Transcript PASSIVE SPACE CONTROL

Dental Care for Children with
Autism
Daniel Ravel, DDS
Fayetteville, North Carolina
Daniel Ravel, DDS
• Professional Affiliations
- American Board of Pediatric Dentistry
- American Academy of Pediatric Dentistry
- NC Academy of Pediatric Dentistry
- Fayetteville Dental Society
• Contact Info
PO Box 74432, Fort Bragg, NC 28307
Cell: (910) 797-1590
E-mail: [email protected]
•
Web Site http://dentalresource.org
Download this lecture from Dr. Ravel’s Facebook page.
Dental Care for
Children with Autism
Presentation Outline
1) Definition of Autism
2)
3)
4)
5)
6)
7)
8)
9)
Incidence of Autism
Signs and Symptoms of Autism
Initial Appointment for the Autistic Child
Communicating with the Autistic Child
Second Appointment for the Autistic Child
Behavior Guidance for the Autistic Child
Dental Management of the Autistic Child
Home Care for the Autistic Child
1) Definition of Autism
• The word “autism” is from the Greek
word “αυτο” meaning self.
• Autism, as an entity, was first described
by Hans Asperger in 1938.
• 1943: Leo Kanner of Johns Hopkins
described a group of children with
symptoms of “an extreme aloneness...
and an obsessive desire for the
preservation of sameness.”
Definition
• Autism belongs to a group of Pervasive Developmental
Disorders called Autistic Spectrum Disorders.
• The other pervasive developmental disorders are:
-1) PDD-NOS (Pervasive Developmental Disorder
Not Otherwise Specified)
-2) Rett Syndrome
-3) Asperger Syndrome
-4) Childhood Disintegrative Disorder.
Reports of
2) Prevalence of
Autistic Spectrum Disorders
• Affects 1 in 110 children
in the United States.
Prevalence of
Autistic Spectrum Disorders
• male : female ratio = 4:1
3) Signs and Symptoms
of Autism
• By 24 months of age, 80% of
parents of children with autism
notice:
- lack of babbling or meaningful
gesturing,
- failure to respond to their name,
- excessive single word usage
without spontaneous phrases.
Signs and Symptoms
• By 24 months of age, 80% of
parents of children with autism
notice:
- an aversion to hugging or
touching,
- repetitive hand flapping,
- and difficulty in making eye
contact.
Signs and Symptoms
Individuals with autism meet the
following diagnostic criteria:
- Impairments in social interactions.
- Stereotyped patterns of behavior.
- Impairments in communication.
Signs and Symptoms
• Hypersensitive or
hyposensitive to light, sound,
touch, smell, or taste.
•No big smiles or other warm,
joyful expressions by 6 months
of age or thereafter.
Signs and Symptoms
Diagnosis
• No medical test or biomarker for autism.
Signs and Symptoms
Diagnosis
• Diagnosis is based on:
- observation of the child’s behavior,
- educational and psychological
testing,
- and parent reporting.
Signs and Symptoms
•Mental disability: 41% have an IQ < 70.
•Physical characteristics:
-developmental disorder with
poor social skills
-lack of interpersonal
relationships
-abnormal speech, language,
and body language
•Communication:
variable to non-existent
Signs and Symptoms
• Inability to relate to people,
events, and objects.
• Lack of social interaction.
• Little or no eye contact.
• Isolation.
• No fear of danger.
Signs and Symptoms
•Repetitive actions like rocking or handflapping.
•A characteristic behavior is ‘finger
flicking.’
•Facial grimaces, jumping, and toe
walking are also common.
•Obsessive desire for maintaining an
unchanging environment and rigidly
following familiar patterns in their
everyday routines.
Signs and Symptoms
• Altered responses to stimuli.
• Show no sensitivity to burns
or bruises.
Signs and Symptoms
• May engage in self-mutilation
• Self abuse, ranging from biting
their hands or hitting themselves
in the is an oft encountered
symptom.
• Some autistic authors have
related that the self-infliction of
pain gives them a “sense of
reality.”
Triad of Autistic Impairment
Impairment of social
interaction
Impairment of language
and communication
Impairment of flexibility
of thought and behaviour
Oral Manifestations
•None specific.
