Med Oral Patol Oral Cir Bucal. 2013 Nov 1;18 (6):e862-8. Dental management of the autistic child Journal section: Medically compromised patients in Dentistry doi:10.4317/medoral.19084 Publication Types: Review http://dx.doi.org/doi:10.4317/medoral.19084 Management of children with autism spectrum disorder in the dental setting: Concerns, behavioural approaches and recommendations Konstantina Delli 1, Peter A. Reichart 2, Michael M. Bornstein 3, Christos Livas 4 1 Oral Medicine and Pathology Specialist and Researcher, Department of Oral and Maxillofacial Surgery, University of Gronin- gen, University Medical Centre Groningen, The Netherlands 2 Visiting Professor, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Switzerland 3 Senior Lecturer, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Switzerland 4 Consultant, Department of Orthodontics, University of Groningen, University Medical Centre Groningen, The Netherlands Correspondence: Department of Orthodontics University of Groningen University Medical Centre Groningen Hanzeplein 1. Postbus 30.001 9700 Delli K, Reichart PA, Bornstein MM, Livas C. Management of children RB Groningen, The Netherlands with autism spectrum disorder in the dental setting: Concerns, beha- [email protected] vioural approaches and recommendations.���������������������������� Med Oral Patol Oral Cir Bu- cal. 2013 Nov 1;18 (6):e862-8. http://www.medicinaoral.com/medoralfree01/v18i6/medoralv18i6p862.pdf Received: 23/01/2013 Article Number: 19084 http://www.medicinaoral.com/ Accepted: 23/05/2013 © Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946 eMail: [email protected] Indexed in: Science Citation Index Expanded Journal Citation Reports Index Medicus, MEDLINE, PubMed Scopus, Embase and Emcare Indice Médico Español Abstract Objectives: This article reviews the present literature on the issues encountered while coping with children with autistic spectrum disorder from the dental perspective. The autistic patient profile and external factors affecting the oral health status of this patient population are discussed upon the existing body of evidence. Material and Methods: The MEDLINE database was searched using the terms ‘Autistic Disorder’, ‘Behaviour Control/methods’, ‘Child’, ‘Dental care for disabled’, ‘Education’, ‘Oral Health’, and ‘Pediatric Dentistry’ to locate related articles published up to January 2013. Results: Most of the relevant studies indicate poor oral hygiene whereas they are inconclusive regarding the caries incidence in autistic individuals. Undergraduate dental education appears to determine the competence of dental professionals to treat developmentally disabled children and account partly for compromised access to dental care. Dental management of an autistic child requires in-depth understanding of the background of the autism and available behavioural guidance theories. The dental professional should be flexible to modify the treatment approach according to the individual patient needs. Key words: Autism spectrum disorder, dental management, children. e862 Med Oral Patol Oral Cir Bucal. 2013 Nov 1;18 (6):e862-8. Dental management of the autistic child Introduction with the Boolean operators ‘AND’ and ‘OR’. Our aim Autism spectrum disorder (ASD) refers to a group of was to identify studies on the dental related problemati- neurodevelopmental disabilities with a core set of defin- que of children with ASD published up to January 2013. ing criteria that comprise impaired social interaction, In this review article, aspects requiring attention in the communication, and restricted or repetitive behavioural management of autistic children from the dental pers- stereotypes. The spectrum consists of autism, Asperger pective are summarized. Disorder (AD), and Pervasive Developmental Disorder- Not Otherwise Specified (PDD-NOS), which differ in Oral health and autism the number and severity of diagnostic features (1). Conflicting results have emerged by the limited number The etiologic background of ASD, though not yet com- of studies that carried out normative oral health assess���- pletely understood, is considered to implicate both ge- ment in children with ASD (1,5,9-16) (Table 1). In this netic and environmental factors. Recent research work has elucidated that parameters such as CNTNAP2 gene, de novo mutations, mitochondrial defects (2), cytokine - dysregulation, high maternally derived intrauterine an- drogen concentrations, and advancing maternal age (3) India India India Israel Spain Emirates Emirates may be involved in the pathophysiology of autism. Based Country United Arab on lately published data (4), ASD prevalence underwent a substantial increase within a decade of surveillance, estimated at 11.3 per 