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ORIGINAL RESEARCH
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 71-75

Comparative evaluation of efficacy of commercially available anticalculus toothpaste with fluoridated toothpaste among autistic individuals: A clinical study


Department of Periodontology, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, Mysuru, Karnataka, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Priya Dayashankar Chaurasia
Room No. 9, Department of Periodontology, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, SS Nagar, Bannimantap, Mysuru - 570 015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_3_17

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   Abstract 


Background: The aim of the present study is to determine the effect of commercially available anticalculus toothpaste and commercially available fluoridated toothpaste on calculus levels of autistic patients and to compare the efficacy of both the pastes. Method: Forty patients were enrolled in the study and randomized in test and control group by lottery method. Test group received anticalculus toothpaste and the control group received commercially available fluoridated toothpaste. Patients received washout toothpaste for ten days prior to commencement of the study. The gingival index (GI), Plaque index (PI) and Volph-Manhold calculus index was measured at baseline 4,12 and 24 weeks. Adverse events were monitored. Result: A statistically significant reduction in the plaque scores was seen over a period of 24 weeks in both the groups (P < 0.05). A statistically significant reduction in the gingival scores was seen over a period of 24 weeks in both intragroup and intergroup comparison. No statistically significant reduction in the calculus group was seen in intragroup and intergroup comparison over a period of 24 weeks. Conclusion: The anticalculus toothpaste did not show any statistical significant changes in the calculus score in intragroup and intergroup comparisons. Thus an oral health program that emphasizes prevention and visual learning is considered of particular importance for children and young people with autism.

Keywords: Anticalculus toothpaste, autism, fluoridated toothpaste, oral hygiene, toothbrush


How to cite this article:
Chaurasia PD, Vajawat M, Rao DP. Comparative evaluation of efficacy of commercially available anticalculus toothpaste with fluoridated toothpaste among autistic individuals: A clinical study. J Int Clin Dent Res Organ 2018;10:71-5

How to cite this URL:
Chaurasia PD, Vajawat M, Rao DP. Comparative evaluation of efficacy of commercially available anticalculus toothpaste with fluoridated toothpaste among autistic individuals: A clinical study. J Int Clin Dent Res Organ [serial online] 2018 [cited 2019 Jan 22];10:71-5. Available from: http://www.jicdro.org/text.asp?2018/10/2/71/249136




   Introduction Top


In 1943, Leo Kanner, the American Child Psychologist, described the autism spectrum disorders (ASDs). This disorder is a pervasive developmental disorder (PDD) defined behaviorally as a syndrome consisting of abnormal development of social skills (withdrawal, lack of interest in peers), limitations in the use of interactive language (speech as well as nonverbal communication), and sensorimotor deficits (inconsistent responses to environmental stimuli).[1] These distinct patterns of the illness are unified in a classification system, referred to as ASDs.

PDDs, commonly referred to as ASDs, is an umbrella term for five disorders, including (1) autistic disorder (AD), (2) Rett disorder, (3) childhood disintegrative disorder, (4) Asperger disorder, and (5) PDD not otherwise specified.[2]

Autism (also known as “AD” and “classic autism”) is a neurodevelopmental condition characterized by impairments in social interaction, communication, and restricted, repetitive, or stereotyped behaviors.[3]

According to Newschaffer et al.,[4] the prevalence for AUDs is 6 per 1000 as a whole and 1–2 per 1000 for autistics.

It has been estimated that there are more than 2 million autistic persons in India. However, in India, the majority of people have not been diagnosed for this disorder and do not receive the services they need as there is a tremendous lack of awareness about autism.[5]

The diagnosis of ASD is established after a careful medical, psychological, and neurological examination and is based on four criteria: serious alterations in social relations; serious alterations in the development of communication; patterns of behavior, interests, and activities that are restricted, repetitive, and stereotyped; early onset (before 3–5 years of age).[6]

Oral manifestation of autistic individuals is harmful oral habits such as bruxism and tongue trusting, dental caries, delayed tooth eruption, trauma and injury, gingivitis, and periodontal disease. The periodontal disease and dental caries are higher in autistics as compared to individuals without developmental disabilities,[7] due to improper brushing and flossing, as they lack necessary manual dexterity. It is also due to the difficulties the trainers and parents encounter when they brush their children's teeth.

In studies on autistic individuals, it was observed that autistic individuals frequently needed assistance in brushing and had a higher rate of periodontal disease and lower caries compared to controls.[8],[9],[10],[11] However, a particular study by Tharapiwattananon[12] showed higher caries incidence in autistic individuals as compared to periodontal diseases.

