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BALKAN JOURNAL OF DENTAL MEDICINE ISSN 2335-0245

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Dental Management of Patients with

Autism Spectrum Disorders

SUMMARY Iosif-Grigorios Al Mochamant,

Dental treatment of patients with Autism Spectrum Disorders (ASD) Ioannis Fotopoulos, Lampros Zouloumis
can be complicated because of the presence of behavioural unpredictability. Department of Hospital Dentistry
This article reviews the present literature on the issues dealt with children Aristotle University, School of Dentistry
with autistic spectrum disorder from the dental perspective. The prevalence Thessaloniki, Greece
of autism is rising worldwide. Consequently, dentists will find an increasing
number of such children in their routine practice, whose treatment will
require special considerations in their dental management. Knowledge
regarding the oral health status of autistic children is essential for the
paediatric dentists. Negative behaviour toward dental treatment was very
clear in autistic children. Self-inflicting trauma/habits were observed in
autistic children. It was concluded that the autistic children do not have a
higher dental caries score compared to that of normal children. Their oral
hygiene was fair; however, they exhibited more debris deposits than normal
children. INFORMATIVE PAPER (IP)
Keywords: Autism; Dental Management; Oral Health Balk J Dent Med, 2015; 19:124-127

Introduction pervasive developmental disorder, not otherwise specified,

specified (PDD-NOS) in the DSM-IV-TR2-4.
Dental anxiety, affecting approximately 20% of the The symptomatology of ASD initiates before the
adult population, is a feeling that something dreadful third year of age and generally undergoes a steady course
is going to happen in relation to dental treatment and is without remission through ageing. Established features in
connected to a sense of losing control. Autism spectrum the autistic child, such as marked impairment in the use
disorder (ASD) refers to a group of neuro-developmental of multiple non-verbal communications, failure to develop
disabilities based on a particular set of defining criteria social relationships and share experiences and interests,
that include impaired social interaction, communication, delay or complete lack of linguistic development, as well
and restricted or repetitive behavioural stereotypes. It is as inflexible adherence to rituals; potentially coexisting
associated with dental caries and missed appointments and with sensory disabilities, mental retardation or epilepsy,
may extend to a total avoidance of dental care, reported by may render professionally delivered and home dental
approximately 5% of the general population1-3. care inadequate, placing individuals with ASD at high
The etiologic background of ASD, though not yet risk for oral diseases. People with ASD commonly report
completely understood, is considered to implicate both abnormal responses to sensory stimuli. Over-reaction
genetic and environmental factors. It is characterized to sound and under-reaction to pain was stated by more
by persistent impairments in social interaction and than 40% of children with ASD. Sensory abnormalities
communication and restricted, repetitive patterns of affect to a greater extent those with more severe autistic
behaviour, interests, or activities and unusual sensory traits compared to those with less autistic traits. Sensory
interests or sensitivities. In the recently revised American sensitivities in children with ASD are also related to
classification system for psychiatric disorders, the DSM- behaviour difficulties in the dental office. There are still
5, ASD now includes previously separate diagnostic no studies on behaviour and experiences of dental care in
categories such as autistic disorder, Asperger disorder, and adults with ASD3,5,6.

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Balk J Dent Med, Vol 19, 2015 Dental Management of Autistic Patients 125

