AUTISM SPECTRUM DISORDERS: AN UPDATE ON ORAL HEALTH MANAGEMENT Roopa P. Gandhi, BDS, MSD, and Ulrich Klein, DMD, MS

ABSTRACT

SORT SCORE A

B

C

NA

SORT, Strength of Recommendation Taxonomy

LEVEL OF EVIDENCE 1

2

3

See page A8 for complete details regarding SORT and LEVEL OF EVIDENCE grading system

Dental professionals caring for patients with a diagnosis of autism spectrum disorder (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. Background With the rising prevalence of autism spectrum disorders (ASD), oral health providers 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. Methods 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. Conclusions A detailed family centered approach based on parental preferences and concerns, 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 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, USA. E-mail: roopa.gandhi@childrenscolorado. org J Evid Base Dent Pract 2014;14S: [115-126] 1532-3382/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jebdp.2014.03.002

Key words: Autism, autistic, autism spectrum disorder, Asperger's disorder, autism dental management

INTRODUCTION

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 disintegrative disorder and pervasive neurodevelopmental disorder not otherwise specified. Previously these diagnoses were subsumed under the umbrella pervasive developmental disorders. Symptoms in this group of neurodevelopmental disorders can be expressed on a continuum ranging from mild to severe and, by definition, must be present from infancy or early childhood.2

PREVALENCE 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

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

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 seen in ASD (Figure 1) is due to heightened awareness and access to services or true increases in prevalence.

include stereotyped or repetitive motor behaviors (hand flapping, rocking back and forth), repetitive use of objects (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 occur as part of one’s life.1

DIAGNOSTIC FEATURES The DSM-5 reduced the diagnostic criteria from three to two areas of impairment1: (A) persistent deficits in reciprocal social communication/interaction and (B) restricted, repetitive patterns of behavior, interests, or activities. Three severity levels further detail these deficits: 1) requiring support, 2) requiring substantial support, to 3) requiring very substantial support (Table 1). Additional specifiers are used to describe if a patient presents with or without accompanying intellectual or language impairment, a known medical or genetic condition or environmental factor, or if the condition is associated with another neurodevelopmental, mental, or behavioral disorder.

CAUSES No specific etiology has been identified to date, but evidence points to a combination of genetics and pre- and postnatal environmental factors such as parental age, maternal infections during pregnancy, and low birth weight.4 Evidence based research has ruled out vaccines as causes of ASDs and has concluded that general peri- and neonatal events increase the risk.5 It is known that environmental factors such as nutrition, psychotropic drugs, maternal autoimmune disease, maternal viral infection during the 1st trimester of pregnancy, or psychological stress can cause epigenetic modifications leading to neurodevelopmental diseases including ASD.6 It has also been suggested that focal brain inflammation caused by a breakdown of the blood-brain-barrier could adversely affect neurodevelopment.7

Of specific importance to dentistry is the hypersensitivity of these patients to sensory input, although hyposensitivity and indifference to pain or temperature extremes can also occur.1 Owing to an overly sensitive nervous system, a number of individuals with ASD exhibit extreme and peculiar responses 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 texture and smell may lead to food idiosyncrasies such as a preference for bland or particularly crunchy foods.

SCREENING AND DIAGNOSIS In the United States pediatricians screen for ASD at the 18 and 24–30-month visits.8 Although no specific signs have been identified, lack of eye contact, poor response to name, or a marked regression in language skills or social behaviors, often during the first 2 years of life, warrant concern.9 The diagnosis is made by integrating information from various sources: thorough history taking, caregiver interviews, structured patient observation, and a detailed medical and neurological examination to rule out associated medical and

Of specific importance to dentistry is the hypersensitivity of these patients to sensory input, although hyposensitivity and indifference to pain or temperature extremes can also occur.

Communication with individuals with ASD may be complicated by language deficits, poor comprehension of speech, or difficulties reading social cues. Additional features of ASD

Volume 14, Supplement 1

116

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

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 Severity level for ASD

Restricted interests and repetitive behaviors (RRBs)

Social communication

Level 3 Requiring very substantial support

 Severe deficits in verbal and non-verbal social communication skills  Very limited initiation of social interactions  Minimal response to social overtures from others

 Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres  Marked distress when rituals and routines are interrupted  Very difficult to redirect from fixated interest or returns to it quickly

Level 2 Requiring substantial support

 Marked deficits in verbal and non-verbal social communication skills  Social impairments apparent even with supports in place  Limited initiation of social interactions and reduced or abnormal response to social overtures from others

 RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in variety of contexts  Distress or frustration when RRBs are interrupted  Difficult to redirect from fixated interest

Level 1 Requiring support

 Without supports in place, deficits in social communication cause noticeable impairments  Difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures from others  May appear to have decreased interest in social interactions

 RRBs cause significant interference with functioning in one or more contexts  Resists attempts by others to interrupt RRBs or to be redirected from fixated interest

Adapted from DSM-5.1

psychiatric comorbidities.2 A study concluded that the typical age at diagnosis is 38 6 15 months, but children with language regression and unusual mannerisms (toe walking) were referred earlier for evaluation.10

behavioral interventions for some children with ASD.14 The goals of Applied Behavioral Analysis (ABA) and the Early Start Denver Model (ESDM) include furthering a patient’s IQ, communication and language skills, and academic performance. They teach adaptive behavior to promote useful social skills such as independence, ability to adapt to the environment, and reduction of inappropriate stereotypic behaviors. Participants in the ESDM range from infancy to preschool age and achieve significant and sustained improvements in IQ, adaptive behaviors, as well as social and emotional milestones by learning child-specific skills through play activities. It is important to provide ongoing education and support for the parents of a child with ASD because they are instrumental in adjusting the environment to the sensory idiosyncrasies of their child.2,4,9

