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Roopa P. Gandhi, BDS, MSD, and Ulrich Klein, DMD, MS


A B C NA Dental professionals caring for patients with a diagnosis of autism spectrum disorder
SORT, Strength of Recommendation Taxonomy (ASD) will need to provide oral health care based on a family-centered approach that
involves a comprehensive understanding of parental concerns and preferences, as well
as the unique medical management, behaviors, and needs of the individual patient.
1 2 3
See page A8 for complete details regarding SORT and Background
LEVEL OF EVIDENCE grading system
With the rising prevalence of autism spectrum disorders (ASD), oral health pro-
viders will find themselves increasingly likely to care for these patients in their daily
practice. The purpose of this article is to provide a comprehensive update on the
medical and oral health management of patients with autism spectrum disorders.
The authors conducted a literature review by searching for relevant articles written
in English in the PubMed database pertaining to the medical and oral health
management of autism, including caries status, preventive, behavioral, trauma, and
restorative considerations.
A detailed family centered approach based on parental preferences and con-
cerns, the patient’s challenging behaviors, and related comorbidities can serve to
improve the treatment planning and oral health management of dental patients
with ASD.
Department of Pediatric
Dentistry, Children’s Hospital
Key words: Autism, autistic, autism spectrum disorder, Asperger's disorder, autism dental management
Colorado and University of
Colorado School of Dental
Medicine, Aurora, CO, USA
Corresponding author. Department of Pediatric
Dentistry, Children’s Hospital Colorado, 13123
E. 16th Avenue, B240, Aurora, CO 80045,
A utism Spectrum Disorder (ASD) is the category used within the newest edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)1 and
encompasses diagnoses such as autistic disorder, Asperger’s disorder, childhood
USA. E-mail: roopa.gandhi@childrenscolorado. disintegrative disorder and pervasive neurodevelopmental disorder not otherwise
specified. Previously these diagnoses were subsumed under the umbrella pervasive
J Evid Base Dent Pract 2014;14S: developmental disorders. Symptoms in this group of neurodevelopmental disorders
can be expressed on a continuum ranging from mild to severe and, by definition,
Published by Elsevier Inc.
must be present from infancy or early childhood.2
While the prevalence of ASDs has risen significantly over the past decades, the ratio of
affected male to females has remained between 3 and 4:1. Data from the Centers for
Disease Control and Prevention’s (CDC) 2009–2010 National Health Interview
Survey (NHIS) estimate the prevalence based on parent report for children aged 3–17
years at 1.1%.3 That translates into approximately 1–1.5 million Americans living with

115 June 2014


Figure 1. Derived from the National Health Statistics Reports (No. 65, March 20, 2013). This figure indicates the increase in autism
prevalence by illustrating the percentage of children aged 6–17 years with parent-reported autism spectrum disorder by age group and
sex in the United States, 2007 and 2011–2012.

