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Pediatric  Dental  Health

January 10, 2005

Dental Management Of Children with Autism

Autism was first described in 1943 by the American child psychologist, Leo Kanner. Autism is a type of neurodevelopmental disorder, and usually appears within the first three years of a child’s life. The hallmark of autism is the lack of communication skills. Affected children also have problems with language, behavior, and social skills.

Autism is a lifelong condition, and its cause is unknown. Environmental and genetic factors do contribute to the development of autism, but most children with autism have normal physical health.

Autism is a neurological disorder that appears during the first three years of life. It is a pervasive developmental disorder defined behaviorally as a syndrome consisting of abnormal development of social skills, limitations in the use of interactive language, and sensorimotor defects. Autism specifically affects brain function in the areas responsible for the development of communication and social interaction skills.

Children with autism may appear normal, but the disorder may prevent them from functioning and communicating in socially appropriate ways. The incidence of autistic disorder is seven per 10,000 persons. It is more common in males than females (4:1 ratio).

The rates of caries and periodontal disease in autistic children is comparable to those in the general population.

The exact cause of autism is unknown, although it may be linked to brain injury and genetics. There are many biologic causes, but none of them are unique to autism.

The causes of autism include:
  • There is a familial genetic tendency for autism. There is a 3-8 percent risk of recurrence if a family already has one autistic child.
  • Fragile X syndrome.
  • Tuberous sclerosis.
  • Prenatal factors such as intrauterine rubella, and cytomegalic inclusion disease.
  • Postnatal factors such as untreated phenylketonuria, infantile spasms, and herpes simplex encephalitis.

    No two children affected by autism display the same behaviors or symptoms.

  • A baby who doesn’t babble or gesture by the age of 12 months.
  • A baby who lacks eye contact with its mother by the age of 12 months.
  • A baby who resists being held or cuddled by its mother.
  • A baby who doesn’t respond when its mother says its name.
  • A baby who appears to be deaf.
  • An infant who doesn’t say single words by the age of 16 months.

  • Autistic children will often run away from caretakers or health care workers. This activity is called elopement.
  • About 50% of autistic children are non-verbal.
  • Autistic children may appear stubborn.
  • They may exhibit echolalia, or may exhibit rambling speech.
  • They may exhibit unusual self-stimulating behavior including hand flapping or rocking back and forth.
  • They may appear deaf or not responsive to you.
  • They may not be able to answer simple questions.
  • They may be sensitive to sound, bright lights, odors, and touch.
  • Seizures occur in 25% of autistic children.

    Experienced clinicians can reliably diagnose autism in children younger than three years of age. The typical presenting symptoms of autistic disorder are delayed speech, or challenging behavior before the age of three.

  • No babbling, pointing, or other gestures by age 12 months.
  • No single words by 16 months of age.
  • No two-word spontaneous phrases by 24 months of age.
  • Loss of previously learned language or social skills at any age.

  • Two levels of evaluation are needed: First, a general screening for developmental problems or risk factors. Second, another evaluation is needed to actually establish the diagnosis of autism.
  • Metabolic and/or genetic testing to rule out other conditions with manifestations similar to autism.
  • Serologic studies, to see if a child has been infected with herpes simplex, intrauterine rubella, or cytomegalic inclusion disease.
  • Hearing tests, to determine if language delay is due to a hearing problem. Two hearing tests are used: the behavioral audiometry test, and the brainstem auditory evoked responsies test.
  • Neuroimaging, such as MRI, is performed if a structural brain lesion is suspected.

  • Rett’s syndrome.
  • Asperger’s disorder.
  • Childhood disintegrative disorder.
  • Stereotypic movement disorder
  • Selective mutism.
  • Schizophrenia with childhood onset.

    Although there is currently no cure for autism, early diagnosis and intervention can significantly enhance the child’s social functioning later in life. Early detection and early intensive remedial education and behavioral therapy are the most important measure which need to be taken. Patience and time are vital to working with these children.

  • Impairment of social skills.
  • Echolalia.
  • Sensorimotor deficiencies.
  • Limited interactive language skills.
  • Seizure disorders.
  • Mental retardation.
  • Stereotypic behavior.
  • Self-injurious behavior.
  • Problems with symbolic thinking.

  • Offer parents and children the opportunity to tour your dental office, so that they may ask questions, touch equipment, and get used to the place. Allow autistic children to bring comfort items, such as a blanket or a favorite toy.
  • Children with autism need sameness and continuity in their environment. A gradual and slow exposure to the dental office and staff is therefore recommended.
  • Solicit suggestions from the parent or caregiver on how best to deal with the child.
  • Children with autism are easily overwhelmed by sensory overload. This can cause “stimming” (flapping of arms, rocking, screaming, etc). Autistic children are hypersensitive to loud noises, sudden movement, and things that are felt.
  • Make the first appointment short and positive.
  • Approach the autistic child in a quiet, non-threatening manner. Don’t crowd the child.
  • Use a “tell-show-do” approach to providing care. Explain the procedure before it occurs. Show the instruments that you will use. Provide frequent praise for acceptable behavior.
  • Invite the child to sit alone in the dental chair to become familiar with the treatment setting.
  • Autistics will want to know what’s going to happen next. Explain what you’re doing so it makes sense to them. Explain every treatment before it happens.
  • Always tell the autistic child where and why you need to touch them, especially when using dental or medical equipment.
  • Talk in direct, short phrases. Talk calmly. Autistics take everything literally – so watch what you say. Avoid words or phrases with double meanings.
  • Once the dental patient is seated, begin a cursory examination using only your fingers. Keep the light out of the eyes.
  • Next, use a toothbrush, or possibly a dental mirror to gain access to the mouth.
  • Praise and reinforce good behavior. Ignore poor behavior.
  • Invite the parent of caregiver to hold the child’s hand during the dental examination.
  • Some autistic children can be calmed by moderate pressure, such as by using a papoose board to wrap the child. One the other hand, “light” touch (such as by air from the dental air syringe) can agitate them. For instance, you are more likely to have problems wrapping a blood pressure cuff around the arm than by inflating it!
  • Some children will need sedation or general anesthesia so that dental treatment can be accomplished. Sedation of autistic children who are 8 years and older simply does not work.

    An article in the American Family Physician discusses the definition of autism, its epidemiology, etiology, recognition and screening, clinical course, and management.

    Prater CD, Zylstra RG. Autism: A medical primer. American Family Physician 2002; 66: 1667-1674.

    Copyright ©2005 Daniel Ravel DDS, FAAPD

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