Commentary :
Autism
is a developmental disorder characterized by difficulties in social and
communication interactions. Parentally induced autism, brain injury/anomalies,
constitutional vulnerability, and developmental aphasia have been incriminated
in the epidemiology of the disease. Other suspected etiologies are structural
cerebellar changes, genetics, viral infections, and immunological abnormalities,
with various teratogens and vaccines. Autism Spectrum Disorders (ASD) displayed
prevalence rates of about 1%, and a fourfold higher predominance of men over
women. The life expectancy of autistic patients is reduced, and the death rates
seem to be higher than in the general population. Dental and oral pathologies
are mainly carious lesions and periodontitis. Many autistic patients are
uncooperative and required general anesthesia during dental treatments. Diagnosis
of autistic dental diseases includes self‐extraction of primary teeth, autistic
syndrome and self-injurious behaviors. Most ASD are unmarried, poorly educated,
and economically deprived. The number of adults with ASD grows. Some have a
level of independence that allows full participation in their healthcare
decisions; others have impairments that require dependence on caregivers to
mediate the healthcare they receive. Leo Kanner first described it in
1943. This pathology is referred to as Autism
Spectrum Disorders (ASD) or as Pervasive
Developmental Disorders (PDD), reciprocal social
interactions, language and comportemental
communication and behavior. A single etiology for autism or
for any of the disorders on the autistic spectrum has yet to be determined.
Suspected causes of these disorders have related autism to very different
underlying neurology and cognitive processes: one is related to interpreting
animate motion and mental states (i.e. the theory of mind) and the other
appears to be associated to recognizing inanimate objects, events or patterns [1].
Abnormalities of the brain structure or function have been identified, but it
is uncertain that they contribute actually to the etiology of autism. Epidemiology ASD
prevalence: The prevalence rate per country give a
current estimate of 1 in 110 children [2]. This was noticed during the three
first years of the Childs life. Autistic infants show less attention to social
stimuli, smile and look at others, and they respond less to their own name. ASD
prevalence rates of about 1%, but with prevalence higher in men. A male:female
ratio of 4.6:1 has been reported on the gender-specific epidemiology of the
autistic disorder. Older ASD children and adults perform worse on tests of face
and emotion recognition. Children with autism are less likely to make requests
or share experiences, and simply repeat others words (echolalia). Joint
attention seems to be necessary for functional speech. For example, they may
look at a pointing hand instead of the pointed-at object, and they consistently
fail to point at objects in order to comment on or share an experience.
Children with autism have difficulty with imaginative play and with developing
symbols into language. Language
functions in general are disturbed in autism. The
difficulty of explaining the whole syndrome on the basis of a single
abnormality is postulated as an alternative hypothesis that a combination of
language, perceptual, motor, and autonomic
impairments is underlying autistic behavior [3]. Asperger
Syndrome, pervasive developmental disorder not
otherwise specified (or atypical autism), Rett
Syndrome and Childhood
Disintegrative Disorder (CDD), have also been identified
in the group of autistic children [4]. However, ASD is up to now the most
studied group. Etiology The etiology of Autistic
Disorder (AD) has not been discovered. It has
been suggested that it is an organic disorder characterized by abnormalities in
the brain, especially the cerebellum and limbic system. Therefore the « theory
of mind » has been implicated in autism [5]. A single computational deficit
with multiple cognitive effects was originally suggested. Neurophysiologic,
psychologic and epigenetic effects are still under evaluation, but without any
solid conclusion. Pollution The frequency of autism has
increased in the 1990s and early 2000s. This may be due to increased awareness
and case reporting. It has long been presumed that there is a common cause at
