Management of Autistic Children at The Dentist

Children with an Autism Spectrum Disorder have impaired social interaction and limited communication abilities, combined with a restricted amount of activities and interests. While parents are often able to manage them in familiar places and situations like the home, it becomes difficult to do the same outside, especially when visiting specialized healthcare providers including dentists.

Considering that 1 in ever 30 Indian children displays signs of ASD, pediatric dentists are very sensitive to their dental needs and specialized management. Even so, parents have a large role to play in ensuring all procedures go smoothly, and children come away with the least amount of stress and mental trauma.

Dentists managing autistic children are aware of them exhibiting specific observable behavior;

IMPAIRED SOCIAL RESPONSE - Children are unable to read and respond to feelings and experiences, with absolute no understanding most times

IMPAIRED COMMUNICATION - Children are unable to use and understand gestures, repetition of words (echolalia) and a rigid body stance is often displayed

Besides the atypical behavioral and impaired communication skills that are observed and need careful handling, below are often the main dental problems that such children exhibit;

* Bruxism or teeth grinding, often when asleep or the child isn't aware of it

* Tongue thrusting or repeated tongue movements

* Chewing at all odd times without presence of food

* Self-injury, where pinching gums, biting lips and creating wounds is common

* Erosion of teeth

* Caries, when teeth aren't brushed thoroughly because the child finds it unpleasant

* Poor oral care at home, because of difficulty in managing the child

* Limited dietary preferences. Autistic children have very strong likes and dislikes (Only pureed food, no vegetables, dislike of particular vegetable color, etc.)

Management of an Autistic Child at the dentist, can be divided into two phases;

PRE MANAGEMENT or BEFORE CHILD MEETS THE DENTIST

• It is important to plan a desensitizing appointment with the dentist to help the child familiarize themselves with the doctor and the staff
• Allow the child to bring things that can comfort them, a favorite blanket, stuffed toy or even hold the parent's hand
• Parents need to discuss with the doctor about the child's tolerance to pain and discomfort, and their threshold
• Share the child's intellectual and understanding abilities with the doctor, so that they can phrase sentences or relate with the child accordingly

POST MANAGEMENT or AFTER THE CHILD MEETS THE DENTIST

• The dentist will communicate with the child at a level he/she can understand. They use phrases such as 'Tell', 'Do', 'Show' when explaining any procedures or methods, always speaking in clear, precise tones
• Oral examination is begun with only fingers first, while the hard feel of dental instruments is brought in later
• Dental instruments are only shown later. Suddeness of movements by the dentist is kept to a minimum and light is kept away from the child's face. Sensory input of any kind is kept as less as possible to avoid distraction
• Dentists place same staff at all examinations and interruptions are kept minimal
• Child's co-operative behavior is always encouraged with positive words and nods
• The child's unusual body movements are always observed and pre-empted

Most pediatric dentists are aware of the extra care and effort it takes to manage autistic children, and are extra cautious while carrying out any kind of dental procedures. As a parent, it is important to know what to expect, understand how the process can be made easy and prepare the child for any kind of dental visit.

Process of Dental Caries in Children

All of us are well aware of what teeth decay actually looks like, how it manifests itself, the physical changes and the causes for it. Not many know the process of decay, and how early intervention can stop and even reverse the deterioration of teeth.

Everyone is susceptible to tooth decay. While adults can prevent it or look after their teeth better, children cannot do the same. It is left up to us parents to ensure we know the stages of caries and how we can intervene at the right time, with the right methods and prevent further damage from taking place.

Dental caries in children unfolds over a prolonged period of time. Below is the process by which this happens,

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•       The mouth is a cavity that is exposed to germs all day, everyday. Bacteria grow in the gut and help in the process of digestion, with the process beginning in the oral cavity. Bacteria also enter the oral cavity with food. The breakdown of food causes the formation of plaques, sticky whitish deposits that collect around the gum line, grooved surfaces of teeth and edges of fillings. Plaque allowed to collect for a prolonged period of time, hardens into 'tartar'.
•       Plaque also uses the remnants of food in the mouth to produce 'acids'. Some foods like beverages and meat are already acidic and affect the teeth.
•       Acid attacks the outer layer of teeth, the enamel and dentine, and erodes them gradually over a period of time. Gradually a small hole or cavity begins to appear on the surface of the tooth or the enamel. This stage is usually painful.
•       Once holes are formed in the enamel or outer lining of the teeth, it becomes easier for plaque and bacteria to reach the dentine (layer just below the enamel). Dentine is usually softer and gets eroded faster. 
•       If treatment doesn't begin at this stage, the bacteria reach the tooth pulp, where nerves are exposed to them, resulting in a excessive pain.
•            When bacteria infect the tissue within the pulp and this isn't treated, it leads to the formation of a dental abscess.

It is often seen that tooth decay typically occurs with molars and pre-molars, large back teeth used for grinding, which have irregular surfaces, making it easier for food to stick and cause infection. These are also unreachable and not cleaned regularly.

Tooth decay in children, can manifest in any number of ways;

•      Breakage of teeth
•      Toothache or pain    
•      Infection of nerve or pulp
•      Death of nerve and numbness 
•      Swelling of face
•      Vomiting, headache and other general symptoms

It is important to remember that dental intervention in children, can save them from pain and many other future problems. It can also help save their milk teeth, in turn ensuring that their permanent teeth grow properly and giving them good oral health for life.

A pediatric dentist not just treats caries once they have begun, but also looks for signs and symptoms of impending tooth damage in children. Beginning a child's dental check-up as early as age 1, can go a long way to ensure that our children don't suffer as much as we do.

Is Dental Decay Contagious?

Tooth decay is the single most common chronic childhood disease, despite also being preventable.

Is dental decay a contagious disease? 

Is it possible to catch it from someone else?

In a previous post we discussed what causes dental cavities. 

To summarise, bacteria (germs) in our mouths convert sugar in food and drink that we consume into acid which damages teeth.

Bacteria live in dental plaque - a sticky film which builds up naturally on our teeth. Dental plaque contains many types of bacteria but only a small number of these cause dental decay. The main type of bacteria which causes dental caries is Mutans streptococci. Studies have shown that individuals with higher levels of Mutans streptococci are at a greater risk of cavities.

Recent research has shown that babies are not born with decay-causing bacteria. Any time after birth bacteria can be passed on from other people, especially mothers and other close caregivers. Once these bacteria are transmitted to a babies mouth, especially after the first teeth come through, they multiply and become established within dental plaque.

Bacteria can enter the baby's mouth by kissing, sharing food utensils, toothbrushes or other habits that transmit saliva.

If parents and other caregivers have cavities and poor oral hygiene they will have higher levels of decay-causing bacteria which can be passed onto their child.

The risk of a child developing cavities will be less if they are not infected with decay-causing bacteria at an early age.

Children can also "catch" bacteria from other children by sharing food and toys, but they are more likely to receive bacteria from their mother and other close relatives before this happens.

What can be done to reduce the risk?

Parents and caregivers can reduce the risk of passing on decay-causing bacteria from their own mouths by:

• cleaning their own teeth well, to reduce the amount of plaque (which contains bacteria)  in their mouths
• avoiding sugary snacks and drinks between meals which can lead to decay 
• visiting the dentist regularly for check-up and getting any cavities filled 
• avoiding sharing items such as food, spoons, cups and toothbrushes with their baby
• kissing the baby on their cheek, rather than the mouth