Improving sensory awareness in a dental setting for patients with autism spectrum disorder (autism)

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder in which the patient is likely to perceive the world and others around them in a different light to a neurotypical patient. Individuals have a certain combination of charateristics associated with social communication, sensory behaviours, repetitive behaviours and restriction in interests that start in early life. The prevalence of ASD is estimated to be <1%; however, this percentage may be higher in higher socio-economic groups.¹ The spectrum means patients may present with a differing number and severity of diagnostic features.²

An in-depth knowledge and understanding of a patient's behavioural patterns is important to ensure a successful dental visit. Patients with ASD may not be able to communicate and share information using spoken language, eye contact or gestures.³ As such, their interpretation of stimuli may result in altered responses to olfactory, tactile, visual, auditory and gustatory signals.⁴ Patients with ASD may have challenging behaviour and one study found 65% of patients with ASD were uncooperative when performing oral health tasks.⁵

The use of sensory tools may have value in facilitating an examination and treatment in patients with ASD. Kim et al found, when conducting a crossover study of 22 patients aged 6–21 years, that the introduction of a sensory adapted dental environment (SADE) significantly improved FRANKL (dental anxiety) scores. Additionally, 46% of parents also showed preference for the SADE for their child's next dental visit.⁶

Oral health adjuncts

Dental biofilm on tooth surfaces and plaque formation are the primary aetiological factors for both periodontal disease and caries formation.⁷ Prevention in the form of dietary adjustments and oral hygiene maintenance are advised to keep oral disease risk low. The most common and encouraged means of plaque removal at home is the use of a toothbrush with fluoridated toothpaste. The ‘Delivering Better Oral Health’ guidance suggests the following:⁸

• A reduction in the amount and frequency of sugars in the diet;
• Brushing twice daily, prior to bed time and one other time during the day;
• Brushing using a fluoridated toothpaste-with higher caries risks patient being prescribed higher fluoridated toothpaste if above the age of 10 years;
• Spitting the toothpaste out after toothbrushing, rather than rinsing with water to avoid diluting the fluoride concentration.

As clinicians, it is important to provide patients, parents and guardians with information to overcome the anxiety surrounding oral sensitivity in patients diagnosed with autism. A cross-matched control study assessing 257 pre-school children with ASD found a significant difference in the barriers to dental care, with a higher frequency in children with ASD. The frequency of performed tooth brushing and toothpaste use was also significantly lower in the group with ASD (P<0.05). Interestingly, among parents who reported tooth brushing as being a difficult task, several cited reasons showed statistical significance compared to the control group. These included the child being scared of the toothbrush, the child not liking anything in their mouth and the child not being able to directly understand the consequences of no tooth brushing.⁹

Toothpaste

A 2017 systematic review of current evidence suggested the possibility of taste hyper-responsiveness in ASD patients,¹⁰ whereby, the traditional mint taste of toothpaste and its foamy nature may be so overpowering that tooth brushing is challenging. Alternative fluoride toothpaste flavours are available as are non-foaming fluoride-containing toothpastes.

Toothbrushing

Multiple toothbrush types are available, including electric toothbrushes and three-sided manual toothbrushes.

Three-sided toothbrushes

The two most commonly available three-sided toothbrushes in use are:

• Collis curve toothbrush (Figure 1).
• Dr Barman's toothbrush (Figure 2).

For both, the prominent design feature is the ability to simultaneously clean and mechanically remove plaque from three tooth surfaces (occlusal, buccal and lingual) by placing the toothbrush on the occlusal surface only.

A 2017 systematic review found that triple-headed manual toothbrushes are more favourable compared to single headed manual toothbrushes with respect to plaque removal in cases where care-dependant individual's teeth are being brushed by caregivers.¹¹

Electric toothbrushes

Some individuals have found the use of an electric toothbrush decreases toothbrushing avoidance in patients with ASD. In a study by Teste et al, parents found the use of an electric toothbrush to have a calming effect. There were also parents who used electric toothbrushes with music as a method of facilitating tooth brushing.¹²

Finger guards and Dent-O-Care mouth rests

Finger guards (Figure 3) and Dent-O-Care (Figure 4) mouth rests can be used by caregivers as a method to maintain mouth opening for access when tooth brushing. The finger guard and rests are used on the opposite side to where tooth brushing is required. In using these adjuncts, the occlusal, lingual and palatal surface of the maxillary and mandibular dentition can be mechanically cleaned.

Information for caregivers regarding oral health

As dental professionals, providing information to assist with oral health maintenance and prevention is a priority. The British Society of Paediatric Dentistry has published a freely available guide: ‘Advice for parents of children with autism’, which provides information on toothbrushing, as well as the first dental visit and treatment provision.¹³ There is also a ‘further reading’ section that directs caregivers to other websites, including those regarding story book use and support pages.

Additionally, the UK National Autistic Society has excellent resources regarding dental visits.¹⁴ It provides a guide on expectations for the dental visit as well as useful tools to assist in ensuring a successful visit. Further resources in helping dentists create a more autism friendly environment are also included. This provides ideas for simple adjustments that can be made in the clinic to improve experiences and decrease sensory loading for individuals with ASD.

