Autism is a lifelong developmental disability that affects how a person communicates with, and relates to, other people. It also affects how they make sense of the world around them. It is a spectrum condition, which means that, while all people with autism share certain difficulties, the condition will affect them in different ways. Some people with autism are able to live relatively independent lives but others may have accompanying learning disabilities and need a lifetime of specialist support. People with autism may also experience over or under-sensitivity to sounds, touch, tastes, smells, light or colours: this can make a dental visit a very distressing experience.
People with autism can experience challenges when there are changes in their routine, and can find it difficult to cope with new or unfamiliar situations and people. A visit to the seemingly-alien environment of a dentist surgery can therefore be an entirely overwhelming experience. If a person with autism experiences sensory overload, they could go into meltdown; other people with the condition may become unable to communicate. This is known as ‘shutdown’.
There are several steps that dental staff, families and carers can take to avoid these outcomes and minimise the stress of a trip to the dentist.
Before and during treatment
Try to minimise the waiting time for a patient with autism as much as possible. The uncertainty experienced when they do not know exactly when they will be seen can lead to increased anxiety. It can also be confusing for a person with autism if they have a ‘fixed’ appointment but do not get seen at that time.
When anxious, people with autism may make sounds or use repetitive movements. This may be a way of coping and should be respected.
Adaptations to the dental environment can be made to counter the difficulties that some people with autism experience if they have heightened sensitivity to light and noise. For example, turn the radio off if a patient finds it hard to deal with this kind of background noise. If possible, find out about potential issues before appointments. You may not be able to alter lighting or the noise made by equipment so if this is an issue, stress balls or visual distractions may be useful. Be aware that some people with autism may find equipment itself and the noise it makes frightening or fascinating.
During treatment, always explain exactly what is happening and what you are about to do. For example, “I will be checking your teeth to make sure they are in good condition,” or “I am going to put a small mirror inside your mouth to check your teeth. The mirror might touch the edges of your mouth”.
People with autism often need extra time to process information, and some may prefer information to be presented visually. A selection of free leaflets for patients can be found on the Easyhealth website (www.easyhealth.org.uk).
Patients that are able to process verbal communication may take things literally, so it is important for dental staff to say exactly what they mean and avoid figures of speech and metaphors. Giving direct requests, such as “open your mouth” is more autism-friendly than asking “can you open your mouth?” This may result in the person keeping their mouth closed or simply eliciting the answer “yes”. The patient may not understand that the dentist is asking them to do something.
Similarly, you cannot rely on gestures or body language to convey information and humour may also be misunderstood. With some patients, you may notice unusual body language and eye contact. Some people with autism find it easier to avoid eye contact completely; others may find it difficult to know how much eye contact to make, and perhaps misjudge things slightly.
If a patient is accompanied, it is usually best to allow their companion to be present during treatment. A companion may make communication easier for the dentist and the patient.
Some people with the condition do not like to be touched. When dental staff need to touch a patient with autism during the course of their treatment, it can be beneficial to give as much warning as possible with clear explanations.
The heightened sensitivities that people with autism can experience can present other challenges. Rinses and chemicals may smell or taste much more intense to people with autism. If at all possible, offer alternatives such as a very mild mouthwash, or none at all. It is also important to be aware that injections and drilling, especially if accompanied by noise or other sensations such as cold water, may be particularly painful.
At the other extreme, patients with autism who are hypo-sensitive to pain may not respond if a dentist is testing for pain.
Finally, it may help to book a double appointment, or spread treatment over several visits. This means the dentist and patient can take things one step at a time, and possibly help to manage a patient’s anxiety.