Provocările tratamentului stomatologic la copiii cu tulburări de spectru autist

Introduction

In 1943, Kanner described the term “autism” in the medical literature, and in the years that followed, the nosology of autism encountered numerous changes and controversies⁽¹⁾. This group of pedopsychiatric disorders was introduced in the DSM III classification in 1980, differing from schizophrenia or other developmental disorders by specific behavioral traits⁽²⁾.

Autism is characterized by a permanent impairment of social communication and affects at least three areas of development⁽³⁾:

• inability to initiate and develop social relationships, to express interest and emotions;

• inability to use language and communication appropriately;

• the presence of stereotypical behavior, including a restrictive and repetitive behavioral pattern.

Given the symptomatic variation of different pervasive developmental disorders, starting with 2013, DSM 5 revised the terminology and brings together diagnostic entities under the name of Autism Spectrum Disorders (ASD), due to the impossibility of delimiting different disorders, which are in fact a single medical condition with different severity degrees. Although symptoms develop before the age of 3 years old, DSM 5 recommends the diagnosis based on childhood symptoms, even if they were later recognized⁽⁴⁾. ASD has become a topic of great interest in the last years, both for clinicians and researchers in the field and for the general public due to the extraordinary increase in prevalence and incidence. According to the data collected since 2018, Centers for Disease Control and Prevention (CDC) revealed that one in 44 children has been diagnosed with ASD, this disorder being four times more common in boys than in girls⁽⁵⁾. 

The behavioral problems of children with autism, the misunderstanding and noncompliance with social norms, along with the communication difficulties make it very difficult to evaluate and diagnose in various medical services different pediatric, surgical or dental patho­lo­gies. Due to the high prevalence of autistic disorders, most pediatric dentists have often encountered patients with developmental disorders in their daily practice, and their evaluation and dental treatments are usually challenging, sometimes extremely difficult. A study published in 2005, which assessed the willingness of 500 dentists to treat pediatric patients with disabilities, reported that only 40% of them had experience and agreed to treat children diagnosed with ASD⁽⁶⁾.

The majority of the studies that evaluated the oral status of children with ASD concluded that the presence of this diagnosis may be considered a risk factor for developing caries, poor oral hygiene being the most influential factor in determining oral pathologies⁽⁷⁾.  In support of these data, a study evaluating 99 children with ASD showed that 59% of the patients had caries secondary to poor oral hygiene and very few visits to the dentist, while only 28% had skills that helped them in maintaining a healthy dental routine⁽⁸⁾.

Risk factors for dental problems in autistic children

Behavioral problems, opposition, intolerance to new environments and difficulties in sensory regulation of children with ASD make it very difficult to collaborate with the dentist, and many parents postpone or avoid requesting a dental consultation. Studies report a proportion of 65% of patients with autism as having an uncooperative behavior and psychomotor agitation in conditions of dental evaluation, while only 35% of them manage to complete dental treatments without anesthesia or sedation⁽⁹⁾. Prediction factors for noncooperation in dental procedures are the absence of expressive language development, the presence of intellectual disability, limited acquisitions on the receptive language area, and the presence of motor stereotypes⁽¹⁰⁾.

Other factors that can influence dental problems are masticatory anomalies which are in close contact with food selectivity and difficulty coordinating the tongue. The fixations regarding the color, texture and shape of the food determine the maintenance of the food for a long time in the oral cavity to the detriment of swallowing as soon as it has been chewed. Preference for soft textures, insufficient brushing due to poor motor skills, refusal of toothbrush texture or toothpaste due to sensory sensitivity make children with autism ideal candidates for dental caries⁽¹¹⁾.

Adolescents with severe forms of autism may experience oral/dental trauma as a result of self-aggression. The most common treatments for this type of lesions at the level of the oral cavity are applied for avulsions, lip injuries, enamel/root fractures and soft tissues ulcerations⁽¹²⁾.

Another intensely researched factor in the recent literature is the level of antioxidants in saliva, which can influence susceptibility to certain oral cavity pathologies. Patients with ASD experiment increased stress levels, their general status may be affected (due to their exposure social contexts that they do not understand and inability to perform daily routines) and, in conclusion, the antioxidants level can be altered. In a study conducted in 2012, Rai and collaborators, using spectrophotometry technics, demonstrated that the antioxidants levels in children with autism was lower compared to their siblings (a medium value 8.14 mg/ml, compared to 43.31 mg/ml)⁽¹³⁾. The presence of gingivitis may cause secondary the increase of free radicals’ production, and, consequently, the decrease in the levels of oral antioxidants. The appearance of gingivitis is due to the hypotonia of the perioral muscles and to the tendency of children with these neuromuscular disorders to breathe through the mouth⁽¹⁴⁾.

The occlusion disorders most commonly associated with autism, of which we mention, are: dental crowding, anterior open bite, crossbite, overjet or tendency to Angle Class II or III, an extremely important factor in the pathogenesis of orodental disorders in this category of children.

There are also not to be ignored the side effects of drugs used in the treatment of ASD, such as:

• CNS stimulants (methylphenidate, dextroamphetamine, mixed amphetamine salts, pemolin) – xerostomia.

• Antidepressants (fluoxetine, sertraline) – xerostomia, dysphagia, sialadenitis, dysgeusia, stomatitis, gingivitis, glossitis, discolored tongue, bruxism.

• Antihypertensive (clonidine) – xerostomia, dysphagia, sialadenitis.

• Anticonvulsants (carbamazepine, valproate) – xerostomia, stomatitis, glossitis and dysgeusia.

• Caution! Excessive bleeding if the medication is combined with either aspirin, or nonsteroidal anti-inflammatory drugs.

