Autism and the clinical implications for dental hygiene.

Autism Defined
It wasn't until the middle of the 20th century that the term
""autism"" was used to define a disorder that
affected approximately 3.5 out of every 1,000 children. (1) it is a
broad name for a variety of symptoms stemming from a neurodevelopmental
disorder that severely impairs social interaction, language, behavior
and cognitive functions of a child. (2) Autistic disorders include
different syndromes identified by their characteristics and include
Asperger's syndrome, Rett syndrome, childhood disintegrative
disorder and pervasive developmental disorder not otherwise specified
(PDD-NOS). The "signature" feature of an autistic disorder is
the child's impaired social interaction. They appear unresponsive
to people, avoid eye contact and seem to lack empathy. Many children
with autism engage in repetitive movements such as rocking and become
obsessive while performing tasks such as placing blocks in a row,
equally spaced and in order. Most children who have autism experience
hypersensitivity to sound, touch or other sensory stimulation. (3)
The cause of autistic disorders is unknown; however, scientists
believe both genetics and environment play a role. Some theories are
that children with autism have abnormal levels of serotonin or other
neurotransmitters in the brain or have irregularities in several brain
regions that affect normal development. (3) Contrary to popular belief,
there is no scientific evidence showing a relationship between vaccines
and autism. There are, however, groups that are at higher risk for

autism disorders. These include boys, siblings of those with autism and
children with other developmental disorders. There is no prevalence
among a specific race, socioeconomic status or parental education level.
(2,4)
Manifestations
The physical and behavioral manifestations of autism can greatly
impact the day to day functioning of a child. Due to their
hypersensitivity to sensory stimulation, everyday tasks can be
overwhelming and lengthy to accomplish. Bathing, feeding and even
brushing teeth can be overly stimulating to a child with autism. They
often obsessively follow routines or schedules and play repetitively.
Any deviation to the routine can be very troublesome to the child. (1)
Although the treatment for autistic disorders is mostly behavioral
therapies, medications are often prescribed to treat some of the
symptoms of autism. These include antidepressants, antipsychotic,
anticonvulsant and stimulant drugs. (3) Many of these drugs have
systemic and oral implications and need to be considered during the
dental appointment. Antipsychotic medications may cause motor
disturbances that affect speech and swallowing and cause xerostomia as
well as orthostatic hypotension. Antidepressants have a myriad of side
effects that include dysgeusia, stomatitis and glossitis. One commonly
prescribed medication, Fluoxetine, causes sucking, lip-smacking and
tongue protrusion, making oral hygiene difficult for both patient and
dental hygienist. Long-term use of the anticonvulsant medications often
prescribed may lead to an increase in bleeding due to either leukopenia
and thrombocytopenia, or anemia disorders. Methylphenidate specifically

may lead to tachycardia or a hypertensive episode if local anesthesia

with vasoconstrictors is administered. (2)
Treatment Considerations for the Dental Team
Patients with autism display a variety of levels of understanding
and cooperation, so treatment modifications should be patient specific.
A preliminary appointment is recommended to assess the child's
office visit capabilities, review thorough medical history and evaluate
dental disease. Ideally, this should be accomplished in a consultation
room, not an operatory, since the noise and dental light may be
stressful for the hypersensitive patient. (2) Making this appointment
short and positive and allowing the child to explore the dental office
will help with behavior during treatment. (5)
For the patient with autism, cooperation between the dentist,
dental hygienist and caregiver is vital. The presence of the
http://bostondentalgroup.com/dental-services/dentures/ parent or
caregiver in the operatory gives the patient a sense of security and
helps achieve cooperation from the child. Having the child bring a
comfort item from home such as a blanket or stuffed animal can help
alleviate some anxiety. (2) Moving slowly and making the child
comfortable with each member of the dental team is very important. While
examining the oral cavity, a dental mouth prop may be helpful in keeping
the patient's mouth open. It is, however, contraindicated to use
"hand over mouth" or "papoose board" restraints, for
they can be very harmful to a patient who feels loss of control or is
hypersensitive to touch. (2) If anesthesia is needed and the child has a
mild autistic disorder with no severe behavioral problems, local

anesthesia and nitrous oxide sedation may be used in the dental office.
Extensive review of the medical and medication history should be the
priority. Consultation with an anesthesiologist may also be considered.
(2)
Oral findings common in patients with autism include traumatic
ulcerated lesions usually brought on by self-injury from head banging,
picking or face tapping. Even though these are self-inflicted, they
should be thoroughly documented. The dentition should be thoroughly
examined, noting signs of bruxism, decay and erosion. Children who have
autism often have food texture sensitivities, a low-varied but
high-sugar diet, xerostomia and frequent regurgitation behaviors. (5)
All of these factors, along with poor oral hygiene, give way to the
child with autism having many dental concerns. (6)
Due to texture sensitivities, hypersensitivity to taste, and acid
regurgitation, the use of prophy paste may be contraindicated. The
coarseness of the prophy paste may be disturbing to the patient, as well
as detrimental to enamel already weakened from acid reflux. A
very-low-abrasive prophy paste is recommended for polishing, followed by
a high-level fluoride application. (7) Products developed for xerostomia
ate alcohol-free and flavorless and are ideal for use by children with
autism.
Dietary concerns should also be discussed with the caregiver. Many
children with autism have texture or taste aversions that often lead to
soft-food or nutritionally deficient diets. A gluten and casein-free
diet has been found to be helpful for some children. Gluten is found in
grains such as wheat, oat, rye and barley and casein is found in milk.

