January 11, 2021
by Robert Carmichael BSc, DMD, MSc, FRCDC
The U.S. Department of Education reports on its website that an astonishing 1 in 59 children in the United States are affected by Autism Spectrum Disorder (ASD) – a far cry from the figure of 1 in 2,500 that had been the accepted prevalence when I entered the dental profession more than three decades ago.
Putting aside the views of anti-vaxers and their baseless opposition to vaccines as the cause of ASD, along with the discredited views of the British gastroenterologist Andrew Wakefield and his co-authors, the etiology of the bewildering increase in ASD diagnoses has been largely speculative and thought to range from genetic influences to environmental factors like antibiotics and elevated rates of television viewing in infants.
Meanwhile, others are asking whether this veritable epidemic of ASD really exists at all. It’s been suggested that there may be alternative explanations for an epidemic, namely loosening of diagnostic criteria that labels more mildly affected kids, reliance on government data submitted by schools rather than more scientific population-based estimates, and diagnosis swapping with other declining diagnostic categories. Another suggested contributor to the reported increase in ASD, a consequence of rushing early identification, is confusion of ASD with other disabilities such as intellectual disability, and even normal variation in development such as late talking.
While it’s likely that the astonishingly high prevalence rates are not entirely real, I think it’s fair to say that children with ASD comprise a growing proportion of the patient populations in most dental practices and hospital dental departments. The result? Tried and true techniques for managing behaviour in children in the dental setting – like Tell Show Do – no longer cut it for this growing segment of our pediatric patients. Another strategy – repeatedly exposing a child to the dental environment in tandem with positive reinforcement of desired behaviours – a kind of desensitization – is more successful the younger the child and usually requires multiple visits to establish the desired change in behaviour. Moreover, reimbursement rates are usually too low to provide any incentive for community-based dental offices to offer desensitization. Yet another strategy, the use of social stories specific to the dental environment to prepare a child for an upcoming dental visit can help to modify maladaptive behaviours, but they require that families read the story once a day each day of the week prior to the upcoming dental appointment. While helpful to some kids, an alternative approach to behaviour modification is being explored at Holland Bloorview Kids Rehabilitation Hospital in Toronto. Dr. Molly Friedman, in this issue of Oral Health, describes how virtual reality, an immersive technology generating a three-dimensional image that appears to surround the user, is being used to help children with ASD and other disabilities prepare for the dental office environment.
Not surprisingly, techniques to modify children’s behaviour in a positive way become more attractive when access to hospital- or community-based sedation and general anesthesia services are limited. Especially, if indeed, the prevalence of ASD is truly on the rise.
About the Author
Dr. Robert Carmichael is a prosthodontist and serves as Chief of Dentistry and Director of the Ontario Cleft Lip & Palate/Craniofacial Dental Program at Holland Bloorview Kids
Rehabilitation Hospital in Toronto. He is also chairman of the International Team for Implantology (ITI) Scholarship Center at Holland Bloorview, coordinator of prosthodontics at Toronto’s Hospital for Sick Children and assistant professor at the University of Toronto. In 2015 Robert was a recipient of the Ontario Dental Association Service Award.