Individuals with autism can be quite challenging to treat in a routine dental-office setting, especially when extensive dental treatment and disruptive behavioral issues exist. Individuals with autism may also be at higher risk for oral disease. Frequently, general anesthesia is the only method to facilitate completion of the needed dental treatment. General anesthesia is not without complications, and unique occurrences are a necessary consideration for special-needs populations. In addition, behavior challenges may occur which can be disruptive to hospital staff. This article describes treatment needs and determines adverse events during the perioperative period for individuals with autism who have had general anesthesia for comprehensive dental treatment in the hospital.
Patients with autism can present quite a challenge in the dental office (Friedlander, Yagiela, Paterno, & Mahler, 2006; Green & Flanagan, 2008). Individuals with autism can disrupt the regular routine of the dental office, which may be unsettling to some dentists. These behavioral challenges could cause harm to patients, clinicians, or staff if treatment is attempted without general anesthesia. Parents or caregivers may be reluctant to take people with autism to the dentist's office out of fear of rejection or an embarrassing incident related to behavior. Locating providers who are capable of transitioning pediatric patients with autism to general dentistry practices that care for adults with special needs can be especially difficult (Nowak, Casamassimo, & Slayton, 2010). There are numerous behavior and sensory issues which make it difficult for parents and caregivers to assist individuals with autism in simple toothbrushing and flossing. One study reported that 12% of children with autism had unmet dental needs. The main barriers were the child's behavior, cost of dental care, and lack of dental insurance (Lai, Milano, Roberts, & Hooper, 2012). As a result, there are significant barriers to oral health care for these individuals.
Autism is not associated with any specific dental problems; however, because of behavior factors, diet choices, food rewards, and medications that cause xerostomia, individuals with autism are frequently at high risk of caries (Marshall, Sheller, & Manci, 2010). Respondents in one study demonstrated that 30% of children with autism had either never visited a dentist or not visited one in the past year. Many of these respondents indicated that they were unable to find a dentist willing or able to work with patients with disabilities (Brickhouse, Farrington, Best, & Ellsworth, 2009).
Despite the fact that children with developmental disabilities are at a higher caries risk than are children without these disabilities, it is interesting to note that the studies for children with autism are quite mixed. Two studies have shown that these individuals tend to have a lower caries rate (DeMattei, Cuvo, & Maurizio, 2007; Loo, Graham, & Hughes, 2008). However, the presence of plaque is consistently high in oral assessments of children with autism (DeMattei et al., 2007). Other studies have shown a higher caries prevalence, poor oral hygiene, and extensive unmet oral-health needs (Jaber, 2011; Lai et al., 2012). The majority of children with autism in Jaber's study (2011) had poor oral hygiene, and almost all had gingivitis. Also, the percentage of decayed, missing, and filled teeth increased with advancing age. In this study group, 77% of the children had dental caries.
Individuals with autism may require advanced behavior-management techniques, including pharmacologic agents. When the treatment needs are extensive and the individual highly resistant to dental care, general anesthesia is frequently necessary. Parents of children with intellectual disabilities tend to have a greater acceptance of general anesthesia for dental treatment when the child is older and when the child has a previous experience with general anesthesia (Borges Oliveira, Martins Paiva, & Almeida Pordeus, 2007). Although general anesthesia performed in the proper environment is regarded as safe, there are risks associated with it (Messieha, 2009). Some of these risks may be unique to patients with special needs. Certainly, general anesthesia should only be considered after other behavioral interventions have been attempted and found unsuccessful (Dougherty, 2009).
In an attempt to determine adverse events during the perioperative period, this article will look retrospectively at individuals with autism who have had general anesthesia for comprehensive dental treatment. All of the patients were treated by a single dentist in clinical practice in the operating room of a local community hospital.
This research was reviewed and approved by the Research Review Board, Adventist Midwest Health AMH 2012-12 (1220121294). Patient charts were reviewed retrospectively from the author's dental practice and hospital record in which the individual had a primary diagnosis by a physician of autism and required general anesthesia for comprehensive treatment. The chart-review period included 50 dental records in which patients had dental treatment in the hospital operating room between April 2010 and July 2012. All patients treated during that period were included in the review.
The dental practice can be described as a private general-dentistry practice; about half of the active patients have been diagnosed with an intellectual and/or developmental disability. The office is able to provide appropriate behavior guidance and sedation techniques as well as treatment under general anesthesia in the hospital. Patients are referred by group homes for people with developmental disabilities, by community-service organizations, and by individual families. Patients were treated in the hospital due to extensive treatment needs and behavioral challenges that would make it impossible to perform dental care in a routine office setting.
The anesthetic technique was similar for each patient, as the anesthesiologists were members of the same practice group and had over 10 years of experience working together. Preoperative sedation to facilitate IV placement was necessary with 60% of the patients studied.
