Dental Health – a
Neglected and
Challenging Problem for a Patient with
Autism Spectrum Disorder
Abstract 960828
Patients with Autism Spectrum Disorders (ASDs) are at an increased risk for many diseases. However, dental problems are uncommon comorbid for patients with ASDs. Based on the previous studies, the inconsistent result is showed for whether or not ASDs are associated with poor dental health. Nevertheless, we report the case of an regularly visiting psychiatric OPD autistic patient who developed severe dental problem which is neglected for several years, misdiagnosed as psychiatric disease deterioration. despite she followed up regularly. Until now, early recognition is still challenging to managing this unusal condition in patients with ASDs.
1. Introduction
Patients with Autism Spectrum Disorders (ASDs) are at an increased risk for many systemic conditions such as seizures, gastro-intestinal problems, motor anomalies, anxiety, mood disorders, ADHD, and mental retardation [1]; however, they do not usually exhibit any specific dental findings. Severe dental problems are rarely seen in patients with ASDs [2-10, 12]. Here, we report the case of a young adult with ASD who presented with severe dental problems and may be easily misdiagnosed with psychotic disease deterioration that required surgery.
2. Case
This 28-year-old, jobless woman was hospitalized in psychiatric ward of CMUH for recurrent irritability, anxiety, aggressive behaviors, and an exacerbation of compulsions (drinking at least 10L of water each day and repeatedly unrolling toilet paper) for 2 weeks.
As a child, she could not finish compulsory education (junior high school) and has since been unemployed and isolated with no known social contacts outside the family.
Developmental information from her parents and sister, with whom she lives, indicated that she tolerated pain and discomfort, never formed friendships or relationships, and preferred to follow a fairly solitary existence. Further information about her persecutory and referential symptoms indicated that she had always been a rigid thinker, and been sensitive to certain voices to which she responded violently.
She was diagnosed as schizophrenic at the age of 13 on the basis of referential and persecutory ideation, and she had been taking antipsychotic medications since then, but with a history of treatment resistance to various antipsychotic agents, such as haloperidol,
risperidone, olanzapine and quetiapine. She also had a history of type II diabetes mellitus and was medicated for 2 years. During this hospitalization, we noted social withdrawal, poor eye contact, obsessions, compulsions, and hyperactivity with anxiety and restlessness. She spoke in incomplete sentences and showed a tendency for routine and ritualistic patterns such as eating the same kind of fast food. After careful re-evaluation of the patient’s history and the
clinical presentation, we determined that she was an adult with autistic disorder that had been misdiagnosed as schizophrenia.
Ziprasidone, fluoxetine and methylphenidate were administrated and the symptoms of obsession, compulsion and hyperactivity dramatically improved. Nevertheless, her core symptoms of autistic disorder such as social withdrawal, lack of eye contact and interaction with people still remained. Additionally, she began to complaint of oral discomfort. Dental examination on 20110406 was practiced at dental department in CMUH, she was seated on a comfortable chair, under natural light using sterile portable equipments which included mouth mirror, explorer and cotton pellets. It showed multiple residual roots, deep caries with pulp exposure, and gingival inflammation. Nineteen of 28 remaining teeth had caries.
Panoramic x-ray findings revealed deep decay in 12, 18 with pulp exposure, fragile residual roots in 13, 21, 23, 24, 25, 26 and missing in 11, 22, 28. After adequate pain management, her irritability and anxiety were markedly resolved. She then had surgery under general anesthesia for her dental problems. Throughout the patient’s life, she had never visited a dentist or received dental care. She sometimes took an analgesic by herself but never disclosed the reason.
3. Discussion
related behaviors such as communication limitations, personal neglect, self-injurious behaviors, dietary habits, effects of medications, resistance to receiving dental care,
hyposensitivity to pain, and possible avoidance of social contact. Little has been published about the dental health of people with ASDs. As shown in Table 1, the findings have been inconsistent as to whether or not ASDs are associated with poor dental health. Possible explanations for an autistic child having fewer dental problems were good home care, fixed eating habits of less sweet food, and less time for eating due to rituals or compulsive
behaviors [7-9]. In contrast, poor oral hygiene, lack of sensitivity to pain, extensive unmet needs for dental treatment, and side effects of medications have been proposed as
contributions to a higher prevalence of dental diseases [10-12]. There is no general consensus on the issue.
Nevertheless, as shown in Table 1, the variation in the mean number of decayed, missing and filled teeth for patients with ASDs was quiet small and the range was only 1.74 to 3 across these studies. It is rare for a patient with ASD to have such severe dental problems. Our patient exhibited a combination of several factors, including an increased appetite after atypical antipsychotics had been administrated, a lack of limitation of food intake by the family, impaired cognition, dry mouth caused by medications, and indifference to pain, all of which may have increased the risk of development of severe dental problems. Besides, more dental hygienic policy for caring of ASD individuals may be needed. Clinical experience
with dental health in adult autism is still limited because the majority of reported studies in autistic populations have included only relatively young individuals.
From the experience of caring for this patient, we understand that patients with ASDs need more attention paid to their dental and physical health. Evidence-based behavioral
management approaches for children with ASD need to be developed to improve compliance with oral care procedures. We hope that this case discussion may be helpful in the future care of patients with this neglected and challenging problem.
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