Autism & Autistic spectrum

Each individual can be totally different as there exists a broad variation of autistic disorders

Highly individual and truly empathetic approach, with well understanding of the background

Initial assessment of general behaviour. Pre-questionnaire can be sent to patient/parents via post with questions regarding patients preferences, fears, phobias, impairments, communication, etc.

Long acclimatization. Being very patient and listen to patient. Lots of reassurance all the way

Empathetic attitude, respect, knowledge and practical competences.

Quiet voice, keep movements to minimum

Use of simple short phrases, repetitions and reassurance,

Clear explanations about findings and proposed treatment

Variations of different types and manifestations

Young patients often focus obsessively on certain subjects, eg. games, movies, cards, dinosaurs, etc.

Non-verbal communication vitally important ! body language much more essential than words. The reason, why autistic patients do not respond well to inhalation sedation – they just to not listen verbal instructions.

Patient may ask a bit unusual questions, eg. “how old are a dentist?” or the opposite – may answer in a repetitive way while asking about eg. brushing: ” I do not know”.

Patients usually less talkative and quiet, allow a longer time for an answer

Short attention span, likely to be distracted, keep appointment time short and simple

Non-verbal communication vitally important !, do not rely on verbal communication ! Some ASD patients do not listen at all.

Good and enhanced ‘peripheral vision’ (“sideways looking”), it means patients can be a very good observers and constantly monitor what is going on around them

Difficulties with maintaining of eye contact but not always.

Some autistic patients can be very chatty (‘chatta box’) and clever.

Dental chair has to be reclined slowly , with pre-warning, some patients do not like ‘flat position’, prefer sitting upright. Dental chair movements demo and gradual familiarization

Little distractions always helpful for young patients, eg. blowing out baloon made of dental glove, pt can draw a smiling face on it.

There is no a single ‘golden advice’ how to manage autistic pt.

Clear explanations regarding aetiology of caries/periodontal diseases (adult patients)

Non-pharmacologic bahaviour management techniques: tell-show-do, positive reinforcement, voice control, humour, protective stabilization.

Way of communication is paramount: discussion with the caregiver/parents about techniques they have found to be effective in managing the patient’s behavior. Share your ideas with them, and find out what motivates the patient. It may be that a new toothbrush at the end of each appointment is all it takes to ensure cooperation.

Patient should be scheduled early in the day if possible. Early appointments can help ensure that everyone is alert and attentive and that waiting time is reduced.

Successful visit needs to by involve the entire dental team from the receptionist’s friendly greeting to the caring attitude of the dental assistant in the operatory.

Repetetive bahaviour can be nicely adjusted in dental settings by using also stereotypical behaviours in our favour.

Oral care provision in an environment with few distractions. Try to reduce unnecessary sights, sounds, or other stimuli that might make it difficult for your patient to cooperate. Some patients, however, enjoy music and may be comforted by hearing it in the dental office during treatment.

Step-by-step evaluation plan, starting with seating the patient in the dental chair. If this is successful, perform an oral examination using only your fingers. If this, too, goes well, begin using dental instruments. Prophylaxis is the next step, followed by dental radiographs. Several visits may be needed to accomplish these tasks.

Consistent in all aspects of providing oral health care. Use the same staff, dental operatory, appointment times, and other details to help sustain familiarity. The more consistency you provide for your patients, the more likely that they will be cooperative. Comfort people who resist oral care and reward cooperative behavior with compliments throughout the appointment.

Unfamiliar environment in the dental office, strong light,  suction noice or high speed noice ‘taste’ of dental materials (eg. ZnOE) may trigger autistic behaviours

Unflavoured and non-foaming toothpaste can be better accepted by autistic patients.

unflavoured toothpaste

Conscious sedation techniques often helpful

General anaesthesia can be the only option to complete more complex dental treatment (extractions, multiple restorations)

The use of Makaton language sometimes halpful as a means of communication to patients who cannot communicate efficiently by speaking

Makaton

Avoid highly distractive elements in dental surgery (bright light, noise)

Paradoxically, some patient with autistic spectrum disorder seem to be more compliant with dental treatment, than ‘routine’ patient, depending on type, severity, degree of autism.

Do not assume, that ‘quiet’ patient with autism would be fully cooperative.

Conduct disorder – antisocial behaviour, ‘too mature’ way of talking

Some meds for ADHD , with extended release (Quillivant XR) couse side effects such as: decreased appetite/weight loss and sleep problems. Patients may act in a strange way: no food intake during the day and obsessive eatign at night, risk of rampant caries

Reactions can be unpredictable: screeming, tears, agitation

Dental procedures may trigger autistic behaviour: sucction, injection, etc.

