This section of the library shall be dedicated to commentaries on the Hubermanlab podcast. Included below is not a summary of the episode (I’ll leave that for you to check out), but rather my comments on the episode in terms of psychology, health, and human behavior. Whenever possible, I draw connections to autism as well. Most of my comments originally appear on Twitter/X, so be sure to follow on there.
How to Improve Oral Health & Its Critical Role in Brain & Body Health
De-Mineralization & Re-Mineralization
This was something I was entirely unaware of and I’m very appreciative for having become educated on the fact that our teeth can be either in a state of de-mineralization or re-mineralization depending on the pH of our saliva and its mineral content. The acronyms for these two processes that are used in the dental community are quite funny, and no doubt can be used for various jokes.
Demin – De-Mineralization
Remin – Re-Mineralization
“Wow, their teeth are in full demin mode!”
“Be a dental exorcist, get your teeth out of demin mode!”
“Purge your inner demins…with better oral health.”
“I didn’t enjoy kissing them; their teeth were all demins.”
Cavities are Caused by Bacteria that Feed on Sugar
The bacteria that feed on sugar produce acid that de-mineralizes the tooth in the focal area we call a cavity; sugar itself does not cause cavities. Again, something I was also uneducated on, although it makes so much sense. I had believed until now the sugar content itself was causing damage to the teeth, so this was a nice eye-opener.
This means I can eat all the sugar I want and have healthy teeth as long as I brush my teeth right afterward to leave no sugar on my teeth for bacteria to feed on. Woo-hoo!
Fluoride
I recently wrote a major commentary on a Children’s Health Defense film on fluoride that highlights the National Toxicology Program’s research (and drama) on fluoride’s impact on children’s IQ. I appreciate very much Dr. Huberman’s neutrality on such matters and his consideration of various lines of research (something I admire very much about him), however, many people, myself included, are not quite as neutral toward fluoride and would rather not have it in their water. Others argue water fluoridation could be considered a form of ‘mass medication’ without informed consent, adding further weight to arguments against water fluoridation. Finally, the interaction between fluoride and various metals in our environment is another cause for concern, and something I touch upon.
Alcohol Based Mouthwash
I knew there was a reason I stopped wanting to use mouthwashes and this episode has validated that. Alcohol-based mouthwashes deplete the mucosal lining of the mouth are not good for the oral microbiome!
This episode did inspire me to look into alternative mouthwashes though, perhaps fluoride and alcohol free, so I will do just that. Maybe an Ayurvedic-based mouthwash assuming its ingredients only have a positive benefit.
Gotta protect the oral microbiome.
Metal Filings
Having myself received metal fillings (I don’t know which metal) perhaps over 2 decades ago when there was less awareness regarding the use of metals in fillings, this was a little scary to hear once again.
Note to Self: Mastic Gum- Don’t use it or it can disrupt metal fillings. The mercury is not bioactive as a filling, but if it becomes disrupted, it can liberate the mercury and get into the body.
I do wonder how many undocumented cases of neurological damage there have been due to filling-liberating as a result of disruption of the filling.
Sigh.
As Dr. Huberman said, more countries are starting to adopt alternatives, and hopefully more quickly.
Autism and Oral Health
Whenever possible, I draw connections between Hubermanlab’s episodes and autism. In regards to oral health, the connection is quite easy.
In clinical ABA practice, problems with brushing teeth is something I often encounter. Sometimes simple solutions can be implemented, like teaching a child to remember to spit after rinsing their mouth. Sometimes it can be as involved as teaching a child the entire sequence of steps for brushing their teeth -this one I try to precede with teaching the child to put in order the printed pictures for all of the steps for teeth-brushing before moving onto having them perform the steps themselves. It can be quite fun and cute, and there’s a lot of online resources to make the task fun and engaging. Nevertheless, for individuals and families on the autism spectrum, oral health is certainly an area of need that is obtaining attention in research, although it is presently unclear whether there are differences in oral health among those on the autism spectrum and the non-autism population.
For example, a 5 year study published in 2024 found no significant differences in dental damage among children with autism and the control group -although I will say their sample size was a miniscule 40 patients, twenty for each group [1]. The authors stated the reason was “probably because most of the patients’ families came from disadvantaged backgrounds with a poor knowledge of the importance of oral hygiene” although the authors did not report data on socioeconomic status to substantiate this claim -unless, of course, it’s because their entire sample size including both groups was low socioeconomic status to begin with, and therefore they would’ve needed a larger sample size to control for socioeconomic status. Research has shown socioeconomic status is related to oral hygiene behaviors, and while I don’t think Dr. Huberman mentioned this in his episode on oral hygiene, it’s irrelevant if one is trying to promote better oral hygiene among everyone regardless of where they are in life -so I understand the omission. Nevertheless, in studies seeking to compare autism oral hygiene or oral health behaviors between neurotypical peers, it would appear the authors of any study comparing the two would need to control for socioeconomic status as a covariate.
