Year : 2008 | Volume
: 26 | Issue : 2 | Page : 82--84
Management of a child with autism and severe bruxism: A case report
MS Muthu, KM Prathibha
Pedo Planet, Pediatric Dental Center, Chennai, India
M S Muthu
Pedo Planet, 2C, Akme Park, Opposite S and S Power Ltd, Porur, Chennai - 600 116
Autism is a developmental disorder characterized by severe deficits in social interaction and communication. A wide spectrum of medical and behavioral symptoms is exhibited by children with autism, which makes routine dental care very difficult in them. Bruxism or forceful grinding of teeth is one of the sleep problems commonly observed in children with autism. Our patient, a 4-year-old male child with autism, presented with complaints of pain and sensitivity of the teeth. There was history of excessive grinding and clenching of teeth. Limited oral examination revealed severe attrition of all primary teeth. Treatment was planned under general anesthesia because of his poor cognitive abilities. Full-mouth rehabilitation, including placement of stainless steel crowns for all primary molars, was done. Following treatment there was a significant decrease in the grinding habit over the next 2 months. Although the communication and behavioral problems in children with autism pose challenges for the dentist, treatment with proper planning and a lot of patience can definitely make a difference.
|How to cite this article:|
Muthu M S, Prathibha K M. Management of a child with autism and severe bruxism: A case report.J Indian Soc Pedod Prev Dent 2008;26:82-84
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Muthu M S, Prathibha K M. Management of a child with autism and severe bruxism: A case report. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2020 Nov 24 ];26:82-84
Available from: https://www.jisppd.com/text.asp?2008/26/2/82/41623
Mental disability is a term which is used when an individual's intellectual development is significantly lower than average, limiting his or her ability to adapt to the environment.  Autism is a neurobehavioral and cognitive disorder characterized by impaired development of interpersonal and communication skills, limited interests, and repetitive behaviors. The incidence of autism is about 0.2%.  This complex mental disability is about four times more prevalent in males but is more severe in females. It manifests during the first three years of life. , There are enormous variations in the behavioral patterns and the severity of illness among individuals with autism. Mental retardation is evident in approximately 70% of individuals with autism. The behavioral symptoms in children include temper tantrums, hyperactivity, short attention span, impulsivity, agitation, anger, and a tendency for aggressive and self-injurious behaviors.  Disorders of language and social communication, poor response to external stimulation, tendency to isolate themselves, and poor eye-to-eye contact are well-recognized symptoms. Children with autism also commonly have damaging oral habits such as bruxism, tongue thrusting, picking at the gingiva, lip biting, and pica.
Sleep disorders in children with autism are frequently reported by their parents. Parasomnias such as sleepwalking and nightmares were among the least frequently reported sleep problems; however, bruxism was reported by Williams et al . to be a relatively common disorder, occurring in approximately one-fifth of the surveyed children.  Bruxism, by definition, is a nonfunctional, involuntary, forceful grinding or gnashing of teeth that affects 10-20% of the population.  Bruxism has a higher than normal prevalence in children with special needs and can result in excessive dental wear, temporomandibular joint pain, avulsion of teeth, and other problems.  The treatment options for bruxism (eg, the use of splints or behavioral modification techniques) are limited in children with autism due to their poor mental capacity and difficulties in communication. Obsessive routines, repetitive behaviors, unpredictable body movements, and self-injurious behavior are symptoms that can interfere with routine dental care in a child with autism. Hering et al . has observed that parents of autistic children often report difficulties in coping with sleep problems.  Schreck and Mulick noted an increased incidence of nightmares, sleepwalking, and bruxism in children with autism.  A case report by Monroy et al. describes the use of botulinum toxin A injections into the masseter muscle for treatment of bruxism.  Providing oral care to children with autism requires patience and a thorough understanding of the patient's degree of mental disability. Chew et al . state that better understanding of the effects of autism on the behavior of an affected individual helps the dental practitioner to deliver oral healthcare in an empathetic and appropriate manner.  In this case report, we present our experience in delivering, under general anesthesia, comprehensive dental management in a child with autism and severe bruxism.
A 4-year-old male child was brought to Pedo Planet, our exclusive pediatric dental practice, by his parents with complaints of pain and sensitivity of teeth and consequent difficulty in eating. There was a history of excessive grinding and clenching of teeth.