the genetic, cognitive, and neural levels for autisms characteristic triad of
symptoms. Exposure to air pollution during pregnancy, especially heavy metals
(e.g. lead and mercury), may increase the risk of autism [6]. Environmental
factors that have been claimed without evidence to contribute to or exacerbate
autism include certain foods, infectious diseases, solvents, Polychlorinated
Biphenyl (PCBs), phthalates and phenols used in
plastic products, pesticides, brominated flame retardants, alcohol, smoking,
illicit drugs, vaccines, and prenatal stress. During pregnancy, the future
mother may have took valproic acid (an antiepileptic drug) or drink alcohols. A
few cases of ASD have been attributed to toxic exposure, teratogens, perinatal
insults, and prenatal
infections such as rubella and cytomegalovirus. Discrepancies
among reports make hypothetical any conclusion. Genes
Research Autism genetic research has
narrowed the suspected genetic cause to chromosome 15. However, chromosomes 2,
7, 9, and 16 have also been implicated in the genetics of autism. Autism
affects information processing in the brain and how nerve cells and their synapses
are connected and organized. The Diagnostic and Statistical
Manual of Mental Disorders, combines autism and less severe
forms of the condition, including Asperger syndrome and Pervasive
Developmental Disorder Not Otherwise Specified
(PDD-NOS) into the diagnosis of autism spectrum disorder. There is an
association between head circumference and deficits in both verbal abilities and
nonverbal Intelligence
Quotient (IQ). As the name indicates, Autism
Spectrum Disorder (ASD) varies widely in its clinical manifestations, however,
dentists are likely to encounter difficulties with communication and
socialization. Autistic individuals can display many forms of repetitive or
restricted behavior, which the Repetitive
Behavior Scale-Revised (RBS-R) categorizes as follows • Stereotyped behaviors:
Repetitive movements, such as hand flapping, head rolling, or body rocking. • Compulsive behaviors:
Time-consuming behaviors intended to reduce anxiety that an individual feels
compelled to perform repeatedly or according to rigid rules, such as placing
objects in a specific order, checking things, or hand washing. • Sameness:
Resistance to change, for example, insisting that the furniture not be moved or
refusing to be interrupted. • Ritualistic behavior:
Unvarying pattern of daily activities, such as an unchanging menu or a dressing
ritual. This is closely associated with sameness and an independent validation
has suggested combining the two factors. • Restricted interests:
Interests or fixations that is abnormal in theme or intensity, such as
preoccupation with a single television program, toy, or game. • Self-injury:
Behaviors such as eye-poking, skin-picking, hand-biting and head-banging. Autistic individuals may have
symptoms that are independent of the diagnosis, but it may affect the
individual or the family. An estimated 0.5% to 10% of individuals with ASD show
unusual abilities, ranging from splinter skills such as the memorization of
trivia to the extraordinarily rare talents of prodigious
autistic savants. Autism is often called autistic
disorder, childhood autism, or infantile autism. Autism refers to the classic
autistic disorder, in clinical practice, autism, ASD, and PDD are often used
interchangeably. ASD, in turn, is a subset of the broader autism phenotype,
which describes individuals who may not have ASD but do have autistic-like
traits, such as avoiding eye contact. Autism can also be divided into syndromal
and non-syndromal autism. The syndromal autism is associated with severe or
profound intellectual disability or a congenital syndrome with physical
symptoms. Screening
Autism (Symptoms of Autism) • No
response to name (or eye-to-eye gaze) by 6 months. • No
babbling by 12 months (18-40 months). • No
gesturing (pointing, waving, etc.) by 12 months. • No
single words by 16 months. • No
two-word (spontaneous, not just echolalic) phrases by 24 months. • Loss
of any language or social skills, at any age. • Patients
taken in charge by pre-school and school children or educational
institutionalized structures (age range 3-21 years). • Adults
(young or old)>18 years, 5(22-49 years, and more). 60% or older. Three different forms of autism allow
