Information for the Dental Team
What is Autism Spectrum Disorder?
Autism Spectrum Disorder (ASD) is the term used to describe a condition that affects development of an individual across their lifespan. About 1 in 100 children, almost 230 000 Australians, have an Autism Spectrum Disorder. This disorder is a severe and lifetime developmental disability that is characterised by major impairment in mutual social interactions, communication skills, sensory processing differences, and repetitive patterns of interests or behaviours. It affects children from all ethnic and social backgrounds. Each person with ASD is unique. The term 'spectrum' indicates that no two people with ASD are the same. The differences depend on the combinations of social ability, communication level, cognitive ability, age, personality and many other factors. This means one has to be very flexible when managing these children.
Studies showed that children with autism have significantly poorer oral hygiene level and poorer gingival status; some also demonstrated these children have significantly higher dental decay rate compared with control groups. Visit to the dentist can be challenging for these children, their families, and the dental team. Because of the unique challenges, research also showed that although many of the children with autism require restorative dental care, many are not receiving such care with greater unmet needs. This may be due to the limited access to the dental services for this group of children, difficulties with the maintaining of oral hygiene at home, the behaviour of these children in the dental settings, or getting the children to attend the dentist. In many circumstances, only emergency treatment is sought when the dental problem is so advanced that the child expressed pain and this frequently resulting in restorations or extractions under a general anaesthetic procedure.
Other common oral problems that have been associated with ASD include: bruxism, non-nutritive chewing, erosion, hyperactive gagging reflex, self-induced injuries (e.g. picking of the gum)
How the dental team can help
Managing children and adults with ASD, and in fact, patients with special needs in general, can be very rewarding. The relationship between the dental team and the families of these patients is usually strong, unique, and long-term. It is worthwhile to spend the effort to create this relationship, and in turn, helps make a difference in maintaining or improving the oral health and overall well-being for these patients.
Educate your team on Autism Spectrum Disorder through Austeeth website, your local Autism association e.g. Autism SA, other professionals who look after clients with ASD or contact us via email or Facebook.
Preparing for the dental visit
It starts with the reception staff when the initial appointment is made. Try to get as much information from the parents or carers as possible about the unique requirments for the child, coping mechanisms, likes, dislikes etc in order to make the visit easier for all. Send the relevant forms from your practice for the parents or carers to fill in prior to the appointment to give your dental team more information on the child, and to avoid the child having to wait too long prior to the appointment. Find out whether the child needs a quiet area to wait and ensure that the waiting time is as short as possible.
Ask what time of the day the parent or carer would think it's best for the child to attend. Also consider scheuling the visit for a time when the office is less busy (for example, first appointment of the day, or after lunchtime), and allow a longer appointment for the initial visit.
Be flexible and be prepared that it may take a few (or many) visits to desensitise the child for routine dental visits or treatment.
Try to stick with the same dental team (and same dental surgery room) if possible as children with ASD often like routine and predictability.
It is important to keep in mind that even with careful preparation, unexpected problems can arise (could be something as simple as a new dental staff asking the child an open-ended question). Look for early signs of a meltdown, or prevent one if possible. Once again, flexibility is the key, and be prepared to reschedule the appointment for another day if required.
The aim in the first instance is to carry out a brief exam to identify any need of urgent attention, for example, large open carious lesions, abscess, traumatised teeth. If not, then your team can take time to work on getting the child to be more comfortable with various steps involved in routine check-ups and care one step at a time. If urgent treatment is required, determine whether your team is happy to manage the patient in your clinic, what further investigations you would need, and whether your facilities allow treatment to be carried out in a non-compromised way, and stress-free for both the patient, the family and your dental team. If you are not sure, talk to your paediatric dentists colleauges for advice or suggestions.
Behaviour management techniques
This technique works with all children, including children with ASD. It is helpful for children with ASD to know about what to expect during a dental visit and the sequence of procedures. Use of visual aids or pictures can also help. Use simple and clear language. Describe what you are doing first, demonstrate if possible (for example, show what the dental mirror looks like, gently blow air on the hand with the triplex syringe, demonstrate the spinning of the prophy cup on the child's fingernail). One instruction at a time. Warn of any changes (for example, moving the dental chair, turning the dental light on). Use a calm, matter-of-fact voice.
This technique is very useful for children with ASD (and also any children who is anxious about going to the dentist or with various dental procedures). It involves a gradual approach to learn to tolerate a specific dental procedure. Be prepared to make time over a series of appointments to achieve a specific goal (for example, sitting in the chair, opening the mouth). Also be flexible and be able to retract the steps as needed. Use positive reinforcement (can be as simple as verbal praise, smiles) for completing each step.
Using a toothbrush initially to keep the mouth open is a good idea as this is a more familiar object or procedure for the child.
If possible, use distractions that the child is already familiar with e.g. their own electronic device, listerning to music. You can also have a few distraction toys or objects that the child can investigate or hold onto.
When giving preventive information, keep in mind that some children with ASD may not be able to change their established habits (which may include dietary habits) easily. Some may even be impossible. Be flexible with your preventive plan and modify to the specific needs of the individual child. It is all about that balance between risk and preventive factors.
Presence of the parent or carer
Most dental visits would benefit from having the parent/carer close by to help with every step along the way (for reassurance, tips to help make things easier for the child). However, every child and situation is different. Talk to the parents/carers and children before the appointment or procedure to see what they prefer.
Some children with ASD have problems with sensory processing or overlading. Ask the child to wear sunglasses or close their eyes when using the overhead denal light. The child may wear headphoes to reduce other noises (for example, from the handpieces). Others may like the feeling of a weighted vest (for example, using the lead apron for radiography) or holding onto a soft toy filled with heavy beans.
It can be helpful to ask the parent or carer, or ask their permission for the dental assistant/nurse to gently stabilise the hands and arms of the child during the examination. This is not to provide negative restraint but to avoid sudden accidental movements for safety. The dental operator can stabilise the head and carry out the examination. A toothbrush can be used as a mouthprop or there are other disposable mouthprop which are comfortable to use.
Visual aids/schedules/social stories area way to help children with ASD to understand a sequence of events, which can help reduce uncertainty and anxiety. We have examples of visual aids here you can use or modify.
What is a 'meltdown'?
A meltdown is a condition where the child with ASD temporarily loses control due to emotional responses to environmental factors. The meltdown appears to most people as a temper tantrum. There are marked differences between the two and the presentation is also different between adults and kids. Kids tend to flop onto the ground and shout, scream or cry. Quite often, they will display violent behavior such as hitting or kicking.
What can cause meltdowns in the dental settings?
Too much demands
Lack of communication
Sense of lost of 'control'
What to do?
Unfortunately, there's not a lot you can do when a meltdown occurs in a child on the autism spectrum. The best thing you can do is to train yourself to recognize a meltdown before it happens and take steps to avoid it.
For more information about the stages of meltdowns and how to prevent this.
Working with other professionals