Demographic data included gender, age, and physical status. The American Society of Anesthesiologists (ASA) physical-status classification was determined by the attending anesthesiologist at the time of treatment. The classification is as follows:
ASA 1: Normal healthy patient
ASA 2: Patient with mild systemic disease
ASA 3: Patient with severe systemic disease
ASA 4: Patient with severe disease that is a constant threat to life
ASA 5: Moribund patient who is not expected to survive without the operation
In addition, the coexistence of various comorbid conditions was reviewed. Since these patients were receiving dental treatment, they all had a diagnosis of dental abscess and/or dental caries as well. The type and frequency of various dental procedures were tabulated, along with the time under general anesthesia. Complications during the perioperative period were also tabulated. The perioperative period was defined as the period from the initial admission to the hospital to the time of discharge from the hospital, including the time during which the patient was under general anesthesia and receiving dental treatment. If any additional complications or comments were recorded in the dental chart, these were noted for reporting in this study.
Tables 1 and 2 display the demographic, procedural, and diagnostic results. The male-to-female ratio was 4.5∶1, about the same as that reported in many autism studies. The mean age of the patients treated was 22 years old, with a range of 5 years to 57 years. The majority of the patients had a physical status of ASA 3, with a range of ASA 1 to ASA 4. Only one patient was given an ASA rating of 4 by the anesthesiologist; this individual had an unstable seizure disorder. Patients were under general anesthesia from 1 to 4 hr, with the mean being 2.46 hr. Of note is that all four of the patients requiring 4 hr under general anesthesia were over 40 years of age. There was also a trend for older patients to require more time under general anesthesia.
Extensive restorative dental treatment was carried out on these patients. A mean of 3.4 restorations were required to rebuild the decayed teeth. The number of restorations ranged from zero to 13 (just one of the patients had 13). Three patients underwent root-canal treatment and two patients had a tooth prepared for a crown. The impression was made in the operating room for the dental laboratory to fabricate the crown. The crowns were cemented in the dental office.
A total of 147 permanent teeth and 32 primary teeth needed to be extracted. Per patient, this came to an average of just over four teeth per individual. One adult required 21 teeth to be removed and one 9-year-old child required 10 teeth removed. Six patients required more than five teeth to be extracted and two of the adult patients required all of their remaining teeth to be removed.
Periodontal treatment was considered present when the patient required more than a simple dental cleaning. These individuals had significant bleeding present upon probing of the gingival tissues, moderate to severe amounts of tartar, and heavy plaque accumulations. Of the 50 patients, 30 required periodontal treatment, representing 60% of the individuals requiring treatment under general anesthesia.
A codiagnosis of seizures was present in eight (16%) of the patients treated. Two patients had Down syndrome and one was diagnosed with fragile X.
Table 3 describes the complications during the perioperative period. The most frequent challenge was excessively disruptive behaviors. These behaviors included ones requiring significant physical restraint and needing multiple persons to administer a sedative medication, and ranged to more physically violent behaviors such as spitting, kicking, or running from the day-surgery patient room. One patient required hospital security to escort him to the treatment area. Another patient got off the bed in the recovery room and attempted to leave the area.
An unusual rash appeared shortly after two patients awakened from general anesthesia. The rash was apparent on the face, torso, and upper extremities. It did not appear to affect the patients in any way and resolved within an hour.
Delayed discharge occurred for six patients. Postoperative nausea and vomiting occurred in three patients. Two patients pulled at the surgical sites, causing excessive postoperative bleeding. One patient required admission due to postoperative seizures. The traumatized uvula did not delay discharge.
It should be noted that all individuals were intubated orally. This route was chosen to minimize postoperative discomfort and minor risk of nosebleed. It is the author's experience that this can be very difficult to manage, considering the hypersensitivity traits of individuals with autism.
Not noted in Table 3, but noted in the patient chart, is that one patient chewed on his lip while it was still numb from the local anesthetic and returned for examination the following day with a swollen and ulcerated lip.
Also of interest is that three of the patients presented with a history of self-injurious behaviors such as head banging, mouth punching, biting, and physical violence toward other individuals, which resolved following the dental treatment. One individual also demonstrated physical violence toward other individuals, which also resolved.
General anesthesia is a safe and necessary procedure for patients with special needs (Messieha, Chelva Ananda, Hoffman, & Hoffman, 2007). The dental treatment of young children under general anesthesia considerably improves their quality of life related to oral health (Gaynor & Thomson, 2012. Treating children's dental disease also results in improvements for the family. Areas such as sleep disruption, greater attention requirements for children, parents' having to take time off from work, and interpersonal conflict are all affected (Thomson & Malden, 2011). Parents have also reported that their children brush their teeth more frequently and eat less sugary foods (Amin, Harrison, & Weinstein, 2006). Overall, relatives and caregivers of patients with intellectual challenges who are undergoing general anesthesia for comprehensive dental care are quite satisfied with this type of service (Escribiano-Hernandez, Garcia-Garraus, & Hernandez-Garcia, 2012).
