Introduction

The purpose of this tutorial is to:

• To help families and health educators recognize the importance of oral home care in individuals with Autism Spectrum Disorder (ASD) and the associated challenges.
• Solutions for better oral home preventative care, injurious behavior, medications, and feeding challenges
• We will also look at the challenges we face as we strive to treat those patients.
  • Part I: Challenges in preventive care
  • Part II: Challenges with behavior management
  • Part III: Challenges with medications
  • Part IV: Challenges faced in feeding

Amount of cavities in children with ASD are higher than the numbers seen in American children, and children with ASD can be more difficult to treat due to behavior management and sensory disorders.

 

 

Part I: Challenges in Preventive Care

Children with ASD experience difficulties with proper oral care due to…

• Toothbrush as a “foreign object”
  • Brushing with a toothbrush is an unfamiliar experience with an unfamiliar object
    • The only things they put in their mouth are food or beverages, which they swallow, or their thumb or pacifier that they suck.
• Uncomfortable activity--> Anxiety and negative reactions
• Anxiety towards toothbrushing
  • Not an enjoyable activity
  • Not an intuitive activity
  • Coordination of toothbrushing movements
    • Children with ASD have a wide spectrum of functionality
    • Difficulty holding the toothbrush and learning brushing motions
    • Sensitivity to toothbrushing and toothpaste
      • Too much stimulation along gums from brushing action
      • Minty flavor of toothpaste may be too strong

Part I: Challenges in Preventive Care - SOLUTIONS

Children with ASD experience difficulties with proper oral care due to…

• Toothbrush as a “foreign object”
  • Caregivers likely need to brush for child.
  • Try giving child control
    • Place very small amount on finger and encourage them to taste. 
    • Place a pea-size amount of toothpaste on a child-size soft bristle tooth brush, and allow them to brush with manual guidance.
    • If they resist, say "OK, we’re almost done", and stop as soon as possible.
• Encourage and practice with child to spit out the toothpaste rather than swallow it to prevent excess fluoride intake
• Gradually increase the length of brushing time to 2 minutes.
• Reward good behavior
• Anxiety towards toothbrushing
  • Predictability
    • Same location
    • Same time: frequency, duration, time of day
• Oral home care technique:
  • Tell, show, do
  • Distractions: counting (1-5), songs
  • Reward for good behavior and proper technique

Children with ASD experience difficulties with proper oral care due to…

• Coordination of toothbrushing movements
  • Better handling and grip for child to brush
  • Examples
    • Add tennis ball to toothbrush handle
    • Add bike handle to toothbrush handle
    • Wrap tape around the handle
• Surround® Toothbrush recommended and used by the University of Pittsburgh School of Dental Medicine
• Surround® Toothbrush has unique heads and multiple sides of bristles
  • Cuts down on brushing time
  • Cover more tooth surfaces

Children with ASD experience difficulties with proper oral care due to…

• Sensitivity to toothbrushing and toothpaste
  • Soft/ultrasoft toothbrush
  • Try fruit-flavored toothpaste (make sure the toothpaste has Fluoride)
  • May need other sources of Fluoride to compensate for lack of Fluoride
    • Why? Daily exposure to Fluoride is important!
    • Typical bottled water does not contain Fluoride, whereas certain public water systems are fluoridated.
      • Check if your public water system is fluoridated: apps.nccd.cdc.gov/MWF/index.asp
      • May need other sources of fluoride to compensate for lack of fluoride
        • Discuss varnish application with your child’s dentist if you experience limited fluoride options
• If child does not accept any kinds of fluoridated or non-fluoridated toothpastes, use of fluoridated water during toothbrushing is the next best option
  • Dip and wet the toothbrush in the fluoridated water (from public water system)
  • rinse mouth with fluoridated water (from public water system)
• The mechanical action of the toothbrush bristles on the gums and teeth is an excellent method to reduce the amount of bacteria that adhere to those surfaces

Part II: Challenges with Behavior Management

There may not be a known reason why children with ASD tend to exhibit certain self-injurious activities. The reason could be because of repetitive actions that allow stimulation.