accurate identification of the pathology: • Communication
disorders. • Social
interaction disorders. • Repetitive
and stereotypical restricted nature of behaviors. Other
forms: Autism is also known as a group of Pervasive
Development Disorders (ASD or PDD) including: • Asperger syndrome:
Normal or above-normal intelligence, but they have social interactions
disorders. • Retts syndrome:
Develops normally up to 6 months and then regression begins, with appearance of
autistic symptoms. Four successive stages have been recognized in Rett
syndrome. Stage 1 begins between 6
and 18 months, Stage 2 begins between
1 and 4 years, Stage 3 begins
between 2 and 10 years, and Stage 4
starts after 10 years and expands in adults. This syndrome is affecting
predominantly females, the gene mutation being located at Xq28. • Disintegrative disorders of
childhood: Has normal development until 2 years,
then the autistic symptoms appear. Symptoms
1: Language is absent or reduced to a few words. Poor understanding, patient
lonely and indifferent and the absence of smile is noted. Symptoms 2: Gestures (shaking hands in front of the eyes), matrices,
hyper or hypo sensitive to noises, pain or tactile stimuli. Mental retardation
is present in 75% cases. In addition, trouble falling asleep, low need to
sleep, and frequent awakenings during the night are added to the
symptomatology. Sleep disturbances are commonly reported both in autistic
children and adults. Risk
Factors, Death and Suicide Rate Risk factors of mortality include
moderate to severe intellectual disability, epilepsy, and female sex. Death occurs
during sudden unexpected death in epilepsy, and accidents. There is also an
increased risk of mortality from a wide variety of causes that are found also
at similar rates in the general population. Age group of moderate to profound
intellectual disability is 17% for the 18-29years old group of subjects, 28.6%
for 30-44 years old group, 44.7 for 45-64 years old group and 9.2 for patients
older than 65 years [7]. The life expectancy is significantly reduced (8-12
years for the pre-school and school-age group, adolescents pre-puberty and adults
13-29 years up to 46 years). Epidemiologic studies found an almost twofold
higher mortality rate in ASD compared to the sex-and age-matched population.
The general mortality risk is higher for men than women. There are no
systematic data on life expectancy in autism, but there is some indication
suggesting that death rates are higher in ASD compared a general population [8]. In people with intellectual
disabilities, deaths are often related to inadequate institutional care, poor
medical supervision, or infection. Approximately 12% of autistic patients
achieve a high level of independence in adulthood [9]. Although some
improvement may be expected over the years, the majority of ASD still suffer
from “significant degrees of symptomatology and dependency” in adult life. The
autism suicide rate "is among the taboos of the public debate". Their
mortality is not the subject of any study and no public interest, probably
because studies focus mostly on childhood, and other factors that some medical
institutions desire to hide. Antipsychotic
and Antidepressants Medications The most common medications
reported were antipsychotics, antidepressants,
(mainly selective serotonin reuptake inhibitors), and anticonvulsants [10]. Most
adult autists are doing well, living independently, and had jobs (often of a
high level). However, some were still living with their parents and a few were
experiencing difficulties with social relationships. Rates of
mental health problems, mainly anxiety and depression,
were higher than in the general population. The
Costs of Supporting Children with ASD The costs of supporting children
with ASDs were estimated to be £2.7 billion each year in the UK. For adults,
these costs amount to £25 billion each year. The lifetime cost, after
discounting is estimated at approximately £1.23 million, and the cost for someone
with ASD without intellectual disability is approximately £0.80 million. For
adults, these costs amount to £25 billion each year [11]. Dental
Treatment of Patients with ASD The
Needs for Dental Treatments ASD displays higher caries
severity than the general population, however these data are controversial.
Kamen and Skier [12] reported a low incidence of caries in autistic children.