Disruptive behaviors are the most frequent complication when treating patients with autism in the hospital. These individuals may exhibit behaviors which can escalate into situations that make it impossible to provide treatment. This would be expected, as these individuals often exhibit disruptive behaviors when faced with treatment in the dental office. One might say that it is inappropriate to classify behavioral challenges as complications, since these are commonly observed in patients with autism. However, when behavioral challenges are so disruptive, certain hospital staff may be unwilling to care for these patients. This could even lead to a professional bias against developmentally disabled patients who require comprehensive dental care.
Anxiety is common for any individual undergoing a procedure in the hospital. For patients with autism there are numerous sensitivity issues as well. Keeping patients distracted and accompanied by trusted family members or caregivers is often helpful. Antianxiety medications can also be of use in helping patients manage their fears. Giving the family visual materials to help patients understand the procedural steps during the process of entering the hospital may also be of use. The hospital staff must be understanding and versed in behavior-management techniques to ensure the most positive experience possible. Dental providers should also comanage these patients, while they are in the hospital, with the nurses and anesthesiologists.
Postoperative nausea and vomiting is especially challenging in individuals who have communication difficulties. It not only is uncomfortable but can cause aspiration pneumonia or dehydration. Of the patients in this study, 6% experienced postoperative nausea and vomiting. This is consistent with other reports. In one study of 231 individuals with mental challenges who underwent general anesthesia for dental treatment, 5.6% experienced postoperative nausea and vomiting. No serious complications were observed in any case (Yumura, Nakata, Miyata, Ichinohe, & Kaneko, 2011). Another study of children receiving dental treatment under general anesthesia found that 16% were reported to vomit (Mayeda & Wilson, 2009). Only 4% of patients experienced nausea and vomiting in a third study (Boynes, Lewis, Moore, Zovko, & Close, 2010).
In discussing informed consent, the potential for postoperative complications must be reviewed. Patients can be at increased risk for seizure due to stress, dehydration, and some anesthetic agents. Biting or chewing on a lip that is numb from anesthesia must be discussed for any patient who has dental treatment. Bleeding is a consideration for all surgical procedures. A sore throat, though usually mild, is a possible complication associated with endotracheal tube placement. In this case review, the ulcerated uvula was an unusual complication. The importance of pretreatment discussion of the possibility of these occurrences is essential for proper communication between the patient, family, and clinician.
The occurrence of a postanesthesia rash that resolves on its own within an hour is also unusual. In this group of patients it was seen twice. Both of these patients were adolescents. This has not been reported specific to individuals with autism in the literature, except in the case of allergic reactions. General anesthesia can result in a significant challenge to the body's biochemical pathways (Rankin, 2009). The unique metabolic problems that people with autism often have may explain this type of rash.
The limitations of this study first relate to the number of patients. As the number of patients studied increases, additional postoperative complications may be found. In addition, this particular team of dental personnel, anesthesiologists, and perioperative nursing staff has worked together on over 200 occasions, treating a variety of individuals with developmental disabilities over the time period studied. The experience gained may contribute to the relatively low number of perioperative complications.
Further research could look at the need for medications for preinduction or for facilitations of IV-line placement. Additional reviews could study behavior complications requiring additional pharmacologic agents to safely manage the patient.
For individuals with autism, complications in the perioperative period are generally similar to those for any individuals undergoing comprehensive dental care under general anesthesia. There are some unique occurrences, however. Many of these relate to communication issues, both before and after the patient is under general anesthesia.
This article also shows that dental-treatment needs for patients with autism can be extensive. One might conclude that the number of teeth requiring extraction seems high. This statistic demonstrates the difficulty that oral-health providers have in providing adequate preventive care to individuals with behavior challenges. Poor oral health can adversely affect overall systemic health. The presence of oral infections may be life threatening. Loss of teeth can be a detriment to good nutrition. These individuals required costly treatments and coordination of case managers, caregivers, and hospital and dental personnel to eliminate their oral disease.
The resolution of self-injurious behavior after dental treatment in a small number of the patients has implications for the management of this activity. Dental pain should be considered early on as a potential cause of any recent onset of self-injurious behavior. It is incumbent upon both oral-health and mental-health professionals to partner together to ensure that these individuals are receiving preventive care to reduce the potential for dental pain.
Just as children should begin behavioral and biomedical interventions at an early age, so should parents and children be taught the importance of proper oral care. This may need to be part of sensory therapies or be included in the individualized education program. The importance of early preventive treatment cannot be overemphasized.
Editor-in-Charge: Glenn Fujiura
Robert E. Rada (e-mail: email@example.com), University of Illinois, Oral Medicine and Diagnostic Sciences, 1415 West 47th St., LaGrange, IL 60525, USA.