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This article offers an overview of current indications and applications of minimal and moderate sedation when treating a child with autism spectrum disorder (ASD). Children with sensory modulation difficulties — such as ASD, attention deficit hyperactivity disorder or a sensory processing disorder — may have difficulty filtering nonessential sensory information. Consequently, they often cannot cooperate in the dental environment. Fortunately, appropriate use of oral sedation can make these patients more receptive to treatment.
Compared to pediatric oral care under general anesthesia, using a combination of nonpharmacological behavior guidance and minimal or moderate sedation (with active or passive immobilization when needed) may offer access to safe and less costly dental services to this patient population. With the goal of safe and effective care, this paper will also present a case that illustrates the decision-making process when choosing one behavior guidance technique over another.
Advanced behavior guidance techniques may be necessary for provision of efficient and effective dental treatment for children with special health care needs.1 Presently, parental/caregiver acceptance of dental sedation and general anesthesia has become more favorable.2–6 White et al6 discovered that many parents/caregivers consider sedation as an appropriate treatment option.
However, sedation appointment approval was correlated with misconceptions. These misconceptions assumed the child would sleep throughout the treatment (82.6%) or the child would be awake, but sleepy (73.2%). Only 54.5% of caregivers were willing to agree to a scenario of a crying child who moves slightly, yet the dentist still manages to repair the patient’s teeth. Moreover, the majority of caregivers thought the purpose of sedation was to repair their child’s teeth in one visit, and that the dentist should not have to use protective stabilization.6 Patel et al7 found that most caregivers rated oral sedation and general anesthesia higher than active or passive immobilization. The acceptance of various behavior management techniques — including the more “aggressive” ones — was related to previous experience, pain/urgency, the perceived need of treatment, cost, and need for multiple appointments.5,7
Some uncooperative preschool-age children with disruptive behavior may have undiagnosed developmental delays. Szczepaniak et al8 reported that children with uncooperative behavior are four times more likely to be at risk for developmental delays, and referral for professional assessment should be considered.
PREVALENCE AND ETIOLOGY
As a neurodevelopmental disorder, ASD represents a substantial burden for individuals, families and society. Surveys have reported a steady increase in ASD prevalence in U.S. children over the past two decades. Changes in nonetiological factors, such as diagnostic criteria, public awareness and referral, as well as in etiologic factors, including genetic and environmental risk factors, have been postulated to account for the previously observed increase in ASD prevalence. In a large, nationwide population-based study, the estimated ASD prevalence from 2014 to 2016 was 2.47% (3.63% in boys and 1.25% in girls) among U.S. children and adolescents.9
The etiology is mostly unknown. Patients with certain genetic syndromes, such as Down syndrome, tuberous sclerosis and fragile X, have a higher propensity for ASD. Environmental factors, including stress, pesticide exposure, prematurity, increasing parental age, and maternal autoimmune disorders, were also suggested to have some influence on occurrence of ASD.10,11
The most common characteristics of autistic behavior are impairment in social interaction and/or communication, stereotypic repetitive behavior or restricted interests, impairment in sensory processing, anxiety, and dyspraxia.10,11 Early signs of ASD are lack of response to name (the patient may act as though deaf), absence of a social smile, and no pointing, gesturing or babbling by age 1. When the child does talk, he or she uses language without social intent.10
Frequently, reported behavior patterns include a lack of eye contact, an inability to read facial expressions, and difficulty with appropriate peer interactions. Approximately 40% of these patients are nonverbal. Others may exhibit delays in acquisition of language skills, and nearly 70% are diagnosed with cognitive impairment. Additional comorbidities may involve sleep difficulties (44% to 89%), depression/anxiety (17% to 62%), bipolar disorder/seizures (30%), hyperactivity (18% to 57%), and aggressive behavior (2% to 8%). These patients may also present with poor muscle tone, inadequate coordination, hyperactive knee spasms and strabismus.10,11
Common oral behavior characteristics of children with ASD may include aversion to certain foods based on temperature, consistency, texture or taste. Those with preference for a sweet and soft diet, along with food pouching, may be at increased risk for caries. The following behaviors and conditions may also be present:
