Treating Wear from Bruxism in Autistic Patients

Inside PERIODONTICS PEER-REVIEWED

Treating Wear From Bruxism in Autistic Patients Crown-lengthening surgery offers conservative alternative to extraction and implant placement Ahmad Soolari, DMD, MS | William E. Kelson, DDS

utism is a developmental and severely worn-down dentition in patients enamel dysplasia, occlusal disharmony, teeth disorder with manifesta- with autism can be challenging, particularly without clinical crowns, and major esthetic tions that include severe because they have difficulty complying with compromise. His condition resulted from a deficits in communication, the at-home care parts of the process. lack of an organized approach to oral care and and children with autism rehabilitation. The patient’s chief complaints commonly engage in brux- Case Report were pain, tooth sensitivity, and difficulty eat- ism (ie, teeth grinding) A 36-year-old male patient was referred ing. In addition, he had a history of excessive during sleep.1 This habit can affect occlusion, for specialty care to coordinate a combined grinding and clenching of the teeth. Clini- Amastication, speech, appearance, self-esteem, periodontal-prosthodontic treatment. The cal and radiographic evaluations were per- and quality of life. In the United States, an es- patient had a medical diagnosis of autism formed, which revealed a severely worn-down timated 2.8% of children aged 3 to 17 years are that required 24-hour home supervision as dentition (Figure 1). In order to facilitate the diagnosed with autism. Some receive no treat- well as a history of incomplete restorative necessary prosthodontic treatment that the ment at all, whereas others are treated either dentistry, bruxism, regurgitation, acid ero- patient required to regain dental function with medication or behavioral therapy.2 The sion, over-retained stainless steel crowns, and improve his speech and esthetics, surgical most frequent oral findings among autistic patients are bruxism, self-inflicted oral lesions, and malocclusions, and behavioral therapy is not expected to resolve bruxism.3 Because autism spectrum disorder inhibits communication and social interaction skills, the process of providing dental hygiene treatment and services to these patients is com- plex. Treating malocclusion, bruxism, pain,

AHMAD SOOLARI, DMD, MS Diplomate American Board of Periodontology

Private Practice Gaithersburg, Potomac, and Silver FIG. 1 Spring, Maryland

WILLIAM E. KELSON, DDS Private Practice Silver Spring, Maryland FIG. 2 FIG. 3 Member Robert T. Freeman Dental Society (1.) Pretreatment full-mouth series of radiographs showing extreme wear on the mandibular anterior teeth and premolars. (2.) Pretreatment retracted facial view following preparation and placement of a temporary mandibular prosthesis. (3.) Pretreatment retracted facial view of mandibular anterior teeth after removal of the temporary prosthesis, showing a significant loss of vertical dimension.

24 INSIDE DENTISTRY | August 2020 | www.insidedentistry.net CareShield TM crown lengthening was recommended. Following crown lengthening, the patient would be restored with dental crowns for teeth Nos. 19 through 30. This treatment plan was accepted by the patient and his caregivers.