1,000, i.e. one in 88, children aged 8 years. In addition, a male: female ratio of 4.6: 1 has - United States analysis analysis analysis analysis Statistical significance No statistical been reported on the gender-specific epidemiology of No statistical the autistic disorder. The symptomatology of ASD initiates before the third year of age and generally undergoes a steady course Not level level Lower Lower without remission through ageing (5,6). Established fea- Lower investigated tures in the autistic child such as marked impairment in Oral hygiene the use of multiple non-verbal communications, failure to develop social relationships and share experiences - Lower SS Thailand analysis analysis and interests, delay or complete lack of linguistic de- analysis Statistical significance No statistical velopment as well as inflexible adherence to rituals (7), No statistical potentially coexisting with sensory disabilities, mental retardation or epilepsy (6), may hinder professionally Not Lower Lower SS Lower Lower NSS Lower SS delivered and home dental care placing individuals with Lower Lower NSS Lower SS Caries Higher SS Lower SS Higher SS Lower SS Variable NSS Higher NSS Turkey prevalence prevalence ASD at high risk for oral diseases. investigated Furthermore, the psychological well-being of parents of a child with diagnosed ASD is significantly influenced by the behavioural difficulties of their offspring. Synop- 0 0 30 50 61 48 sis of the existing literature reveals accentuated stress, 386 more psychological distress and depressive signs, low- 16 (DD) Lower NSS Higher NSS United States 12 (SCHI)(NI) Higher 43 (MR), (CP),29 ered living standards and increased rates of physical and 16 (DS), 26 (OTH) mental health problems in guardians of autistic children (7). Upbringing a child with ASD generates stressful 30 61 22 32 39 106 101 395 483 conditions which in most cases are associated with ad- (NI) 15 (I), 17 aptation to child’s routine, interference with education Subjects (N) Controls (n) and health care systems, coordination of multidiscipli- nary caregivers, and limited availability of resources (8). Subsequently, a scheduled dental visit may repre- *** *** sent a major ordeal for all parties involved; children , with autism, parents and care providers. A MEDLINE (www.ncbi.nlm.nih.gov/pubmed) search Study was conducted using alternatively the Medical Subject Headings terms ‘Autistic Disorder’, ‘Behaviour Control/ methods’, ‘Child’, ‘Dental care for disabled’, ‘Educa- Studies that evaluated theoral health status in autistic patient groups. tion’, ‘Oral Health’, and ‘Pediatric Dentistry’ combined Subramaniam and Gupta, 2012 (6)* Vishnu et (7)** al. 2012 Rai et 2012 al. (8)***** Orellana al.2012et (9)**** Jaber (10)*** 2011 Altun et (11)*** al. 2010 Luppanapornlarp et 2010 al. (12)*** Loo et 2009 al. (2)*** 2007 DeMattei al. (13)**** et Shapira et (14) al. 1989 Table 1. Table *: *: Results compared to other studies, Results**: of children in primary dentition comparedcomparison to at childrenthe p<0.05 level of significance,in mixed Statistical ****: and permanent comparison dentitions, at the levelof p<0.01 significance, Statistical***: Statistical*****: comparisonsignificance, of level at the MR:Mental p<0.001 Retardation, CerebralCP; Down DS: Syndrome,Palsy, OTH: Other Disability, DevelopmentalDD: Disabilities, I: Institu tionalized, NI: Nonistitutionalized, SCH: Schizophrenic patients, Statistically SS: significant results,No statisticallyNSS: significant results. e863 Med Oral Patol Oral Cir Bucal. 2013 Nov 1;18 (6):e862-8. Dental management of the autistic child context, higher caries prevalence has been previously Barriers to dental care access reported for autistic populations compared to other oral Child’s attitude towards dental procedures, expenditure conditions (10), non-autistic controls (5), and schizo- and lack of insurance coverage have been acknowledged phrenic patients (16). In contrast, lower caries indices as the main burdens to oral care delivery for children with in rela�����������������������������������������������tion to healthy siblings (1,�������������������11) and developmen- ASD by a recent large-scale parent survey (19). Aversion to tally disabled children (15) have been also assigned to dental treatment, complications associated with the medical ASD patients. Interestingly, there have been merely two condition, and difficulties in locating a practitioner willing controlled studies with unaffected counterparts that an- to provide care have been further reported by guardians of nounced statistically significant caries susceptibility for children with autism and other developmental disabilities autistic samples, either higher (5) or lower