•May see trauma from self-abusive
behavior.
•More than 20% of children with
autism bite objects or introduce
their fingers in the mouth routinely,
resulting in traumatic lesions.
•Oral lesions may also be present
due to auto-aggression or
convulsive crisis.
Oral Manifestations
• Bruxism (20-25%)
• Tongue thrusting
• Self-injury (picking at gingiva,
biting lips
• Erosion (many parents report
regurgitation)
Oral Manifestations
•People with ASD were more likely to be caries-free and
had lower DMFT scores than did their unaffected peers.
• There were no significant differences in the rates
of traumatic dental injuries among children and young
adults with and without autistic disorder.
At the Pre-visit Intake Interview:
• Standard health history forms
are usually not sufficient.
• Discuss the patient’s physical
function, sensory and
behavioral issues, and
communication style.
At the Pre-visit Intake Interview:
• Parents/caregivers need a
routine for home so that
visiting the dental office
becomes a “game” with
rewards.
• The parent can be given
materials from the dental
office prior to the visit, to
train the patient at home.
At the Pre-visit Intake Interview:
• Encourage parents to create a ‘visual
schedule’ for their child.
• Parent should teach following steps:
- Putting hands on the stomach
- Putting feet out straight
- Opening wide
- Holding the mouth open
- Counting the teeth
- Cleaning with a power brush
- Taking X-Rays
The ‘Visual Schedule’
• In the ‘Dental Guide’
http://autismspeaks.org
- Hands on stomach
- Feet out straight
- Open mouth wide
- Hold mouth open
- Count teeth
- Take x-rays
- Clean teeth
- Spit into sink
4) The Initial Appointment for the
Autistic Child
• Invite the child to tour your
dental office.
• Encourage the child to ask
questions, touch equipment,
and get used to the place.
•Children with autism need
sameness and continuity in
their environment.
•Make the first appointment
short and positive.
The Initial Appointment
• The initial appointment’s primary
goal is to establish trust.
• The initial appointment should
include an interview, an
orientation to the dental practice.
The Initial Appointment
•Talk to parent/caregiver about child’s
tolerance to physical contact and note
findings.
•Determine the child’s level of
intellectual and cognitive abilities.
The Initial Appointment
•Allow autistic children to bring a
comfort item, such as a blanket or
a favorite toy.
The Initial Appointment
• Set aside time when the clinic is
less busy to reduce distractions
and give kids more personal
time.
• Remove the clutter in your
office that may distract the
child.
• Dim the lights.
• Turn down loud noises.
The Initial Appointment
• The child should be allowed
to determine where the exam
will take place.
• Let patient sit in chair (in your
chair, stool, etc.)
• Use a toothbrush to get patient
to open for exam (patients do
better with familiar items)
5) Communicating with the
Autistic Child
• Maintain eye contact.
• Use clear, understandable
directions.
• Use a counting framework
(“Let me do this for a count
of 10”).
Communicating with the
Autistic Child
• Initially, a request for a
“high five” can be very effective.
• Be sure to reward immediately
following appropriate behavior.
Communicating with the
Autistic Child
•Phrases such as “look at me,”
“hands on tummy” can be used.
•Communicate with the child at a
level that he/she can understand.
6) The Second Dental Appointment
for Autistic Child
• Keep instruments out of sight.
• Keep distracting noises to a
minimum.
• Keep lights out of the patient’s
eyes.
The Second Dental Appointment
• Use a headlamp instead of the
overhead or dental lights.
• Constant sincere reinforcement.
• Involve the same dental team
members each time.
• Use the “tell-show-do” technique of
treatment.
7) Behavior Guidance
Advice for the Clinician
•
“slow down, you’re going too fast.”
Behavior Guidance
• Don’t crowd the child.
•Approach the autistic child in a
quiet, non-threatening manner.
•Explain the procedure before it
occurs.
Behavior Guidance
• Start the oral examination slowly,
using only fingers at first
• Reduce other sensory input such
as sounds and odors that may be
distracting to the child.
Behavior Guidance
• Reward cooperative
behavior with positive verbal
reinforcement.
