Case 42

Will you see my son?

failure. Recently he has been putting objects into his mouth

and biting his clothes. His mother is worried that he may
be in pain but is unable to tell her.

Medical history
The patient was diagnosed with autism at age 3 years. He
has no other medical conditions and takes melatonin to help
him sleep. His mother thinks that he may be allergic to
wheat and dairy produce and consequently tries to exclude
these from his diet.

Examination
Extraoral examination
The patient is shown in Figure 42.1.
What do you see?

SUMMARY
The mother of a 6-year-old child brings him to your
practice to ask for an appointment. She cannot find
another dentist to see him.

In a still photograph the patient appears essentially normal, as

most children with autism do. However, he fails to make eye
contact (or look at the camera) and has a relatively large
head, a feature seen in some young children.
While you speak to the mother in the waiting room the child
is flapping his hands and rocking backwards and forwards.
He does not seem to be aware of his surroundings.
It appears that you will not be able to perform an examination easily.

What is autism?
Autism is a developmental disorder, more accurately
described as autistic spectrum disorder (ASD) because it
includes a range of conditions. All are characterized by three
key diagnostic features:
1. Impairment of social interaction
2. Impairment of communication
3. Repetitive, stereotypical patterns of behaviour.
Autism has a wide range of expression. Some individuals
have normal or near-normal intelligence, though threequarters have some degree of learning disability. Males are
four times more frequently affected than females. The mildest
form, Aspergers syndrome, is compatible with a near-normal
life.

What is the cause of autism?

Fig. 42.1 The patient on presentation.

History
Complaint
The mother reports that she has asked several dentists to
see her autistic son, but they all find reasons not to.

History of complaint
No one has ever been able to perform a proper check-up on
her son. A recent attempt by another dentist ended in

Autism is considered to be primarily genetic in origin. It is not

unusual for siblings to be affected, though they may not be
recognized if signs are limited to subtle lack of social skills or
failure of language development. Autism appears to be a
complex multifactorial condition and several genes have
been identified that may contribute, on both autosomes and
sex chromosomes. It appears that there are changes in brain
structure in autism, but these remain to be defined.

What features of autism will affect your management?

Verbal communication is a major problem. Many children
never develop functional speech and are reliant on
communication aids. Some develop the ability to repeat back
what is said to them (echolalia), seemingly understanding,
but usually not. One positive aspect of this behaviour is that
copying the sound ah may allow you to see inside the
mouth.

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W ill y o u s e e m y s o n ?
Lack of nonverbal communication may prevent you from
using alternative strategies. There is a lack of eye contact,
making it difficult to gain and maintain attention, and an
inability to interpret nonverbal signals or emotions from facial
expression or tone of voice.
Aversion to physical contact makes examination, treatment
and the usual means of physical reassurance ineffective.
Hypersensitivity to sights, sounds, smells and touch
may be a feature and present problems with tooth brushing
and dental treatment.
Idiosyncratic behaviours, such as highly specific insistence
on the colour or consistency of food, are frequent. This may
make dietary control difficult.
Resistance to change. Autism is associated with a strong
need for routine. Individuals will like events to be predictable
and new experiences may unbalance the whole day.
Unusual diets are frequent because many parents exclude
wheat, dairy products or yeast in an attempt to improve the
condition. In combination with the patients own dietary
demands, this may make dietary prevention very difficult.

You may also need to consider that the parents themselves

may suffer a mild form of the disorder and their communication and social interaction may appear unusual.

Are other significant medical conditions associated with

autism?
Yes, the behavioural pattern of autism can have several causes
and 10% of individuals will have other conditions such as
Retts syndrome, fragile X syndrome, tuberous sclerosis or
phenylketonuria.
Epilepsy is a common association and, if not present in
childhood, often manifests as in adolescence. Attention deficit
hyperactivity disorder is sometimes present and patients may
take methylphenidate (Ritalin) to help address this behaviour.

Should this patient be referred for hospital or specialist

care?
Given time and careful planning you would probably be able
to examine and carry out simple treatment for the patient. If
you consider that there is severe pain, infection or other acute
condition, then immediate referral to a specialist care centre
where general anaesthesia is available would be appropriate.
However, you still need to examine him to explore
alternatives. There is no reason why patients at the more able
end of the spectrum cannot be treated in general practice for
routine preventive and even simple restorative care.

What will you do next?

It appears that the patient may be in pain. You will wish to
determine the cause quickly, but without a careful plan of
action you will probably fail. Before you can proceed you will
need some information from the mother.

What information will help you plan treatment?

The following information would be helpful:

Patients likes and dislikes useful in establishing a

rapport with the child
Any communication aids that are used (see below)

Possible associated behavioural conditions such as

attention deficit hyperactivitiy disorder
Possible associated medical conditions such as
medication and epilepsy
Therapies being used to help the condition
Whether tooth brushing is managed and whether
toothpaste is tolerated
Whether the child is able to give a degree of cooperation
and accept physical contact. Experiences such as having
a haircut are often good indicators of this.
If you see many patients with special care requirements you
would probably have a special questionnaire to collect this
information, but this is an emergency situation.

Might treatment for autism affect or aid dental care?

Drug treatments include antiepileptics, methylphenidate
(Ritalin), selective serotonin reuptake inhibitors, antigastric
reflux drugs and melatonin. While these have some oral
adverse effects, such as dry mouth, they should not
compromise treatment. Some medication addresses anxiety
and aggressive behaviour.
Behavioural therapy is the most effective treatment but is
very labour-intensive, costly and of limited availability. Applied
behavioural analysis (ABA) breaks down learning into tiny
chunks, using imitation and reinforcement to encourage
autistic children to communicate, then speak and follow
commands, before moving on to more advanced skills.
Positive responses are rewarded by reinforcers such as food,
social interactions, games or toys. Given more time, visits to
the dentist could be rehearsed with the patients ABA teacher.
If, as here, this cannot be undertaken, at least knowing the
rewards used may be very helpful in reinforcing good
behaviour at this, and future, visits.
Complementary treatments are often sought by
parents. Some parents consider that fluorides, amalgam or
foods worsen or cause autism. Some negotiation and
compromise may be required on both sides to allow
successful treatment.

