This course was published in the October 2011 issue and expires October 31, 2014. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Define the group of developmental disabilities called autism spectrum disorders (ASDs).
- Discuss the etiology and prevalence of ASDs.
- Detail the symptoms of ASDs.
- List dental treatment strategies for patients with ASDs.
Autism spectrum disorders (ASDs) are a group of developmental disorders defined by significant impairment in social interaction and communication skills, in addition to the presence of unusual behaviors and interests. ASDs affect the neurodevelopmental system, which usually results in distinct learning and behavioral characteristics. These disorders have an underlying biological/genetic cause (some believe there is also a gastrointestinal cause) that produces organic and/or physical changes during brain development, resulting in atypical cognitive and social development and behaviors.
Many individuals with ASDs have different ways of learning, paying attention, or reacting to stimuli. The assessment and learning abilities of children and adults with ASDs can vary from gifted to severely challenged. ASDs begin before the age of 3 years (developmental differences can be noted during the first year of life) and last throughout a person’s life.1 There is no cure for ASDs, though most children and adults can learn to cope with their disabilities, depending on the type and severity of the condition and their access to effective treatment.
The etiology of ASDs is unknown. Scientists have hypothesized that both genetic and environmental factors play a role in their genesis.2,3 Approximately 10% of children with an ASD have an identifiable genetic neurological disorder, such as fragile X or Down syndrome.4
According to Derrick MacFabe, MD, director of the Kilee Patchell-Evans Autism Research Group at the University of Western Ontario in Canada, emerging research indicates that autism may be caused by a number of environmental triggers influencing whole body metabolism and immune function—particularly in the gastrointestinal system. Infectious factors, particularly unique gut bacteria, may play important roles. These bacteria may derive from longterm antibiotic exposure not only in children with ASDs, but also in hospital or community settings—mirroring the increase of “superbug” infections in Western countries.5
ASDs affect one out of 91 children in the United States, or approximately 1% of all American children.6 Affecting people of all racial, ethnic, and socioeconomic groups, ASDs are four times more common among boys than girls.7
Certain populations experience higher prevalence rates of ASDs. For instance, although the country of Somalia does not have an increased prevalence of ASDs, there is a higher rate of ASDs among the children of Somali immigrants residing in Stockholm, Sweden.8 Research is ongoing to uncover the reasons behind the increased risk among Somali children living outside of their native country.
ASDs are not new diseases, but diagnosis, treatment, and advocacy are modern phenomena. People have probably lived with what we know of today as ASDs throughout history.
There is no evidence that shows any relationship between vaccines and ASDs.9 The British medical journal, The Lancet, which published the paper in 1998 showing a relationship between autism and the measles, mumps, and rubella vaccinations, retracted the paper and has deemed the evidence fraudulent. The lead author, Andrew Wakefield, MD, has lost his license to practice medicine in Great Britain.
ASDs fall under a large umbrella that encompasses several distinct syndromes (Table 1).10–14 People with ASDs differ greatly in their behavior and capabilities—a symptom may be mild in one person and severe in another. Table 2 provides a list of common symptoms.
Children with ASDs develop at different rates. They may experience significant delays in language, social, and cognitive skills, while their motor skills might be on par with other children their age. They might be very good at solving puzzles or computer problems, but unskilled in other areas, such as talking or making friends. A child with an ASD also may learn a skill and then lose it.11
Therapies and behavioral interventions are designed to remedy specific symptoms and encourage improvement among children with ASDs. Applied behavioral analysis, or ABA therapy, is performed by specially trained therapists. ABA therapists may come from a variety of backgrounds, including: psychology, social work, child development, mental health, education, and early interventions. ABA can include educational behavioral interventions, such as structured, intensive skill-oriented training sessions to help children develop social and language skills, and counseling for parents and siblings to help families cope with the challenges of living with a child with an ASD.
