Abstract

General anaesthesia (GA) may be required to undertake dental treatment for children with special needs including Autism Spectrum Disorder (ASD) Learning Disabilities (LD) and Global Developmental Delay (GDD). It may be required due to behavioural challenges, severe dental anxiety or phobias and extent of dental treatment needed. Guidance is needed for teams delivering dental treatment for paediatric patients with Autism using GA due to the potential risks, implications, and costs of using GA to deliver effective dental care ensuring smooth journey for patients and families. This article aims to present evidence-based recommendations for teams involved in providing GA for dental care to patients with ASD and special needs. The need for comprehensive and person-centred assessment and planning should be prioritised. Thorough assessment for every stage (starting from initial dental consultation to recovery and discharge post-operatively) to ensure safe and effective dental and medical care.

Keywords: Autism Spectrum Disorder; General Anaesthesia; Dental Treatment; Holistic approach; Tailored treatment

Abbreviations:ASD: Autism Spectrum Disorder; LD: Learning Disabilities; GDD: Global Developmental Delay; GA: General Anaesthesia; OPG: Orthopantomogram; LA: Local anaesthetic; IM: Intramuscular

Introduction

Globally, around 2% of the population is estimated to have a learning disability (LD). In England, there are approximately 75,000 children and young people with moderate to severe learning disabilities. In this context, “special needs” refer to a learning disability (IQ<70), language and communication disorders, or any disability that hinders a child from coping well with new experiences. While children with learning disabilities may generally have good physical health, Global Developmental Delay (GDD) often accompanies a syndrome or condition linked with other physical health issues (e.g., cerebral palsy, Down’s syndrome, metabolic disorders) [1]. The anaesthesia management for treatment for these patients has been well documented in literature. However, this paper aims to discuss dental treatment of children with Autism Spectrum Disorder (ASD) under General Anaesthesia (GA). Many children with special needs visit hospitals for medical investigations or surgical management and may experience high levels of anxiety due to unfamiliar surroundings and struggle to adapt to typical patterns of care. In severe cases, children may become so distressed that their procedure needs to be postponed, abandoned, or performed using heavy sedatives. Therefore, it is crucial to find ways to tailor treatment to individual needs, address concerns, manage challenges, particularly in areas such as information sharing, communication, anxiety management, and provision of a smooth and positive experience for patients and their family. This article will briefly discuss aspects of dental care under general anaesthesia for patients with Autism Spectrum disorder (ASD) and special needs including psychological and social aspects, logistics, pharmacological and clinical care. This review article has been structured into sections to briefly discuss and explore all steps of care and therefore, does not follow the typical format of an original research article (introduction, methodology, results, discussion, conclusion).

Autism Spectrum Disorder

Patients with special needs, such as autistic spectrum disorder (ASD), learning difficulties (LD), disabilities, and global developmental delay (GDD), may require a flexible treatment approach. ASD is a lifelong developmental disability characterized by a 4:1 male-to-female ratio and a ‘Triad of impairments’.1 Patients with ASD may have a lower-than-average IQ, but may exhibit normal or high intelligence. Autistic individuals have a ‘theory of mind’ deficit, where it may be difficult to understand or relate to others’ perspectives and intentions [2]. They may also face difficulties with social communication, interactions, and imagination. There may also be various perceptual deficits seen in patients with ASD. Patients with ASD may exhibit specific behaviours such as avoiding direct eye contact or physical touch and may engage in repetitive behaviours. Their diet might be restricted to a limited range of preferred food or drinks (preferring a specific texture, colour, taste and avoiding certain smells or consistency of food). They may have limited or nonverbal communication [3]. Conversely, they may demand repeated complex factual explanations. Patients with moderate to severe Autism tend to understand basic functions such as moving and eating but may struggle to appreciate higher mental functions like thinking, dreaming, and keeping secrets. In terms of appearance to reality distinction, patients with ASD may face difficulties in understanding dual identities of objects, for example, identifying a candle shaped as an apple. Another challenge is the understanding of false belief – patients with ASD may struggle to grasp that people’s minds do not hold the same information, leading to confusion in communication and meeting their needs [4]. Lastly, children with ASD may lack social imagination and exhibit deficits in flexible thinking regarding interests, routines, perspectives, and rules.

