Dental Support is vital in the good management planning of a child or adult with Fetal Alcohol Spectrum Disorder

Dental issues are common in individuals with Fetal Alcohol Spectrum Disorders (FASD), including a higher prevalence of malocclusions, hypodontia, misaligned teeth, and enamel defects. These problems can impact oral health-related quality of life and may require specialised dental care and potentially general anaesthesia for treatment. 

Dental Anomalies Associated with FASD:
Malocclusion:
Improper alignment of the teeth when the jaws are closed, including crossbites and distal occlusion (a bite where the lower teeth are behind the upper teeth) are more common in individuals with FASD. 
Misaligned or Missing Teeth:
Hypodontia (missing teeth), delayed eruption, and malformed or misshapen teeth are also observed. 
Enamel Defects:
Enamel hypoplasia, where the enamel layer is thin or absent, can occur, making teeth more susceptible to decay. 
Other Oral Habits:
Mouth breathing, thumb/dummy/soother sucking, and nail biting are also more prevalent in children with FASD and can contribute to dental problems. 

Orofacial abnormalities in FASD may include:
 

• Microdontia with defective enamel; cleft lip; cleft palate; malocclusions; and poor tongue thrusting.

• Mouth breathing resulting from orofacial deformities can lead to dry mouth, as well as contribute to malocclusions with increased or decreased overjet, anterior and posterior crossbite, open bite, and contact point displacement. The net effect is an increase in the long-term risk of caries, occlusal trauma, and periodontal diseases.

• Dental eruption may be slightly delayed.

• Labial inclination of the upper incisors may result from a high rate of non-nutritive sucking (thumb, dummy/soother or tongue suction).​

• Temporomandibular joint (TMJ) disorders occur at elevated rates.

• Sleep apnea may be related to retraction of the midface.

• Poor oral hygiene related to behavioural and emotional issues may manifest as gingivitis, spontaneous gingival bleeding, plaque, and decay.

• Gingival overgrowth may be present if the patient/client is taking the anticonvulsant phenytoin for seizure control.

 

Fetal Alcohol Spectrum Disorder has 328 possible co-morbid (co-occurring) conditions, an example of this might be cardiac conditions or seizures that would require require medical clearance for certain co-morbid conditions. 

Impact on Oral Health:

Increased Risk of Decay:
Malocclusions and enamel defects can make teeth more difficult to clean, increasing the risk of cavities. 
Pain and Difficulty Eating:
Malocclusions can cause pain and difficulty with chewing, and some children & adults  may have difficulty with speech. 
Psychological Impact:
Dental problems can affect a child's self-esteem and social interactions, with some children reporting being teased or bullied because of their teeth. 

The dental hygienist can play an important role in first identifying FASD where further training & research should be considered as best practice. 

The dental hygienist should always follow good practice and screen the patient/client with FASD prior to treatment. This includes collating information related to behavioural, neurological (including seizure), mental health, and physical manifestations.

The dental hygienist should express a supportive, non-judgmental attitude, which will assist in overcoming reluctance on the part of the patient/client and/or parent/guardian to disclose a history of FASD; if a carer or parent is present a conversation away from the child/adult or possibly a phone call would be more appropriate. 

Patients/clients with fetal alcohol spectrum disorder have a high prevalence of dental anomalies and speech pathologies that often require early intervention. Other co-morbidities are also common.

The patient/client may exhibit behavioural, emotional, and/or physical difficulties that complicate the provision of oral healthcare. These might  include: aggressive behaviour when upset; impulsiveness; anxious, hostile, and uncooperative behaviour; hyperactivity; short attention span and distractibility; inability to answer questions appropriately due to speech disorder or brain dysfunction; memory impairment; danger of self-injury from removable prosthetic devices; and motor skills impairment.

A calm appointment environment is therefore essential where if a child/adult is anxious best practice a referral to a 'dental access centre'* is preferrable where reasonable adjustments can be made including a longer appointement time, a larger & clinic waiting room, gentle lighting and FASD/SEND trained staff.

Management of dry mouth may be indicated for mouth breathing and/or as result of side effects from medications used to treat hyperactivity or attention deficit or epilepsy.

Nutritional counseling and caries risk assessments may positively influence the patient/client’s oral health, particularly if there are undesirable eating patterns (including snacking on high sugar foods). However this is to be carefully considered and where a carer is with the child/adult talk away from them or arrange for a phone call at a separate time. 

Manual dexterity should be evaluated, because difficulties in handwriting have been reported in persons with FASD, which may also affect their ability to brush and floss properly.

