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IM-IV Sedation on a 9 year old child with Mild Autism.

A case Report

 by: Dr. Anna Mejia, RTP-3 Philippine Pediatric Dentistry Centre

Pediatric dentists are not only faced with the challenge of treating normal children but are also confronted with managing the handicapped and mentally disabled in the dental office. Included in this group of children are the autistic patients. The goals in choosing the appropriate treatment modality are to provide quality dental care and to induce a positive dental attitude towards dental treatment. Using sedative medication to alter consciousness has proven to be an effective way to achieve this end in many clinical situations.

Autism is a complex developmental disability that was first described by Dr. Leo Kanner, a psychiatrist at Johns Hopkins University in 1943. Kanner said autism is an "inability to relate themselves in the ordinary way to people and situations from the beginning of life."

Etiology: unknown; genetic and environment factors may play a role.

Diagnosis: no medical tests; based on observation of individual's communication, behavior and developmental levels. The earlier a child is diagnosed, the earlier the child can begin benefiting from one of the many specialized intervention approaches.

Treatment: none; educational approaches which reduces some of the challenges associated with the disability

CASE REPORT

This is a case of a 9-year old male child with mild autism referred to the Pediatric Dentistry Center because of a painful molar on the lower right quadrant.

Dental History reveals that the patient was brought to 3 dentists in the past but treatment was unsuccessful due to his unmanageable behaviour.

Medical History reveals the patient was diagnosed with mild autism in 1998, when he was 4 years old. He has no history of hospitalization and no known allergies. Medications taken in the past were Paracetamol for fever and antibiotics for respiratory tract infection.

Social and Family History reveals that the patient is an only child, with him being the only person in the family on both sides with the autistic disorder. The parents did not understand his condition then. He attended school with a class of students with Down Syndrome when he was 5 years old (1999). When they consulted with a SPED diagnostician in the same year, he recommended that the child be immediately pulled out from the school and go through one-on-one education. He went through this for 2 years. He was assessed regularly and when he was 7 years old (2001), he was recommended to attend regular school. He is now grade 2 at this regular school. He is in a class of 9 normal children. He still goes through regular assessment every year and sees a psychologist every other week.

Extraoral and Intraoral Exam. Extraoral exam reveals no significant findings. Intraoral exam reveals that the patient has fair oral hygiene, moderate plaque accumulation and multiple carious teeth.

Orthodontic Analysis. Patient has a slightly convex soft tissue profile; a Class II molar and canine relationship; a 4 mm overjet and a 3 mm overbite. His midline has a shift to the right and there is crowding present on the lower anteriors.

Behavior. Patient's behavior is Frankl 3 since he can follow simple instructions when asked to do so.

Course and Progress of Treatment

After the initial exam, it was recommended that oral rehabilitation be done under IM-IV sedation. The mother was given pre-sedation instructions both by the operator and the attending anesthesiologist and a medical clearance was obtained from the pediatrician. IM-IV sedation was done after obtaining the patient's vital signs and confirmation of NPO status.

Composite restorations, pulp therapy and stainless steel crowns were done per quadrant. After all these were finished, the extractions were followed after 1 carpule 2% lidocaine HCl with 1:100,000 epinephrine was administered using local infiltration. Bleeding on the extraction sites was controlled after which topical fluoride was applied on all the teeth. After post sedation criteria were met, patient was dismissed.

Patient was recalled after one week. Extraction sites were checked and oral hygiene instructions were reinforced with the mother.

Discussion

In the Pediatric Dentistry Center, parents of autistic children are given different sedation choices in order to aid the operator in the management of their children. These are the following: oral sedation, IM-IV sedation, or general anesthesia.

Oral sedation, as the word implies, is the administration of the sedative drug via the oral route to the GI tract. It is simple and convenient. Especially if the child has only mild autism, it teaches the child to accept the dental situation as an experience that he or she must meet several times a year for the rest of his life. Since absorption is relatively slow, allergic reactions are seen less frequently and tend to be less severe. Results tend to be somewhat unpredictable since there is a great individual variation in drug need. Monitoring oral premedicated patients consists of observation, and at most, the use of a pulse oximeter.

