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Table of Contents
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 42-47

Oral defensiveness in children with autism spectrum disorders at Biruku Foundation, Bandung

1 Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Indonesia
2 Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Padjadjaran, Indonesia

Date of Submission03-Sep-2021
Date of Decision15-Nov-2021
Date of Acceptance16-Dec-2021
Date of Web Publication21-Feb-2022

Correspondence Address:
Agus Susanto
Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_99_21

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Background: Oral defensiveness (OD) is a reaction to avoid stimulation of touch, texture, or taste of certain foods and feeling irritated with any activities involving the mouth in general. Children with autism spectrum disorder (ASD) who have OD have difficulty with anything that involves touching in and around the child’s mouth. OD can lead to fight or flight reactions including screaming, aggressive behavior, and withdrawal in an effort to avoid stimuli. Objective: The objective of this study was to assess OD in children with ASD at the Biruku Foundation, Bandung. Methods: A descriptive study with a cross-sectional approach using total sampling technique was conducted with the parents of 24 children with ASD at the Biruku Foundation, Bandung with inclusion criteria—children with ASD who had been diagnosed by a pediatrician—and exclusion criteria—parents of children who were unwilling to participate. The research used an Oral Sensory Processing Questionnaire by Winnie Dun (1999) with a total of 12 questions. Respondents filled out the questionnaire using a 5-point Likert scale. Results were classified into three categories: typical, probable, and definite. Results: A total of 10 respondents (41.7%) were classified as typical (normal), 6 (25.0%) were classified as probable (moderate), and 8 (33.3%) were classified as definite (OD). Overall, 14 children with ASD (58.3%) were classified as having OD. Conclusion: Most children with ASD at the Biruku Foundation, Bandung have OD.

Keywords: Autism spectrum disorders, oral defensiveness, oral sensory processing

How to cite this article:
Jody, Susanto A, Sasmita IS. Oral defensiveness in children with autism spectrum disorders at Biruku Foundation, Bandung. Sci Dent J 2022;6:42-7

How to cite this URL:
Jody, Susanto A, Sasmita IS. Oral defensiveness in children with autism spectrum disorders at Biruku Foundation, Bandung. Sci Dent J [serial online] 2022 [cited 2023 Jun 5];6:42-7. Available from: https://www.scidentj.com/text.asp?2022/6/1/42/338007

  Background Top

Cases of autism spectrum disorder (ASD) have become more common in the last few decades due to increasing awareness of ASD among parents, doctors, and researchers. Children with ASD have a limited ability to carry out daily activities or live productively. Some individuals can live independently and productively but most live with limitations. According to the American Psychiatric Association in 2000, individuals with ASD were identified as having difficulties with social interaction and communication skills, as well as having unusual interests and habits with slow or abnormal growth and development before the age of 3.[1],[2] The background cause of ASD in children is still unclear and not fully understood but is considered to involve genetic and environmental factors.[3],[4],[5]

The number of ASD cases in the world has increased significantly. The UNESCO (United Nations Educational, Scientific, and Cultural Organization) data from 2011 identified as many as 3 million cases of ASD worldwide, meaning 6 out of every 1000 people in the world suffer from ASD.[6] The CDC (Centers for Disease Control and Prevention) revealed an increase in the number of ASD cases between 2000 and 2016. Cases of ASD were found at a ratio of 1 out of 150 cases in 2000, increasing to 1 out of 68 in 2016.[7] In Indonesia, in 2009, the Jakarta Ministry of Health reported the prevalence of children with ASD as 1 in 150, a number that continues to increase.[8]

Children with ASD are known to have unusual sensory processing, called sensory processing disorder (SPD). Research shows that 70% of all children diagnosed with ASD have SPD.[9],[10] This sensory processing problem often manifests in children with ASD as hypersensitivity or hyposensitivity with varying degrees of oral defensiveness (OD), also referred to in the literature as oral sensitivity.[9],[11] Children with ASD who have manifestations of OD tend to avoid certain foods that involve specific tastes, textures, and irritations as well as activities involving the mouth in general.[12] Until recently, the etiology of OD was unknown and unproven, but according to some researchers, it is mostly related to stress syndrome and a state of excessive alertness.[11],[12] In addition to alertness and hypersensitivity, OD is also characterized by rejection and resistance when food or items are about to be put into the patient’s mouth. A study conducted by Roseaan estimated the prevalence of sensory problems in children with ASD as varying from 45% to 96%.[13] Baranek et al.[14] found that responses to sensory stimuli significantly affected 69% of children with ASD, particularly among those who had an unusual sensory profile, including dysfunction of oral sensitivity.

