As health care professionals who see and treat children with autism spectrum disorders every day, we have concerns about the November JADA article by Dr. Arthur Friedlander and colleagues, "The Neuropathology, Medical Management and Dental Implications of Autism" (
JADA 2006;137[11]:1517–27
).
We feel that this presentation does not reflect first-hand experience in the field of autism, where we are moving away from a medical definition of autism into an understanding of this as a social condition. The authors present a good historical review of the autism literature, but miss several important clinical points.
The authors give generalized descriptions of autistic children’s behaviors and ability to learn, but fail to give the reader an appreciation for the "spectrum" and wide variability among those affected with respect to their cognitive and emotional capabilities, sensory characteristics and learning potential.
In contrast to what is stated in the article, most, not "some," children with autism learn to dress and feed themselves. Many are cuddly and like to be touched. Similarly, the authors refer to an apparently unitary unknown "cause" of the behaviorally defined syndrome we call "autism." In fact, there are many well-known causes (such as fragile X, Down and Rett syndromes) for the clinical presentation of autism in about 10 percent of cases, even though causes for the rest are still to be discovered.1
The challenge of treating patients with autism is presented as though a pharmacologic approach is essential. On the contrary, it is precisely the way in which autistic children and adults learn that can provide the dentist with an opportunity for a calm, routine dental visit without the use of systemic medication. Recommendations for management approaches have been contemporized, and new approaches correspond to and parallel learning techniques used in the school environment.2 Hand-over-mouth is no longer an accepted technique in pediatric dentistry. Verbal cueing and reinforcement alone often are not effective, and the "papoose board" or lead apron may even serve as a comforter.
Although discussion of the drugs used clinically in the medical management of these patients is necessary for good dental care, the authors present no quantifiable yardstick that would allow dentists to accurately determine the likelihood of encountering these events in a practice setting.
The authors point out that characteristics found in patients with autism—such as social reticence, anxiety and obsessive-compulsive disorder—are more common in families with autistic children. It must be noted that these are also personality traits in functional nondisabled members of society. In contrast to the conclusions of the authors, these features of the parents with whom we interact each day are assets to the treatment process, not impediments. The parents of children and adults with this disorder are quite motivated to take advantage of the repetitive nature of their children’s learning style and are themselves adaptive, creative and determined to make the dental visit a success.
Finally, it is unfortunate that the authors chose to quote review articles instead of important original works in the field. For example, reference is made to the accelerated overgrowth of the brain in autism, which was first elucidated by Courchesne and colleagues.3 In that article, a smaller-than-normal head circumference was seen at birth, not a possible overgrowth during the prenatal period, as stated, and smaller head size was followed by rapid and increased head growth by 6 to 14 months of age.
Seminal work on the neuropathology of autism by Bauman and Kemper4 and more recently Vargas and colleagues,5 showed changes in the cerebellum, cortical microstructure and neuroinflammation that indicate prenatal onset and persistent postnatal immune activation.
We commend The Journal for publishing pertinent work on the important topic of autism, but look forward to future articles that will benefit dentists and their patients with autism.
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