Protocolli terapeutici nei pazienti affetti da patologie sistemiche o sindromi. Disturbo dello Spettro Autistico: un aggiornamento sulla gestione della salute orale in età pediatrica

Autism spectrum disorder (ASD) is a complex developmental condition that involves persistent challenges in social interaction, speech and nonverbal communication, as well as in restricted repetitive behaviour. It is more common in males than in females (with a ratio of 4:1) and is usually first diagnosed in early childhood (around 2-3-year-old) with many of the most-obvious symptoms. The effects of ASD and the severity of symptoms differ from person to person. While some people with ASD can live independently, others have severe disabilities and require life-long care and support. ASD prevalence appears to be increasing globally over the past 50 years. There are many possible explanations for this increase, including better diagnostic tools, improved reporting, greater propensity for families to accept the pathology, greater presence in the territories of support structures and associations and changes in health policies. A report of 2018 from the World Health Organization estimates that 1 in 160 children (i.e., 62.5/10,000) worldwide have one of the various forms of ASD and that ASDs begin in childhood and tend to persist during adolescence and adulthood As far as Italy is concerned, prevalence estimates are based on surveys performed on patients attending the National Health System (NHS). The most recent estimates indicate prevalence of 23/10,000 for the Emilia-Romagna region in subjects aged up to 18 years (year 2016) and of 29/10,000 for the Piemonte region (year 2010). These estimates rise respectively to 80/10,000 and 42/10,000 if only children in primary school age (6-10 years) are considered. Another recent prevalence estimates for the province of Pisa in 2018 is as high as 1 in 87. Despite the differences in the reported prevalence, all these studies clearly indicate that ASD is a pathology with a strong social impact and important public health implications. In this respect, oral health problems represent a key component. Normal daily activities a such as tooth brushing as well as understanding the behavior of other individuals, constitute a constant challenge for children affected by ASD. Due to these difficulties to maintain a good oral hygiene and to be periodically examined and eventually treated, children with ASD have significantly more untreated caries and a higher prevalence of periodontitis and gingivitis as well as higher values of DMFT/dmft and caries prevalence compared to the average population. In addition, dental care, for patients with such disorders, requires special procedures and adaptations. It has been proved, that some patients with moderate or slight intellectual disorders can be successfully treated through paying particular attention to the procedures even if they adapt slowly and with difficulty to them. Autistic children, if compared to other patients with psychiatric disorders, show a greater obstacle to deal with, which is anxiety. A dental surgery is full of potential frightful stimuli, due to the peculiar environment and equipment used. In these children, it is often more difficult to interpret, beforehand, the signs of fear and anxiety and thereby to prevent the loss of cooperation, but it is possible to carry out dental care when such anxiety signs are recognized and duly considered. Evidence-based psychosocial interventions, such as behavioral treatment and parent skills training programmers, can reduce difficulties in communication and social behavior, with a positive impact on well-being and quality of life for persons with ASD and their caregivers. These type of interventions, that require special training programs for the dentists operating with children affected by ASD, represent an important economic load for families and/or national public health systems. The worsening of periodontal health due to scarce domestic hygiene and food habits for this population, already highlighted in some of the existing literature for similar populations, stresses the need for establishing specific preventive and intervention programs for children with ASD. One important aspect of such a program should include a collaboration between therapists/neuropsychiatrists and dentists and hygienists. This collaboration could have very beneficial effects in terms of improvement of dietary and horal hygiene habits of the children and would allow an early diagnosis and treatment of their oral health problems drastically reducing the need for general anesthesia. It is hoped that, a surveillance system will be set up to better understand the need for treatment and the outpatient management enhancing existing approach to dental care of patients with ASD taking into account the communicative and behavioural difficulties that these patients present48.