Submitted: 19 January, 2023 Accepted: 06 May, 2023 Published: 03 January, 2024 DOI:10.22514/jocpd.2024.

004

ORIGINAL RESEARCH

Dental problems in children with autism: a 5-year study

Paola Martina Marra1, *, Luca Fiorillo2,3,4,5, *, Gabriele Cervino2 , Cesare D’Amico2 ,
Salvatore Crimi6 , Aida Meto5 , Giuseppe Minervini7,8, *, Marco Cicciù6

1
Complex Operative Unit of Abstract
Stomatological surgery in
Developmental age, University of
Caries experience of children and complex clinical circumstances are an actual challenge
Campania Luigi Vanvitelli, 80138 Naples, for any healthcare professional. To investigate the early childhood caries (ECC) in
Italy autistic and non autistic children (≤4 years of age) evaluating the amount of dental
2
Department of Biomedical and Dental damage and the treatments carried out in both groups. Data regarding the oral health
Sciences and Morphofunctional
Imaging, School of Dentistry, Messina
status of 40 patients (≤4 years of age) were assembled. The sample group was
University, 98100 Messina, Italy constituted of 20 autistic children (12 males with a mean age of 2.5 years and 8
3
Multidisciplinary Department of females with a mean age of 3.2 years) whereas 20 patients without the autistic spectrum
Medical-Surgical and represented the control group (11 males with a mean age of 3 and 9 females with a
Odontostomatological Specialties,
University of Campania “Luigi Vanvitelli”,
mean age of 3.3 years). There were no significant differences between the two groups
80121 Naples, Italy as regards both the extent of dental damage and the treatments carried out. About
4
Department of Prosthodontics, Dr. D.Y. the frequency, in the autistic group, the most frequent caries were the white spots and
Patil Dental College and Hospital, Dr. enamel proximal lesions (2.2%), followed by only white spots (1.2%) and brown-black
D.Y. Patil Vidyapeeth, 411018 Pune, India
5
Department of Dentistry, University of
cavities and root stumps (0.6%). In the control group, the brown-black cavities and
Aldent, 1000 Tirana, Albania root stumps represented the most frequent findings (2.2%), followed by white spots
6
Department of Biomedical and Surgical and enamel proximal lesions (1.4%) and white spots (0.4%). Regarding the treatments,
and Biomedical Sciences, Catania the most repeated management of dental damage among autistic patients was composite
University, 95123 Catania, Italy
7
Saveetha Dental College and Hospitals,
restorations (2.2%) while in nonautistic patients were tooth extractions (2%).
Saveetha Institute of Medical and
Technical Sciences (SIMATS), Saveetha Keywords
University, 600077 Chennai, India Autistim spectrum disorder; Dental care; Pediatric dentistry; Early childhood caries
8
Multidisciplinary Department of
Medical-Surgical and Dental Specialties,
University of Campania Luigi Vanvitelli,
80121 Naples, Italy

*Correspondence
[email protected]
(Luca Fiorillo);
[email protected]
(Giuseppe Minervini);
[email protected]
(Paola Martina Marra)

1. Introduction [2–5].
A protracted demineralization can cause dentin’s corrosion
Early childhood caries (ECC) is an oral pathology which affect and cavitation [6]. Developmental enamel defects, such as
primary dentition of children younger than 6 years of age; enamel hypoplasia and children with juvenile diabetes mellitus
primary upper incisors and primary upper and lower molars or special needs, are described by the literature [7] as signifi-
are severely decayed and disrupted [1–3]. Despite substantial cant risk factors for developing early childhood caries.
improvements in preventive dentistry, ECC continues to affect
A low socioeconomic background and prenatal and perinatal
very small children globally. In 4- to 6-year-old children, the
malnutrition influence the occurrence of caries in children;
prevalence generally ranges from 27% to 48% [1–3].
poor oral hygiene and the consumption of highly sugary foods
The aetiology is multifactorial and complex and can regard are related to a lower level of education [7–10]. As contribu-
the interaction between cariogenic microbiota, vulnerable teeth tory risk factors the literature describes caregiver psychosocial
and fermentable carbohydrates; in many cases, the children stresses [10]. As regards the most involved primary teeth, the
slept with honey on the feeding bottle at naptime and bedtime. upper central incisors are among the first to erupt, so, they
The lactic acid, which reduces the intraoral pH and produces will be exposed to the bacteria for longer (Figs. 1A,B,2A)
demineralization of tooth enamel, is generated by the bacteria [10]; most of the time, the primary lower incisors are totally
that consume carbohydrates like sucrose, fructose and glucose healthy or slightly affected since they are protected by the