Emerging evidence suggests that ASD may be linked to biochemical and metabolic issues, such as mitochondrial dysfunction, increased lactate, B-vitamin complex deficiency (connected to intestinal problems or limited dietary intake), and increased oxidative stress related to abnormal lipid levels in cell membranes [5]. While most children with ASD can handle GA and sedation without any problems, a small number of patients may experience unpredictable regression in skills and behaviour after GA [6]. In such cases, it may be advisable to use an anaesthetic technique suitable for patients with mitochondrial disease. Recommendations include ensuring good hydration, minimal fasting, using caution with Hartmann’s solution (due to elevated blood lactate levels), maintaining normal blood glucose, body temperature, and acid–base balance, and avoiding oxidative stress [6].

Patient and Family Journey for Dental Treatment Under General Anaesthesia

History and examination

Patients with limited or non-verbal communication skills may have trouble describing symptoms including pain or providing their medical history. Therefore, it is crucial to obtain an objective view and history from the parents, legal guardians or caregivers. If patients also have difficulty with physical contact during an examination, it may be necessary to conduct the examination under GA and decide on surgical treatment during the procedure. While this approach offers some flexibility, it can complicate the consent process [7] and may necessitate the surgeon speaking to parents while the child is anaesthetized. Having multiple clinicians on site may facilitate this process. History taking from parents/ carers can assist in predicting the need for premedication, response to physical touch, acceptance of oral medication, predictability of challenging behaviour associated with unfamiliar surroundings of fasting. An Autism passport may prove helpful with visual clues. This can also be undertaken by telephone (at preoperative assessment stage) or by a parent/guardian/ carer visiting the hospital without their child before the admission. An example of patient passport for patients with learning disabilities at Chelsea and Westminster Hospital NHS Trust, as shown in Figure 1 [8].

Investigations

Patients may be unable to understand the instructions required to perform investigations (e.g. Orthopantomogram - OPG) [9] and may have difficulty cooperating with more invasive investigations (e.g. blood tests). Therefore, piggyback procedures with other team and facilitation of blood tests can be undertaken (e.g. opportunistic blood sampling while anaesthetized) [10].

Dental Treatment planning

Autistic patients can face significant challenges in oral care and dental treatment. Sensory issues, such as the taste and texture of toothpaste and toothbrushes, can make cleaning at home very difficult. The dental and hospital setting can be overwhelming for the patient from the touch, sounds, smells and new faces. Communication difficulties can delay the child seeking out a dentist until they are visible distress and pain. Other conditions can present by behaviours related to autism such as self-injurious behaviour, restrictive eating habits, use of medication and hyposensitivity to pain [11]. Dentists should be understanding, empathetic and encouraging to the patients and carers.

Examination and treatment can be extremely difficult where general anaesthesia is the only realistic option to complete treatment. Dental treatment options and plan may differ considerably compared to a fit and well child for example management of carious teeth and dental trauma. Guidelines are to be applied using careful evaluation of specific clinical circumstances, the clinician’s judgement and the patient’s characteristics including probability of compliance and understanding of the immediate and long-term outcome of the various treatment options [12].

Depending on the patient, consultation and access to care, treatment can range from restorations, extractions to full rehabilitation including root canal treatment, impressions for removal or non-removable prosthesis. Carers must be aware of the limitations and possible need for second or repeat general anaesthetic in the future. Local anaesthetic (LA) agents may be administrated but there is limited evidence for the analgesic benefit for the child in the presence of systemic analgesia. The patient may become distressed by the numbness sensation with the risk of trauma to tongue, lips and cheeks [13]. Completing the dental treatment and access can be difficult from factors such as method of intubation, increased salivation from anaesthetic agents and patient’s anatomy. A holistic approach to care must be undertaken.

Pre-Operative Assessment and Logistics

Following initial GA assessment and dental treatment planning appointment, the logistics are confirmed including time slot for the treatment (longer slots for more complex treatment), necessity of pre-operative assessment undertaken by Anaesthetic nurse specialist or Consultant Anaesthetist for patients with complex medical history and comorbidities [14]. Any interprofessional liaison with professionals including healthcare providers including nutritionist, dietician, speech and language therapist, social workers, school nurses are undertaken at this stage to avoid unpredictable outcomes.

