This article provides comprehensive insights into the dental management of children with Autism Spectrum Disorder (ASD), outlining behavioural challenges and strategies for creating a supportive, sensory-adaptive dental environment.

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Childhood autism was described with various names like Kanner’s syndrome, early infantile autism, and infantile psychosis or childhood schizophrenia. Using the term ‘autistic child’ is derogatory which has been now replaced with ‘child with autism’.  

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Incidence & prevalence

According to the National Health Interview Survey (NHIS) and National Survey of Children’s Health (NSCH), by Centres for Disease Control and Prevention (CDC) prevalence rate is 5.7 per 1000 and 5.5 per 1000 births respectively. 

The term ‘autism’ is derived from the Greek word ‘autos’ meaning ‘self’, which appropriately describes the characteristic feature of this disorder, namely a profound withdrawal from people and from social reactions with people, even parents. 

Autism spectrum disorder consists of five subtypes, which include:

Autism disorder (AD) 

• Asperger’s syndrome  
• Rett’s disorder
• Childhood disintegrative disorder (CDD) and pervasive developmental disorder not otherwise specified (PDD-NOS) 
• ASDs are lifelong neurobiological disorders manifested by a wide range of abilities and outcomes

Despite the broad range of severity. All ASDs share common deficits in 3 areas of functioning:  

• Language (Only two-thirds of autistic children achieve some functional speech)
• Social skills (little or no attachment to their parents)
• Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities; (self-sufficient, introvertedx, want to be alone and frequently relate well to objects)

The degree of severity of ASD is described in DSM V (Diagnostic and Statistical Manual of Mental Disorders)  

• Level 3 - Requiring very substantial support 
• Level 2 - Requiring substantial support 
• Level 1- Requiring support 

Kopel in 1977 described 12 behavioural characteristics of this disorder:  

1. Extreme aloneness  
2. Language disturbances  
3. Mutism  
4. Parrot-like repetitious speech  
5. Difficulty with the concept of ‘yes’  
6. Confusion in the use of personal pronouns  
7. An obsessive desire for the maintenance of sameness  
8. Eating disturbances such as holding food in the mouth and preference for a soft diet  
9. Intrigue with spinning objects  
10. Self-stimulatory behaviour
11. Hyperactivity, nystagmus and mental retardation  
12. Seizure disorder

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Dental findings of an autistic child

1. Higher susceptibility to caries: Due to soft and sweetened food, pouching due to poor tongue coordination and difficulties in brushing and teeth flossing.  
2. Bruxism: Forceful grinding of teeth is one of the sleep disorders in autistic children.  
3. Damaging oral habits: tongue thrusting, picking at gingiva, lip biting, and pica.  
4. Traumatic injuries: Traumatic ulcerated lesions are usually brought on by self-injury from head banging, picking or face tapping.  
5. Gingivitis and poor oral hygiene: Occur due to heavy plaque accumulation and hormonal influences. 

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Dental management

1. 1st appointment should be short and positive. Parents and children must be offered a tour of the dental office where a child may be allowed to bring items that comfort him like a toy.  
2. The child must be approached in a non-threatening manner.  
3. Autistic infants show an intense desire to maintain a consistent environment. Thus, parental suggestions are of utmost importance.  
4. It must always be kept in mind that even the smallest changes in the environment may trigger extreme anxiety in the child.  
5. When autistic children are held, they show extreme resistance and react inappropriately to fearful situations. They are susceptible to loud noises and movements.  
6. The child must be allowed to sit on a dental chair to familiarise with the dental operatory environment.  
7. Dentists must talk calmly and in short phrases. The light must be kept out of the eyes.
8. Incorporation of positive reinforcement.  
9. Moderate pressure such as wrapping the child with a papoose board can be used to calm.  
10. Despite all such measures some children must still need general anaesthesia or sedation so that proper paediatric dental therapy can be delivered. 

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Considerations

1. Preappointment counselling

Help parents prepare their child as well as try and understand the behavioural patterns of the child. 

Children with ASD usually possess a “leaky gut”. It is characterised by the intestine being permeable to even large molecules of gluten and casein. These large molecules of gluten and casein enter into systemic circulation and tend to have harmful effects on cerebral function and an impaired immune system.  

Thus, dietary modifications in the form of a gluten-free, casein-free (GFCF) diet are recommended in these patients.  

2. Sensory adaptive dental environment

1. Children are reactive to strong light, sound as well as changes in taste thus efforts should be made to adjust the dental clinic environment sensitively to avoid any unpleasant reaction by children. 
2. Music therapy is associated with improvement in core symptoms of ASD. 
3. Audio stimulation in the form of rhythmic music should be played in the dental clinic to elicit positive behaviour. 

3. Applied behaviour analysis (ABA)

1. Branch of psychology that deals with the exploration and shaping of human behaviour.  
2. It is accepted by AAPD which improves dental etiquette of children with limited communication as compared to conventional behaviour management practices.  
3. It reduces the need for restraints, sedation and GA.  
4. It includes home-based as well as in-office preparation of the child. Home-based preparation through ABA procedures includes familiarisation with dental instruments as well as teaching prerequisite skills such as “open your mouth” or “counting teeth”. 
5. In dental operatories, the use of visual media in the form of picture cards or books can be done to enhance the effectiveness of a child’s behaviour during dental and oral examinations. 
6. Positive Reinforcement is one of the fundamental concepts of ABA. A reward like a toy or praise may positively reinforce the child’s behaviour on a dental chair.  

4. Social stories

1. Autistic children have difficulties in identifying social cues such as body language, facial expressions, eye contact etc.  
2. This method involves formulating a story in writing, video or picture illustrations according to the individual needs of the child. The story is read out to the child every day until the child understands the social situation or learns the behaviour. 

5. Picture exchange communication system (PECS)

1. A distinct form of augmentative and alternative communication (AAC). The AAC is developed and widely used for learners with ASD which aids in improving their communication skills.  
2. A recent meta-analysis (2012) supported the prospect that PECS is a promising interventional method for children with ASD.  
3. Positive change in behaviour as well as a decrease in the dependence on parents/caregivers to maintain oral hygiene was observed in children where PECS-based interventions were used. 

6. Visual pedagogy

1. It is a nonpharmacological behaviour management strategy in dental clinics. 
2. It involves watching videotapes of adults, peers or children themselves engaging in behaviour that is being taught. 
3. It encourages a positive change in behaviour in children with ASD. 

7. Communicative behaviour management techniques

Methods such as Tell Show Do, voice control, and positive and negative reinforcements enable dentists to communicate with autistic children to undergo dental examinations. 

8. Pharmacological approaches

Patients with ASD having moderate to severe behavioural problems who do not respond well to non-pharmacological behaviour management strategies are treated in the dental office by using advanced behaviour management techniques such as physical restraints or pharmacologic methods like sedation or GA. 

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Neha Kalantri is a practising dentist from Nashik.