Conflicting results have emerged from the limited number of studies which were
carried out on normative oral health assessment of children with ASD. With
respect to dental
treatments, these children were uncooperative
[13,14]. However, it is also possible that the problem of autistic children to
co-operate to dental treatment in some cases resulted from an inferior
precision of the diagnostic procedures. Some decayed surfaces might have
escaped to detection. A significantly higher percentage
of patients with ASD
required dental treatment to take place under General
Anesthesia (GA). Caries prevalence and severity in patients with ASD was not
associated with institutionalization or to additional diagnosis. Young (2-5
years old) and children (9-12 years old) patients with ASD need treatment under
general anesthesia in the operating room. GA was necessary in 37% of all
patients when comprehensive care was required or difficult procedures were
carried out. ASD adults need preventive and restorative procedures to reduce
the impact of dental caries and gingivitis. Caries
and Treatment Needs by Dental Patients with Autism
By definition, an individual with
autism will have difficulty with three domains: • Language
and communication, • Socialization,
and • Repetitive
behaviors. Excessive anxiety may be a
secondary characteristic of ASD. This anxiety may be responsible for the Self-Injurious
Behaviors (SIBs) that as many as 50% of ASD children experience. For the most
part, these behaviors are mild [15]. The majority of autistic
children had poor oral hygiene, and almost
all of them had gingivitis. It could be due to lack of necessary manual
dexterity of autistic children, which result in inadequate tooth brushing, or the
side effects of medications used to control the manifestations of autism.
Children with autism exhibited higher caries prevalence, poor
oral hygiene and extensive unmet needs for dental
treatment compared with the non-autistic control group. Dental caries or Decayed,
Missing, and Filled Teeth (DMFT) were found to be lower that the values found
for institutionalized schizophrenics. In primary dentition the patients with AD
demonstrated a significantly higher caries rate than the group « control »
during initial examination. However, at recall, Decay-Missing-Filled (DMF)
values were comparable [16]. In some cases, the prevalence of caries in
children with AD could even be comparatively lower. Almost autistic children
had gingivitis due either to psychoactive
drugs or anticonvulsants [2]. The oral status of 4,732 adults
with Intellectual
and Developmental Disabilities (IDD) was
studied by Morgan et al. [17]. 32.2 % had untreated dental caries, 80.3% had
periodontitis. Detailed medical history, physical examination, clinical
intraoral and radiographic examination, incisional biopsy, neuropaediatrical,
psychological and speech evaluation were necessary. Diagnosis included
hypochromic macrocytic anemia, caries, coronal fracture, periodontitis,
self‐extraction of primary teeth and permanent teeth buds, non‐specific oral
ulcer with inflammatory reaction, mild mental
retardation, speech impairment, autistic syndrome
and self-injurious behaviour consisting of putting fingers and foreign objects
in the gingiva, fingernail biting and hair pulling. Altogether, these ASD
symptoms implicate dental
preventive and restorative treatments [18]. Procedures
Commonly used to Reduce Phobic Behavior to Dental Fear in Children with Autism Clinicians can work with patients
on the autism spectrum and their supporters in order to find effective
strategies and accommodations to reduce barriers due to the pathology. In
people with nontraditional communication or atypical cognition, illness is
often presents as a change from baseline behavior or function. Clinicians should
consider a full differential diagnosis, including common medical and
psychosocial causes [19,20]. Studies showed that when low IQ (Intelligence
quotient) autistic children were compared with mentally retarded non-autistic
children, very few group differences were found, but when high IQ autistic
children were compared with typically developing children the differences were
quite marked. Dental
Treatments of ASD are Possible, Closely Associated with Four Methods that seems
to be Efficient or at Least Useful Visual
pedagogy: The process known as functional behavioral
assessment may take place during the pre-visit
consultation of parents. At that time, the dentist can organize the home-centered
preparation that includes familiarization with dental instruments, teaching of
skills required for the dental examination using phrases such as open your
mouth, and developing custom-made photo books to assist the child to get
acquainted with the dental operatory room. Most of the parents found