This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

J Clin Pediatr Dent. 2024 vol.48(1), 26-31 ©2024 The Author(s). Published by MRE Press. www.jocpd.com
 27

tongue’s position. At the beginning, the maxillary incisors One examiner grouped all data (intraoral and extraoral pho-
show a white demineralization spot near the gingival margin, tos, periapical or panoramic X-ray). The sample group was
generally unnoticed by the parents. The white spot slowly constituted of 20 autistic children (12 males with a mean age
progresses to brown-black extensive cavities (Fig. 2A). In of 2.5 years and 8 females with a mean age of 3.2 years)
more severe cases (Fig. 2B,C), the crowns of the upper incisors whereas 20 patients without the autistic spectrum represented
appear destroyed and only the root stumps are present. the control group (11 males with a mean age of 3 years and 9
Some authors [9] showed that the enamel of the primary females with a mean age of 3.3 years).
teeth can be demineralized much more rapidly since it is As regards the autistic group, only patients with the diagno-
less structured and significantly thinner than in the permanent sis of mild or moderate autism were included.
dentition. The following parameters were considered for each patient
The most common microorganisms associated with ECC of both groups:
were mutans streptococci (MS) bacteria, which included the - Age and gender;
species S mutans and S sobrinus [9]. Some investigations - The dental damage;
revealed that children with very high levels of MS presented - The treatments carried out (Chlorhexidine varnish, varnish
additional cavities over time 6 times more than those without topical fluoride with resin base, composite restoration, com-
MS at first visit [10–13]. The treatment is very complex posite restoration technique and pulp treatment, stainless steel
and often can be executed only under sedation or general crowns and tooth extraction);
anaesthesia. It depends on many factors, including the age of Syndromes, craniofacial anomalies, diagnoses of severe
the children, their compliance and health state and the amount autism and convulsions represented the exclusion criteria.
of dental damage. The obtained data were coded and entered into Microsoft
Frequently, young children with the autistic spectrum are Excel which was then subjected to statistical analysis. Chi-
involved [11–14]. square test and Yates’ chi-square and Yates’ p-value test were
Autism or autistic disorder is a set of alterations in brain performed. The results were expressed in percentage. With
development, which vary from one subject to another, leading the Chi-square test performed, significant data have been ob-
to impaired social and language skills, as well as various tained according to Table 3. First of all, the Chi-square value
behavioural disorders [11–13]. The first symptoms of autism performed at 2.857 with a degree of freedom of 5. The p-value
in children appear early in childhood [14]. The etiology of is 0.722, so the previous assumption could be confirmed that
autism is still not clear, but it is generally classified as primary the difference between groups is not significant with p > 0.05.
or idiopathic autism, which has a non-specific genetic base Yates’ chi-square is 5.681 and Yates’ p-value is 0.338; data
[13]. Mental retardation is described in 70% of the cases [13]. were analysed using the statistical package Statistical Package
In small children, extensive dental decays represent a sig- for the Social Sciences (SPSS Software, Version 14, IBM
nificant dentofacial health problem that can provoke medical, Corp., Armonk, NY, USA).
aesthetic and psychological consequences [15, 16].
To date, no studies described the different stages of early 3. Results
childhood caries both in children with and without the autistic
Table 1 shows the age and sex distribution of the sample and
spectrum during a period. The present study aimed to inves-
control group. In the last 5-year findings, males presented
tigate the frequency of early childhood caries in autistic and
more early childhood caries than females in the sample and
non-autistic patients (≤4 years of age) pointing out the most
control group; respectively, 2.4% and 2.2%.
frequent treatments carried out in both groups.
There were no significant differences between the two
groups as regards both the extent of dental damage (p <
2. Materials and methods 0.920) as shown Table 2 and the treatments carried out (p <
0.338) as shown in Table 3.
The present retrospective study was conducted on all autistic
This manuscript has been checked with the Fi-index tool and
and non-autistic patients (≤4 years of age) from November
obtained a score of 0.86 on the date 16 November 2022. No
2017 to November 2022.
according to Scopus® for the first author only [17, 18].
The pathology of early childhood caries was retrieved from
a database.
4. Discussion
For all patients the data had been collected at the initial visit
followed by the screening until the treatments were carried Caries experience of children and complex clinical circum-
out. During the first visit, the parents were asked to sign an stances are an actual challenge for any healthcare professional.
informed consent in order to record the data of their children. To date, very few dated articles [17–24] have dealt with this
From the first visit, the patients were recalled within a month topic in very small children (≤4 years of age) and no articles
to be able to carry out the treatment suitable for their needs. analyzed the same oral health condition in children (≤4 years
After treatment, they were recalled after 6 months for a follow- of age) with the autistic spectrum comparing them with an
up. age-matched control group. It is very important to intercept
When the collaboration of the children made it possible, these oral pathologies as early as possible, to allow children
along with dental examinations, intraoral periapical radio- to eat, to decrease the pain and discomfort, and to avoid or
graphs (Fig. 3) or a panoramic X-ray were performed. limit repercussions on the permanent dentition as showed in
28