- Tongue thrusting, and coordination difficulties
- Oral tactile sensitivities
- Bruxism (20% to 25%) and tooth abrasion (aggravated by medication-induced hyposalivation)
- Gastroesophageal reflux disease (GERD) and tooth erosion
- Increased risk of self-inflicted oral injury and dental trauma10,11
A number of patients with ASD are medically managed with various combinations of antipsychotics, anticonvulsants, antihypertensives, and/or central nervous system (CNS) stimulants. These may be prescribed to treat comorbidities and symptoms, including seizures, aggression, self-mutilation, hyperactivity, anxiety, depression, impulsivity, inattention, compulsive behaviors, delusions, hallucinations and insomnia.10
The adverse effects of these medications may involve:
- Motor disturbances affecting speech, swallowing or sialorrhea; medication examples include risperidone, atomoxetine, clonidine and olanzapine
- Xerostomia; medication examples include clonidine, guanfacine and selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine or sertraline
- Orthostatic hypotension; drug examples include risperidone, olanzapine or clonidine
- Thrombocytopenia; medication examples include risperidone, valproate, carbamazepine and methylphenidate
- Leukopenia, coagulopathy and anemia; drug examples include valproate and carbamazepine
- Increased bleeding time; medication examples include SSRIs
- Insomnia; drug examples include SSRIs, methylphenidate, amphetamines and atomoxetine
- Diarrhea, nausea, dizziness, dysgeusia, stomatitis and glossitis; medication examples include SSRIs
Drug interactions with other agents — including certain sedatives, analgesics and local anesthetics — should also be considered. For example, clonidine, olanzapine, risperidone and SSRIs may increase CNS depression of other CNS depressants.10 Additionally, SSRIs inhibit cytochrome P450 3A4 isoenzymes; this potentiates the benzodiazepines alprazolam, triazolam and midazolam, and might cause a prolonged and deeper level of sedation than intended.10 Another consideration is that SSRIs inhibit the cytochrome P450 2D6 needed to metabolize codeine, tramadol and, to a lesser extent, hydrocodone and oxycodone. This may render these analgesics less desirable for pain control or sedation.12
Caution is advised when administering local anesthetics containing vasoconstrictors to patients medicated with either amphetamine, atomoxetine or methylphenidate, as higher risk of tachycardia and hypertension may be induced by large amounts of vasoconstrictors.10
As noted at the outset, this case scenario is intended to illustrate the decision-making process when choosing one behavior guidance technique over another. A 7-year-old male (25 kg) presented with both parents for an oral comprehensive examination. The child had never been seen by a dentist before.
- Medical history: Mild to moderate ASD, mild asthma, and GERD.
- Medications: Singulair, ranitidine, guanfacine, albuterol inhaler as needed.
- Allergies: None reported.
- Behavior: The child was receptive to some verbal commands and opened his mouth briefly to a toothbrush. The intraoral exam required the parents’ assistance and use of a mouth prop.
- Intraoral findings: Early mixed dentition, poor oral hygiene, Angle Class I (molars and incisors), overjet = 4 mm, overbite = 30%, mild erosion and abrasion, and moderate calculus. Tooth #8 had small enamel crown fractures that did not require restoration. No caries lesions were detected on visual and tactile examination. The first permanent molars were fully erupted, with deep grooves that would benefit from sealants. The child was uncooperative for X-rays. A prophylaxis was attempted, but the child rejected the handpiece and treatment was aborted.
Guidelines from the American Academy of Pediatric Dentistry recommend that, when indicated, new patients with transitional dentition be evaluated radiographically with posterior bitewings, along with a panoramic exam or selected periapical images.12 However, the child was not expected to cooperate for a panoramic X-ray. The parents were informed of the value of obtaining bitewings and maxillary occlusal radiographs to evaluate the presence of interproximal caries and monitor the development of the premaxillary area (important considering the patient’s history of dental trauma). The treatment plan included scaling and sealants. Should other pathologies be discovered following radiographic examination, the treatment plan would be reassessed. Alternatives to treatment under sedation were reviewed with the parents, who elected to proceed with care under minimal to moderate sedation. They also gave consent for use of active or passive protective stabilization, as needed.
Upon approval, treatment was successfully completed with premedication of hydroxyzine hydrochloride, supplemented with nitrous oxide inhalation sedation. Passive protective stabilization with a papoose board was utilized throughout the procedure. A parent was present in the operatory and provided valuable support, particularly at the settling-in phase.