What is your plan to examine the child?

As the child may be in pain, you need to make some attempt
to examine the mouth. If you are not successful, you need to
ensure that the visit does not become a negative experience.
You will need to reinforce all positive behaviour and regard
this as the first of, perhaps several, short experience visits.
These may achieve little more than saying hello and allowing
the child to see you, your staff and the surgery and
experience its smells. Autistic children are highly anxious in
new situations but repeated exposure helps.
Invite the mother and child into the surgery. Reassure the
mother that her childs behaviour does not worry you or your
staff and try to appear confident. Make sure there is a quiet
calm atmosphere, without distractions such as telephones
ringing. Observe the childs behaviour and remember that the
most likely cause of poor behaviour will be anxiety.
Dont expect him to sit in a dental chair. Try engaging him at
a sink, playing with running water. Try a toothbrush, if
acceptable. This may allow you to view the childs mouth.

W ill y o u s e e m y s o n ?
How can you communicate with the patient?
There are some basic rules that will stand you in good stead.
Keep the language very simple and limit yourself to a few
concepts.

Use the childs name at the beginning of every sentence

to get his attention.
Always look at the child when you are talking to him.
Speak slowly.
Omit unnecessary words, especially social language
please and thank you will only be understood by
mildly affected individuals.
Avoid idiomatic expressions. Take a seat will be taken
literally.
Humour has no effect and will not be understood.
Be patient.
Some individuals may use pictorial communication aids
such as Makaton or the Pictorial Exchange Communication
System (PECS). Makaton uses iconic symbols and line
drawings to convey the meaning of words. The more userfriendly PECS system teaches nonspeaking children to
exchange pictures of things that they want for the item,
using their visual rather than verbal skills. An example is
shown in Figure 42.2.
Parents or teachers can produce a series of pictures or
photographs to make a social storyline that will help
prepare the child for the next dental visit and reduce anxiety.
An example is shown in Figure 42.3. You will need to investigate the childs own communication strengths.
Try to engage the child. Knowing what he likes and
dislikes is most important. Try to identify something in the

Toothbrush
Fig. 42.2 A pictorial exchange picture.

Fig. 42.3 Example of social storyline preparing for a visit to the dentist.

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surgery, perhaps moving the dental chair, playing with

the light or a toy, that can be used to reinforce good
behaviour.

If the patient is in pain, what causes would be likely?

Without having set up the visit in the way described above,
you may only achieve a glimpse of the teeth so you will
need to know likely causes in advance. For this patient,
these are:
Caries, especially if the diet or behavioural reinforcers
are cariogenic
Trauma from a nonvital deciduous incisor, because
children with autism with epilepsy are prone to trauma
Self-mutilation is sometimes seen: patients may pick at
their gingivae causing ulceration or inflammation
Mobile lower incisors resulting from physiological loss
in a child aged 6 years
Discomfort or pericoronitis associated with erupting
first permanent molars.
The history of mouthing and chewing objects would be
suggestive of either of the last two causes.
Using the strategies described above you manage to get
the child to let you look at his teeth while his mother brushes
them. No caries is obvious, but both lower central deciduous incisors are very mobile. These appear to be the cause
of the discomfort and the mother can be reassured. No
intervention is likely to be helpful or possible. This is a selflimiting problem.
If caries had been noted, there would probably have been
no option but to refer the patient for treatment under
general anaesthetic. This would have the benefit of allowing
a complete examination and radiographs, which might
otherwise take months to achieve. If the first permanent
molars were erupted, fissure sealing could also be performed under anaesthetic.
You ask the mother to bring the child back for a subsequent visit. There will be time for the child to be properly
prepared using pictures, as described above, and possibly
one or more trips to your surgery waiting room. The mother
should bring the patients own toothbrush and paste. These
form a conceptual link for the patient between visiting the
dentist and his teeth and also allow you to capitalize on

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W ill y o u s e e m y s o n ?

behaviour that is normally part of the patients home

routine. The parent should be instructed to show the mobile
teeth to the child in a mirror.

What is your strategy for further visits?

Plan frequent short visits making progress in small
increments, until the child accepts dental examination sitting
in the dental chair. The aims are to provide an intensive
preventive regime so that treatment is unnecessary and to be
able to undertake examinations to ensure the regime is
effective. The social storyline prepared for the next visit is
shown in Figure 42.3.
Dietary analysis is critical, given the unusual diets noted
above. Safe reinforcers and snacks may need some
imaginative thought since wheat and dairy products are
unacceptable, chronic diarrhoea rules out fruit and the child

will only eat food of one colour. Sugar-free confectionery may

have to be considered.
Establishing toothbrushing habits is essential for autistic
children. Not only does it maintain gingival health but it will
also deliver fluoride toothpaste. As for other children with
disability, an adult toothpaste with a high fluoride dose is
appropriate given the importance of preventing caries. If
toothbrushing habits are established, a toothbrush is usually
the best way to entice children with learning difficulty to
open their mouth.
The dental treatment of children with autism in a general
practice can be a challenge. The dental visit can be a very
positive experience for some families with children who are
mildly affected. However, the degree of learning disability and
communication in the majority of patients usually requires
referral to a specialist.