Friday, January 14, 2011

Dentistry and the Autism Spectrum

Dr. Greg Evans DDS
www.biggrinswithdrgreg.com

In my pediatric dental practice I like to say we treat children. And I like to pause at the end of that sentence. No qualifiers. My father, a junior high school teacher of thirty years, said it a little differently:
“They are all good kids, only the time and circumstances have changed”
Each child has basic needs, including oral health. Those basic needs do not change based on the developmental age, social environment, or neurological wiring of the child.

The circumstances have changed, though. In my early school years, children with special needs were routinely sequestered from the mainstream, and those practices carried over to healthcare. Now the schools show progress, though in healthcare, some of those ‘traditions’ continue. With separation came differences in treatment and different standards of care ,and that has led to a dearth of knowledge within the medical and dental professions offering good basic care for special needs kids.

For autism, the increasing acceptance of the diagnosis has led to the need for Dentistry to find good treatment options. Several articles in both Pediatric and General Dentistry Journals have featured autism in the past year. Mostly, these articles seek to educate practitioners about Autism. They do not offer many actual treatment hints for procedures.

The same is true for a dental sedation course I attended by the leading Pediatric Sedation authority in the nation, “no, autism is usually a contraindication for in-office sedation due to the unknown (and un-researched) possible reactions to the traditional sedatives.” When I asked how other pediatric dentists treat children with profound autism, no one had any answers beyond the customary ‘go to the hospital’ alternative.

So where does that leave us? For Autism, for your child, personal experience is the best we have to go on. As one article stated,
“Autism treatment and research have been separate entities. Children with autism need help now and cannot wait for research to be conducted and treatment to be developed.”.
I firmly believe that establishing a long term relationship with an office and dentist is the best way to go about treating a child with an Autism Spectrum Disorder.  Becoming comfortable in an office is a two way street, the parents and child gain familiarity and trust, and the dentist can try to adjust behavior modification methods over time with a history to draw from.

The very nature of the dental visit is difficult for a child with autism. The disruption of a schedule, the unfamiliar noises and interaction with new children, intrusion into the mouth with heavy physical contact, and lying prone are all problematic. And I haven’t mentioned any actual procedures yet! So where do you start?  Below is an outline of how I would suggest choosing a provider and getting treatment for your child:

Research
Pediatric dentists are going to be your best resource for experience with autism; general dentistry provides no training whatsoever. Call the offices and look online. If the dentist mentions special needs and the staff is comfortable discussing your child’s autism, chances are good they have experience and are comfortable with the challenge. You can always call the dentist directly to discuss philosophy.  Be careful not to use the conversation as a means to express your expertise on Autism -- dentists are human, too and won’t be receptive to a new person dictating treatment in lecturing. It’s a relationship you’re trying to feel out and begin after all!

Go in for a desensitizing visit
If you can find the time, visit the dentist office before you have a formal appointment. You can turn in paperwork or pick up some so you don’t to mess with it later. More importantly, give your child a chance to see the surrounding in a non-agenda driven manner. This will help to phrase your conversations later and give you a feel for the atmosphere of the office.

Schedule
Pick a time the dentist and dental team can devote to your first visit. In our practice, we set aside time every day during less busy clinic time, to slow the pace, reduce distractions, and give kids more personal time. You are also going to want time to consult with the dentist to talk about how to treat your child based on his or her performance during the appointment.

Be realistic about the first appointment
Depending on the degree your child is affected by autism, you should set your goals accordingly.  For some, a cursory exam to rule out big problems or pain may be the best that can be done. I have a 23 year oldd, six foot four autistic boy whom I have seen for the last fifteen years (we started in my residency!). At first all he could do was to get into the room. Our first exam was done with him sitting cross legged on the floor. Last year, we completed a porcelain crown for him in the office, by himself.  Of course we had help from his Count Dracula doll, and a very long term relationship to draw from.  Incremental successes contribute to our long term goals of overall health.

Discuss options for treatment
If treatment needs exist, fillings, deep cleaning, a suspicious area that needs an x-ray, how can we get it done? For kids with Asperger’s or mild autism, routine behavior techniques work well with the right dentist. Tell-show-do, watching other children, and firm direction often work just fine [and social stories! -Eds]. For the kids whose autism is more intense, a mild anti-anxiety medication such as Ativan or Klonopin may help to take the edge off fears, or disorient the child enough to be led through treatment. You need to check with your dentist and your state to see what constitutes anti-anxiety and minimal sedation (don’t forget to call your insurance to find out what can be covered). It is sometimes best to take a child to the hospital for general anesthesia. Under general anesthesia, complete x-rays and a thorough cleaning and exam can be done, as well as any restorative needs or preventive sealants, mouthguard fabrication, etc. In my practice I often coordinate with other medical professionals while patients are under general anesthesia, to do blood draws, ear tube placement, eye exams, pap smears, toenail removal, you name it!


Ask your questions
Often I am lumped in with my medical colleagues and often parents have had a history of having to scream to be heard when advocating care for their child. I understand that, but be aware that a relationship starts with a position of mutual respect.   Ask questions about the dentist’s view on nitrous oxide use, what is in the prophy paste, views on fluoride, and the rest in a non-threatening manner, and give the dentist time to research his or her answer. There are no dental or skeletal manifestations of Autism, in other words, teeth are teeth. That being said, if you do have thoughts on alternative medications, diet, etc. don’t paint your dentist into a corner. In fact he or she may be grateful for some reading material. Having your child’s dentist on your side for emergencies, etc. is critical. And when I know a kid well enough to note him being mischievous versus assuming behavior is based on his diagnosis, it takes the burden off the parent and lets your kid be a kid. Letting your child be himself or herself in the dental office is the ultimate goal. Taking a long-term, relationship approach is the best way to reach that goal. How you get there or if you ever get there will be largely based on the way you set up the relationship with a qualified dentist.

I will be seeing little Tyler in the hospital next week -- only he is not so little anymore. He has Down syndrome and autism, and while his behavior in the office got a little better around age nine, it has deteriorated now that he is 13 and 110 pounds.  Neither the parents nor I are really happy with the reality that Tyler could not progress to independent behavior in the office, but over the years we have, together, tried everything to meet that goal.  Now, we can honestly talk and figure out the best way to care for Tyler.  General  anesthesia every two years with the best cleaning we can do in the office between times is what everyone is comfortable with. That’s dentistry for real people making a real effort every day.

If you have further questions or comments let me know at greg@biggrinswithdrgreg.com, or 970-481-6728.  I want to help you raise happy, healthy, beautiful children.

- Greg Evans, DDS Diplomat of the American Board of Pediatric Dentistry

For more information about Dr. Greg, his wonderful caring staff and Big Grins: www.biggrinswithdrgreg.com

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A version of this essay originally appeared at Sensory Flow: An Online Magazine for All Things Sensory: www.sensoryflow.com

1 comment:

Devon Asdell said...

Bravo, and I couldn't agree more. I was fortunate enough to discover Dr. Darrell Phillips at the Children's Dentistry of Knoxville from the getgo. They have special rooms to deal with difficult procedures and always schedule extra time into A's appointments. They also did a fantastic job the one time she really did give them a problem: http://community.advanceweb.com/blogs/ot_9/archive/2010/04/29/visiting-the-dentist-fear-of-the-laughing-gas.aspx I'm so very glad we have them, and a lot of it has to do with the open communication you're talking about and the idea of working together. Excellent post.