This week it's autism awareness week... so let's learn about the condition...

You may have read some of my previous posts about Autism, but let's have a recap...

Autism or Autistic Spectrum Disorder (ASD) is a lifelong developmental disability that affects the way a person communicates and relates to the world around them. It has differing degrees of severity (hence the spectrum). 

Incidence is around 1 in 100 people with males being more diagnosed than females (4:1 ratio), although this is thought to be due to social masking of symptoms in females. 

70% have a learning disability. Although a triad of symptoms was traditionally described as what defines a diagnosis, more up to date thinking is a dyad of impairment:

Plus additional difficulties can be described. 

There are some co-morbidities that are associated with ASD including:

• Development e.g. hypotonia, cognitive disabilities
• Psychiatric e.g. Anxiety, OCD
• Behavioural e.g. self-harm, aggressive behaviour
• Sensory e.g. hypersensitivities/hyposensitivities
• Neurological e.g. seizures/epilepsy
• Gastrointestinal e.g. food sensitivity, GORD
• Sleep disruption

Patients with ASD may be verbal or non-verbal. Many may take what you say very literally, so here are some tips when communicating with these patients:

• Use their name 
• Use a special interest to engage them 
• Say less and speak slower
• Limit questions
• Use less non verbal communication
• Use visual supports
• Be aware of background noise, it can distract the patient from what you are saying
• Establish a 'stop' signal 
• Patients will probably avoid eye contact - this doesn't mean they are not listening 
• Give patients space and time to digest what you are saying
• Some patients use Makaton signs to help communicate

As I've already mentioned, some patients with ASD have hyper/hyposensitivities. This can be very apparent in a dental setting, so here are some tips:

• Patients might be sensitive to the dental light. Dark glasses can be used 
• With patients who are sensitive to touch, minimise any contact with the patient, including how long you are using instruments inside the mouth
• Patients can be sensitive to noise - some may have ear defenders. Noises like the suction or high speed drill can be almost painful for these patients. Avoid them or play music the patient likes 
• Patients can also be sensitive to smells/tastes including mouthrinses, filling materials. This might decide what materials you can use for a patient to materials they tolerate

Although there are no specific oral health issues that feature in patients with ASD, there are some common patterns that arise:

• Poor oral hygiene can be because of lack of compliance, dislike of taste/texture of toothpaste. Behavioural management from their carers, realistic expectations and the use of flavourless, non-foaming toothpaste can help
• If they have a limited diet, this can impact of their oral health, for example if there is high sugar intake
• Patients may be bruxists and have tooth surface loss, or chew things for sensory feedback. This is known as stimming. Safe chew toys can be advised which are kind on teeth
• Self-injurious behaviour can present in the mouth, as ulceration, lip biting or gingival clefts
• Due to possible high risk of caries/perio, prevention is key! Fluoride varnish/toothpaste and follow ups should be advised

Seeing some patients with ASD in the dental surgery can be a challenge, here are my tips:

• Preparation is key. If their carer/parent can come beforehand to take pictures of the environment/team this can prepare the patient, help construct a social story or use simple leaflets/questionnaires about the patient so the patient, their carer and the dental team are prepared e.g. if the patient doesn't like seeing people in uniform, the team can remove prior to appointment 
• Minimise waiting time in the waiting room 
• Plan the visit so there is no surprises
• Consider domiciliary visits
• The same team and surgery should be used to establish routine
• See the patient at the time of day that least disturbs their routine 
• Plan a sugar-free reward after the visit e.g. favourite take-away or activity, or even just a sticker!
• Keep background noise to minimum
• Use a time indicator 
• The patient may require several acclimatisation visits 
• Sedation or general anaesthesia is an option

The diagnosis of autism is based of a triad of symptoms: 

1. Social interaction difficulty
2. Repetitive behaviours
3. Communication difficulties

Autistic patients will often take the literal meanings of words or phrases and have difficulties with non-verbal communication e.g. they do not create eye contact. 

Give increased processing time for these patients, don't give them too much information at once and give instructions in stages/allow them to prepare e.g. Ben, sit in the dental chair then open your mouth then I will use this mirror to look at your teeth. 

Try structure the environment so they are familiar with their surroundings e.g. see them in the same surgery with same nurse etc. Try to arrange an appointment time that disrupts their day as little as possible and stick to a structured appointment. 

Encourage the parents to create a routine surrounding their oral hygiene regime and create a reward system following the routine e.g. brush teeth, add a sticker to a tooth brushing chart. 

Autistic people can be very sensitive to sound, light, touch and so it's something to be aware of in a dental surgery full of foreign experiences! Be aware of use of the dental light - many autistic patients do no like it as well as loud noises like the suction or dental drill. They may also be sensitive to the taste of your dental gloves, toothpaste, fluoride varnish etc. 

For light consider the use of sunglasses. Autistic patients often have ear defenders to block out sound. If patients do not like the sound of vibration of an electric toothbrush, use of a Dr Barman's toothbrush can be useful. 

A usual acronym with interacting with people with Autism is SPELL:

Structure

Positive approach (language use, visual)

Empathy and seeing things from another point of view

Low arousal, low stress

Links and consistency

To see other tips in managing Autistic patients see my previous post. Many thanks to NAS for the informative talk!

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

Our Community Dental Service serves the special care patients of City and Hackney and Tower Hamlets. Patients can be self-referred in some cases or are referred from other health professionals. These are commonly General Dental Practitioners, GPs, Speech and Language Therapists, School Nurses etc. 

