Chemical Dependency: Alcoholism
Center for Contining Dental Education
Fetal alcohol syndrome (FAS), is a disorder characterized by growth retardation, facial abnormalities and central nervous system dysfunction, but is most characterized by the affected individual's bad judgment and the inability to recognize the consequences of their actions. As dental professionals, highly skilled in performing extra- and intra-oral examinations on all our patients, we are in the ideal position to detect the presence of fetal alcohol syndrome (FAS) since so many of the manifestations involve facial structures.
It is interesting to note that the incidence of FAS today surpasses Down's syndrome and spina bifida. FAS is estimated to occur once in every 500 - 750 births. Since many cases go undiagnosed or misdiagnosed, it is assumed that this reported number is lower than the actual number of babies born with FAS.
FAS has no cure, but it is 100% preventable.
The terms "fetal alcohol effect" (FAE) and "alcohol-related birth defects" are used to describe individuals who exhibit only the mental/behavioral attributes (and not the physical attributes) of FAS and thus do not fulfill the overall diagnostic criteria for the syndrome.
FAS, first described in the published medical literature in 1968, refers to a myriad of physical abnormalities, most obvious in the features of the face and in the reduced weight of the newborn, and in problems of behavior and cognition, found in children born to mothers who drank heavily during pregnancy.
The costs of FAS and related conditions can be quite high—for the individual, for the family, and for society. Rates of FAS in several of the most complete studies are similar—on the order of 0.5 to 3 cases per 1,000 births. This translates into 2 to 12 thousand FAS births per year in the USA. These incidence figures emphasize the magnitude of a problem,-for the individual and for society.
FAS is caused by prenatal exposure to high levels of alcohol. FAS is not a "drunk" baby or a baby physically dependent on or addicted to alcohol. Although the manifestations of FAS might change with age, FAS never completely disappears and, as with many developmental disabilities, there is no cure.
Utilizing MRI technology, researchers are able to perform non-invasive examinations of the brains of living children who have histories of prenatal alcohol exposure. Studies have shown FAS brains ar an average of 25 percent smaller than the brains of those in a control group. The volume of the cerebellum was reduced by about 20 percent, and other defects were also present.
Another study using MRI technology assessed the corpus callosum in children exposed to significant amounts of alcohol in utero. The corpus callosum is a bundle of fibers that connect the right and left hemispheres of the brain, thus facilitating transmission of information between the hemispheres. In this study, the corpus callosum was completely absent in some children, while the overall area of the corpus callosum in the remaining children was significantly smaller than in a control group of children. Damage to either the corpus callosum, or the right or left hemispheres causes very poor, or inappropriate responses. For example, when the corpus callosum can't access the appropriate information quickly enough, the person's reaction to stimuli will be spontaneous, impulsive, and based on instinct. In effect, the "wiring" to the brain has been severely damaged.
Another recent study reported an elevated risk for brain hemorrhage, or white matter damage in infants whose mothers reported consuming at least seven drinks per week or at least three drinks per occasion during pregnancy. Other studies indicate that alcohol acts as a dessicant and literally dries up the brain of the developing fetus.
One theory to explain how alcohol does its damage to the fetus involves hypoxia, or lack of oxygen.
According to the National Institute on Alcohol Abuse and Alcoholism, hypoxia has been called the most common cause of all cell death. In the fetus, hypoxia may play an important role in alcohol teratogenesis (disruption of growth process). Alcohol constricts the blood vessels of the placenta and umbilical cord in humans which will produce profound effects on blood flow. Alcohol can also suppress fetal "breathing" movements.
Certain brain areas such as the hippocampus (plays a role in memory) may be more vulnerable to hypoxia since they are very vascularized and have a high concentration of neurons. A leading FAS researcher, Ernest Abel, has shown that some of the neurons grow too fast and some grow too slow and some do not migrate to the right place in the brain. Some lose direction as to what kind of neural cell they are to become. Most of the effect occurs during the cell's latent or planning period in between growth spurts. It is for this reason that no amount of behavior modification is going to change the behavior of the FAS individual.
Another important finding is that nutritional factors can contribute to alcohol's teratogenic effects. The ability of the placenta to transfer nutrients to the developing fetus can be compromised when the mother is abusing alcohol, even if the mother is adequately nourished herself. Also, by virtue of the fact that the mother is an alcoholic or abusing alcohol, she is most likely undernourished, which in turn leaves her with sub-optimal levels of essential nutrients to transfer to the fetus.
