I tried to wrap all the important information regarding Autism spectrum disorder for dentist ( GPs) and pediatric dentist

1. Medical , Dental Manifestations
and Management of Autism
Spectrum Disorder
PRESENTED BY:
DR. RAHAF NAJJAR

2. Presentation Outline:
Introduction:
- Definition
- Epidemiology
- Etiology
Clinical Features and Diagnosis
Management
Oral Health Status
Dental Management

3. Presentation Outline:
Introduction:
- Definition
- Epidemiology
- Etiology
Clinical Features and Diagnosis
Management
Oral Health Status
Dental Management

4. Different Names!!
Autism
Autism spectrum disorder (ASD)
Autism spectrum condition (ASC)
Classic autism
Kanner autism
Pervasive developmental disorder (PDD)
High-functioning autism (HFA)
Asperger syndrome
Pathological Demand Avoidance (PDA)
Different diagnostic
manuals and tools

5. Introduction
 Autism spectrum disorder ( ASD) is a neurodevelopmental disorder that impairs
a the ability to communicate, interact socially with others, and respond to
certain stimuli in their surroundings.
 Can be diagnosed at any age.
 Symptoms generally appear in the first two years of life.

6. Introduction
Autism is known as a “spectrum” disorder because there is wide variation in the
type and severity of symptoms people experience.

7. Introduction
Autism is not an illness or disease and CANNOT be 'cured'.
It occurs in all ethnic, racial, and economic groups.

8. Introduction
A lifelong disorder, management and services can improve a person’s symptoms
and ability to function.
Meaning people need different levels of support

9. Epidemiology
1/68
Globally
1.4/10,000
Oman
29/10,000
UAE
4.3/10,000
Bahrain
18/10,000
Saudi Arabia
Salhia, Huda O., et al. "Systemic review of the epidemiology of autism in Arab Gulf countries." Neurosciences 19.4 (2014): 291.

10. Etiology
 No known single cause
Brain scans show differences in the shape, size and structure of the brain in
children with ASD(cerebellum).

11. Different
Theories
Genetic
Autoimmune
Hormonal
Disturbance
Nutritional
Deficiency
Environmental
Toxin
Mitochondrial
Dysfunction

12. Risk Factors
>
4 : 1

13. Risk Factors
Having a sibling with ASD.
Having older parents.
Certain genetic conditions such as Down syndrome.
Very low birth weight

14. Presentation Outline:
Introduction:
- Definition
- Epidemiology
- Etiology
Clinical Features and Diagnosis
Management
Oral Health Status
Dental Management

15. Clinical Features
Uneven intellectual development.
Repetitive body movements.
Hyperactivity.
Limited attention span and low frustration threshold.

16. Clinical Features
High pain threshold.
Tactile and auditory hypersensitivity.
Exaggerated reactions to light and odours.
Dislike changes in their environment and need sameness and continuity.

18. What can Trigger ASD Children?

20. Autism Disorder
According to American Psychiatric Association, people with Autism Disorder
have:
 Difficulty with communication and interaction with other people.
Restricted interests and repetitive behaviours.
Symptoms that hurt the person’s ability to function properly in life.

21. Asperger’s Disorder
Intense, but very narrow interests.
Speech that was unrelated to the conversation’s topic.
Interest in letters & number’s at a very young age.
Normal to high IQ score.
Clumsiness.
Difficulty controlling volume of voice when speaking.
Trouble adjusting to school.

23. Diagnosis of ASD
Diagnosed by looking at a child’s behaviour and development.
 No medical tests can be performed to diagnose ASD.

24. Diagnosis of ASD
Diagnosing involves 2 step process:
1) Developmental screening tools: performed for children during regular
paediatric check-ups.
2) Comprehensive diagnostic evaluation: help the clinician determine if the
child meets certain criteria that indicate the child has autism, by rank the child
on a number of criteria, such as behaviours, past behaviour as reported by the
parents, and other direct observations.