ASD. It is not known, however, whether the steady increase include stereotyped or repetitive motor behaviors (hand
seen in ASD (Figure 1) is due to heightened awareness and flapping, rocking back and forth), repetitive use of objects
access to services or true increases in prevalence. (spinning coins, lining up objects), or repetitive speech. Many
such patients insist on sameness, adhere to strict routines in
their lives, and may have a more rigid thinking pattern. They
will react adversely to even minor changes or transitions that
The DSM-5 reduced the diagnostic criteria from three to two occur as part of one’s life.1
areas of impairment1: (A) persistent deficits in reciprocal social
communication/interaction and (B) restricted, repetitive pat-
terns of behavior, interests, or activities. Three severity levels CAUSES
further detail these deficits: 1) requiring support, 2) requiring No specific etiology has been identified to date, but evidence
substantial support, to 3) requiring very substantial support points to a combination of genetics and pre- and postnatal
(Table 1). Additional specifiers are used to describe if a patient environmental factors such as parental age, maternal in-
presents with or without accompanying intellectual or language fections during pregnancy, and low birth weight.4 Evidence
impairment, a known medical or genetic condition or envi- based research has ruled out vaccines as causes of ASDs and
ronmental factor, or if the condition is associated with another has concluded that general peri- and neonatal events increase
neurodevelopmental, mental, or behavioral disorder. the risk.5 It is known that environmental factors such as
nutrition, psychotropic drugs, maternal autoimmune disease,
Of specific importance to dentistry is the hypersensitivity of
maternal viral infection during the 1st trimester of pregnancy,
these patients to sensory input, although hyposensitivity and
or psychological stress can cause epigenetic modifications
indifference to pain or temperature extremes can also occur.1
leading to neurodevelopmental diseases including ASD.6 It has
Owing to an overly sensitive nervous system, a number of
also been suggested that focal brain inflammation caused by a
individuals with ASD exhibit extreme and peculiar responses
breakdown of the blood-brain-barrier could adversely affect
to specific sounds, light, scents, textures, or touch, all of which
invariably occur as part of a dental appointment. The ensuing
sensory overload can quickly lead to overstimulation and
subsequent avoidance reactions. Their increased awareness of SCREENING AND DIAGNOSIS
texture and smell may lead to food idiosyncrasies such as a In the United States pediatricians screen for ASD at the 18
preference for bland or particularly crunchy foods. and 24–30-month visits.8 Although no specific signs have
Of specific importance to dentistry is the hypersensitivity of been identified, lack of eye contact, poor response to name,
these patients to sensory input, although hyposensitivity and or a marked regression in language skills or social behaviors,
indifference to pain or temperature extremes can also occur. often during the first 2 years of life, warrant concern.9 The
diagnosis is made by integrating information from various
Communication with individuals with ASD may be compli- sources: thorough history taking, caregiver interviews, struc-
cated by language deficits, poor comprehension of speech, or tured patient observation, and a detailed medical and
difficulties reading social cues. Additional features of ASD neurological examination to rule out associated medical and

Volume 14, Supplement 1 116


Table 1. Three severity levels identified in DSM-5 detail the deficits in social communication and restricted interests and repetitive
behaviors (RRBs) of patients with ASDs

level for Restricted interests and repetitive behaviors
ASD Social communication (RRBs)
Level 3  Severe deficits in verbal and non-verbal social communication  Preoccupations, fixated rituals and/or repetitive behaviors
Requiring very skills markedly interfere with functioning in all spheres
substantial  Very limited initiation of social interactions  Marked distress when rituals and routines are interrupted
support  Minimal response to social overtures from others  Very difficult to redirect from fixated interest or returns to it
Level 2  Marked deficits in verbal and non-verbal social communica-  RRBs and/or preoccupations or fixated interests appear
Requiring tion skills frequently enough to be obvious to the casual observer and
substantial  Social impairments apparent even with supports in place interfere with functioning in variety of contexts
 Limited initiation of social interactions and reduced or  Distress or frustration when RRBs are interrupted
abnormal response to social overtures from others  Difficult to redirect from fixated interest
Level 1  Without supports in place, deficits in social communication  RRBs cause significant interference with functioning in one or
Requiring cause noticeable impairments more contexts
support  Difficulty initiating social interactions and demonstrates clear  Resists attempts by others to interrupt RRBs or to be redirected
examples of atypical or unsuccessful responses to social from fixated interest
overtures from others
 May appear to have decreased interest in social interactions
Adapted from DSM-5.1