The dental team should be aware of the variability in behavior of children with ASD. A treatment that works for one individual may not work for another. Whenever possible, the dentist should attempt to learn more about the specific patient in question. Ideally, this discussion should be away from the operatory. Caregivers can offer valuable information regarding their child’s fear level, toilet training, toothbrushing, haircut tolerance, academic achievement and language. These may assist the dental team in predicting patient cooperation within the dental environment.13,14 Assessment of toothbrushing ability may provide clinicians with valuable information regarding possible management issues, as it may desensitize the child to future dental work.10,11
Caregivers may also offer information regarding their preference of behavior guidance techniques. Some families are already utilizing the D Termined program of familiarization and sequential tasking. This is based on applied behavior analysis theory and uses the “familiarization through repetitive tasking” philosophy. Clinically useful strategies include: (1) saying “look at me” to encourage eye contact; (2) asking the patient to “put your feet out straight and hands on your tummy” for positional modeling; and (3) using a verbal “1, 2, 3, 4” or visual (e.g., picture stories or charts) to promote compliance. A dentist who would consider working with caregivers and utilizing special tools, such as a social story and picture book, will gain the trust of both patient and parents. Some families might wish to proceed gradually and take training sessions at home before the visit using simple tasks, such as utilizing pictures of toothbrushing. During the visit, it is advisable to first meet and evaluate the child away from the dental chair (due to the possibility of visual and auditory hypersensitivity). The caregiver can provide security to the child, along with assistance to the dental team as an interpreter. Providers should level themselves to the patient’s height, but refrain from touching at the first contact.
Ideally, the operatory should be prepared in advance (e.g., chair reclined and lights on). Using tell/show/do with short, clear commands and positive and negative verbal reinforcement, the clinician should prompt the child to approach the dental chair. Desired skills should be divided into small components and reinforced through repetition.10,11 Worth noting is that use of a mouth prop in a compliant child is not considered protective stabilization.12
Preferably, at each visit the child should be seen by the same team in the same operatory. Deep touch pressure refers to firm holding, hugging and squeezing. It acts as a calming or focusing agent to increase activity in the parasympathetic division and reduce activity in the sympathetic division of the autonomic nervous system. This increases endorphin, serotonin and dopamine levels, which produce a feeling of calm and may decrease both heart rate and blood pressure. The use of deep pressure on the arms of child with ASD reduces self-injurious and self-stimulation behavior.15–17 Caregivers of children with special health care needs were reported to be more accepting of protective stabilization for a checkup and prophylaxis than those of typical children (most notably if they had experienced it in the past).18,19
There are many products available that — following appropriate verbal and written consent from the guardian — may be utilized either with or without sedation. Examples include a papoose board, wraps, stabilizing systems and straps. Nevertheless, some caregivers prefer active protective stabilization by lying on top of the child. Occasionally, a weighted blanket may provide sufficient relaxation that obviates the need for stabilization.
A controlled multisensory-adapted dental environment that uses relaxing lights (e.g., direct fluorescent lighting at 50 Hz) was documented as flickering and disturbing for patients with ASD. Instead, deep proprioceptive sensation and music have been recommended for children with developmental disabilities. This approach was reported to successfully reduce the mean duration and magnitude of anxious behaviors, while inducing a state of lower arousal (i.e., greater relaxation) in patients with intellectual disabilities. It also reduces distress, sensory discomfort, and the perception of pain in children with ASD receiving oral prophylaxis.20,21
FACTORS INFLUENCING INTERVENTION
The decision of how to treat a pediatric dental patient is influenced by urgency of dental needs, predoctoral dental education, society, marketing, media, communication, technology and parenting practices.22,23 When cognitive disabilities prevent routine delivery of oral health care using communicative guidance techniques, the dentist may consider additional advanced behavior guidance techniques, such as passive protective stabilization, premedication (with or without supplemental inhalation of nitrous oxide), or treatment under general anesthesia. In some cases, referral, deferral or limited treatment — such as periodic application of silver diamine fluoride, silver-modified atraumatic restorative technique, interim therapeutic restorations, or the Hall technique — may be considered as alternatives to sedation or general anesthesia.24–26
The objective of minimal or moderate sedation is to place the child in a receptive state of mind, enhance communication and patient cooperation, increase tolerance for longer appointments, and reduce anxiety and gagging.24 The appropriate minimal or moderate pharmacologic intervention should be utilized as an adjuvant to the more basic behavior guidance techniques previously discussed. The decision regarding the specific sedation regimen should consider characteristics related to the patient, provider and environment.
Patient-related characteristics include the patient’s medical status, airway, physiological condition, physical condition, mental and emotional status, amount and difficulty of dental treatment, potential side effects, drug interactions, and factors related to the caregiver.22,27–31
Provider-related characteristics involve the dentist’s training, clinical preferences, and factors that influence the type and route of sedative medication.