Personalised self-care instruction with modifications is warranted to optimise plaque control support. 

In around 10% of those with FASD distinctive orofacial characteristics include: smooth, indistinct philtrum; thin upper lip and vermilion border; and incomplete development of midface. Mandibular micrognathia and maxillary hypoplasia contribute to collapse of the midface.

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For more information on What is FASD, please refer to our information page.

*Dental Access Centres in the UK are NHS services providing urgent dental care for those who cannot access a regular dentist. They treat patients experiencing dental pain or needing urgent treatment, often offering appointments within 48 hours. These centers also cater to individuals with specific needs, such as those with qualifying physical, mental health, or learning difficulties, or those with high anxiety about dental treatment. 

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'An individualised management plan sets out the intervention and support needs identified during assessment and diagnosis of FASD. The plan signposts the child or young person with FASD and their family to resources and services. It covers the basic and immediate needs of the child or young person after assessment as well as their long-term needs.

 

Because FASD has lifelong effects, a staged management plan may be needed to anticipate upcoming problems at planned intervals and revision should be considered at all transition stages in the person's life. A management plan also helps people with FASD, their families, carers and service providers to understand and address the associated challenges. The plan helps to coordinate care across a range of healthcare professionals, as well as education and social services, and improves outcomes.' 

NICE Quality Standards FASD 

Source of reference: 

• Popova S, Lange S, Shield K, et al. Comorbidity of fetal alcohol spectrum disorder; a systematic review and meta-analysis. The Lancet. 2016;387(10022):978-987. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01345-8/fulltext
  Health Needs Assessment UK https://www.gov.uk/government/publications/fetal-alcohol-spectrum-disorder-health-needs-assessment/fetal-alcohol-spectrum-disorder-health-needs-assessment

• Cohen-Lévy J. Radio-“Logical” Reflections. An innocent victim (fetal alcohol syndrome). J Dentofacial Anom Orthod. 2014;17(408):1-8. https://www.jdao-journal.org/articles/odfen/pdf/2014/04/odfen2014174p408.pdf

• Riley EP, Alejandra Infante M, Warren KR. Fetal Alcohol Spectrum Disorders: An Overview. Neuropsychol Rev. 2011;21(2):73-80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779274/

• Chudley AE, Conry J, Cook JL, et al. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005;172(5 suppl):S1-S21.
  https://www.cmaj.ca/content/cmaj/172/5_suppl/S1.full.pdf?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&title=Fetal%20alcohol%20spectrum%20disorder%253A%20Canadian%20guidelines%20for%20diagnosis&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&s

• Moore EM, Riley EP. What Happens When Children with Fetal Alcohol Spectrum Disorders Become Adults?. Curr Dev Disord Rep. 2015;2(3):219-227.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4629517/

• Nicita F, Verroti F, Pruna D, et al. Seizures in fetal alcohol spectrum disorders: evaluation of clinical, electroencephalographic, and neuroradiologic features in a pediatric case series. Epilepsia. 2014 Jun;55(6):e60-66.
  https://www.ncbi.nlm.nih.gov/pubmed/24815902

• Government of Ontario https://www.ontario.ca/page/fetal-alcohol-spectrum-disorder-fasd-programs-and-services (Fetal Alcohol Spectrum Disorder)

• Centre for Addiction and Mental Health https://www.camh.ca/-/media/files/pdfs—reports-and-books—research/who-fasd-report-english-april2018-pdf.pdf?la=en&hash=347373E4C8C362E1F746C28BB063C7DA9E2987AE
  https://www.camh.ca/-/media/files/pdfs—reports-and-books—research/the-burden-and-economic-impact-of-fetal-alcohol-spectrum-disorder-in-canada-february-2015.pdf

• Government of Canada
  https://www.canada.ca/en/public-health/services/diseases/fetal-alcohol-spectrum-disorder/health-professionals.html

• CanFASD (Canada FASD Research Network) https://canfasd.ca/guidelines/

• Centers for Disease Control and Prevention https://www.cdc.gov/ncbddd/fasd/facts.html
  https://www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessible.pdf
  https://www.cdc.gov/ncbddd/fasd/secondary-conditions.html

• National Institute on Alcohol Abuse and Alcoholism https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/fetal-alcohol-exposure

• Dimensions of Dental Hygiene https://dimensionsofdentalhygiene.com/article/oral-health-effects-of-fetal-alcohol-spectrum-disorder/

• MedlinePlus https://medlineplus.gov/fetalalcoholspectrumdisorders.html

• Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.