Autism overview& case report

Dr Dima Rushdi BDS -Jordanian Board in Pediatric Dentistry Supervised by Dr Hind Alnsor

AUTISM Defined by the Autism Society Of America (ASA)

as: " a complex developmental disability that typically

appears during the first three years of life and is the result of a neurological disorder that affects the normal functioning of the brain, impacting development in the areas of social interaction and communication skills. Both children and adults with autism typically show difficulties in verbal and non-verbal communication, social interactions, and leisure or play activities.”

CHARACTERISTICS OF AUTISM No fear of danger.

Over or under sensitivity to pain. May avoid eye contact with you. May prefer to be by him/herself. Has difficulty expressing what they want or need - may then try to use gestures. May echo words or phrases. May have inappropriate attachments to objects. May spin his/herself or objects. Prolonged repetitive play. May insist on things/routines always being the same. May exhibit inappropriate laughing (laughing when not appropriate to the situation). May display tantrums for no apparent reason. May avoid cuddling. May exhibit self injurious behavior when upset i.e. biting selves or banging heads. An overall difficulty interacting with others.

Noticable physical overactivity or extreme underactivity. Unresponsive to normal teaching methods.

CAUSES OF AUTISM autism is a complex disorder whose core aspects have distinct causes that often co-occur. Genetic the mutation that causes the autism is not present in the parental genome (spontaneous deletions or duplications in genetic material during meiosis).

Environmental All known teratogens related to the risk of autism appear to act

during the first eight weeks from conception. Their role has not been confirmed by reliable studies. Include certain foods, infectious disease, heavy metals, diesel

exhaust, PCBs (Polychlorinated Biphenyls) , phthalates and phenols used in plastic products, pesticides, alcohol, smoking and routine vaccination.

Classification

Pervasive Developmental Disorders: 1. Autism. 2. Asperger syndrome. 3. PDD-NOS . 4. Retts Disorder . 5. Childhood disintegrative disorder.

Epidemiology a prevalence of:

1–2 per 1,000 for autism worldwide. 9 per 1,000 children in the US. 15 per 10,000 in Jordan.

(Newschaffer CJ. Annu Rev Public Health. 2007). The increase in number of reported cases of autism since the 1980s is largely attributable to changes in diagnostic practices, referral patterns, availability of services, age at diagnosis, and public awareness. Boys are at higher risk for ASD than girls. The sex ratio averages 4.3:1

Pathophysiology An excess of neurons that causes local overconnectivity in key brain regions. Unbalanced excitatory–inhibitory networks. Abnormal formation of synapses or by poorly regulated synthesis of synaptic protein. Disrupted synaptic development may also contribute to epilepsy, which may explain why the two conditions are associated. Relationship with neurochemicals (serotonin and group I metabotropic glutamate receptors mGluR). Relations have been found between autism and schizophrenia based on duplications and deletions of chromosomes.

Screening Failure to meet any of the following is an absolute

indication to proceed with further evaluations: No babbling by 12 months. No gesturing (pointing, waving bye-bye, etc.) by 12 months. No single words by 16 months. No 2-word spontaneous phrases by 24 months. Any loss of any language or social skills, at any age.

Diagnosis Diagnosis is based on behavior

Autism is exhibiting at least six symptoms total including:

at least two symptoms of qualitative impairment in social interaction,

at least one symptom of qualitative impairment in communication,

at least one symptom of restricted and repetitive behavior.

Onset must be prior to age three years.

Autism Symptoms Checklist

Six or more symptoms from (1), (2), or (3) Yes No

(1) Impairment in social interaction, as indicated by AT LEAST TWO of the following:

a. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction b. Failure to develop peer relationships appropriate to developmental level

c. Stereotyped and repetitive use of language or idiosyncratic language

d. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace

e. Lack of social or emotional reciprocity

(2) Impairments in communication as indicated by AT LEAST ONE of the following:

a. Delay in, or total lack of, the development of spoken language (without an attempt to use alternative modes of communication such as gesture or mime) b. In individuals with adequate speech - marked impairment in the ability to initiate or sustain a conversation with others c. Stereotyped and repetitive use of language or idiosyncratic language

d. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace

(3) Restricted repetitive and stereotyped patterns of behavior,interests, and activities, as indicated by AT LEAST ONE of the following:

a. Preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus b. Adamantly demands specific, nonfunctional routines or rituals

c. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) d. Persistent preoccupation with parts of objects

Management The main goals when treating children with autism

are to lessen associated deficits and family distress, and to increase quality of life and functional independence.

Approaches include applied behavior analysis, developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy.

Many medications are used to treat ASD symptoms that interfere with integrating a child into home or school when behavioral treatment fails. Children diagnosed with ASD are prescribed psychoactive drugs or anticonvulsants, with the most common drug classes being antidepressants, stimulants, and antipsychotics. Treatment is expensive with medical care, extra education.

