The relevance of autism in orthodontic management

Autistic spectrum disorder

Autism is a common developmental disorder that can prove to be a barrier to dental treatment due to challenging behaviour management. Autism originates from the Greek word ‘autos’ meaning self and was first described in 1943 by Dr Leo Kanner. He studied children that appeared to have an inborn developmental disorder that affected emotional and social understanding.¹

In 2009, the National Centre for Social Research estimated that 1 in 100 children suffer from some form of autism under the umbrella term of Autism Spectrum Disorder (ASD). In 2001, there were over 13 million children; we can therefore estimate that there are approximately 133,500 children affected by ASD in England.²

Clinically, the presentation can vary dramatically from child to child. Currently, ASD includes Asperger's syndrome, pervasive developmental disorders not otherwise specified and classic autism. The differentiating features are displayed in Figure 1.³

There are common traits that exist in a child's ability to socialize and interact throughout the spectrum. This is commonly identified in the first two years of his/her life. Children may not respond to their own name, maintain eye contact and there may be a lack of a response to social stimuli. In later years, the clinical presentation of autism can be more apparent due to a delay in development of language and social skills.⁴ These signs and symptoms that may appear at a later age are summarized in Figure 2.⁵

With regard to dental disease, ASD children do not show a significant predisposition to it. However, active periodontal disease can be easily attributed to poor oral hygiene and this can be linked to the fact that brushing and oral hygiene regimes may involve unpleasant stimuli that act as a deterrent. More importantly, the understanding of ASD children of the significance of oral hygiene is poor, leading to a lack of motivation.⁶ Therefore, orthodontic treatment may be contra-indicated owing to poor understanding of the importance of maintaining oral hygiene.

Studies have indicated that higher orthodontic malocclusion rates may exist in ASD individuals compared with control groups. Luppanapornlap et al carried out a randomized control trial comparing 8–12 year-old autistic Thai children with a control group in regards to periodontal health and dental malocclusion. They excluded patients that had received orthodontic treatment. They found that, ‘children with autism showed missing teeth, spacing, diastemas, reverse overjets, open bites and Class II molar relationships in a higher percentage than non-autistic individuals'. It was suggested that it was due to self-inflicted behaviours, such as pica eating (appetite for non-nutritive food substances) or thumb sucking.⁷ Furthermore, Planefeldt and Herrstrom assessed differences in Swedish autistic children aged 3–19. Although it was a small sample, there were no significant differences in malocclusion rates between ASD and control groups. It was stated that there was a higher demand for orthodontic treatment by parents of autistic individuals but the reason why was not investigated.⁸

Autonomy and consent

The clinical need that exists must be carefully balanced with the desires of the patient and parents. In medicine and dentistry, autonomy is one of the fundamental ethical principles that must be upheld. It provides the patient with the opportunity to choose a treatment modality that coincides with his/her wishes. Furthermore, it is important that this is undertaken in a spirit of free will without coercion or influence.⁹

In 1990, the Department of Health provided an advice sheet on obtaining consent. It was defined as:

Under English law, one is considered competent and an adult at 18 years of age. In regards to 16-year-olds receiving medical and dental treatment, section 8 of the Family Law Reform Act 1969 allows their right to consent. It states that:

Under 16s that are not competent have consent undertaken via proxy. Under law, the biological mother, the child's legally appointed guardian or the courts have the power to do so. A child's father who is not married to the mother at the time of birth or conception and who has not married her subsequently cannot, in law, give legally binding consent for the child, unless he has obtained a parental responsibility order via the court system. However, children born after the 1st December 2003 can have consent undertaken by an unmarried father only if his name is present on the birth certificate.¹²

Mental Capacity Act

The Mental Capacity Act 2005 provides a framework in which it aims to protect individuals that lack capacity or may do so in the future. A summary of the basic principles underpinning the act can be found on the UK government's legislation website.¹³

As a result of the enforcement of the Mental Capacity Act in 2007, the Department of Health revised its guide to consent in 2009 to aid the clinical professional in obtaining consent. The DoH incorporated the main principles of the Mental Capacity Act and also described in depth the importance of providing valid consent. In addition to this, it is stated that the patient is assumed to have capacity unless proven otherwise. An individual at a specific time of making a decision must understand the information given, retain it for a period of time and fully communicate his/her decision after considering the information in a thought process.¹⁴ In summary, it is essential to ascertain the views and opinions of all involved after sufficient information has been given.

