From Volume 50, Issue 6, June 2023 | Pages 517-520
Autism is a lifelong neurodevelopmental disorder characterized by its impact on social communication and interaction. This article reviews its basic epidemiology, and provides advice based on current literature on how to manage behaviour, communication and prevention to provide optimal dental care.
Autism is a lifelong neurodevelopmental disorder characterized by its impact on social communication and interaction, and often marked by repetitive, or restrictive, and inflexible patterns of behaviour.1 Characteristics for the condition can vary dramatically between individuals, from those with only mild neurodiversity to those with severe learning disability.2 Co-existing conditions are common, such as additional mental health issues (anxiety, phobia, attention deficits), learning disability and language disorders.3,4 The large degree of variation in the presentation of autism means that planning suitable care in different settings is vital; individuals need time to gain familiarity in unknown situations, and preparation can ameliorate anxieties that surround inflexible expectations.5 Co-working and planning between care providers and the patients enables better access to services, and helps in the delivery of successful interventions and treatments,6 for example to prepare someone who is likely to develop anxiety in new situations, or when they feel out of control, such as being in the dental chair. Dental interventions can be challenging for individuals with autism because interventions can be uncomfortable and invasive. Oral intervention in the face of hypersensory needs and unfamiliarity leads to dental environments being potentially high-stress, high-anxiety situations.
Autism prevalence is approximately between 1% and 2% of the population nationally, as well as globally7 and has increased in the past 10 years.8 In the UK, this means that up to 2/100 children have autism. Since 1998, the highest growth in diagnoses has occurred in adults, with an overall rise in new cases of 787% across two decades.9 Typically, the prevalence of autism is higher in boys than girls (estimated to be about 3:1), but girls tend to be under-diagnosed,10 and there is a suggestion that increasing numbers of girls are being referred at a younger age than previously. There is a lack of data for the prevalence of autism in different ethnic groups. However, within the UK, it has been suggested that there are differences between prevalence estimates in children from Minority Ethnic groups and White children.11
Challenging behaviour may occur when adults with autism are faced with an unfamiliar or anxiety-provoking situation.5 People with autism often need to be in control of what is happening to them. There are many sensory stimuli in the dental setting, including visual stimuli, auditory, tactile and olfactory stimuli (Table 1).
| Type of stimuli | Surgery stimuli | Possible solution |
|---|---|---|
| Visual | Bright ceiling lights | Dim/switch off non-essential ceiling lighting |
| Dental light | Careful positioning of dental light. Use of sunglasses, preferably the patient's | |
| Surgery clutter | Keep surfaces in surgery clear and clutter free | |
| Auditory | Handpieces | Use of ART and hand instruments only where possible. If unavoidable then a countdown of how long the handpiece is to be used for: ‘3,2,1’ |
| Suction | Slowly introduce, and use ‘tell-show-do’. Smaller bore suction is less aggressive and quieter | |
| Tactile | All clinical procedures | Slow introduction. ‘Tell-show-do’, social story for procedure being carried out, practice at home if exam only planned |
| Olfactory | Certain dental materials have a definitive smell | Declutter of surfaces and storage of materials carefully to avoid smell, eg zinc oxide/eugenol |
To reduce anxiety for patients with autistism, the key goal is to provide a non-threatening and friendly environment for care.
First of all, communication has to be clear and concise, because parts of the conversation can be taken literally, such as when suggesting to have radiographs taken ‘this will only be a few seconds’. Body language needs to be taken into account, many autistic patients prefer not to have direct eye-to-eye contact.
Secondly, preparing autistic patients for their visits and treatments is important. Since many autistic patients are highly sensory, it is important to give them plenty of time to get used to the new stimuli (environments, smells, sounds etc) that they are likely to experience during their dental visits. Even starting with the journey from home to the clinic, for some patients, can be a major step towards enabling the patient to feel comfortable in the dental environment and ultimately, supporting their co-operation with the provision of a dental exam and dental care. It is important to remember that one rule does not fit all, owing to the spectrum of behaviours evident. Ultimately, it is important to seek the views of the families and carers who support the patient with autism to have a clear understanding of what works well and what does not for the patient. A pre-assessment appointment/discussion with family members/carers can be beneficial for both the clinical team and the parent/carer to ensure the most seamless interaction can be achieved for the patient.
A social story, which may include a video, photographs of the clinic (Figure 1) and team or Picture Exchange Communication System (PECS; Figure 2) can be useful in preparation for such patients. Videos can be successfully used to take the patient through their journey in hospital and can include both visible information and sounds.
For many adult patients including those with autism, the level of anxiety associated with dental treatment may require referral for conscious sedation or general anaesthesia,12,13 especially as both children and adults with autism have an identified higher need for dental GA. This is especially the case if the patient has an additional moderate or severe learning disability.