ASSOCIATED COMORBIDITIES Fragile X-syndrome (FXS) is the most common (5%) single gene cause and an important subtype of ASD: half of all males with FXS fall somewhere on the ASD spectrum. Both diseases are linked at the molecular level through a mutation in the FMR1 gene. This association with FXS has a strong potential for development of targeted treatments for non-FX autism.11 One of the clinical neurologic manifestations of the neurocutaneous disorder tuberous sclerosis (TSC) includes ASD. TSC is the established medical cause for 1–4% of all cases of autism and 20–60% of individuals with this disease have a diagnosis of ASD. The common pathway of dysfunctional mTOR (mechanistic target of rapamycin) signaling between these diseases provides a model for understanding the pathophysiology of this subset of ASD.12

To date, there are no specific medications available that can treat the core symptoms of ASD. However, a number of drugs are commonly prescribed for associated conditions such as sleep disturbances, epilepsy, GI problems, hyperactivity, irritability, self-injury, aggression, or anxiety. Medications that are more frequently used in patients with ASD are selective serotonin reuptake inhibitors (for repetitive behaviors, rigidity), methylphenidate (for ADHD), and melatonin (for sleep problems).4,9

ASD often occurs together with Attention-Deficit/Hyperactivity 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 in their dental practice. Decision-making about dental treatments may be complicated by parental concerns about restorative materials or the refusal to use fluoride-containing

THERAPEUTIC APPROACHES A Cochrane review found some evidence that early intensive behavioral intervention (EIBI) programs represent effective

117

June 2014

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

dental setting. An over-stimulated patient may find relief by self-stimulatory behaviors such as twisting hands, flapping arms, making noises, or making other repetitive movements.20 Early recognition and quick removal of the offending stimulus is desirable, whereas trying to stop the self-stimulatory behavior is not a meaningful approach for anxiety reduction.21

toothpaste due to their child’s hypersensitivities or their own concerns for its toxicity.15 A family centered approach to care requires an empathetic relationship with parents or caregivers who can provide unique and valuable information such as their child’s likes and dislikes, and behavior triggers.

Parents may also have preferences regarding behavior management strategies, choice of dental staff or even the operatory, because they are most familiar with their child’s idiosyncrasies. Dismissing such requests as naïve or unfounded without exploring their basis can prove detrimental to the patient’s dental experiences, the family’s trust, and ongoing cooperation with the dental provider. A family centered approach to care requires an empathetic relationship with parents or caregivers who generally provide unique and valuable information about their child’s likes and dislikes and behavior triggers. Such collaborative care planning, rather than a paternalistic approach, can build a strong foundation for the effective long-term oral health of the patient.

Self-injurious Behavior Self-injurious behavior (SIB) is perhaps the most challenging and distressing behavior encountered by dental professionals treating patients with autism. With a reported prevalence of 4.9%, ASD is an identified risk marker for SIB.22 While these behaviors can impact any part of the body of the affected individual, more than 75% involve the head and neck region23 and are likely to occur in those with expressive language deficits and a diagnosis of autism within ASD.24 Worsening SIB may also be a consequence of the patient’s inability to 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 to repetitive gouging by fingernails or foreign objects, cheek or lip biting, or self-extraction.23,26

BEHAVIORS Patients with ASD can present the dental provider with challenging behaviors that are as wide-ranging as the neurocognitive symptoms associated with this spectrum of disorders. They may be the by-product of a child’s frustration that a daily routine has been interrupted or the anxiety induced from exposure to an unfamiliar setting. In a dental context, challenging behaviors can be designated as non-compliance, hyperactivity, sensory hypersensitivity, and self-injurious behavior.16 The severity of a given behavior can be attributed to the deficit in language development and the type of ASD diagnosis.17 Children with ASD who are anxious in an unfamiliar dental setting can become non-compliant for dental care and display such anxiety in the form of emotional outbursts and temper tantrums. In more severe cases, their aggressive behavior can translate into destruction of furniture or fixtures, or harm to others by scratching, biting, kicking, or head butting.18

Treatment strategies involve a multidisciplinary approach with input from team members including the psychologist, psychiatrist, and occupational therapist.27 Behavioral approaches such as positive reinforcement, extinction, and time-out may also be used.23,28 Positive reinforcement is a common and effective strategy that involves specifically praising the patient for appropriate behaviors as a substitution for SIB.26,28 Aripiprazole and risperidone are medications that have been used successfully for managing SIB, in combination with a behavioral approach.29,30 In severe cases, physical restraints and/or oral appliances such as mouth guards are necessary to minimize further oral self-injury.31

ORAL HEALTH STATUS The caries status of primary and permanent dentitions in children with autism spectrum disorders (ASD) has been explored in a number of studies with conflicting results. Some report lower caries prevalence in primary, mixed and permanent dentitions and no significant association between caries prevalence, severity of ASD or the institutionalized status of patients.32 Others report higher caries prevalence in primary and permanent dentitions.33–35

Hyperactivity Those with autism are often described as hyperactive, which may be related to the associated co-morbidity of ADHD.19 In the dental setting, such hyperactivity can be manifested by the patient pacing within the operatory, or exiting the operatory or dental setting entirely.

Sensory Hypersensitivity

While there are divergent conclusions regarding caries status, the majority of studies unequivocally point to poor oral hygiene in children and adults with ASD33–36 although many individuals with ASD receive regular assistance with toothbrushing.33,34,36,37

Sensory hypersensitivities in children with autism can trigger defensive responses that may include attempts to escape from the dental environment because their senses are overwhelmed by the loud sounds, smells, or textures in a typical

Volume 14, Supplement 1

118

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

insurance, and the child’s behavior. In particular, the child’s behavior was a major barrier to dental care and children with poor perceived behavior had higher odds of having unmet dental needs.

