Child Dental Patient with AUTISM SPECTRUM DISORDERS (ASD)

Good to know

   the Child Dental Patient with


 

 

Autism spectrum disorders (ASD) 

 

 

 

Definition


Autism spectrum disorders include a wide range of disorders - like autism, Asperger’s syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.
                

Prevalence


  • 3.3-3.6 in 10000 for Caucasians
  • 16-21.1 per 10000 Japanese
  • steadily increased over the past two decades
  • 4x males than females

Etiology


Both genetic and environmental factors :

  • mitochondrial defects, cytosine disregulation, high maternally-derived intrauterine androgen concentrations
  • families with an older child suffering from ASD
  • older ages of parents
  • maternal metabolic conditions: diabetes mellitus, hypertension, obesity
  • extremely preterm babies, low birth weight

Characteristics


  • delayed or inexistent verbal skills
  • difficulty in developing social relationships
  • inflexible adherence to rituals
  • mental retardation
  • repetitive movements
  • developing daily routine activities
  • resistance to changes

Oral health problems


  • harmful behavioral problems
  • dental anomalies
  • difficulty in maintaining oral hygiene
  • food habits (award- based behaviour management systems)
  • medication
  • High caries prevalence
  • Gingivitis / periodontitis

Behavioral problems


 

  • bruxism
  • tongue thrusting
  • lip, tongue, cheek biting
  • ulcerations
  • auto-extraction of teeth
  • self-mutilation

Dental anomalies



Non-specific malocclusions:

  • dental crowding
  • anterior open bite
  • crossbite
  • overjet
  • tendency to Class II and III

Difficulty in maintaining oral hygiene 


  • mental retardation
  • poor tongue coordination
  • dislike of toothpaste taste
  • difficulty in performing oral hygiene
  • lack of the necessary manual dexterity
  • prolongued food retention in the oral cavity
  • difficulties of the trainers/parents in children’ toothbrushing

 Food habits


  • preferences for soft and sweetened food
  • tendency  to pouch food inside the mouth
  • chewing with the mouth open
  • alimentary rewards used during therapies

Side effects of drugs used in ASD 


  • CNS Stimulants (Methylphenidate Dextroamphetamine, Mixed amphetaminesalts, Pemolin) – xerostomia
  • Antidepressants (Fluoxetine, Sertraline) - xerostomia, disphagia, sialadenitis, disgeusia, stomatitis, gingivitis, glossitis, discolored tongue, bruxism
  • Antihypertensive (Clonidine) - xerostomia, disphagia, sialadenitis
  • Anticonvulsants (Carbamazepine, Valproate) - xerostomia, stomatitis, glossitis, and disgeusia.
    • Excessive bleeding if medication is combined with either aspirin or non-steroidal anti-inflammatory drugs
  • Antipsychotics (Risperidone, Clozapine, Olazepine, Haloperidol) - xerostomia, sialorrhea, disphagia, disgeusia, stomatitis, gingivitis, tongue edema, glossitis, discolored tongue.

Atention!


Caution when prescribing narcotic analgesics to children who are on haloperidol:

  •  drowsiness
  •  reduced motor control
  •  xerostomia

 

Major problems in providing dental treatment to autistic children:


Lack of co-operation

 
 

Inability to establish appropriate patient-dentist interaction

More problems...


► difficulties in controlling these children
► limited access to dental services
► lack of preventive treatment

often emergency treatment is sought (when patient experiences
dental pain)
        ⇨ filling/extraction
        ⇨ mental association between pain/discomfort and visit to the dental office

► Unresponsive to demonstrations
► Resistance to personal contact and communication
► ‘tell-show-do’ techinque can’t be always used (lack of social and emotional capacity)

Important for the paediatric dentist


  • Experienced, empathetic, professional and appropriate dental care - ESSENTIAL
  • Dental appointments schedule  as not to disrupt the daily routine of the child
  • Positive reinforcement; verbal praising, token rewards
  • Use of pharmacological agents when needed
  • Visual teaching model for improving oral hygiene
  • Custom-made polymer mouthguards for reducing self-injurious behaviour

Dental health education


  • information/guidance on reducing the frequency of sugary foods and drinks
  • good oral hygiene (electric toothbrush may help)
  • high fluoride content toothpaste
  • early dental visits for advice and care ► DENTAL HOME

Pharmacological management


  • Nitrous oxide
  • Diazepam
  • Hydroxyzine 
  • Chloral hydrate
  • Diphenhydramine
} limited to moderate success rate

Dental treatment under GA


Indications:

  • resistance to establish personal contact
  • ineffective sedation techniques/ atypical response patterns
  • high complexity dental treatment needed
  • unsuccessful behavior modification

Important for the orthodontist


 


” less patient-reliant, more patient-resistant “ appliances
 
  • appliances with simple construction
  • quick and comfortable movement of the teeth
  • requiring minimal patient compliance

 

CONCLUSIONS


► Clinical management of autistic children needs to be adjusted in accordance with patients’reactions; no “patterns”

► Autism is NOT an absolute indication for treatment under GA

Anamnesis → source of important info for behaviour management; “DO”s and “DON’T”s

Perseverance is needed; routine is appreciated

Expectations need to be adjusted in accordance to possibilities

► Raising family’s awareness is crucial → early and regular check-ups → efficient prevention, interception → less complex dental problems → less complex treatment needed → better compliance

You’ve seen ONE autistic child means you’ve only seen ONE autistic child.