Nevertheless, can we restrict orthodontic treatment in autistic patients owing to their difficulty with behaviour management?

Becker et al discussed that autistic individuals may find it difficult to ascertain a need for orthodontic treatment. Their perception of dento-alveolar anomalies is poor and their capacity may be in question. Although this may be true, we must not deny individuals orthodontic treatment. In the absence of other significant factors, the denial of orthodontic treatment would be unjust.¹⁵

Balancing the need for orthodontics

We must carefully balance the indications for treatment and the patient's needs. The index of treatment need (IOTN) is utilized in England and Wales to assess whether patients are eligible for NHS orthodontic treatment. Furthermore, it is an objective method of considering the orthodontic need of an individual.¹⁶ In addition to this, the aesthetic component scale supplements the IOTN with a visual component. This attempts to assess the psychosocial impact of aesthetics thus aiding the clinician in the decision process.¹⁷ There are no studies available that discuss the autistic patient's perspective and the psychosocial impact of his/her malocclusion. This may be due to the difficulty in interpreting and understanding social norms. Becker et al assessed motivation and satisfaction of orthodontic treatment in disabled children and discovered that they could recognize an improvement in their malocclusion. It may be concluded that, even though orthodontic treatment in this group does not affect social influence, the individual benefits may be great.¹⁸

Clinical experience suggests that well aligned dental arches aid in reducing the risk of caries and improving tooth cleansing. It has been determined, however, that motivation and dental hygiene play a bigger part in maintaining hygiene.¹⁹ Orthodontic treatment may also reduce the risk of trauma in teeth as patients with prominent incisors of more than 9 mm have a 45% increased risk of trauma.²⁰ Treatment can have a significant psycho-social impact on a child's social life. Shaw et al ascertained that a child's dental aesthetics caused the most distress compared to items such as clothes or their weight.²¹

In principle, the aim of orthodontic treatment is to ensure a functional and aesthetic result is achieved. Patient compliance plays an important role in successful outcomes. Therefore, careful consideration must be taken in regard to planning treatment. It should be comprehensive, limited or provide no treatment at all for patients with ASD. An example of an autistic patient who is having comprehensive treatment with temporary anchorage devices (TADs) can be seen in Figure 3.

The pharmacological management of autism spectrum disorder individuals for other dental treatment is common but impractical for periodic orthodontic treatment visits.²² When the pharmacological agent wears off, the patient may find it difficult to cope with the appliance. In addition, non-pharmacological behaviour management of ASD patients can be demanding for a clinician not regularly exposed to such individuals.

Behaviour management

There are many different non-pharmacological techniques that have been utilized to help facilitate treatment outcomes. To ensure the ASD patient is comfortable, it is preferable that he/she is given the first appointment of the day. This is to ensure that there is a reduced waiting time and to minimize disruption to his/her normal daily pattern. In regards to assessing compliance, it is important to gain information from an accompanying parent or guardian.²³ We can gain an insight into the patient's previous dental history, compulsive behaviours and history of heightened sensitivity to stimuli by producing a simple questionnaire (Appendix A).

Building rapport with ASD patients

Communication is important in gaining rapport and therefore compliance. In ASD patients, interaction is complicated by the diminished capacity of social interaction. There is reduced eye contact and patients can take the meaning of expressions literally. For example, when asking an autistic patient ‘to take a seat’ he/she may attempt to pick up the chair rather than sit on it. Furthermore, he/she can also present with echolalia. This is defined as the automatic repetition of sounds made by someone else.²⁴

It is well documented that ASD individuals follow inflexible daily routines that play an integral part in their life to aid in coping with the environment. As a result, patients may find it uncomfortable to be exposed in a new setting, such as a dental clinic, with a large number of unpleasant stimuli. A basic exposure therapy to the dental environment which has been proven to acclimatize such patients effectively is ‘Tell-show-do’. This visual form of communication can be an effective means of improving the interaction process. Morisaki et al developed a structured visual guide based on the ‘Tell-show-do’ principle.²⁵ It primarily consists of a storyboard with a series of pictures that acclimatize the autistic patient to dental treatment. It is discussed at home repeatedly to reinforce the stages of treatment and brought to the dental appointment. This technique can easily be introduced into orthodontic treatment. The dental environment, staff, orthodontic equipment and simple procedures can be exposed to the autistic patient using the structured visual guide (Figure 4).