Clinical Treatment The treatment plan was coordinated with the referring dentist, who pre- pared the teeth and placed a temporary prosthesis prior to the crown- lengthening surgery (Figure 2). Because the patient’s cognitive abilities and motor skills were developed enough to facilitate his cooperation during dental treatment, local anesthesia in the dental chair was sufficient to perform the crown-lengthening surgery. The patient and his parents were provided with education and motivated to perform an acceptable level of oral hygiene at home as well as advised to adhere to three rota- tional recall appointments between the offices of the periodontist and the primary care dentist. TM Prior to the surgery, the patient was prescribed 500 mg of amoxi- cillin to be taken 3 times a day for 1 week and 600 mg of ibuprofen to CareShield be taken as needed. At the surgical appointment, the temporary pros- An easy to use transparent barrier with an integrated HVE suc on thesis was removed from the mandibular teeth (Figure 3). Using a No. func on that removes droplets and aerosols that harbor poten ally 12 blade (No. 12 Carbon Steel Sterile Surgical Blade, Benco Dental), dangerous pathogens. envelope incisions were made from the distal aspect of tooth No. 18 to the distal aspect of tooth No. 31 to enable access to the root and bone Reasons to use CareShield via a full-thickness raised flap. Once the flap was elevated, osseous Reduces the spread of aerosols and droplets. reduction was performed 360° around the teeth (Figure 4 through Keeps personal protec ve equipment from cross contamina on. Figure 6). The flap was closed with 4.0 silk sutures, and then a peri- Improves the overall experience of your pa ents and your sta . odontal dressing (COE-PAK™ AUTOMIX, GC America) was placed. Stays in place with an easy to set up Handsfree Stand. The patient’s healing progression following the surgical procedure was within normal limits. Transparent The purpose of the crown-lengthening surgery was to increase the Disposable Shield surface area of the crown preparations because minimal clinical crown was present. Four weeks after the surgery, the general dentist com- pleted the crown preparations and took an impression, and the crowns for teeth Nos. 19 through 30 were delivered 2 weeks later (ie, 6 weeks after crown lengthening). The crowns were fabricated with an occlusal design that facilitated intercuspation, which limits lateral movement and reduces the potential for bruxing. At the 3-month recall appointment, the patient’s parents stated that he was no longer grinding his Autoclavable teeth and was able to chew solid food properly. Photographs and radio- Connector graphs taken 1 year after treatment demonstrate that all of the treated teeth are fully functional with no mobility, no widened periodontal liga- ment, no endodontic treatment, and no bleeding on probing (Figure 7 Call us Today! 203.491.2273 through Figure 12). Distributed & Available in USA by Directa Inc. For this patient, crown-lengthening surgery produced a stable dental Available through your favorite dealer. condition within 1 year with a concomitant decrease in clenching and grinding, which may possibly be attributed to a reduction in sensitivity following placement of the final crowns. Long-term care included A Division of DirectaDentalGroup increasing the frequency and efficiency of oral hygiene measures with the help of the patient’s caregivers, application of a fluoride gel or rinse, intake of healthy noncariogenic foods, and frequent recall appointments. In addition, future treatment was discussed, which would focus on the upper jaw with similar management. (Circle 12 on Reader Service Card)

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FIG. 5

FIG. 4 FIG. 6

(4.) Postoperative retracted right lateral view of crown-lengthening surgery. (5.) Postoperative retracted facial view. (6.) Postoperative retracted left lateral view.

Discussion implant cases develop complications within Many individuals who have disabilities— “For this patient, crown- 10 years of insertion.7 With this patient’s age physical or developmental—typically do lengthening surgery of 36 and an expected life-span of 70 to 80 not have the financial resources to obtain years, maintenance of the natural teeth was medical and dental care, and this can lead produced a stable dental the best plan, and implants can still be con- to progressively adverse effects. Ultimately, sidered when he is older should his natu- financial constraints become a deciding condition within 1 year ral teeth fail. Preservation of the natural factor when considering possible treat- with a concomitant dentition is typically preferred by patients ment modalities. For the patient in this and is economically justifiable.8 Because case report, the treatment options included decrease in clenching this patient required assistance with basic saving teeth with minimal to no clinical activities of daily living, it was assumed that crowns or extracting them and delivering and grinding, which may his risk of developing complications from a removable or fixed prosthesis. The fixed possibly be attributed dental implants would have been higher,9 option would require the placement of den- and that the cost of maintenance would be tal implants following tooth extraction, and to a reduction in correspondingly higher than that of his nat- the incidence of implant-related complica- sensitivity following ural teeth.10 tions is on the rise. Surgical crown lengthening must include Most dental treatments for children with placement of the final the consideration of factors such as biologic autism, who often have nutritional prob- width, attached gingiva, furcations, restorative lems, are tooth extractions, and the rate of crowns.” needs (eg, ferrule), and the loss of bone sup- utilization of dental services for this group port around adjacent teeth. In this case, the is low.4 The oral health status of children purpose of crown-lengthening surgery was to with autism can be negatively affected by a case is to remove the affected teeth and provide proper resistance and retention form factors such as eating problems, clench- replace them with dental implants. How- for the restorations while avoiding biologic ing and grinding behaviors, sleep disorders, ever, in this case, crown-lengthening sur- width invasion, which can feel like a splinter. and speech impediments; therefore, caregiv- gery offered a good therapeutic prognosis, This requires 3 mm of space between the mar- ers should be informed and encouraged to especially considering that implant therapy gin of the restoration and the bone. provide the dental care that patients with was not a treatment of choice for this patient Prior to crown-lengthening surgery, it autism require.4 because of his grinding habit, the longevity is highly recommended to break contact For the patient in this case report, clinical of implants in patients with severely worn- points, prepare the teeth, and place well- observation revealed severely worn-down down dentition does not surpass that of com- fitted provisional restorations that can be dentition, loss of vertical dimension, and promised but successfully treated natural easily removed. Delivery of restorations fol- traumatic occlusion. Currently, the first teeth,5 and biologic and prosthetic compli- lowing crown-lengthening surgery is rapid treatment option that is usually recom- cations commonly develop over time.6 Lang and simple because crown-lengthening sur- mended in the dental community for such and colleagues estimated that up to 50% of gery enables easier impressions, less stress