Another, more simplified explanation, is that when a pregnant woman consumes an alcoholic beverage, her blood alcohol content reaches an equilibrium with the fetal blood level since alcohol crosses the placenta freely and enters the embryo or fetus through the umbilical cord.
It takes longer for the alcohol to clear from the fetus than from the mother, however, and the concentration remains high in the placenta long after it has cleared from the mother. This fetal alcohol concentration will adversely affect developing tissues, organs and neural structures.
Notice the facial features on this infant born with FAS.
It is important to note that facial characteristics may not be as apparent immediately after birth, during adolescence or adulthood as they are between the ages of two and ten.
Photo reprinted with permission of Teresa Kellerman,
FAS Community Resource Center
http://www.come-over.to/FASCRC
Other physical features associated with FAS may include:
limitations in joint movement
slow growth, with an unusually slender appearance prior to puberty, including height and weight below the 10th percentile range
deformities in the small joints of the hand as well as incomplete rotation at the elbow
vision problems, primarily nearsightedness
auditory problems, primarily inflammation of the ear
shortness of stature
As the child gets older, however, the physical features associated with FAS become less distinct. This emphasizes the importance of a diagnosis of FAS early in life so assistance can be provided to the child and their family. The behavioral and learning problems associated with FAS do NOT diminish as the child gets older.
Other birth defects, such as congenital heart disease, cleft lip and palate, anomalies of the urinary tract and genitals, and spina bifida occur 5 to 60 times more frequently in children exposed prenatally to alcohol than to the general public.
According to the FAS Community Resource Center, most infants with FAS are irritable, with a poor appetite, sleeping problems, hypersensitive to sensory stimulation with a strong startle reflex. They may hyperextend their heads or limbs, and can exhibit either too much muscle tone (hypertonia) or too little muscle tone (hypotonia).
The most serious characteristics of FAS are the invisible symptoms of neurological damage that results from prenatal exposure to alcohol. These symptoms include:
attention and memory deficits
hyperactivity
difficulty with abstract concepts (math, time, money)
poor problem solving skills
difficulty learning from consequences
poor judgment
immature behavior with poor impulse control
Additionally, there are sensory integration issues with most children with FAS. They are more sensitive to light, sound and touch.
The dental treatment of children with FAS DOES require modifications and it can be a bit challenging to dental hygienists, assistants and dentists alike.
According to "Treating the Patient with Fetal Alcohol Syndrome," by Peggy Seo Oba, RDH, MPA, MBA, the following tips will help the dental professional provide these patients with optimal care:
Provide a steady, structured and unstimulating environment to make your patient feel comfortable and to reassure them.
To make the "newness" of the dental office easier to handle, take photos of the building, parking lot, doors, staff, instruments, equipment and any other things your patient may encounter on their visit. Allow the parent to show these to the child every day, starting 2 weeks prior to their visit. Also have them talk to their child about the entire experience - what will be done that day, what equipment will be used and what the purpose of the visit is. Role playing, with the child playing the part of the dental professional, is recommended.
Try to schedule the child to walk through the office on a day when it's empty and prior to their visit. Role play what their entire visit will be like and use the actual chair, equipment and instruments that you will use for their appointment. Patients with FAS cannot generalize well and one instrument is not the same as another.
Try to schedule your patient at the end of the day, after other patients have already left or when the patient load is light.
Remove posters, plants and any extraneous materials that may distract the child. Close the blinds, but if the curtains have a "busy" design on them, do not draw them closed - this may also distract the child and set off "pseudo-absence seizures". Be certain the room is quite, plain, uncluttered and non-stimulating. This will help make the child calm while in your chair.
Repeat these procedures EVERY time the child comes to your office, particularly if there has been any length of time between visits
Once the child is in your operatory, reacquaint them with the equipment, etc. Since their hearing may be very acute, warn them ahead of time before turning on the aspirator. Music headphones are a viable option.
Dark glasses can be worn by your patient so the overhead light doesn't bother their sensitive eyes.
To be certain you have their attention, touch them gently on the arm.
Look into their eyes when you speak to them. This will assure that they hear you. You could use sign language or be very demonstrative with your hands as you talk to them.
It's a good idea to allow the parent or caregiver to stay with the child while dental treatment is being rendered to keep them calm and provide reassurance so they don't lose control.
If your patient with FAS is a teenager or older, they will need to have any instructions regarding the maintenance of their oral health or prescribed medications written down. These patients are very visual and not very auditory.
