There are a variety of behavior guidance techniques to effectively treat patients with autism in the dental office. Treatment planning and preventive strategies need to be individualized for these patients. Parents must make the dentist aware of the patient’s history, diagnosis and communication abilities treatment strategies. Despite the challenges, maintaining good oral health for the patient with autism can be an especially rewarding experience.
Both parents and providers must recognize that the mouth can be an especially sensitive area for these individuals. Numerous communication and behavior guidance techniques will be described. These visual supports and social schedules can be used to instruct the individual on dental office procedures. They allow for a structured processing of information at the individual’s own pace. People with autism are familiar with these systems in their classroom learning and daily activities.
There are many potential sensitivity issues in the dental office. The bright lights, especially those of the dental light, can be very uncomfortable to a child with autism. Sounds of the dental drill, suction machine or ultrasonic cleaner can be difficult for the patient to tolerate. Just the touch of the suction tip may bring a fear to the patient. For some patients, even the feeling of the patient napkin can be very unsettling. Finally, there are smells associated with the dental office and tastes associated with various dental materials which can make it difficult to provide treatment for a patient with autism. These will all be described for parents or caregivers to determine how to slowly introduce new experiences to the patient.
Desensitization activities can also help make it easier for the patient to experience dental care. This may be as simple as allowing the dentist to place a mouth mirror in a patient’s mouth to more complicated manipulation of the teeth with dental instruments. Desensitization techniques frequently work best when family and caregivers are involved in the process, reinforcing the activities at home. The process works best when practiced in a non-threatening environment, not the dental operatory. Desensitization helps the individual build awareness and self-control.
The dental staff may attempt some of these activities; however the use of occupational or behavioral therapists should not be underestimated. Occupational therapists are perfect individuals to fill in the gap of patient education, specifically related to maintaining oral health. Dental hygienists frequently do not have the time to provide the activities to patients that occupational therapists can offer. Occupational therapists include demonstration, modeling, return demonstration, positive reinforcement and corrective feedback in self-care.
Occasionally a patient will require some form of protective stabilization to perform a dental procedure. Protective stabilization requires that that an informed consent process be completed, which will usually involve some type of signed form. Protective stabilization is for a patient who requires diagnosis or treatment and cannot cooperate because of lack of maturity, cognitive or physical disabilities.
For some patients with autism, sedation or even general anesthesia will be necessary. It is interesting to note that treating children with severe caries in one session under general anesthesia results in a general overall improvement in quality of life for the entire family. Dental caries can have far reaching effects for the family of a child with autism.
When developing a dental treatment plan for a patient with autism there are numerous factors to consider. The clinician should ask if there are any chronic jaw or tongue movements, bruxism or bite reflexes. These may impact the design of a removable or fixed prosthesis. Inquire as to whether the patient has difficulty swallowing or if there is a particularly sensitive gag reflex. If the patient has poor motor coordination, susceptible to falling or has seizures, orthodontic correction of protrusive anterior teeth should be considered. The patient may exhibit oral scratching, scraping or picking habits that may be addressed with rubber chew implements. If the patient demonstrates pica, behavioral therapy interventions should be suggested. If the individual has recently developed some type of adverse behavioral issues or self-destructive behaviors, oral pain or infection should be investigated as a possible cause.
Of paramount importance in developing an oral health care plan is preventive care. The individual with a healthy mouth is relatively simple to care for in the dental office. Behavioral guidance techniques are often effective as the appointments are short and non-threatening. The clinician should ask who performs oral hygiene care and educate that individual as well as the patient. Some patients will prefer a manual toothbrush and others will prefer the feeling of an electric toothbrush. Oral therapy should begin at a young age so that personal mouth care becomes standard practice in the individual’s daily routine.
Environmental factors guide many parents in determining the courses of treatment for their children with autism. The parental concern over environmental toxins may result in potential conflicting opinions when the child requires dental treatment. Parents and dental health care workers not only have to address the challenges of behavior management for the patient with autism, they must also be prepared to discuss additional concerns of family members. Family members may voice concerns surrounding mercury, fluoride, nitrous oxide, antibiotics and acetaminophen. On the other hand, dental health care workers may not be as aware, resulting in adversity and a lack of confidence on the part of both parties. Parents can be advocates for their children in a constructive and collegial manner.
When choosing a dental office to care for an individual with autism, or any individual with a developmental disability, the successful dental team will make all efforts to respect the patient’s dignity. The dentist should show a calm and confident demeanor and taking an appropriate amount of time is essential for a successful appointment. A dentist who takes the time to become familiar with the patient can make the dental appointment a success story for everyone.
Robert E. Rada, D.D.S.
Dentist in private practice
Robert Rada's private practice is devoted to individuals with developmental disabilities, and he treats patients with autism on an almost daily basis. He has lectured to dental professionals and parents throughout the country on this topic, including at the 2012 US Austism and Asperger Association Conference.
