtained. Child's diet on the previous day was recorded using 24-h recall method and sugar exposure was calculated using Dental Diet Diary (D3) mobile application. Oral Hygiene Index-Simplified (OHI-S), deft and DMFT were recorded. Results showed no significant differences in sugar exposure, deft and DMFT between the groups. Although oral hygiene practices were significantly better in children with ASD, their OHI-S was significantly worse. Significantly more children with ASD reported mouth-breathing, bruxism and self-injurious habits.

Toothbrushing in children with autism spectrum disorders: qualitative analysis of parental difficulties and solutions in France

PURPOSE

The oral care of a child with autism spectrum disorders (ASD) is a challenge, not only for dentists, but also for parents. The objective of this study was to evaluate the difficulties encountered by parents in maintaining oral hygiene in autistic children and the solutions they found to facilitate this daily act.

METHODS

A questionnaire with closed and open questions about characteristics of the child and oral health at home, conducted via Google Form, was sent to French families through 301 associations of parents with autistic children. For the quantitative analysis, logistic regression was used. The open answers were analysed by theme.

RESULTS

This study included 756 offspring aged 14.4 (± 8.1) years. Girls were 1.7 (95% CI: 1.1-2.8) times more likely to have toothbrushing difficulty than boys. Nonverbal patients (OR:3.2; 95% CI: 2.2-4.9), autistic patients (OR:2.8; 95% CI: 1.4-5.2), patients using pictograms (OR:1.6; 95% CI: 1.1-2.4), and younger children (OR:0.9; 95% CI: 0.9-0.9) were significantly more likely to encounter difficulties in tolerating toothbrushing. The qualitative analysis showed that parents used three main ways to facilitate toothbrushing: planning, modelling and making it enjoyable. Seventy-nine percent of parents did not feel sufficiently informed about the different oral hygiene prevention tools and techniques for their ASD children and would like to be educated in the daily management of oral hygiene.

CONCLUSION

The role of parents remains essential and professionals should work in collaboration with them.

Exploring Eating Challenges and Food Selectivity for Latinx Children with and without Autism Spectrum Disorder Using Qualitative Visual Methodology: Implications for Oral Health

Diet and food choices significantly impact teeth, including enamel quality and development of dental caries. However, studies focusing on diet and its relation to oral care in Latinx children with and without Autism Spectrum Disorders (ASD) have been minimally addressed in research. This qualitative study used an inclusive visual methodology to explore what Latinx caregivers learned about their child's diet preferences and food routines in relation to their oral health. As a secondary aim, the study sought to explore whether notable differences in diet emerged between Latinx children with and without ASD. Participants were 32 Latinx caregivers from 18 families with children with and without Autism (n = 8 with a typically developing child and n = 10 with a child with ASD) who completed a food journal activity and photo elicitation interview. Interviews were thematically coded for themes pertaining to parents' perceptions of their child's diet and oral health. Findings of this study indicate that the process of taking photos helped Latinx caregivers to better situate the barriers and behaviors influencing everyday food routines in their children within the context of relating to their overall oral health. Via their active participation in the research process, parents were empowered to note strategies they could employ that would directly impact their child's oral health outcomes, such as reducing juice intake and monitoring sugar consumption. Therefore, visual research methodologies are an important strategy for researchers to consider in order to empower participants to be part of the research process and part of the outcomes, and to offer better understanding of the lived experience of populations underrepresented in the literature, such as Latinx children with and without ASD and their families.

Correlates of Feeding Difficulties Among Children with Autism Spectrum Disorder: A Systematic Review

Feeding difficulties related to selective intake, or eating a limited variety of foods, are very common in children with autism spectrum disorder (ASD). A systematic search of PubMed, Embase, PsycInfo, and CINAHL identified 29 studies that evaluated eight correlates: age, ASD symptoms and severity, cognitive and adaptive skills, sensory processing and perception, challenging behavior, weight status, gastrointestinal symptoms, and parenting stress. Feeding difficulties related to selective intake are consistently correlated with impaired sensory processing and perception and tend to be positively associated with rigidity and challenging behavior. These feeding difficulties tend to persist with advancing age. Other correlates demonstrated inconsistent findings. A significant limitation of research reviewed is variability in terminology, definitions, and measurement of feeding difficulties.