The presence of calculus is an indication for poor gingival and periodontal health. Calculus is a dental plaque that has undergone mineralization. Anticalculus ingredients that reduce calculus buildup on teeth include various pyrophosphates. These ingredients form a chemical bonding with the saliva. Pyrophosphates (crystal growth inhibitor) act as chelating agents and remove calcium from the saliva to form a soluble complex that can be rinsed away with water, thereby controlling new calculus builtup, thus preventing calculus formation. In this study, we use toothpaste containing pyrophosphate and compare it with fluoridated toothpaste.

Due to improper brushing and lack of manual dexterity, autistic individuals are more prone to plaque deposition and calculus formation. Hence, this study aims to evaluate the efficacy of anticalculus toothpaste in autistic patients.


   Materials and Methods Top


The study population and design of the study is given in [Figure 1]. This is a single-blind, randomized, controlled, clinical study, conducted between December 2015 and May 2016. Ethical approval was obtained from the ethical committee of our institution. Individuals with a diagnosis of typical AD were screened for the study from an autistic institution. The study details were explained to the participant parents to ensure that they were fully informed about the study purposes and rules and signed informed consent forms were obtained. Inclusion criteria for the participants were individuals diagnosed as typical AD, minimum of 20 teeth present, aged between 5–20 years, not undergone scaling for the last 6 months, cooperative patient, and consent from the parent/caretaker. Participants were excluded if they had any other systemic disease known to cause dental problems, individuals undergoing orthodontic therapy and prosthesis, and uncooperative patients.
Figure 1: study population and design

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Eligible individuals were chosen and randomly allotted into two groups using the lottery method, comprising 20 participants in each group. At the start of the study, both the groups received a washout paste for 10 days. Individuals in the test group received a commercially available anticalculus toothpaste (X-Tar, ICPA Health Products Ltd, 216-219, Adarsh Industrial Estate, Sahar Road, Chakala, Andheri [East], Mumbai - 400 099), and the control group received commercially available fluoridated toothpaste (Colgate Cibaca, Colgate – Palmolive [India] Limited, Colgate Research Center, Main Street, Hiranandani Gardens, Powai, Mumbai - 400 076).

Individuals from both groups were instructed to brush their teeth with the soft bristle brush, which was provided to them. Demonstration of the brushing technique was given to each patient and his/her caregiver using a model and a toothbrush. The circular Fones technique was selected as it is easy to learn, and individual patient and caregivers were taught how to brush with a tooth model and toothbrush. They were asked to brush their teeth twice daily for 3 min each time. Caregivers were asked to supervise the patients during toothbrushing for the entire period of the study. Every participant was asked to demonstrate the technique that he/she learned. Individual tailor-made oral hygiene instructions (OHIs) were given to the patient and caretaker at baseline and reinforced at 1 week.

One examiner recorded the clinical parameters using the plaque index (PI, SilnessP and Loe H, 1964), gingival index (GI, Loe H and Silness, 1963) and calculus index (Volpe-Manhold calculus index) at baseline and 8, 12, and 24 weeks.

The patients were evaluated after 1 and 4 weeks to check their compliance. The patients were also questioned whether they had experienced any adverse events, such as discomfort while brushing, bitter or alteration in taste, and allergic reactions arising from the use of the products. This examiner also checked carefully for any changes in their health conditions that were product related.

Statistical analysis

Statistical analysis was done using (SPSS for Windows, Version 11.0, released 2001. SPSS Inc., Chicago, IL, USA). Both descriptive (mean and standard deviation) and inferential statistics (independent t-test and repeated measure ANOVA) were employed for data analysis. All statistical analyses were accepted at a significance level of 0.05. Independent t-tests were conducted to compare the differences between groups in baseline and follow-up PI, GI, and calculus index. ANOVA was used to compare the mean plaque, gingival, calculus score between the test and control groups.


