Sunday, 8 January 2017

Special Care Dentistry: Autism Spectrum Disorder

Since starting in community, seeing children with learning disabilities has become an everyday regularity for me. Seeing those with ASD (or autism) has been a bit more challenging than I intially expected and managing these patients is very different from any other set of patients.


As part of one of our training days, we were given a really informative and useful talk about managing these patients by Wendy Bellis. This blog post is based on her talk. 

What is ASD?

According to The National Autistic Society, ASD is a lifelong developmental disability that affects how people perceive the world and interact with others. It is not an illness or disease and cannot be 'cured'. The disorder is a spectrum that can affect people in different ways and can be associated with other learning disabilties, mental health issues or other conditions in 70% of cases e.g. ADHD, epilepsy, OCD, anxiety.

A diagnosis of ASD is commonly described as a triad of symptoms:

  1. Difficultiies in socialisation
  2. Difficulties in communication
  3. Limited and repetitive patterns of behaviour and dislike of change
Recent figures have estimated in the UK 1 in 100 children have some form of ASD. There is also a 4:1 ratio of male: females.


What are the types of ASD?

As I mentioned above, ASD is a spectrum but there are some different labels given to individuals.

Asperger's Syndrome are of average or above above intelligence. They don't have as many issues with speech (such as 25-40% of autistic children who are non-verbal), but may have problems understanding and processing language. Some high profile fictional characters with Asperger's Syndrome are Rain Man (from the film of the same name) and Christopher from the novel and play 'The Curious Incident of the Dog in the Night Time'.

Children with Pathological Demand Avoidance (PAD) share the aspects of difficulties in interaction, communication and imagination but they are driven to avoid demands and expectations. They have an anxiety based need to be in control and are able to use their better understanding of social interactions and communication to their advantage compared with others on the spectrum.


What problems you can encounter when seeing these patients?

Children with ASD can be hypo/hypersensitive to sensory inputs such as light, smells, tastes. This can mean that the things you experience every day in your dental surgery such as the dental light, the smell of your materials, the taste of your gloves can be overstimulating for those on the spectrum.

This sensitivity is not only an issue in your dental surgery, but at home oral hygiene routines can be affected. They may dislike the texture,  taste or smell of toothpaste or even the brush. As well as oral hygiene, this can affect their diet. Autistic children are notoriously fussy eaters and it may even be a struggle to get them to eat enough. Many of these children may be on high calorie drinks or substitutes which contain high levels of sugar!

It may not only be what they eat, but when they eat it. Parents may have gotten into habits like taking a bottle to bed or rewarding good behaviour with snacks. These are often a dentist's worse nightmare. I remember seeing an 8 year old severely autistic boy who was non-verbal and showed violent and disruptive behaviour so his mum used sweets to calm him down. The only way she could get him to sit in my dental chair was to entice him with sweets... and of course I could see the affect of this habit in his mouth. 

Moreover, the co-morbidities associated with ASD may have affects on their oral health. If they are on medications which contain sugar or induce xerostomia this can increase their caries risk. I remember seeing a child with ASD who also had epilepsy who had trauma to their dentition following a seizure. These are all things to remember but one of the most profound problems I have encountered is how exhausted the parents of these children can be. Asking them to manage to brush their child's teeth twice a day can be a big ask for some parents where even taking their children to school can be a serious challenge!


Tips in the management of these patients


  • Early contact is key! Sometimes these patients are diagnosed very late and so you see them when they are 4 or 5 and sometimes by then it's too late and there's caries already! Getting these children in when they are young to build up their confidence and acclimatise them to the environment is key, as well as instilling good habits in their everyday life
  • Sending out a pre-appointment letter can be useful to let the parent know what to expect from the appointment and you could also attach a ASD-specific questionnaire to get to know the child a little. For example, I saw a 4 year old boy with Asperger's who had an anxiety about seeing people in uniform, so we decided to change out of our scrubs to see him (and use other PPE instead of course).
  • Letting the parents take pictures of the practice and surgery to make a story to show to the child before their dental appointments can be a useful aid
  • Communication is very important. Remember children with ASD find it difficult to imagine things and can take what you say literally, so you may need to adapt your usual child language e.g. talking about using a hoover to suck up water in their mouth. You should also talk slowly and clearly to give the child enough time to process what you're saying. Also don't ask open ended questions, give them direct instructions e.g. 'First Christopher you need to sit in the chair, then open wide so I can see your teeth'.
  • Ask the parents what sort of day is it for the child. Sometimes they will be having a bad day e.g. if they haven't followed their usual routine of things, and so getting enough compliance for a dental exam may be impossible; but bringing them back on another day when things a little better may mean they will let you.
  • Children with ASD do not like to be kept waiting so be on top of your time management
  • Use counting as a timer e.g. counting down from 10 so the child knows when you will be finished
  • If the parent has been giving the child sweets as rewards, try to change the reward to something else e.g. stickers, grapes, sugar-free sweets
  • If there is difficulty with oral hygiene, try brushing without toothpaste to see if it's the taste/texture/smell of the toothpaste they don't like. Use of an electric toothbrush may help but sometimes some patients do not like the sensation of this. There are non-foaming toothpastes and unflavoured ones e.g. Oranurse available to use. 
  • Some children with ASD may respond well to tooth brushing charts. Also the longer it is left to get the child into a routine with brushing, the more difficult it can be as they get older so getting into good habits early is very important. 
  • Some children with ASD like the sensation of chewing on or biting things. Soft safe toys that be hung around their necks are available. Parents often see me thinking their child is in pain because they are chewing on things, but often it's just because they like the sensation (this is called Stimming). Sometimes this habit can lead to ulcers in their mouths. 

The most important point that I learnt from Wendy's talk as well as what I've learnt so far in treating these patients is get to know them. Every patient is different with different habits and behaviours. Building in some of the child's own preferences and habits into how you treat them can be a really useful skill. Being patient and calm is also very important, especially when things are not quite going to plan!

For more information about autism, see the National Autistic Society - they have a fantastic page about dentistry.

Do you treat autistic patients? Let me know how you manage these patients in the comments section.


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