The challenge is preventing common oral manifestations seen in children with ASD due to self-injurious behaviors that may be caused by the following:

• Grinding teeth (Bruxism)
  • Easier to address than other oral manifestations
  • Tongue thrusting (see picture Below)
  • Non-nutritive chewing (ie: cheek biting)
  • Self-injury (picking of gums, biting lips)

Part II: Challenges with Behavior Management - SOLUTIONS

• Removable appliance
  • Warning: Do not use mouth guards (or other removable appliances) if child has seizures
• Worn during the day between meals and/or at night after proper oral hygiene routine
• If tolerated, protects teeth from aggressively grinding together and from self biting

 

Part III: Challenges with Medications

Be aware of the side effects associated with commonly prescribed medications used to treat behavioral symptoms of ASD. Challenge: dealing with side effects of medications that can affect the oral enviorment

• Certain medications may have a side effect that causes “dry mouth”(Xerostomia)
• Xerostomia can increase the likelihood of developing cavities due to the decrease in salivary flow
  • Saliva neutralizes acids in the mouth
  • Saliva rinses away food debris from the gums and teeth
  • Saliva contains phosphorus and calcium, which can rebuild lost enamel
• Common medications that may cause “dry mouth”(Xerostomia) and increase chance of developing cavities:

Part III: Challenges with Medications - SOLUTIONS

• Discuss alternative medications with your child’s physician that do not include xerostomia as a side effect
• If medication with xerostomia as a side effect is unavoidable, it is even more crucial to exercise proper oral care preventive measures

 

 

 

Part IV: Challenges Faced in Feeding

• Craving sweet beverages
  • Children with Xerostomia are regularly thirsty
  • Seem to prefer and fill up on sweet drinks
  • Get full from juice and other drinks, so they do not want to eat à poor nutrition
    • Drinks with lots of sugar à cavities
• Inappropriate eating behavior
  • Regurgitating and re-eating
    • Acid erosion of teethà yellowing of teeth
    • May cause pain or discomfort during eating
• Stomach and digestive problems
  • Children with ASD tend to have stomach or digestive problems  such as vomiting, diarrhea, and upset stomach
• Picky eaters
  • Refusal to eat healthier meals forces parents to give child unhealthy foods.
  • Sweets and junk food may be inappropriately used as rewards
  • Food selectivity and restricted diets à risk for nutritional deficiencies.
    • noncompliance with fruits and vegetables more common in children with ASD

Part IV: Challenges Faced in Feeding - SOLUTIONS

• Craving sweet beverages
  • Try introducing healthier alternatives
• Inappropriate eating behavior
  • Medication: Proton Pump Inhibitors
  • Discussion with Occupational Therapist for muscle training
    • Deep breathing techniques
• Stomach and digestive problems
  • BRAT diet: Bananas, Rice, Applesauce, Toast
    • Short term, 2-3 days
    • Makes stool harder
    • Replaces lost potassium from vomiting
    • Bland and easier to keep in stomach
    • May add yogurt if child had digestive problems
  • Consult a nutritionist for advice and recommendations
• Picky eaters
  • Selective Eating
    • Must eat a little of refused food before eating desired food.
    • Give positive attention and praise for eating undesired food.
    • consult a nutritionist for advice and recommendations

 

Remember

• ASD is a wide spectrum
  • Not all children with ASD tolerate the same things…
    • Trial and error
    • Patience
    • Routine
    • Explanations
    • Tell, show, do
    • Rewards, praise
• Always remember to reinforce positive outcomes with rewards
  • Rewards SHOULD NOT BE junk food & sweet drinks
  • Rewards can be social and/or non-social
    • Social rewards
      • verbal praise
      • positive facial expressions
      • Non-social rewards
        • Stickers
        • Prizes
        • favorite TV show

 

Overall

 Oral Health in Primary Care

• Oral health screening recommended at age 1 year
• Children typically begin to see dentist at age 3 to 6 years
• Pediatric clinicians can provide initial screening and care for oral health at health maintenance visits (6 in year 1, 3 in year 2)
• Counseling about prevention
• Analysis of children's risk factors for ECC
• Possible interventions, such as applying fluoride varnish
• Clinicians should recommend dentist and help reduce barriers to care for children at high risk of ECC

Items to Remember

• Genetic malformations of enamel are extremely rare
• Prenatal exposure to medications are not a major cause of early caries
• Fluorosis rarely occurs in baby teeth
• Cavities are most likely due to diet and feeding, not tooth brushing technique

All health professionals have a shared responsibility to recognize and discuss oral disease with patients and their families/caregivers. The knowledge and skills of non-dental health professionals can help patients and caregivers improve oral health. They can assist with home care and accessing dental treatment.

 

Role of Health Professionals

Enabling families to provide better oral hygiene and nutrition for their child.

Educating families about oral health needs.

Establishing good preventive habits.

Identifying the skills, procedures, and therapies in each profession which can be used to improve oral health.

Appreciate your responsibility for your patients overall health.

Refer and Coordinate with the patient’s dentist.

 

Together, we CAN make a difference!