AUTISM SPECTRUM DISORDERS:

AN UPDATE ON ORAL HEALTH

MANAGEMENT
Roopa P. Gandhi, BDS, MSD, and Ulrich Klein, DMD, MS

SORT SCORE ABSTRACT

A B C NA Dental professionals caring for patients with a diagnosis of autism spectrum disorder
SORT, Strength of Recommendation Taxonomy (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
LEVEL OF EVIDENCE
as the unique medical management, behaviors, and needs of the individual patient.
1 2 3
See page A8 for complete details regarding SORT and Background
LEVEL OF EVIDENCE grading system
With the rising prevalence of autism spectrum disorders (ASD), oral health pro-
viders 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 con-
cerns, 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
Key words: Autism, autistic, autism spectrum disorder, Asperger's disorder, autism dental management
Colorado and University of
Colorado School of Dental
Medicine, Aurora, CO, USA
INTRODUCTION
Corresponding author. Department of Pediatric
Dentistry, Children’s Hospital Colorado, 13123
E. 16th Avenue, B240, Aurora, CO 80045,
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
USA. E-mail: roopa.gandhi@childrenscolorado. disintegrative disorder and pervasive neurodevelopmental disorder not otherwise
org
specified. Previously these diagnoses were subsumed under the umbrella pervasive
J Evid Base Dent Pract 2014;14S: developmental disorders. Symptoms in this group of neurodevelopmental disorders
[115-126]
can be expressed on a continuum ranging from mild to severe and, by definition,
1532-3382/$36.00
Published by Elsevier Inc.
must be present from infancy or early childhood.2
http://dx.doi.org/10.1016/j.jebdp.2014.03.002
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

