Impact of the burden of caregivers of children with ASD on oral health

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INTRODUCTION
Autism spectrum disorder (ASD) is a neurological development disorder, impairing communication, social, behavioral and intellectual performance, with impaired communication and social interaction, demonstrated by withdrawal and lack of interest in other people 1,2 .The prevalence of ASD has increased over the last 2 decades 3 .According to 2020 data, the prevalence in the United States of America (USA), one in 36 children aged 8 years (approximately 4% of boys and 1% of girls) was estimated to have ASD 4 .In Brazil there is still no estimate; however, it is believed to be close to what was found in the USA and Europe 3 .
Oral hygiene in patients with ASD may be deficient due to the lack of manual dexterity and the need for help with correct hygiene, which may result in an increase in bacterial plaque and a higher rate of gingivitis 5,6 .Authors report that these individuals have a higher prevalence of periodontal diseases such as gingivitis and gingival hyperplasia 7,8 .In this context, a study demonstrated that individuals with ASD who lived with their parents had a lower rate of gingivitis compared to those who did not live with their parents, but the manifestations and clinical signs of bruxism were greater in those who lived with their parents 9 .
The caregiver has a fundamental importance in helping the autistic person to carry out their daily activities and maintain their connection with society throughout their growth and development into adulthood 10,11 .However, time spent on excessive tasks, such as meeting a child's social, physical, emotional and learning needs, coupled with few specialized guidance and social support services, can cause stress, depression and anxiety and directly affect the caregiver's quality of life (QoL) 11,12 .
Furthermore, the lifelong responsibility of caring for a person who is within the spectrum related to reduced attention to their own health, leads caregivers to feel overwhelmed.Caregiver burden has been determined as a multidimensional reaction to the set of physical, mental and socioeconomic problems suffered by those who care for sick people, and the effects can be physical and mental disorders and low quality of life 13,14 .Thus, burden can be a significant predictor of worse QoL and could also influence the maintenance of oral health 11,15,16 .Thus, the objective of the present study was to compare the burden on caregivers of individuals with ASD with individuals neurotypical (N) and to evaluate the correlation of the burden on these caregivers on the impact of oral health.

MATERIAL AND METHOD
This is a cross-sectional observational clinical study with a convenience sample approved by the Ethics and Research Committee (CAAE: 59159422.0.0000.5420).The project followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines 17 .

Selection of Patients
The sample was selected by simple random sampling.A total of seventy patients were included in the study.Thirty-five diagnosed with ASD were studied in outpatient care at the Dental Care Center for People with Disabilities (CAOE) to form the group ASD.Thirty-five patients with neurotypical were recruited from the Pediatric Dentistry clinic of the Faculty of Dentistry of Araçatuba and comprised the group N.Those responsible for the patients were individually 3/8 informed about the nature of the study and signed an informed consent form.Patients who understood were presented with the consent form, which was also signed by their legal guardians.
Individuals with ASD must meet the following inclusion criteria: patients diagnosed with ASD levels 1, 2 and 3; both sexes; age ≥ 5 and ≤ 12 years; being monitored at the specialized assistance center.In the case of individuals N, the same inclusion criteria were considered with the exception of the diagnosis of ASD.
The exclusion criteria were: non-collaborating patients; need for sedation; unstable health condition; blood disorders; edentulous patients; active cancer; patients supplemented with vitamins in the last two months; use of anti-inflammatory drugs or antibiotics in the last 3 months 18,19 .

Personal, Sociodemographic and Oral Questionnaire
Initially, a questionnaire was applied to the parents/guardians of the research participants.The questionnaire addressed issues related to patient identification and length of outpatient follow-up, systemic and behavioral characteristics, assessment of oral habits/care and assessment of parents/guardians' knowledge about oral health.

Overload Questionnaire
Parents/guardians were examined according to the burden felt using the Burden Interview (BI) questionnaire, translated, culturally adapted and validated for use in Brazil 20 .The BI contains 22 items used to assess the health, social and personal life, financial situation, emotional wellbeing, and interpersonal relationships of caregivers.Responses were graded on a Likert scale of 5 points, ranging from 0 to 4 (never, rarely, sometimes, often, and always).All items were evaluated, and the total scale score was obtained by adding all items, which could range from 0 to 88.In the present research, the level of overload was categorized according to the scores obtained by parents and includes: little or no overload (0 -21 points); light to moderate load (21 -40 points); moderate to severe load (41 -60 points); severe load (61 -88 points) 21 .

Visible Plaque Index (VPI)
The of VPI (present or absent) in individuals with ASD and N was assessed in six sites of six teeth in the oral cavity (first permanent molars, upper central incisor, lower central incisor), totaling 36 sites.In the absence of any permanent tooth, its corresponding deciduous tooth or the closest tooth (mesial) of the hemiarch was evaluated 22 .This clinical parameter was performed with a millimeter periodontal probe (PCPUNC-15, Hu-Friedy, Chicago, IL, USA).The assessment was conducted by a single calibrated examiner (JVSR).

Statistical Analysis
The collected data were tabulated and organized in the JAMOVI 2.2.5 program (Sydney, Australia).For all tests, a significance level of 5% was considered.The Shapiro-Wilk normality test was applied for each parameter.
For both groups, caregiver burden and VPI were compared using the Spearman Correlation test; dependence on hygiene and dependence on caregivers were compared to VPI using the Mann-Whitney U test; and VPI was analyzed between groups using the Mann-Whitney U test.For the ASD group, the degree of autism and VPI were compared using the Spearman Correlation test.

