Posted on August 15, 2014
Dentistry and Autism Spectrum
In my pediatric dental practice I like to say we treat children. And I like to pause at the end of that sentence. No qualifiers. My father, the junior high teacher of thirty years, said it a little different; “they are all good kids, only the times and circumstances have changed.” Each child has basic needs to take care of including oral health, and those basic needs do not change based on the developmental age, social environment, or neurological wiring of a child.
The circumstances have changed though, in my early school years, children with special needs were routinely sequestered out of the mainstream, and those practices carried over to healthcare. Now, the schools show progress, but in health care some of those “traditions” continue. With separation came differences in treatment and different standards of care, and that has led to a dearth of knowledge within the medical/dental profession to offer good basic care for special needs kids.
For Autism, the increasing acceptance of the diagnosis has led to a need for Dentistry to find good treatment options. In the last year several articles have featured Autism in both the pediatric dentistry and general dentistry journals. Mostly, these articles seek to educate practitioners about Autism. They do not offer many actual treatment hints or procedures.
That was the same story for a dental sedation course I attended by the leading pediatric dental sedation authority in the nation. “No, autism is usually a CONTRAindication for in office sedation due to the unknown (and unresearched) possible reactions to traditional sedatives. “ When I asked how other pediatric dentists treated children with profound autism, no one had any answers beyond the customary go to the hospital alternative.
So where does that leave us? For Autism, for your child, personal experience is the best we have to go on. As one article stated, “Autism treatment and research have been separate entities. Children with Autism need help now and cannot wait for research to be conducted and treatment to be developed.” I firmly believe that establishing a long term relationship with an office and dentist is the best way to go about treating a child with Autism Spectrum. Becoming comfortable in an office is a two way street, the parents and child gain familiarity and trust, and the dentist can try and adjust behavior modification methods over time with a history to draw from.
The very nature of the dental visit is difficult for a child with Autism. The disruption of a schedule, the unfamiliar noises and interactions with new children, the intrusion into the mouth with heavy physical contact and laying prone are all problematic. And I haven’t mentioned any actually procedures yet! So where to you start? Below is an outline of how I would suggest choosing a provider and getting treatment for your child:
1) Research. Pediatric dentists are going to be your best resource for experience with autism; general dentistry provides no training whatsoever. Beyond that, call the office and look online. If the dentist mentions special needs and the STAFF is comfortable discussing your child’s autism, chances are good that they have experience and are comfortable with the challenge. And you can always call the doctor directly to discuss philosophy. Be careful not to use the conversation as a means to express your own expertise on autism- dentists are human too and won’t be receptive to a new person dictating treatment and lecturing. It’s a relationship you’re trying to feel out and begin after all!
2) Go in for a desensitizing visit. If you can find the time, visit the dentist office before you have a formal appointment. You can turn in paperwork or pick some up so you don’t have to mess with it later. But, more importantly, give your child a chance to see the surroundings in a non agenda driven manner. This will help to phrase your conversation later and give you a feel for the atmosphere of the office.
3) Schedule. Pick a time the dentist and dental team can devote to your first visit. In our practice we set aside time every day to slow the pace and give kids more time at a less busy practice time so distractions are cut down. You are also going to want time for a consult with the dentist to talk about how to treat your child based on his or her performance for the appointment.
4) Be realistic about the first appointment. Depending on the degree your child is affected by Autism, you should set your goals accordingly. For some, a cursory exam to rule out big problems or pain may be the best that can be done. I have a 23 year old Autistic boy who I have seen for the last 15 years (we started in my residency!) At first all he could do was to get into the room. Our first exam was done with him sitting Indian style on the floor. Last year, we completed a porcelain crown for him in the office, by himself, at six foot four. Of course we had help from his Count Dracula doll, and a very long term relationship to draw from. Incremental successes contribute to our long term goals of overall health.
5) Discuss options for treatment: If treatment needs exist, fillings, deep cleaning, a suspicious area that needs an x ray, how can we get it done? For the Asperger’s or mildly autistic kids, routine behavior techniques work well with the right dentist. Tell-show-do, watching other children, and firm direction often work just fine. For the more profoundly affected, a mild anti anxiety medication such as Ativan or Klonopin, may help to take the edge off fears or disorient the child enough to be led through treatment. You need to check with your dentist and your state to see what constitutes anti-anxiety and minimal sedation. And don’t forget to call your insurance to find out what can be covered. Finally, it is sometimes best to take a child to the Hospital for treatment under general anesthesia. In this manner, complete x rays, a thorough cleaning and exam can be done and any restorative needs or preventive sealants, mouthguard fabrication, etc. can be done. In my practice I often combine with other medical professionals to do blood draws, ear tube placement, eye exams, pap smears, toenail removal, you name it!
6) Ask your questions: Often I am lumped in with my medical colleagues and often parents have had a history of having to scream to be heard in advocating care for their child. I understand that, but be aware that a relationship starts with a position of mutual respect. Ask questions about the dentist’s view on nitrous oxide use, what is in the prophy paste, views on fluoride and the rest in a non threatening manner, and give the dentist time to research his or her answer. There are NO dental or skeletal manifestations of Autism, in other words, teeth are teeth. That being said, if you do have thoughts on alternative medicaments, diet, etc. don’t paint your dentist into a corner. In fact he or she may be grateful for some reading material. I list some below. Having your child’s dentist in your corner for emergencies, etc. is critical. But, when I know a kid well enough to note him being mischevious versus assuming behavior is only based on his diagnosis, it takes the burden off the parent and let’s your kid be a kid.
Letting your child be himself or herself in the dental office is the ultimate goal. Taking a long term, relationship approach is the best way to reach it. How you get there or if you ever get there will be largely up to the way you set up the relationship with a qualified dentist.
I will be seeing little Tyler in the hospital next week. Only he is not so little anymore and with his Down syndrome and Autism his behavior in the office got a little better around age 9 but has deteriorated to our current state at age 13 and 110 pounds. Neither the parents nor myself are really happy with the reality that Tyler could not progress to independent behavior in the office, but over the years we have, together, tried everything to meet that goal. Now, we can honestly talk and figure out the best way to care for Tyler. General anesthesia every two years with the best cleaning we can do in the office between times is what everyone is comfortable with. That’s dentistry for real people making a real effort every day. If you have further questions or comments let me know, firstname.lastname@example.org or 970 481 6728. I want to help you raise happy and healthy, beautiful children. Greg Evans, DDS Diplomate of the American Board of Pediatric Dentistry
Rada, Robert E. Controversial issues in treating the dental patient with autism. JADA 2010;141 (8): 947-953
DePalma and Raposa. Building Bridges Part 2; Understanding and Guiding the Dental Patient with Autism. Supplement to AGD publication on pediatric dentistry June 2010 . contact ineedce.com The Academy of Dental Therapeutics and Stomatology.
Altun et. Al. Dental Injuries in Autistic Patients. Pediatric Dentistry. Vol 32(4) July/ August 2010: 343-346