Dental Procedures and the Patient with Fetal Alcohol Syndrome
Peggy Seo Oba, RDH, MPA, MBA
(A slightly abbreviated article was published in ACCESS: Journal of the American Dental Hygienists Association in May-June, 1997. Pages 60-64 under my maiden name of "Seo".)
Fetal Alcohol Syndrome (FAS) is a form of neurological brain disorder that can happen when a pregnant woman drinks 2 or more alcoholic drinks per day, an average of 14 drinks per week or 4 or more drinks on any one occasion during her pregnancy. One out of every three women who drink heavily may have a child with Fetal Alcohol Syndrome. The prevalence of Fetal Alcohol Spectrum Disorders (FASD) which includes full FAS and a full range of behavioral disorders may occur 4-5 times the rate of FAS. (It is estimated that full FAS occurs at a rate of .5 to 3 per 1,000 live births and FASD may occur as frequently as 1 in 100 live births.) The neurological damage in both full FAS and FASD is irreparable. In most cases, the neurological damage occurs on a microscopic level. Neurons and synapse connections grow too much, not enough or not at all. Premature cell death is also a problem. In many cases, the brain cells migrate to areas where they do not belong. White brain cells end up in gray cell matter and gray cells may end up in white cell matter. Some ventricles in the brain may be too large or disappear. Certain areas of the brain, such as the corpus callosum, may be overly small, asymmetrical or non-existent. The basic outcome is that normal methods of behavior modification and physical treatments do not always work with the patient who has Fetal Alcohol Syndrome. This can create unusual problems in dental treatment.
The physical signs of full Fetal Alcohol Syndrome are characterized by:
(1) A spectrum of facial features that include microcephaly, short palprebral fissures, a flat midface, indistinct philtrum, epicanthal folds over the eyes (exaggerated in Asians and American Indian populations), low nasal bridge, minor ear malformations, short upturned "button" nose, and micrognathia.
(2) Damage to the central nervous system that affects gross and fine motor skills, skin and muscle innervation, intelligence, math skills and most importantly behavioral aspects of the patient's personality. Signs are very similar to mild Cerebral Palsy and epilepsy. The behavior may bear a resemblance to mild autism such as Pervasive Developmental Disorder or Aspergers or be much worse.
(3) The patient with FAS may experience prenatal and/or postnatal growth problems. Height and weight may be in the 10th percentile or less. Girls may experience an increase in weight during puberty but the height factor still tends toward the shorter stature.
Dental problems occur in nearly 80% of children with FAS. Dental anomolies that can occur with FAS include cleft palate, hypo and hyperplasia of the maxilla and mandible, malformed, missing and/or misaligned teeth. Other problems that can occur are weak oris obicularis muscles around the mouth that make it difficult to take food off a fork or spoon or suck on a straw or the nipple of a bottle; unusual taste preferences for salty or spicey food at an inappropriate age; gross caries at a young age; prolonged and excessive drooling; weak buccinator muscles that prevent the proper placement of food for chewing; late loss of the primary dentition; late eruption of permanent teeth. In addition, the patient with FAS may have unusual behavioral patterns and tissue and physical sensitivities that make dental treatment difficult.
One of the ways in which the patient with FAS makes sense of his world is to have a great deal of structure and routine in his environment. Unfortunately, dental visits are breaks in the normal routine and may be upsetting to the patient. In order to avoid the suddenness of a dental visit, take photos of the dental office and staff before hand to remind the patient of previous visits. Review the photographs each day for about two weeks prior to the appointment.
Make the appointment at the quietest time of the day or even after regular hours. On a practice visit, walk the patient through the procedures and use the exact treatment rooms and instruments that you intend to use. Patients with FAS are very literal and they will become confused if you use the term "like this" and then that instrument or procedure is not used. Show them the exact instruments and materials you will be using to avoid confusion and misunderstanding.
Review the medication history carefully. Many patients with FAS have extreme reactions to medications and it is best to consult with the parent and pediatrician when administering anesthetics.
Sensory integration dysfunction is a neurological condition that causes sights, sounds, and physical sensations to be over or under exaggerated. It is also not uniform in each individual; hypo and hyper sensitivities may exist in different areas on the same individual.
Visually, objects on the wall or hanging from the treatment lamp may be disturbing. Patterned curtains that sway near an air vent may be very distracting. Making the treatment room as plain and uncluttered as possible will help to prevent over excitement and over stimulation. Dark glasses will reduce the glare from overhead lights.
Patients with FAS may experience more "loud" sounds than the average person. The sound of the handpiece may seem extremely loud to them. Music headphones can be a great help. Warn patients of noise and new phases of the procedure will reduce tension. Speak directly to a patient with FAS. They are very visual and often cannot understand if you turn away when you speak. Hand gestures, signing, and visual aids will help them to understand you more clearly.
Patients with FAS often need to "unwind" or calm themselves down before treatment begins. This may include walking around the room or fidgeting with their hands. You may want to give them a rubber ball to squeeze. One calming aid is the lead apron used during dental x-rays. The weight of the lead apron is very comforting to the patient and it may be useful to let them wear it throughout the treatment.
Sensory integration dysfunction of the oral cavity may create some unusual problems. You may want to suggest another type of toothpaste if the taste or texture annoys the patient. Baking soda is a good semi-tasteless substitute and brushing with water is better than no brushing at all. (There are commercial rinses that contain plaque removers and/or fluoride that would help with your child's oral hygiene.) Rinsing should be practiced and done often during the day. Flossing or use of the waterpik may be more comfortable. The oral cavity may be de-sensitized with oral massage. Daily massaging with a small portion of a towel or a rubber stimulator will help the patient to become used to objects in the mouth.
Patient education is a vital segment of good oral health. Patients with FAS benefit from visual reminders to brush and floss. A series of photos or hand drawn pictures can lead them up to an through the daily routine of good oral health. Step by step pictures are the best. Break down the instructions into doable segments; do not combine instructions or make them overly long. Have patients demonstrate their oral hygiene for you. Simply repeating the instruction does not mean that they understand them...remember patients with FAS are visual and literal and need to be very hands on. It helps to remember that patients with FAS may have an emotional age that is one half of their chronological age...gear your explanations to that emotional level.
Another important responsibility of the dental team is nutrition. Patients with FAS are very sensitive to taste and texture. A patient may not like raw whole carrots, but slicing or shredding the food might make it more acceptable. Fresh tomatoes may not be pleasant for the patient but peeling and removing the seeds or using them in a sauce might be fine. At times, mixing foods may make them more palatable. At other times, separating foods may be better so that there is not an unusual combination of tastes and textures. Patients may also benefit from smaller, more frequent meals and this also affords the opportunity to practice rinsing and oral massage.
It is a challenge to work with patients with neurological impairments but armed with the proper knowledge and dedication, dental personnel can be effective in providing the very best of care to a segment of the population in great need.
For a more extensive description of the physical and behavioral characteristics of Fetal Alcohol Syndrome as well a list of educational links, please go to <http://www.fasin,org>
For the most recent research on FAS(D) and dental problems, please go to <http://www.thejcdp.com/issue024/naidoo/naidoo.pdf>