Environmental-related characteristics include the clinic setup, state and specialty dental board guidelines, and pertinent regulations.
The risks and benefits of combining sedative medications should be carefully assessed. Desirable effects, such as anxiolysis, sedation, hypnosis, amnesia, analgesia, antiemesis, anticholinergic, antihistaminic, muscle relaxation effects, and reducing risk of convulsions, as well as the possibility of adverse effects, such as histamine release, disinhibition and emergence delirium, should assist in selecting the sedative regimen.30
The dentist should keep in mind that combining medications may enhance the sedative effect beyond the intended level, and the risk of side effects is higher — particularly when three or more drugs are used.27,32,33
The rationale for the sedative regimen selected in this case was based on the following parameters. Patient-related characteristics: The parent’s attitudes were positive, and they reported the child had experienced a favorable reaction to deep pressure sensation in the past. Additionally, dental work of minimal difficulty was anticipated. Provider-related characteristics: Antihistaminics (such as hydroxyzine hydrochloride) possess broncho relaxation (anticholinergic and antihistaminic) and antiemetic properties, which were perceived as advantageous in this specific case. Meperidine was contraindicated due to risk of histamine release, which could have precipitated an asthmatic attack. It also could have increased the risk for nausea and vomiting, which was not advisable in a patient with GERD. Furthermore, the patient also took ranitidine on a daily basis, which inhibits cytochrome P450 3A4 in the liver. Sedation with midazolam would have required dose adjustment and titration — which is not advisable via an oral route.
In conclusion, many patients with ASD may receive preventive, comprehensive and orthodontic dental care in-office. Often, children with ASD may not require any pharmacological intervention; others may be premedicated with single mild sedatives, such as diazepam, hydroxyzine or meperidine — with or without concomitant inhalation of nitrous oxide. Minimal or moderate sedation can induce a state that is receptive to treatment. That said, due to variability of presentation (including financial and insurance benefits), as well as patient needs, multiple treatment options should be considered based on the characteristics of the specific patient.20,21,34–36
- This overview explores the applications of minimal and moderate sedation when treating a child with autism spectrum disorder (ASD).
- Among U.S. children and adolescents, a large, nationwide population-based study estimated ASD prevalence at 2.47% (3.63% in boys and 1.25% in girls).9
- Using a combination of nonpharmacological behavior guidance and minimal or moderate sedation (with active or passive immobilization when needed) may facilitate the provision of safe and effective care.
- Patients with ASD may be medically managed with various combinations of antipsychotics, anticonvulsants, antihypertensives, and/or central nervous system stimulants. Consequently, providers should consider possible drug interactions when choosing an oral sedation regimen.
- Ultimately, the objective of minimal or moderate sedation is to place the child in a receptive state of mind, enhance communication and patient cooperation, increase tolerance for longer appointments, and reduce anxiety and gagging.24
- The appropriate minimal or moderate pharmacologic intervention should be utilized as an adjuvant to the more basic behavior guidance techniques discussed in this paper.
- Wilson S, Houpt M. Project USAP 2010: use of sedative agents in pediatric dentistry — a 25-year follow-up survey. Pediatr Dent. 2016;38:127–133.
- Murphy MG, Fields HW, Machen JB. Parental acceptance of pediatric dentistry behavior management techniques. Pediatr Dent. 1984;6:193–198.
- Eaton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent. 2005;27:107–113.
- Fields HW Jr, Machen JB, Murphy MG. Acceptability of various behavior management technique relative to types of dental treatment. Pediatr Dent. 1984;6:199–203.
- Lawrence SM, McTigue DJ, Wilson S, Odom JG, Waggoner WF, Fields HW Jr. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent. 1991;13:151–155.
- White J, Wells M, Arheart LK, Donaldson M, Woods AM. A questionnaire of parental perceptions of conscious sedation in pediatric dentistry. Pediatr Dent. 2016;38:116–121.
- Patel M, McTigue DJ, Thikkurissy S, Fields HW. Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry. Pediatr Dent. 2016;38:30–36.
- Szczepaniak D, McHenry MS, Nutakki K, Bauer NS, Downs SM. The prevalence of at-risk development in children 30 to 60 months old presenting with disruptive behaviors. Clin Pediatr (Phila). 2013;52:942–949.
- Xu G, Strathearn L, Liu B, Bao W. Prevalence of autism spectrum disorder among U.S. children and adolescents 2014–2016. JAMA. 2018;319:81–82.