The majority of studies unequivocally point to poor oral hygiene in children and adults with ASD compared to unaffected individuals.

Poor oral hygiene has also been positively associated with greater caries experience, increased severity of ASD symptoms, and the presence of generalized gingivitis.33,35,38 The concern for periodontal disease as sequelae to poor oral hygiene in patients with ASD has been supported by the finding of significantly poorer periodontal status in children with autism compared to unaffected children.39

BASIC BEHAVIOR GUIDANCE

Traditional Approaches Currently used basic behavior guidance techniques (BGTs) include positive reinforcement, tell-show-do (TSD), distraction methods, non-verbal communication, and voice control (Table 2).43 These techniques can be effective in typically developing patients, however they may not always be successful in patients with ASD in which expressive and receptive language deficits can negatively impact the ability to utilize these techniques. They may not understand the use of “good 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 effectively utilizing TSD methods because they require the child to model the dentist for a given procedure.44 A preappointment consultation can be a critical step to gauge the patient’s behaviors and symptoms, and to customize the use of basic BGTs.

Orthodontic concerns in individuals with ASD compared to healthy individuals include an increased tendency toward anterior open bite and dental crowding.36,40 Other studies have reported spacing, reverse overjet, open bites, and Class II molar relationship.39

CARIES RISK FACTORS Potential caries risk factors of individuals with ASD relate predominantly to diet, oral hygiene, and age. The xerostomic side effects of psychoactive medications have been not been found to be a risk factor for caries in some studies, however no hypotheses have been provided for such findings.33,37 Inconclusive evidence regarding psychoactive medications and their contribution to caries risk may warrant further investigation in future studies. The observed preference of these individuals for soft sticky foods as well as the use of sweet food as rewards makes diet a significant caries risk factor.33,37 Oral hygiene, however, is the most influential risk indicator in children with autism and special attention should be given to the presence of visible plaque and gingivitis in individual patients with ASD.33

Visual Pedagogy Visual pedagogy takes advantage of the ability of children with autism to respond better to pictures rather than words.

Visual pedagogy is a non-traditional approach to behavior guidance that takes advantage of the ability of children with autism to respond better to pictures rather than words.45 It involves the use of books with color photographs, social stories, or video modeling and can be combined with traditional BGTs such as positive reinforcement and TSD to account for the neurocognitive deficits in patients with ASD.

Oral hygiene may be the most influential caries risk indicator in children with autism and special attention should be given to the presence of visible plaque and gingivitis in patients with ASD.

Books

UNMET DENTAL NEEDS AND BARRIERS TO CARE

Bäckman et al demonstrated the use of visual pedagogy in their study involving the use of a book with a series of colored photographs to describe all the steps involved in a dental visit to preschool children with autism.45 The authors reported improved cooperation over a 11/2 year period in the children who were exposed to this behavioral approach, compared to those children with ASD who were not.

The child’s behavior has been identified as a major barrier to dental care and children with poor perceived behavior had higher odds of having unmet dental needs.

Dental care has been reported as the most prevalent unmet health care need of children with special health care needs (SHCN), including those with ASD.41 Recent studies have specifically focused on the issue of unmet dental needs and related barriers to dental care in these patients: 12% of children with ASD had unmet dental needs and of the 93% of children who had been to a dentist, 11% still reported unmet needs.42 The main barriers were the cost of treatment, lack of

Social Stories Visual pedagogy has also been used for the development of Social Storiesä, which are a widely used strategy for children with ASD.46,47 Initially developed by the special education teacher Carol Gray, social stories attempt to further a child’s accurate understanding of social information for a setting or

119

June 2014

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

Table 2. A summary of traditional and non-traditional behavior guidance approaches in for patients with ASD Basic behavior guidance

Table 3. Internet resources for visual pedagogy based methods such as social stories (A) and video modeling (B)

Advanced behavior guidance

Traditional approaches: Positive reinforcement Tell-Show-Do Distraction

Protective stabilization Sedation General anesthesia

Nitrous oxide Non-traditional approaches: Visual pedagogy with books Social stories

(A) Resources for social stories:

(B) Resources for video modeling:

My Dental Social Story – POAC www.poac.net/image/pdfs/Dentist/ socialstoryDental.pdf

Model Me Kids www.modelmekids.com/

Printable Easy Social Stories for Children with Autism or Asperger’s http://easysocialstories. com/

Social Skill Builder www.socialskillbuilder.com

Social Storiesä – The Gray Center www.thegraycenter.org/socialstories

Look At Me Now! Videos for Children with Autism http://lookatmenow.org/

Social Story Examples – Autism Help www.autismhelp.info/

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 cues. They can be easy to create and practitioners seeking to formulate a social story for a dental visit should review the guidelines associated with their construction.48 A variety of these types of stories about dental visits are readily available on the Internet from a number of sources (Table 3(A)).

other intellectual disabilities.28 The process is initiated by first learning from the parents the type of positive reinforcer that is valuable to their child (e.g., stickers, stamps). Then, the steps associated with a procedure such as a dental examination are practiced in a mock environment (e.g., their home) by combining the use of the positive reinforcer with praise. Ideally, practice sessions would be followed by visits to the dental office where the actual dental examination takes place. However, professional desensitization can be a timeconsuming process that requires the availability of facilities and dental staff. For this reason, consultation with the child’s therapist to practice mock dental visits at the therapist’s office prior to the actual dental examination can be considered.

In children with ASD, social stories can improve social behaviors such as increasing hand washing, greeting people appropriately, and sharing toys. There is evidence that disruptive behaviors can also be reduced with the repetitive use of a social story.47 In addition to visual cues social stories do rely on reading skills and basic auditory processing skills, in addition to visual cues. Therefore, the reading ability and auditory performance should be assessed before considering this method.