psychiatric comorbidities.2 A study concluded that the typical behavioral interventions for some children with ASD.14 The
age at diagnosis is 38 6 15 months, but children with language goals of Applied Behavioral Analysis (ABA) and the Early Start
regression and unusual mannerisms (toe walking) were Denver Model (ESDM) include furthering a patient’s IQ,
referred earlier for evaluation.10 communication and language skills, and academic perfor-
mance. They teach adaptive behavior to promote useful social
skills such as independence, ability to adapt to the environ-
ASSOCIATED COMORBIDITIES ment, and reduction of inappropriate stereotypic behaviors.
Fragile X-syndrome (FXS) is the most common (5%) single Participants in the ESDM range from infancy to preschool age
gene cause and an important subtype of ASD: half of all males and achieve significant and sustained improvements in IQ,
with FXS fall somewhere on the ASD spectrum. Both dis- adaptive behaviors, as well as social and emotional milestones
eases are linked at the molecular level through a mutation in by learning child-specific skills through play activities. It is
the FMR1 gene. This association with FXS has a strong po- important to provide ongoing education and support for the
tential for development of targeted treatments for non-FX parents of a child with ASD because they are instrumental in
autism.11 adjusting the environment to the sensory idiosyncrasies of
their child.2,4,9
One of the clinical neurologic manifestations of the neuro-
cutaneous disorder tuberous sclerosis (TSC) includes ASD. To date, there are no specific medications available that can
TSC is the established medical cause for 1–4% of all cases of treat the core symptoms of ASD. However, a number of
autism and 20–60% of individuals with this disease have a drugs are commonly prescribed for associated conditions
diagnosis of ASD. The common pathway of dysfunctional such as sleep disturbances, epilepsy, GI problems, hyperac-
mTOR (mechanistic target of rapamycin) signaling between tivity, irritability, self-injury, aggression, or anxiety. Medications
these diseases provides a model for understanding the path- that are more frequently used in patients with ASD are se-
ophysiology of this subset of ASD.12 lective serotonin reuptake inhibitors (for repetitive behaviors,
rigidity), methylphenidate (for ADHD), and melatonin (for
ASD often occurs together with Attention-Deficit/Hyperactivity
sleep problems).4,9
Disorder (ADHD): almost 1/3 of children with ASD also meet
diagnostic criteria for ADHD and another 24% of children with
ASD exhibit sub-threshold clinical symptoms for ADHD.13 PARENTAL CONCERNS AND PREFERENCES
With the rise in prevalence of ASD, oral health care providers
are increasingly likely to encounter patients with this diagnosis
THERAPEUTIC APPROACHES in their dental practice. Decision-making about dental treat-
A Cochrane review found some evidence that early intensive ments may be complicated by parental concerns about
behavioral intervention (EIBI) programs represent effective restorative materials or the refusal to use fluoride-containing

117 June 2014


toothpaste due to their child’s hypersensitivities or their own dental setting. An over-stimulated patient may find relief by
concerns for its toxicity.15 self-stimulatory behaviors such as twisting hands, flapping
arms, making noises, or making other repetitive movements.20
A family centered approach to care requires an empathetic
Early recognition and quick removal of the offending
relationship with parents or caregivers who can provide unique
stimulus is desirable, whereas trying to stop the self-stimula-
and valuable information such as their child’s likes and dislikes,
and behavior triggers. tory behavior is not a meaningful approach for anxiety
Parents may also have preferences regarding behavior man-
agement strategies, choice of dental staff or even the oper-
Self-injurious Behavior
atory, because they are most familiar with their child’s
idiosyncrasies. Dismissing such requests as naïve or unfounded Self-injurious behavior (SIB) is perhaps the most challenging
without exploring their basis can prove detrimental to the and distressing behavior encountered by dental professionals
patient’s dental experiences, the family’s trust, and ongoing treating patients with autism. With a reported prevalence of
cooperation with the dental provider. A family centered 4.9%, ASD is an identified risk marker for SIB.22 While these
approach to care requires an empathetic relationship with behaviors can impact any part of the body of the affected
parents or caregivers who generally provide unique and individual, more than 75% involve the head and neck region23
valuable information about their child’s likes and dislikes and and are likely to occur in those with expressive language
behavior triggers. Such collaborative care planning, rather than deficits and a diagnosis of autism within ASD.24 Worsening
a paternalistic approach, can build a strong foundation for the SIB may also be a consequence of the patient’s inability to
effective long-term oral health of the patient. communicate physical pain, including oral pain, which should
be considered as an exacerbating trigger for the harmful
behavior.25 Oral self-injury can present as gingival defects due
BEHAVIORS to repetitive gouging by fingernails or foreign objects, cheek or
Patients with ASD can present the dental provider with lip biting, or self-extraction.23,26
challenging behaviors that are as wide-ranging as the neuro-
cognitive symptoms associated with this spectrum of disor- Treatment strategies involve a multidisciplinary approach with
ders. They may be the by-product of a child’s frustration that a input from team members including the psychologist, psy-
daily routine has been interrupted or the anxiety induced chiatrist, and occupational therapist.27 Behavioral approaches
from exposure to an unfamiliar setting. In a dental context, such as positive reinforcement, extinction, and time-out may
challenging behaviors can be designated as non-compliance, also be used.23,28 Positive reinforcement is a common and
hyperactivity, sensory hypersensitivity, and self-injurious effective strategy that involves specifically praising the patient
behavior.16 The severity of a given behavior can be attributed for appropriate behaviors as a substitution for SIB.26,28 Ari-
to the deficit in language development and the type of ASD piprazole and risperidone are medications that have been
diagnosis.17 Children with ASD who are anxious in an unfa- used successfully for managing SIB, in combination with a
miliar dental setting can become non-compliant for dental behavioral approach.29,30 In severe cases, physical restraints
care and display such anxiety in the form of emotional and/or oral appliances such as mouth guards are necessary to
outbursts and temper tantrums. In more severe cases, minimize further oral self-injury.31
their aggressive behavior can translate into destruction of
furniture or fixtures, or harm to others by scratching, biting,
kicking, or head butting.18 ORAL HEALTH STATUS
The caries status of primary and permanent dentitions in
Hyperactivity children with autism spectrum disorders (ASD) has been
Those with autism are often described as hyperactive, which explored in a number of studies with conflicting results. Some
may be related to the associated co-morbidity of ADHD.19 In report lower caries prevalence in primary, mixed and per-
the dental setting, such hyperactivity can be manifested by the manent dentitions and no significant association between
patient pacing within the operatory, or exiting the operatory caries prevalence, severity of ASD or the institutionalized
or dental setting entirely. status of patients.32 Others report higher caries prevalence in
primary and permanent dentitions.33–35
Sensory Hypersensitivity While there are divergent conclusions regarding caries status,
Sensory hypersensitivities in children with autism can trigger the majority of studies unequivocally point to poor oral hy-
defensive responses that may include attempts to escape giene in children and adults with ASD33–36 although many
from the dental environment because their senses are over- individuals with ASD receive regular assistance with
whelmed by the loud sounds, smells, or textures in a typical toothbrushing.33,34,36,37

