Autoextraction in a child with autistic spectrum disorder

KEY POINTS * Dentists treating patients with autistic spectrum disorder (ASD) should be aware of the high levels of self-injurious behaviour within this group. * Exfoliation of a deciduous

tooth with an intact root warrants further investigation. * Unexplained dental pain in a child with autism may be due to self-injury. ABSTRACT Many children with mild/moderate autistic

spectrum disorder (ASD) receive care in general dental practice. We report a seven year old boy with ASD presenting with dental pain who auto-extracted one of his deciduous canines. Children

with ASD may have hyposensitivity to pain and can exhibit unusual forms of self-injurious behaviour. You have full access to this article via your institution. Download PDF SIMILAR CONTENT

BEING VIEWED BY OTHERS AUTISM SPECTRUM CONDITION: AN UPDATE FOR DENTAL PRACTITIONERS - PART 2 Article 20 December 2024 THE NEW NORMAL - DENTISTRY AND THE AUTISTIC PATIENT Article 10

September 2021 THE DENTAL DEMOLITION DERBY: BRUXISM AND ITS IMPACT - PART 3: REPAIR AND RECONSTRUCTION Article Open access 10 June 2022 INTRODUCTION Autistic Spectrum Disorder (ASD) is a

disorder of behaviour, socialisation and communication. Sufferers may receive their dental care in general dental practice or in community clinics. In general, patients with ASD do not

exhibit any specific dental findings1 and have a low caries rate.2 The only truly unique oral findings are wounds resulting from self-injurious behaviour (SIB).3 It has been reported that as

many as 70% of autistic patients may show self-injury at some time in their lives,4 but this is generally seen in more severely affected individuals and can take many forms such as head

banging, scratching, bruising and biting. Autoextraction of teeth is an unusual form of SIB and is rarely seen in children with ASD. We report a case of a young child with mild ASD who

presented with unexplained dental pain and who subsequently went on to extract his own lower right deciduous canine tooth (73). CASE REPORT A seven-year-old boy, who had been a patient of

the community dental service for the last three years, presented with dental pain. His medical history revealed autistic spectrum disorder (ASD) and occasional eczema. Initially, dental

examination had only been possible with him sitting on his mother's knee, but over the three years he had grown in confidence and was now happy to be examined. No dental treatment had

been necessary before this episode of care. He had been born at term and during his early childhood had repeated ear infections. By two years his language was not developing well and he had

a very limited vocabulary. He was also slow to sit and walk. Grommet surgery did not help with his speech and he developed non-verbal communication, such as pointing. A diagnosis of

disordered language was made, but the development of further problems with social interactions and communication led to a diagnosis of ASD when he was six years old. He has also demonstrated

SIB in the form of head banging. However, he remained only mildly affected and continued in mainstream school. He was brought to the clinic complaining of pain of about one week's

duration that was increasing in intensity. The pain was present most of the time and was not sensitive to hot, cold or sweet stimulus. Clinical examination did not reveal any evidence of

caries or infection in this area. It did, however, reveal a need for sealant restorations in upper first permanent molars (16 and 26) and fissure sealants in lower first permanent molars (36

and 46). Within 24 hours the patient was again back at the clinic, as the pain had not resolved with ibuprofen, and by this time his lower right deciduous canine (83) was very slightly

mobile. An OPG showed no alveolar bone loss, normal root anatomy of 83, and 33 lying close to the border of the mandible with only crown formation completed. By the next day the patient had

extracted his lower 83 (Fig. 1), witnessed by his mother. He claimed it had been 'itching' him until he got it out. The socket looked completely normal and the pain resolved

immediately. The mother gave permission for the tooth to be sent to the University Dental Hospital of Manchester for further investigation, and in particular to exclude the diagnosis of

hypophosphatasia. Further appointments to restore upper first permanent molars (16 and 26) and fissure seal lower first permanent molars (36 and 46) were successful and no further pain was

experienced. DISCUSSION We describe a case of unexplained dental pain in an autistic boy who went on to self-extract a deciduous tooth. It has been reported that autistic children frequently

have atypical responses to sensory stimuli, such as an apparent hyposensitivity to pain.5 In this case the patient did experience some pain — presumably as a response to his attempts to

pull the tooth out — but not enough to deter him from autoextraction. There have been several reports of autoextraction in the literature, but most of these have been in adults. One

29-year-old patient with a diagnosis of a psychotic illness, who extracted both upper canine teeth, reported that the act decreased his tension and was painless.6 Another 27-year-old

psychiatric patient attempted to extract 12 permanent posterior teeth with pliers, but caused multiple crown fractures and all roots had to be removed surgically.7 Those reports which

describe children include one 11 year old girl who caused traumatic gingival ulceration whilst undergoing orthodontic treatment.8 In common with our patient she described an

'itchy' feeling and had an uncontrollable urge to scratch the area. Another report of self-extraction in children describes six patients with familial dysautonomia.9 There were 11

self-extracted teeth of which five were from the primary dentition. These authors conclude that self-extraction of teeth was mostly unintentional. In three patients it occurred during play

while pulling a toy held tightly between the teeth. We think it is unlikely that these teeth had the same root length as in this case. Although there are a number of rare causes of deciduous

tooth loss in children,10 nearly all of these are associated with significant alveolar bone loss (Table 1). In this case, the normal alveolar bone limits the differential diagnosis to two

or three causes. Child abuse was felt very unlikely, as the child was brought to the clinic in pain before the tooth was lost and there were no other accompanying signs. Munchausen by proxy

was discounted as the patient gave a history of extracting his own tooth. Hypophosphatasia was excluded following histopathological examination of the extracted tooth at the University

Dental Hospital of Manchester. No abnormality of formation of the dental hard tissues was found and both cellular and acellular cementum were present in normal quantity. Resorption of the

root apex cementum had just commenced. CONCLUSION A wide range of disorders may cause exfoliation of a deciduous tooth with an intact root. The occurrence should prompt a careful review of

the clinical history, (including family history), thorough examination and where appropriate, special tests including radiology and laboratory investigations. Those of us treating patients

with ASD should be aware of the high levels of self-injurious behaviour within this group. When faced with dental pain, which cannot be explained by more common causes such as caries or

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Paediatr Dentist_ 2003; 13: 130–137. Article  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Clinical Head of Community Dental Department, Community Dental

Service, Princess of Wales Hospital, Lynn Road, Ely, CB6 1DN M Ross-Russell * Professor of Oral Pathology, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15

6FH P Sloan Authors * M Ross-Russell View author publications You can also search for this author inPubMed Google Scholar * P Sloan View author publications You can also search for this

author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to M Ross-Russell. ADDITIONAL INFORMATION REFEREED PAPER RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE

CITE THIS ARTICLE Ross-Russell, M., Sloan, P. Autoextraction in a child with autistic spectrum disorder. _Br Dent J_ 198, 473–474 (2005). https://doi.org/10.1038/sj.bdj.4812250 Download

citation * Received: 17 November 2003 * Accepted: 10 May 2004 * Published: 23 April 2005 * Issue Date: 23 April 2005 * DOI: https://doi.org/10.1038/sj.bdj.4812250 SHARE THIS ARTICLE Anyone

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