Nitrous Oxide Video Modeling

There are equivocal accounts for the success of nitrous oxide (N2O) as a behavior guidance technique for dental patients with autism. Some authors have stated that nitrous oxide is not efficacious because it only works well if combined with communication-based BGTs such as distraction, TSD, and positive reinforcement to which patients with autism may not be amenable.52 Others, however, have recommended the use of N2O for patients with mild behavioral issues.53,54 In one recent prospective study, patients with autism were reported to have a success rate as high as 87.5% with 50% N2O.55

For patients who have limited reading and auditory skills, video modeling may be an alternative visual pedagogy-based method that draws upon the growing propensity of electronic screen media use by children with autism.49 Its efficacy in teaching and changing behaviors has expanded its positive impact on functional living skills and non-compliant behaviors.50,51 While there is limited evidence regarding the use of video modeling in dentistry, practitioners can find videos that are specifically designed to improve compliance with oral 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 their children, most likely out of concerns about negative systemic effects from its interaction with potential methylene tetrahydrofolate reductase (MTHFR) gene mutations or abnormalities of folate metabolism. There are reports of MTHFR related gene mutations and the dysregulation of folate metabolism in patients with autism56 and study has

Desensitization Desensitization appointments are designed to repeatedly expose a child to the dental environment and are aimed at furthering the child’s trust and adaptation. The use of desensitization can result in increased cooperation for dental examinations and debridements in children with ASD and

Volume 14, Supplement 1

120

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

documented a lethal outcome in a child patient with MTHFR deficiency who was exposed to high and prolonged levels of nitrous oxide under general anesthesia.57 Currently, there is no evidence for fatal systemic effects when the typically lower levels of nitrous oxide are administered in the dental setting.

The practitioner must rule out other comorbidities that contraindicate the use of sedation as well as medications that can interact with or jeopardize the success of a sedation regimen. Adherence to established sedation guidelines should guide the practitioner in providing a safe sedation environment. For patients where there is a doubt about the safety of a sedation regimen, general anesthesia (GA) serves as an advanced approach to provide comprehensive dental care.

Providers should discuss nitrous oxide use with concerned parents and help them make informed decisions by explaining risks and benefits, as well exploring other treatment modalities. Consultation with the patient’s physician regarding possible genetic mutations or abnormalities of folate metabolism will also aid in the decision-making process, especially in cases of longer and higher concentrations of nitrous oxide exposure such as under general anesthesia.

General Anesthesia Among dental patients with SHCN, autism is one of the most frequent indications for providing dental care under general 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 other treatment alternatives have failed or when the patient is planned for care under GA by other medical services which can be combined with dental treatment.37

ADVANCED BEHAVIOR GUIDANCE

Protective Stabilization Patients with autism may require active or passive protective stabilization for the purposes of an urgent diagnosis or treatment, as part of a procedural sedation, or because they exhibit uncontrolled movements that can jeopardize their own safety and that of the dental staff and families.58 Protective stabilization may in fact calm the autistic child due to the deep pressure produced by its placement.28,52,59 However, it should be considered with due care as restraint related injuries can occur in patients who do not always respond in the anticipated manner. The majority of such injuries involve scratches and minor bruises, but more serious injuries are possible. The care provider should pay close attention to how tightly the wrap is placed over the patient as it can limit respiration or may lead to overheating. Fewer injuries have been shown to occur with passive compared to active stabilization and in situations where passive stabilization was used in a planned rather than emergent manner.52

Parents of children with autism are likely to have a positive attitude toward GA. The hospital environment, however, can produce defensive responses in their child, which can increase a family’s stress and preclude an uncomplicated stay.52 While GA is generally considered a safe procedure64 adverse events related to its use in patients with autism include significant disruptive behaviors (12%) and postoperative vomiting that delays discharge (6%), but rarely fatalities.65 Other less frequent adverse events are extensive post-operative bleeding from patient manipulation of surgical sites and post-operative seizures requiring hospital admission. The hospital environment can produce defensive, hypersensitive responses in a child with autism which can preclude an uncomplicated stay and increase the family’s stress.

The risk for peri-operative complications and the general hypersensitivity of patients with autism requires judicious preoperative planning.66 Autistic patients may benefit from a preanesthesia visit to the hospital to become desensitized to this environment. The use of visual pedagogy can also be useful in this context and may involve either books or videos describing the processes involved on the day of the GA procedure.

Parents of children with autism may be hesitant about the use of protective stabilization, but acceptance can be improved by positive explanations and a detailed informed consent accounting for their concerns and preferences.52,60 Parental presence during the use of protective stabilization should be encouraged and parents may be more accepting of active restraints when they are personally involved.52

The dentist should relay pertinent information to the anesthesia provider about the child’s specific ASD diagnosis, the presence of related comorbidities, and any challenging behaviors pre-operatively.

