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A BETTER UNDERSTANDING OF AUTISM
(Part 1 of 2)

Autism and Autism Spectrum Disorders (ASD) are one of the most common medical conditions pediatricians and pediatric dentists will come across in their daily practice.

According to a new study from the Centers for Disease Control, it is estimated that 1 out of every 110 children will be affected by an ASD. The prevalence has been recorded as high as 1 in 58 in males. Being able to meet the needs of these children has become an ever increasing priority for dentists and other medical professionals.

Autism Facts:

  • Incidence 1 in 110 children
  • Incidence 1 in 88 Military families
  • Reported as high as 1 in 58 in males
  • Average cost of comprehensive treatment program: approx. $6,500 per month
  • Most children do not receive adequate treatment
     

To better treat ASD patients, it is important to first remember that Autism and ASDs are not merely behavioral problems. They are spectrum of neurological and biochemical diseases that result in behavioral manifestations. Patients with ASD generally have difficulties with social interaction. They may act scared or may have separation anxiety at any age, and they may exhibit generally erratic behaviors. Some other noticeable behaviors include limitations in communication. Some patients may be completely non-verbal. Patients may have difficulty relating to others or participating in back and forth conversations, whether verbal or non-verbal. Others may have repetitive or stereotypical behaviors. Patients may be hyper- or hypo-sensitive to light, sound, touch, smell and taste. All these factors have to be considered when caring for patients with Autism and ASD, making general interactions and dental work extremely challenging.

Behavioral Manifestations:

  • Difficulty with social interactions
  • Separation anxiety at any age
  • Generally erratic behavior
  • Limited in verbal and non-verbal communication
  • Difficulty with back and forth communication
  • Some patients may be non-verbal
  • Hyper or Hypo-sensitive to sound, touch, or smell
     

Staff education is vital since they are the first contact for the parents, and it is important for them to be able to communicate effectively with the patient and their caretakers. Knowing some of the "lingo" commonly used in the daily life of these patients will help the communication process. Parents and caretakers commonly use terminology such as IEP, SLP, or NLD (Individualized Education Program, Speech Language Pathologist, and Non-Verbal Learning Disorder, respectively). The list of acronyms and definitions is endless, however, being involved means exposing yourself and your office staff to educational material on a regular basis. The internet is a great resource for educating your staff, and sites such as Talk About Curing Autism (TACA) or Autism Care Today (ACT) are a great wealth of information.

Helpful Information to Obtain Prior to First Visit

  • Child's preferred nickname
  • Inappropriately anxious
  • Patient's mental/social age
  • Inappropriately emotional
  • Fear of noises
  • Lack of curiosity about environment
  • Level of speech
  • Inappropriate laughter or crying
  • Makes sounds or squeals
  • Ignores pain
  • Monotonous speech
  • Does not like to be touched or held
  • Uses inappropriate language
  • Hates crowds
  • Hand/Finger flapping
  • Self stimulation/mutilation
  • Obsession with a toy or a topic
  • Stubborn rituals and routines
  • What is their optimum time of day
     

Each child is different and reacts uniquely to different situations. What works best for one patient may not work for another. Therefore, you can perform some information gathering about your particular patient prior to their first visit by having a detailed phone interview with mom, dad or the caregiver regarding the child's likes and dislikes. Find out what age level the patient functions. For example, an eight year old who functions at a two year old level has different fears and concerns than a child who functions at an eight year old level. This information also becomes important when sedating patients for dental work, especially during the recovery phase. It is also important to find out individual patient pleasures and enjoyments, as such things may be used during the treatment, in order to keep patients cooperative. Some patients enjoy music or television, and that may serve well to distract them. For others, the sound of music or television may make them agitated. Knowing this information beforehand may help guide your therapy, and provide a smooth transition into and out of the dental chair.

In our next newsletter, we will discuss how to get your office and your staff prepared for the family's first visit, and what techniques to use to treat children with Autism and ASD. We will touch upon such subjects as distraction and imagery.

