Autism Spectrum Disorders and the Role of General Dental Practitioners: A Review

  

    
Dental situations causing sensory    defensiveness
    
Non pharmacological Methods to decrease    sensory defensiveness
  
  

    
High speed drills or suction high    pitched noises
      
 
      
Sensitive to tooth polishing
    
-Use hand instruments to    clean teeth and remove decay
      
-Visual    Schedule/Pictures
      
-Allow child to listen    to calming or favourite music with headphones during treatment and while    waiting in waiting room
      
-Have parent/guardian    do deep pressure orally with electric toothbrush
  
  

    
Dental chair changing position
      
 
      
 
    
-Inform patient of what    is about to happen
      
-Keep x-ray coat on    patient to act as deep touch pressure
      
-Use pictures and    visual schedule to show patient what is going to happen
      
-Visual    Schedule/Pictures
  
  

    
Taste of polishing prophy paste or    local anaesthetic gel
    
-Give patient choice of    paste flavour by saying
      
“Which flavour do you    want, mint or bubble-gum, pick one”
  
  

    
Dental light is too bright
    
-Give patient tinted    protective glasses
      
-Inform patient of what    is about to happen
      
-Visual Schedule/Pictures
  
  

    
Over reactive gag response
    
-Avoid areas that cause    gagging
      
-Inform patient of what    is about to happen
      
-Deep touch pressure
  
  

    
Generalised noises of the dental    office are distressing (i.e. phone ringing, doors closing)
    
-Allow child to listen    to calming or favourite music with headphones during treatment and while    waiting in waiting room
  
  

    
Generalised anxiety
    
-Keep x-ray coat on or    have child chew something very chewy prior to appointment (deep touch    pressure)
      
-Allow child to listen    to calming or favourite music during treatment and while in waiting room
      
-Short appointments
      
-Use firm touch    whenever touching the child
      
-Allow child to bring    favourite toy to appointment
      
-Give rewards to child to    reinforce positive behaviour
  

Table 2:  Non-Pharmacological methods to cope with sensory defensiveness in ASD patients in the dental environment.

Oral health issues

Currently there is debate on the caries and periodontal risk associated with ASD. Some studies have reported that ASD patients (mostly autism) experience a significantly higher decayed, missing or filled (DMF) rate than non ASD individuals [31,32], whilst other reports indicate, no significant different in caries risk when compared to non-ASD patients [33] [17,19,32,34]. It appears that the higher incidence of caries in some ASD patients is more likely due to poor oral hygiene compliance rather than a biological (enamel/dentine based) predisposition [35], which could also explain the higher incidence of generalised gingivitis in ASD individuals [18,35]. Poor oral hygiene compliance appears to be a relatively common behavioural issue with ASD children and further research should be undertaken to identify whether poor oral hygiene is a significant factor in caries prevalence [33,36]. Until research shows that ASD does or does not cause a biological risk for caries, it is best to place patients on a high-risk oral hygiene regime.

Other oral health issues include, drooling, tongue thrusting and difficulty swallowing; the cause of which appears to be poor muscle tone rather than excessive saliva production [33]. Orthodontic assessment is essential to monitor and treat protruded incisors, high arched palate and difficulty breathing. Increased wear facets (a common sign of bruxism/grinding) as well as erosion and hyper responsive gag reflex are also common [37]. Pouching food is also common, where patients leave the bolus in their buccal sulcus due to a lack of tongue control, increasing their risk of caries [18,38,39] so parents should be informed of this at every hygiene appointment. Self-injury is also a commonplace finding in ASD patients, both cutaneous and oral, and recurrent bruises, abrasions, cuts and oral ulcers should be viewed with suspicion [40]. Making sure parents check in the mouth at night and morning will help to keep track of the patient’s behaviours.

Management of ASD in the dental office

Management of ASD can be difficult without first understanding the different types of management available to the dental operator. Managing the ASD patient is not only about treating them in the dental chair, it is also about making sure the patient and their parent/ guardian has the oral health knowledge to properly clean each day. There are two overarching methods of managing ASD patients: Pharmacological and Behavioural. Pharmacological management includes conscious sedation, and general anaesthesia. Behavioural management includes hand-over-mouth technique, getting acquainted appointments/familiarization, restraint, and deep touch pressure.