TA B L E 1. Demographics of the sample group (autistic babies born after maternal complications during pregnancy or
children) and control group (non-autistic children). who experienced a painful birth must be considered at risk
Age (yr) of developing caries when exposed to disproportionate bottle
Sex N
Mean ± SD nursing.
Sample group Some authors [27] investigated the factors related to the
susceptibility of early childhood caries in 392 children; they
Males 12 2.5 ± 2.0 found significant differences in three factors: eating too many
Females 8 3.2 ± 1.5 sweets each day, brushing before and after sleeping, and par-
ents helped to brush. However, they also found a significant
Control group relation between the parents’ level of education and oral health
Males 11 3.0 ± 3.5 understanding and the ECC. We agree with the findings of the
authors [27], the patients with brown-black cavities and root
Females 9 3.3 ± 2.0 stumps came from a poor background and their family were
SD: standard deviation. socially disadvantaged.
Otherwise from other authors [28–31], who found in autistic
children a higher caries prevalence and poor oral hygiene
TA B L E 2. Distribution of the extent of dental damage in reporting more invasive dental treatments carried out respect
the sample and the control group. to non-autistic children, in our outcomes, we didn’t find any
significant differences among autistic and non-autistic chil-
Autistic Control
dren, probably because most of the patients’ families came
Group Group
from disadvantaged backgrounds with a poor knowledge of the
Extent of dental damage importance of oral hygiene.
White spot 6 (1.2%) 2 (0.4%) Many studies [10–13] reported a higher prevalence in ECC
in autistic patients with a higher age; in our case, since they
White spots and 11 (2.2%) 7 (1.4%) were very young children, probably they were more monitored
enamel proximal by the parents despite the disadvantaged social context.
lesions According to the literature [32], the crowns are one of the
Brown-black cavities 3 (0.6%) 11 (2.2%) most long-lasting, retentive and relatively inexpensive restora-
and root stumps tive materials that have shown good long-term retention and
significant clinical success in the restoration of larger carious
lesions [33–38].
TA B L E 3. Treatments were carried out in the sample Since preserving primary teeth is essential for maintaining
and the control group. maxillary growth [39–41], aesthetics, mastication function and
speech [42–45], when possible, pulp treatments, composite
Treatments Autistic Control
restoration, chlorhexidine varnish and varnish topical fluoride
Group Group
with resin base were also performed in non-autistic group un-
Chlorhexidine varnish 1 (0.2%) der sedation. Fluoride helps to remineralize the demineralized
tooth surfaces injured by caries increasing the resistance. This
Varnish topical fluoride with 2 (0.4%)
study presents some limitations: the limited number of patients
resin base
and no randomization was performed. Paediatricians have an
Composite restoration 11 (2.2%) 2 (0.4%) essential role in intercepting these oral pathologies; they can
teach parents to realize early oral and dental hygiene, adopt an
Composite restorative tech- 2 (0.4%)
appropriate diet, and show them how to recognize early signs
nique and pulp treatment
of rampant caries, such as white spots.
Stainless steel crowns 3 (0.6%)
5. Conclusions
Figs. 1,2,3. The dentist and the paediatrician have to intercept oral prob-
lems in pediatric patients to avoid dental and psychological
Some authors [21] showed that a significant number of complications. The extent of dental damage and the treatments
parents, whose children had early childhood caries, knew about carried out were not statistically different between autistic and
the damaging effects of putting sugary constituents on the baby non-autistic group. The control and the management of ECC
bottle for a long time. Instead, according to our findings, is arduous, due to the multifarious behavioral problems that
another studies [24–26] concluded that the awareness of ECC derive from social, economic and environmental factors of the
was generally lower among parents of ECC children than families. Preventive approaches should focus on early dental
among parents of children without ECC. Moreover, they found inspection, tooth brushing, limiting an excessive use of sugar
also that the percentage of babies with ECC weaned from the and using topical fluoride.
bottle after 14 months old was higher (36.8%) than babies
without the condition (26.5%) Other authors [23] showed that
 29

