# Oral Health Status of Children with Autism in Central Italy
## 2 Materials and Methods
### Data Collection  
Data were collected by a single International Caries Detection and Assessment System (ICDASTM) calibrated researcher, having a degree in dentistry with clinical and epidemiological experience (training was conducted by a core member of the International Caries Detection and Assessment System Coordinating Committee). Prior to the study, the researcher completed a six-month training period with a qualified autism therapist to acquire the relational skills necessary for an effective communication and interaction with the children participating in the study. Intra-examiner reliability was assessed according to WHO guidelines [30]. Parents gave consent to the study and it was performed in accordance with the Declaration of Helsinki. Kappa statistics was used to determine intra-examiner reliability. The kappa test was adopted on a tooth-by-tooth basis in order to check the intra-examiner agreement in caries diagnosis according to the methodology described by [PERSON] et al. (2001). A kappa value of 0.82 was obtained. Information on demographic attributes (gender, age, nationality), dietary habits, medical history (type of delivery, vaccines, medications, previous experiences of general anesthesia) was obtained from a face-to-face interview with the parents of the children using a questionnaire especially designed for this study. Clinical data (caries severity, gingival status, plaque accumulation) were obtained from the clinical examination at the Unit of Special Needs of the Policlinico Umberto I in Rome according to the World Oral Health Survey [30]. The Frankl scale, a reliable behavior rating system in common use in both clinical dentistry and research in ASD patients [31], was used to measure the level of cooperativeness at the first dental visits. Each child was classified, by a dentist experienced in treating ASD children, in one of the four categories of the Frankl scale: definitely negative, negative, positive, and definitely positive (for details, see Table 1). \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Gender (N\({}_{\text{tot}}\) = 229)** & **\%** & **Medications (N\({}_{\text{tot}}\) = 217)** & **\%** \\ Male & 75.98\% & Yes & 27.19\% \\ Female & 24.02\% & No & 72.81\% \\ \hline
**Age (N\({}_{\text{tot}}\) = 229)** & 9.61\% & **Prev. anesthesia (N\({}_{\text{tot}}\) = 224)** & \\
5 & 10.48\% & Yes & 8.04\% \\
6 & 10.92\% & No & 91.96\% \\
7 & 14.85\% & **Plaque Index** (N\({}_{\text{tot}}\) = 218) & \\
8 & 15.72\% & No plaque & \\
9 & 11.79\% & Plaque detectable with the & \\
10 & 12.23\% & periodontal probe & \\
11 & 5.68\% & Plaque visible to the naked eye & \\
12 & 6.11\% & at the gingival margin & \\
13 & 2.61\% & Abundant accumulation of & \\
14 & & Calculus beyond the margin & \\ \hline \hline \end{tabular}
\end{table} 
Table 1: Descriptive statistics (frequency tables) for the 12 factors considered in the study. N\({}_{\text{tot}}\) = total number of responses for each factor. For the Frankl scale, the rating is as follows. Definitely negative: Refusal of treatment, crying forcefully, fearful, or any other evidence of extreme negativism; Negative: Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced, i.e., sudden withdrawal; Positive: Acceptance of treatment, at times cautious, willingness to comply with the dentist, at times with reserve, but patient follows the dentist’s directions cooperatively; Definitely positive. Good relationship with the dentist; interested in the dental procedures; laughing and enjoying the situation. The sum of decayed, missing, and filled teeth in the primary dentition (dmft) and in the permanent dentition (DMFT), denoted by DMFT/dmft, was used to determine caries severity. Caries prevalence was defined as the proportion of patients with a positive dental caries history, i.e., with a positive value of DMFT/dmft. Plaque and gingival indices (with four and three levels, respectively) were used to assess the general prevalence of periodontal health according to the World Oral Health Survey.