Sedation The use of sedation is a viable option that may be considered for patients with autism when basic BGTs have failed. Benzodiazepines such as diazepam and midazolam are suggested in combination with nitrous oxide administration with reported success rates ranging from 77% to 100%.61–63 Midazolam is reportedly more successful in regulating patient behavior than diazepam but it has a shorter working time and this should be considered when choosing between the two agents.62

The dentist should relay pertinent information about the specific ASD diagnosis to the anesthesia provider, the presence of related comorbidities, and any potentially challenging preoperative behaviors because they will dictate the choice of pre-medication and the need for additional staff or restraints. In the case of related comorbidities, such as uncontrolled epilepsy, a pre-anesthesia visit can predict the risk for post-

121

June 2014

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

operative complications as well as address the need for a 23-h admission in a planned manner.

with autism, the caregivers received oral hygiene instructions over 1, 3 and 6 monthly dental visits with statistically significant improvements in oral hygiene.71 Visual pedagogy such as placing color photographs of oral hygiene steps in the patient’s bathroom are helpful when combined with recall evaluations.72

THE DENTAL ENVIRONMENT AND CARE TEAM

Caregiver Consultation Parental input regarding the behaviors and preferences of their child can be of tremendous value to the success of an oral health care appointment. Key questions such as a child’s ability of to read, the use of expressive language, developmental age, toilet training, and concurrent diagnoses can be asked as a guide about potentially effective BGTs.67 Children who have minimal language skills, lack toilet training, or are unable to read by 6 years of age are likely to be more uncooperative for the dental visit. Parental input may be solicited in the form of a pre-appointment questionnaire or during an office visit and be used to address parental preferences and concerns about future treatment needs.

Prevention strategies need to account for the sensory processing difficulties and hypersensitivities of children with autism. “Sensory over-responders” may face oral hygiene challenges such as a dislike for the taste and texture of certain toothpastes and gagging with toothbrushing.68 A trial and error strategy with caregivers is encouraged to find a fluoride containing toothpaste that the patient is likely to use. Also, discussions with the patient’s occupational therapist or psychologist should be considered to develop a sensory integration approach that can improve the individual patient’s adaptation to the oral hygiene procedure.

Fluoride

Dental providers should ask key questions such as the ability of a child to read, use of expressive language, developmental age, toilet training and concurrent diagnoses to help guide them about potentially effective BGTs.

The primary reason for a parent’s refusal of fluoride-containing toothpastes may be related to their child’s sensory difficulties with the flavor, texture, or taste of toothpaste. They may also be concerned that their child has difficulty spitting out toothpaste or could swallow it, with a risk for toxicity.73 Some parents have heard that the use of fluoride can potentiate neurotoxic effects, which has been propagated in the alternative medicine literature.74 In any case, the reason for refusal of fluoride containing products should be explored further with the parents in conjunction with a careful assessment of the patient’s caries risk and other potential sources of fluoride exposure.

Operatory Design A dental operatory filled with unwelcome smells, noises, and colors can be an over-stimulating environment to a patient who suffers sensory processing difficulties.68 The basis of sensory adaptation is to modify a given environment to a patient’s needs and thereby reduce negative and anxious behaviors. To minimize anxious and uncooperative behaviors, a relaxing light, rhythmic music provided with or without headphones, and white noise should be considered to adapt the dental environment to an autistic patient’s hypersensitivities.69 Keeping the patient to the same operatory for each visit and having minimal visual stimuli on the walls can also be useful to improving cooperation. The dentist may consider designating a specific and separate waiting area for patients with ASD to minimize anxiety-inducing situations created by the extended exposure to other patients.

CONSIDERATIONS FOR RESTORATIVE TREATMENT Typically used restorative materials in patients with autism include amalgam, resin-based composites and glass ionomers. Dental amalgam is characterized by excellent moisture tolerance and longevity75 making it a suitable choice for posterior teeth in patients where moisture control is more difficult to achieve. However, many parents of patients with ASD express concern about the use of dental amalgam because of potential mercury poisoning emanating from dental amalgam restorations.15 The use of the word “mercury” may be key to addressing parental concerns according to one survey that found that the majority of parents of children with ASD agreed to the use of “metal filling or “amalgam alloy,” but not to the placement of a “mercurycontaining” dental material.73

PREVENTION STRATEGIES

Oral Hygiene The evidence that poor oral hygiene occurs frequently in individuals with autism and is associated with an increased risk of gingivitis, periodontitis and caries drives prevention strategies aimed at improving the oral hygiene of these patients. Some have deficits in their motor skills and may be at risk for rare but serious toothbrush impalement injuries if left unsupervised for daily oral hygiene.70 Teaching caregivers about oral hygiene and more frequent recall visits than the traditional six monthly recall visits should also be considered. In one study of a dental plaque control program for children

Volume 14, Supplement 1

It has been demonstrated that the small amounts of mercury vapor released from dental amalgams either prenatally (from maternal dental amalgam) or during early childhood are not associated with either neurocognitive or other physical

122

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE

developmental deficits.76 Parents who believe that their child may be unable to excrete the mercury vapor released from dental amalgam can be appraised of prospective studies that have refuted this theory.77,78

infections and whether any particular antibiotics have resulted in worsening symptoms or adverse reactions.

OROFACIAL TRAUMA

Alternative available materials such as resin-based composite may raise objections due to their presence of bisphenol-A (BPA).79 Resin-based composites and sealants that do not contain BPA are potentially acceptable restorative choices in such instances. Other restorative alternatives include glass ionomers and stainless steel crowns. While glass ionomers do release aluminum, this metal does not fall into the list of heavy metals that would stir parental concerns regarding neurotoxicity. However, glass ionomer’s fluoride release may cause concern and should be addressed. In the instance of preformed stainless steel crowns, parents may be reassured that although these materials do degrade chronically in the oral cavity to release nickel, chromium and iron, the levels released are low and do not impact systemic health.80

While aggressive and self-injurious behaviors in patients with autism suggest a risk for traumatic injuries to the primary and permanent dentition, there is a lack of evidence to support this association.86 Soft tissue injuries subsequent to self-injurious behavior are more likely23,26 and practitioners should investigate whether any injuries may be the result of SIB. The earlier described strategies involving a multi-disciplinary approach should be considered if this is a concern. While less probable, there are documented reports of neglect or abuse resulting in orofacial trauma to patients with special health care needs, including ASD.87 The oral health care provider as a mandated reporter should keep this in mind when assessing any case of trauma until a comprehensive review of the patient’s history suggests otherwise.