   Results Top


The mean age in the test group was 9.5 years and the control group was 10 years. The PI at baseline and 8-, 12-, and 24-week plaque scores is shown in [Table 1]. Intragroup analysis in both test (P < 0.05) and control (P = 0.05) groups showed statistically significant reduction in plaque scores over a period of 24 weeks. Intergroup analysis showed a no statistically significant reduction in plaque scores in the test group as compared to the control group (P = 0.073). [Table 1] shows the mean plaque scores in both groups at various time intervals. The GI at baseline and 8-, 12-, and 24-week gingival scores is shown in [Table 2]. Intragroup analysis in both test (P < 0.05) and control (P < 0.05) groups showed a statistically significant reduction in gingival score over a period of 24 weeks. Intergroup analysis showed a statistically significant reduction in gingival scores (P = 0.042). [Table 2] shows the mean gingival scores in both groups at various time intervals. The Volpe–Manhold calculus index at baseline and 8-, 12-, and 24-week calculus scores is shown in [Table 3]. Intragroup analysis in both test (P = 0.874) and control (P < 0.787) groups showed no statistically significant reduction in calculus score over a period of 24 weeks. Intergroup analysis showed a no statistically significant reduction in calculus scores (P = 0.787). [Table 3] shows the mean calculus scores in both groups at various time intervals.
Table 1: Intra- and inter-group comparison of plaque index at baseline and 8, 12, and 24 weeks

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Table 2: Intra- and inter-group comparison of gingival index at baseline and 8, 12, and 24 weeks

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Table 3: Intra- and inter-group comparison of Volpe-Manhold calculus index score at baseline and 8, 12, and 24 weeks

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   Discussion Top


The purpose of the present study was to assess and compare the effect of anticalculus toothpaste and a commercially available fluoridated toothpaste on the decrease in the calculus formation in young individuals diagnosed as typical AD by clinical method after reinforcement of adequate OHIs. The primary outcome of this study was to achieve lower calculus scores in autistic patients. The secondary outcome was to achieve lower plaque and gingival scores in autistic patients. The composition of anticalculus toothpaste was potassium pyrophosphate, sodium pyrophosphate in a combined concentration of 5% and sodium fluoride 0.24%. The mechanism of action of the anticalculus toothpaste is that the pyrophosphates present in the anticalculus toothpaste reduce calculus buildup on teeth. Pyrophosphate acts as chelating agents, which forms chemical bond with saliva and removes calcium from the saliva to form a soluble complex. This complex can be rinsed away with water thereby preventing new calculus formation.

In a study of autistic patients in India, it was observed that autistic individuals frequently needed assistance in brushing and had a higher rate of periodontal disease and lower caries compared to controls patients.[10] Thus, the present study used an anticalculus toothpaste to reduce the calculus formation and aid in reduction in the periodontal diseases. Good compliance was observed in both groups. Majority of autistic children had poor oral hygiene, and almost all of them had gingivitis. The PI reduced significantly in the intragroup comparison, but no statistically significant reduction was noted in the intergroup comparison. There was a statistically significant reduction in the GI score in both intragroup and intergroup comparison. The drawback of the study was that the calculus score was not made zero at the start of the study by scaling and polishing. Thus, the calculus score did not show any reduction in the intragroup and intergroup comparison, but the calculus formation was more in the control group when compared with the test group; however, this result was not statistically significant. This is in accordance with the previous study done by Koontongkaew et al.[13] that concluded that pyrophosphate-stabilizing agents in the anticalculus toothpaste are not fully effective in the oral cavity. In addition, the pyrophosphate-containing toothpaste has no influence on the state of calcium and phosphate in the saliva.

Another study by van Loveren et al.[14] concluded that neither a therapeutic benefit (in terms of less gingivitis or less caries) nor a societal benefit (in terms of less treatment demand) has been demonstrated as a result of the anticalculus and whitening effects of toothpastes.

One of the reasons for the increase in the calculus score in both the groups was that the baseline plaque and calculus scores could not be made zero as performing supragingival scaling in the autistic institution was not feasible. The reduction in plaque and gingival scores in both the groups can be attributed to the constant reinforcement of OHI, given to the subjects and supervision by the caregivers.

To the best of our knowledge, this was the first interventional study using anticalculus toothpaste on this autistic population. This study teaches various preventive measures to improve oral health. Attempts should be made by parents and dentists to teach oral hygiene methods to these patients by constant repetition and patience as autistic individuals can develop skills over a period. The positive point of the study was that the follow-up of the patients was at regular intervals for 6 months (24 weeks). This is a good follow-up period because the suggested follow-up for any given anticalculus toothpaste is only 3 months (12 weeks).

Two major management approaches for these autistic individuals is Treatment and Education of Autistic and Communication-related handicapped Children (TEACCH) concept[15] and applied behavior analysis (ABA).