Pharmacotherapy is also used in the treatment of ASDs. Anticonvulsants are prescribed to prevent seizures, and stimulant drugs—such as those used in children with attention deficit disorders—are sometimes recommended to decrease impulsivity and hyperactivity. Antidepressant medications are prescribed to treat anxiety, depression, and obsessive-compulsive disorders. Antipsychotic medications are used to treat severe behavior problems.15
ASSOCIATED ORAL CONDITIONS
Complex neurodevelopmental disabilities may exacerbate the poor oral hygiene habits and dental disorders found in the general population. Adults and children with ASDs are at risk of caries, generalized gingivitis, advanced periodontitis, oralfacial pain, xerostomia, and poor diet.16 Eating disturbances are common, due to idiosyncrasies and insistence on “sameness” of diet. In addition, some young children with ASDs have a pica eating disorder, which is characterized by persistent and compulsive cravings to eat nonfood items. Most young children put nonfood items in their mouths because they are naturally curious about their environment. Children with pica, however, go beyond this innocent exploration of their surroundings. Pica is most common among people with developmental disabilities, including ASDs and other intellectual disabilities.17
Children and adults with ASDs often prefer soft food and food with high sugar content. Pocketing and pouching of food may contribute to increased incidence of caries. In addition, therapists often use sweets as rewards during ABA therapies, which can lead to increased risk of decay.
They also experience limited self-cleansing of the oral cavity due to poor tongue and cheek coordination. Oral hygiene may be a low priority due to the overwhelming attention required by parents/caretakers to other needs.
People with ASDs are at high risk of mouth injuries because of self-abuse tendencies and a predisposition to accidents. They also experience an increased incidence of bruxism. Due to a high rate of medication usage, children and adults with ASDs often experience xerostomia. Their gingival health may also be compromised due to an increased incidence of anemia.
PROVIDING DENTAL TREATMENT
The actual procedures of oral health care for people with ASDs are similar to those provided to the general population. Modifications in practitioner-patient-staff-parent/guardian interactions, however, may be necessary to ensure effective care for individuals with ASDs. Providing dental care and ensuring follow-up self-care for individuals with ASDs will vary by patient age, type and level of disorder, and family/living arrangements.
New experiences can cause problems for people with ASDs. Planning for a dental visit with the parent/guardian can reduce this anxiety. Desensitizing the patient by practicing tasks with familiar items may be useful. For example, the parent/guardian can practice opening the patient’s mouth while retracting the cheek with the toothbrush and counting teeth with the soft end of a cotton swab. Parents/guardians can work with patients before the actual dental appointment on making the operatory seem more familiar through the use of dental pictures, toy models, and even a “walkthrough” visit of the dental office.
During the dental visit, the parent/guardian can demonstrate the task, and eventually transfer the task to the dental professional as the patient becomes more familiar with the setting. The same practice exercises can be used to introduce the taste of prophylaxis paste, texture of gloves, sounds of the suction and handpiece, bright lights, and the sensation of the polishing procedure.
In addition to the standard medical/dental and social histories, a thorough record of the patient’s limitations and reactions to previous medical and dental services (eg, attention span limits and any difficulties that arose in the past) should be kept.
Longer appointments should be scheduled for patients with ASDs. Although the actual dental procedures may not take any longer, the behavior guidance required by these patients means additional time and patience are necessary. The average attention span for many of these patients is limited.18
Sometimes treatment may require medical immobilization/protective stabilization. A bite block/opening device may be used. Patients with ASDs are also more prone to lip biting after the delivery of local anesthesia. Consumption of food should be delayed until full sensation returns.
Always give a patient and parent/guardian something to practice between appointments—whether it is placing an X-ray sensor holder in the patient’s mouth or counting the patient’s teeth. This prepares the patient for a more successful follow-up visit.
The parent/guardian can help dental professionals understand a patient’s level of functioning. When possible, talk to the patient at his or her level of understanding. Communicating in a soft voice and using gentle touch will go a long way toward helping the patient relax.18
In the past, many children and adults with ASDs were residents of state institutions where they received needed dental and medical services. Today, most of these individuals reside in our communities and are dependent on local practitioners for care. The increasing number of children with ASDs and their need for increased health, education, and social services are frequently discussed topics. Oral health care practitioners, societies, and charities have responded by developing listings of practitioners who are willing and adequately trained to provide care for patients with ASDs and other disabilities. Greater numbers of dental professionals ready to provide care are needed.