CONSIDERATIONS FOR PRESCRIPTION OF MEDICATIONS

CONCLUSIONS

Analgesics

Dental professionals are likely and more than ever to encounter patients with a diagnosis of ASD in their practice. Therefore, they need a greater familiarity with the medical and dental management of this special group of patients. A detailed family centered approach based on parental preferences and concerns, the child’s challenging behaviors, and related comorbidities can foster mutual trust. Close interactions between patients, parents and providers are also likely to produce the best treatment decisions.

Acetaminophen use during pregnancy, early childhood, or after measles, mumps and rubella vaccination has been implicated in increasing the risk for ASD. Unsubstantial evidence from two studies suggests that immunological or neurotoxic derangements are able to potentiate this risk.81,82 While neither of these studies inferred a causal relationship between acetaminophen and autism, the primary hypothesis for the association has been proposed as a defect in the sulfation pathway. To date, there is no evidence that ibuprofen is associated with adverse effects in children with autism, and therefore may be an acceptable alternative in the light of any parental concerns.

REFERENCES 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

Antibiotics

2. Lauritsen MB. Autism spectrum disorders. Eur Child Adolesc Psychiatry 2013;22(suppl 1):S37-42.

In patients with autism, gastrointestinal (GI) symptoms such as constipation, diarrhea, abdominal pain, and bloating have been reported as common comorbidities although one study reported that the overall incidence of such symptoms is not different between affected and healthy children.83 There is also limited evidence for the pathogenic role of intestinal microorganisms such as Clostridium difficile in individuals with autism.84 In an attempt to alleviate gastrointestinal symptoms, patients with autism may be prescribed vancomycin and metronidazole.85 Reported improvement of GI symptoms with the use of these antibiotics also suggests improved neurocognitive function of the affected patient. If antibiotic use is revealed in an autistic patient’s history, a key question is whether these were used for GI symptoms or specific

3. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health surveillance among children–United States, 2005-2011. MMWR Surveill Summ 2013;62(suppl 2):1-35. 4. Tchaconas A, Adesman A. Autism spectrum disorders: a pediatric overview and update. Curr Opin Pediatr 2013;25(1):130-44. 5. Gardener H, Spiegelman D, Buka SL. Perinatal and neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics 2011;128(2): 344-55. 6. Miyake K, Hirasawa T, Koide T, Kubota T. Epigenetics in autism and other neurodevelopmental diseases. Adv Exp Med Biol 2012;724:91-8. 7. Angelidou A, Asadi S, Alysandratos KD, et al. Perinatal stress, brain inflammation and risk of autism-review and proposal. BMC Pediatr 2012;12:89.

123

June 2014

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE 8. Johnson CP, Myers SM. Identification and evaluation of children with autism spectrum disorders. Pediatrics 2007;120(5):1183-215.

28. Klein U, Nowak AJ. Autistic disorder: a review for the pediatric dentist. Pediatr Dent 1998;20(5):312-7.

9. Manning-Courtney P, Murray D, Currans K, et al. Autism spectrum disorders. Curr Probl Pediatr Adolesc Health care 2013;43(1):2-11.

29. Marcus RN, Owen R, Kamen L, et al. A placebo-controlled, fixed-dose study of aripiprazole in children and adolescents with irritability associated with autistic disorder. J Am Acad Child Adolesc Psychiatry 2009;48(11):1110-9.

10. Valicenti-McDermott M, Hottinger K, Seijo R, Shulman L. Age at diagnosis of autism spectrum disorders. J Pediatr 2012;161(3):554-6.

30. Aman MG, McDougle CJ, Scahill L, et al. Medication and parent training in children with pervasive developmental disorders and serious behavior problems: results from a randomized clinical trial. J Am Acad Child Adolesc Psychiatry 2009;48(12):1143-54.

11. Hagerman R, Hoem G, Hagerman P. Fragile X and autism: intertwined at the molecular level leading to targeted treatments. Mol Autism 2010;1(1):12. 12. Ehninger D, Silva AJ. Rapamycin for treating tuberous sclerosis and autism spectrum disorders. Trends Mol Med 2011;17(2):78-87.

31. Cehreli ZC, Olmez S. The use of a special mouthguard in the management of oral injury self-inflicted by a 4-year-old child. Int J Paediatr Dent 1996;6(4):277-81.

13. Yerys BE, Wallace GL, Sokoloff JL, et al. Attention deficit/hyperactivity disorder symptoms moderate cognition and behavior in children with autism spectrum disorders. Autism Res 2009;2(6):322-33.

32. Loo CY, Graham RM, Hughes CV. The caries experience and behavior of dental patients with autism spectrum disorder. J Am Dent Assoc 2008;139(11):1518-24.

14. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev 2012;10:CD009260.

33. Marshall J, Sheller B, Mancl L. Caries-risk assessment and caries status of children with autism. Pediatr Dent 2010;32(1):69-75.

15. Rada RE. Controversial issues in treating the dental patient with autism. J Am Dent Assoc 2010;141(8):947-53.

34. Subramaniam P, Gupta M. Oral health status of autistic children in India. J Clin Pediatr Dent 2011;36(1):43-8.

16. Johnson NL, Rodriguez D. Children with autism spectrum disorder at a pediatric hospital: a systematic review of the literature. Pediatr Nurs 2013;39(3):131-41.

35. Jaber MA. Dental caries experience, oral health status and treatment needs of dental patients with autism. J Appl Oral Sci 2011;19:212-7. 36. Orellana LM, Silvestre FJ, Martínez-Sanchis S, Martínez-Mihi V, Bautista D. Oral manifestations in a group of adults with autism spectrum disorder. Med Oral Patol Oral Cir Bucal 2012;17(3):e415-9.

