By Andrea Hare, RDH, M.Ed.
and Autumn Penney, Bethany Thompson, Desiree Bennett, Hailey Buhler, & Shayna Coish
2024 graduates of Dalhousie’s Diploma of Dental Hygiene
Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental condition affecting various aspects of an individual’s life, including behaviour, sensory processing, communication, cognition, and social interaction.1 Its prevalence is increasing, with 1 in 68 people diagnosed in Canada.2
Research suggests children with ASD face a heightened risk of caries and periodontal disease, yet many are hesitant to attend preventive care appointments.3,4 This reluctance can lead to worsening oral health conditions and the need for more complex dental procedures requiring anesthesia or sedation.3
The pediatric dentistry unit in Halifax, part of the IWK Health Centre, provides specialized care for individuals under 16, including those with ASD.5 Currently, the average wait time for surgical procedures stands at 801 days,5 possibly contributing to patients experiencing ongoing oral pain, sleep disturbances, and disruptions to schooling and extracurricular activities.
Ideally, children with ASD would access preventative care within their own communities, reducing the burden on our healthcare system and alleviating long wait times. However, children diagnosed with ASD often find it challenging to cope with new experiences.6 The dental environment, with its variety of sounds, smells, and visual stimuli, can intensify feelings of anxiety and fear for them.6
In addition to heightened fear and anxiety, research highlights other barriers that may contribute to an overall reluctance to access preventive oral healthcare:
- Challenges understanding verbal and non-verbal cues1
- Comfort with personal space1
- Difficulty adapting to change1
- Trouble with verbal communication1
- Hypersensitivity leading to anxiety and discomfort1
- Negative behaviour responses to stress1
Considering the rising prevalence of ASD diagnoses, it’s important for oral health professionals to equip themselves with the necessary skills and strategies to provide preventive oral care to this demographic in their communities. Navigating the intricacies of ASD requires a thoughtful approach, but research suggests that simple, cost-effective measures can yield remarkable results. The following strategies have been shown to be effective:
1. Dental desensitization
Children with ASD may react strongly to new environments and stimuli, like noises and smells.7,8 Offering a tour of the dental office can help familiarize them with the setting, staff, and equipment used during their appointment. This approach is most effective when the tour occurs shortly before the appointment.7,8
2. Social stories
Social stories provide clear, step-by-step information, clarifying ambiguous situations or activities.9 Dental offices can customize social stories to their clinic and team members, starting from outside the building and detailing a typical appointment sequence for the child.9,10
3. Tell, show, do
‘Tell, show, do’ introduces procedures in a stepwise manner. The child first understands the procedure through explanation, then it is demonstrated in a way that involves the appropriate senses before the procedure is performed on the child.11 For example, before applying fluoride varnish, explain what the fluoride varnish is used for, show the child the fluoride varnish, use the brush on their finger, then apply fluoride to their teeth.11
4. Noise-cancelling headphones
About 70% of children with ASD experience heightened sensitivity to auditory stimuli, potentially leading to adverse behavioural reactions. Noise-cancelling headphones offer a cost-effective solution which is highly effective in reducing low-frequency noises while still allowing human voices to remain audible.12
5. Alternative toothbrushes
Children with ASD may exhibit uncooperative behaviour due to touch sensitivity, particularly in relation to oral sensations.13 Work with parents/guardians/caregivers to discover the best toothbrush option. Various alternatives like three-sided, electric, singing, or silicone toothbrushes are readily accessible.14,15
6. Visual aids
Visual aids are invaluable tools for improving oral hygiene skills and cooperation in children with ASD.6 They help familiarize children with dental environments, reduce anxiety, and facilitate learning. Further, pictures or videos are effective for non-verbal or non-fluent patients, increasing the likelihood of cooperation during oral health care.6
7. AV interventions
Audiovisual distractions are shown to be successful in reducing children’s pulse rate and can be an effective distraction to reduce fear, anxiety, and uncooperative behaviour.4 One study revealed that a tablet device fixed to the dental chair was superior in pain control during an IAN block when compared to AV glasses, a virtual reality box, or no intervention. While audio aids are more commonly accessible, audiovisual aids overall exhibit greater effectiveness.4
8. Video or peer modelling
Children show a preference for visual information, such as television or videos.4 Consider showing a video of another child’s preventive dental treatment, covering all aspects of a typical appointment.4 In one study, children with ASD watched a desensitizing video before their appointment, which resulted in decreased anxiety and improved cooperation.3
9. Light sensitivities
The impact of lighting on children with ASD is profound and can influence both their mood and behaviour. Neutral lights promote a calming atmosphere. LED lightbulbs are preferred over fluorescent.16 Additionally, having the ability to adjust or dim the lighting can significantly enhance the child’s emotional state and behaviour during their visit.16
The many barriers faced by children with ASD emphasize the importance of individualized, patient-centred care, as there is no ‘one-size-fits-all’ solution. Utilizing these simple accommodation solutions can aid in increasing clinician confidence and patient comfort during oral healthcare visits. Additionally, it can contribute to easing the burden on surgical wait times while fostering inclusivity and understanding within our communities.
