A Practical Approach to Special Care in Dentistry. Группа авторов

present and local anaesthesia may be avoided in some procedures (e.g. some filings)Acclimatisation with the same process being repeated may be effectiveIf local anaesthesia cannot be given safely, alternative approaches should be consideredSedationThe effectiveness of conscious sedation is unpredictable (paradoxical effect may occur)Inhalational sedation with nitrous oxide and oxygen may not be accepted due to use of the nasal hood/contact with the faceGeneral anaesthesiaMay be required for patients needing complex dental treatment and those where sedation is not effectiveA single side room rather than a bed on an open ward is preferableA day‐stay modality is desirableDental treatmentBeforeIndividualised risk assessment required to identify potential triggers that can cause distressConsider the possibility of pain insensitivityDuringIn the event of intolerance to the noise of the rotary instrumentation, chemical–mechanical caries removal techniques may be employed – headphones may also helpThe dental chair light may also not be tolerated – dark patient glasses may help; alternatively, consider fibreoptic handpieces and/or smaller light sourcesTerminate the appointment if the patient demonstrates signs of anxiety/stress as this can quickly escalate to challenging behaviourAfterArrange another appointment, ideally at the same time, with the same dentist and in the same dental officeDrug prescriptionPatients taking selective serotonin reuptake inhibitors (SSRIs) may not experience adequate pain relief from codeine or its derivatives (SSRIs inhibit several families of hepatic enzymes, which may delay the biotransformation to the active metabolite of codeine)Education/preventionInvolve the relatives and caregivers where requiredUse pictogramsConsider that some patients cannot tolerate electric toothbrushes due to the noise and vibrationConsider the use of flavour‐free/mild‐flavoured toothpastes and mouthwashes; non‐foaming toothpastes may also be better acceptedDietary counsellingFigure 2.2.3 Desensitisation with visual support may be helpful.Figure 2.2.4 A visual timer may improve co‐operation.

Section II: Background Information and Guidelines

      Definition

      Autistic spectrum disorders are a heterogeneous series of developmental disorders characterised by poor social skills, lack of interpersonal relationships, restricted interests and compulsive or ritualistic behaviour with repetitive stereotyped activities. Their estimated prevalence in the general population is 1%, preferentially affecting males, and 70% of patients have other comorbidities.

      Aetiopathogenesis

       The cause is unknown

       Several risk factors have been identified, including advanced maternal age (increased incidence of germinal mutations) and gestational factors that affect neurodevelopment (including infections, vitamin deficiencies and exposure to chemical agents during pregnancy)

       It has also been suggested that autism is an expression of atypical neuronal connectivity, in which certain genetic abnormalities have been implicated (mainly of genes located in chromosomes 5 and 7)

      Clinical Presentation

       Isolated in their own world (fascinated by some inanimate object, Figure 2.2.5a)Figure 2.2.5 (a) Fascination by an inanimate object. (b) Ritualistic behaviour and fixation with a toy.

       Antisocial behaviour

       Difficulty communicating (avoid visual contact, speech disorders may be present)

       Obsessive resistance to change

       Repetitive actions (hand movements, flapping, body balance)

       Lack of response to external stimuli

       Ritualistic or compulsive behaviour (Figure 2.2.5b)Table 2.2.2 Common concurrent conditions in the autism spectrum disorders.CategoriesExamples of conditionsDevelopmental abnormalitiesIntellectual disability (70%) Hyperactivity and attention deficit disorder (35%) Tics (25%) Motor deficits (75%)Medical disordersEpilepsy (25%) Sleep disorders (65%) Gastrointestinal diseases (40%)Psychiatric disordersAnxiety (50%) Depression (40%) Obsessive–compulsive disorder (25%)Behavioural problemsAggressiveness (60%) Self‐harm (50%) Pica (30%)

       Hypersensitive to sensory stimuli (but occasionally insensitive to pain and cold)

       Common concurrent conditions (Table 2.2.2)

      Diagnosis

       There are no specific genetic, medical or laboratory diagnostic tests

       Diagnosis based on clinical findings suggestive of deficiencies in the area of communication, socialisation or restricted behaviour

      Management

       Behavioural interventions and support

       Special education programmes

       Antipsychotic drugs (e.g. risperidone), selective serotonin reuptake inhibitors (e.g. fluoxetine) and stimulants (e.g. methylphenidate)

      Prognosis

       The mortality risk is 2.8‐fold higher than in the general population of the same age and sex, mainly due to the coexistence of other medical determinants

      A World/Transcultural View

       In the US, children of racial ethnic minorities, of low‐income families and/or non‐English speakers with autism spectrum disorders are diagnosed later than white children, and have greater difficulty accessing healthcare facilities

       Autistic traits and their descriptors are not universal due to cultural differences. For example, asking whether the patient ‘enjoys social events’ has an excellent predictive value in the United Kingdom and Japan but is not applicable in India

Recommended Reading

      1 Chandrashekhar, S. and Bommangoudar, J.S. (2018). Management of autistic patients in dental office: a clinical update. Int. J. Clin. Pediatr. Dent. 11: 219–227.

      2 Corridore, D., Zumbo, G., Corvino, I. et al. (2020). Prevalence of oral disease and treatment types proposed to children affected by autistic spectrum disorder in pediatric dentistry: a systematic review. Clin. Ter. 171: e275–e282.

      3 Delli, K., Reichart, P.A., Bornstein, M.M., and Livas, C. (2013). Management of children with autism spectrum disorder in the dental setting: concerns, behavioural approaches and recommendations. Med. Oral Patol. Oral Cir. Bucal 18: e862–e868.

      4 Lai, M.C., Lombardo, M.V., and Baron‐Cohen, S. (2014). Autism. Lancet 383: 896–910.

      5 Limeres‐Posse, J., Castaño‐Novoa, P., Abeleira‐Pazos, M., and Ramos‐Barbosa, I. (2014). Behavioural aspects of patients with Autism Spectrum Disorders (ASD) that affect their dental management. Med. Oral Patol. Oral Cir. Bucal 19: e467–e472.

      6 Nelson, T., Chim, A., Sheller, B.L. et al. (2017). Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program. J. Am. Dent. Assoc. 148: 485–492.

      7 Rouches, A., Lefer, G., Dajean‐Trutaud, S., and Lopez‐Cazaux, S. (2018). Tools and techniques to improve the oral health of