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FIG. 7 FIG. 8

FIG. 9

FIG. 12

(7.) One-year posttreatment retracted right lateral view of the final restorations. (8.) One-year posttreatment retracted facial view. (9.) One-year posttreatment retracted occlusal view. (10.) One-year posttreatment retracted left lateral view. (11. AND 12.) Comparison of pretreatment radiograph and FIG. 10 FIG. 11 1-year posttreatment radiograph. for the primary care dentist, and more pre- behaviors and reactions to the dentist’s treatment outcomes. The goal is to develop dictable results. The patient in this case commands. A dental appointment is a sig- a long-term relationship in an office setting report was happy with the outcome, and nificant event for most patients but is espe- that minimizes anxiety so that you can pro- the restorative dentist was pleased with the cially stressful for the guardian of an autistic vide quality dental care. efficiency of the work. The patient wanted patient. Dental professionals should make Other modifications to improve the treat- restoration of his lost dentition and to be the visit simpler and easier for everyone ment experience for autistic patients include disease-free while the restorative specialist by reviewing the patient’s medical, dental, minimizing distractions (eg, no staff mem- wanted to deliver a long-term restoration and psychological history and preferences bers should enter the treatment room if they in a healthy environment. The provision of in advance. Parents of autistic children want are not directly involved in the care of the crown-lengthening surgery enabled the res- to ensure that their child will receive per- patient) and limiting the noise to soothing, toration of teeth that would otherwise have sonalized, attentive, and predictable care to rhythmic music. In addition, ceiling lights needed to be extracted, and the outcome of minimize the number of future visits. may be turned off, the patient may be sup- the team approach was restored function, Proper preparation by the dental prac- plied with dark protective goggles with side stability, and an esthetic appearance. tice is essential. The practice should con- shields to minimize peripheral vision, and the When developing a treatment plan, den- tact the patient’s treating physician, educa- surgical area may be covered with a periodontal professionals are taught to address the tors, mental health counselor, and general tal dressing to prevent the patient’s access to patient’s chief complaint, but autistic dental dentist prior to the appointment to get to the sutures and to increase comfort. Parents patients may not be able to effectively com- know the patient and his or her caregivers. or caregivers should be educated about the municate, which can complicate their oral Assign a specific staff member to extend a procedure that will be performed and given healthcare. A personalized, preventive, and warm and welcoming phone call to the fam- both oral and written instructions for home predictable treatment plan should be for- ily, set up a short appointment, and fill out care. A follow-up phone call should be made mulated. This requires the cooperation of all of the necessary paperwork in advance in to ensure that the patient is not experienc- parents or caregivers and a thorough under- order to avoid an extended wait. Having to ing any pain, swelling, or discharge. Overall, standing by the dentist and dental assistant sit in the waiting room while administrative the dental treatment and management of of the individual patient’s needs. When deal- matters are handled can frustrate attention- patients with autism requires a family-cen- ing with autistic patients, emotional skills deficient autistic patients. Not having to wait tered approach that addresses the concerns are more useful than intellectual and clin- creates trust in the dental staff, and this and preferences of caregivers in tandem with ical skills,11 and patients will vary in their trust is a currency for delivering successful the needs and behaviors of patients.12 Oral