17. Maskey M, Warnell F, Parr J, Couteur A, McConachie H. Emotional and behavioural problems in children with autism spectrum disorder. J Autism Dev Disord 2013;43(4):851-9.

37. Klein U, Nowak A. Characteristics of patients with autistic disorder (AD) presenting for dental treatment: a survey and chart review. Special Care Dentist 1999;19(5):200-7.

18. Hellings JA, Nickel E, Weckbaugh M, McCarter K, Mosier M, Schroeder SR. The overt aggression scale for rating aggression in outpatient youth with autistic disorder: preliminary findings. J Neuropsychiatry Clin Neurosci 2005;17(1):29-35.

38. Rai K, Hegde AM, Jose N. Salivary antioxidants and oral health in children with autism. Arch Oral Biol 2012;57(8):1116-20.

19. Lowe K, Allen D, Jones E, Brophy S, Moore K, James W. Challenging behaviours: prevalence and topographies. J Intellect Disabil Res 2007;51(8):625-36.

39. Luppanapornlarp S, Leelataweewud P, Putongkam P, Ketanont S. Periodontal status and orthodontic treatment need of autistic children. World J Orthod 2010;11(3):256.

20. Beard-Pfeuffer M. Understanding the world of children with autism. RN 2008;71(2):40-5.

40. DeMattei R, Cuvo A, Maurizio S. Oral assessment of children with an autism spectrum disorder. J Dent Hyg 2007;81(3):65.

21. Scarpinato N, Bradley J, Kurbjun K, et al. Caring for the child with an autism spectrum disorder in the acute care setting. J Spec Pediatr Nurs 2010;15(3):244-54.

41. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000; 105(4):989.

22. Cooper SA, Smiley E, Allan LM, et al. Adults with intellectual disabilities: prevalence, incidence and remission of self-injurious behaviour, and related factors. J Intellect Disabil Res 2009;53(3):200-16.

42. Lai B, Milano M, Roberts M, Hooper S. Unmet dental needs and barriers to dental care among children with autism spectrum disorders. J Autism Dev Disord 2012;42(7):1294-303.

23. Medina AC, Sogbe R, Gómez-Rey AM, Mata M. Factitial oral lesions in an autistic paediatric patient. Int J Paediatr Dent 2003;13(2):130-7.

43. Guideline on behavior guidance for the pediatric dental patient. American Academy of Pediatric Dentistry Reference Manual 2012– 2013;34(6):170-82.

24. Dominick KC, Davis NO, Lainhart J, Tager-Flusberg H, Folstein S. Atypical behaviors in children with autism and children with a history of language impairment. Res Dev Disabil 2007;28(2):145-62.

44. Barbaresi WJ, Katusic SK, Voigt RG. Autism: a review of the state of the science for pediatric primary health care clinicians. Arch Pediatr Adolesc Med 2006;160(11):1167-75.

25. Raposa KA. Behavioral management for patients with intellectual and developmental disorders. Dent Clin North Am 2009;53(2):359-73.

45. Bäckman B, Pilebro C. Visual pedagogy in dentistry for children with autism. ASDC J Dent Child 1999;66(5):325-31.

26. Johnson C, Matt M, Dennison D, Brown R, Koh S. Preventing factitious gingival injury in an autistic patient. J Am Dent Assoc 1996;127(2):244-7.

46. Crozier S, Tincani M. Effects of social stories on prosocial behavior of preschool children with autism spectrum disorders. J Autism Dev Disord 2007;37(9):1803-14.

27. Symons FJ, Devine DP, Oliver C. Self-injurious behaviour in people with intellectual disability. J Intellect Disabil Res 2012;56(5):421-6.

Volume 14, Supplement 1

124

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE 47. Ozdemir S. The effectiveness of social stories on decreasing disruptive behaviors of children with autism: three case studies. J Autism Dev Disord 2008;38(9):1689-96.

65. Rada RE. Treatment needs and adverse events related to dental treatment under general anesthesia for individuals with autism. Intellect Dev Disabil 2013;51(4):246-52.

48. Gray CA. Writing Social Stories With Carol Gray. Arlington, TX: Future Horizons; 2000.

66. Nelson D, Amplo K. Care of the autistic patient in the perioperative area. AORN J 2009;89(2):395-7.

49. Mineo B, Ziegler W, Gill S, Salkin D. Engagement with electronic screen Media among students with autism spectrum disorders. J Autism Dev Disord 2009;39(1):172-87.

67. Marshall J, Sheller B, Williams BJ, Mancl L, Cowan C. Cooperation predictors for dental patients with autism. Pediatr Dent 2007;29(5):369-76. 68. Stein LI, Polido J, Cermak SA. Oral care and sensory over-responsivity in children with autism spectrum disorders. Pediatr Dent 2013;35(3):230-5.

50. Rayner CS. Video-modelling to improve task completion in a child with autism. Dev Neurorehabil 2010;13(3):225-30.

69. Shapiro M, Melmed RN, Sgan-Cohen HD, Parush S. Effect of sensory adaptation on anxiety of children with developmental disabilities: a new approach. Pediatr Dent 2009;31(3):222-8.

51. Wilson K. Teaching social-communication skills to preschoolers with autism: efficacy of video versus in vivo modeling in the classroom. J Autism Dev Disord 2013;43(8):1819-31.

70. Sasaki R, Uchiyama H, Okamoto T, et al. A toothbrush impalement injury of the floor of mouth in autism child. Dent Traumatol; 2012.

52. Marshall J, Sheller B, Williams BJ. Parental attitudes regarding behavior guidance of dental patients with autism. Pediatr Dent 2008;30(5): 400-7.

71. Dias G, Prado EGB, Vadasz E, Siqueira J. Evaluation of the efficacy of a dental plaque control program in autistic patients. J Autism Dev Disord 2010;40(6):704-8.