maintaining good oral hygiene easier than they had found it before the study
and concluded that visual pedagogy was a useful tool for helping people with
autism in improving their oral
hygiene. A gentle introduction to tooth
brushing using alternatives, such as a washcloth, toothbrushes of different
texture and de sign or an electric toothbrush may enhance the acceptance of
toothbrush by the child with ASD. Sensory
adapted environment: Children with ASD may present
hypersensitivity in intraoral and perioral regions, and therefore experience
frustration by a light touch or even fall back during dental examination. The
experimental introduction of relaxing light conditions, rhythmic music, and
deep pressure in the dental setting diminished adverse patient reactions and
enhanced positive participation in dental prophylactic cleaning. Duration of
the dental visit, and sensory sensitization should be kept to a minimum. Applied
Behaviour Analysis (ABA): ABA principles have been also
adopted in young autistic patients with needle phobia and diabetes to permit
medical monitoring of the blood glucose levels. The positive or negative
reinforcement classification depicts whether the increase of the behaviour is
linked with initiation or termination of the stimulus respectively. For
example, giving a sticker, a good job or well done praise might serve as a
positive reinforcer, in case there is proof it leads to enhanced compliance in
the dental
chair. On the other hand, the child may be
negatively reinforced or motivated to stand still during drilling for a
predetermined time period, for instance counting from 0 up to 10, if
immediately after the intervention is interrupted for a while. The sequence of
events is repeated as long as necessary for the procedure to be completed.
Using shaping and reinforcement as per case requirements may be beneficial in
founding communication with a child with ASD. Advanced
behaviour guidance methods: Antipsychotic
medications are most commonly prescribed for ASD
patients to alleviate symptoms of irritability, distress, self-injurious
behaviour, aggression and delusions. The dental specialists should be aware of
the oral adverse reactions of the aforementioned drugs, which can be summarized
as xerostomia, sialorrhea, sialadenitis, stomatitis, gingival
enlargement, edema and discoloration of the tongue. Clinical
Recommendations and Future Research Goals Dental care should be viewed as
integral part of comprehensive health care program coordinated by the medical
home. Based on the higher frequency of the regular medical screening of
autistic children compared to scheduled dental visits, it can be presumed that
an interdisciplinary approach with the childs physician might help to overcome
the anxiety of the dental appointment [21]. Pharmacological
behavior: Frequently used drugs were nitrous
oxide, diazepam, hydroxyzine, chloral hydrate, and promethazine, in contrast to
chlorpromazine, diphenhydramine, and meperidine. The drugs were administered in
different dosages and regimens, such as a sole agent or in various
combinations. Physicochemical properties of saliva, dietary
and oral hygiene habits: Individuals with autism have
neither higher salivary flow rate nor superior buffer capacity related to
non-autistic controls. Determination of the total antioxidant concentration of
salivary samples collected from autistic children revealed significant reduced
values compared to normally developed subjects of the same age, which
apparently did not affect the caries experience. Tell-Show-Do:
Frequent positive and negative reinforcement paired with firmness are
necessary. However a higher rate of flexibility is required to comply with
quickly changing patient needs. Other recommendations, gain based on the modeling
effects of constant positive reinforcers are immediate verbal praise after each
accomplished step of a procedure and a prize at the end of a dental session.
The oral commands should be clear, short, and simple sentences. Visual pedagogy
involves the series of colored photographs describing step-by-step dental visit
and tooth brushing to introduce oral
hygiene to autistic children. Many autistic children are
visual learners. Visual schedule may help to reduce the apprehension in
children by understanding the sequence of procedures. Beneficial relaxing effects of
deep touch pressure for children with AD have been described. Calming effects
were also noted by some dentists. Tell-show-do, voice control with short, clear
commands and positive reinforcement are successful first-line management Cliniques
for the autistic patient. Impaired social interaction, communication, cognitive
dysfunctions and other associated psychiatric symptoms may impede dental care.