We are now more commonly sharing the care of these patients with their other professionals. These include the following sets of patients:

Patients who have HIV, AIDS or who are/have been infected with Hepatitis B or C have traditionally been a subset of patients we see in the community dental setting; however, this group is not really seen as a special care group any longer unless there are other complicating factors or they fall into one of the other groups below.

I have been discharging some of these patients to the general dental services and many of them feel apprehensive about the way they may be treated in a high street dentist. It is discrimination to treat these patients any differently (we should be using universal precautions for all patients) and I am having to reassure patients it is illegal for practices to refuse to see them due to their medical status.

We see adults and children with moderate to severe learning difficulties such as autism (see my post about ASD here), ADHD, patients with syndromes who have associated learning difficulties e.g. Down's.

With these sort of children you often have to think outside the box about how to manage them or even attempt to look in their mouths. You also need to put yourself into the parent's shoes - is brushing their teeth twice a day actually achievable or will you have to compromise?

With adults you may have the same issues as trying to treat children but also the added challenge of obtaining valid consent. In these cases you may need to act in a patient's best interest and if there are complications, involve the help of an IMCA.  

Physical disabilities may make access to a regular dentist challenging; this could be because the dental surgery is up some stairs or the doors are too narrow. GDPs are obliged to make reasonable adjustments to facilitate the access for these patients, but in some cases this just isn't possible.

As a service we also can provide transport to assist those who are less able to come to their appointments and we also can use a hoist to transfer patients to the dental chair in those who are not able. As well as physical disabilities, we also see patients who are deaf or blind. Treating these patients can make you really think about how you usually communicate with patients and again you need to think outside the box when communicating with these patients. Sometimes we have to book in BSL interpreters to help communicate with those who are deaf. 

Whether this be alcohol or recreational drugs, substance abusers can be quite a challenge. They are often sporadic attenders, have rampant dental disease and other complicating social factors such as homelessness or mental health problems. You also need to consider the effect of the substance on their systemic health e.g. liver damage in alcoholics where clotting may be impaired.

When I see these patients, I try to get as much done in one appointment as possible and the focus is to stabilise the disease so I usually use Glass Ionomer to stabilise their caries.

We see a lot of patients who are living in forensic mental health units as well as visiting these patients in their wards. Diagnoses can vary, but common mental health problems I see are schizophrenia, anxiety and depression, Bipolar Disorder and Personality Disorders. Just because these patients have a mental health problem doesn't mean they lack capacity so you need to take things on a case by case and appointment by appointment basis.

In these cases you need to ensure your communication is very clear and also be aware of your own safety: escorts are essential with some patients!

Out of all the special care groups, patients or family members can self-refer themselves to the service apart from dental phobias. In these cases we need a referral from a health professional, usually a dentist.

For these patients we can either use acclimatisation techniques but also the use of conscious sedation (oral, inhalation, intranasal or intravenous), but we can also use other anxiolytic measures such as the use of the wand for delivering local anaesthetic. We also are the gateway for patients to be referred for general anaesthetic in extreme cases. 

I get referred a lot of children with caries from GDPs with behavioural issues. It takes a lot of practice working with children to learn ways of management to get their compliance. In some cases it is not always possible and they require a referral for general anaesthetic or the use of inhalation sedation. But you'd be surprised how many children you can treat with acclimatisation appointments and lots of patience!

To read tips about taking radiographs in children, read my previous post here.

These patients are often black-listed in general practices due to their high failure to attend their appointments or late cancellations. In community, they often do the same; however, we have the capacity to be more lenient and we try to understand how their lives can be nomadic and sporadic and their priorities change.

They often have other issues as I have mentioned above e.g. substance abuse, mental health problems and you also need to be realistic about how achieving good oral hygiene may not be possible as they may not be able to access running water.

Over Christmas, I volunteered for Crisis, a homeless charity. To read about my experience, see my post here.

These can be those with social problems, learning difficulties, mental health problems or those who are elderly.

Most of the time, I like to see these patients and involve their carer or key worker in their treatment as sometimes involving them is the only way to get a valid history.

Community is the intermediate setting before referring a patient onto secondary care so we often see lots of patients with complex medical histories. This may not mean treating them any differently to how a GDP would, but we have closer links with other services e.g. their GP or doctor. We are also more experienced in the management of certain patients for example, patients who are about to undergo heart valve surgery or those at risk of infective endocarditis, patients who are at risk of MRONJ and oncology patients.

These patients may be looked after children, those who are under care or have guardians who are not their biological parents. In some cases, we need to liaise closely with their social workers (once we have consent to do so), especially if we are concerned about a child's welfare e.g. repeated missed appointments, dental neglect.

To read about safeguarding, see my post here.



Our service delivers domiciliary care to those who are housebound; whether that be to their own home, to care homes or to hospital wards. I am learning to drive at the moment (about time!) so I do not do this visits myself but I do have exposure to these patients on clinics. If these patients need extractions or more extensive treatment that cannot be done on a domiciliary visit, then we arrange transport to bring them to clinics to have their treatment done.

When I have treated these patients, I have learnt to ask questions that you wouldn't necessarily think obvious. For example, to manage post-op pain after an extraction, if this patient is in a ward or care home you may need to write a prescription for them as their carers may not be able to give them pain relief otherwise.

Overall, managing these patients can be challenging but I really enjoy the lateral thinking that comes with their treatment and management. As you can see, a lot of the time a patient may belong to more than one special care group. With community dental services being re-commissioned and evolving we are seeing more and more complex patients within the service. For me this means I need a good night's sleep after a day packed full of challenging, but stimulating clinical situations!

Do you work in special care dentistry or community? Let me know your thoughts on special care groups in the comment section below!

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.