When a child with oral hypersensitivity is presented with sensory stimuli while in the dental office, “fight or flight” reactions may occur, including physical withdrawal, screaming, aggressive behavior, or attempts to block these stimuli.[15],[16] The fight or flight reaction is an automatic physiological reaction to an event that is considered stressful or frightening.[17] When children with OD are given sensory stimulation, they may perceive it as a threat that can activate the sympathetic nervous system and trigger an acute stress response. Dentists must be aware of the clinical signs and symptoms of children who come to the dental office and are diagnosed with OD by occupational therapists, so that dentists can appropriately facilitate and communicate with children and parents.[12] No prior research has been conducted on OD in children with ASD at the Biruku Foundation, Bandung. This research will serve as a bridge for initial information in the field of dentistry regarding a child with ASD who has OD as the child will have difficulty receiving dental and oral care at the clinic. The study also aims to find out how to address OD in children with ASD at the Biruku Foundation, Bandung, which can be useful for health workers and the government in planning treatment and conducting health service programs.

  Materials and Methods Top

The study used a descriptive method with a cross-sectional approach. Respondents were parents who have children with ASD at the Biruku Foundation in Bandung. The study used a total sampling method for the sampling technique as the number of samples was the same as the population. Samples were selected based on inclusion and exclusion criteria: inclusion criteria were children with ASD who had been diagnosed by a pediatrician; exclusion criteria were parents of children with ASD who were uncooperative and unwilling to participate in the research. The research method used a simple method—total sampling—due to the limited cases of children with ASD. The use of total sampling is more likely to obtain an accurate result. Biruku is a foundation that focusses on raising and protecting children with ASD in Bandung. Most other foundations involve other disabilities in addition to autism.

The study was conducted online in April 2021, with 24 parent respondents representing their children in a Zoom meeting; Google Forms was used as a platform for filling out questionnaires. Data collection and research procedures were carried out through an online questionnaire to diagnose OD in children with ASD because of the COVID-19 pandemic. This was done to limit unnecessary in-person meetings and to minimize the unwanted spread of COVID-19. Furthermore, this research was conducted online and used a questionnaire as a measuring tool because of Indonesian government regulations in implementing mobility restriction called Pembatasan Sosial Berskala Besar program to reduce the spread of COVID-19. The study began with the issuance of a research permit by the Faculty of Dentistry at Padjadjaran University. The study also has received ethical approval from the Health Research Ethics Commission of Padjadjaran University, Bandung under number 213/UN6.KEP/EC/2021.

The research instrument used was the Oral Sensory Processing Questionnaire, developed by Winnie Dun (1999), which contained 12 questions and became the primary data. The questionnaire used to measure OD was tested for validity and reliability with 12 respondents. The results of the validity test were declared valid with all R-counts above an R-table value of 0.576. The results of the reliability test were declared reliable with a Cronbach’s alpha of 0.941.

The study began with an online counseling webinar on Zoom in April 2021 that explained to parents how to fill out the questionnaire and obtained their informed consent. The purpose of the counseling was to provide basic knowledge and information about dental and oral health to parents of children with ASD before filling out the research questionnaire. Respondents filled out the questionnaire using a 5-point Likert scale: 1 = Always (SS), 2 = Often (S), 3 = Sometimes (KK), 4 = Seldom (J), 5 = Never (TP). The Likert scale ratings for each question were collected and grouped into two classifications: “typical” (typical performance), which indicates the presence of sensory oral processing ability with a score range of 60–46, and “atypical,” which indicates possible sensory oral processing difficulties. The atypical classification was further classified as “probable,” indicating a possible sensory processing problem with a score range of 45–40, and “definite,” indicating a sensory processing disorder with a score range of 39–12. The results show OD atypical (sensitive) and typical (normal).[18]

