Autism spectrum disorder (ASD) defined as neurodevelopmental condition that has affect on 3 main domains: (1)Language delay, (2)social interaction and impairment communication, (3) repetitive actions (1). Also, autistic mostly associated with intellectual disability, gastrointestinal disorders, epilepsy and immune disorders. The word “autism” was first used by Kanner in 1943 (2). Etiology of ASD remaining unknown but genetic factor play a major role in ASD, with heritability estimates from twin studies as high as 90%(3). The prevalence of ASD without associated medical conditions in siblings of children with Autism has been estimated to range from 3 to 10 percent(4). In addition, the environmental factors play critical role to the development of autism are consanguineous marriage, maternal age during pregnancy, low family income, some medications taken by the mother during pregnancy and vitamin D deficiency in diet of the child (5).The Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC) these are widely use to diagnose autistic children(6). Another diagnostic tools based on DSM-IV criteria, theses information getting from parent and child interviews, rating scales, and examination of school and hospital records(7).
Children with autism have behavioral problems Which consider a challenge for pediatric dentist or general dentist when implementing routine treatment plan(8). Some study found programs to improve social behavior of autistic patient. One of these behavior methodologies is the Program of Familiarization and Repetitive Tasking (D-TERMINED). this technique based on behavior analysis and use familiarization to repetitive tasking philosophy (9).
The findings presented in this case report is about management of Child with autism in dental clinic.
8-year old boy patient attedned to King Abdulaziz university Faculty of Dentistry clinics with chief complaint according to his father: “my son cannot sleep at night due to sever dental pain related to lower molar area in both side” . The patient showed signs of both physical and mental retardation. His Weight is 67 Kg up and his Height is 135 cm.
Medical history: child was diagnosed autism spectrum disorder when he was 3 Years old ,Attention-Deficit Hyperactivity Disorder (ADHD) and Obesity. Child was born due to Abnormal increased volume of amniotic fluid but full term pregnancy, when he born he did not cry as a normal baby behavior. When he was 5 months, mother noticed that baby has no reactions nor feelings such as hunger, happy or sad.
When he was 1 year and ½ mother saw instant laughing for long period of time ( hour and ½) till he slept suddenly . but when he was 4 year; heavy shaking of the bed were noticed from parents and saliva was coming out from his mouth and convulsions. Child was taken to Hospital and took anti-convulsion and diagnosed as severe autism and ADHD.
Now, child undergoing speech therapy, mental exercises and behavior management. In addition, the child under “Arpenia” medication for ADHD to improve the attention. Child received all vaccination regularly and up to date. Family history; Parents with no history of ASD in their families. His mother’s age twenty-nine and father’s age is forty. As his parent reported; he is brushing his teeth irregularly and not on daily bases & he never use the floss. In addition; No history of trauma for the primary dentition or abnormal oral habit was reported. The past dental history multiple extraction for most of primary molars in Emergency clinic at King Abdulaziz University dental clinic.
Upon clinical examination; Extra oral examination found; scar on his forehead. His mother reported when he was 4 Y, he was a hyper active child which lead him to fall down and injured his forehead.
Intra-Oral examination found; Soft tissue within normal limit. But poor oral hygiene and physiological pigmentation. patient has multiple decayed teeth, he needs multiple restorations and sealant.
For this patient used D-Termined Program of Familiarization and Sequential Tasking for 5 times. In each 5 visits; prophy was done and informed his parent to show him movie every day about dental clinic to make him familiar with dental clinic and brush his teeth regularly at home and at school.
Also, treat him in the same clinic in each visit, Open his favorite movie to distract him, noticed, when repeat order for him, he start crying so, so will not use repetitive order and Short appointment. Patient cannot tolerate more than 20 minutes.
14 Pits and Fissure Sealant
16 Class I Composite (Modified)
16 Indirect Pulp Capping
53 Class V Composite
55 Class I Composite (Modified)
24 Pits and Fissure Sealant
26 Class I Composite (Modified)
65 Class I Composite (Modified)
36 Class I Composite
36 Indirect Pulp Capping
84 Class I Composite
46 Class I Composite (Modified)
Treatment plan ( table no.1)
Patient was in fifth visit; familiar with dental clinic and cooperative, Shashank, fill cope with water, and he adjusted dental chair by his self and immediately set on dental chair and open his mouth for 20 mints.
Oral health is an important aspect of general health, especially with medical compromised children (10). Children with ASD have special behavior problem that lead to difficulty to understand and communicate with dental team. In addition; that will increase risk for dental caries due to some type of medication or dietary choice such as (preferences for certain food and sweets) and poor oral hygiene(11). American Academy of Pediatric Dentistry’s guideline on Caries Risk Assessment have classified Autistic or any child with health care need under High risk for dental caries(12).
Family that has a children with special health care needs and assess them to maintain good oral health; through routine dental hygiene of autistic children under their parents or caregivers supervision that lead to avoid medical interventions. Most intervention will be stressful for child and family. On other hand; maintain good oral health for ASD children depend on characteristics such as (mental disability)and tolerance to some dental procedures or materials (13). In dental clinic; management of autistic child should be shaped and adapted to their needs , tolerance and characteristics (14). This study found that the D-TERMINED program have a positive result on behavior on ASD children. This program showed; improving the behavior of ASD children compared to the first dental visit.But this technique need more cooperation from families that have autistic child. Also Cost-effectiveness of the D-TERMINED program is consider another area that needs to investigate.
In conclusion, dentist that contact with autistic children, they face multiple challenges to manage these patients. D-TERMINED program may help autistic children to learn the cooperation during dental treatment in the clinic and this program can decrease the need for OR referral.