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Oral Considerations and Care for Children With Autism

Autism is the third most common developmental disability in the U.S. and, recent years have shown a notable increase in persons born with the disability. In fact, it has been reported to occur in 7-14 births per 10,000. It also occurs more often in males than females by a ratio of 4:1.

Autism, or AD, is a complex neurodevelopmental disorder, that diminishes one’s ability to communicate, and impairs one’s social, behavioral, and intellectual abilities. Usually the signs or symptoms appear during the first three years of a child’s life. Although there is no cure for AD, early diagnosis and intervention can greatly improve a person’s social functioning later in life.
Some of the early signs are:

• A baby who doesn’t babble or gesture by the age of 12 months
• A baby who lacks eye contact with his/her mother by age of 12 months
• Resists being held or cuddled by his/her mother
• A baby who doesn’t respond when his/her mother says its name
• Appears to be deaf
• Doesn’t say a single word by the age of 16 months

Autism is a life-long condition, and no one knows for certain what causes the disability to occur. Although environmental (i.e. trauma) and genetic factors can contribute to the development of autism, they do not necessarily cause or are unique to the disorder. Some prenatal factors include intrauterine rubella (acute disease resembling scarlet fever and measles), and cytomegalic inclusion disease (a member of the herpes viruses that is now the most commonly acquired birth infection of infancy). Postnatal factors can include untreated phenylketonuria, infantile spasms, and herpes simplex encephalitis. Many have coexisting medical conditions and/or disorders, such as epilepsy, fragile-X symdrome, tuberous sclerosis, and phenylketornuria, (a disease caused by the body’s failure to oxidize an amino acid because of a defective enzyme that, left untreated, can cause brain damage and severe mental retardation).

It is important to realize that no two persons with autism will demonstrate the same symptoms or behaviors. In fact, symptoms and severity of the disability will vary widely. However, the following is a list of behaviors that a child with AD may exhibit:

• Child will often run away from caretakers, or health care workers (called elopement)
• About 50% are non-verbal communicators
• May appear to be stubborn
• May exhibit echolalia (involuntary parrot-like repetition of words spoken by others, often accompanied by twitching of muscles)
• May exhibit rambling speech
• May exhibit unusual self-stimulating behavior, including hand-flapping or rocking back and forth
• May appear deaf or non-responsive
• May not be able to answer simple questions
• May be sensitive to bright lights, sound, odors, and touch
• Seizures occur in 25% of autistic children
• 75% have some degree of mental retardation

Although the rates for dental decay and gum disease in children/people with AD are comparable to the general population’s, it is also noted that children with autism may experience more dental problems due to oral sensitivities around the mouth, their diet, difficulty with brushing, and difficulty in accessing dental care. Autistic children are seldom able to verbalize complaints about any dental problems they may be experiencing; so therefore, regular, periodic dental exams, both at home and in a dental office, are essential to ensure good health!

If you are a parent or caretaker of a child with autism, it is important to remember to apply the same common sense practices that you would with a child without the disability. For instance, the germs that cause cavities can be passed from parent to child, so it is important not to kiss the infant/child on the lips, or share foods or eating utensils. Remember that baby teeth are important for sleep, nutrition (difficult for child to eat or sleep if his/her teeth hurt!), speech, and self-esteem. Other tips (for all children) are:

• Start to clean your baby’s mouth early on, and begin to brush as soon as his/her first tooth erupts (eruption times may be delayed).
• Don’t put your child to bed or let your child walk around with a bottle or “sippy” cup that contains anything but water.
• Ask you child’s dentist or doctor about taking a fluoride supplement.
• Take you child to the dentist for a dental check-up by age 1 (this will get him/her familiar with visiting the dentist and will help to eliminate future fear).
• If your child has his/her permanent molars, ask your dentist about sealants to prevent future decay.
• Start flossing your child’s teeth when the teeth begin to touch each other.
• Give your child healthy snacks (like cut-up fruits and vegetables), and avoid using sweet treats for rewards (use alternative rewards, such as a favorite toy, activity, or meal out at a favorite restaurant).
• Avoid fizzy drinks, or juices, if possible, and use water or milk.
• Avoid sticky or sugary foods like fruit roll-ups or raisons because they increase the time the sugar is on the teeth to cause cavities.
• Ask for sugar-free medicines whenever possible, and remember to give your child lots of water after any medicine.
• Check labels for “hidden” sugars. Remember that any ingredient ending in –ose is a sugar, such as fructose, sucrose, dextrose, etc.

Helping an autistic child/person with their home oral care can be difficult, and go slowly at first; but with determination, patience, and perseverance, the results are well worth the effort and can have a rewarding, positive impact on your child’s oral health and quality of life. You will have to assess your child’s needs and abilities for establishing oral hygiene. Here are some tips (that may or not apply) for toothbrushing:

• If your child has seizures, be prepared to manage one.
• Make toothbrushing a routine, and if you are using picture schedules, add a picture of toothbrushing as part of your morning and bedtime routine.
• Take pictures of you and your child before, during, and after brushing (smiling!). Put the pictures together with a brief story about brushing, and read it every day. Do the same thing with flossing, or a trip to the dentist.
• If your child is sensitive to bright lights, noises, or smells, remember to choose a place that is void of these triggers, and minimize distractions. Consistency works best, so try to use the same location, timing, and positioning.
• Avoid brushing at the sink, or with your child standing at the sink. Instead, stabilize your child’s head by having your child sit in the high chair or corner of the couch.
• Start by touching the lips or just inside the mouth for a few seconds, morning and night. Build up to brushing, and then, for longer times (you might use an egg timer). Remember that a quick brush, even if it’s only a few teeth, is better than not brushing at all. Praise your child after each touch!
• Use a very small, pea-sized amount of toothpaste. If your child objects to toothpaste, try a mouth rinse (I recommend ACT; it has several different flavors, has a non-alcoholic formula, and contains fluoride)—or just use plain water.
• Use the “tell, show, do” approach.