53. Friedlander AH, Yagiela J, Paterno VI, Mahler ME. The neuropathology, medical management and dental implications of autism. J Am Dent Assoc 2006;137(11):1517-27.

72. Pilebro C, Backman B. Teaching oral hygiene to children with autism. Int J Paediatr Dent 2005;15(1):1-9.

54. Green D, Flanagan D. Understanding the autistic dental patient. Gen Dent 2008;56(2):167-71.

73. Capozza LE, Bimstein E. Preferences of parents of children with autism spectrum disorders concerning oral health and treatment. Pediatr Dent 2012;34(7):480-4.

55. Faulks D, Hennequin M, Albecker-Grappe S, et al. Sedation with 50% nitrous oxide/oxygen for outpatient dental treatment in individuals with intellectual disability. Dev Med Child Neurol 2007;49(8):621-5.

74. Blaylock RL. A possible central mechanism in autism spectrum disorders, part 3: the role of excitotoxin food additives and the synergistic effects of other environmental toxins. Altern Ther Health Med 2009;15(2):56-60.

56. Pas¸ca SP, Dronca E, Kaucsár T, et al. One carbon metabolism disturbances and the C677T MTHFR gene polymorphism in children with autism spectrum disorders. J Cell Mol Med 2009;13(10): 4229-38.

75. Bernardo M, Luis H, Martin MD, et al. Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc 2007;138(6):775-83.

57. Selzer RR, Rosenblatt DS, Laxova R, Hogan K. Adverse effect of nitrous oxide in a child with 5,10-methylenetetrahydrofolate reductase deficiency. N Engl J Med 2003;349(1):45-50.

76. Watson GE, van Wijngaarden E, Love TMT, et al. Neurodevelopmental outcomes at 5 years in children exposed prenatally to maternal dental amalgam: the Seychelles Child Development Nutrition Study. Neurotoxicol Teratol 2013;39:57-62.

58. Protective stabilization for pediatric dental patients. American Academy of Pediatric Dentistry Reference Manual 2012–2013;34(6).

77. Abdullah M, Ly A, Goldberg W, et al. Heavy metal in children’s tooth enamel: related to autism and disruptive behaviors? J Autism Dev Disord 2012;42(6):929-36.

59. Edelson SM, Edelson M, Kerr DC, Grandin T. Behavioral and physiological effects of deep pressure on children with autism: a pilot study evaluating the efficacy of Grandin’s Hug Machine. Am J Occup Ther 1999;53(2):145-52.

78. Wright B, Pearce H, Allgar V, et al. A comparison of urinary mercury between children with autism spectrum disorders and control children. PLoS One 2012;7(2):1-6.

60. Kupietzky A, Ram D. Effects of a positive verbal presentation on parental acceptance of passive medical stabilization for the dental treatment of young children. Pediatr Dent 2005;27(5):380-4.

79. de Cock M, Maas YGH, van de Bor M. Does perinatal exposure to endocrine disruptors induce autism spectrum and attention deficit hyperactivity disorders? Acta Paediatr 2012;101(8):811-8.

61. Capp PL, de Faria M, Siqueira SR, Cillo MT, Prado EG, de Siqueira JT. Special care dentistry: Midazolam conscious sedation for patients with neurological diseases. Eur J Paediatr Dent 2010;11(4):162-4.

80. Kodaira H, Ohno K, Fukase N, et al. Release and systemic accumulation of heavy metals from preformed crowns used in restoration of primary teeth. J Oral Sci 2013;55(2):161-5.

62. Pisalchaiyong T, Trairatvorakul C, Jirakijja J, Yuktarnonda W. Comparison of the effectiveness of oral diazepam and midazolam for the sedation of autistic patients during dental treatment. Pediatr Dent 2005;27(3): 198-206.

81. Schultz ST, Klonoff-Cohen HS, Wingard DL, et al. Acetaminophen (paracetamol) use, measles-mumps-rubella vaccination, and autistic disorder: the results of a parent survey. Autism 2008;12(3):293-307. 82. Bauer AZ, Kriebel D. Prenatal and perinatal analgesic exposure and autism: an ecological link. Environ Health 2013;9(12):41.

63. Loo CY, Graham RM, Hughes CV. Behaviour guidance in dental treatment of patients with autism spectrum disorder. Int J Paediatr Dent 2009;19(6):390-8.

83. Ibrahim SH, Voigt RG, Katusic SK, Weaver AL, Barbaresi WJ. Incidence of gastrointestinal symptoms in children with autism: a population-based study. Pediatrics 2009;124(2):680-6.

64. Messieha Z. Risks of general anesthesia for the special needs dental patient. Special Care Dent 2009;29(1):21-5.

125

June 2014

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE 84. Finegold SM. State of the art; microbiology in health and disease. Intestinal bacterial flora in autism. Anaerobe 2011;17(6):367-8.

86. Altun C, Guven G, Yorbik O, Acikel C. Dental injuries in autistic patients. Pediatr Dent 2010;32(4):343-6.

85. Ramirez PL, Barnhill K, Gutierrez A, Schutte C, Hewitson L. Improvements in behavioral symptoms following antibiotic therapy in a 14-yearold male with autism. Case Rep Psychiatry 2013;2013:2.

87. Nandyal R, Owora A, Risch E, et al. Special care needs and risk for child maltreatment reports among babies that graduated from the Neonatal Intensive Care. Child Abuse Negl 2013 Dec;37(12):1114-21.

Volume 14, Supplement 1

126

Autism spectrum disorders: an update on oral health management.

Dental professionals caring for patients with a diagnosis of autism spectrum disorder (ASD) will need to provide oral health care based on a family-ce...
462KB Sizes 1 Downloads 3 Views