Since these children have experienced brain damage, they have unique problems that your "average" patient may not have, such as hypersensitivity and hyposensitivity on different parts of their body. The oral structures may be hypersensitive, hyposensitive or a combination of both. Their tongue may not be completely under their control and their cheek muscles may be weak. It may be difficult for them to swallow. Take these things into consideration when planning your treatment.
You can use the lead apron to lay over the child, as its weight reassures the child. An option would be to tuck a blanket around them.
Some recommendations to make to the parent/caregiver about their personal oral hygiene:
-Use a toothpaste that the child doesn't object to, or baking soda may be used. If all else fails, water can be the sole agent on the toothbrush - it's better than not brushing.
-The parent can desensitize the child's oral tissues by running their fingers over oral tissues daily.
- Flossing and rinsing after meals should be encouraged, also.
Following are messages (spelling and grammar not changed from original message) from parents/caretakers regarding dental treatment for their children:
Case #1
I will tell you a little bit about my son's dental history. Anyhoo my son came into my foster care at the age of 1 year weighing 12 lbs that was known as failure to thrive. He also had droopy lids and so had to cock his neck back at the atlas-axis to see out and even with that positioning had to search new objects, floors and people with his mouth in order to explore them. His hands were sometimes even held behind a little and not in use. His mouth was his hands at first.
We always had dental exams consisting of counting his teeth and taking a Polaroid of his mouth while he lay across two laps - mine and the intern of the day. These counting exams were looking for malformations. These are usually crowding and are among the list of syndrome characteristics presenting in FAS, to my best recollection this was from age 10 mo. until 4-ish.
Later - at around 4 and 5 years old we saw a dentist who worked with both special and normal kids and who had a quiet room for cleanings and fluoride treatment and general orientation to dentistry. This doc was very gentle and caring and we tried to use the same hygienist whenever possible for consistency. I held him on my lap the first few times there.
At around eight he had some other surgery and while we had him out on the table under general anesthesia, the head of pediatric dentistry at his hospital of birth gave him dental care consisting of exam, x-ray, cleaning, sealant onto molars, smoothing of a rough spot, filled one cavity, and plucked 1 or 2 baby teeth our of the way. Then we moved to another state and I was told if he was wiggly or uncooperative he could be harnessed to the chair. O boy. We have managed to have him cleaned 1-2x per year here though presently no dentist in a 75-mile radius to our rural home takes the public aide card.
My son needs braces now because of the large teeth he has in such a small jaw. His canines are buried up in his gums as he approaches 11 years old. His molars are in the way where the canines should be and he has a lower jaw that sticks out (partly, I feel, from that posture I mentioned in his first year). He also has low tone and slow growth, plus eating disorders (no appetite) and so it remains to be seen if he will tolerate the braces due to sensory defensiveness, how long his jaw growth will take vs. the 1 - 2 years estimated, and whether I can get enough calories into him with braces on.
Case #2
My daughter is only 5 3/4 years old, so I will tell you of her experience, what helps and what doesn't.
She needs to be constantly thinking about something except what she is going through. It worked when the dentist counted her teeth and made it fun. When they were polishing her teeth they kept talking exciting things to her. It was devastating when they bonded her two back molars because she had to keep her mouth open and in a set position for a while. It seems like there could be a mouth piece to hold the mouth open and the tongue down - or just put the child to sleep. She really made a spectacle of herself and others who were listening must have thought she was being tortured. Oh, and the waiting time (in the chair) is probably what made everything 90% worse. If you can get these kids in and out, with NO waiting after they've been called in, it would be so much easier.
Case #3
I have only had my 8 year old boy for about 8 months now but we have made 3 trips to the dentist. First he had 5 baby teeth fall out and I felt it was time for a check-up. Since brushing his teeth is a major chore for him...mainly he forgets unless I stand over him; he had 2 cavities. The first visit was for a cleaning and check-up. The next 2 visits were for fillings in his baby teeth. I had to space his fillings over a period of a month as doesn't like things in his mouth - fingers, cotton, instruments, etc.
He was quite brave and I never heard a peep out of him but after he was very tired and cranky. As soon as the freezing was gone he was fine but tired from the ordeal. After each visit he would refuse to go again. That's why the spacing of the visits. His adult teeth are a bit crooked and he will need braces when all his adult teeth are in. I'm not looking forward to that as he really doesn't like foreign objects in or on him. He dislocated his elbow once and spent a great deal of time trying to remove the cast; to the point it had to be redone. Some children with FAS cannot tolerate some tastes, textures or restrictions via casts or braces.
