1. Daniel Ravel, DDS Fayetteville, North Carolina Dental Care for Children with Autism

2. Daniel Ravel, DDS Professional Affiliations - American Board of Pediatric Dentistry - American Academy of Pediatric Dentistry - NC Academy of Pediatric Dentistry - Fayetteville Dental Society Contact Info PO Box 74432, Fort Bragg, NC 28307 Cell: (910) 797-1590 E-mail: danielravel@hotmail.com Web Site http://dentalresource.org

3. Download this lecture from Dr. Ravel’s Facebook page.

4. Dental Care for Children with Autism

5. Presentation Outline 1) Definition of Autism 2) Incidence of Autism 3) Signs and Symptoms of Autism 4) Initial Appointment for the Autistic Child 5) Communicating with the Autistic Child 6) Second Appointment for the Autistic Child 7) Behavior Guidance for the Autistic Child 8)Dental Management of the Autistic Child 9) Home Care for the Autistic Child

6. 1 ) Definition of Autism The word “autism” is from the Greek word “αυτο” meaning self. Autism, as an entity, was first described by Hans Asperger in 1938. 1943: Leo Kanner of Johns Hopkins described a group of children with symptoms of “an extreme aloneness... and an obsessive desire for the preservation of sameness.”

7. Definition Autism belongs to a group of Pervasive Developmental Disorders called Autistic Spectrum Disorders. The other pervasive developmental disorders are: -1) PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified) -2) Rett Syndrome -3) Asperger Syndrome -4) Childhood Disintegrative Disorder.

8. 2) Prevalence of Autistic Spectrum Disorders Affects 1 in 110 children in the United States. Reports of

9. Prevalence of Autistic Spectrum Disorders male : female ratio = 4:1

10. 3) Signs and Symptoms of Autism By 24 months of age, 80% of parents of children with autism notice: - lack of babbling or meaningful gesturing, - failure to respond to their name, - excessive single word usage without spontaneous phrases.

11. Signs and Symptoms By 24 months of age, 80% of parents of children with autism notice: - an aversion to hugging or touching, - repetitive hand flapping, - and difficulty in making eye contact.

12. Signs and Symptoms Individuals with autism meet the following diagnostic criteria: - Impairments in social interactions. - Stereotyped patterns of behavior. - Impairments in communication.

13. Signs and Symptoms Hypersensitive or hyposensitive to light, sound, touch, smell, or taste. No big smiles or other warm, joyful expressions by 6 months of age or thereafter.

14. Signs and Symptoms No medical test or biomarker for autism. Diagnosis

15. Signs and Symptoms Diagnosis is based on: - observation of the child’s behavior, - educational and psychological testing, - and parent reporting. Diagnosis

16. Signs and Symptoms Mental disability: 41% have an IQ < 70. Physical characteristics: -developmental disorder with poor social skills -lack of interpersonal relationships -abnormal speech, language, and body language Communication: variable to non-existent

17. Signs and Symptoms Inability to relate to people, events, and objects. Lack of social interaction. Little or no eye contact. Isolation. No fear of danger.

18. Signs and Symptoms Repetitive actions like rocking or hand- flapping. A characteristic behavior is ‘finger flicking.’ Facial grimaces, jumping, and toe walking are also common. Obsessive desire for maintaining an unchanging environment and rigidly following familiar patterns in their everyday routines.

19. Signs and Symptoms Altered responses to stimuli. Show no sensitivity to burns or bruises.

20. Signs and Symptoms May engage in self-mutilation Self abuse, ranging from biting their hands or hitting themselves in the is an oft encountered symptom. Some autistic authors have related that the self-infliction of pain gives them a “sense of reality.”

21. Triad of Autistic Impairment Impairment of social interaction Impairment of language and communication Impairment of flexibility of thought and behaviour

22. Oral Manifestations None specific. May see trauma from self-abusive behavior. More than 20% of children with autism bite objects or introduce their fingers in the mouth routinely, resulting in traumatic lesions. Oral lesions may also be present due to auto-aggression or convulsive crisis.

23. Oral Manifestations Bruxism (20-25%) Tongue thrusting Self-injury (picking at gingiva, biting lips Erosion (many parents report regurgitation)

24. Oral Manifestations People with ASD were more likely to be caries-free and had lower DMFT scores than did their unaffected peers. There were no significant differences in the rates of traumatic dental injuries among children and young adults with and without autistic disorder.

25. At the Pre-visit Intake Interview: Standard health history forms are usually not sufficient. Discuss the patient’s physical function, sensory and behavioral issues, and communication style.

26. At the Pre-visit Intake Interview: Parents/caregivers need a routine for home so that visiting the dental office becomes a “game” with rewards. The parent can be given materials from the dental office prior to the visit, to train the patient at home.

27. At the Pre-visit Intake Interview: Encourage parents to create a ‘visual schedule’ for their child. Parent should teach following steps: - Putting hands on the stomach - Putting feet out straight - Opening wide - Holding the mouth open - Counting the teeth - Cleaning with a power brush - Taking X-Rays

28. The ‘Visual Schedule’ In the ‘Dental Guide’ http://autismspeaks.org -Hands on stomach -Feet out straight -Open mouth wide -Hold mouth open -Count teeth -Take x-rays -Clean teeth -Spit into sink

29. 4) The Initial Appointment for the Autistic Child Invite the child to tour your dental office. Encourage the child to ask questions, touch equipment, and get used to the place. Children with autism need sameness and continuity in their environment. Make the first appointment short and positive.

30. The Initial Appointment The initial appointment’s primary goal is to establish trust. The initial appointment should include an interview, an orientation to the dental practice.