- Friedlander AH, Yagiela J, Paterno VI, Mahler ME. The neuropathology, medical management and dental implications of autism. J Am Dent Assoc. 2006;137:1517–1527.
- Tesini DA. Providing comprehensive, quality dental care to children with autism spectrum disorder. Inside Dental Assisting. 2014;11:22–27.
- American Academy of Pediatric Dentistry. The Reference Manual of Pediatric Dentistry 2018–2019. pp. 101–103,254–273,321–329.
- Martin MD, Kinoshita-Byrne J, Getz T. Dental fear in a special need’s clinic population of persons with disabilities. Spec Care Dentist. 2002;22:99–102.
- Marshall J, Sheller B, Williams BJ, Mancl L, Cowan C. Cooperation predictors for dental patients with autism. Pediatr Dent. 2007;29:369–376.
- Chen HY, Yang H, Chi HJ, Chen HM. Physiological effects of deep touch pressure on anxiety alleviation. J Med Biol Eng. 2011;33:463–470.
- McClure MK, Holtz-Yotz M. The effects of sensory stimulatory treatment on an autistic child. Am J Occup Ther. 1991;45:1138–1142.
- Schaaf RC, Benevides T, Mailloux Z, et al. An intervention for sensory difficulties in children with autism: a randomized trial. J Autism Dev Disord. 2014;44:1493–1506.
- Brandes DA, Wilson S, Preisch JW, Casamassino PS. A comparison of opinions from parents of disabled and non-disabled children on behavior management techniques used in dentistry. Spec Care Dentist. 1995;15:119–123.
- Marshall J, Sheller B, Mancl L, Williams BJ. Parental attitudes regarding behavior guidance of dental patients with autism. Pediatr Dent. 2008;30:400–407.
- Shapiro M, Melmed RN, Sgan-Cohen HD, Parush S. Effect of sensory adaptation on anxiety of children with developmental disabilities: a new approach. Pediatr Dent. 2009;31:222–228.
- Cermak SA, Stein Duker LI, Williams ME, Dawson ME, Lane CJ, Polido JC. Sensory adapted dental environment to enhance oral care for children with autism spectrum disorders: a randomized controlled pilot study. J Autism Dev Disord. 2015;45:2876–2888.
- Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent. 2004;26:111–113.
- Becker A, Shapira J, Chaushu S. Orthodontic treatment for the special need’s child. Prog Orthod. 2009;10:34–47.
- Cote CJ, Wilson S. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines of monitoring and management of pediatric patients before, during and after sedation for diagnostic and therapeutic procedures: Update 2016. Pediatrics. 2016;138:e20161212.
- Alvear Fa B, Jew JA, Wong A, Young D. Silver modified atraumatic restorative technique (SMART): an alternative caries prevention tool. Stoma Edu J. 2016;3:243–249.
- Santamaría RM, Innes NP, Machiulskiene V, Schmoeckel J, Alkilzy M, Splieth CH. Alternative caries management options for primary molars: 2.5-year outcomes of a randomised clinical trial. Caries Res. 2017;51:605–614.
- Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000;106:633–644.
- Goleman J. Cultural factors affecting behavior guidance and family compliance. Pediatr Dent. 2014;36:121–127.
- Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367:766–780.
- Sapir S. Minimal and moderate sedation in pediatric dentistry. Decisions in Dentistry. 2019;5(1):35–39.
- Wright ZG, Kupietzky. Behavior Management in Dentistry for Children. 2nd ed. Philadelphia: Saunders; 1975:146–148.
- Sapir S, Zitterell C, Kane JD. Letter to the editor and responses to the letters to the editor. Pediatr Dent. 2017;39:94–96.
- Sapir S. Emergency airway management during moderate sedation. Decisions in Dentistry. 2018;4(6):36–39.
- Ashley PF, Williams CE, Moles DR, Parry J. Sedation versus general anesthesia for provision of dental treatment to patients younger than 18 years. Cochrane Database Syst Rev. 2015;28:CD006334.
- Avalon S, Gozal Y, Kaufman E. The use of conscious sedation versus general anesthesia in modern dentistry: rising ethical dilemmas. Refuat Hapeh Vehashinayim. 2004;21:19–26,93–94.
- Lee JY, Vann WF Jr, Roberts MW. A cost analysis of treating pediatric dental patients using general anesthesia versus conscious sedation. Anesth Prog. 2001;48:82–88.
From Decisions in Dentistry. September 2021;7(9)14-16,18,21.