  Results Top

[Table 1] shows the distribution of respondents’ characteristics in the study of 24 parents of children with ASD at the Biruku Foundation, Bandung. [Table 1] shows that the majority of the respondents’ children are males (83.3%), and one-sixth of respondents’ children are females (16.7%). Based on the age range used by the Ministry of Health of the Republic of Indonesia in 2009, most respondent’s children are in the age range of 17–25 years old with 11 people (45.8%) in their late teens. Six children (25.0%) are in the age range of 12–16 years old, five children (20.8%) are in the age range of 6–11 years old, and only two children (8.3%) are in the age range of 0–5 years old.
Table 1: Respondents’ characteristics

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[Figure 1] describes the final results, identifying most of the respondents’ children with ASD—14 children (58.3%)—as having OD. This figure is the combined result of the six children (25.0%) with the probable classification, which means that the child is most likely to have OD, and the eight children (33.3%) with the definite classification, who show definite OD. Ten of respondents’ children (41.7%) were classified with the typical classification.
Figure 1: Frequency distribution of respondents’ OD

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[Table 2] shows the number of characteristics each respondent child exhibited with the classification of OD (typical, probable, definite). Based on gender, more male children exhibited OD: 5 male children (20.8%) were identified with the definite classification, 5 male children (20.8%) with the probable classification, and 10 male children (41.7%) with the typical classification. However, definite classification was the highest among female children with three children (12.5%) classified as definite and one child classified as probable (4.2%).
Table 2: Distribution of OD based on respondents’ characteristics

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Based on the age range, the most definite classifications were found in the 12–16 age range, with four children (16.7%) in this age range classified as definite; the probable classification was found to be more in the 17–25 age range with three children (12.5%) in this age range classified as probable; and the most typical classification was found in the 17–25 age range with six children (25.0%) in this age range classified as typical.

[Table 3] describes the calculations for the OD classification. A total of eight children (33.3%) were classified as definite, indicating a sensory oral processing problem. Six children (25.0%) were classified as probable, indicating the possibility of sensory oral processing difficulties, and 10 children (41.7%) were classified as typical, indicating a normal sensory oral processing ability.
Table 3: OD based on classification

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  Discussion Top

The results of this study illustrate that most respondents (14) have children with OD (58.3%) classified as definite or probable. This is close to the results of a study by Baranek,[10] which showed that 69% of children diagnosed with ASD also had sensory processing disorders or OD. The study results are also in line with a study by Demattei et al.,[19] which stated that approximately 50% of children with ASD were proven to have OD. However, distinct results were revealed by Flanagan[20],[21] in 2009. Flanagan showed that atypical responsiveness to sensory stimuli could occur at even higher rates, as high as 95% in children with ASD.

The relationship of OD in children with ASD is affected by the presence of SPDs. According to Leekam et al.’s[22] study, in a sample of 200 children with ASD, 90% had SPDs. Children with SPDs do not have the ability to filter or process information from several senses at the same time. Abnormal sensory processing can cause individuals with ASD to exhibit unusual behavior.[23] The lack of sensory information filtering combined with altered connectivity within the brain slows processing time and results in delayed or absent response from the child. Children with ASD express SPD by showing sensory-seeking behavior or sensory overload (defensiveness), one example of which is OD.[24] This sensory overload creates great anxiety for the child, and the child will often try to run away from the overwhelming situation.[25] This can be seen in the behavior of children with OD who try to avoid or even refuse stimulus around their mouth.

[Table 1] shows the gender frequency distribution of children who have ASD, showing that most respondents in this study were males—20 children (83.3%) are male, whereas 4 children are female (16.7%). The ratio of male to female is 5:1. This suggests that the prevalence of ASD in children is more common in males than in females. [Table 2] shows the gender distribution of children with ASD with as many as 10 males (41.6%) classified as having OD and 4 females (16.6%) classified as having OD. However, according to the research from Dunn and Westman[26] in 1997 and Cheung and Siu[27] in 2009, no significant gender differences were found in the sensory profile or sensory processing disorders.