RESULTS
In the ASD group, 35 patients were included, 26 boys and 9 girls (age 7.63 ± 1.82).In the N group, 35 patients were included, 20 boys and 15 girls (age 8.17 ± 1.98).Regarding the general dependence of individuals in the ASD group, 25 of them were dependent on their guardians for basic daily activities.In the N group, of the 35 children, only 13 were dependent on their parents.When evaluating the degree of dependence in oral hygiene, the ASD group had 24 dependent children, and in the N group, only 3 depended on their guardians for mouth brushing.
When evaluating the level of overload of caregivers in the ASD group, 9 fell into the "no overload" category, 19 parents with "little overload" and 7 parents with "moderate overload".Regarding the parents in N group, 23 fell into the "no overload" category, 11 parents with "little overload" and only 1 with "moderate overload".According to statistical data, no person in charge of either group fell into the "severe overload" category.Questions 2, 7, 10, 12, 17, 19 and 22 showed a statistically significant difference between the two groups (p <0.001).
In ASD group it was observed that there was no statistical difference between the VPI and the "no overload", "mild to moderate", "moderate to severe" and "severe" groups (Figure 1).There was also no statistical difference in VPI between the "self-sufficient" and "dependent" groups.There was no statistical difference in VPI between the "independent" and "partially dependent" groups of the ASD group.In N group there was no statistical difference between the VPI and the "no burden", "mild to moderate", "moderate to severe" and "severe" groups (Figure 2).There was also no significant difference in VPI between the "self-sufficient" and "dependent" groups.There was no statistical difference in VPI between the "independent" and "partially dependent" groups of the N group.
There was no statistical difference in the VPI analysis between the N and ASD groups (Figure 3).

DISCUSSION
The prevalence of ASD is 3.5 times higher in men compared to women 3 .The present study was able to reaffirm data from the literature, since there was a prevalence of male children in the ASD group.In relation to neurotypical children, going to the dentist is more common among male children aged 2 to 7 years, this is because there is a higher incidence of trauma to primary teeth 23 .Another study in the literature states that female children are more prone to tooth decay due to reduced salivary flow and biochemical changes in saliva 24 .In this study, there was a prevalence of males in the N group.However, the main complaint was not related to trauma, but rather the prevention and treatment of caries disease.
ASD brings behavioral and intellectual changes to individuals, thus compromising their development and learning, depending on constant care from parents and guardians 25 .From the results obtained in this study, it is clear that children with ASD are more dependent on their parents, both related to general dependence and dependence on oral hygiene.The data shows that 71% (25 children) of children with ASD depended on their parents to carry out general daily activities and 68% (24 children) depended on their parents for oral hygiene.
Those responsible for individuals with disabilities may present different ways to deal with challenging situations, in the face of different stressful situations 26 .With the increase in the diagnosis of children with ASD, it is necessary to understand the burden that these caregivers carry 26 .During the development of the research, those responsible for children with ASD did not personally appear, for the most part, to be overburdened with caring for their children.However, when answering the BI questionnaire, the results showed that more than half of them fell into some category of burden (mild or moderate).
The burden on parents of individuals with ASD is greater than that of neurotypical individuals 27 .The results of the present study corroborate this statement because, according to the BI questionnaire, 66% of those responsible for neurotypical children classified as "no overload", 31% "mild burden" and 3% "moderate burden", compared to those responsible for individuals with ASD, of which 26% classified as "no burden", 54% "mild burden" and 20% "moderate burden".
Caregivers of children with ASD may experience feelings of anguish and sadness, as families are often prone to uncomfortable exposure situations 28 .When observing questions 2, 7, 10, 12, 17, 19, 22 of the BI questionnaire, which were specifically aimed at the burden of children, these statements become very evident.There was a significant difference between the groups, demonstrating that parents of individuals with ASD are more overwhelmed.
When analyzing the VPI of the ASD group, it was observed that there were no statistical differences compared to the burden level of parents and guardians.The same results also indicate that there are no differences in the VPI of the ASD group when related to general dependence and dependence on oral hygiene.VPI is the result of poor hygiene in neurotypical children, showing a greater need for parental supervision when brushing.Comparing the VPI of the N group with the burden level of parents and guardians, the same results were obtained as in the ASD group.There was no statistical difference in IPV between the N and ASD groups.

CONCLUSION
In conclusion, ASD group caregivers have greater burden when compared to N group and the degree of burden did not influence the level of oral hygiene of the child with ASD.

Figure 1 .
Figure 1.a) Spearman Correlation test for VPI in the ASD group with the degrees of overload "no overload", "mild to moderate", "moderate to severe" and "severe".b) Mann-Whitney U test for VPI in the ASD group with the degree of dependence on oral hygiene.c) Mann-Whitney U test for VPI in the ASD group with the degree of general dependence.

Figure 2 .
Figure 2. a) Spearman Correlation test for VPI in the N group with the degrees of overload "no overload", "mild to moderate", "moderate to severe" and "severe" b) Mann-Whitney U test for VPI in the N group with the degree of dependence on oral hygiene c) Mann-Whitney U test for VPI in the ASD group with the degree of general dependence.

Figure 3 .
Figure 3. Mann-Whitney U test for VPI between the N and ASD groups.