However, it is not just a simple case of sedating or anaesthetizing a patient. The same levels of high anxiety that may have been shown by the patient receiving the treatment in the dental surgery, may also be experienced both pre-operatively and post-operatively, especially as the procedure will take place in an unfamiliar place, with potentially invasive medical and dental interventions. Negative experiences for autistic patients are often due to communication and sensory processing challenges,14 all of which can be aggravated by an unusual and very unfamiliar clinical environment and unfamiliar staff. Referral for GA is not necessarily a ‘magic cure’ for a patient with any type of learning disability. When it is deemed the most appropriate option, treatment under GA for patients with autistism needs to be carefully planned, and comprehensive treatment provided, to avoid the need for repeat GA episodes.15
To allow patients to more comfortably receive treatment under GA, carefully tailored treatment can involve administration of one or both of the following anxiety control methods to reduce the stress associated with anaesthetic induction:
These will be based on the techniques discussed above, but in addition, activities specific to the hospital and procedure being undertaken. These can include: photos and pictorial guides on which social stories can be developed; timing the procedure so that waiting between admission and treatment is minimized; private rooms that are quieter and calmer; and both theatre and ward staff who have an awareness of autism and of appropriate communication methods.
This can involve using benzodiazepines, either as a small dose taken at home to help with the journey to the hospital, and/or given intranasally by the anaesthetist while in hospital, to assist passage from the ward/room to the clinical areas (anaesthetic room/theatre). Where co-operation is still a challenge, at some centres intramuscular ketamine can be administered.
A small dose of diazepam or temazepam can often be effective to reduce pre-operative anxiety, but additionally, lorazepam is another useful medication that is sometimes indicated for this use. As lorazepam is unavailable for direct prescribing in the UK via the Dental Practitioner Formulary, liaison with the patient's GP or psychiatrist will be needed.
An alternative technique for reducing pre-operative anxiety is the use of a concentrated aerosol intranasal spray of midazolam, which is administered to the patient using a 1 ml syringe and a special atomization device (Figure 3). This has the advantage of being rapidly and predictably absorbed into the patient's blood stream, providing a safe and effective dose prior to cannulation. It is more commonly used in dentistry as an adjunct to intravenous sedation, alleviating anxiety prior to cannulation,16 but can also be used by the anaesthetic team prior to cannulation and induction in the GA setting.
Dental prevention needs to be a shared responsibility between both the patient and family/carers, adhering to healthy lifestyle choices, and the dental professional providing the necessary information and where necessary, supplements to support maintenance of healthy oral tissues. This focus on prevention is, perhaps, even more important in any individual for whom normal dental treatment is difficult to provide by the dental team. This includes patients for whom any operative care is provided under GA and for whom immediate access to these services is unlikely to be available in an emergency.17
Delivering Better Oral Health18 provides a universal toolkit that outlines effective prevention strategies for obtaining and maintaining good oral health. It is therefore useful in the care of patients with autism, in the sense that if oral health can be optimised, the need for fillings, cleaning and other operative dental interventions can be limited, with dental episodes focusing on checking and advice. This includes the use of prescription-only high fluoride toothpaste (Duraphat), which has been shown to have a significant effect on reducing caries, including in adolescents with less than ideal brushing habits.19 The idea of effective prevention being a simple matter of replacing the toothpaste a patient normally uses, is in most cases a fairly simple change to bring about.
For patients with sensory issues and who can not tolerate the strong minty taste of the majority of toothpastes, flavour-free versions are available (Oranurse), but only at a normal fluoride concentrations, so they do not have the same decay-reducing benefit of the high-strength prescribed toothpastes.
As mentioned previously, the most important aspect of dental care for any patient is maintaining a healthy mouth by following good dental prevention advice and adhering to healthy behaviour patterns. As the majority of patients with autism are diagnosed at a young age, an opportunity exists for these patients to receive dental care along with the rest of the family, and for life, within general dental practice.20 Recent schemes, such as ‘Dental Check by One’, encourage all children to start attending the dentist before their first birthday, so, not only is the familiarity of the dentist promoted to the toddler, but good prevention messages can be discussed and implemented at a very early stage in a person's life and hopefully established for adulthood too.21
For those patients whose anxiety precludes dental treatment being provided in this way, referral to the special care/community dental services is likely to be indicated. These services will have better access to providing comprehensive dental surgery, with the use of sedation and general anaesthetic where needed.
Excellent dental health is vital for all adult patients including those with autism. The principle of reasonable adjustment in many cases will be needed to allow patients to receive successful care. However, with careful planning and attention to detail, these variations are often reasonably simple and suitable for use by all informed, dental professionals.
In certain cases and for certain treatments, however, referral to specialist dental services will be needed.
