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References

International Classification of Disease 10 (ICD-10).: World Health Organization; 2015
World Health Organization. Autism spectrum disorders. 2017. http://www.who.int/mediacentre/factsheets/autism-spectrum-disorders/en/
Brugha T, Cooper SA, McManus S, Purdon S, Smith J, Scott FJ Estimating the prevalence of autism spectrum conditions in adults: Extending the 2007 Adult Psychiatric Morbidity Survey.: NHS Information Centre for Health and Social Care; 2012
Motofsky SH, Burgess MP, Gidley Larson JC. Increased motor cortex white matter volume predicts motor impairment in autism. Brain. 2007; 130:2117-2122
Shapira J, Mann J, Tamari I, Mester R, Knobler H, Yoeli Y Oral health status and dental needs of an autistic population of children and young adults. Spec Care Dent. 1989; 9:38-41
Lowe O, Lindemann R. Assessment of the autistic patient's dental needs and ability to undergo dental examination. ASDC J Dent Child. 1984; 52:29-35
Ohmori I, Awaya S, Ishikawa F. Dental-care for severely handicapped-children. Int Dent J. 1981; 31:177-184
Kendal NP. Oral health of a group of non-institutionalised mentally handicapped adults in the UK. Community Dent Oral Epidemiol. 1991; 19:357-359
Waldman HB, Perlman SP, Swedloff M. Orthodontics and the population with special needs. Am J Orthod Dentofacial Orthop. 2000; 118:14-17
Ozgen H, Hellemann GS, Stellato RK, Lahuis B, van Daalen E, Staal WG Morphological features in children with autism spectrum disorders: a matched case-control study. J Autism Dev Disord. 2011; 41:23-33
Bondy AS, Frost LA. The picture exchange communication system. Semin Speech Lang. 1998; 19:373-389
Zink AG, Diniz MB, Rodrigues dos Santos MTB, Guaré RO. Use of a Picture Exchange Communication System for preventive procedures in individuals with autism spectrum disorder: pilot study. Spec Care Dentist. 2016; 36:254-259

Orthodontic management of patients with autistic spectrum disorder

From Volume 46, Issue 7, July 2019 | Pages 646-652

Authors

Hesham Ali

BDS, MDPH, MSc (Orthodontics), MFDS RCSEd, MOrth RCSEng, FDS(Orth), RCSEd

Senior Registrar in Orthodontics, University Dental Hospital of Manchester and Salford Royal NHS Foundation Trust

Articles by Hesham Ali

Email Hesham Ali

Brekhna Mushtaq

BDS

Consultant in Orthodontics, University of Manchester Dental School and Salford Royal NHS Foundation Trust, Stott Lane, Manchester M6 8HD, UK

Articles by Brekhna Mushtaq

Ovais Malik

BDS, MSc (Orth), MFDS RCSEd, MOrth RCSEng, MOrth RCSEd, FDS (Orth) RCSEng

Consultant in Orthodontics, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH, UK

Articles by Ovais Malik

Abstract

Autism is a life-long developmental disability that affects how people perceive the world and interact with others. The aetiology of autism has not been clearly identified. Affected individuals experience difficulty in social interaction and changes in their environment. There appears to be a higher percentage of malocclusion within the population with special needs than the normal population, and the demand for orthodontic treatment from this group of patients is likely to increase in line with awareness of autism and access to care. The strategies available to manage patients with autism successfully are discussed here.

CPD/Clinical Relevance: Understanding the difficulties faced by individuals affected by autistic spectrum disorder and anticipating the challenges in the provision of their care is of paramount importance in the context of their orthodontic management. These challenges, and the strategies available to successfully negotiate them, are concisely presented.

Article

What is autism?

Autism is a life-long developmental disability that affects how people perceive the world and interact with others. It is part of the autism spectrum disorders (ASD), which refers to a range of conditions characterized by some degree of impaired social behaviour, communication and language. The spectrum includes childhood autism, atypical autism and Asperger's syndrome, which are listed as pervasive developmental disorders by the WHO (World Health Organization).1 Affected individuals often express interest in a small range of pursuits or activities which tend to be carried out repetitively.2 In the UK, ASD affects approximately 1.1% of the population, with a higher prevalence in men (2%) than women (0.35%).3 Epidemiological studies indicate that the prevalence of ASD appears to be increasing globally.