25. Autism Assessment Tools
Childhood Autism Rating Scale (CARS)
Autism Diagnostic Interview – Revised (ADI-R)
Autism Diagnostic Observation Schedule – Generic (ADOS-G)
Checklist for Autism in Toddlers (CHAT)
Screening Tool for Autism in Two-Year- Olds (STAT)
Autism Behavior Checklist (ABC)
Detection of Autism by Infant Sociability Interview (DAISI)
Most commonly used

26. Presentation Outline:
Introduction:
- Definition
- Epidemiology
- Etiology
Clinical Features and Diagnosis
Management
Oral Health Status
Dental Management

27. Management
• To improve overall communication. This makes it possible
for people with ASD to improve their ability to
form relationships and function in day-to-day life.
Speech Therapy
• Help child to learn positive behaviours and reduce
negative ones.Behavior Treatments
• Help patient learn to deal with bright lights, certain
sounds, or the feeling of being touched
Sensory Integration
Therapy
• Studies have shown that medication is most effective when
it’s combined with behavioural therapies.Medications

29. Abnormal child Behavior
Assessment by Pediatrician
Role out ENT problems
psychiatric evaluation
Management
Speech
Behavior
Occupational
Medication

30. Presentation Outline:
Introduction:
- Definition
- Epidemiology
- Etiology
Clinical Features and Diagnosis
Management
Oral Health Status
Dental Management

31. Oral Health Status for ASD
Caries Periodontal Oral Habits Tooth Eruption

32. Dental Caries
Data on the incidence of dental caries among autistic children is inconclusive.
Some studies show that they have a lower caries rate than their healthy
counterparts.
Another studies have reported that ASD patients experience a significantly
higher DMF score than healthy individuals.

33. Dental Caries
Children with ASD prefer soft and sweetened foods.
They tend to pouch food inside the mouth instead of swallowing it.
Poor tongue coordination.
Psychoactive drugs or anticonvulsants, which can cause xerostomia and delayed
tooth eruption.
HIGH CARIES RISK !!
J U, M M V, J P, Srinivasan I. Autism Disorder (AD): An Updated Review for Paediatric Dentists. J Clin Diagn Res. 2014 Feb;8(2):275-9. doi: 10.7860/JCDR/2014/7938.4080. Epub
2014 Feb 3.

34. Periodontal Health
Majority of ASD children had poor oral hygiene .
Irregular brushing habits.
Lack of the necessary manual dexterity of ASD children.
Side effects of medications which were used to control the manifestations of
autism, such as psychoactive drugs or anticonvulsants.
Gingivitis ( Generalized / Localized)
J U, M M V, J P, Srinivasan I. Autism Disorder (AD): An Updated Review for Paediatric Dentists. J Clin Diagn Res. 2014 Feb;8(2):275-9. doi: 10.7860/JCDR/2014/7938.4080. Epub 2014 Feb 3.
Klein U, Nowak AJ. Characteristics of patients with autistic disorder (AD) presenting for dental treatment: a survey and chart review. Spec Care Dentist. 1999; 19: 200-207.

35. Oral Habits
Drooling, tongue thrusting and difficulty swallowing; due to be poor muscle
tone.
Increased wear facets (a common sign of bruxism/grinding) as well as erosion
and hyper responsive gag reflex .
Self-injury is also a common finding, both cutaneous and oral, and recurrent
bruises, abrasions, cuts and oral ulcers should be viewed with suspicion . WHY?!
Washington State Oral Health Program. Oral Health Fact Sheets for Patients with Special Needs. Washington: University of Washington. 2010.
Weiss JA. Self-Injurious Behaviours in Autism: A Literature Review. JoDD 2002; 9: 129-144.

36. Tooth Eruption
Tooth eruption may be delayed due to phenytoin-induced gingival hyperplasia.
Phenytoin is commonly prescribed for people with ASD.
J U, M M V, J P, Srinivasan I. Autism Disorder (AD): An Updated Review for Paediatric Dentists. J Clin Diagn Res. 2014 Feb;8(2):275-9. doi:
10.7860/JCDR/2014/7938.4080. Epub 2014 Feb 3.

37. Presentation Outline:
Introduction:
- Definition
- Epidemiology
- Etiology
Clinical Features and Diagnosis
Management
Oral Health Status
Dental Management

38. It is important for dental practitioners to understand the aetiology, mental,
social and oral health challenges that individual’s with an ASD face.
Communication problem means patients have difficulty with verbal and non-
verbal communication.