28 INSIDE DENTISTRY | August 2020 | www.insidedentistry.net home care for autistic patients should be tai- preserving patients’ natural dentition with Implants Res. 2007;18(Suppl 3):15-19. lored to suit their abilities and may include good occlusal harmony. The treatment did 6. Derks J, Schaller D, Håkansson J, et al. Effectiveness of the use of an electric toothbrush, topical not eliminate all of the etiological factors of implant therapy analyzed in a Swedish population: prev- fluoride applied with a toothbrush, and due bruxism, but it did alter the magnitude and alence of peri-implantitis. J Dent Res. 2016;95(1):43-49. to their reduced ability to perform self-care, direction of the condition by changing the 7. Lang NP, Berglundh T, Heitz-Mayfield LJ, et al. more frequent prophy appointments to aid occlusal scheme, which resulted in the elim- Consensus statements and recommended clinical pro- in maintaining the restorations and prevent ination of pain as well as improved chewing cedures regarding implant survival and complications. recurrent decay. efficiency, sleep patterns, speech, appearance, Int J Oral Maxillofac Implants. 2004;19(Suppl):150-154. and psychological well-being. 8. Donos N, Laurell L, Mardas N. Hierarchical decisions Concluding Remarks on teeth vs. implants in the periodontitis-susceptible For the patient in this case report, crown- References patient: the modern dilemma. Periodontol 2000. lengthening surgery yielded a favorable 1. Muthu MS, Prathibha KM. Management of a child 2012;59(1):89-110. long-term prognosis, allowing him to retain with autism and severe bruxism: a case report. J Indian 9. Lindhe J, Meyle J, Group D of European Workshop on his natural dentition and avoid unneces- Soc Pedod Prev Dent. 2008;26(2):82-84. Periodontology. Peri-implant diseases: consensus report sary extractions and the insertion of dental 2. Xu G, Strathearn L, Liu B, et al. Prevalence and treat- of the sixth European workshop on periodontology. J implants. Dentists should be tolerant with ment patterns of autism spectrum disorder in the United Clin Periodontol. 2008;35(8 Suppl):282-285. autistic patients and plan ahead for the fac- States, 2016. JAMA Pediatr. 2019;173(2):153-159. 10. Fardal Ø, Grytten J. A comparison of teeth and im- tors involved in their visit and treatment in 3. Orellana LM, Silvestre FJ, Martínez-Sanchis S, et al. plants during maintenance therapy in terms of the num- order to produce favorable results that ben- Oral manifestations in a group of adults with autism ber of disease-free years and costs -- an in vivo internal efit all parties involved. spectrum disorder. Med Oral Patol Oral Cir Bucal. control study. J Clin Periodontol. 2013;40(6):645-651. The results of this case demonstrate that 2012;17(3):e415-e419. 11. Chandrashekhar S, Bommangoudar JS. Management teeth with minimal clinical crowns can be 4. Onol S, Kirzioğlu Z. Evaluation of oral health status of autistic patients in dental office: a clinical update.Int retained with the aid of appropriate peri- and influential factors in children with autism.Niger J J Clin Pediatr Dent. 2018;11(3):219-227. odontal surgery. Crown-lengthening sur- Clin Pract. 2018;21(4):429-435. 12. Gandhi RP, Klein U. Autism spectrum disorders: an gery increases the amount of coronal tooth 5. Holm-Pedersen P, Lang NP, Müller F. What are update on oral health management. J Evid Based Dent structure available to retain restorations, the longevities of teeth and oral implants? Clin Oral Pract. 2014;14(Suppl):115-126.

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