Since January 2006, the Commission on Dental Accreditation instituted new standards for dental and dental hygiene education programs to provide didactic and clinical education on caring for people with developmental disabilities, complex medical problems, significant physical limitations, and other people with special needs. The standards define patients with special needs as “those whose medical, physical, psychological, or social situations make it necessary to modify normal dental routines in order to provide dental treatment.”19
The modification of standards for dental and dental hygiene education programs will help prepare the next generations of practitioners who will be called on to care for individuals whose physical and intellectual limitations extend beyond the traditional definition of a “medically compromised patient.”17
The authors would like to thank Karen A. Raposa, RDH, MBA, for her contributions to this article.
- Ozonoff S, Heung K, Byrd R, Hansen R, Hertz-Picciotto I. The onset of autism: patterns of symptom emergence in the first years of life. Autism Res. 2008;1:320–308.
- Muhle R, Trentacoste SV, Rapin I. The genetics of autism. Pediatrics. 2004;113:472–486.
- Newschaffer CJ, Croen LA, Daniels J, et al. The epidemiology of autism spectrum disorders. Annu Rev Public Health. 2007;28:235–258.
- Centers for Disease Control and Prevention. Autism spectrum disorders overview. Available at: www.cdc.gov/ncbddd/autism/overview.htm. Accessed September 21, 2011.
- MacFabe DF, Cain NE, Boon F, Ossenkopp KP, Cain DP. Effects of the enteric bacterial metabolic product propionic acid on object-directed behavior, social behavior, cognition, and neuroinflammation in adolescent rats: relevance to autism spectrum disorder. Behav Brain Res. 2011;217:47–54.
- Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators; Centers for Disease Control and Prevention (CDC). Prevalence of autism spectrum disorders-Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR Surveill Summ. 2009;18;58:1–20.
- Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011;127:1034–1042.
- Barnevik-Olsson M, Gillberg C, Fernell E. Prevalence of autism in children of Somali origin living in Stockholm: brief report of an at-risk population. Dev Med Child Neurol. 2010;52:1167–1168.
- Institute of Medicine (US) Immunization Safety Review Committee. Immunization Safety Review: Vaccines and Autism. Washington, DC: National Academies Press; 2004.
- National Institute of Neurological Disorders and Stroke. What is Asperger Syndrome? Available at: www.ninds. nih.gov/disorders/asperger/asperger.htm. Accessed September 23, 2011.
- Centers for Disease Control and Prevention. Autism spectrum disorders: signs and symptoms Available at; www.cdc.gov/ncbddd/autism/asd_ symptoms.htm. Accessed September 20, 2011.
- Yale Developmental Disabilities Clinic. Childhood Disintegrative Disorder. Available at: www.med.yale.edu/chldstdy/autism/cdd.html. Accessed September 20, 2011.
- Yale Developmental Disabilities Clinic. Pervasive Developmental Disorder–Not Otherwise Specified (PDD-NOS). Available at: www.med.yale.edu/chldstdy/autism/pddnos.html. Accessed September 21, 2011.
- National Institute of Neurological Disorders and Stroke. Rett Syndrome Fact Sheet. Available at: www.ninds.nih.gov/disorders/rett/detail_rett.htm. Accessed September 23, 2011.
- Nazeer A. Psychopharmacology of autistic spectrum disorders in children and adolescents. Pediatr Clin North Am. 2011; 58:85–97.
- Jaber MA. Dental caries experience, oral health status and treatment needs of dental patients with autism. J Appl Oral Sci. 2011;19:212–217.
- Waldman HB, Perlman SP. Preparing to meet the dental needs of individuals with disabilities. J Dent Educ. 2002;66:82–85.
- Lawton L. Providing dental care for special patients: tips for the general dentist. J Am Dent Assoc. 2002; 133: 1666–1770.
- Commission on Dental Accreditation. Accreditation Standards for Dental Education Programs. Chicago: American Dental Association; 2004.
From Dimensions of Dental Hygiene. October 2011; 9(10): 62-64, 67.