Pharmacological management of ASD

Pharmacological treatment of ASD is usually prescribed by a Paediatrician and aims to improve mental, social and behavioural symptoms. Behavioural symptoms affiliated with ASD include repetitive behaviours that interfere with normal daily life, irritability, aggression, motor hyperactivity and/or inattention, and deficits in communication skills. Mirtazapine, a tetracyclic antidepressant, helps patients deal with anxiety, irritability, self-injury, and repetitive behaviours but results appear preliminary [25]. Irritability is believed to occur in 30% of children and adolescents with ASD [26] and can be dealt with reasonably effectively using antipsychotics [25]. Motor hyperactivity and/or inattention are considered common behavioural problems in ASD [11], however treatment is not highly efficacious often resulting in adverse effects; headaches, constipation, sleep disturbance and sedation [25]. Sleep disturbance can be an issue if the patients is still in orthodontic growth and early cephalocaudal growth assessment may aid the practitioner in preventing malocclusion. There is little pharmacologic research for treatment of social impairments in ASD, but some trails (not placebo controlled) have demonstrated improvements using selective serotonin reuptake inhibitors (SSRI) and antipsychotics [27,28] but others report there is no true substitute for educational and behavioural therapy for social and communication deficits [29]. Such data impacts dentists as early acquaintance with the dental environment may help reduce patients anxiety (I.e. starting at one year).Of clinical dental relevance is the fact that tricyclic antidepressants, SRIs and antipsychotics cause a significant reduction in salivary flow, with up to 27% of individuals taking TCAs reporting dry mouth [30]. Salivary substitutes, chewing sugarless gum, avoiding acidic foods or drinking water after eating acidic or ‘sugary’ foods can help alleviate damage to the dentition and such preventive methods should be taught to ASD affected individuals and their carers or families.

Conscious sedation

Conscious sedation, such as nitrous oxide (NO) gas or benzodiazepine tablets (e.g. midazolam) is a method of relaxing the patient and increasing the pain threshold so that the patient can cope with dental treatment that would normally cause the patient extreme fear and/or anxiety. Many studies have been conducted on the effectiveness of conscious sedation as well as parental acceptance of conscious sedation versus general anaesthesia (GA). Often times parents request a GA for their children’s dental treatment without knowing the risks associated and these should be outlined as follows: increased risk of adverse medical outcome, treatment will have to be more radical as patient will likely only be under GA once due to medical risk or financial cost (e.g. extractions, crowns), children who have conventional treatment tend to be able to return for preventive appointments and have lower fear and anxiety levels [53]. Operators should offer alternative to GA, like midazolam, benzodiazepines or NO and check for medication interactions.

Behavioural management and therapy

It is accepted that mild anxiety can be normal when attending dental appointments, but when fear begins to affect the patients’ oral health (i.e. not attending appointments, not having necessary treatment) then treatment of that fear is indicated [41]. This is often the case for ASD individuals for a number of reasons including a fear of the unknown, communication deficits, or concurrent mental disability. Many different pathways exist from which dental fear arises and understanding the cause of the fear may aid in treating it [42], but there has been little research into the pathways of dental fear associated to ASD [42]. In children, speech and language develop rapidly between the ages two and three [43]. Although not the case in ASD patients, such knowledge of the different strategies for behavioural management and therapy is required to facilitate adequate dental treatment. Such strategies include the hand over mouth technique (HOM), getting acquainted appointment, restraint, and deep touch pressure (DTP).

Hand over mouth (HOM)

Communication problems and concurrent non-compliance are perhaps the most common issue experienced by operators when dealing with ASD patients. Authors report the benefits of special visual aids and rewards at the end of the child’s appointment [9]. Parents and caregivers seem to concur that rewards are a useful tool not only to enhance co-operation during treatment but also to build an environment of trust [46]. Rewards should, however only be utilised when acceptable or improved behaviour is displayed. One technique that has been taught in University settings for many years is the ‘hand over mouth’ (HOM) technique. Over the last two decades the literature has seen a decline in its appropriateness and acceptance [19]. Accordingly in May 2006 HOM was removed from the list of recommended advanced behavioural management techniques at the General Assembly of the AAPD (American Academy of Paediatric Dentistry) Annual Session [20].