Gluten and milk can be found in many foods, so following this type of
diet is difficult. (1) Processed foods contain very little, if any,
gluten or casein and tend to be the main food choices of children with
autism. These foods are also highly fermentable carbohydrates, which can
lead to an increase of dental caries. A diet low in sugar, acid, and
processed foods should be encouraged.
The Dental Hygienist and the Patient with Autism
Typically, the dental hygienist is the first member of the dental
team that a child with autism will see. Therefore, it is vital that a
safe and happy relationship between the patient and dental hygienist
exists. Due to the patient's need for consistency, it is important
that the same dental hygienist or dental team members treat the patient
at each recall appointment. If new people ate needed, a slow
introduction is recommended. The long-term dental care of these patients
should consist of increasing exposure to and frequency of encounters
with the whole dental team and oral hygiene procedures such as brushing,
flossing and fluoride application by both dental professionals and
caregivers. (8) Key components of dental hygiene care should include
oral hygiene instruction to both patient and caregiver, daily use of
fluoride gel or rinse, limiting cariogenic foods and frequent preventive
recall appointments. It is recommended that patients with autism be seen
in early morning before they are overstimulated by daily activities. (5)
Both the dental hygienist and caregivers should always encourage
positive behavior and ignore negative behavior. Children with autism
will repetitively perform tasks for which they are rewarded.
Conclusion

Given the high prevalence of children with autism, it is very

likely dentists will have one or more of these children in their
practice for many years. As part of a dental team, we must show
compassion and provide optimum care for special needs patients and their
families. Unfortunately, caregivers are often too overwhelmed with the
daily needs of a patient with autism to fully comply with dental hygiene
requests. Understanding the patient's needs and the
caregiver's concerns allows for a comfortable transition into
regular dental care and achieving the best possible oral hygiene.
Educating patients and caregivers and modifying those plans to
continually meet their needs are critical to the success of the patient
with autism in obtaining optimal oral hygiene.
1 Tips for Dental Hygienists (5)
* Approach the child slowly and in a non-threatening manner.
* Use a "tell-show-do" approach. Explain each procedure
before it occurs and provide praise for acceptable behavior.
* Always tell the child with autism where and why you will be
touching them. This tends to decrease their hypersensitivity to touch.
* Talk calmly in short, direct phrases. Avoid words or phrases with
double meanings.
* Use a toothbrush to gain access to the oral cavity. It will be
familiar to the patient and allow for improved cooperation.
* Some children with autism are calmed by moderate pressure,
whereas light pressure can be bothersome. Placing a lead apron on the
child during treatment may be comforting and lead to positive behavior,
but air from the dental air syringe may agitate them.

* Allow the caregiver to watch procedures. Educate them about

findings and oral hygiene practices.
* Find a manual toothbrush that the patient likes. Some
toothbrushes may have features or sizes that are bothersome to the
patient. Most children with autism have motor skill deficiencies, so
electric toothbrushes seem ideal; however, they can be overstimulating
to most patients.
* Some days, a patient with autism may be Dr.Jayadevan overstimulated by the
time they get to the appointment. Make each visit a positive experience
regardless of what or how much is accomplished. Provide the care you
can, and reschedule if necessary.
References
(1.) National Institute of Mental Health. Autism Spectrum Disorders
(Pervasive Developmental Disorders). NIH. Available at
www.nirnh.nih.gov/health. Accessed May 30, 2008.
(2.) Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. The
neuropathology, medical management and dental implications of autism. J
Am Dent Assoc 2006; 137: 1517-27.
(3.) National Institute of Neurological Disorders and Stroke,
Autism fact sheet. NIH 2008; Publication No. 06-1877.
(4.) National Institutes of Health, Autism Spectrum Disorders.
NICHD. Available at www.nichd.nih.gov/health. Accessed May 30, 2008.
(5.) Ravel D. Dental Management of Children With Autism. Pediatric
Dental Health 2005. Available at www.dentalresource.org.
(6.) Burtner P. Mental disorders, developmental disorders: autism.
Available at www.dental.ufl.edu. Accessed May 30, 2008.

(7.) Shaw L, Smith AJ. Paediatric dentistry: dental erosion--the

problem and some practical solutions. Br Dent J 1999; 186: 115-18.
(8.) The National Autistic Society. Dentist: preparing for a visit.
National Autistic Society 2008.
By Karen Sue Williams, RDH, MS
Karen Sue Williams, RDH, MS, has been a licensed dental hygienist
for 18 years. Currently, she is an assistant professor at the University
of Bridgeport, Fones School of Dental Hygiene where she is the first
year clinic coordinator. She holds a master's degree in Human
Nutrition from the University of Bridgeport and has presented dental
hygiene and nutrition CE courses on both the local and state level.