Oral Health and Nutrition Concerns in Autism Spectrum Disorders

BY JANE ZIEGLER, DCN, RDN, LDN, EVAN SPIVACK, DDS AND KAREN STANFAR, MPH, RDN, LD

Autism spectrum disorder (ASD) is the umbrella term for a complex and diverse group of developmental disorders characterized by deficits in communication, behavior and socialization. (Hyman, Levy, and Myers 2020) The number of children being diagnosed as "being on the spectrum" has risen dramatically, with current estimates placing the number of children with ASD at 1 in 54 nationally. (Hyman, Levy, and Myers 2020) The prevalence of autism has increased globally as improvements in diagnosis have coupled with greater recognition and awareness of the disorder. The lack of definitive biomarkers and the complexity of ASD, however, have made prevalence difficult to track. (Maenner et al. 2020) Recognizing the complexity of the disorder, there has been a recent shift towards adopting an interdisciplinary approach in addressing the needs of individuals with ASD. The relationship between oral health and nutrition in ASD is becoming increasingly solidified in both the clinical and academic realms. (Leiva-García et al. 2019)

Unlike what is seen in numerous genetic disorders, there are no oral health concerns specific to ASD. Studies indicate that caries incidence in this population may be similar to or lower than that in the population at large, while there may be an increased prevalence of periodontal disease as a result of poor oral hygiene practices. (DeMattei, Cuvo, and Maurizio 2007; Jaber 2011) Oral health issues may arise, however, due to autism-related behaviors, dietary habits, medical comorbidities and medication use. (DeMattei, Cuvo, and Maurizio 2007; Jaber 2011)

Seizure disorder is commonly seen in individuals with ASD. Although present in 1 to 2 percent of the neurotypical population, it may be observed in up to 30 percent of those with autism. (Besag 2018; Reilly et al. 2014) Pain and infection are common triggers for seizure activity, increasing the importance of appropriate and timely dental surveillance and treatment of active disease. Oral hygiene should be stressed, as increased amounts of plaque and calculus can exacerbate gingival tissue overgrowth often seen with several common anticonvulsant medications. (Brodie and Dichter 1996)

Damage to tooth structure may occur as a result of several possible causes. Bruxism (grinding or clenching of the teeth) is an involuntary parafunctional habit that leads to loss of enamel from the occluding and other tooth surfaces; often, it results from sleep disorders. (Kato et al. 2013) In the ASD population, disordered sleep is experienced by up to 83 percent of children, as opposed to only 25 percent of their neurotypical peers. (Devnani and Hegde 2015) Factors contributing to sleep disorders in ASD include obstructive sleep apnea (OSA), seizures and food allergies or intolerances. (Spicuzza, Caruso, and Di Maria 2015)

Damage to the teeth and other oral structures, such as the tongue and lips, may also occur as a result of self-injurious behaviors (SIBs). Hitting, biting, scratching and lip and tongue biting may be associated with communication difficulties, concurrent psychiatric disorders or comorbid intellectual disability. (Folch et al. 2018)

Anticonvulsants, antidepressants and other neuroacting medications may also have oral implications. Among the most significant and common of these is xerostomia (dry mouth), a side effect observed as a result of several hundred medications. Dry mouth may be uncomfortable, lead to oral fungal infections and contribute to poor oral hygiene and failing dental restorations. (Turner 2016) Tardive dyskinesia, a neurological disorder causing involuntary and repetitive movements often affecting the face, mouth and tongue, is also an adverse effect of numerous neuroacting medications. Other oral adverse effects of a broad spectrum of commonly-used medications include inflammation, altered taste, abnormal bleeding and bone loss.

While diet and medication use may impact oral structures, those factors may also exert significant effect on other body systems. Constipation is among the most common gastrointestinal problems, affecting over 25 percent of this population. Individuals with autism often have a diet that is poor in fiber, or they may have low fluid intake. (Lefter et al. 2019) These nutritional findings will often lead to hard stool and the chronic need for stool softeners or manual disimpaction. (Sanchez and Bercik 2011)

Dysautonomia, or autonomic nervous system dysfunction, has been associated with autism. (Ming et al. 2005) The autonomic nervous system plays a major role in the gastrointestinal system and its dysfunction is linked to constipation, reflux, diarrhea and other issues often leading to nutritional concerns. (Keller et al. 2018)

Individuals with ASD are far more likely than their neurotypical peers to exhibit feeding issues and food allergies. (Lefter et al. 2019) Dietary intervention has become more common in autism, with lay advice advocating the benefits of casein and gluten restriction. This diet eliminates foods and beverages that contain the proteins gluten (found in wheat, barley and rye) and casein (found in milk and other dairy products). It was originally hypothesized that children with ASD had difficulty digesting these two proteins, resulting in physical discomfort and subsequent behavioral symptoms. It was further hypothesized that a change in brain chemistry occurred as a result of some of these proteins entering the circulatory system and then the brain. (Mulloy et al. 2010; Marí-Bauset et al. 2014; Sathe et al. 2017) Multiple studies have failed to demonstrate a relationship between ASD and abnormal intestinal permeability or specific GI pathology. (Mulloy et al. 2010) Adverse consequences that may be associated with this diet include decreased bone cortical thickness and stigmatization as well as potential nutritional deficiencies secondary to restrictive eating patterns (Neumeyer et al. 2018; Neumeyer et al. 2016; Ranjan and Nasser 2015) Nutritional deficiencies in calcium, vitamin C and vitamin D are often noted. The lack of calcium and vitamin D, in particular, have been shown to have deleterious effects on the dentition, requiring supplementation if a casein-free diet is utilized. (Ranjan and Nasser 2015)