In addition, there are available language programmes that can improve the communicative process of the storyboard. A popular programme used for ASD patients is Makaton. This was developed in 1972 when research was undertaken on institutionalized patients that were deaf and cognitively impaired. It was noticed that behaviour and communication improved. This has developed into approximately 4500 published core concepts.²⁶Figure 5 shows an example of Makaton symbols utilized for a dental setting taken from the Makaton dental book. The method of presenting symbol sentences in this way is widely accepted as good practice with individuals with a known visual learning preference.²⁷

Distraction techniques relevant to ASD patients

Distraction techniques are often utilized to avert the attention of the patient in order to reduce the sensation of unpleasant stimuli. There is a variety of methods available which include conversation, games, toys, pictures, music and videos. In regards to autism, it can be difficult to incorporate distraction techniques to aid in compliance. This is due to the possibility of introducing stimuli that can overwhelm the autistic patient.²⁸ On the other hand, it has been shown that television and video-game use in ASD patients is significantly high. Mazurek and Wenstrup state that, compared to typically developing siblings, children with ASD spend 62% more time watching TV and playing video games.²⁹ Using compulsion behaviour to distract the patient during treatment has been implied.

There has been literature to show the value of audio–visual distraction techniques, particularly in children and anxious patients. A child's favourite television show or movie can be placed on a screen for his/her attention to be averted during treatment. The audio may also dampen sounds of dental equipment, masking their significance. In addition, audio-visual methods aid in focusing the attention of the patient away from the periphery and isolating them from the dental environment.³⁰

In comparison to other distraction techniques, such as music; audio-visual methods have been suggested as being more effective. Prabhakar et al focused on the effectiveness between audio-visual and audio distraction. Using physiological markers of anxiety (pulse rate and oxygen saturation) and anxiety scales, they concluded that audio-visual distraction was more effective in managing anxious patients.³¹ In a recent split mouth study undertaken by El Sharkawi, 48 children undertook treatment for bilateral mandibular primary molars with and without audio-visual distraction. Children had been randomly assigned to receive the audio-visual glasses at one visit and no distraction during the other visit. Two different pain assessment scales were used: the pain faces scale (PFS) and consolability scale (FLACC). It was shown that audio-visual glasses were effective in reducing pain when undertaking dental injections.³²

Head mounted displays (HMDs)

HMDs were introduced in 1996 and are display devices that can be worn. With the emergence of wireless networking and technological advances in electrical miniaturization, HMDs can be utilized as an effective distraction technique in a dental setting. According to new market research undertaken, the HMD field is expected to reach approximately $4478 million by 2017, with a compound annual growth rate of 60% from 2012 to 2017. The demand for HMDs rising at this rate can be attributed to improved user experience, connectivity to content and the rise in video-gaming and augmented reality. Currently, there is an enormous selection of HMDs on the market.³³ Although this is true, an internet search revealed that there are only a select few manufacturers that advertise the use of their HMDs in dentistry (Table 1).

Generally, these devices are HMDs that are small, simple to use and have a high connectivity to multiple formats of media. There are a number of important attributes one must consider when purchasing a HMD. As the HMD is worn by patients, it is important to adhere to cross-infection protocols. All manufacturers advise that no alcohol should be utilized to disinfect the lens as it may affect its longevity. It is recommended that a detergent on a dry wipe be used. In regards to the ear pieces, the ear bud foam pieces can be simply replaced between each patient.

The use of cables to provide media input for the HMD may not abide with legislation set out in the Health and Safety Act 1974. Slips and trips relate to over a third of all major injuries reported and therefore it is suggested either to limit or cover them.³⁴ The majority of HMDs can accommodate connections to mobile phones and memory cards, which are safe and do not introduce a risk, but one must advise caution in regards to attaching power cables or video-game systems when using the HMD on the patient (Figure 6).

Although this is true, we must advise a word of caution. Specific HMD models may not provide sufficient eye protection and may require additional personal protective equipment. Finally, the use of HMDs in ASD patients that suffer from epilepsy caused by flashing images should be avoided.

Conclusion

Clinicians should not assume that orthodontics is contra-indicated for autistic patients. There are novel techniques available to improve patient management to be able to provide simple treatment. However, we must assess each case on its merits. There is a paucity of data for evidence-based practice in managing ASD patients. More research in non-pharmacological behaviour management techniques utilized in orthodontics and dentistry is needed to aid decision-making for the clinician.