[Table 2] shows that the largest definite classification is in the 12–16 age range with a total of four children (16.7%). This is contrary to the results of a study by Baranek et al.,[14] who reported that children with ASD aged 2–7 years showed sensory over-responsiveness with a high prevalence of OD (56%). A study by Ben-Sasson et al.[28] on children with ASD aged 1–4 found the prevalence of OD at 75%. Research by Baranek et al. and Ben-Sasson et al. indicated that, over time, the existence of OD in children with ASD will decline as it appears to occur slightly less frequently in older children. Some researchers believe that this is because age can affect how children with ASD concentrate on something. By increasing the age of the individual, the maturity of various physiological functions also increases.[29] In addition, children with ASD will have a lot of experiences and lessons, both at school and at home, that can cause low OD in older children.[30] The difference between these results and the results of previous studies involves a more mature age range as respondents in this study extended into the 17–25 age range. In addition, the sample in this study was narrower, and there were differences in the grouping of age ranges.

OD often causes fight or flight behavior, which is associated with aggravating or uncooperative behavior in the dental clinic.[16] According to one study, dentists reported that this behavior was the biggest barrier to continue dental care examination and treatment.[31] Casamassimo et al.’s study also confirmed that 80% of children with ASD who have OD will experience behavioral difficulties at the dental clinic. The presence of behavioral problems like this is the biggest barrier for dentists to treat and provide adequate oral care, especially in children with ASD.[31] Discomfort caused by OD can involve direct stimulation from the cleaning and dental care provided. This is confirmed by Casamassimo et al.’s study, which found that 75.9% of children experience difficult oral and dental care when at the dental clinic. Children often feel or interpret these stimuli as very distressful. These stimuli include repeated light touch in or around the mouth by the dentist trying to hold the mouth open as well as the texture, taste, and smell of various oral dental treatments.

Research conducted by DeGangi et al.[11] in 2000 found that oral desensitization can be done as a therapeutic treatment to reduce defensiveness in and around the child’s mouth due to hypersensitivity by massaging from the face to the gingiva with a soft bristle brush using the Fones brushing technique. Oral desensitization therapy in the dental chair can also be performed by the dentist or clinician. First, place both hands on the child’s shoulders for a long duration of time, then use two fingers to touch the child’s face in the perioral area. This technique is performed by the dentist before attempting intraoral examination or touch of the child. All these techniques can be implemented by following the principle of Tell, Show, and Do (TSD). Researchers believe that this provides a calming stimulus to the child to avoid fight or flight behavior. Therefore, the continuing education role of dental professionals and parents is important in overcoming the difficulties faced by children with ASD who have OD in the dental chair.

This study successfully described OD in children with ASDs at the Biruku Foundation, Bandung, which had not been previously researched. However, this study has several limitations such as the small area coverage and the number of respondents because it was only conducted in one place, the Biruku Foundation, Bandung. Hopefully, future research can be carried out beyond the city of Bandung and with a larger number of respondents to provide more accurate results. Therefore, we suggest further clinical research by conducting direct face-to-face studies for a more precise assessment and further research on the relationship between over-responsiveness and under-responsiveness in children with ASDs.

  Conclusions Top

Most children with ASDs at the Biruku Foundation, Bandung have OD. OD in children with ASD shows a sensory processing disorder that leads to sensory overload. This describes the avoidance or defensive behavior shown by children with ASD during dental treatment. The results of these research data are expected to be used as primary data for further research and as material for government health planning and programs to increase general knowledge of OD in children with ASD. We hope the results of the study can also benefit parents by knowing the characteristics of OD in children with ASD, so that parents can be more aware when taking their children to the dentist for treatment.


The authors would like to thank the Universitas Padjadjaran and Academic Leadership Grand (ALG) who have funded this research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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