The exact aetiology of ASD has not been identified, but an inter-play between genetic, neurobiological and environmental factors is thought to result in the characteristic behavioural symptoms (Table 1). To date, no specific environmental triggers have been identified. ASD often co-occurs with other conditions, including anxiety, depression and attention deficit hyperactive disorder (ADHD).


Genetic factors More common in males than females
20% of infants with affected older siblings develop ASD
Associated with other conditions, eg muscular dystrophy, Down's syndrome, neurofibromatosis
Environmental factors Pre-natal considerations:
  • Complications during pregnancy
  • Premature birth earlier than 35 weeks
  • Alcohol and drug use
  • Medicine-related, e.g sodium valproate
    		•
    Post-natal considerations:
  • Diet
  • Exposure to toxins, insecticides or drugs
    		•
    Neurobiological factors Structural and functional abnormalities of the brain

    What are the difficulties in managing autistic patients?

    The severity with which ASD manifests in an individual is hugely varied. Affected individuals range from those needing life-long care to high-functioning individuals with better than normal cognition, and therefore the extent to which ASD impacts a patient's care will also vary. As awareness of autism increases and access to care improves, the demand for orthodontic treatment from this group of patients is likely to increase. General difficulties which may be encountered in treating patients affected by ASD include:

  • Social communication and interaction;
  • Rigid behaviour and sensory challenges;
  • Mental illness.

    • Social communication and interaction

    Individuals with ASD may find it difficult to start or maintain conversations. This difficulty is compounded by speech difficulties, literal interpretation of speech, and not understanding humorous or sarcastic language. Patients often use unusual or repetitive language and may have inappropriate facial expressions and body language. Another common feature is a lack of empathy and difficulty in establishing relationships with others. Patients may have few or no friends, and the difficulty they experience in processing emotions is reflected in their lack of eye-contact, struggle to work with others, and failure to share interests or enjoyment with others. As a result, it can be difficult to assess what issues an affected patient has, or how much something concerns them. Ascertaining what features of their malocclusion are important to them, or if there are any concerns during the delivery of orthodontic treatment, may prove to be an arduous task. Establishing rapport and forming a relationship between clinician and patient may be challenging. Furthermore, an inability to communicate effectively will lead patients to feel frustrated and increases the challenge in the clinical setting.

    Rigid behaviour and sensory challenges

    Patients affected by ASD display characteristic behaviour, and tend to favour established routines. They often respond unfavourably to change, and may have an obsession with particular objects, interests or manner of doing things. Specific stimuli may elicit adverse and disapproving reactions. For example, the taste of toothpaste may be disliked, and therefore maintaining a disease-free mouth may prove to be a challenge. Attending an appointment may represent a significant change to their usual routine: a specialist orthodontic practice or out-patient department may be a busy and noisy environment, where one interacts with many new people, in an unfamiliar setting, participating in new activities which may be unexplained and over which the patient has no meaningful control. All of this must be negotiated just for an assessment, before one even considers the prospect of providing active treatment.

    Mental illness

    Approximately 40% of people on the autistic spectrum suffer symptoms of some anxiety disorder. Anxiety is thought to be caused by biological variance in structure and function of the brain in combination with social difficulty, and affected patients may have difficulty vocalizing how they feel. Similar effects may be seen in individuals affected by depressions and obsessive compulsive disorder, both of which are seen with much higher prevalence in the autistic population. Feelings about their dento-facial appearance and perceived difficulty in visiting a dentist or orthodontist may give rise to symptoms of anxiety and depression in autistic patients, and their failure to describe symptoms presents another barrier to the provision of care. Treatment typically takes the form of medication or cognitive behavioural therapy.

    How does autism affect malocclusion?