The patient's medical history included a diagnosis of autism. The family history was non-contributory. He was not on any medications at the time and had no history of drug allergies. The parents reported that the boy had previously undergone extraction of the maxillary primary left lateral incisor. A limited oral examination was performed and it revealed severe attrition of all the primary teeth [Figure 1] and [Figure 2]; pictures were taken during the procedure under general anesthesia). The maxillary right primary central incisor was nonvital and there was an abscess (labial) associated with it. The poor cognitive and motor abilities of the child prevented us from managing him on a dental chair. A complete oral rehabilitation was planned under general anesthesia. The child was given fitness for the procedure by our anesthetist. A preliminary alginate impression was taken and we performed a full-mouth rehabilitation, including placement of stainless steel crowns for all the primary molars [Figure 4], extraction of the maxillary right primary central incisor [Figure 3], and thorough oral prophylaxis. His postoperative recovery was uneventful. The parents were educated on the proper oral hygiene measures to be adopted and the need for regular dental visits in the future. The patient was reviewed after 3 months and, again, after 12 months, by which time the clenching and grinding behavior had decreased significantly. His eating habits had also improved to a great extent because he was able to consume semisolid and solid foods instead of the liquid diet that he had had before treatment.
Autism is an incapacitating disturbance of mental and emotional development characterized by severe deficits in social interaction and communication and the presence of repetitive, ritualistic behaviors.  There are no specific genetic, medical, or laboratory tests available to confirm the diagnosis of autism and the comprehensive management of autism includes parental counseling, special education in a highly structured environment, speech therapy, and social skills training, with the ultimate goal of facilitating independence in activities of daily living and self-care. Children with autism have multiple medical and behavioral problems, which make their dental treatment extremely difficult. Communication problems and poor mental capabilities are central concerns when treating children with autism; these children exhibit wide variations in their ability to cooperate during dental treatment. 
For our patient, full-mouth rehabilitation was planned and was executed under general anesthesia because he suffered from severe mental retardation. Children with autism who have mild to moderate mental retardation and an absence of severe behavioral problems can be treated successfully in the general practice setting. Nevertheless, behavioral problems like hyperactivity and quick frustration can hamper the provision oral health care in patients with autism. Also, the invasive nature of oral care may trigger violent and self-injurious behavior such as temper tantrums or head banging.  In our patient, it was very obvious that it would be difficult for him to comprehend instructions and cooperate on a dental chair and hence the treatment was done under general anesthesia. General anesthesia gives the dental surgeon an opportunity to perform a comprehensive and unhurried management of all problems in a single appointment. 
Our patient was totally caries-free; this could be attributed to a spaced dentition, absence of any retentive area (flat occlusal surface due to bruxism), and open proximal contacts. Also, the mother was well trained in the maintenance of the child's oral hygiene. In general, children with autism prefer soft and sweetened foods and they tend to pouch food inside the mouth instead of swallowing it due to poor tongue coordination, thereby increasing the susceptibility to caries. , Moreover, the risk for dental caries can be expected to be higher in these patients due to difficulties in brushing and flossing in them. Noninstitutionalized children with autism had caries rates that were similar to the rates in functionally independent peers in a study conducted by Shapira et al.  Rajic et al . report that a combined treatment, provided by a dental team and a pedopsychiatric team working together, resulted in a decreased prevalence of caries in a group of children with autism as compared to another group who did not receive any treatment. 
Our patient presented with severe attrition of all teeth, which could be corrected with stainless steel crowns. The option of using an intraoral appliance was not considered because it was unlikely that the child would comprehend and cooperate with this form of treatment and also because of the risk of aspiration. Monroy et al. reported a reduction in the frequency and severity of bruxism in an autistic child following injections of botulinum toxin into the masseter muscle.  In spite of the good results and minimal side effects observed with this procedure, we did not opt for it because of its short duration of action, the lack of adequate information on the most effective dose and the best site of delivery of the injection, and the relatively high cost of treatment. In addition, we were reluctant to carry out a procedure that is not commonly practiced in our region and we had doubts about the ability of our patient to tolerate it. The patient underwent extraction of the maxillary right primary central incisor; this tooth was nonvital and had an abscess associated with it. We did not attempt to preserve the tooth as there was only 1-2 mm of tooth structure above the gingival margin. We emphasized the need for routine dental check-ups and regular practice of oral hygiene measures to the parents. At the follow-up at 3 months and after 12 months, the mother reported a significant decrease in his clenching and grinding behavior. This might be attributed to the reduction in sensitivity to thermal stimuli following placement of the stainless steel crowns. The treatment also greatly improved his eating habits as he could now chew solid foods. Long-term care includes increasing the frequency and efficiency oral hygiene measures with the help of the parents, application of fluoride gel or rinse, intake of healthy noncariogenic foods, and frequent recall appointments. .
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