F I G U R E 1. Brown-black cavities. (A) Intraoral frontal view of 3-year autistic male who shows extensive decays of primary
incisors. (B) Intraoral frontal and lateral views of 2.7-year female who shows brown-black cavities in the upper and lower arches
except for the lower incisors that not present any caries.

F I G U R E 2. Root stumps. (A) Intraoral frontal view of 3-year no autistic female who shows extensive decays of primary
dentition and root stumps in the upper and lower arches; the lower primary incisors, except for the left lateral incisor, appear
healthy. (B) Intraoral frontal view of 3-year female who shows root stumps in the upper and lower arches; the lower primary teeth
are also affected. (C) Intraoral frontal view of 2.5-year autistic female showing root stumps and extensive decay in both arches.
30

CONFLICT OF INTEREST

The authors declare no conflict of interest. Giuseppe Minervini

is serving as one of the Editorial Board members of this journal.
We declare that Giuseppe Minervini had no involvement in the
peer review of this article and has no access to information
regarding its peer review. Full responsibility for the editorial
process for this article was delegated to APG.

R EF ERENCES
[1] Feldens CA, Rodrigues PH, de Anastácio G, Vítolo MR, Chaffee
BW. Feeding frequency in infancy and dental caries in childhood: a
prospective cohort study. International Dental Journal. 2018; 68: 113–
121.
[2] Cheng H, Chen R, Milosevic M, Rossiter C, Arora A, Denney-Wilson
E. Interventions targeting bottle and formula feeding in the prevention
and treatment of early childhood caries, overweight and obesity: an
integrative review. International Journal of Environmental Research and
Public Health. 2021; 18: 12304.
[3] van Meijeren-van Lunteren A, Voortman T, Elfrink MC, Wolvius E, Kragt
L. Breastfeeding and childhood dental caries: results from a socially
diverse birth cohort study. Caries Research. 2021; 55: 153–161.
[4] Garrocho-Rangel A, Navarro-Padilla P, Guzmán-Uribe D, Torre-
Delgadillo G, Ruiz-Rodríguez S, Pozos-Guillén A. Clinical interventions
F I G U R E 3. Periapical radiograph showing tooth decay for caries management through minimal intervention procedures in young
and a periapical lesion. children: an updated evidence-based review. Journal of Clinical Pediatric
Dentistry. 2023; 47: 1–10.
[5] Ganesh A, Muthu MS, Padmanabhan R, Nuvvula S. Association of sleep-
AVA IL AB ILI T Y OF DATA AN D M AT E R I A L S time feeding practices with early childhood caries: a case-control study.
Caries Research. 2022; 56: 399–406.
[6]
Not applicable. Zhu F, Chen Y, Yu Y, Xie Y, Zhu H, Wang H. Caries prevalence of the
first permanent molars in 6–8 years old children. PLOS ONE. 2021; 16:
e0245345.
[7] Anil S, Anand PS. Early childhood caries: prevalence, risk factors, and
A U TH OR CO NT RI BU TI ONS
prevention. Frontiers in Pediatrics. 2017; 5: 157.
[8] Kınıkoğlu İ, Türkoğlu Kayacı Ş, Arslan H. Short fiber reinforced
PMM—conceptualization; LF—methodology, formal
composite on fracture strength of immature permanent anterior teeth with
analysis; LF and AM—software; GC—validation, simulated regenerative endodontic procedures: an in vitro study. Journal
investigation; CDA—resources; LF, SC and AM— of Clinical Pediatric Dentistry. 2023; 47: 171–177.
[9]
data curation; PMM and GM—writing–original draft Twetman S, Dhar V. Evidence of effectiveness of current therapies to
preparation; CDA and GM—writing–review and editing; prevent and treat early childhood caries. Pediatric Dentistry. 2015; 37:
246–253.
MC—supervision, project administration. All authors [10] Topçuoğlu G, Kolçakoğlu K. Evaluation of accuracy of an electronic
contributed to editorial changes in the manuscript. All authors apex locator in presence of sodium hypochlorite in primary teeth with
read and approved the final manuscript. and without resorption. Journal of Clinical Pediatric Dentistry. 2023; 47:
150–154.
[11] Wilkenfeld DA, McCarthy AM. Ethical concerns with applied behavior
E T H I CS A PPR OVA L AN D CONS E N T TO analysis for autism spectrum “disorder”. Kennedy Institute of Ethics
PA RT ICI PAT E [12]
Journal. 2020; 30: 31–69.
Yu H, Zhang Z, Liu J, Hu P, Liu Z. Association study between genetic
variants in vitamin D metabolism related genes and childhood autism
Ethical approval was obtained from the ethics committee of
spectrum disorder. Metabolic Brain Disease. 2020; 35: 971–978.
the University of Aldent, Faculty of Oral Sciences (Reference [13] Saito A, Stickley A, Haraguchi H, Takahashi H, Ishitobi M, Kamio
number: 22/2; Date: 20 March 2023). Written informed Y. Association between autistic traits in preschool children and later
consent has been obtained for all patients prior to the start of emotional/behavioral outcomes. Journal of Autism and Developmental
the study. Disorders. 2017; 47: 3333–3346.
[14] C. Barthelemy. Autism, a neuro-developmental disorder. La Revue du
Praticien. 2019; 69: 738–742. (In French)
[15] Marra PM, Parascandolo S, Fiorillo L, Cicciù M, Cervino G, D’Amico
AC K NOW LED G ME N T C, et al. Dental trauma in children with autistic disorder: a retrospective
study. BioMed Research International. 2021; 2021: 1–6.
Not applicable. [16] Fiorillo L. Fi-index: a new method to evaluate authors Hirsch-index
reliability. Publishing Research Quarterly. 2022; 38: 465–474.
[17] Fiorillo L, Cicciù M. The use of fi-index tool to assess per-manuscript
F U ND ING self-citations. Publishing Research Quarterly. 2022; 38: 684–692.
[18] Khadra-Eid J, Baudet D, Fourny M, Sellier E, Brun C, François P.
This research received no external funding. Development of a screening scale for children at risk of baby bottle tooth
 31