Sing a song while brushing:

Brush, brush, brush your teeth. Brush them every day. That’s the way we fight Mr. Tooth Decay! (sing to the tune of “Row, Row, Row, Your Boat”)
• Break down your child’s brushing routine into six small steps when brushing your child’s teeth:
  1. Brush the outside of the bottom back teeth on one side of the mouth (i.e., right side). Then move to the inside and brush. Then brush the tops, or chewing surface, of the teeth.
  2. Brush the bottom front teeth outside and inside.
  3. Move to the opposite (left) side and brush the bottom teeth, outside, inside, and tops.
  4. Brush the top back teeth, inside and out, and chewing surfaces on one side (right).
  5. Brush the top front teeth, inside and out.
  6. Brush the opposite top back teeth (left), inside, outside, and chewing surfaces.
  
• Try (can be purchased from a pharmacy) disclosing tablets. Have your child chew a tablet, swish, and spit. Then look to see where he/she is missing. Brush any of the “pink” still visible off.
• Don’t give up! Once a routine is established, brushing will become easier!
• Once your child accepts brushing, start flossing. Use the same step-by-step approach that you use for brushing.
• Remember to reinforce each step by praising, smiling, clapping, and saying “Good Brushing!” or “Good flossing!”
• Periodically, lift your child’s lip and look for chalky white or brown spots, especially the upper front teeth where early childhood cavities often start. If you see spots, take your child to the dentist.

As your child grows and develops, encourage him/her to brush and floss independently, but depending on the severity of the disability, realize that your child may never be able to brush or floss without help, or may always need to have it done for him/her. Your child may also have some other oral concerns that are common among children/people with AD:

• Damaging oral habits such as clenching, or grinding the teeth
• Tongue thrust
• Self-injurious behaviors, such as picking at the gums, biting the lips, or eating inappropriate objects, such as gravel, cigarette butts, or pens (a mouth guard might be helpful, if it can be tolerated by the child/person—ask your dentis!)
• If your child is taking phenytoin, commonly prescribed for seizures, be aware that it may cause the gums to over-grow, and may eventually need professional intervention.
• Falls, accidents, or seizures may require immediate professional attention, especially if a tooth is broken.
• Know the steps to save a knocked out tooth! (link)
• Some medications cause “dry-mouth” (xerostomia), which can contribute to higher decay rates, making good oral homecare, fluoride, regular dental check-ups, and cleanings especially important!
• Your child may pouch food (holding food in their cheeks, or other areas of their mouth). Check! Have your child rinse well, or finger sweep these areas, whenever possible.

Your child’s special needs may require more frequent visits and professional cleanings because of dry mouth, gums that over-grow, injurious behaviors, etc. (Your dentist really isn’t just trying to get more money!) Another thing, because providing services to children with special needs can be difficult, it is easier for both patient and dentist if problems are kept small and not allowed to develop into something more serious. Here are some good tips for choosing a dentist, and for taking your autistic child to the dentist:

• Find a pediatric dentist who has experience with children with special needs, or a general dentist who has experience with children and persons with special needs.
• Keep your dentist informed of your child’s special needs, Be sure to let him/her know about any other medical conditions, such as seizures, medications, behaviors, or sensitivities (light, sound, or touch).
• Let your dentist know if your child does not respond to pain; or, if your child responds to pain or discomfort in an unusual manner.
• Try to make the appointment for the quietest time of the day, with the fewest distractions.
• Ask for a private exam room, if possible.
• Ask your dental professional, or physical therapist, whether a modified toothbrush or floss aid might be helpful. A power toothbrush is often more effective, and can make brushing easier. Your child may still require help or supervision, however. Ask whether other interdental cleaning aids or oral irrigators might be helpful for your child (usually for older child or person).
• Ask the receptionist to mail any paperwork so it can be filled out in advance of the appointment time.
• Ask if you can schedule an “orientation” visit for your child to familiarize himself/herself to the office and meet the dentist and staff. Have the staff let him sit in the dental chair, and show your child how it can swivel or go up and down. If your child will not get in the patient chair, try to persuade him/her to sit on the operator’s stool.
• Read a book about going to the dentist, or get a video about visiting the dentist for your child to watch before going for a dental visit.
• Buy a disposable mouth mirror from a pharmacy and practice looking in your child’s mouth with it before going to the dentist.
• Bring your child’s favorite toy or comfort item, such as a blanket, or music.
• Don’t forget to ask your dental professional about fluoride, sealants, mouth guards, or other preventative recommendations.
• If your child suffers from dry-mouth caused from medications, ask your dentist about an at-home saliva substitute.

Sources: "Healthy Smiles for Children with Autism" from Children’s Hospital and Health Center
"Practical Oral Care for People with Autism," U.S. Department of Health and Human Services
Dental Hygiene Theory and Practice (2nd ed.) Norfolk, VA: Michele Darby, BSDH, MS, Margaret Walsh, RDH, MS, MA, EdD. Saunders, St. Louis, MO, 2003, p. 826-830.

Links:

www.aapd.org
www.eparent.com
www.nidcr.nih.gov
http://dentalresource.org/topic55autistic.htm.

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