• Maintain a routine of
“same chair, same dental
assistant.”
•Avoid interruptions and
have as few staff as needed.
Behavior Guidance
• Explain every treatment before
it happens.
• Always tell the autistic child
where and why you need to
touch them
Behavior Guidance
• Always show the familiar first: the
toothbrush…water…etc.
•Position patient upright in the chair.
•Next, use a toothbrush, or possibly a
dental mirror to gain access to mouth.
Behavior Guidance
• Use the first name frequently when
addressing the child.
“Hi, Ben!”
•Praise and reinforce good behavior.
Ignore poor behavior.
•Strive for eye contact whenever
possible.
“Look at me, Ben. Where is Ben?
There he is!”
Behavior Guidance
• Assuming that the autistic
child is not in pain, screaming
or crying does not have to
prevent completion of
necessary treatment.
Behavior Guidance
• These medications increase
the sedative potential of CNS
depressants, such as nitrous
oxide or demerol :
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Pimozide (Orap)
- Risperidone (Risperdal)
- Olanzepine (Zyprexa)
Behavior Guidance
•Some autistic children can be
calmed by moderate pressure
from a lead apron.
Behavior Guidance
•Some autistic children can be calmed by
moderate pressure, by using a papoose
board.
•Always obtain informed consent for this.
Nitrous Oxide
•For people with vitamin
B12 (cobalamin )
deficiency, exposure to
nitrous oxide may cause
pernicious anemia .
Nitrous Oxide
KEYWORDS!
METABOLIC DISORDER, MTHFR,
METHYLMALONIC ACID,
‘METYL…,’ “VITAMIN B 12
•Using nitrous oxide on an
autistic patient with a defect
in the MTHFR
(methylenetetrahydrofolate
reductase) gene could result
in increased oxidative
stress, and inflammation.
Behavior Guidance
• May be necessary to perform
treatment in the O.R. under general
anesthesia.
• This permits an exam, radiographs,
prophy, sealants, and restorative
treatment.
•Combine time with other medical
professionals to do blood draws, ear
tube placement, tonsillectomy, eye
exams, etc.
8) Dental Management for the
Autistic Child
•May see drug-induced
xerostomia.
•May see bruxism.
Xerostomia
Hyperactivity
•CNS Stimulants (Methylphenidate)
•Antihypertensive (Clonidine)
Repetitive Behaviors
•Antidepressants (Fluoxetine and Sertraline)
Aggressive Behaviors
•Anticonvulsants (Carbamazepine and Valproate)
•Antipsychotics (Olanzapine and Risperidone)
Bruxism
•Consider prescribing a mouth
guard for higher functioning
children with severe bruxism or
self-injurious behavior.
•Taking an impression may be
very difficult – so consider a
store-bought mouth guard.
Preventive Care
• The in-office fluoride treatment of
choice is fluoride varnish.
- 5% NaF (varnish).
- 22,6000 ppm of fluoride.
• Sealants
Autism: Treatment Planning
• Rampant caries, large
interproximal lesions,
hypoplasia, pulp exposures,
and gross decalcifications:
require full coverage with
SSCs.
•Rubber dams are
recommended, but may not be
accepted by the child.
•Space maintainers might be
pulled out by the child.
9) Home Care for the
Autistic Child
Brushing Your Child’s Teeth
• Stand or sit behind your child with their
head on your chest.
• Put a pea size amount of toothpaste on
the center of the brush.
• Guide the brush as if you were brushing
your own teeth.
Home Care
• Set a timer for 5-10 seconds for the
first brushing session.
• This allows the patient to brush
alone, to help build confidence in
the skill.
• Final goal: a full minute of
brushing.
Home Care
• Recommend a power toothbrush.
• Helps to desensitize patients to
similar types of oral sensations
during dental visits.
Latest Dental Reference on Autism
JADA 2011; 142(3): 281-287
Purnima Hernandez, DDS, MA; Zachary Ikkanda, BCaBA
Applied behavior analysis. Behavior management in
children with autism spectrum disorders in dental
environments.
Summary
With education and understanding,
we can treat this special group.
Questions or Comments?