• Antipsychotics (risperidone, clozapine, olanzapine, haloperidol) – xerostomia, sialorrhea, dysphagia, dysgeusia, stomatitis, gingivitis, tongue edema, glossitis, discolored tongue.

The prevalence of sensory integration deficits in autistic children is cited in recent studies up to 100%⁽¹⁵⁾. At the behavioral level, the difficulties of sensory regulation can be observed as states of agitation and opposition when touched by certain textures or by people, massive discomfort when they hear certain sounds that others consider imperceptible, all based on an uncomfortable sensory processing of sensory stimuli. Overreactivity to exposure to sensory stimulus may be minimal or may be exacerbated to aggressiveness and agitation, depending on the degree of previous exposure the patient had to that stimulus.

The visit to the dentist can be very challenging in terms of difficulties in processing the numerous sensory stimuli⁽¹⁶⁾. We present the possible sensory challenges of the patient with ASD in the dentist’s office:

• overresponsiveness to unforeseen touches to the body, the face and particularly inside oral cavity, which is especially a very sensitive area;

• uncomfortable physical states at the movements of the dental units;

• fear of bright light or fear of the dentist when he has his face covered with a mask;

• overreactions when hearing the noise of dental instruments;

• refusal of administered solutions or toothpaste due to smell, texture or taste.

The difficult access of these children to pediatric dental services is due, besides the behavioral problems, to the lack of national and international implementation of some institutions with the role of preventing the dental problems in these patients. In most countries, treatment services are insufficiently covered by state insurance, and in the majority of cases, families have to cover the costs of dental interventions. Those costs are extremely high for children who need anesthesia in order to perform dental treatments. Studies report that 30% of autistic children require anesthesia in operating units for efficiently delivering the dental treatments⁽¹⁷⁾.

The difficulties in controlling these children, the limited access to dental services and the lack of preventive treatment are the most important reasons why emergency treatment is often sought (when the patient experiences dental pain).

Strategies to approach children with ASD to increase compliance to dental treatment

It is recommended that, before the child’s visit to the dentist, there should be a preliminary discussion between parents, therapists and the medical team. The advice given to the parents will be useful in preparing the children regarding the steps to be followed during the evaluation of the patient. Therapists can also apply role-play techniques to increase adaptability and predictability. Familiarizing the child with the basic dental procedures can also be done with the help of cognitive behavioral desensitization techniques⁽¹⁸⁾.

In order to reduce discomfort, an emphatic attitude on the part of the medical team is necessary, and the reduction of the waiting time is indicated especially for hyperkinetic patients with a tendency to opposition. Given the adherence to routines and the need to follow a well-established schedule, it is desirable that the visits to the dentist be made on the same days and time slots and with the same staff. Viewing a timetable, a clock or an hourglass can help the patient understand when the procedure will end. It is necessary to verbally describe or even draw the procedures in order to prepare the patient about what is to come. It is advisable to start from the premise that even the nonverbal patients understand the instructions and inputs like “I will do this until the count of 10”, or using pictograms may be helpful⁽¹⁹⁾.

It is recommended that the evaluation of the patient be carried out in a quiet room; if possible, to listen to white sounds or the patient’s favorite music in headphones. It would be advisable to avoid the patient’s touch, and if it is necessary, to be a firm touch rather than a fine one. The use of gloves, soaps or disinfectants with a low odor or toothpaste with an unpronounced taste may decrease the olfactory sensory aversion.
The presence of the parent favors the child’s collaboration, brings positive reinforcement and mediates the communication with the medical staff. All the studies that evaluated the parents’ opinion regarding the communication with the doctor who evaluates their autistic child have specified that the empathetic attitude, the desire to understand how to approach the patient’s problems and the understanding attitude regarding the behavioral outbursts were the key to a successful collaboration in order to complete the dental treatment⁽²⁰⁾. Watching cartoons on TV or holding a favorite toy can be considered distraction techniques that help complete the procedures.

• Experienced, empathetic, professional and appropriate dental care are essential.

• Dental appointments schedule as not to disrupt the daily routine of the child.

• Positive reinforcement, verbal praising, token rewards are the most appropriate techniques for the behavior management at the ASD diagnosed children.

• Use of pharmacological agents when needed, but with careful observance of the prescribed precautions.

• Visual teaching models for improving oral hygiene are useful and efficient.

• Custom-made polymer mouthguards for reducing self-injurious behavior are also listed.

Most international guidelines recommend avoiding aversive techniques that involve physical contention during procedures⁽²¹⁾. In severe cases, where all the behavioral approaches fail, sedation or anesthesia is recommended.

On the other hand, the issue of dental treatments under general anesthesia is being discussed more and more frequently. The decision to resort to this pharmacological method of behavior management in the ASD children must be the result of a careful and detailed evaluation, and its application will be made only in cases with clear indications, such as:

• resistance to establish personal contact;

• ineffective sedation techniques/atypical response patterns;

• high complexity of the dental treatment needed;

• unsuccessful behavior modification.

Conclusions

As the prevalence of autism spectrum disorders has increased, it becomes more and more likely that dentists will encounter in their daily practice the challenges of evaluating and treating the dental problems of these children, and the dissemination of techniques to overcome the communication and behavioral barriers that this category of patients can present are of great importance. In order to facilitate successful oral care for these patients, we consider very important the knowledge of those adaptable behavioral techniques by all the dental professionals. There is no uniform approach for all patients with ASD, but adapting them to the patient’s need, to his/her cognitive status and to the level of development of expressive and receptive language can bring benefits in improving addressability and meeting their needs in terms of dental health.  

Conflict of interests: The authors declare no con­flict of interests.