Children with ASD exhibit more dental behaviour of oral hygiene seen in ASD patients. They could also
management problems (uncooperative behaviours) be caused by lack of the necessary manual dexterity of
compared to typically developing children, with research autistic children, which may have resulted in inadequate
indicating that approximately 50-72% of children with tooth brushing. Furthermore, poor dental awareness,
ASD exhibit uncooperative behaviour during dental a lack of dental education and deficiency in receiving
treatment. Uncooperative and aggressive behaviour during oral hygiene instructions from dental staff seem to be
dental treatment have the potential to impede, change, or contributing factors for periodontal diseases. Another
reduce access to care for children with ASD. For instance, possible explanation for the presence of generalized
the greatest barrier to general dentists’ willingness to treat gingivitis might be the side effects of medications which
children with disabilities is the child’s behaviour, with were used to control the manifestations of autism, such
60-80% of dentists stating that they were unwilling to as psychoactive drugs or anticonvulsants, with the most
treat patients with developmental disabilities because of common drug classes being antidepressants, stimulants,
their resistive behaviours. Additionally, such behaviour and antipsychotics11-14.
may be the determining factor in deciding if restraint or Harmful oral habits are common, which consist of
pharmacologic methods are required and if treatment bruxism, tongue thrusting, picking at the gingiva and lip
can occur in the dental office setting or needs to be biting. Bruxism or forceful grinding of teeth is one of the
completed elsewhere (e.g., in a hospital, under general sleep problems which are commonly observed in children
anaesthesia)4-6. with autism. Dentist can recommend a mouth guard
to stop this self-injurious behaviour. Even though the
communication and behavioural problems in children with
autism pose challenges for the dentist, treatment given
Oral Health and Dental Patients with proper planning and a lot of patience can definitely
with ASD make a difference15,16.
The rate of dental injuries is higher among autistic
Patients with ASD do not present very specific children. The most common dental injury was enamel
oral disorders. High, otherwise paradoxical, oral health fracture and the most frequently injured teeth were the
standards observed elsewhere might be also attributed permanent maxillary central incisors15,17.
to the dental hygiene routine of children with ASD, Tooth eruption may be delayed due to phenytoin-
supervised or performed on a regular basis by parents induced gingival hyperplasia (phenytoin is commonly
and caregivers. As for dental caries, it was found that prescribed for people with autism)15,18.
institutionalized autistic individuals exhibited lower Presumably, the compromised dental status in
caries rate than institutionalized schizophrenics. In the conjunction with harmful habits including bruxism,
primary dentition, the patients with ASD demonstrated tongue, thrusting, and lip biting often displayed
a significantly higher caries rate (dmf) than the controls by children with autism may result in certain
during initial examination, but at recall examinations, malocclusions10,15.
dmf values were comparable. In patients with permanent
dentition, both at baseline and recall, DMF scores were
not different between the groups. In a recent study, autistic
individuals were compared with non-autistic healthy Management of the ASD Patient in
controls and they were found to have neither a higher Dentistry
salivary flow rate nor a better buffer capacity of the saliva
and similar dental caries experiences were observed People with ASD may be unable to cooperate in the
in both primary and permanent dentitions. In general, dental clinic due to their difficulties with social interaction
children with autism prefer soft and sweetened foods and communication. The failure to develop joint attention,
and they tend to pouch food inside the mouth instead of which means lack of curiosity for the environment and
swallowing it, due to poor tongue coordination, thereby incapability of the child to share information using
increasing the susceptibility to caries. Furthermore spoken language, gestures and eye contact, represent a big
difficulties in brushing and flossing can worsen the above challenge for a dentist. Therefore, treatment approaches
mentioned situation. Oddly, there have merely been that may produce a positive outcome in one patient may
2 controlled studies with unaffected counterparts that prove to be ineffective for another. Most importantly, the
announced statistically significant caries susceptibility for dental professional during examination should bear in
autistic samples, either higher or lower1,7-10. mind that autistic individuals exhibit wide variation in
Gingivo-periodontal pathology is more prevalent in abilities, intelligence, and performance. It is conceivable
patients with ASD compared to healthy control groups. that lack of responses to demonstrations and inability to
These differences are explained by the poorer levels establish personal contacts with the personnel may impede

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126 Iosif-Grigorios Al Mochamant et al. Balk J Dent Med, Vol 19, 2015

