Care under general anesthesia of patients with autistic spectrum

Introduction: The dental treatment of an autistic patient is the most diffi cult and the patient's collaboration is often lacking. Objective: Thus, the objective of this report is to present a clinical case of a non-collaborating autistic patient in which it is the only viable option for carrying out treatment under general anesthesia in a hospital environment. Case report: Male patient, 24 years old, who was consulted for a dental appointment for the fi rst time to assess the oral cavity. It was observed that there is a need for dental treatment and extractions. The patient was non-verbal, uncooperative and aggressive. Altered behavior control was indicated for general anesthesia for treatment dental care. Result: All dental treatment was performed with the patient under general anesthesia, including prophylaxis with prophylactic masses, a restoration and two extractions in the upper arch and one extraction in the lower arch. Conclusion: General anesthesia allows adult autistic patients not to cooperate to be considered effective and with quality. Case Report Care under general anesthesia of patients with autistic spectrum Paola da Cunha Busquet1, Desirée de Jesus Portelinha2, Monica Lage da Costa1 and Viviane de Andrade Cancio de Paula2* 1 Dentistry Student, School of Dentistry, Salgado de Oliveira University, Rua Marechal Deodoro 217, Centro, Niterói, RJ, CEP 24040-110, Brazil 2 DDS, MSc, PhD, Department of Pediatric Dentistry, School of Dentistry, Fluminense Federal University, Rua Mário Santos Braga, No. 30-Campus Valonguinho, Centro, Niterói, RJ, CEP 24040-110, Brazil Received: 24 February, 2021 Accepted: 05 March, 2021 Published: 06 March, 2021 *Corresponding author: Dr. Viviane Andrade Cancio de Paula, DDS, MSc, PhD, Department of Pediatric Dentistry, School of Dentistry, Fluminense Federal University, Rua Mário Santos Braga, No. 30-Campus Valonguinho, Centro, Niterói, RJ, CEP 24040-110, Brazil, Tel: 55 21 2629-9829; E-mail:


Introduction
Autism spectrum disorder is defi ned as a spectrum of developmental disorders that starts early, characterized by impaired motor, social and communication skills, in addition to stereotyped behaviors. Autism does not yet have its etiology fully defi ned, but it is known that it is multifactorial and is associated with genetic links [1].
The characteristics of autism are noticeable before the age of three, when the child's language is delayed, lack of social interaction, limited and stereotyped patterns. There are atypical behaviors that characterize autism and manifest themselves in different ways and levels. One can fi nd autistic people who speak and others who do not; some may have intellectual disability and others with a high intellectual level; others with no social relationship and others with a good social relationship. A recent survey in the United States found that the prevalence of autism is 1 in every 54 children born. In addition, ASD is 4 times more common in boys than in girls [2].
The cause of autism spectrum disorder is not yet well defi ned in the literature, but you know the sooner for an intervention the better for the quality of life. Therefore, early diagnosis is an important importance, since a late diagnosis makes any type of approach diffi cult [3].
For the dental treatment of these patients, caution, patience and understanding of those who are not equal to those who see them are necessary; therefore, it causes the changes caused by sensory and stressful stimuli, to be released and objective and rotating care [4]. But not all of these stimuli are always a guarantee of good dental care, and in the latter case, it is necessary to use general anesthesia [5].
General anesthesia is an anesthetic technique that promotes total unconsciousness and inhibits pain. It is done when the other methods are ineffective for patients who are unable to be treated under normal conditions, where they usually suffer physical or mental changes [6,7]. For these cases it is extremely important to have knowledge of the patient's hospitalization process, what type of procedure and to control the postoperative period, thus enabling surgical intervention by inhalation or intravenous medication, but in dentistry local anesthesia is not dispensed for the case extractions. In this process, it is also important to request surgical risk so that a procedure can be performed with greater safety. The risk includes preoperative physical status before general anesthesia is actually performed [8].
People with autism often have serious health problems, which increases their anesthetic risk [9]. Therefore, the choice of anesthetic is of great importance and responsibility, it must present fast and smooth anesthesia, safely recovering its effects, having a wide safety margin and not having side effects [10].
General anesthesia can be divided into three phases: the induction phase, this fi rst phase is fundamental to all sedation processes, its duration is variable, depending on the anesthetic agents used. The maintenance phase takes place after the beginning of the deep phase, allowing completing the procedures and fi nally, the recovery phase, where the interventions are fi nalized until the patient regains his mental state. The most frequently used drugs are isofl uorane and sevofl uorane, as they offer great safety with little side effect.
Isofl uorane is the most widely used anesthetic, as it has low toxicity and is poorly metabolized [11].
Having intravenous induction as the most used, with the respiratory function completed with devices called mechanical ventilators, where the lungs are connected to the devices through the nasotracheal or orotracheal tube. General anesthesia is one of the safest, considering that in most cases the patient is discharged on the same day [12].
This paper aims to report the clinical case of a male patient who underwent dental treatment under general anesthesia.