Volume 14, Supplement 1 118


insurance, and the child’s behavior. In particular, the child’s

The majority of studies unequivocally point to poor oral hy-
behavior was a major barrier to dental care and children with
giene in children and adults with ASD compared to unaffected
individuals. poor perceived behavior had higher odds of having unmet
dental needs.
Poor oral hygiene has also been positively associated with
greater caries experience, increased severity of ASD symp-
toms, and the presence of generalized gingivitis.33,35,38 The
concern for periodontal disease as sequelae to poor oral Traditional Approaches
hygiene in patients with ASD has been supported by the Currently used basic behavior guidance techniques (BGTs)
finding of significantly poorer periodontal status in children include positive reinforcement, tell-show-do (TSD), distrac-
with autism compared to unaffected children.39 tion methods, non-verbal communication, and voice control
(Table 2).43 These techniques can be effective in typically
Orthodontic concerns in individuals with ASD compared to developing patients, however they may not always be suc-
healthy individuals include an increased tendency toward cessful in patients with ASD in which expressive and receptive
anterior open bite and dental crowding.36,40 Other studies language deficits can negatively impact the ability to utilize
have reported spacing, reverse overjet, open bites, and Class II these techniques. They may not understand the use of “good
molar relationship.39 job opening your mouth” or register a firm tone of voice.
Limitations in social interactions, e.g., the inability to participate
in pretend play and imitation, can be a significant barrier to
CARIES RISK FACTORS effectively utilizing TSD methods because they require the
Potential caries risk factors of individuals with ASD relate child to model the dentist for a given procedure.44 A pre-
predominantly to diet, oral hygiene, and age. The xerostomic appointment consultation can be a critical step to gauge the
side effects of psychoactive medications have been not been patient’s behaviors and symptoms, and to customize the use
found to be a risk factor for caries in some studies, however of basic BGTs.
no hypotheses have been provided for such findings.33,37
Inconclusive evidence regarding psychoactive medications and Visual Pedagogy
their contribution to caries risk may warrant further investi-
gation in future studies. The observed preference of these Visual pedagogy takes advantage of the ability of children with
individuals for soft sticky foods as well as the use of sweet autism to respond better to pictures rather than words.
food as rewards makes diet a significant caries risk factor.33,37
Oral hygiene, however, is the most influential risk indicator in Visual pedagogy is a non-traditional approach to behavior
children with autism and special attention should be given to guidance that takes advantage of the ability of children with
the presence of visible plaque and gingivitis in individual pa- autism to respond better to pictures rather than words.45 It
tients with ASD.33 involves the use of books with color photographs, social
Oral hygiene may be the most influential caries risk indicator in stories, or video modeling and can be combined with tradi-
children with autism and special attention should be given to the tional BGTs such as positive reinforcement and TSD to ac-
presence of visible plaque and gingivitis in patients with ASD. count for the neurocognitive deficits in patients with ASD.

