Mental Health

Autism: Dentistry Necessities for Autistic Individuals

MedPiper Technologies and JournoMed with Daffodil Health conducted a webinar on April 22, 2022, titled “Celebrating Autism – An Awareness Webinar in Association with Daffodil Health” where the speaker Dr. T. Paavani covered the various orthodontics aspects in autistic individuals.

Dr. T. Paavani is the Chief Pediatric Dentist and Myofunctional Orthodontist and founded Dantham Dental Hospital, Nugumbakkam in 2016. She works in special kids’ care and is a committee member of the federation of special kids’ dentistry.

Diagnostic Criteria for Autism (NAPC – National Autism Plan for Children)

A total of six items from criteria 1,2 and 3, with at least two from criteria 1, and one each from criteria 2 and 3.

  1. Qualitative impairment in social interaction:
    1. Marked impairment in the use of multiple non-verbal behaviours such as eye to eye gaze, facial expression, body posture, and gestures to regulate social interaction.
    2. Failure to develop peer relationships appropriate to developmental level.
    3. Lack of spontaneous speaking to share enjoyment, interests, and achievements with other people (eg lack of showing, bringing or pointing out objects of interest)
    4. Lack of social or emotional reciprocity.
  2. Qualitative impairment in communication:
    • Delay in or total lack of development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime.)

A dentist must be able to identify that the child is autistic since the parents may not be forthcoming with this information as they are only there for orthodontic procedures but it changes the management plan.

Drugs given to Autistic Individuals and their side effects on oral health

  • CNS stimulants – Methylphenidate
  • Antipsychotics – Clozapine and Olansepin
  • Anticonvulsants – Carbamazepine and valproate
  • Antihypertertensive – Clonidine

They mostly cause xerostomia (dryness of the mouth), dysphasia (difficulty in swallowing), tongue edema, gingivitis, gum swelling, bruxism (teeth rubbing), and sialoadenitis. Saliva contains fluoride and when less saliva is secreted, there is an increased risk of developing cavities.

Dental Problems that can arise in Autistic Individuals

  • Delayed eruption – This is due to gingival hypertrophy caused by phenytoin.
  • Gum issues – institutionalised autistic individuals who have a higher frequency of more serious periodontal problems but exhibited low caries. According to Chandrasekhar et al, the unique fixation of diet and preference for low textured food by these patients can contribute to the low incidence of caries. But others observed that children with autism have poor tongue coordination and prefer soft and sweetened food and tend to pouch food inside their mouth instead of swallowing it. This long-time presence of food within the oral cavity and difficulty in brushing and flossing, and high sensitivity to taste of toothpaste increase the risk of caries.
  • Parents must instruct and reinforce the tooth brushing technique in an encouraging manner while avoiding bright lights and loud sounds. The technique must be broken down into simple steps.

Oral Hygiene Aids for Autistic Individuals

  • Low, Mild or no taste toothpaste.
  • A soft toothbrush having a three-faced head. A foam or stress ball can also be wrapped around the handle of the toothbrush.

Changes in Dental Clinic Environment

  • Adjust the dental clinic to avoid distracting stimuli such as sound, light and taste.
  • The experimental introduction of relighting conditions, rhythmic music and deep pressure in the dental setting diminish adverse patient reactions and enhanced involvement in oral prophylactic procedures.
  • Parents must make the children familiar with the dentist beforehand.
  • Have a calm, secured sole operatory with reduced decoration and dimmed lights.
  • A single operating room may also be reserved to treat the autistic child.

Appointment Rules

  • Waiting time should not exceed 10 to 15 minutes.
  • To address autistic individuals’ preference for sameness and aversion to change, a routine should be established by maintaining days, times and personnel for each dental visit.
  • Discussion of any procedure of actual work should be avoided.
  • A dental assistant should be able to able to identify trigger points.

Behaviour Management for Dentists: Tell, Show, Do.

  • Modelling
  • Smaller Steps – let the children do tasks
  • Picture exchange communication system as visual acceptance is more
  • Restraints/Deep Pressure Touch
  • Reinforcements – negative reinforcement like drilling can be handled by doing the procedure for a predetermined period like counting.
  • Nitrous Oxide – Longer duration and higher concentration needs to be given for desired level of anesthesia.

Controversies in Dentistry Techniques to Treat Autistic Individuals

  • Fluoride Varnish Controversy – Fluoride application is a possible neurotoxin leading to GI irritation and dental fluorosis so application in autistic patients is controversial.
  • Amalgam restoration is durable and preferred to composite. Composite contain Bisphenol A which is an endocrine disrupter.

Author:

Rupali Sachdev

Rupali Sachdev is an intern doctor at Grant Medical College and Sir JJ Group of Hospitals in Mumbai. With experience in writing, design, medical technology, public speaking, and social service, she believes that doctors need to broaden their horizons and look at patient care more holistically.

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