Dental Sedation and Autism

Oral health care for a child with the diagnosis of autism is not much different from the oral health care of other children. However, children with autism often have difficulty in communication skills, so cooperation from your child might be a difficult challenge when visiting the dentist. For parents of children with autism, a visit to the dentist is more than a child opening his or her mouth and getting a reward after.  If your child cannot tolerate the procedure and it cannot wait, the dentist may need to use sedation.

What is dental sedation? Is it necessary? Is it safe?  

Sedation is the utilization of medications called “sedatives” to create a state of relaxation. It is usually done to facilitate a medical, or in this case, dental procedure. These are the levels of sedation most used with children who need extensive dental care:

• Moderate sedation (once called "conscious sedation") is inducing a minimally depressed level of consciousness that retains the patient’s ability to maintain an open airway independently and continuously and respond appropriately to physical stimulation or verbal commands.
• Deep sedation is a type of sedation in which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes, including the ability to maintain an airway or to respond properly to physical stimulation or verbal commands.
• General anesthesia is an induced state of unconsciousness.  The patient cannot respond to physical or verbal stimulation of any kind and it will be up to the dentist to ensure that an airway is maintained.

Most people immediately associate sedation with general anesthesia, in which the patient is put to sleep during the whole procedure and awakens afterward in a recovery room. However this is normally the last possible choice for a pediatric dentist.  The dentist will recommend a lower level of sedation instead where possible, trying to use whichever form of anesthesia has the lowest risk while being effective. To make that decision the dentist will take the child’s age, cognitive level, coping and communication skills, physical health, the attitude of the parents toward anesthesia and the urgency of the procedure into consideration.

Although the decision regarding which level of sedation to be used on your child must ultimately be made by the dentist, you as the parent should always have a say in the matter. If you are not comfortable with the suggestion of your dentist, make sure that your concerns about it are heard. To help you further understand the decision the dentist will be making, here are some guidelines from the American Academy of Pediatric Dentistry (AAPD) that the dentist will be using in making his recommendation: (American Academy of Pediatric Dentistry, 2010)

The AAPD's guidance lists moderate sedation for:   

• Preschool children who cannot understand or cooperate for definitive treatment
• Patients requiring dental care who cannot cooperate due to lack of psychological or emotional maturity
• Patients requiring dental treatment who cannot cooperate due to a cognitive, physical or  medical disability
• Patients who require dental care but are fearful and anxious and cannot cooperate for Treatment
• The AAPD recommends deep sedation or general anesthesia for:
• Patients with certain physical, mental or medically compromising conditions
• Patients with dental restorative or surgical needs for whom local anesthesia is ineffective
• The extremely uncooperative, fearful, anxious or physically resistant child or adolescent with substantial dental needs and no expectation that the behavior will improve soon
• Patients who have sustained extensive orofacial or dental trauma Patients with dental needs who otherwise would not receive comprehensive dental care

Sedation Procedure  

Dental Sedations are usually done in an outpatient dental clinic that is well-equipped. The whole procedure usually won’t take more than 90 minutes for most procedures.  Although some details vary depending on the dentist’s practice among other things, in general the process will go like this:

• Initial assessment of the pediatric dentist and scheduling of the actual procedure.
• Consent signing by the parents
• Guidelines are given prior to the procedure – your child will be told when to stop eating and drinking beforehand (NPO, nothing by mouth). Current guidelines generally allow clear liquids up to 2 hours before, breast milk up to 4 hours, and formula, milk or a light meal up to 6 hours, but follow your dentist's exact instructions. Fasting lowers the risk of stomach contents getting into the lungs during sedation.
• Sedation medication is introduced via injection, an IV line, rectal line (just like when you give suppositories for fever), orally or thru inhalation.
• Dental procedures are done. Ask in advance whether any protective stabilization (a papoose board) would be used; it needs your informed consent and should be a last resort. Your child's breathing and oxygen level should be watched the whole time, with a pulse oximeter on continuously and, for deeper sedation, a trained person whose only job is monitoring; oxygen and emergency equipment should be in the room (Coté et al., 2019).
• Monitoring of the patient until the sedative wears off.

Safety of Sedation  

Sedation in children is safest when the team follows the guideline: the right drug and dose, fasting, trained staff, continuous monitoring and watching your child until fully recovered (Coté et al., 2019). Most states require a dentist to hold a separate permit for each level of sedation, so ask whether your child's dentist holds one for the level proposed.

Usually, dentists who specialize in treating pediatric patients are also well equipped to handle children with Autism Spectrum Disorder.

Reference:

American Academy of Pediatric Dentistry. (2010). Reference Manual 2010-2011. Chicago, IL: American Academy of Pediatric Dentistry.

Coté, C. J., Wilson, S., American Academy of Pediatrics, & American Academy of Pediatric Dentistry. (2019). Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics, 143(6), e20191000.

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