UNMET DENTAL NEEDS AND BARRIERS TO Bäckman et al demonstrated the use of visual pedagogy in
CARE their study involving the use of a book with a series of colored
photographs to describe all the steps involved in a dental visit
The child’s behavior has been identified as a major barrier to to preschool children with autism.45 The authors reported
dental care and children with poor perceived behavior had higher improved cooperation over a 11/2 year period in the children
odds of having unmet dental needs.
who were exposed to this behavioral approach, compared to
Dental care has been reported as the most prevalent unmet those children with ASD who were not.
health care need of children with special health care needs
(SHCN), including those with ASD.41 Recent studies have Social Stories
specifically focused on the issue of unmet dental needs and Visual pedagogy has also been used for the development of
related barriers to dental care in these patients: 12% of chil- Social Storiesä, which are a widely used strategy for children
dren with ASD had unmet dental needs and of the 93% of with ASD.46,47 Initially developed by the special education
children who had been to a dentist, 11% still reported unmet teacher Carol Gray, social stories attempt to further a child’s
needs.42 The main barriers were the cost of treatment, lack of accurate understanding of social information for a setting or

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Table 2. A summary of traditional and non-traditional behavior Table 3. Internet resources for visual pedagogy based methods
guidance approaches in for patients with ASD such as social stories (A) and video modeling (B)

Advanced behavior (A) Resources for social (B) Resources for

Basic behavior guidance guidance stories: video modeling:
Traditional approaches: My Dental Social Story – POAC Model Me Kids
Positive reinforcement Protective stabilization www.poac.net/image/pdfs/Dentist/ www.modelmekids.com/
Tell-Show-Do Sedation
Printable Easy Social Stories for Social Skill Builder
Distraction General anesthesia Children with Autism or www.socialskillbuilder.com
Nitrous oxide Asperger’s http://easysocialstories.
Non-traditional approaches: com/
Visual pedagogy with Social Storiesä – The Gray Center Look At Me Now! Videos
books www.thegraycenter.org/social- for Children with Autism
stories http://lookatmenow.org/
Social stories
Social Story Examples – Autism
Video modeling
activity and the related behavioral expectations. Social stories
are typically short by design and rely on a ratio of descriptive,
perspective and/or affirmative sentences, in addition to visual other intellectual disabilities.28 The process is initiated by first
cues. They can be easy to create and practitioners seeking to learning from the parents the type of positive reinforcer that is
formulate a social story for a dental visit should review the valuable to their child (e.g., stickers, stamps). Then, the steps
guidelines associated with their construction.48 A variety of associated with a procedure such as a dental examination are
these types of stories about dental visits are readily available practiced in a mock environment (e.g., their home) by
on the Internet from a number of sources (Table 3(A)). combining the use of the positive reinforcer with praise.
In children with ASD, social stories can improve social behaviors Ideally, practice sessions would be followed by visits to the
such as increasing hand washing, greeting people appropriately, dental office where the actual dental examination takes place.
and sharing toys. There is evidence that disruptive behaviors can However, professional desensitization can be a time-
also be reduced with the repetitive use of a social story.47 In consuming process that requires the availability of facilities and
addition to visual cues social stories do rely on reading skills and dental staff. For this reason, consultation with the child’s
basic auditory processing skills, in addition to visual cues. therapist to practice mock dental visits at the therapist’s office
Therefore, the reading ability and auditory performance should prior to the actual dental examination can be considered.
be assessed before considering this method.
Nitrous Oxide
Video Modeling There are equivocal accounts for the success of nitrous oxide
For patients who have limited reading and auditory skills, (N2O) as a behavior guidance technique for dental patients
video modeling may be an alternative visual pedagogy-based with autism. Some authors have stated that nitrous oxide is
method that draws upon the growing propensity of electronic not efficacious because it only works well if combined with
screen media use by children with autism.49 Its efficacy in communication-based BGTs such as distraction, TSD, and
teaching and changing behaviors has expanded its positive positive reinforcement to which patients with autism may not
impact on functional living skills and non-compliant behav- be amenable.52 Others, however, have recommended the use
iors.50,51 While there is limited evidence regarding the use of of N2O for patients with mild behavioral issues.53,54 In one
video modeling in dentistry, practitioners can find videos that recent prospective study, patients with autism were reported
are specifically designed to improve compliance with oral to have a success rate as high as 87.5% with 50% N2O.55
hygiene and dental visits from several resources (Table 3(B)).
In the face of limited evidence, parents or caregivers may
further confound the dentist by refusing the use of N2O for
Desensitization their children, most likely out of concerns about negative
Desensitization appointments are designed to repeatedly systemic effects from its interaction with potential methylene
expose a child to the dental environment and are aimed at tetrahydrofolate reductase (MTHFR) gene mutations or ab-
furthering the child’s trust and adaptation. The use of normalities of folate metabolism. There are reports of
desensitization can result in increased cooperation for dental MTHFR related gene mutations and the dysregulation of
examinations and debridements in children with ASD and folate metabolism in patients with autism56 and study has

