Friday, 5 October 2012

Teeth, dentists and autism

In this post I want to cover some of the collected research looking at teeth, oral hygiene and dentists in relation to autism spectrum conditions in light of this paper by Yi-Chia Wang and colleagues* and the various indications for the use of dental anesthesia indicating paediatric autism.

I have, in passing, mentioned teeth and autism in previous posts; most notably in this post on self-injurious behaviour (SIB) and the potentially wide variety of reasons to account for instances of SIB in autism outside of just impulsivity and stereotypy (see here).

Anyone who has experienced the discomfort of toothache or those so-called wisdom teeth making a slow and protracted appearance might understand the feelings involved. Imagine if you will what potentially might happen were you not able to communicate such discomfort or get the required medical attention that you might need?

There is however so much more to this area.

Oral hygiene and trips to the dentist are often not an easy thing for many children and adults, whether diagnosed with autism (or anything else) or not. Brushing, flossing and mouth-washing have been instilled as an integral part of the daily routine across many parts of the world in order to keep our pearly whites, pearly white and reduce the instance of tooth decay (caries) and beyond. Aside from poor adherence to a good oral health regime, including watching what you eat, there are however a multitude of reasons why people in general still have issues with their teeth (see here).

The collected literature on autism and dental health is quite extensive both in topic and findings but with a few common points raised:

  • Health inequality. For whatever reason, children (and adults) with autism, as in several other conditions, often have high rates of unmet dental needs as per studies like this one from Nelson and colleagues** and this one from Brickhouse and colleagues***. There are several possible reasons for this health inequality including: cost, locality and the availability of professional skills and experience of dentistry in cases of autism. I might add that such inequalities seem also to extend to other areas of healthcare too.
  • Autism and anxiety. I don't think I need to say too much more about the relationship between autism, stress and anxiety that hasn't already been said before. Anxiety can happen for lots of different reasons outside of the more classical 'out of routine' line which is pretty extensively described. Doctors appointments have been mentioned as a potential source of anxiety (see here) and one has no reason to doubt that a visit to the dentist (white coats, bright lights, funny sounds and smells) might also bring about similar feelings for some, particularly if previous visits have not been altogether unadventurous. Not surprisingly papers like this one from Loo and colleagues**** add to the Wang paper and their talk about dental patients with autism as being more likely "uncooperative and required dental treatment to take place under general anesthesia". The anaesthetic bit automatically implies that the risks are heightened for some people with autism, even for what should be routine dental work.
  • Dental health. There is still a degree of discussion about whether the presence of autism correlates with an increased risk of dental caries or not. The paper from Loo et al said not, as did Namal and colleagues*****. Other results say there is, as per this paper by Jaber******. There are potentially many factors influencing tooth decay so I will perhaps reserve judgement on what the main suggestion is in this area.
  • Dental injuries. I've kinda touched upon this area previously in a post discussing the issue of pica and autism (the eating of non-food materials). Suffice to say that not every instance of pica will be over something soft like dirt or paper as per the bezoars and other items that have been reported in cases of autism. Rocks, coins and related hard matter are generally not good news for teeth. Allied to this area are reported instances of rumination (eat, regurgitate, re-eat) in cases of autism******* (full-text) which given the acidity of such contents is likely to be as detrimental to oral health as repeated vomiting. Finally, there is the potential effects of bruxism (gnashing of teeth) in cases of autism. I can't readily find any reliable figures about the overlap between bruxism and autism but certainly it is relationship that has been noted as per this article by Orellana and colleagues******** and when chronically present will most certainly impact on oral health. 

There are other areas which I could have talked about such as the oral effects of certain medicines, dietary patterns and habits in cases of autism and the whole sensory side of things in relation to oral health. I'm going to stop round about here though save you all getting too bored.

If there is any conclusion from the analysis of this area it is that oral health and wellbeing is an important part of healthcare in relation to autism. Understanding the issues which can follow autism is central to maintaining good oral health; not least in the provision of trained, professional dental care sensitive to those issues.

To close, the music chatter at the moment is all about Adele and the latest Bond theme tune. I have to say that out of all Daniel Craig's outings as 007, the Casino Royale theme tune was pretty good...


* Wang YI. et al. Dental anesthesia for patients with special needs. Acta Anaesthesiol Taiwan. 2012; 50: 122-125.

** Nelson LP. et al. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatric Dentistry. 2011; 33: 29-36.

*** Brickhouse TH. et al. Barriers to dental care for children in Virginia with autism spectrum disorders. Journal of Dentistry for Children. 2009; 76: 188-193.

**** Loo CY. et al. The caries experience and behavior of dental patients with autism spectrum disorder. Journal of the American Dental Association. 2008; 139: 1518-1524.

***** Namal N. et al. Do autistic children have higher levels of caries? A cross-sectional study in Turkish children. Journal of the Indian Society of Pedodontics & Preventive Dentistry. 2007; 25: 97-102.

****** Jaber MA. Dental caries experience, oral health status and treatment needs of dental patients with autism. Journal of Applied Oral Science. 2011; 19: 212-217.

******* Rhine D. & Tarbox J. Chewing gum as a treatment for rumination in a child with autism. JABA. 2009; 42: 381-385.

******** Orellana LM. et al. Oral manifestations in a group of adults with autism spectrum disorder. Medicina Oral, Patalogia Oral Y Cirugia Bucal. 2012; 17: e415-e419.

---------- Wang YC, Lin IH, Huang CH, & Fan SZ (2012). Dental anesthesia for patients with special needs. Acta anaesthesiologica Taiwanica : official journal of the Taiwan Society of Anesthesiologists, 50 (3), 122-5 PMID: 23026171