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.

How you can influence your child's dental health

Children learn by copying important adults in their lives. This is a natural process by which children learn about the world around them. 

Your behaviour, expressions  and reactions will usually have a greater impact on your child than what you say to them. 

Parents have a unique position of influence in their children's lives, as a role model and first teacher. This influence can have either a positive or negative effect. How can we use this influence in a positive way to improve our children's oral health?

• Parents choose what babies and young children eat. Parents usually introduce children to the same foods that they eat.  If children are given a healthy, balanced diet at an early age they are much more likely to choose a healthy diet themselves when they are older. 
• If you are constantly snacking on high fat and high sugar snacks your children are likely to do the same. When shopping, plan your meals and also think about healthy food to keep in the house for snacks when you or your children get hungry between meals. 
• For more information on a diet that is good for you teeth see this link.

• Give your children a good example to follow by letting them see you brushing your teeth regularly. 
• Teach your child about the importance of looking after their teeth. There are books and videos which can make learning fun.

• You will need to brush your child's teeth until they can learn to do it effectively for themselves from around six years old. Older children will still require encouragement and supervision. Also see post on top toothbrushing tips.
• Children whose parents regularly visit the dentist are more likely to do the same.
• Take your child to visit a dentist before they have any pain or problems. Find a dentist who is good with children. Regular check-ups enable the dentist to assess your child's risk for developing decay or gum disease and give preventive advice. Any problems can also be seen early and treated or prevented from progressing.

Did you know that children whose parents are anxious about visiting the dentist are much more likely to become anxious themselves? A recent study showed that parents' attitude towards dentistry are often passed on to their children.

Children look to their parents to learn how to respond  to a new situation and can pick up on their parent's anxiety. This means that some children are very anxious even before they first visit the dentist.

We will look at ways to help anxious children in a future post. For help on overcoming your own anxiety, see this blog (click for link)

Even if you are anxious, try not to let this show to your child. Avoid making negative remarks about the dentist in front of your children.

Once children get interested in looking after their teeth they can be encouraged to see the dentist as someone who helps them to stay healthy.

Which foods cause tooth decay?

Your child's diet is one of the most important factors in developing dental decay and small changes can make a big difference. 

In the previous blog post we looked at how foods containing sugar combine with bacteria in plaque to produce acid. If the teeth are subjected to frequent or long periods of acid attack, decay becomes likely to occur.

Most people are aware that children who eat too many sweets and candies are likely to get cavities. However, any foods that are are high in refined carbohydrates (starch), such as crackers and chips, can cause decay if the foods remain stuck to the teeth for long periods of time, as the starch breaks down into sugar. In fact, one good way to determine if a snack is good for a child is to check their teeth 20 minutes after consumption. If the teeth are still filled with food, the risk for dental decay will be higher. These foods should be eaten only rarely and teeth should be brushed afterwards.

There are a lot of "hidden sugars" in processed food. If you read the ingredients, they may be labelled as sucrose, glucose, lactose, or fructose - these are all types of sugar. In addition to containing high levels of sugar, many children's breakfast cereals also stick onto the teeth. Even diet soda drinks and concentrated fruit juices can cause decay as they are acidic.

It is not realistic to ban your child from eating sweets. altogether. Instead, limit consumption of sweets and candy to maximum of once a day, preferably at the end of a meal. Those treats that dissolve and clear from the mouth quickly eg. a milk chocolate bar, are better than hard candies, lollipops or sticky caramels. Sweets should be eaten in one go, rather than continually snacking on them.

Children do get hungry and need to snack. Choose healthy snacks such as fresh fruit and vegetables, nuts, cheese. For drinks in between meals go for water or milk without added sugar.

What causes dental cavities?

When you consume any food or drink containing carbohydrate, or sugar, the bacteria in the plaque on your teeth metabolise it, producing an acid attack which lasts for at least 20 minutes. The acid dissolves the outer surface layer of the teeth (enamel).

The acid attack will be much longer if the food remains stuck onto the teeth, or if snacking continues over a period of time, eg. eating a bag of sweets one by one, or continuously licking a lollipop. Also, If babies or toddlers fall asleep with a bottle, or whilst nursing, the milk will remain on their teeth for a longer period of time.

If food and drinks containing sugar are limited to mealtimes, with sugar free snacks and drinks in between, the teeth can recover from these short periods of acid attacks. In the early stages of decay (before a cavity is formed), the enamel can repair itself by taking in minerals from saliva. Fluoride also helps to strengthen the enamel in this process.

However, with frequent snacks and drinks containing sugar, cavities become much more likely to occur.

Once the enamel layer crumbles, a cavity is formed, bacteria enter and the decay process spreads rapidly.

To prevent dental decay, the aim should be to reduce the amount of time that any food containing sugar is present in the mouth. Drinking water or rinsing after eating can help. Try to make snacks and drinks, between meals, sugar free as far as possible. 

 

Regular, thorough brushing to remove plaque build-up from the teeth will also help but, as it is not possible to prevent plaque from building up again after brushing, diet is of extreme importance in preventing cavities.