Volume 14, Supplement 1 120


documented a lethal outcome in a child patient with MTHFR The practitioner must rule out other comorbidities that
deficiency who was exposed to high and prolonged levels of contraindicate the use of sedation as well as medications that
nitrous oxide under general anesthesia.57 Currently, there is can interact with or jeopardize the success of a sedation
no evidence for fatal systemic effects when the typically lower regimen. Adherence to established sedation guidelines should
levels of nitrous oxide are administered in the dental setting. guide the practitioner in providing a safe sedation environ-
ment. For patients where there is a doubt about the safety of
Providers should discuss nitrous oxide use with concerned
a sedation regimen, general anesthesia (GA) serves as an
parents and help them make informed decisions by explaining
advanced approach to provide comprehensive dental care.
risks and benefits, as well exploring other treatment modal-
ities. Consultation with the patient’s physician regarding
possible genetic mutations or abnormalities of folate meta-
General Anesthesia
bolism will also aid in the decision-making process, especially Among dental patients with SHCN, autism is one of the most
in cases of longer and higher concentrations of nitrous oxide frequent indications for providing dental care under general
exposure such as under general anesthesia. anesthesia37,52,63 due to factors such as high caries activity
with the need for extensive treatment, female gender, and
uncooperative behavior.63 GA should be considered when
ADVANCED BEHAVIOR GUIDANCE other treatment alternatives have failed or when the patient is
Protective Stabilization planned for care under GA by other medical services which
can be combined with dental treatment.37
Patients with autism may require active or passive protective
stabilization for the purposes of an urgent diagnosis or Parents of children with autism are likely to have a positive
treatment, as part of a procedural sedation, or because they attitude toward GA. The hospital environment, however, can
exhibit uncontrolled movements that can jeopardize their produce defensive responses in their child, which can increase
own safety and that of the dental staff and families.58 Pro- a family’s stress and preclude an uncomplicated stay.52 While
tective stabilization may in fact calm the autistic child due to GA is generally considered a safe procedure64 adverse events
the deep pressure produced by its placement.28,52,59 How- related to its use in patients with autism include significant
ever, it should be considered with due care as restraint related disruptive behaviors (12%) and postoperative vomiting that
injuries can occur in patients who do not always respond in delays discharge (6%), but rarely fatalities.65 Other less
the anticipated manner. The majority of such injuries involve frequent adverse events are extensive post-operative bleeding
scratches and minor bruises, but more serious injuries are from patient manipulation of surgical sites and post-operative
possible. The care provider should pay close attention to how seizures requiring hospital admission.
tightly the wrap is placed over the patient as it can limit
The hospital environment can produce defensive, hypersensi-
respiration or may lead to overheating. Fewer injuries have
tive responses in a child with autism which can preclude an
been shown to occur with passive compared to active sta- uncomplicated stay and increase the family’s stress.
bilization and in situations where passive stabilization was used
in a planned rather than emergent manner.52 The risk for peri-operative complications and the general
hypersensitivity of patients with autism requires judicious pre-
Parents of children with autism may be hesitant about the use
operative planning.66 Autistic patients may benefit from a pre-
of protective stabilization, but acceptance can be improved by
anesthesia visit to the hospital to become desensitized to this
positive explanations and a detailed informed consent ac-
environment. The use of visual pedagogy can also be useful in
counting for their concerns and preferences.52,60 Parental
this context and may involve either books or videos
presence during the use of protective stabilization should be
describing the processes involved on the day of the GA
encouraged and parents may be more accepting of active
restraints when they are personally involved.52
The dentist should relay pertinent information to the anes-
Sedation thesia provider about the child’s specific ASD diagnosis, the
presence of related comorbidities, and any challenging behaviors
The use of sedation is a viable option that may be considered pre-operatively.
for patients with autism when basic BGTs have failed. Ben-
zodiazepines such as diazepam and midazolam are suggested The dentist should relay pertinent information about the
in combination with nitrous oxide administration with re- specific ASD diagnosis to the anesthesia provider, the pres-
ported success rates ranging from 77% to 100%.61–63 Mid- ence of related comorbidities, and any potentially challenging
azolam is reportedly more successful in regulating patient preoperative behaviors because they will dictate the choice of
behavior than diazepam but it has a shorter working time and pre-medication and the need for additional staff or restraints.
this should be considered when choosing between the two In the case of related comorbidities, such as uncontrolled
agents.62 epilepsy, a pre-anesthesia visit can predict the risk for post-