Case report
Male patient, F.G.L. 24 years old, leucoderma, with autism spectrum disorder, presented himself to the dental offi ce with his person in charge to assess his oral health, with no apparent main complaint.
In the anamnesis, it was reported that the patient was non-   arch, extraction of the right lower third molar, semi-enclosed, was performed with quinelate forceps 17 (Figures 6-8). The extractions were sutured with a resorbable violet Vicryl 3.0 thread (Atramat®). There were no complications during the surgery. And the orofaging plug was removed at the end of the surgery.
The patient was then referred to the RPA and then to the room. He was under the care of the nursing staff until the end of the day and was discharged at 16:00 on the same day. with what is real, what causes great diffi culty or even the impossibility of communication [13,14].

Discussion
Autism is a highly complex developmental disorder, defi ned by multiple etiologies, different degrees of behavior and degrees of severity. Characterized by severe specifi c delays, motor and cognitive dysfunctions. It is considered one of the most serious neuropsychiatric disorders, where it is more prevalent in boys, but when in girls it tends to be more compromised [9].      Behavioral manifestations that defi ne the characteristics of autism include its diffi culty in social interaction, repetitive and stereotyped behavior patterns, poor communication and little interest in activities, when this interest is always for the same thing. Stereotyped patterns include resistance to change, clapping repeatedly, and gait and tend to repeat words. Communication diffi culties happen to different degrees, many have good verbal skills and others are non-verbal, others have immature language characterized by echolalia [15].
The diagnosis has several reinforcements, in which most assess communication, social interaction, repetitive behavior patterns and disinterest in conventional activities. However, there is still a need for greater diagnostic criteria with more precision so that there is an increasingly early and individualized intervention and diagnosis for each case. Treatment consists of skill establishments with instant functionality, including social skills among other skills for greater social interactions [16]. A limitation of this work is the risk inherent to general anesthesia. The risks of this technique (risk of the patient's life) were weighed, however this was the only possible way for this assistance.
The patient in this non-verbal and aggressive autistic case report went to the dental offi ce for the fi rst time, but because he has no social interaction, is non-verbal and is an adult with great physical and aggressive strength, it was concluded that treatment would be unfeasible dental chair. For the feasibility of patient / dentist care, treatment under general anesthesia was mandatory [17].
General anesthesia in patients with special needs is of great importance when in some cases it is not possible to carry out the treatment in the dental chair, since most of them have conditions that make them impossible, but there are contraindications [17]. Routinely undergoing treatment under general anesthesia, the patient cannot have a weakened immune system, presenting with a cold, fever, asthmatic crisis or heart failure [12].
People with special needs, such as those with autism, can present serious health problems, with this, there is a greater anesthetic risk, and therefore the anesthesiologist is responsible for adjusting the chemical containment dose. The anesthetic must have fast and smooth action; have good safety and good recovery after anesthetic effect. Before administering the sedative, the best therapeutic option must be chosen, where it can perform actions and start quickly, drugs of short duration to avoid prolonged analgesia, duration of the predictable action being monitored for a certain period, moderate cardiovascular effects, the effects and the duration cannot be altered by the disease carried by the patient. Previous laboratory tests are also required to assess the patient before general anesthesia [18].
The most used drugs are isufl uorane and sevofl uorane, which offer greater safety with few side effects, have low toxicity and are poorly metabolized. During the operative process, vital signs are monitored by equipment that shows your temperature, blood pressure, shows your electrocardiography and your O2 saturation. Capnography assessment, analysis of inhaled anesthetic gases, analysis of inhaled anesthetic gases and assessment of nasotracheal pressure are required. The average duration of dental treatment under general anesthesia lasts around six hours, with the fi nal two hours for patient recovery. In the vast majority of cases, the patient is discharged on the same day after the procedure if there are good oral and systemic health conditions [19].
Dental treatment performed under general anesthesia is not a viable and routine option. However, in this case, it was possible to show that treatments can be performed in the operating room safely for the team and for the patient. These treatment options must be disseminated in order to bring this possibility to the patient and the professionals to understand how it works so that it is more and more widespread [20].

Conclusion
Adult patients with ASD should receive different treatment, prioritizing the prevention of oral diseases and emphasizing the guidelines regarding diet and oral hygiene. For some more aggressive patients such as the one in the reported clinical case, outpatient care is not feasible, thus, the restoration of oral health occurred through general anesthesia. It is essential to monitor patients with ASD to maintain oral health.