Improve the Oral Health of Patients with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent impairment in social communication and restricted, repetitive patterns of behavior and interest.¹ The global occurrence of ASD is approximately 1%, while in the United States, about one in 44 individuals is diagnosed with ASD, most frequently during childhood.^2,3 The age of diagnosis can vary, but 2 years is typically the age at which most diagnoses are made. Boys are four times more likely to be affected by ASD than girls.² 

Characteristics of ASD include difficulty communicating and relating with others, impaired social interaction, and repetitive behaviors.⁴ Children with ASD may also display abnormal emotional and linguistic development, intellectual disability, and sensory perception problems.^5,6 Early signs and symptoms may include absence of speech, language and other developmental delays, and lack of eye contact.⁶ Among those diagnosed after age 8, the signs and symptoms may also include hand flapping, extreme tantrums or outbursts, self-injurious behavior, and head banging.⁷ 

Some evidence shows that genetics play a role in the etiology of ASD.^8,9 Studies have shown that up to 40% of ASD cases present with genetic aberrations.¹⁰ Environmental factors may also increase the risk of ASD. These include both exogenous factors, such as maternal exposure to tobacco and alcohol, and endogenous factors, including advanced parental age at conception, oxidative stress, or mitochondrial dysfunction.^9,11 Some evidence suggests that maternal stress may contribute to an increased occurrence of ASD traits.^9–11 

Obtaining a Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the current standard used for diagnosis of all categories of ASD. After the American Psychiatric Association (APA) adopted a new standard for ASD in the DSM-5 criteria in 2013, a patient diagnosed with any of the four following conditions: autistic disorder, Asperger syndrome, pervasive developmental disorder (PDD), and pervasive developmental disorder not otherwise specified (PDD-NOS) are now diagnosed under the umbrella of ASD.¹² Previously, ASD was deemed more clinically severe than PDD-NOS.¹³ On the other hand, some disorders previously diagnosed within the spectrum are no longer included in the DSM-5 diagnosis of ASD. For instance, social communication disorder (SCD), which is the absence of both verbal and nonverbal abilities to form social connections, is now classified separately from ASD. 

When ASD is first suspected by parents/caregivers or primary healthcare providers, an initial screening exam is completed that includes both a patient and provider questionnaire along with a physical examination. If ASD is tentatively diagnosed during the screening exam, the patient will be referred to a specialist who will perform further testing to confirm the diagnosis. This comprehensive testing typically involves a series of both physical and mental assessments and may include genetic testing as well. Specific tests and diagnostic instruments are approved by the American Academy of Pediatrics and APA to confirm a diagnosis and reduce the likelihood of misdiagnosis, including  Ages and Stages Questionnaire, Communication and Symbolic Behavior Scales, Parents Evaluation of Developmental Status, Modified Checklist for Autism in Toddlers, and the Screening Tool for Autism in Toddlers and Young Children.^6,11,12 

Problems with social interaction, attention deficit, and executive functioning frequently affect the lives of people with ASD. These issues can make caregiving by family members, educators, and healthcare providers challenging.^14,15 One study suggests that—due to sensory, motor, and cognitive deficiencies—individuals with ASD are twice as likely to lack essential oral healthcare than those without developmental disabilities.¹⁶ As a result of these barriers, individuals with ASD may be at an increased risk of developing dental caries.^17,18

Autism Spectrum Disorder and Dental Caries

Dental caries is the most common chronic disease of childhood, impacting 45.8% of those between the ages of 6 and 19 in the United States.^1,19 Nine out of 10 US adults (ages 19 to 64) also have experienced caries in their permanent teeth.¹ These high rates of decay emphasize the importance of early intervention, prevention, and treatment to promote optimal oral health. Some studies suggest that adults and children with ASD have a higher prevalence of dental caries, malocclusion, enamel hypoplasia, gingivitis, and periodontal diseases.⁴ Other studies, however, show that patients with ASD experience a similar or even lower caries prevalence than patients without ASD. This variation may be the result of differences on how various studies score caries prevalence, demographics of the population studied (such as age and gender), oral hygiene abilities, diet, and access to professional dental care.^20–23 

While inconsistencies exist in ascertaining caries prevalence among those with ASD, a number of studies focused on children, adolescents, and young adults.^24,25 For example, in 2016, Gonçalves et al²⁶ concluded that their preteen to teenage group of subjects with ASD showed a higher incidence of dental caries, averaging 70%. Other studies found that children and young adults with ASD were at high risk for tooth decay.^27,28 Table 1 details additional studies that show a higher prevalence of caries in those with ASD. 