Prognosis It is not known how often recovery happens; reported rates have ranged from 3% to 25%. Helt M et al. Neuropsychol Rev. 2008.

Although core difficulties tend to persist, symptoms often become less severe with age. Acquiring language before age six, having an IQ above 50, and having a marketable skill all predict better outcomes.

Autism in Jordan

Epidemiology: 15 per 10,000 in Jordan. ≈ 7000-8000 child with autism in Jordan.

Autism Academy of Jordan,2009.

Centers: no public centers available. Cost of management:

in most private centers special education cost aroud 6000 JD per year ( can reach up to 25000 jd in some centers).

Autism & Dentistry

Health Challenges in Autism. Dental visit tips. Unique oral issues.

Challenges: 1.BEHAVIOR PROBLEMS The invasive nature of oral care may trigger violent and self-

injurious behavior such as temper tantrums or head banging.

2.COMMUNICATION PROBLEMS and MENTAL CAPABILITIES

determine your patient's intellectual and functional abilities, and then communicate with the patient at a level he or she can understand.

3.UNUSUAL RESPONSES TO STIMULI Autistic patients are usually hypersensitive to their environment and may react out of sensory overload. They don’t take well to a change in their schedules, new noises, smells, sounds, and activities.

4. UNUSUAL AND UNPREDICTABLE BODY MOVEMENTS

These movements can jeopardize safety as well as your ability to deliver oral health care.

5. SEIZURES usually be controlled with anticonvulsant medications.

6. BARRIERS TO DENTAL CARE An inability to find a dentist with the skills or willingness to work

with people with disabilities was the most frequent reason cited for not having a regular dental provider.

(Brickhouse TH J Dent Child, 2009)

Dental visit tips Before the appointment, obtain and review the patient's medical history. Consultation with physicians, family, and caregivers is essential to assembling an accurate medical history. Offer parents and children the opportunity to tour your dental office, so that they may ask questions, touch equipment, and get used to the place. Allow autistic children to bring comfort items, such as a blanket or a favorite toy. Children with autism need sameness and continuity in their environment. A gradual and slow exposure to the dental office and staff is therefore recommended.

Ask for suggestions from the parent or caregiver on how best to deal with the child. Autistics will want to know what’s going to happen next. Explain what you’re doing so it makes sense to them. Explain every treatment before it happens. Always tell the autistic child where and why you need to touch them, especially when using dental or medical equipment. Talk in direct, short phrases. Talk calmly. Autistics take everything literally – so watch what you say. Avoid words or phrases with double meanings. Make the first appointment short and as uninvasive as possible . Approach the autistic child in a quiet, non-threatening manner. Don’t crowd the child.

Use a “tell-show-do” approach to providing care. Explain the procedure before it occurs. Show the instruments that you will use. Provide frequent praise for acceptable behavior. Invite the child to sit alone in the dental chair to become familiar with the treatment setting. Once the dental patient is seated, begin a cursory examination using only your fingers. Keep the light out of the eyes. Next, use a toothbrush, or possibly a dental mirror to gain access to the mouth. Praise and reinforce good behavior. Ignore poor behavior. Invite the parent of caregiver to hold the child’s hand during the dental examination.

Be prepared to manage a seizure. If one occurs during oral care, remove any instruments from the mouth and clear the area around the dental chair. Attaching dental floss to rubber dam clamps and mouth props when treatment begins can help you remove them quickly. Do not attempt to insert any objects between the teeth during a seizure. Some children will need sedation or general anesthesia so that dental treatment can be accomplished. Sedation of autistic children who are 8 years and older simply does not work. Caution is necessary because some patients with developmental disabilities can have unpredictable reactions to medications.

Behaviour guidance in dental treatment of patients with autism spectrum disorder.

Loo CY, Graham RM, Hughes CV (Int J Paediatr Dent. 2009). The dental charts of 395 patients with ASD patients and 386 unaffected

patients were reviewed. RESULTS: Within both groups, younger patients were more

uncooperative. patients with an additional diagnosis were more uncooperative. ASD patients with higher caries severity, who were uncooperative or female, were more likely to require GA.

Use of protective stabilization was associated with lower caries severity, presence of seizure disorder, uncooperative behaviour, male gender, or residency in a group home/institution. A significantly higher percentage of patients with ASD than unaffected patients were uncooperative and required dental treatment to take place under general anesthesia.

Cooperation predictors for dental patients with autism.

Marshall J, Sheller B, Williams BJ, Mancl L, Cowan C. (Pediatr Dent. 2007).

