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For most people, the beginning of each day is generally structured and routine. However, for people with autism, the day is anything but predictable. Things that did not affect them one day can cause them to have emotional and physical outbursts on another. Autism is not a cookie-cutter disorder; it does not affect any two people the same way.
It can be difficult to make sense of the disorder; virtually none of the questions about autism can be answered with repeatable scientific certainty. How can dentists treat patients with autism confidently and consistently to assure the long-term success of their procedures? The answer is, they can’t.
What every dentist can do is understand what autism is and is not, and prepare for the unknown. It is important to be knowledgeable on what is known about autism and compassionate about the elements that are still unknown and controversial. This will enable dental providers to advocate for patients with autism and their families.
What is Autism?
Autism is a developmental neuropsychiatric disorder that was first described in 1943 by the American child psychologist Leo Kanner.1 It is described in three diagnostic behavioral domains: impairments in social interactions, impairments in communication, and repetitive or restrictive behaviors.2
Autism is divided into three diagnostic groups: autistic disorder, Asperger syndrome, and pervasive developmental disorder-not otherwise specified. Severity varies within all three of these groups, giving rise to the concept of an autism spectrum.3
In the United States alone, there are more than 3 million people with autism. The most recent findings posted by the Centers for Disease Control and Prevention (CDC) in March 2014 showed 1 in 68 children being diagnosed on the autism spectrum. This is a 62% increase over the past 10 years. Males are four to five times more likely to be diagnosed than females; however, females are more likely to exhibit more severe mental retardation.4
What We Know
Researchers have been unable to determine the exact cause of autism, and there are currently no biological tests to diagnose it. This has led to debate and controversy between researchers, health care providers, and family members as to whether the disorder is caused by genetic defects, environmental factors, or a combination of both.3,5-9
Studies have shown higher rates of autism in parts of the country where there are greater levels of environmental pollutants.7 However, there is no scientific proof that environmental factors are the direct cause for the increase. This point has ignited much controversy and has resulted in strong conflicting opinions between modern medicine and alternative medicine and between doctors and family members. All sides have valid points supporting their stance on the issue, but repeatable scientific results are still lacking.
What sparks concerns for family members of people with autism is the potential association of environmental toxins with this disorder and their effect on health, behavior, and possible future “recovery.” This can lead to conflicting opinions between family members and dental care practitioners on materials and procedures used during dental treatment of patients with autism.
Regardless of the cause, one fact remains indisputable: there is no cure for autism. Without a known cause or cure, solutions will only come from a comprehensive collaboration of all parties to determine the best course of treatment for patients with autism.
Dentistry-Related Battleground Topics
Mercury
Dental amalgam fillings are considered a safe and effective restorative material.10 The American Dental Association11 and U.S. Food and Drug Administration12 both support this position. Amalgam fillings are easily placed and are not affected by moisture contamination, which is valuable for treating patients who have a difficult time keeping still.
Alternative medical literature suggests that children who have autism are genetically predisposed to an inability to clear the body of heavy metal contaminants such as aluminum or mercury.13-16 A 2007 study showed an excess of mercury in the dental pulps of primary teeth in children with autism.17 The results, however, could not be replicated. Nevertheless, family members have great concerns about the use of dental amalgam for restoring cavities in teeth.
Dentists need to be aware of this study and be prepared to discuss alternative choices for the materials used. Both resin composites and resin-reinforced glass ionomers can be used instead of amalgam as long as the dentist and family members discuss the longevity factors associated with each—especially the potential for moisture contamination—during the consent process prior to starting treatment. The decision factors for each of these options are summarized in Table 1.
Fluoride and Xerostomia
Another topic of concern for some parents of children with autism is the use of fluoride. Alternative medical literature suggests that fluoride inhibits critical antioxidant enzymes and has been linked to excitotoxic reactions within the brain.18 Some patients with autism have a difficult time rinsing and spitting after brushing, or may tend to eat the toothpaste. This can lead to serious concerns about gastrointestinal irritation and fluorosis.19 Parents may believe limiting the amount of fluoride or eliminating fluoride altogether will benefit their child.