decay. Arch Pediatrics. 2012; 19: 235–241. (In French) monolithic and cutback all-ceramic crown designs: 3D finite element
[19] Peretz B. Early childhood caries (ECC)/baby-bottle tooth decay—a study. Prosthesis. 2021; 3: 173–180.
reminder. Refuat Hapeh Vehashinayim. 2002; 19: 92. [34] Zhu H, Lian L, Zhu K, Yu Y, Zhang W. Guardian factors affecting
[20] Mummolo S, Sapio S, Falco A, Vittorini OL, Quinzi V. Management of high prevalence of dental caries in preschool children. Oral Health &
pedodontic patients in moderate sedation in clinical dentistry: evaluation Preventive Dentistry. 2022; 20: 157–164.
of behaviour before and after treatment. Journal of Biological Regulators [35] Alazmah A. Early childhood caries: a review. The Journal of
and Homeostatic Agents. 2020; 34: 55–62. Contemporary Dental Practice. 2017; 18: 732–737.
[21] Alsadat FA, El-Housseiny AA, Alamoudi NM, Elderwi DA, Ainosa AM, [36] Seminario AL, Ivančaková R. Early childhood caries. Acta Medica. 2003;
Dardeer FM. Dental fear in primary school children and its relation to 46: 91–94.
dental caries. Nigerian Journal of Clinical Practice. 2018; 21: 1454–1460. [37] Marra P, Nucci L, Abdolreza J, Perillo L, Itro A, Grassia V. Odontoma
[22] Uribe SE, Innes N, Maldupa I. The global prevalence of early childhood in a young and anxious patient associated with unerupted permanent
caries: a systematic review with meta‐analysis using the who diagnostic mandibular cuspid: a case report. Journal of International Oral Health.
criteria. International Journal of Paediatric Dentistry. 2021; 31: 817–830. 2020; 12: 182.
[23] Mubaraki S, AlOlyan R, AlBrekeit J, AlFouzan S, Abosharkh M, AlSaeri [38] Qazi N, Pawar M, Padhly PP, Pawar V, D’Amico C, Nicita F, et
N, Baseer MA. Prevalence of caries in first permanent molar among al. Teledentistry: Evaluation of Instagram posts related to bruxism.
children in Saudi Arabia: a retrospective study. European Review for Technology and Health Care. 2023; 31: 1923–1934.
Medical and Pharmacological Sciences. 2022; 26: 7550–7555. [39] Rathi S, Chaturvedi S, Abdullah S, Rajput G, Alqahtani NM, Chaturvedi
[24] Karikoski E, Sarkola T, Blomqvist M. Dental caries prevalence in children M, et al. Clinical trial to assess physiology and activity of masticatory
with congenital heart disease—a systematic review. Acta Odontologica muscles of complete denture wearer following Vitamin D intervention.
Scandinavica. 2021; 79: 232–240. Medicina (B Aires). 2023; 59: 410.
[25] Frencken J. Caries epidemiology and its challenges. Monographs in Oral [40] Di Francesco F, Lanza A, Di Blasio M, Vaienti B, Cafferata EA, Cervino
Science. 2018; 27: 11–23. G, et al. Application of botulinum toxin in temporomandibular disorders:
[26] Herford AS, Lu M, Akin L, Cicciù M. Evaluation of a porcine matrix a systematic review of randomized controlled trials (RCTs). Applied