Case #4
My adopted daugher has quite a few dental problems. Her baby teeth came in crooked. She tongue thrusts out of one side of her mouth. Her cheek muscles are not strong enough to put the food on her teeth so the food just sits in her mouth no matter how much she drinks. Late eruption for everyting - about 4 months late.
She can't use her lips to wipe food off a spoon, so she wipes the food off with her teeth, OK that makes your hair stand on end - you ought to hear it! She has about three facial expressions, smile, cry and nothing. I expect her adult dentition will come in large and crooked and perhaps supernumerary. Her tastes run to salty - some FAS kids seem to love sweets. Speech is slurred and indistinct. She had 13 cavities on her third birthday and drooled until the age of three.
Case #5
John's baby teeth came in so perfectly, that I felt thankful for something in his little body not being affected by the prenatal exposure to alcohol that had such adverse effects on his heart, his bones, his eyes, and his brain. His first dental problem, as perceived by the dentist, was thumb sucking.
First we tried the Thum medicine at bedtime, but he just sucked it off. We tried tying his hands in socks, but he just sucked through them. The dentist installed a wire prong appliance to the roof of his mouth, which was effective during the six-months it was wired in, but as soon as it was removed, the thumb sucking resumed. I wish now we had just left it alone, perhaps he would have stopped on his own. Perhaps not. John still sucks his thumb at bedtime, and it has not caused an overbite or any other problems. His suck is not very strong anyway, so no harm is done.
When his secondary teeth began to emerge on time, I was horrified that they began coming in crooked and were misshapen. He required dental surgery to remove 9 adult teeth, including one extra front tooth. The doctors couldn't tell which of the three in the x-rays was the extra one, but I think they must have guessed right, because the two that came in were relatively well positioned. Of course, John required major orthodontia, wearing braces for over 6 years to the tune of about $12,000, only half of which was covered by systems such as private insurance, state health care, and adoption subsidy. He surprisingly tolerated the followup year of wearing a retainer at night, never losing or destroying it.
Flouride treatment was a problem for John, because it entailed a swish-and-spit routine that was difficult for him to follow. When a child with FAS, who has the emotional/social development of a child half his chronological age, is expected to have something sweet in his mouth and then spit, it is more than likely going to be swallowed inadvertently on impulse, with the child have little or no control over that impulse.
John tolerates dental care relatively well now, but as a child, it was an experience full of anxiety and fear. John's FAS disability includes sensory integration issues, which means that John experiences input to his senses in abnormal ways. His sense of hearing and touch are extremely sensitive, so that minor noises startle him easily and what would be considered mild pain for most people would be felt as extreme pain for John, depending on the situation.
Emotionally, John was very easily frightened by many things as a child, especially things that made sudden or loud noises, such as motorcycles, sewing machines, vacuum cleaners, and - you guesssed it - dental drills. This is very typical for children with FAS or FAE. John needed me close by for all types of dental or medical procedures, to keep him calm so he wouldn't lose control and bring the procedure to a screaming halt. It was difficult for me to convince medical and dental personnel that I was not just an overprotective mother, that I knew what I was talking about when I said John needed to have me present. John also went through emotional developmental levels much later than normal, so at age 4 and 5, he was still experiencing separation anxiety. Although he never really had any fear of strangers, he had many unreasonable fears of other sorts, and often that was not understood by the professionals treating him.
Other aspects of the FAS disability that affect John's teeth include poor enamel and excessive saliva, which I think counteracted the poor enamel. John had sealants applied to his teeth when he was younger, but eventually the sealants must have worn off, and he ended up with about 3 small cavities a few years ago (about age 18). The increased saliva presented a great problem while John was growing up. Specialists explained that John's salivary glands were producing more saliva than he needed, that he had a reverse tongue thrust, and that his lips had decreased sensation, and that his jaw was underdeveloped, and all these contriubted to the drooling. This was a big problem in that he accidentally spit on people while talking, soaked his shirt, and got his school work wet. When John started to take Ritalin, I noticed that the saliva production seemed to normalize. I also noticed that he dried up to a normal amount when he took antihistamines like Benadryl. Now that John is on Ritalin during the entire day, the excess saliva is no longer a problem.
My advice to anyone giving treatment to a child or young adult with FAS or FAE is to consider the lower social/emotional developmental in this person. The general rule of thumb is to take the chronological age and divide by two. Most teens with FAS have the emotional and social skills of a 6 year old, even those with normal or near normal intelligence, even those with few of the facial characteristics.