A variety of basic behaviour guidance techniques may be utilized to enable dental
treatment of patients with ASD, including
the presence of parents or aides, and the use of the tell-show-do technique [13,14,22]. Prevalence,
Social and Treatments Needed by ASD Autistic patients demonstrate
varying degrees of function. Many “high functioning” adults can live in
society. However, at present, the research emphasizes early diagnosis and
treating infants and children rather than adults. Adolescents are 10-21 years
old, and adults 22-53 years old may be included in this cohort. Some affected
patients are non-verbal but others are echoic (repeating statements heard from
others) [23]. ASD
Prevalence Rates: A Public Health Problem Most often due to lack of public
support, many adults with autism depend on their families for the support they
need, including housing, financial support. As families get older, have less
opportunity to provide the support they need, or when parents die, the
unsustainability of a system that relies too much on family support is
unimportant. Governments must urgently meet the support needs of aging people
with autism and ensure that they can continue to live in dignity and enjoy
their rights at a later age. The increase of autism becomes an
“urgent” public health problem. 1.7% of American children are autists. The
average is 1 child in 68 children in 2014 (vs. the situation nowadays: one in
34 children and vs. Arkansas 1 in 76 children). In old age, social isolation
and loneliness have negative effects on the quality of life. There is greater
risk of mortality, depression, and poorer health. Individuals with ASD have
fewer friendships, and they may be even more affected than neurotypicals by the
loss of loved ones and shrinking family networks due to illness and immobility.
The mean age for the patients surveyed was 43.4 (range 26.2-60.5) years and
mean follow-up time was 35.5 (range 21.3-47.0) years. The ASD prevalence is about 1%,
higher in men than women [23]. There are no systematic data on life expectancy
in autism, but there is some indication that death rates are higher than in the
general population. The mean age at death for individuals with autism was 36.2
years (SD=20.9 years), compared with 72.0 years (SD= 9.2 years) for the general
population. Research on healthcare experiences of individuals with autism has
been almost uniformly limited to studies of children and their families, who
consistently report more difficulty obtaining health care for their children
and less satisfaction with that care, once received. Adults with autism are
just as likely as other adults to have a primary care provider, but are more
likely to have unmet physical and mental
health needs, and they are less likely to receive
preventive care. The number of adults with autism
spectrum disorders will continue to grow. Some will have a level of
independence that allows for full participation in their healthcare decisions,
others will have impairments that require dependence on caregivers to mediate
the healthcare they receive. Old
Autist Patients Many siblings expressed
considerable anxiety about what would happen when their parents died, leaving
them as the main person responsible for their sibling with autism. Although
only a minority of the adults with autism was still living at home, their
parents, many of whom were now in their 70s or 80s, also expressed fears about
the future and who would look after the welfare of their son or daughter when
they will be no longer alive. There were particular fears that, with
forthcoming financial cuts to social services, people currently living in
adequate residential placements may be relocated to cheaper, less appropriate
settings if they had no one to advocate for them. The average proportion of adults
still living at home was 48%, the average proportion in employment (regular,
supported, or sheltered) or full-time education was 46% and, for those in
employment, jobs were often at a low level and poorly paid. What happens to people with
autism as they approach old age? Almost all current adult outcome studies have
focused on people in their 20s to 40s. Knowledge about the aging process in ASD
is almost nonexistent, and systematic information about the physical and mental
health needs of elderly people with ASD is lacking , and limited to children with
autism, aged 31- 44 years [4]. The public health problem is increasing for
early childhood and adolescents which are more numerous per each decade. This
problem will probably increase in the next future, despite the shorter and
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E-mail: mgoldod@gmail.com
Goldberg M. Dental treatment of autistic patients (2019)
Dental Res Manag 3: 77-81. Autism, Men, Women, Communication disorders,
Life expectancy, Caries, Periodontitis.Dental Treatment of Autistic Patients
Michel Goldberg
Abstract
Full-Text
Autism
Spectrum Disorders: Epidemiology, Etiology and Groups
ASD
Changes with Time
References
*Corresponding author
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Keywords