Data were collected from 108 parent/child pairs. RESULTS: Frankl scores were 65% uncooperative and 35%

cooperative. Multiple factors predicted uncooperative behavior: (1) appointment

type (2) concurrent medical diagnoses (3) nonverbal/minimal or echololic language (4) inability to understand language appropriate for age (5) inability to follow multistep instructions (6) parents providing most/all tooth-brushing (7) partially or not toilet trained at 4+ years (8) inability to sit for a haircut (9) attending special education and (10) inability to read at 6+ years.

CONCLUSIONS: Preappointment inquiry about toilet training, toothbrushing, haircuts, academic achievement and language can give the dentist insight into the child's ability to respond positively to behavior guidance techniques based on communication.

Parental attitudes regarding behavior guidance of dental patients with autism.

(Marshall J, Sheller B, Mancl L, Williams BJ. Pediatr Dent. 2008).

Parents most accurately predicted if their child would permit an examination in the dental chair and would cooperate for radiographs BGTs utilized most often were positive verbal reinforcement (PVR), tell-show-do (TSD), mouthprops, and rewards. The most acceptable techniques in order were: PVR, TSD, distraction, rewards, general anesthesia, hand-holding by parent, and mouth-props. All BGTs, including a stabilization device, were highly acceptable, except for staff restraint.

Unique Oral Issues

Many autistic patients have the same dental issues as “normal” patients, although sometimes these are exacerbated by improper oral hygiene (either by the patient or caregiver, or where the patient simply won’t allow even a toothbrush into their mouth) and overindulgence in sweets, often used as rewards.

DAMAGING ORAL HABITS are common and include bruxism; tongue thrusting; self-injurious behavior such as picking at the gingiva or biting the lips; and eating objects such as pens. If a mouth guard can be tolerated, prescribe one.

DENTAL CARIES risk increases in patients who have a preference for soft, sticky, or sweet foods; damaging oral habits; and difficulty brushing and flossing.

Caution patients or their caregivers about medicines that reduce saliva or contain sugar. Suggest that patients drink water often, take sugar-free medicines when available, and rinse with water after taking any medicine.

Although commonly used medications and damaging oral habits can cause problems, the rates of caries and periodontal disease in people with autism are comparable to those in the general population.

People with ASD were more likely to be caries-free and had lower DMFT scores than did their unaffected peers.

(Loo CY, J Am Dent Assoc. 2008). Oral hygiene may be the most influential risk indicator

associated with new caries in children with autism. (Marshall J, Pediatr Dent. 2010).

PERIODONTAL DISEASE Occurs in people with autism in much the

same way it does in persons without developmental disabilities.

Some patients benefit from the daily use of an antimicrobial agent such as chlorhexidine. TOOTH ERUPTION

May be delayed due to phenytoin-induced gingival hyperplasia as Phenytoin is commonly prescribed for people with autism.

TRAUMA Injury to the mouth from falls or accidents

occur in people with seizure disorders. Caregivers should know how to preserve

the lost or broken tooth and know to seek dental treatment right away.

Physical abuse often presents as oral trauma. Abuse is reported more frequently in people with developmental disabilities than in the general population. If you suspect that a child is being abused or neglected, you should report it.

Dental injuries in autistic patients. (Altun C, Guven G, Yorbik O, Acikel C. Pediatr Dent. 2010).

There were no significant differences in the rates

of traumatic dental injuries among children and young adults with and without autistic disorder. The most frequently injured teeth were the permanent maxillary central incisors, and the frequency of injury to these teeth differed significantly between AG and CG. The distribution of types of traumatic dental injuries differed significantly between the 2 groups.

Case Report 1

Wala Ahmad, 5 years old. Referred from her dentist as having multiple carious teeth, being mentally behind and uncooprative. Medical history: Parent denied any medical problem but while examining the patient the father informed us that she is autistic and that she attends a special center. Dental exam: fair oral hygiene

carious E BA AB DE E D DE

1st visit was only introductory with preventive measures (fluoride varnish). As 1st visit need to be short & uninvasive.

pt sat alone but was catious. 2nd visit B class V GIF.

patient was seen by the same staff that treated her in the 1st visit.

Patient was highly uncooprative despite the use of BMT of PVR, TSD and rewards referred for treatment under GA.

Case Report 2

Ahmad Osama, 4 years old. Patient was referred as having multiple carious teeth that need ttt. Medical history: autism. ( parent informed the referring dentist of the child’s problem).

patient does not attend a special center because of financial problems. Dental exam: poor oral hygiene

carious D D ED DE

1ST visit pt chief complain was pain in D So, minimal excavation and temporization as pt was

uncooprative and any invasive procedures delayed for another visit.

Oral hygiene instructions given. Parent was adviced to put pt into a special center and bring

a copy of his medical file on the coming visit. On his 2ND dental visit he came with his mother and did not bring the medical record.

pt was uncooprative although we used TSD, PVR and same dental staff.

The mother stated that his father can controll him better. So, he was given another appointment to be accompanied by his father but he never showed up after that.