    While behavioural and mental health concerns present challenges in managing autistic patients, autism may also have a more direct impact on malocclusion. Some of the effects, which are discussed below, include:

  • Underdeveloped motor skills;
  • Dental health experience;
  • Barriers to care;
  • Prevalence of malocclusion.

    • Underdeveloped motor skills

    While some autistic patients show well developed motor coordination and dexterity, many others experience motor dis-coordination, with various degrees of dyspraxia being displayed. Indeed, research has indicated a link between neural structure and reduced motor performance in autistic subjects.4 Of relevance to orthodontics are those who are affected at the level of fine motor skills: affected individuals may experience significant difficulties in cleaning appliances, inserting and removing intra-oral or extra-oral appliances, and using inter-maxillary elastics. Such patients do not learn new motor skills as quickly as completely healthy patients, possibly due to differences in neural structure and development. Their learning may be further compounded by anxiety about new experiences and negative sensory feedback.

    Dental health experience

    Data on the caries experience of autistic subjects is inconclusive, with studies presenting contrary views on prevalence compared to normal subjects.5,6 Additional risk factors, however, may be identified in autistic children; for example, some medications can cause dry mouth while other medications or supplements may contain sugar. While the caries experience may not be different, treating caries in autistic patients presents challenges; decay may progress further before an autistic patient raises a concern. Once a concern is raised, treating that patient may be difficult for the reasons previously described, and therefore more extreme measures may be adopted, eg extraction of teeth rather than restoration, leading to secondary problems, such as loss of space and impaction of teeth.

    The difference is more apparent when considering periodontal status, with autistic patients displaying greater plaque and food accumulation and poorer periodontal health compared with the normal population.6 With reduced motor skills, possible aversion to toothbrushing and taste of toothpaste, and dislike for others to clean for them, home care measures may prove exceedingly difficult for some affected individuals and their carers.

    Barriers to care

    Attitudes to dental health may shape the access to care for some patients; dental health and orthodontics may have a low priority in the context of other illness, disability, and socio-economic status.7 A lack of perceived need or an inability to express need or self-care are barriers to accessing dental and orthodontic services.8 Other barriers to care include fear or anxiety around treatment, logistical issues (eg arranging ambulance transport) and cultural considerations.

    Prevalence of malocclusion

    There is a higher percentage of malocclusion within the population of children and adolescents with special needs than the normal population,9 although some authors have challenged this view. It is conceivable, given the delays and difficulties in the dental healthcare provision described above, that those autistic patients may present with complicated malocclusions. There is also a relationship between autism and the increased observation of some morphological features in affected individuals, notably prominent premaxilla, high-vaulted and narrow palate, open-mouth appearance and prominent lower jaw.10 Some of the dental features include macrodontia, teeth asymmetry and abnormally shaped teeth.

    What strategies are available to manage these challenges?

    There are many facets to the successful management of autistic patients. Below is a discussion of the strategies which can be used.

    Communication

    Adjust style of language

    Some small adjustments to the manner in which we communicate can be beneficial when treating autistic patients. Use the patients' names first to get their attention before asking a question or directing them to a task such as opening their mouth. When speaking, use concise and precise language, which reduces the volume of processing required by the patient. Once a question has been asked or an instruction given, allow greater processing time.

    Autistic patients often appreciate an explanation of what is happening, and what will happen next, being quite literal with the use of vocabulary. Explain the sequence of events in the correct order to minimize the probability of misunderstanding or confusion. Similarly, when discussing options, maintain clear and concise language.

    Patients affected by autism will glean less from non-verbal communication compared to the general population; therefore, use less eye contact, fewer facial expressions and gestures and less body language when trying to communicate with such autistic patients.

    Routinely check their understanding of what has been discussed and encourage them to ask for help if they feel overwhelmed. Patients will often lead the conversation in a particular direction, and this should be followed in trying to establish rapport before diverting the conversation to the relevant clinical discussion. Finally, ensure that adequate time is set aside for effective communication.