A clinician’s toolbox for providing exceptional care to children with ASD
- Electronic screen media, like tablets, can serve as an engaging distraction, promoting a positive focus.3
- Visual aids and video peer-modelling offer visual cues, helping comprehension and eliminating uncertainty.3
- Dental desensitization appointments provide a structured and gradual introduction to the dental environment, helping to ease anxiety in children with ASD.6
- Social stories help with executive functioning and sequencing.9
- ‘Tell-show-do’ allows clinicians to demonstrate procedures step-by-step, enhancing predictability for the child with ASD.10
- Using earmuffs or noise-cancelling headphones helps minimize sensory overload, creating a quieter and more controlled atmosphere.11
- Alternative toothbrush options cater to individual sensory preferences.12
- Neutral and controllable lighting contributes to a calming environment, accommodating those with sensitivities to bright and/or flickering lights.16
References
1. Autistic Characteristics Across the Lifespan [Internet]. Autism Speaks Canada. Available from: https://www.autismspeaks.ca/autistic-characteristics-across-the-lifespan/Dental
2. Public Health Agency of Canada. (2018a, April 19). Government of Canada. Canada.ca. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/autism-spectrum-disorder-children-youth-canada-2018.html
3. Isong IA, Rao SR, Holifield C, Iannuzzi D, Hanson E, Ware J, et al. Addressing Dental Fear in Children with Autism Spectrum Disorders. Clinical Pediatrics. 2014 Jan 3;53(3):230–7.
4. Dental care and autism – a guide for dentists [Internet]. www.autism.org.uk. Available from: https://www.autism.org.uk/advice-and-guidance/topics/physical-health/going-to-the-dentist/dentists#:~:text=Lack%20of%20understanding
5. Extractions and Restorations (Pediatric) [Internet]. Nova Scotia Wait Time Information. Available from: https://waittimes.novascotia.ca/procedure/dental-extractions-and-restorations-pediatric
6. Balian A, Cirio S, Salerno C, Wolf TG, Campus G, Cagetti MG. Is visual pedagogy effective in improving cooperation towards oral hygiene and dental care in children with autism spectrum disorder? A systematic review and meta-analysis. International journal of environmental research and public health. 2021 Jan;18(2):789.
7. Cai J, Habib D, Bedos C, Santos BF. Parents’ perceptions regarding the effectiveness of dental desensitization for children with autism spectrum disorder. Pediatric Dentistry. 2022 May 15;44(3):192-7.
8. Martínez Pérez E, Adanero Velasco A, Gómez Clemente V, Miegimolle Herrero M, Planells Del Pozo P. Importance of Desensitization for Autistic Children in Dental Practice. Children. 2023 Apr 28;10(5):796.
9. Social Stories for Going to the Dentist – Pathfinders for Autism [Internet]. [cited 2024 Feb 19]. Available from: https://pathfindersforautism.org/articles/healthcare/social-stories-for-going-to-the-dentist
10. Marion IW, Nelson TM, Sheller B, McKinney CM, Scott JM. Dental stories for children with autism. Special Care in Dentistry. 2016 Mar 2;36(4):181–6.
11. Roberts JF, Curzon ME, Koch G, Martens LC. Behaviour management techniques in paediatric dentistry. European Archives of Paediatric Dentistry. 2010 Aug; 11:166-74.
12. Ikuta N, Iwanaga R, Tokunaga A, Nakane H, Tanaka K, Tanaka G. Effectiveness of Earmuffs and Noise-cancelling Headphones for Coping with Hyper-reactivity to Auditory Stimuli in Children with Autism Spectrum Disorder: A Preliminary Study. Hong Kong journal of occupational therapy. 2016;28(1):24–32.
13. Khrautieo T, Srimaneekarn N, Rirattanapong P, Smutkeeree A. Association of sensory sensitivities and toothbrushing cooperation in autism spectrum disorder. International journal of paediatric dentistry. 2020 Jul;30(4):505-13.
14. Teste M, Broutin A, Marty M, Valéra MC, Soares Cunha F, Noirrit-Esclassan E. Toothbrushing in children with autism spectrum disorders: qualitative analysis of parental difficulties and solutions in France. European Archives of Paediatric Dentistry. 2021 Dec;22(6):1049-56.
15. Sukanto S, Lazuardi PR, Ermawati T, Probosari N, Setyorini D, Budirahardjo R, Prihatiningrum B, Shita AD. The Effectiveness of Using an Electric Toothbrush as a Plaque Control Tool in School-Autistic Children. International Journal of Medical Science and Clinical Research Studies. 2023 Oct 28;3(10):2485-8.
16. Nair AS, Priya RS, Rajagopal P, Pradeepa C, Senthil R, Dhanalakshmi S, et al. A case study on the effect of light and colors in the built environment on Autistic Children’s behavior. Frontiers in Psychiatry. 2022;13. doi:10.3389/fpsyt.2022.1042641