Studies have shown that children who have autism tend to have a lower caries rate than children in the general population; however, the presence of plaque is consistently higher in children who have autism.20 This is caused by poor oral hygiene, special diets of soft foods that can stick to the teeth, and certain habits such as pocketing food in the cheeks and mouth breathing, all of which can contribute to tooth decay.21
Another dental concern stems from the use of psychotropic and anti-seizure medications by patients with autism. In a study of children with autism spectrum disorder, 56% were prescribed at least one psychotropic medication.22 These medications are known to cause xerostomia. Nearly 25% were treated with anti-seizure medications, which can also cause xerostomia as well as gingival overgrowth. Both classes of medication can lead to an increase in the risk of caries.23 Dentists need to counsel parents with concerns about fluoride use on alternative solutions, including more frequent prophylaxis visits, the use of fluoride varnish, parent-assisted oral hygiene home care, and occupational therapy to help children who have autism learn and accept tooth brushing. Eliminating fluoride completely is not the solution. However, understanding individual children’s needs and abilities along with parents’ concerns will ultimately lead to a hygiene protocol upon which everyone can agree.
Sedation/Immobilization
The final area that brings the most fear and conflict is the topic of sedation/immobilization. The main challenge to the dental team may be the reduced ability of patients with autism to communicate and relate to others.24 Children with autism disorders are highly sensitized to various things like bright lights, loud noises, and sudden movements, which can make routine dental treatment unpredictable, time consuming, and dangerous for both the child and the dental team. Many dentists immediately refer children with autism to be sedated because of these challenges, but not every child needs sedation. Managing the patient with autism in the dental office often requires a time-consuming conditioning and positive reinforcement process before treatment can be started.25 Appropriate scheduling and shorter appointment times are key for success.
When sedation is necessary, the three most common forms are nitrous oxide, oral sedation, and intravenous sedation. Some studies have recommended the use of nitrous oxide for patients with autism who have mild behavioral issues.26,27 However, there are others who do not recommend the use of nitrous oxide for patients with autism because there may be a potential risk for serious systemic adverse effects.28 Regardless of the type of sedation recommended, the patient’s general physician should be consulted for possible adverse effects prior to treatment, and family members should be informed of all possible complications.
Immobilization techniques are occasionally used, because patients with autism frequently have issues with support, balance, and even aggressive behaviors. This can be a danger to both the patient and dental team. Stabilization can be obtained by having team members restrain the patient’s legs and arms or by using a restraint board, as shown in Figure 1 through Figure 5. There is controversy among dentists over the use of physical restraints for patients with autism. Case reports and studies from occupational therapists have shown that applying a firm wrap, firm pressure, and/or firm touch to patients with autism can have a relaxing and calming effect.29 Regardless of an individual dentist’s professional stance on the use of protective stabilization techniques, it is of vital importance to discuss the pros and cons with the family members and obtain their written consent prior to treatment. In some cases, the use of stabilization techniques can eliminate the need for sedation. This can allow procedures to be done in dental offices quickly and without the risks of any systemic side effects from sedation medications.
Conclusion
Treating patients with autism can be one of the most challenging parts of a practitioner’s job but also one of the most rewarding. The uncertainty, the fear of the unknown, and the extra effort required to step outside the normal routine of the dental practice are the road blocks dentists experience when patients with autism walk into their practice. However, with the entire dental team working together in conjunction with the family members, dentists can play a huge role in the long-term care and health of patients with autism.
Understanding concerns from family members about sensitive topics regarding dental procedures such as the use of dental amalgam, fluoride, and sedation/immobilization, dentists can help guide family members in making the proper informed decisions about the best dental care for their loved ones. Family members are one of the biggest assets in treating patients with autism, so dentists will benefit from openly communicating with them regarding their concerns and valuing their input. This collaboration can provide both a positive dental experience and a successful plan for long-term dental health.
References
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2. Steyaert JG, De la Marche W. What’s new in autism? Eur J Pediatr. 2008;167(10):1091-1101.
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11. Statement on dental amalgam. American Dental Association website. www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-dental-amalgam. Accessed October 21, 2014.
12. About dental amalgam fillings. Food and Drug Administration website. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DentalProducts/DentalAmalgam/ucm171094.htm. June 6, 2014. Accessed October 21, 2014.
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About the Author
Jacob Dent, DDS
Sugar Land Modern Dentistry
Sugar Land, Texas