A survey for caregivers of children with autism published in 2023, while incorrectly stating that the increase in incidence in autism is due to “age of diagnosis, the availability of services, public awareness, and referral patterns,” nevertheless found that 61% of caregivers of children with autism used a regular toothbrush with their children instead of a modified or electronic toothbrush -reasons not investigated [2]. Interestingly, the differences between the use of fluoridated and non-fluoridated toothpaste were small, 46% and 42% -with 10% of caregivers indicating they use the toothbrush alone, curiously enough. Finally, parents reported concerns with various oral behaviors, such as bruxism (clenching), thumb-sucking, mouth breathing, and tongue-thrusting -these are behaviors that undoubtedly could impact the pH of the saliva and oral microbiome. When discussing socioeconomic status, the authors state “moreover, people with low socioeconomic statuses oftentimes consider a child with ASD to be a burden and confer less attention to the needs of this child.” I did find this statement both assuming and concerning given the authors provided no citation for it. To my understanding, socioeconomic status research is conflicting in regards to autism, with some studies finding a relationship between them, some an inverse relationship, and other studies no relationship. As stated earlier, this would be an important covariate to adjust for in studies.
Another study published in 2023 gathering information regarding the oral health of an autism population divided into pediatric and adult groups found differences in the level of cooperation during the dental visit among the two groups [3], such that adults were more likely to fall in the lowest rating for level of cooperation (65.51%) compared to the pediatric group (41.93%). Nevertheless, both groups were high in the un-cooperativeness ratings overall, with both groups having collectively less than 15% on the positive side of ratings. It was heartening to see the authors recommend ABA as a method of helping children and adults’ dental visits. “A useful approach may be the ABA method (Applied Behaviour Analysis), which helps to change patients’ behaviour by teaching specific competences. The patient is desensitised to the dental procedures by dividing them in specific and less difficult tasks, which are taught individually to gain a positive reinforcement at the end of every stage.” Certainly, desensitization is a great strategy to shape a behavior.
In line with this ABA recommendation, a study published in 2023 on the effectiveness of behavior interventions for dental visits found that an intervention that consisted of visual aids and one-hour educational parent training appointments every 2 months significantly improved children’s collaboration behaviors during dental visits, and most of this improvement was achieved within the first 7 visits (or the first year of treatment) [4]. Unfortunately, little information was provided on what visual aids were used or the content of the parent training, which would have been informative.
So, what is the issue?
Why is oral care a problem in the autism population?
Well, a review published in 2023 found that Sensory-Adaptive-Dental-Environment (SADE) was effective in reducing dental anxiety to increase cooperation among children with autism [5]. Although it is ‘dental anxiety’ that various dental practices aim to reduce, they implement SADE to achieve this, which can consist of darkening the room, playing gentle rhythmic music, and deep pressure stimulus through the dental chair itself to help the child achieve as much relaxation as possible [6]. In the example shown on the right, the wings of the butterfly wrap themselves around the child to provide a ‘hugging’ sensation during treatment. Curiously, although the review of 6 studies in the literature resulted in the authors’ conclusion regarding the ability of SADE to assist in dental care, the authors concluded: “It is not always effective and feasible for pediatric dentist to manage in dental care due to the stress of dental
anxiety in children with ASD. Also, it is necessary for ASD children to conduct preoperative psychological assessment, to investigate parents’ expectations and cooperation, and determine whether to start corresponding dental treatment.” The authors did mention behavioral intervention strategies as another tool to assist, and perhaps the authors allude that the behavioral option is more feasible than dental practices always being prepared to manage children with autism.
Sami et al. (2023) conducted a review of the literature on the oral health statuses of children and adults with autism [7]. Dr. Huberman, in this episode, iterated the importance of oral health in its relation to the oral microbiome, and this was a topic that came up in this review, highlighting a study that found children with autism had lower pH levels in their saliva compared to the control group, as well as higher levels of bruxism. Interestingly, however, that same study found no differences in dental caries among children with autism and controls. The research appears to be contradictory overall, with some studies finding worse dental health outcomes in the autism population, while other studies report no differences. The authors indicate that this is likely due to heterogeneity of methods and sample sizes, and the lack of studies considering “the temporal and contextual aspects driving oral health inequalities among people with ASD,” -so perhaps not adjusting for socioeconomic status then. The authors conclude that more rigorous research is needed in this area, while still drawing attention to studies that do find poorer oral health outcomes in children with autism as cause for increased research on the matter.