‘Dental Passport’ can be be useful, with pt’s photo and details: what pt likes, what sort of fears pt is having

Highly individual (customised) treatment plan – ideally sent via letter to parents following dental exam – is a very good option! Clear statement point by point re: oral hygiene regime, diet, adjuvant technique and aids

Step-wise technique should be used, with the use of ZnOE, GIC or Biodentine to acclimatise patient with more invasive dental treatment

Bulk composite to accelerate procedural time as short attention span

UV toothbrush sanitiser as a ‘dental gadget’ which may encourage for regular brushing

Give enough time to patient to allow him/her to gradually build up the confidence

Postpone non-urgent procedures if not trully necessary

Leave ‘ready to exfoliate’ teeth to come out in natural way

To monitor eg. retained deciduous teeth/roots if asymptomatic

‘social stories’ using pictures – is extremelly useful way for accliatisation of autistic patient

Colour pictures can be used to make patient familiar with dental offcie

The National Autistic Society, “Dentist: preparing for a visit”

Gentle clinical holding or just head support by: stabilizing patient’s head/mandible between hands preventing from involuntary movements.

Even just a slight touching within temporal/cheek areas may make patient much more calm, relaxed and compliant.

The ipad app. cADET (in French) to teach autistic child proper brushing

 

 

Groups of patients – range;

1. extremely quiet, withdrawn, polite, hypoactive

2. interrupted speach, sudden reactions,

3. wants to know everything about dentally-related issues

4. just scarred/anxious

5. talkative, many questions all over

6. agitated

 

Persons with autistic spectrum disorders can be also successfully manager in general dental practice by using well prepared and structured sessions, including: perparation, maintaining contact, using stereotypical bevaiours in our favour, assimilation and feedback.

Case scenario (examples):
4 years old patient referred by GDP due to recurrent odontogenic inflammation associated with grossly carious second deciduous molar tooth.
Second visit to dentist. Patient generally very cooperative, sat in chair on his own. Medical history non-contributory apart from ‘borderline autistic spectrum’. Communcation impaired but patient generally happy, not anxious at all, smiling all the way, allowed a full dental examination. Lower E poss. pulpally involved, swollen alveolar mucosa, recurrent abscess, repeated opening and drainage did not work. AB coure started finished recently. Would tolerate radiographs. The rest of deciduous teeth appear to be clinically sound. Options discussed with parents who prefers to try routine treatment under LA first and would not consent for XGA. Patient seems to be generally very good and compliant, just shy. XLA completed successfuly with long acclimatisation and tell-show-do approach.
Above 5 years old, with diagnosed autism since the age of 3,  occasional spontaneous dental pain associated with decayed LR6, patient seems to be partially cooperative. Gradual confidence build up via acclimatization visit(s), long discussion with parents/guardians, distraction, desinsitisation technique, CBT. Attempt of proper full mouth examination, attempt of rads, provisional treatment plan and discussion with parents. Familiarization with dental environment supported by dental therapist (OHI, preventative adv). To try a proper examination next visit in the next few days if not compliant durign the first appointmentt. NSAID paracetamol adv if not co-operative. If predicted unsuccessful use of conscious sedation (IHS) then  GA is likely the only option. Second orthodontic opinion if available and possible, ideally following OPT before XGA(s).
Teenager 16 y.o with diagnosed autism, attended recall appt., Mum stayed in the waiting room. Seems to be very cooperative and behaved like a ‘routine’ patient apart from the fact that suddenly reacted to ultrasonic vibrations and noice whiel attempting scaling. Conclusion: any new procedure must be thoroughly explained before commencing it.
25 years old patient with autism, challenging bahaviour, slight anxiety as does not like a new situations. High caries rate, multiple restorable cavities. Referred by GDP. Very talkative, keeps asking lots of questions related to causes of decay and proper oral hygiene. Likes fizzy drinks, stressed importance of reducing sugar intake and to avoid sugary/acidic drinks. Had some conservative dental treatment done in the past. Undersood well treatment plan, including multiple fillings under LA, consented in writting.
Patient above 10 years old. Attended with Mum. Referred by GDP who as not ablet to complete even an initial dental examination. Patient did not allow any brief assessment and using any instruments for dental check up. Very shy and not talkative at all. Mum said – patient stopped brushing a few monts ago, occasionally uses manual toothbrush, dislikes  TP, very apprehensive  regarding oral hygiene. Furtunately, pretty good Only discussion and slow acclimatisation during initial appointment. Plastic dental mirror given to practice at home. OHI given, along with dietary adv, OraNurse unflavoured TP given.

 

Collin Curve toothbrush