Behavioural adjuncts

Hyper- and hypo-responsiveness to sensory features has been reported in 42–88% of older autistic children, depending on the study reviewed,^15,16 highlighting this as a common concern for this population of patients. While there is little research available on the use of sensory adjuncts in paediatric dentistry, these tools have been known to work well in a school setting to improve social communication¹⁷ and are recommended by our play therapy colleagues as a method to improve focus, communication and positive experience levels.

iPad use

Greenspan and Weider noted difficulties with auditory processing, with 100% of the ASD patients' who were studied demonstrating processing difficulties.¹⁸ iPads (Figure 5) can be used in a variety of ways to distract patients including: YouTube videos, favourite music and animations. Although there is limited research on the use of technology for ASD patients, a recent study assessing iPad use for social communication and emotional regulation in ASD pupils highlighted the technology's potential to support the pupils' communication, collaboration, relaxation and transition through collaborative training and multimodal teaching methods.¹⁹

Sensory toys/stress balls

While visual spatial skills are often more advanced than other developmental areas in patients with ASD, individual differences may be noted.²⁰ The use of sensory toys (Figure 6) and stress balls have proved beneficial when providing treatment. They can distract patients and channel anxiety.

Chew toys

Luiselli et al found the use of chew toys (Figure 7) to be beneficial in patients with ASD for access to matched oral stimulation.²¹ A number of oral chew toys are available including toys on a lanyard and for wrist wear.

Social stories/picture boards

Gray suggested the use of social stories (Figure 8), which should be individualized and consist of only a few basic sentence types:²²

• Directive
• Descriptive
• Affirmative
• Perspective.

Gray also suggested that the social story should only contain one directive sentence for every five sentences within the story.²²

Delano and Snell reviewed three elementary-age students with autism.²³ The children were assessed on four social skills to evaluate the effects of social stories on the appropriateness of social engagement. The findings suggested that social stories in isolation had the possibility of increasing the duration of social engagement.²³

Social story boards are useful for different dental activities, including examination, restoration appointments, inhalation sedation use and general anaesthetic appointments. These can be sent to guardians to prepare children as part of the pre-assessment information. Parents/guardians should read the social story with the child multiple times prior to the visit to ensure the story provides positive terms for the dental activities and clear behavioural guidance. Prior use of the social story in a familiar setting, for example at school or home, is important because children with ASD can sometimes become distressed by small changes in their daily routine, including the type of book read, or an unfamiliar situation. Great success when using this protocol in collaboration with occupational teams has been reported.²⁴

Clocks

Visual clocks have been found to be particularly helpful in managing time and providing a common goal when carrying out dental treatment.²⁵

Mirror use

While there is some evidence on the use of mirrors as a treatment method to improve and increase imitation skills in patients with ASD, there is limited evidence of mirror use as distraction tool for dental treatments and examination. Anecdotally, being able to see themselves, as well as the dental examination being conducted, has helped to ensure successful visits.

Environmental factors

Clinicians should provide continued thought and adaptation to the working environment to meet individual needs. Sensory-friendly environments and altering sensory stimuli encountered during dental care can decrease stress and anxiety.²⁶ The use of weighted blankets and calming music could benefit certain patients and create an inviting and relaxed environment to provide dental treatment. A study including 85 individuals, 47 of whom were children under 17 years old, who presented with a diagnosis of ASD or ADHD, demonstrated weighted blanket use improved sleeping habits and relaxation during the day.²⁷ Using weighted blankets, before and during distressing sensory events, for example within a dental setting, can help a patient who finds it difficult to process everyday sensory information. While there are no studies that look at this technique in a dental setting, several studies do support this method as a way to reduce sensory overload.^28,29

Preparation prior to the dental visit can also increase familiarity to commonly used dental tools. For example, plastic mirrors can be provided to the patient to take home and practice with, which can improve the clinical experience and minimize unknown elements within a dental examination appointment. Creation of a patient passport that outlines likes and dislikes can also be used to aid adaptation of the environment to make dental examinations less stressful for the patient and accompanying guardian.

Reducing bright lights, loud noises and the number of people present for the examination may also improve cooperation. Dimmed lighting and keeping the dental worktops free from equipment will reduce distraction. For some patients, a pre-reclined dental chair can reduce sensitivity to motion and provide a fixed environment for patient dental care to take place.

Face-to-face communication strategies

The language used when consulting with patients with ASD needs to be short and direct. In order to achieve an appropriate focus level when engaging the patient in oral health, literal language with concrete thinking needs to be considered.³⁰ For example, asking a patient with ASD to ‘jump up on the chair’ may be taken literally, and therefore wording should be adapted to ‘please sit down on the chair in the middle of the room’.

In cases where autism is more severe, other communication methods can be used including Makaton, widgits and Picture Exchange Communication System (PECs). Prior to a dental visit, dentists and carers can communicate directly with day centres and schools where the patient can be prepared using a communication strategy familiar to the patient. This may involve creation of a dental widgit, or providing a comprehensive and clear idea of the sequence of events that will take place during the dental examination or treatment.

Makaton

Makaton is a method for communicating using symbols, signs and speech. It can help both children and adults to communicate independently while developing language skills. For children who prefer to communicate using pictures, Makaton symbols can be used with the PECS. Further information about the use of Makaton and training opportunities can be found at: https://makaton.org/TMC/TMC/About_Makaton/Help_with_autism_and_communication.aspx

PECs

PECs is an alternative communication strategy initially implemented with pre-school children diagnosed with ASD in the US. The aim of PECs is to form independent communication through prompting and reinforcement strategies. By omitting verbal prompts, independent communication can be instilled early on. PECS is made up of six phases, with the aim of creating sentences using pictures. Further information can be found at: https://pecs-unitedkingdom.com/pecs/

Widgits

Widgits are designed for all ages who have difficulties with text or communication and use pictorial symbols as an alternative, or alongside text, to provide a basic and quick communication strategy for patients. Healthcare widgits are available at: https://widgit-health.com/

Conclusion

Awareness and understanding of ASD as a medical diagnosis, and its impact on dental care provision, is important for clinicians. Providing an environment where sensory processing difficulties are reduced and oral health and behavioural adjuncts are used is important to improve success rates for dental examinations and treatment visits for patients with ASD.