A review conducted by Jones et al. (2024) on the barriers to accessing oral healthcare for individuals with autism highlighted research regarding parental concerns over finding a dentist capable of treating an individual with autism [8]. In other words, many parents feel unable to find a dentist who is knowledgeable about treating individuals with autism and is prepared to manage behaviors, or perhaps implement strategies such as SADE. In conjunction, parental embarrassment over their child’s behaviors is reported as another obstacle in the literature, such that many parents develop self-defeating attitudes due to perceptions of how their child will be received in a dental practice -resulting in decreased likelihood of attempting to access oral healthcare for their child. A third barrier noted by research was negative past experiences and failure by parents to prioritize dental healthcare, such that if a parent is not a regular visitor of the dentist, neither will the child. Finally, the last two barriers identified by the literature review could be argued to impact one another: clinician bias against individuals with special needs and clinician education on treating individuals with special needs. It could be argued that all of these barriers to accessing oral healthcare impact one another, and the authors of the review also note this: “There is overlap in the themes identified due to the inter-related combination of factors perceived by the recipients of care (parents, carers, and individuals) and the providers (dental practitioners).”
In exposing myself for the first time to literature in this area, it makes perfect sense. Parental stress can often be so overwhelming that a self-defeating attitude toward oral care takes over until strategies are put in place to help both them and the child. Desensitization toward the dentist procedures is something I’ve implemented: from having parents buy dentist-kit toys, to exposing the child to videos where other children visit the dentist while having them eat their favorite snack and/or play with their favorite toy at the same time (a little classical conditioning thrown in with operant conditioning). I’ve also witnessed some children incapable of tolerating many, many types of toothpastes, resulting in their parents scouring through the Internet to find an appropriate toothpaste tolerable by them. Thus, it cannot be understated that the significance and barriers in access to oral healthcare for children with autism are real, and no doubt the degree to which the parents themselves pay attention to their own oral healthcare is correlated with their concern for their child’s oral healthcare.
Thanks for the 1:1 this week Dr. Huberman.
References
- Marra, P. M., Fiorillo, L., Cervino, G., D’Amico, C., Crimi, S., Meto, A., Minervini, G., & Cicciù, M. (2024). Dental problems in children with autism: a 5-year study. The Journal of clinical pediatric dentistry, 48(1), 26–31. https://doi.org/10.22514/jocpd.2024.004
- Alqahtani, A. S., Gufran, K., Alsakr, A., Alnufaiy, B., Al Ghwainem, A., Bin Khames, Y. M., Althani, R. A., & Almuthaybiri, S. M. (2023). Oral Healthcare Practices and Awareness among the Parents of Autism Spectrum Disorder Children: A Multi-Center Study. Children (Basel, Switzerland), 10(6), 978. https://doi.org/10.3390/children10060978
- Gallo, C., Scarpis, A., & Mucignat-Caretta, C. (2023). Oral health status and management of autistic patients in the dental setting. European journal of paediatric dentistry, 24(2), 145–150. https://doi.org/10.23804/ejpd.2023.1656
- Pastore, I., Bedin, E., Marzari, G., Bassi, F., Gallo, C., & Mucignat-Caretta, C. (2023). Behavioral guidance for improving dental care in autistic spectrum disorders. Frontiers in psychiatry, 14, 1272638. https://doi.org/10.3389/fpsyt.2023.1272638
- Tang, S. J., Wei, H. L., Li, C. Y., & Huang, M. N. (2023). Management strategies of dental anxiety and uncooperative behaviors in children with Autism spectrum disorder. BMC pediatrics, 23(1), 612. https://doi.org/10.1186/s12887-023-04439-7
- Cermak, S. A., Stein Duker, L. I., Williams, M. E., Dawson, M. E., Lane, C. J., & Polido, J. C. (2015). Sensory Adapted Dental Environments to Enhance Oral Care for Children with Autism Spectrum Disorders: A Randomized Controlled Pilot Study. Journal of autism and developmental disorders, 45(9), 2876–2888. https://doi.org/10.1007/s10803-015-2450-5
- Sami, W., Ahmad, M. S., Shaik, R. A., Miraj, M., Ahmad, S., & Molla, M. H. (2023). Oral Health Statuses of Children and Young Adults with Autism Spectrum Disorder: An Umbrella Review. Journal of clinical medicine, 13(1), 59. https://doi.org/10.3390/jcm13010059
- Jones, J., Roberts, E., Cockrell, D., Higgins, D., & Sharma, D. (2024). Barriers to Oral Health Care for Autistic Individuals-A Scoping Review. Healthcare (Basel, Switzerland), 12(1), 103. https://doi.org/10.3390/healthcare12010103
The Causes of Autism 