PROPOFOL

Stay Ahead of the Curve

The recent recall of the popular pharmaceutical and anesthetic agent, Propofol, has left the medical and dental world scrambling to increase their inventory, in fear of a shortage, and forcing some to use recalled medications.

The recall occurred in the factory where some batches were found to contain particulate matter. These particulate matters do not dissolve in blood, leading to emboli and culminating in stroke, cardiac and respiratory failure, kidney and liver failure, and death.

Most manufacturers, such as Hospira and Teva have completely stopped the production of Propofol. Presently, the demand far outweighs its production.

We share your care and concern for our patients. We urge everyone to follow the manufacturer's recommendation and return all affected bottles. This shortage did not affect our ability to provide superior anesthesia, since we can easily provide a Propofol-free anesthetic, if need be. If you have any questions or if you want additional information regarding this matter, please feel free to contact our office at 949.367.0800.

FIRST PUBLIC DEMONSTRATION OF ETHER

More than one hundred fifty years ago, on an autumn day, in the operating theatre on the top floor of Massachusetts General Hospital (MGH) in Boston, one of the greatest moments in medicine occurred. It was October and the operating theatre was cold and dark.  The only light was the sunlight coming through the ceiling shutters, which were mechanically adjusted with the help of pulleys.  The floor of the operating theatre was small and circular, about ten feet in diameter.  The wooden benches surrounding the theatre floor formed steep amphitheater-like seating.  The top row had uncomfortable bicycle style seats for late arrivals.  But, every seat had a perfect view of the floor of the theatre.

On October 16, 1846, William T.G. Morton, a Boston dentist, walked into this operating theatre and changed the face of surgery, anesthesia and medicine forever.  He was the first to demonstrate the use of ether, as an anesthetic, during surgery.  Prior to this day, surgery was typically an exceedingly noisy affair, punctuated by blood-curdling screams. This operation was conducted in silence.  That day ended the indescribable pain, and the overwhelming dread, that had previously been associated with surgery.

Morton was born in 1819 in Charlton, a village in Worcester County, Massachusetts. He had a common school education, and he had tried his hand as a printer, a clerk, and a salesman.  As a youngster, he had suffered through an operation without anesthesia, and he experienced, first hand, the pain associated with such surgery.  In 1840, Morton enrolled at the world's first dental school: Baltimore College of Dental Surgery. Shortly thereafter, he left without graduating, and he became a student and then business partner of Hartford dentist, Horace Wells. The partnership was not a great success, and dissolved after six months.

Morton persisted with his dental practice, curious to find pain relief during surgery. He experimented with opioids and stimulants, however, neither one was able to successfully relieve the pain of surgery.  Later, he experimented with ether on himself and various animals.  He successfully performed a dental extraction in his office, which led to a favorable article in a Boston newspaper, and an arrangement with the Chief MGH surgeon, Dr. John Collins Warren, to stage a public demonstration of this yet "unknown" chemical.

The patient was Gilbert Abbott, a 52-year-old printer who had come to the MGH for treatment of a vascular tumor on his jaw. At the pre-set hour, Dr. Morton was nowhere to be found, and Warren almost started the procedure without him.  Dr. Morton arrived at the last minute, and using a specially designed glass inhaler containing an ether-soaked sponge, he administered the anesthetic to Abbott.  After several minutes, Abbott was rendered unconscious. Dr. Warren then surgically removed the tumor. Upon awakening, the patient informed the curious and skeptical doctors and students in the theater that he had experienced no pain and had no memory of the procedure.

News of the discovery of ether soon reached around the globe and a new era of medicine began. Within months, it was hailed as "the greatest gift ever made to suffering humanity."  Dr. Morton's commitment and innovation opened the field of surgery beyond anyone's imagination.  