In our study, we have followed the TEACCH concept, which says “visual learning” is very helpful for autistic individuals. We have given individually tailored OHIs by demonstrating on tooth models and brush.[15]

Another approach is the “ABA” that emphasizes on analysis and modification of human behavior. In dentistry, the use of these procedures precludes or decreases the need for more intrusive methods such as restraints and sedation. This is helpful for simple and routine dental procedure.[16],[17]


   Conclusion Top


Within the limitations of the study, the anticalculus toothpaste did not show any significant changes in the calculus score in intragroup and intergroup comparisons. The use of anticalculus toothpaste, constant reinforcement of OHI, patience, and motivation of the autistic individuals can improve their oral health. Thus, an oral health program that emphasizes prevention and visual learning is considered of particular importance for children and young people with autism.

Acknowledgment

We would like to thanks the Academy for Severely Handicapped and Autistics, Mr. Lancy (statistician).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. p. 866. Available from: http://www.psychiatryonline.com/DSMPDF/dsm-iv.pdf. [Last accessed on 2010 Mar 08].  Back to cited text no. 1
    
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Volkmar FR, Reichow B, McPartland J. Classification of autism and related conditions: Progress, challenges, and opportunities. Dialogues Clin Neurosci 2012;14:229-37.  Back to cited text no. 2
    
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Barbaresi WJ, Katusic SK, Voigt RG. Autism: A review of the state of the science for pediatric primary health care clinicians. Arch Pediatr Adolesc Med 2006;160:1167-75.  Back to cited text no. 3
    
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Newschaffer CJ, Croen LA, Daniels J, Giarelli E, Grether JK, Levy SE, et al. The epidemiology of autism spectrum disorders. Annu Rev Public Health 2007;28:235-58.  Back to cited text no. 4
    
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Available from: http://www.autism-india.org/afa_autisminindia.html. [Last accessed on 2014 Dec 13].  Back to cited text no. 5
    
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Limeres-Posse J, Castaño-Novoa P, Abeleira-Pazos M, Ramos-Barbosa I. Behavioural aspects of patients with autism spectrum disorders (ASD) that affect their dental management. Med Oral Patol Oral Cir Bucal 2014;19:e467-72.  Back to cited text no. 6
    
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Nagendra J, Jayachandra S. Autism spectrum disorders: Dental treatment considerations. J Int Dent Med Res 2012;5:118-21.  Back to cited text no. 7
    
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Jaber MA, Sayyab M, Abu Fanas SH. Oral health status and dental needs of autistic children and young adults. J Investig Clin Dent 2011;2:57-62.  Back to cited text no. 8
    
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Loo CY, Graham RM, Hughes CV. The caries experience and behavior of dental patients with autism spectrum disorder. J Am Dent Assoc 2008;139:1518-24.  Back to cited text no. 9
    
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Shapira J, Mann J, Tamari I, Mester R, Knobler H, Yoeli Y, et al. Oral health status and dental needs of an autistic population of children and young adults. Spec Care Dentist 1989;9:38-41.  Back to cited text no. 10
    
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Vajawat M, Deepika PC. Comparative evaluation of oral hygiene practices and oral health status in autistic and normal individuals. J Int Soc Prev Community Dent 2012;2:58-63.  Back to cited text no. 11
    
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Tharapiwattananon T. Autistic child and dental management. CU Dent J 1994;17:1-10.  Back to cited text no. 12
    
13.
Koontongkaew S, Surarit R, Phantumvanit P. Effect of an anticalculus toothpaste containing pyrophosphate on pyrophosphatase activity and the state of calcium phosphate in saliva. J Nihon Univ Sch Dent 1993;35:85-90.  Back to cited text no. 13
    
14.
van Loveren C, Duckworth RM. Anti-calculus and whitening toothpastes. Monogr Oral Sci 2013;23:61-74.  Back to cited text no. 14
    
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Welterlin A, Turner-Brown LM, Harris S, Mesibov G, Delmolino L. The home TEACCHing program for toddlers with autism. J Autism Dev Disord 2012;42:1827-35.  Back to cited text no. 15
    
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Hernandez P, Ikkanda Z. Applied behavior analysis: Behavior management of children with autism spectrum disorders in dental environments. J Am Dent Assoc 2011;142:281-7.  Back to cited text no. 16
    
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Myers SM, Johnson CP; American Academy of Pediatrics Council on Children with Disabilities. Management of children with autism spectrum disorders. Pediatrics 2007;120:1162-82.  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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