121 June 2014


operative complications as well as address the need for a 23-h with autism, the caregivers received oral hygiene instructions
admission in a planned manner. over 1, 3 and 6 monthly dental visits with statistically signifi-
cant improvements in oral hygiene.71 Visual pedagogy such as
placing color photographs of oral hygiene steps in the pa-
tient’s bathroom are helpful when combined with recall
Caregiver Consultation evaluations.72
Parental input regarding the behaviors and preferences of
their child can be of tremendous value to the success of an Prevention strategies need to account for the sensory pro-
cessing difficulties and hypersensitivities of children with
oral health care appointment. Key questions such as a child’s
autism. “Sensory over-responders” may face oral hygiene
ability of to read, the use of expressive language, develop-
challenges such as a dislike for the taste and texture of certain
mental age, toilet training, and concurrent diagnoses can be
toothpastes and gagging with toothbrushing.68 A trial and
asked as a guide about potentially effective BGTs.67 Children
error strategy with caregivers is encouraged to find a fluoride
who have minimal language skills, lack toilet training, or are
containing toothpaste that the patient is likely to use. Also,
unable to read by 6 years of age are likely to be more un-
discussions with the patient’s occupational therapist or psy-
cooperative for the dental visit. Parental input may be solicited
in the form of a pre-appointment questionnaire or during an chologist should be considered to develop a sensory inte-
gration approach that can improve the individual patient’s
office visit and be used to address parental preferences and
adaptation to the oral hygiene procedure.
concerns about future treatment needs.
Dental providers should ask key questions such as the ability of Fluoride
a child to read, use of expressive language, developmental age, The primary reason for a parent’s refusal of fluoride-con-
toilet training and concurrent diagnoses to help guide them
taining toothpastes may be related to their child’s sensory
about potentially effective BGTs.
difficulties with the flavor, texture, or taste of toothpaste.
They may also be concerned that their child has difficulty
Operatory Design spitting out toothpaste or could swallow it, with a risk for
A dental operatory filled with unwelcome smells, noises, and toxicity.73 Some parents have heard that the use of fluoride
colors can be an over-stimulating environment to a patient can potentiate neurotoxic effects, which has been propagated
who suffers sensory processing difficulties.68 The basis of in the alternative medicine literature.74 In any case, the reason
sensory adaptation is to modify a given environment to a for refusal of fluoride containing products should be explored
patient’s needs and thereby reduce negative and anxious further with the parents in conjunction with a careful
behaviors. To minimize anxious and uncooperative behaviors, assessment of the patient’s caries risk and other potential
a relaxing light, rhythmic music provided with or without sources of fluoride exposure.
headphones, and white noise should be considered to adapt
the dental environment to an autistic patient’s hypersensitiv- CONSIDERATIONS FOR RESTORATIVE
ities.69 Keeping the patient to the same operatory for each TREATMENT
visit and having minimal visual stimuli on the walls can also be
Typically used restorative materials in patients with autism
useful to improving cooperation. The dentist may consider
include amalgam, resin-based composites and glass ionomers.
designating a specific and separate waiting area for patients
Dental amalgam is characterized by excellent moisture
with ASD to minimize anxiety-inducing situations created by
tolerance and longevity75 making it a suitable choice for
the extended exposure to other patients.
posterior teeth in patients where moisture control is more
difficult to achieve. However, many parents of patients with
PREVENTION STRATEGIES ASD express concern about the use of dental amalgam
Oral Hygiene because of potential mercury poisoning emanating from
dental amalgam restorations.15 The use of the word “mer-
The evidence that poor oral hygiene occurs frequently in
cury” may be key to addressing parental concerns according
individuals with autism and is associated with an increased risk
to one survey that found that the majority of parents of
of gingivitis, periodontitis and caries drives prevention strate-
children with ASD agreed to the use of “metal filling or
gies aimed at improving the oral hygiene of these patients.
“amalgam alloy,” but not to the placement of a “mercury-
Some have deficits in their motor skills and may be at risk for
containing” dental material.73
rare but serious toothbrush impalement injuries if left unsu-
pervised for daily oral hygiene.70 Teaching caregivers about It has been demonstrated that the small amounts of mercury
oral hygiene and more frequent recall visits than the tradi- vapor released from dental amalgams either prenatally (from
tional six monthly recall visits should also be considered. In maternal dental amalgam) or during early childhood are not
one study of a dental plaque control program for children associated with either neurocognitive or other physical