Detecting Feeding Problems in Young Children with Autism Spectrum Disorder

Feeding problems are prevalent in children with ASD. We investigated whether the Montreal Children’s Hospital Feeding Scale (MCH-FS, Ramsay et al. in Pediatrics and Child Health 16:147–151, 2011) can be used for young children with ASD. Participants (1–6 years) were selected from a clinical ASD sample (n = 80) and a general population sample (n = 1389). Internal consistency was good in both samples. In general, parents of children with ASD reported more feeding problems than those from the population sample. The response patterns on the individual items was highly similar. There was a slight increase in symptoms with age in the population sample, but not in the ASD sample. These results suggest that the MCH-FS can be used in populations that include children with ASD.

Oral Health Status of Chinese Children With Autism Spectrum Disorders

OBJECTIVES

To assess and compare the oral health status of children with and without autism spectrum disorders (ASD) in China.

METHODS

This study recruited 144 children with ASD and 228 unrelated children with typical development (TD) aged 3-16 years from China. Data were collected using parent-reported questionnaires. Oral problems (oral symptoms and habits), oral health measures (oral hygiene practice and dental care experience), and the impact on the child's quality of life (based on a modified version of the Parental-Caregiver Perception Questionnaire) were assessed and compared between the two groups.

RESULTS

Children with ASD had worse oral health status than children with TD. Oral symptoms were more prevalent in the ASD group, especially halitosis (p < 0.001), food impaction (p < 0.001), and oral lesions (p < 0.001), than the TD group. The rate of damaging oral habits, including mouth breathing (p < 0.001) and object biting (p < 0.05), was also high in the ASD group. Compared with the TD group, more children with ASD did not brush their teeth independently and frequently (p < 0.001), had difficulty accessing dental care (p < 0.01), and reported unpleasant dental experiences (p < 0.001). The presence of ASD was associated with decreased oral health-related quality of life (p < 0.001) in these children and their families.

CONCLUSION

Oral problems such as halitosis and bad oral habits are more prevalent among children with ASD. These children also lack oral hygiene practice and dental visits. This situation negatively impacts their quality of life, and must be brought to the attention of their treating dentists.

Comparative Evaluation of Oral Health Status in Healthy Children and Children with Autism Spectrum Disorder

Objective Autism spectrum disorder (ASD) is regarded a severe neuropsychiatric disorder. The objective of this study was to compare the status of the oral health between children with and without ASDs.

Methods A total of 95 children (44 with ASD and 51 without ASD) were included. dmft/DMFT (d/D: decay; m/M: missing; f/F: filling; t/T: teeth) scores and plaque data of all participants were recorded. Saliva Streptococcus mutans and lactobacilli load were determined using CRT bacteria.

Results Streptococcus mutans load was >105 CFU in 54.5% of the ASD group and 43.1% in the non-ASD group. Lactobacilli load was >105 CFU in 47.70% of the ASD group and 49.0% in the non-ASD group. There was no statistically significant difference in the S. mutans or lactobacilli loads between the ASD and non-ASD groups. A total of 83.1% of the ASD group had caries, with dmft = 3.25 and DMFT = 5.10. In the non-ASD group, 81.10% of patients had caries, with dmft = 3.10 and DMFT = 4.90; 38.6% of the ASD group and 29.4% of the non-ASD group had no clinical signs of periodontal disease.

Conclusion The examination of the amount of saliva S. mutans and lactobacilli at intervals with these patients will provide quantitative data to evaluate the effectiveness of oral health care.