professional oral care proceedings. Thus, malfunction in of ASD. In dentistry, the use of these procedures has the
interpretation of stimulus intake may result in aberrant potential to improve the results of traditional behaviour
responses to visual, auditory, tactile, olfactory and management procedures. ABA principles have been also
gustatory signals. Practitioners may need to target their adopted in young autistic patients with needle phobia
therapeutic approach to the unique characteristics of each and diabetes to permit medical monitoring of their blood
presenting child5,15, 19. glucose levels. Using shaping and reinforcement as
Several basic behaviour guidance methods have been per case requirements may be beneficial in founding
recommended to accommodate dental therapy of autis- communication with a child with ASD. By increasing
tic patients, including the presence of parents, the use the likelihood of patients who accept simple and routine
of tell-show-do technique, short, clear commands, and dental procedures dentists can decrease the need for more
differential verbal reinforcement. Autistic children may intrusive procedures, such as restraints and sedation5,6,22.
respond better to certain management techniques, such as Communicative Behaviour Management Techniques:
positive reinforcement5,15,19, 20. Techniques that are commonly used in patients with
Appointment Structure: Duration of the dental visit, ASD are the same as those that are used for non-autistic
and sensory sensitization should be kept to a minimum. individuals: tell, show, do and immediate, frequent
Because of the limited attention span of ASD patients positive and negative reinforcement, paired with firmness,
short, well-organized appointments should be planned wherever necessary. However, higher rate of flexibility is
and the waiting time should not exceed 10-15 minutes, to required to comply with quickly changing patient needs.
avoid upsets21. Other recommendations, which are again based on the
Dental Environment: Environmental factors in modelling effects of constant positive reinforces, are
determining the comfort level of children with ASD immediate verbal praise after each accomplished step
during stressful medical events are very important. of a procedure and a prize at the end of a dental session.
Discussion of any aspect of the actual work should be The oral communication should be carried out in clear,
avoided during the course. Light and music might be short, and simple sentences. Also, the Internet has become
beneficial. Distraction, aversive reaction and behavioural nowadays the second most popular source of health care
difficulties may be invoked by loud, unexpected, nearby consultation for families, dental professionals should post
noises. Anyone participating in the procedure should on the practice Web site controlled, user-friendly, and
minimize movements, because an autistic child can be reliable data regarding dental treatment of patients with
easily distracted15,22. special care needs together with evidence-based education
Visual Pedagogy: Stimulation of aversive behaviour materials15,23,24.
may contribute in establishing favourable conditions for Pharmacological Behaviour Management Techniques:
the autistic child to cooperate at the dental practice. A The presence of adverse effects on the oral cavity from
study that showed a structured method and technique of medicines have also been described, particularly hypo-
tooth brushing was made by Bäckman and Pilebro23,24. salivation (paroxetine, fluoxetine, imipramine), oral
Pictures were placed in the bathroom or wherever tooth ulcers (carbamazepine), delayed scarring (valproic acid)
brushing was performed. 14 children with autism, aged or gingival enlargement (phenytoin).The drugs were
between 5 and 13 years, were involved. After 12 months, administered in different dosages and regimens, as a sole
the amount of visible plaque was reduced. After 18 agent or in various combinations. In some patients, several
months, most of the parents found maintaining good oral different regimens and combinations were attempted in
hygiene easier than they had found it before the study order to be successful.
and concluded that visual pedagogy was a useful tool A lengthier administration and higher concentrations
for helping people with autism in improving their oral of nitrous oxide than usual were required to achieve
hygiene. A gentle introduction to tooth brushing using the desired level of sedation in patients with ASD.
alternatives, such as a washcloth, toothbrushes of different Giving treatment in the operating room by using general
texture and design or an electric toothbrush may enhance anaesthesia was considered only if all other approaches
the acceptance of toothbrush by the child with ASD. As a had failed25-27.
final point, child’s self-protectiveness may be eliminated
by intensive behaviour programming, instructed by
parents familiar with reinforcement-based teaching20,23.
Applied Behaviour Analysis (ABA): Applied Concluding Remarks
behaviour analysis is a branch of psychology that is
focused on the analysis and modification of human Patients with ASD do not present very specific oral
behaviour, the environment intends to modify behaviours disorder; however, they may be unable to cooperate in the
to achieve desired effects. Procedures based on ABA dental clinic due to their difficulties with social interaction
are evidence based and they have been accepted by the and communication. Several basic behaviour guidance
American Academy of Paediatrics in the management methods have been recommended to accommodate

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Balk J Dent Med, Vol 19, 2015 Dental Management of Autistic Patients 127

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