How can you tell a patient has FAS or FAE without the facial characteristics? You can't. But you can assume the child MIGHT be alcohol effected if the child is a foster child or is adopted, as 80% of children in the foster/adopt system are born to women who abuse alcohol and are at risk of being FAE, possibly without diagnosis or recognition. If the patient acts inappropriately or is unusually friendly, you might consider that this patient could have alcohol effects and proceed with caution.
Warn him/her about the equipment you are about to use, try to avoid making him/her wait too long. Be patient with behavior problems and reassure the mother that you understand. Don't assume that problem behaviors are a result of poor parenting skills, the mothers hear this all the time, and they are probably trying their best to work on the child's behavior problems. Sensory integration issues (sensitivity to light, sound and touch) are important. The noise of the drill could be extremely scary and cause lots of anxiety. Even the motor used to position the chair can set off a child with FAS/FAE. It might be a good idea to let them try it themselves before they even sit in the chair. Let them know each time you are going to use anything that makes noise, raise or lower the chair, turn on the big light, etc.
There may be increased or decreased pain tolerance (or combined, which is not unusual). A child might be very sensitive to pain in the mouth, but not be bothered by stubbing his toe. Often a child will not be bothered much by mouth pain, and therefore the parent and provider need to be extra alert for conditions that would eicit complaints in a non-disabled person, as symptoms could be masked by altered pain tolerance.
Some children with FAS or FAE might take shorter or longer time periods for pain medications to take effect. They might need their doses altered to every three hours if the usual dose is every four hours because of their altered rate of metabolism.
Don't assume the mother is the birth mother, and don't assume the birth mother is still abusing alcohol. The few birth moms who keep their children who are affected are usually in recovery and need support and understanding. Most birth moms are dead by the time the child (now in foster/adoptive care) starts school.
Please be aware that when it comes to juvenile patients, many of the children who will be seen are going to be UNRECOGNIZED victims of FAS or FAE. Only 11% of these kids get diagnosed early before they have severe social behavioral problems.
The effects of prenatal exposure to alcohol last a lifetime, and parents will be taking care of these children well beyond the time they legally reach adulthood. Caring for children with FAS/FAE is extremely stressful and is emotionally draining. Your understanding and patience will be greatly appreciated. Thank you for taking the time to learn about Fetal Alcohol Syndrome and Effects.
Teresa in Tucson, Arizona
Mother of John (FAS, 22)
The National Organization on Fetal Alcohol Syndrome (NOFAS)
Fetal Alcohol Syndrome Community Resource Center
March of Dimes
Fetal Alcohol Syndrome Family Resource Institute
In closing.....
This year in Arizona:
85,274 babies will be born
4 of these babies will be HIV positive.
23 of these babies will be born with Muscular Dystrophy.
25 of these babies will be born with Spina Bifida.
75 of these babies will have Down Syndrome.
170 of these babies will have Fetal Alcohol Syndrome.
852 babies will have Alcohol Related Neurodevelopmental Disorders.
The cost to taxpayers for treating Arizona residents with Fetal Alcohol Syndrome and related disabilities is estimated to be $140 million each year.
As noted by the Institute of Medicine's 1996 Report to Congress on FAS: "These incidence figures are offered not as established facts but to emphasize the magnitude of a problem that has serious implications - for the individual and for society."
-taken from the FAS Community Resource Center newsletter, revised Fall, 2007
Congratulations - you have just completed the fourth module of this online course.
This concludes the online Chemical Dependency: Alcoholism course. Upon completion of the Post-test (Module 5), with a score of 80% or better, you will receive a certificate within 2 weeks stating your successful completion of 2 continuing education clock hours of credit. If you have not yet officially registered or paid your registration fee for the course, please contact the Center for Continuing Education (see below) immediately xo that you may receive credit.
Special recognition is given to Debby Kurtz-Weidinger, RDH, MEd for her original development upon which this course is based.
Contact Information:
Your comments and feedback about this course are welcome. See the contact information below to comment on or to find out about additional programs and courses offered by the Center for Continuing Dental Education.
Phoenix College Department of Dental Programs
Center for Continuing Dental Education
1202 West Thomas Road
Phoenix, Arizona 85013
602-285-7331
Email: Diana.richardson@pcmail.maricopa.edu
Website: www.pc.maricopa.edu/departments/dental
Return to the Table of Contents to continue and click on the Module 5 to take the post-test.