Social Impact

There is a significant social impact of a hospital visit on a child with special needs and their family. Research suggests families often perceive inadequacies in the health care provided, mostly related to the social aspects rather than the medical treatment. Some examples include staff lacking in understanding of the specific challenges faced by families, reliance on family caregivers in the hospital, the impact of the child’s hospitalization on caregivers and families, difficulty in coping due to changes in routine or the unfamiliar nature of the hospital setting (for the child and carers). Additionally, there are challenges of managing daily activities such as feeding, entertainment, and hygiene needs outside of the familiar home environment. Understanding the aforementioned potential sources of frustration and distress and aiming to minimise them can greatly improve a family’s experience [15]. Childcare responsibilities may also impact the care given on the day of procedure, adding additional pressure on parents/ carers or legal guardians. Carers should be clearly instructed to block half a day for the procedure and recovery, sorting other childcare responsibilities and ensuring other children (siblings) should not attend on the day of the procedure as patients may require undivided attention pre and post operatively. Table 1 shows factors to take into consideration at different stages of GA to ensure all needs are tailored and met.

Admission process

Children with special needs may not fully understand why they are in a hospital or why certain procedures are necessary [16]. These procedures, such as measurement of weight or height, or preparing for an I.V. cannulation site, can sometimes be uncomfortable or even painful for them. Expressing their distress can be difficult for these children, and they may respond by being uncooperative or disruptive. They often rely on a familiar daily routine, and deviations from this routine can be challenging for them. Lengthy waits in noisy environments and prolonged fasting can exacerbate their distress. The order of a list must be determined based on both medical and psycho-social factors to effectively mitigate medical risk and minimize distress associated with waiting, as well as to prevent disturbance to other patients.

The order of the list and time of admission must be planned strategically to minimize waiting times and the distress or anxiety associated with delays. Table 2 shows anxiolysis strategies that can be adopted to minimize patient distress and anxiety preoperatively.

Team Brief

Prior to the start of a session, it is important to conduct a team brief which includes introductions, prioritizing the tasks at hand, and addressing any potential key issues. The briefing should also cover the patient’s journey to the operating room, roles and responsibilities of all staff members during this journey, the planned GA induction method, airway management approach, and the necessity for intra‐operative investigations to ensure safe care delivery [1]. The method employed for management of airway should be decided during the team briefing after a thorough discussion between the anaesthetist and surgeon/ clinician, considering both factors affecting patient and procedure to be undertaken.

Staff working in the theatre and involved in caring for patients with special needs should receive training in positive behaviour management and patient management. During the anaesthesia induction, a caregiver or family member should be present to provide reassurance, support, and clinical holding (if needed). To help anxious patients who may find the theatre environment distressing, the number of theatre staff present during the anaesthesia induction should be limited. Medication, equipment and instruments should be prepared well in advance by the anaesthesia team ensuring any sharps, needles and syringes that may cause stress and heighten anxiety in patients are removed from direct sight [9].

General Anaesthesia strategies

It is important to establish and communicate a system within the team responsible for the care of a patient with special needs well in advance of the procedure. This will enable the specific needs of the patient to be identified, evaluated, and addressed. A checklist completed before admission can be beneficial in understanding the physical and psychological needs of the child, including details about their mobility, methods of communication, preferences, aversions, fears and phobias [17]. Parents or caregivers can provide assistance with information regarding the child’s weight, height, and baseline observations on the day of admission. Gathering this information ahead of time is crucial for planning the logistics of the surgical day, such as arranging a quiet waiting area (such as a cubicle or sensory room), prioritizing the child on the operating list to minimize fasting time and expedite discharge (being scheduled first or second on the list), requesting a surgical trolley of appropriate length, and ensuring availability of airway management tools for patients with a high BMI, among other considerations. In some instances, the anaesthetist may decide to schedule the child as the second case on the list due to the anticipated time required for premedication to take effect. Families should be encouraged to bring toys, tablets, video games, or other familiar items that can soothe and engage their child. Accessibility and availability to a “communication passport” can be highly beneficial during the admission process as the document highlights patients’ needs, usual routines, and management or communication strategies.

Understanding the child’s level of comprehension and communication needs is crucial for ensuring a smooth preoperative and postoperative journey. However, these resources can be valuable for special needs children who have some understanding and need detailed explanations of events. For instance, Figure 2 demonstrates a social story for treatment under general anaesthesia. The presence of a familiar caregiver, the maintenance of physical comfort, and the availability of personal comfort aids such as soft toys and headphones can significantly contribute to creating a familiar and comforting environment for these children [1,17].

Premedication

Children with special needs can often benefit from receiving sedative premedication to lower anxiety and encourage cooperation prior to general anaesthesia induction. It’s important to communicate effectively and prepare the child well to ensure they take the oral medication. Mixing the medication with beverages like juice can help mask the taste and make it more pleasant. Topical local anaesthetic cream is usually effective for IV cannulation, although not all patients may tolerate it well. In such instances, inhalation induction can be a suitable alternative [9].