with and without platelet-derived growth factor for bone graft coverage Sciences. 2022; 12: 12409.
[41] Crescente G, Minervini G, Spagnuolo C, Moccia S. Cannabis bioactive
in pigs. International Journal of Oral and Maxillofacial Implants. 2012;
27: 1351–1358. compound-based formulations: new perspectives for the management of
[27] Sun HB, Zhang W, Zhou XB. Risk factors associated with early childhood orofacial pain. Molecules. 2022; 28: 106.
[42] Cervino G, Fiorillo L, Laino L, Herford AS, Lauritano F, Giudice GL,
caries. Chinese Journal of Dental Research. 2017; 20: 97–104.
[28] Jaber MA. Dental caries experience, oral health status and treatment needs et al. Oral health impact profile in celiac patients: analysis of recent
of dental patients with autism. Journal of Applied Oral Science. 2011; 19: findings in a literature review. Gastroenterology Research and Practice.
212–217. 2018; 2018: 1–9.
[29] [43] Ozaydin MS, Doganturk L, Ulucan-Karnak F, Akdogan O, Erkoc P.
Nagaraja VH, da Ponte Lopes J, Bergmann JHM. Reimagining prosthetic
control: a novel body-powered prosthetic system for simultaneous control Contemporary tools for the cure against pernicious microorganisms:
and actuation. Prosthesis. 2022; 4: 394–413. micro-/nanorobots. Prosthesis. 2022; 4: 424–443.
[30] [44] Malcangi G, Inchingolo AD, Inchingolo AM, Piras F, Settanni V, Garofoli
Tallarico M, Galiffi D, Scrascia R, Gualandri M, Zadrożny Ł, Czajkowska
M, et al. Digital workflow for prosthetically driven implants placement G, et al. COVID-19 infection in children and infants: current status on
and digital cross mounting: a retrospective case series. Prosthesis. 2022; therapies and vaccines. Children. 2022; 9: 249.
[45] Morar L, Băciuț G, Băciuț M, Bran S, Colosi H, Manea A, et al. Analysis
4: 353–368.
[31] Ballini A, Cantore S, Farronato D, Cirulli N, Inchingolo F, Papa of CBCT bone density using the hounsfield scale. Prosthesis. 2022; 4:
F, et al. Periodontal disease and bone pathogenesis: the crosstalk 414–423.
between cytokines and porphyromonas gingivalis. Journal of Biological
Regulators and Homeostatic Agents. 2015; 29: 273–281. How to cite this article: Paola Martina Marra, Luca Fiorillo,
[32] Troiano G, Laino L, Cicciù M, Cervino G, Fiorillo L, D’amico C, et al. Gabriele Cervino, Cesare D’Amico, Salvatore Crimi, Aida Meto,
Comparison of two routes of administration of dexamethasone to reduce et al. Dental problems in children with autism: a 5-year study.
the postoperative sequelae after third molar surgery: a systematic review Journal of Clinical Pediatric Dentistry. 2024; 48(1): 26-31. doi:
and meta-analysis. The Open Dentistry Journal. 2018; 12: 181–188. 10.22514/jocpd.2024.004.
[33] Ramos NdC, Ramos GF, Penteado MM, de Melo RM, Borges ALS,
Bottino MA, et al. Comparative stress evaluation between bilayer,