Dental providers consistently strive to provide comfortable care to all patients. However, children on the autism spectrum present a particular challenge in dental care due to sensory and communication issues.
The prevalence of diagnosed autism disorders has increased. According to the Centers for Disease Control and Prevention, one in 36 children has been identified with an autism spectrum disorder.1 This is an increase from one in 150 children in 2000.2 It is unclear how much this is due to changes to the clinical definition of autism spectrum disorder (ASD), which may include more people than previous definitions, and better efforts to diagnose ASD, which would identify people with ASD who were not previously identified. However, a true change in the number of people with ASD is possible and could be due to a combination of factors.1
Information about therapy and dental management of children with ASD is available: Check out autismsociety.org and autismspeaks.org. However, I thought it would be interesting to speak with the patients themselves and their parents to help understand their perspective of the dental experience.
I asked three different families with verbal, high-functioning children some basic questions:
- What helps make your visits to the dentist more comfortable?
- What are some things you don’t like about going to the dentist?
- What can we do to help you develop a home care routine?
- Is there anything you wish you could tell your dentist or dental hygienist?
Just as symptoms of autism present on a spectrum, patient experiences vary widely. However, I found some common themes with the families I interviewed.
More Comfortable Visits
One common theme with all families was that the children feel more comfortable with visual, auditory, or tactile stimulation. Some kids feel better with a favorite blanket or plush toy. Watching a movie or listening to headphones can also be calming. Some patients have found that having a spinner toy or fiddling with a ring on their finger helps them relax and hold still.
The patients also mentioned that pediatric specialists really help because the environment is welcoming from the moment they walk in the door. One patient mentioned that he looked forward to his appointments because they had video games and movies.
Another strategy I found interesting is that a weighted blanket can be very comforting. This is an easy accommodation we can make in the dental operatory because we have lead aprons. Ask the child if they would like a blanket and, if they would, use the lead apron to provide a sense of security.
A common thread during the conversations was that most patients on the spectrum have trouble with change – they thrive with consistency. Try to ensure that the patient sees the same provider and assistant at each visit. This helps establish patterns of communication and eliminates the fear of the unknown.
I also learned a new concept in communication – first/then statements. While researching this, I discovered that this is also called the Premack Principle. This principle hypothesizes that the opportunity to engage in a high-probability behavior after a low-probability behavior will function as a reinforcer.3 In other words, telling the patient they need to do something first (desired behavior), then afterward they can do what they want to do.
To use this in practice, talk with the parents about what the patient likes to do if left to their own devices. It may be looking at a favorite book, using a tablet, or going to the park. Then, for example, you could tell the child that first, they need to hold really still and open their mouth, and then they can take a short break and look at their tablet.
At first glance, it seems like bribery. But to a patient on the spectrum, it can help them order events in their mind and ease compliance.
Dental Office Dislikes
Overwhelmingly, the kids mentioned that they highly dislike the bright lights and loud noises in dental offices. What to us seems like a normal dental office environment can feel like sensory overload to them.
Bright lights can easily be softened by using sunglasses. Our handpieces make obnoxious noises that irritate anyone. One child mentioned that it helps to warn him about noises. So maybe it would be good to show the patient the handpiece outside the mouth and demonstrate how it makes a whistling sound before placing it in the mouth. The patient may prefer to listen to headphones during treatment to filter out noises.
Home Care Routines
One advantage of working with patients on the autism spectrum is that they thrive on routines. Our goal then is to work oral care into their daily routine. Once this is accomplished, they most likely will not stray from what they have been taught. Many patients who have worked with educators and therapists have rigid daily routines, even boards that show them what they do and when. It can be very distressing to them if they are not able to complete their daily tasks. Give the patient homework, such as brushing and interdental cleaning, and talk to the parent about creating a specific time for home care.
When teaching home care techniques, relying on visual and tactile instruction is invaluable instead of just explaining what needs to be done. Use the mirror and slowly show what is expected when caring for their mouth at home. Ask the patient if they would like to try, and then coach them.
Some parents mentioned that the sensory stimulation of brushing was difficult for their child at home. The act of brushing can seem invasive and overwhelming to the child, causing them to be combative. Many children are very sensitive to tactile stimulation. An interesting solution I heard from one parent was body brushing. Also known as the Wilbarger Protocol, it involves using a soft plastic brush to run over the child’s skin with firm pressure. This can be very soothing to children with sensory sensitivity. After calming, the parent can move on to the oral tactile technique where the parent repeatedly wipes a finger along the inside of the child’s cheek.4 Once the child has accommodated this intraoral stimulation along with brushing the body, defensiveness to brushing may be reduced.
Tips from the patients and their parents include:
- Be extra clear about intentions and expectations
- Take one step at a time, and explain to the patient before proceeding
- Use real objects and pictures to reinforce meanings
- Every child is different; talk to the parent before treatment to understand common triggers and motivators
- Start slowly with easy, positive visits to build trust and a routine for the patient
- Keep the same providers and assistants
- Ask about their interests
- Use a soft voice
- Avoid bright lights and loud noises
- Praise often
From Them to You
When I asked what they wished they could tell their dentist or hygienist, I honestly expected to hear complaints. Happily, I heard nothing but appreciation. They wanted to thank us for our patience, our kindness, and our empathy. They live in a world that often judges and misunderstands what they are going through and they love the fact that we want to help improve their lives.
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References
- Autism Data Visualization Tool. (2023, March 23). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/autism/data/index.html
- Data and Statistics on Autism Spectrum Disorder. (2023, April 4). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/autism/data.html
- Long, S. (n.d.). Why “First, Then” Actually Works. The Autism Helper. https://theautismhelper.com/first-actually-works/
- The Wilbarger Protocol (Brushing) for Sensory Integration. (n.d.). National Autism Resources. https://nationalautismresources.com/the-wilbarger-protocol-brushing-therapy-for-sensory-integration/