Some studies revealed lower rates of dental caries in children with ASD. In 2008, Loo et al²⁹ observed significantly lower rates of caries in  children ages 8 to 12 with ASD compared to children of the same age without ASD. Table 2 explores additional studies demonstrating a lower prevalence of dental caries in patients with ASD compared to nonASD populations. Table 3 shows studies that observed no difference in dental caries prevalence between ASD and nonASD populations. The inconsistencies in these studies reveal the need for further research with larger population groups. 

Role of the Dental Hygienist in Caries Prevention

Patients with ASD may avoid dental treatment due to sensory processing deficits that can create anxiety, often leading to uncooperative behavior during the dental appointment.^30,31 Reducing anxiety by desensitization and implementing specific treatment strategies prior to and during dental appointments are effective in patients with ASD.^32,33 By facilitating the provision of dental care for this patient population in traditional private dental practices, the burden of seeking treatment under general anesthesia or hospital-based providers is eased. Dental hygienists play an important role in this process and help to significantly improve oral hygiene and reduce caries incidence.

Dental hygienists can improve oral healthcare for patients with ASD by providing the following: 

• Verbal preparation for the patient and parent/caregiver prior to treatment
• Firm deep touch rather than light touch 
• Reclining the dental chair prior to patient seating
• Dark glasses for the patient to wear to block out bright lights
• Head phones to decrease the noise associated with dental care
• Various textures and tastes in prophylaxis pastes
• Weighted blanket to provide comfort
• Management of certain dental tools and practices to address needs of individual patients³⁴ 

Effective communication with patients with ASD and their parents/caregivers is critical to supporting oral health and reducing caries risk. Dental hygienists can help this patient population address risks caused by diet, functional habits, and the presence of xerostomia due to medication usage.⁴ For instance, behavioral and educational interventions can be introduced to reduce the consumption of sugar-sweetened beverages.³⁵ In addition, materials, such as pamphlets, posters, website links, books, and videos, can be recommended to patients with ASD and their caregivers. Pretreatment desensitization techniques are also available on smartphone and tablet apps that help patients with ASD and their parents/caregivers be well prepared for the dental office experience.³⁰ 

Oral hygiene instruction is imperative for improving the oral health of patients with ASD. Caries risk assessment tools, such as those developed by the American Dental Association and the University of California San Francisco School of Dentistry (caries management by risk assessment, or CAMBRA), can be instrumental in preventing decay among patients with ASD.²⁸ 

Educating Providers

As the incidence of ASD continues to increase, all oral health professionals should become educated on treatment strategies for this population beginning in dental and dental hygiene schools. Dental hygiene programs should incorporate didactic, clinical, and simulation-based content into their curriculum in order to better prepare students to effectively address patient needs, including those with ASD. Dao et al³⁶ found that much improvement is needed in the application and delivery of education on treating patients with special needs, especially in undergraduate dental education programs. In 2020, the Commission on Dental Accreditation began requiring all undergraduate dental hygiene programs to provide evidence of competency in providing dental hygiene care for patients with special needs.^37,38 

As more dental hygiene programs train students to treat patients with special needs, including ASD, more dental hygienists working in clinical practice will be prepared to provide care to these populations. 

Conclusions

While it remains uncertain whether those with ASD are at higher risk for dental caries, it is clear that oral health professionals are key to helping these patients maintain their oral health. Clinicians should seek further education to support their efforts at ensuring professional care is feasible for this patient population and to help them most effectively educate patients and their caregivers on strategies to improve and maintain oral health for a lifetime. 

References

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From Dimensions of Dental Hygiene. February 2022;20(2):35-38.