Sensory sensitivities are commonly seen in autism. (Cermak, Curtin, and Bandini 2010; Dovey et al. 2008) Light, sound and smell can trigger behavioral responses in this population, and strong tactile preferences are often evident. Gustatory preferences are common as well, with many adults and children with autism having only a very limited list of foods that they will eat. This presents obvious difficulties in attempting to guide the patient towards a healthy and noncariogenic diet. Food selectivity and sensory sensitivity appear to be significant problems for individuals with ASD. Food selectivity may occur due to oral over-responsiveness or oral defensiveness which results in difficulty with food textures. Oral under-responsiveness, on the other hand, may occur where the child does not seem to perceive sensations and may overeat or overstuff their mouth. Other behaviors include oral seeking behaviors in which the child puts non-food items in his or her mouth for purposes of oral stimulation. These oral aversions can result in restriction of types, textures and variety of foods. (Cermak, Curtin, and Bandini 2010; Dovey et al. 2008; Chistol et al. 2018)

A WIDER FOCUS: The relationship between oral health and nutrition in autism spectrum disorder is becoming increasingly solidified in both the clinical and academic realms.

Conclusions

Children with ASD present with numerous challenges, with common concerns affecting both oral health and nutritional status (Table 1). An interdisciplinary approach, involving both dentist and nutritionist, will allow for the development of a care plan that accounts for not just autism itself, but any existing comorbidities, medications and associated behaviors. Table 2 presents numerous interventions demonstrating the importance of adopting a coordinated and multi-specialist approach to instituting this care plan.

Table 1. Common Oral Health and Nutrition Concerns in the ID/DD Population (DeMattei, Cuvo, and Maurizio 2007; Jaber 2011; Cermak, Curtin, and Bandini 2010; Dovey et al. 200

Oral Health Concerns 

• Retaining food in mouth

• Oral hypersensitivities

• Gingivitis

• Bruxism

• Behavior issues

- uncooperative 

- difficulties managing oral health prevention strategies

Nutrition Concerns

• Poor calorie/nutrient intake

• Limited food intake or food selectivity

• Chewing difficulties

• Drug-nutrient - supplement interactions

• Altered GI function

• Underweight

• Overweight/obesity

• Restrictive diets

Table 2. Diet and Oral Health Interventions for Individuals with ID/DD (adapted from: Jaber 2011; Cermak, Curtin, and Bandini 2010; Dovey et al. 2008)

Concerns/Issues

• Modified / restrictive diets including gluten free casein-free/soy free diet

• Assess diet for nutrient adequacy based on age/sex.

• Specifically assess adequacy of calcium, vitamin D, protein and other micronutrients.

• Refer to feeding clinic with registered dietitian nutritionist (RDN). • Food selectivity

• Assess textures and types of food consumed.

• Refer to feeding clinic and RDN for in-depth nutrition intervention.

• Behavioral feeding issues

• Frequent intake of fermentable carbohydrates

Interventions

• Assess diet for nutrient adequacy based on age/sex.

• Specifically assess adequacy of calcium, vitamin D, protein and other micronutrients.

• Refer to feeding clinic with registered dietitian nutritionist (RDN).

• Food selectivity

• Assess textures and types of food consumed.

• Refer to feeding clinic and RDN for in-depth nutrition intervention.

• Behavioral feeding issues

• Frequent intake of fermentable carbohydrates

• Referral to psychologist for strategies to address manipulative behaviors

• Encourage tooth-friendly snacks at defined times between meals. Cheeses, unsweetened yogurt with fresh fruit, vegetables. Drink water between meals.

ABOUT THE AUTHORS:

Jane Ziegler, DCN, RDN, LDN is Associate Professor and Director Doctor of Clinical Nutrition, Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences; NJLEND Mentor, Boggs Center on Neurodevelopmental Disabilities; Adjunct Associate Professor, Division of Nutrition, Rutgers School of Dental Medicine. Evan Spivack, DDS is Professor, pediatric dentistry and director, Special Care Treatment Center; Department of NJLEND Mentor, Boggs Center on Neurodevelopmental Disabilities Pediatric Dentistry, Rutgers School of Dental Medicine. Dr. Spivack is a professor of pediatric dentistry and leads the Special Care Treatment Center at the Rutgers School of Dental Medicine. A 1991 graduate of the University of Maryland Dental School, Dr. Spivack completed a general practice residency at St. Barnabas Hospital (Bronx, N.Y.) and was senior fellow in special care dentistry at Helen Hayes Hospital (West Haverstraw, N.Y.). He has a strong interest in interdisciplinary care and education. Karen Stanfar, MPH, RDN, LD is Clinical Dietitian in Ohio, Doctor of Nutrition Student in the Department of Clinical and Preventive Nutrition Sciences School of Health Professions, Rutgers Biomedical and Health Science; and NJLEND Fellow, Boggs Center on Neurodevelopmental Disabilities.

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