31. Talk to parent/caregiver about child’s tolerance to physical contact and note findings. Determine the child’s level of intellectual and cognitive abilities. The Initial Appointment

32. Allow autistic children to bring a comfort item, such as a blanket or a favorite toy.

33. The Initial Appointment Set aside time when the clinic is less busy to reduce distractions and give kids more personal time. Remove the clutter in your office that may distract the child. Dim the lights. Turn down loud noises.

34. The Initial Appointment The child should be allowed to determine where the exam will take place. Let patient sit in chair (in your chair, stool, etc.) Use a toothbrush to get patient to open for exam (patients do better with familiar items)

35. 5) Communicating with the Autistic Child Maintain eye contact. Use clear, understandable directions. Use a counting framework (“Let me do this for a count of 10”).

36. Communicating with the Autistic Child Initially, a request for a “high five” can be very effective. Be sure to reward immediately following appropriate behavior.

37. Communicating with the Autistic Child Phrases such as “look at me,” “hands on tummy” can be used. Communicate with the child at a level that he/she can understand.

38. 6) The Second Dental Appointment for Autistic Child Keep instruments out of sight. Keep distracting noises to a minimum. Keep lights out of the patient’s eyes.

39. The Second Dental Appointment Use a headlamp instead of the overhead or dental lights. Constant sincere reinforcement. Involve the same dental team members each time. Use the “tell-show-do” technique of treatment.

40. 7) Behavior Guidance Advice for the Clinician “slow down, you’re going too fast.”

41. Behavior Guidance Don’t crowd the child. Approach the autistic child in a quiet, non-threatening manner. Explain the procedure before it occurs.

42. Behavior Guidance Start the oral examination slowly, using only fingers at first Reduce other sensory input such as sounds and odors that may be distracting to the child.

43. Behavior Guidance Reward cooperative behavior with positive verbal reinforcement. Maintain a routine of “same chair, same dental assistant.” Avoid interruptions and have as few staff as needed.

44. Behavior Guidance Explain every treatment before it happens. Always tell the autistic child where and why you need to touch them

45. Behavior Guidance Always show the familiar first: the toothbrush…water…etc. Position patient upright in the chair. Next, use a toothbrush, or possibly a dental mirror to gain access to mouth.

46. Behavior Guidance Use the first name frequently when addressing the child. “Hi, Ben!” Praise and reinforce good behavior. Ignore poor behavior. Strive for eye contact whenever possible. “Look at me, Ben. Where is Ben? There he is!”

47. Behavior Guidance Assuming that the autistic child is not in pain, screaming or crying does not have to prevent completion of necessary treatment.

48. Behavior Guidance These medications increase the sedative potential of CNS depressants, such as nitrous oxide or demerol : - Fluoxetine (Prozac) - Sertraline (Zoloft) - Pimozide (Orap) - Risperidone (Risperdal) - Olanzepine (Zyprexa)

49. Behavior Guidance Some autistic children can be calmed by moderate pressure from a lead apron.

50. Behavior Guidance Some autistic children can be calmed by moderate pressure, by using a papoose board. Always obtain informed consent for this.

51. For people with vitamin B12 (cobalamin ) deficiency, exposure to nitrous oxide may cause pernicious anemia. Nitrous Oxide

52. KEYWORDS! METABOLIC DISORDER, MTHFR, METHYLMALONIC ACID, ‘METYL…,’ “VITAMIN B 12 Using nitrous oxide on an autistic patient with a defect in the MTHFR (methylenetetrahydrofolate reductase) gene could result in increased oxidative stress, and inflammation. Nitrous Oxide

53. May be necessary to perform treatment in the O.R. under general anesthesia. This permits an exam, radiographs, prophy, sealants, and restorative treatment. Combine time with other medical professionals to do blood draws, ear tube placement, tonsillectomy, eye exams, etc. Behavior Guidance

54. May see drug-induced xerostomia. May see bruxism. 8) Dental Management for the Autistic Child

55. Hyperactivity CNS Stimulants (Methylphenidate) Antihypertensive (Clonidine) Repetitive Behaviors Antidepressants (Fluoxetine and Sertraline) Aggressive Behaviors Anticonvulsants (Carbamazepine and Valproate) Antipsychotics (Olanzapine and Risperidone) Xerostomia

56. Bruxism Consider prescribing a mouth guard for higher functioning children with severe bruxism or self-injurious behavior. Taking an impression may be very difficult – so consider a store-bought mouth guard.

57. Preventive Care The in-office fluoride treatment of choice is fluoride varnish. - 5% NaF (varnish). - 22,6000 ppm of fluoride. Sealants

58. Autism: Treatment Planning Rampant caries, large interproximal lesions, hypoplasia, pulp exposures, and gross decalcifications: require full coverage with SSCs. Rubber dams are recommended, but may not be accepted by the child. Space maintainers might be pulled out by the child.

59. 9) Home Care for the Autistic Child Brushing Your Child’s Teeth Stand or sit behind your child with their head on your chest. Put a pea size amount of toothpaste on the center of the brush. Guide the brush as if you were brushing your own teeth.

60. Home Care Set a timer for 5-10 seconds for the first brushing session. This allows the patient to brush alone, to help build confidence in the skill. Final goal: a full minute of brushing.

61. Home Care Recommend a power toothbrush. Helps to desensitize patients to similar types of oral sensations during dental visits.

62. Latest Dental Reference on Autism JADA 2011; 142(3): 281-287 Purnima Hernandez, DDS, MA; Zachary Ikkanda, BCaBA Applied behavior analysis. Behavior management in children with autism spectrum disorders in dental environments.

63. Summary With education and understanding, we can treat this special group.

64. Questions or Comments?