Volume 14, Supplement 1 122


developmental deficits.76 Parents who believe that their child infections and whether any particular antibiotics have resulted
may be unable to excrete the mercury vapor released from in worsening symptoms or adverse reactions.
dental amalgam can be appraised of prospective studies that
have refuted this theory.77,78
Alternative available materials such as resin-based composite
may raise objections due to their presence of bisphenol-A While aggressive and self-injurious behaviors in patients with
(BPA).79 Resin-based composites and sealants that do not autism suggest a risk for traumatic injuries to the primary and
contain BPA are potentially acceptable restorative choices in permanent dentition, there is a lack of evidence to support
such instances. Other restorative alternatives include glass this association.86 Soft tissue injuries subsequent to self-inju-
ionomers and stainless steel crowns. While glass ionomers do rious behavior are more likely23,26 and practitioners should
release aluminum, this metal does not fall into the list of heavy investigate whether any injuries may be the result of SIB. The
metals that would stir parental concerns regarding neuro- earlier described strategies involving a multi-disciplinary
toxicity. However, glass ionomer’s fluoride release may cause approach should be considered if this is a concern.
concern and should be addressed. In the instance of pre- While less probable, there are documented reports of neglect
formed stainless steel crowns, parents may be reassured that or abuse resulting in orofacial trauma to patients with special
although these materials do degrade chronically in the oral health care needs, including ASD.87 The oral health care
cavity to release nickel, chromium and iron, the levels released provider as a mandated reporter should keep this in mind
are low and do not impact systemic health.80 when assessing any case of trauma until a comprehensive
review of the patient’s history suggests otherwise.
Analgesics Dental professionals are likely and more than ever to
Acetaminophen use during pregnancy, early childhood, or encounter patients with a diagnosis of ASD in their practice.
after measles, mumps and rubella vaccination has been Therefore, they need a greater familiarity with the medical and
implicated in increasing the risk for ASD. Unsubstantial evi- dental management of this special group of patients. A
dence from two studies suggests that immunological or detailed family centered approach based on parental prefer-
neurotoxic derangements are able to potentiate this risk.81,82 ences and concerns, the child’s challenging behaviors, and
While neither of these studies inferred a causal relationship related comorbidities can foster mutual trust. Close in-
between acetaminophen and autism, the primary hypothesis teractions between patients, parents and providers are also
for the association has been proposed as a defect in the likely to produce the best treatment decisions.
sulfation pathway. To date, there is no evidence that
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