Shar Alikhani M.D.
Dr. Shar Alikhani, Founder and Director of Pediatric and Dental Anesthesia Associates is a Board Certified Physician Anesthesiologist who is fellowship trained in Pediatric Anesthesia.  Dr. Alikhani completed his anesthesia and critical care residency at Massachusetts General Hospital and Harvard Medical School, where he served as Chief Resident and as a clinical faculty member. His postgraduate training includes a fellowship in Pediatric Anesthesia at Children's Hospital in Boston. With more than ten years experience at a major trauma center, he is now devoted to the safety and comfort of children during outpatient procedures. He brings a wealth of experience and information in applying hospital standards to management of patient care in your office. You can find out more information at www.DrShar.com. 

THE ART OF TAKING CARE OF PATIENTS WITH AUTISM

(PART 2 OF 2)

Providing dental care to patients with autism requires patience and modification of skills we use on a daily basis. Our first article on autism and autism spectrum disorders (ASD) focused on the etiology and diagnosis of these disorders. We also discussed tips on how to get the staff and office ready for that most important first visit. Lastly, we reviewed specific questions to ask the caretaker prior to the first visit in order to familiarize oneself with the patient, their likes and dislikes, and also their fears and habits. (Please call or email our office if you would like a copy of part 1 of this article) In this issue, we will discuss some practical aspects of care in the office setting.

First Visit
Plan the first appointment for patients with autism or ASD as a desensitization visit. Schedule them during a quiet time for the office, and place them in a private examination room away from the busy areas. To accommodate the child, it helps to find out, prior to the visit, the preferred time of day for each particular patient. This initial visit will help the patient become familiar with the office, the equipment, and the staff. A simple show and tell approach usually works best. Sometimes, just getting patients to sit in a dental chair may be a challenge. If multiple office visits are needed, try to use the same room and staff. Remember the first exam may be a cursory visual exam, and using a familiar object such as a toothbrush will be help the patient relax.

Light
A general detail to anticipate beforehand is patients with autism may be sensitive to light. It is important to keep the lighting consistent throughout the office. If possible dim the lights of the office and the procedure room because walking from a dimly lit room to a bright examination room may render the child uncooperative, even before the exam starts. Also, make sure the exam light is not shining directly in the patient's face. This bright light can also startle the patient and cause a difficult office visit.

Sound
During a dental examination, a quiet environment is best; however, some children with ASD are mesmerized by television or music. If this is the case, then make it an advantage and provide a familiar movie or music for the patient. The number of loud noises should be kept to a minimum. If parents are present, make sure they turn their cell phones off and avoid unnecessary conversation. Turn on each instrument individually so the child can see what each instrument does and get acclimated to the sound. Also, remove clutter in the office and decrease any possible distractions, which may make the child anxious. Let children and parents know what you will be doing. Your movements should be gentle, monotonous, and consistent. Sudden movements may startle the child.

Smell/Taste
Children with ASD may get agitated by the powder or scents on some gloves. After putting on gloves, rinse hands with water or use a wet gauze to clean the gloves off. If using scented gloves, make sure to do a smell test prior to starting the exam to make certain the child likes the scent.

When to Stop
If the child or parent gets restless or uncooperative, it is time to end the session and continue at the next appointment. Each visit should end on a positive note. Positive reinforcement such as an age appropriate toy is an excellent reward. Make certain to provide clear and accurate information for the child and parent for the period between visits.

Homework
Consider giving parents some homework to do for the next session. Flossing kids can be rewarding for parents and children. One method of flossing children and desensitizing them for dental visits, is for parents to sit on the floor or on a bed and for the child to lay supine in the their lap. Flossing from this angle will help children get accustomed to having their mouth examined. Since this approach is similar to the dentist's approach, if performed daily, it may get children more accustomed to having dental procedures.

Repetition
It may be necessary to repeat these steps over several appointments to familiarize patients and build trust to perform a complete dental exam. Working with the families and caretakers on this process will build a stronger relationship. The extra steps are well worth the rewards, as it will build a foundation for good dental care and oral health in this difficult to treat population. I hope we can make a difference together.