Getting acquainted appointment/familiarisation

To modify social aversion experienced SCDA member’s report they prefer to either give special instruction to parents before their child’s treatment (78%) or allow parents to accompany their child in the operating room (90%) [9]. Less common techniques were letting the patients observe other children (47.6%) or letting patients observe their parents (38.7%) [9]. 71% also used familiarisation visits to calm the child before the first appointment, by which the patient merely meets the staff and sits in the chair for their first appointment. Interestingly, the child’s favourite music or video was only considered by a few as method to calm the child [9,46]. The authors of the current study suggest parents should engage their children with photos or positive stories about the dental office (‘show and tell’) as a method of increasing familiarity prior the appointment [46]. Thus the initial appointment, often known as the ‘get acquainted’ appointment, should be used as a trust building exercise between physician and patient and all of the above techniques should be employed to discover which one works best as each child is unique.

Deep Touch Pressure (DTP)

DTP is a form of tactile sensory input, most commonly provided by hugging, used to alleviate anxiety and appears to be especially efficacious in ASD patients though results are preliminary [23]. Possible anxiolytic effects of DTP could be useful in minimally invasive treatment however there are questions on clinical usefulness and further research is required to determine its effectiveness in the dental office [17,19,24].

Parents/carers and ASD

Often times parents, carers or guardians will try to avoid telling the ASD individual that they have a dental appointment until the day of the appointment to avoid upsetting the patient. If the patient also has a phobia or fear of the dentist it may be helpful for the parent or carer to be mindful of the nature of dental fear so that they can utilise techniques that address individual specific fear [42,56]. Regardless of whether ASD patient are fearful or anxious of dental procedures, it is generally accepted that such patients be modelled (familiarized /desensitization) well in advance (e.g. a week prior) to allow for better adaption and alleviate emotional distress that could be associated with a procedure [7]. It has been reported that, the parent, carer or guardian could play an active role in this familiarization/ desensitisation process by implement a few simple home drills (Table 3 ) prior to the appointment to ensure the patient is as comfortable as possible [7,9].

  

    

      
Use story books or    videos such as those provided by the Autism Speaks Foundation �to familiarise    the patient with the dental environment (i.e. reception, chair, lights)
      
Use time indicators    as it is important for the patient to realise that the appointment will not    last forever and they can monitor the length of their appointment (e.g. stop    watch, sand timer)
      
Use social stories    or visual schedules to make the patient aware of why they need to go to the    dentist and what is going to happen at their appointment
      
If this is the patient    first appointment at a new practice, have a ‘get acquainted’ appointment    before any treatment”.
      
Use a power    toothbrush at home as this will desensitize the patient to the noise and    vibration of the dental instruments Teach the patient what ‘open wide’ means    so that this is not a foreign phrase when the dentist uses it
      
Try different    toothpastes at home to get the patient used to different tastes and textures
      
Make sure the    patient is aware they are allowed to take their favourite toy with them to    the dentist as this can make the experience more ‘normal’
    
  

Table 3:  Recommended home drills to ensure better patient compliance.

  

    
Indications
    
Contraindications
  
  

    

      
Patient requires    immediate diagnosis and/or limited treatment and cannot cooperate because of    lack of maturity or mental or physical disability
      
The safety of the    patient, staff, dentist or parent would be at risk without restraint
      
The sedated patient    requires limited stabilization to help decrease untoward movement
    
    

      
The non-sedated    patient is cooperative
      
The patient cannot    be immobilized safely because of associated medical or physical conditions
      
The non-sedated    patient with elective treatment requires lengthy appointments
      
The patient has    experienced previous physical or psychological trauma from physical restraint    unless no other alternatives are available.”
    
  

Table 4:  Indications and contraindications of restrain as a method of managing ASD patients.

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Citation: Carter AE, Carter G and George R. Autism Spectrum Disorders and the Role of General Dental Practitioners: A Review. J Dent App. 2015;2(7): 254-260. ISSN : 2381-9049

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