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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.
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 pat-
terns 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 envi-
ronmental factor, or if the condition is associated with another
neurodevelopmental, mental, or behavioral disorder.
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.
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 compli-
cated by language deficits, poor comprehension of speech, or
difficulties reading social cues. Additional features of ASD
Volume 14, Supplement 1
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
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 in-
fections 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
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, struc-
tured patient observation, and a detailed medical and
neurological examination to rule out associated medical and
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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 Social communication
Level 3  Severe deficits in verbal and non-verbal social communication
Requiring very skills
substantial  Very limited initiation of social interactions
support  Minimal response to social overtures from others
Level 2  Marked deficits in verbal and non-verbal social communica-
Requiring tion skills
substantial  Social impairments apparent even with supports in place
 Limited initiation of social interactions and reduced or
support
abnormal response to social overtures from others
Level 1  Without supports in place, deficits in social communication
Requiring cause noticeable impairments
support  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
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
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 dis-
eases are linked at the molecular level through a mutation in
the FMR1 gene. This association with FXS has a strong po-
tential for development of targeted treatments for non-FX
autism.11
One of the clinical neurologic manifestations of the neuro-
cutaneous 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 path-
ophysiology of this subset of ASD.12
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
THERAPEUTIC APPROACHES
A Cochrane review found some evidence that early intensive
behavioral intervention (EIBI) programs represent effective
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Restricted interests and repetitive behaviors
(RRBs)
 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
 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
 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
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 perfor-
mance. They teach adaptive behavior to promote useful social
skills such as independence, ability to adapt to the environ-
ment, 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
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, hyperac-
tivity, irritability, self-injury, aggression, or anxiety. Medications
that are more frequently used in patients with ASD are se-
lective serotonin reuptake inhibitors (for repetitive behaviors,
rigidity), methylphenidate (for ADHD), and melatonin (for
sleep problems).4,9
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 treat-
ments may be complicated by parental concerns about
restorative materials or the refusal to use fluoride-containing
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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 man-
agement strategies, choice of dental staff or even the oper-
atory, 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.
BEHAVIORS
Patients with ASD can present the dental provider with
challenging behaviors that are as wide-ranging as the neuro-
cognitive symptoms associated with this spectrum of disor-
ders. 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 unfa-
miliar 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
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
Sensory hypersensitivities in children with autism can trigger
defensive responses that may include attempts to escape
from the dental environment because their senses are over-
whelmed by the loud sounds, smells, or textures in a typical
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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-stimula-
tory behavior is not a meaningful approach for anxiety
reduction.21
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
Treatment strategies involve a multidisciplinary approach with
input from team members including the psychologist, psy-
chiatrist, 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 Ari-
piprazole 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 per-
manent 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
While there are divergent conclusions regarding caries status,
the majority of studies unequivocally point to poor oral hy-
giene in children and adults with ASD33–36 although many
individuals with ASD receive regular assistance with
toothbrushing.33,34,36,37
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The majority of studies unequivocally point to poor oral hy-
giene 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 symp-
toms, 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
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 investi-
gation 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 pa-
tients with ASD.33
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.
UNMET DENTAL NEEDS AND BARRIERS TO
CARE
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 chil-
dren 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
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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.
BASIC BEHAVIOR GUIDANCE
Traditional Approaches
Currently used basic behavior guidance techniques (BGTs)
include positive reinforcement, tell-show-do (TSD), distrac-
tion 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 suc-
cessful 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 pre-
appointment consultation can be a critical step to gauge the
patient’s behaviors and symptoms, and to customize the use
of basic BGTs.
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 tradi-
tional BGTs such as positive reinforcement and TSD to ac-
count for the neurocognitive deficits in patients with ASD.
Books
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.
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
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Table 2. A summary of traditional and non-traditional behavior
guidance approaches in for patients with ASD
Advanced behavior
Basic behavior guidance guidance
Traditional approaches:
Positive reinforcement Protective stabilization
Tell-Show-Do Sedation
Distraction General anesthesia
Nitrous oxide
Non-traditional approaches:
Visual pedagogy with
books
Social stories
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)).
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.
Video Modeling
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 behav-
iors.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)).
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
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Table 3. Internet resources for visual pedagogy based methods
such as social stories (A) and video modeling (B)
(A) Resources for social (B) Resources for
stories: video modeling:
My Dental Social Story – POAC Model Me Kids
www.poac.net/image/pdfs/Dentist/ www.modelmekids.com/
socialstoryDental.pdf
Printable Easy Social Stories for Social Skill Builder
Children with Autism or www.socialskillbuilder.com
Asperger’s http://easysocialstories.
com/
Social Storiesä – The Gray Center Look At Me Now! Videos
www.thegraycenter.org/social- for Children with Autism
stories http://lookatmenow.org/
Social Story Examples – Autism
Help
www.autismhelp.info/
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 time-
consuming 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.
Nitrous Oxide
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
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 ab-
normalities of folate metabolism. There are reports of
MTHFR related gene mutations and the dysregulation of
folate metabolism in patients with autism56 and study has
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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.
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 modal-
ities. Consultation with the patient’s physician regarding
possible genetic mutations or abnormalities of folate meta-
bolism 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.
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 Pro-
tective stabilization may in fact calm the autistic child due to
the deep pressure produced by its placement.28,52,59 How-
ever, 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 sta-
bilization and in situations where passive stabilization was used
in a planned rather than emergent manner.52
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 ac-
counting 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
Sedation
The use of sedation is a viable option that may be considered
for patients with autism when basic BGTs have failed. Ben-
zodiazepines such as diazepam and midazolam are suggested
in combination with nitrous oxide administration with re-
ported success rates ranging from 77% to 100%.61–63 Mid-
azolam 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
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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 environ-
ment. 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.
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
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, hypersensi-
tive 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 pre-
operative planning.66 Autistic patients may benefit from a pre-
anesthesia 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.
The dentist should relay pertinent information to the anes-
thesia provider about the child’s specific ASD diagnosis, the
presence of related comorbidities, and any challenging behaviors
pre-operatively.
The dentist should relay pertinent information about the
specific ASD diagnosis to the anesthesia provider, the pres-
ence 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-
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operative complications as well as address the need for a 23-h
admission in a planned manner.
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, develop-
mental 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 un-
cooperative 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.
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.
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 hypersensitiv-
ities.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.
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 strate-
gies 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 unsu-
pervised for daily oral hygiene.70 Teaching caregivers about
oral hygiene and more frequent recall visits than the tradi-
tional six monthly recall visits should also be considered. In
one study of a dental plaque control program for children
Volume 14, Supplement 1
with autism, the caregivers received oral hygiene instructions
over 1, 3 and 6 monthly dental visits with statistically signifi-
cant improvements in oral hygiene.71 Visual pedagogy such as
placing color photographs of oral hygiene steps in the pa-
tient’s bathroom are helpful when combined with recall
evaluations.72
Prevention strategies need to account for the sensory pro-
cessing 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 psy-
chologist should be considered to develop a sensory inte-
gration approach that can improve the individual patient’s
adaptation to the oral hygiene procedure.
Fluoride
The primary reason for a parent’s refusal of fluoride-con-
taining 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.
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 “mer-
cury” 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 “mercury-
containing” dental material.73
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
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 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
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 neuro-
toxicity. However, glass ionomer’s fluoride release may cause
concern and should be addressed. In the instance of pre-
formed 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
CONSIDERATIONS FOR PRESCRIPTION OF
MEDICATIONS
Analgesics
Acetaminophen use during pregnancy, early childhood, or
after measles, mumps and rubella vaccination has been
implicated in increasing the risk for ASD. Unsubstantial evi-
dence 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.
Antibiotics
In patients with autism, gastrointestinal (GI) symptoms such as
constipation, diarrhea, abdominal pain, and bloating have been
reported as common comorbidities although one study re-
ported 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
123
infections and whether any particular antibiotics have resulted
in worsening symptoms or adverse reactions.
OROFACIAL TRAUMA
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-inju-
rious 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.
CONCLUSIONS
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 prefer-
ences and concerns, the child’s challenging behaviors, and
related comorbidities can foster mutual trust. Close in-
teractions between patients, parents and providers are also
likely to produce the best treatment decisions.
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