39. Patients may have difficulty understanding or relating to a person’s body
language may become stressed  uncooperative child.

40. Management of ASD
Pharmacological
Behavioral
Al Mochamant, Iosif-Grigorios & Fotopoulos, Ioannis & Zouloumis, Lampros. (2015). Dental Management of Patients with Autism Spectrum Disorders. Balkan Journal of Dental
Medicine. 19. 10.1515/bjdm-2015-0046.

41. Pharmacological Management
Behavior
shaping
Medications
Conscious
Sedation
GA

42. Behavior shaping Medications
Pharmacological treatment of ASD is usually prescribed by a Paediatrician/
psychiatric and aims to improve mental, social and behavioural symptoms.
Helps patients deal with anxiety, irritability, self-injury, and repetitive
behaviours.

43. Conscious Sedation
Nitrous oxide (NO2) or benzodiazepine tablets (e.g. midazolam) is a method of
relaxing the patient and increasing the pain threshold.
CONSEDERATION IN USING NO2
It inhibits the enzyme methylene-tetrahydrofolate reductase (MTHFR), which is
involved in the metabolism of folate; this can limit the synthesis of DNA severely
causing megablastic changes in blood cells and bone marrow.
Rada RE. Controversial issues in treating the dental patient with autism. J Am Dent Assoc. 2010; 141: 947-953.

44. Conscious Sedation
If the patient has minimal dental treatment needs that can be accomplished in
two operative appointments or less, then conscious sedation can be selected as
a treatment plan.
Chandrashekhar S, Bommangoudar JS. Management of Autistic Patients in Dental Office: A Clinical Update. Int J Clin Pediatr Dent 2018;11(3):219-227.

45. General Anesthesia
Management of autistic patients under general anaesthesia is effective and it
will help the patients to tolerate conventional treatment.
It permits the dentist to perform full mouth rehabilitation t in a single
appointment.

46. Behavioral Management and Therapy
Voice ControlRestraintFamiliarization

47. Familiarization
Familiarization Visits: to calm the child before the first appointment, by meeting
the staff and sits in the chair for their first appointment.
Allow parents to accompany their child in the operating room .
Letting the patients observe other children or their parents.
Al Mochamant, Iosif-Grigorios & Fotopoulos, Ioannis & Zouloumis, Lampros. (2015). Dental Management of Patients with Autism Spectrum Disorders. Balkan Journal of Dental
Medicine. 19. 10.1515/bjdm-2015-0046.

48. Familiarization
Parents should engage their children with photos or positive stories about the
dental office (‘show and tell’) as a method of increasing familiarity prior the
appointment.
The initial appointment, ‘get acquainted’ appointment, should be used as a trust
building exercise between physician and patient.
Al Mochamant, Iosif-Grigorios & Fotopoulos, Ioannis & Zouloumis, Lampros. (2015). Dental Management of Patients with Autism Spectrum Disorders. Balkan Journal of Dental
Medicine. 19. 10.1515/bjdm-2015-0046.

49. Restraint
Restraint has been reported to be useful in some situations but it is a
controversial subject.
Approval by the caregiver/parent is essential for restraining .
(AAPD) notes that the use of physical restraint can be physically dangerous
making the development of dental phobia significantly more likely.
Al Mochamant, Iosif-Grigorios & Fotopoulos, Ioannis & Zouloumis, Lampros. (2015). Dental Management of Patients with Autism Spectrum Disorders. Balkan Journal of Dental
Medicine. 19. 10.1515/bjdm-2015-0046.

50. Voice Control
The e parents/caregiver should be well versed about the voice control, to avoid
any misunderstandings during treatment.
It can be used in any patients; however, autistic patients with hearing deficits
would not be good candidates
Al Mochamant, Iosif-Grigorios & Fotopoulos, Ioannis & Zouloumis, Lampros. (2015). Dental Management of Patients with Autism Spectrum Disorders. Balkan Journal of Dental
Medicine. 19. 10.1515/bjdm-2015-0046.