General Anesthesia is a controlled state of unconsciousness accompanied by partial or complete loss of reflexes including inability to maintain an airway independently and respond purposefully to physical stimulation or verbal command." Here, patient cooperation is not absolutely essential, thus quality and complete dental rehabilitation may be performed. Done in a hospital setting, this is perceived to be safe due to the availability of equipment that can be used. The designated anesthesiologist does constant monitoring. But since patient is unconscious, the protective reflexes are not intact. Vital signs of the patient are depressed and more drugs are used. These conditions increase the risks for intra and post-operative complications to happen. Additionally, extensive pre-operative evaluation is required and the cost of the procedure is greater compared to the other two pharmacologic techniques mentioned earlier.

IM-IV sedation has gained popularity at PDC these past months. In order to understand it better, we should bear in mind that sedation occurs in a dose-related continuum, is variable and depends on each patient's response to various drugs. There are levels of sedation progressing on a continuum from a high state of consciousness to unconsciousness.

A. ANALGESIA AND ANXIOLYSIS - Reduction or elimination of pain and anxiety in a conscious patient; he is easily awakened by normal or softly spoken verbal commands and is oriented when awake; all vital signs are stable; no significant risk of losing protective reflexes

B. SEDATION AND ANALGESIA -A

state of depressed level ofconsciousness in which the patient is able to maintain a patent airway independently and continuously and can be aroused by physical stimuli. These patients are unable to hold a conversation, but respond to commands by appropriate action or brief verbalization. Patients un dergoing sedation and analgesia have a small risk of unexpectedly progressing to deep se dation and losing protective reflexes.

C. DEEP SEDATION -A medically controlled state of consciousness or unconsciousness from which the patient is not easily aroused by physical stimuli; may have a significant risk of partial or complete loss of protective reflexes including the inability to respond purposefully to physical stimulation or verbal commands. Loss of gag reflex, inability to maintain oral secretions and loss of swallowing reflex may occur.

Like GA, the operator can render quality dental care all in one sitting in the dental office. The child is sedated and the drugs administered control the behavior of the child. It is more affordable than general anesthesia and the patient can be sent home after the procedure once discharge criteria are met. Working with an anesthesiologist adds to the advantages because they do not only administer the drugs and monitor the patient throughout the procedure, they also do a thorough patient history and work-up before anything is done to the patient.

RECOMMENDATION

In the dental office it is important to follow a protocol in the management and dental care of the AUTISTIC CHILD:

- Prevention of oral disease is very important for autistic children, and repeated oral hygiene instructions are essential.

- Autistic children rarely verbalize complaints about dental problems, and periodic dental evaluations are therefore essential.

- Autistic children are hypersensitive to loud noises, sudden movement, and things that are felt. The dental treatment area should therefore be as free from auditory and visual stimuli as possible.

- Children with autism need sameness and continuity in their environment. A gradual and slow exposure to the dental office and staff is therefore recommended.

- Dental appointments should be short.

- A slow and step-wise approach to performing dental treatment is recommended.

- Instructions should be presented in clear, short, simple sentences.

- The Tell-Show-Do method of behavior management is useful, along with frequent positive reinforcement for acceptable behavior.

CONCLUSION

Individuals with autism, like everyone, are individuals first and foremost. They have unique strengths and weaknesses. What people with autism have in common is a developmental disability, a disorder of communication, which manifests itself differently in each person. Some individuals with autism may be of average to above average intelligence, while others may be below average.

In the dental scenario the treatment of a child with autism is a challenge that not every dentist is willing to accept. We must understand not only the child's physical, mental or emotional condition, but also the parent's conflicting feelings and reactions. Whatever the problem, we are treating a person that deserves an empathic and considerate approach. All our efforts will be fully appreciated. A personalized preventive program, at the office and at home, is a priority in our treatment plan. Referral to specialists in order to address complex orthodontic problems is our responsibility as pediatric dentists. Working hand in hand with other health professionals and the people involved with the child's life will help us better serve our handicapped children.

For those interested to read this whole case report, it may be read at the Pediatric Dentistry Center Library.

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