The most commonly used premedication is Midazolam, however, in certain cases its use may cause paradoxical dysphoria rather than sedation. At times, sedation may not prove effective and be inadequate due to insufficient or delayed timing of sedative administration to GA induction, the type of sedative agent used, administration route and dose. If historically, the child previously spat out oral medication, administering the medication via intranasal route may ensure better drug delivery. If premedication was previously unsuccessfully due to lower dosage used, a higher dose of the same agent or a synergistic medication combination may prove effective [18,19]. For children exhibiting challenging behaviour or previously failed premedication attempts, a combination premedication regime [18,19] can be followed, as shown in Table 3.

Premedication options are suggested in Table 4 with medication characteristics, taken from a review article by Heikel and Start [19].

If oral medications are not an option, either due to refusal, contraindication, or lack of success, alternative routes such as buccal or intranasal midazolam, or intramuscular (IM) ketamine can be considered. Additionally, clinical holding to support cannulation by caregivers or parents, and rapid administration of anaesthetic agents via buccal, intranasal, or IM routes may be considered as alternatives [20,21].

Intraoperative Care

It is crucial to have a simple, straightforward, and flexible plan for anaesthesia to ensure a successful outcome from sedation to the recovery phase. Effective pain management can be achieved by using local anaesthetic (LA) methods, paracetamol, and non-steroidal anti-inflammatory drugs. An antiemetic agent and isotonic crystalloid fluid bolus may prove to be effective in reducing postoperative nausea and vomiting. These measures are especially important in patients with special needs, as it can be challenging to differentiate between potential causes or reasons of postoperative discomfort, such as pain, nausea, numbing effect of local anaesthetic, post-sedation confusion, unfamiliar setting and staff, and residual disorientation remaining from preoperative sedation [1,9,18,19].

A cuffed endotracheal tube is the recommended approach for managing the airway of special needs children under general anaesthesia. When considering the use of a nasal tube, the dental team should weigh between the benefits (better access and visibility) and risks (nasal trauma and bleeding). The aesthetic and dental teams should have a conversation to decide on the most suitable approach for each individual case. A laryngeal mask airway (LMA) device is another option; however, it hinders access and visibility to the operative field and may provide an incomplete seal (and may pose a risk especially if irrigation fluid is being used). Therefore, laryngeal masks should be used with caution for dental treatment in special needs children, unless it is a short and simple procedure for a patient with an uncomplicated airway. Throat packs should be considered on an individual case basis, especially when significant debris is expected from the dental treatment planned [22]. It is mandatory to document the insertion and removal of a throat pack when it is used. Only the anaesthetist should make adjustments or replacements to an anaesthetic airway.

Postoperative Care

Pain assessment and management can pose challenges when dealing with children who have limited or non-verbal communication skills, as they may struggle to articulate the location or nature of their pain. Therefore, it is essential to utilize scales based on individual pain behaviour to ensure effective pain management [23]. Pre-emptive analgesics should be administered intra-operatively to facilitate the transition to children’s ibuprofen or acetaminophen postoperatively [24]. In circumstances where oral analgesics are not accepted, suppositories may be considered. It’s crucial to prioritize a quick and seamless recovery for special needs patients who have had simple day surgery procedures. The removal of intravenous (I.V.) cannula should be done promptly once full airway control is confirmed and there’s no immediate need for additional I.V. medication. Following consultation with caregivers, patients can be discharged once they have returned to their typical level of orientation and mobility, even if they haven’t met standard discharge criteria (such as eating, drinking, or urinating) [25]. This decision should be communicated during the pre-procedure team briefing and to the admissions and recovery team. An Autism pathway recommendation is outlined in Table 5. A multidisciplinary team approach is vital for the management of patients with special or additional needs and to achieve overarching goals of improving quality of care, ensuring smooth journey for patients and families. This pathway is designed to be used by all professionals within the dental and theatre teams who look after children or young people with Autism, in Paediatric theatres. Caregivers should be given guidance and instructions on providing appropriate pain relief at home. It’s also important to advise caution in helping a child protect an area that has been treated with local anaesthetic (for example, avoiding lip biting after dental surgery).

Conclusion

Managing dental care for pediatric patients with autism under general anesthesia can be challenging for the patient, caregivers, and healthcare providers. A comprehensive and personalized approach with input from multiple disciplines is essential. With proper training, teamwork, preparation, and understanding, we can make a positive impact on their oral and overall well-being, ensuring a smooth journey for the patient and their family.

References

1. Judith Alison Short, Alyson Calder (2013) Anaesthesia for children with special needs, including autistic spectrum disorder, Continuing Education in Anaesthesia Critical Care & Pain 13(4): 107-112.
2. Baron-Cohen S (2001) Theory of mind in normal development and autism. Prisme 34: 174-183.
3. Sanctuary MR, Kain JN, Angkustsiri K, German JB (2018) Dietary Considerations in Autism Spectrum Disorders: The Potential Role of Protein Digestion and Microbial Putrefaction in the Gut-Brain Axis. Frontiers in nutrition 5: 40.
4. Manzi F, Savarese G, Mollo M, Iannaccone A (2020) Objects as Communicative Mediators in Children with Autism Spectrum Disorder. Frontiers in psychology 11: 1269.
5. Herbert MR (2005) Autism: a brain disorder or a disorder that affects the brain. Clinical Neuropsychiatry 2(6): 354-379.
6. Brown S (2024) Autism and anaesthesia: a simple framework for everyday practice. BJA Education 24(4): 129-137.
7. The Role of General Anaesthesia in Special Care and Paediatric Dentistry; Inclusion Criteria, consent and Clinical Indications (researchgate.net)
8. https://www.chelwest.nhs.uk/your-visit/advice-and-support/learning-disabilities/links/Learning-Disabilities-Passport.pdf
9. Geddis-Regan AR, Gray D, Buckingham S, Misra U, Boyle C (2022) British Society for Disability and Oral Health. The use of general anaesthesia in special care dentistry: A clinical guideline from the British Society for Disability and Oral Health. Special care in dentistry: official publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry 42(S1): 3-32.
10. Reducing general anaesthetic episodes: ‘piggyback' procedures - Birmingham Children's Hospital experience | British Dental Journal (nature.com).
11. Morales-Chávez MC (2020) Oral health assessment of a group of children with autism disorder. J Clin Pediatr Dent 41(2): 147-149.
12. Bourguignon C, Cohenca N, Lauridsen E, Flores MT, O'Connell AC, et al. (2020) International association of dental traumatology guidelines for the management of traumatic dental injuries: Introduction 36: 310.
13. Microsoft Word - LA 18.08.11 Main Dental Guidelines (bspd.co.uk)
14. Key W, Swart M (2019) Chapter 2: Guidelines for the Provision of Anaesthesia Services for Preoperative Assessment and Preparation 2019. London: Royal College of Anaesthetists.
15. Brown FJ, Guvenir, J (2009) The experiences of children with learning disablilities, their carers and staff during a hospital admission. British Journal of Learning Disabilities 37(2): 110-115.
16. Being a child with intellectual disabilities in hospital: The need for an individualised approach to care - Oulton - 2024 - Journal of Applied Research in Intellectual Disabilities - Wiley Online Library.
17. Howley M, Arnold E (2005) Revealing the hidden social code: Social stories for people with autistic spectrum disorders. Jessica Kingsley Publishers.
18. Rainey L, Van Der Walt JH (1998) The anaesthetic management of autistic children. Anaesthesia and intensive care 26(6): 682-686.
19. Anxiolytic premedication for children - BJA Education.
20. Hanamoto H, Boku A, Sugimura M, Oyamaguchi A, Inoue M, et al. (2016) Premedication with midazolam in intellectually disabled dental patients: intramuscular or oral administration? A retrospective study. Med Oral Patol Oral Cir Bucal 21: e470‐e476.
21. Lim SW, So E, Yun HJ (2018) Analysis of the effect of oral midazolam and triazolam premedication before general anesthesia in patients with disabilities with difficulty in cooperation. J Dent Anesth Pain Med 18(4): 245-254.
22. Anderson CR, Premakumar Y, Navaratnam AV, Rouhani M, Singh A (2020) The use of throat packs in ear, nose and throat, oral and dental surgery: a systematic review. Rhinology 58(4): 306-313.
23. Carter B, McArthur E, Cunliffe M (2002) Dealing with uncertainty: parental assessment of pain in their children with profound special needs, J Adv Nurs 38: 449-457.
24. Wong M, Copp PE, Haas DA (2015) Postoperative Pain in Children After Dentistry Under General Anesthesia. Anesthesia progress 62(4): 140-152.
25. Kumar G, Mythen M, Walker D (2019) Chapter 4 Guidelines for the Provision of Anaesthetic Services for Postoperative Care. London: Royal College of Anaesthetists.