    Visual aids

    With patients who have difficulty initiating conversation or have speech difficulties, the use of visual aids can help them bridge the communication gap. PECS (Picture Exchange Communication System) was developed as a communication aid for children with social communication deficits.11 The system uses pictures as the means of communication; early users of PECS learn to use images to identify items or activities they desire, while those with greater experience of the system can use it to construct sentences, answer questions and comment on observations or feelings. An early study has shown that PECS is an effective tool in communicating with autistic patients,12 and could feasibly be used in the orthodontic setting. Similarly, clinicians may use other visual aids, such as communications boards, books and cue cards. A freely downloadable example is shown in Figure 1.

    Figure 1. A free to download example of PECS.

    Non-verbal patients

    A proportion of autistic children may experience a delay in the use of language, while some will continue into adulthood without the use of speech. Other channels of communication need to be established in such cases. One approach is the use of Augmentative and Alternative Communication (AAC) devices. AAC is any form of a language, other than speech, which can help a person in an interaction. One approach is the use of voice output communication aids, such as the application Proloquo2Go.13 This award-winning application (Figure 2) can be downloaded to smart phones and tablets, and allows users to communicate single words or full sentences. The interface and vocabulary are easily customizable, and the experience can therefore be tailored to the needs and preferences of individual patients. The application produces speech in response to user input, and therefore an effective means of communication can be developed.

    Figure 2. A basic communication template from the Proloquo2Go application.

    Behaviour management strategies

    Rigid behaviour, along with sensory challenge, is a main presenting feature of autistic patients. There are various strategies and techniques which can be employed to modulate patients' behaviours in order to make treatment a more pleasant experience. These are listed in Table 2.


    Before Treatment
    Visual aids Parents/carers can talk about and demonstrate what will happen during an appointment to help the patient cope. The use of social stories and story books can aid greatly in this regard.
    Patient information sheets A well-designed leaflet about treatment and how it is carried out should be provided so patients can familiarize themselves before having appliances fitted.
    Arranging appointment Ensure the appointment is early in the day, which reduces waiting time. There may also be less noise and other sensory stimuli at this time. Booking additional time for the appointment is also a good approach.
    Pre-visit pack Send out a package containing common equipment (eg gloves, mask, disposable mirror) so that the patient may become familiar with them.
    During Treatment
    Environment Ensure that staff are aware of patients' needs and adjust their behaviours accordingly.Reduce the light levels and eliminate any other noises in the surgery if the patient is sensitive to these stimuli.Avoid the use of cleaning agents which produce smell.
    Comforters/distractors This may help to occupy or distract the patient. The use of music has been advocated.
    Treatment Modify communication style as necessary.Consider limiting the aims of orthodontic treatment.
    Sedation Some aspects of orthodontic treatment (eg debonding of fixed appliances) may cause significant distress for autistic patients, and it may be necessary to consider sedating them.

    Clinical considerations

    While some autistic patients may be treated the same as the general orthodontic patient population, others may require an adjustment in treatment which reflects their ability to cope with orthodontic work. These considerations include:

  • Type of appliance;
  • Change treatment delivery;
  • Limited treatment aims.

    • Type of appliance

    Fixed appliances require high levels of compliance with oral hygiene maintenance, diet and treatment in the dental chair. The use of removable appliances may be a feasible alternative which could reduce the burden of care on the patient, eg the use of a Roberts' retractor to reduce overjet.

    Change treatment delivery

    The method of how orthodontic treatment is delivered should also be considered. More comfortable, less intrusive means should be used if at all possible. For example, the use of indirect bonding may speed up the process of placing fixed appliances; or the use of ‘tasteless cement’ or any other materials may improve the treatment experience for autistic patients.

    Limited treatment aims

    Orthodontic treatment aims are agreed upon, with patients, following thorough clinical and radiographic assessment, and this should be no different for autistic patients. Depending on the multitude of factors previously discussed, however, it may be wise to limit treatment aims in agreement with autistic patients and/or their carers. In conjunction with this, the type of appliance used may also be chosen to suit the patient and the aims of treatment best. For instance, a patient with a large overjet who struggles with diet or oral hygiene may be best treated with a functional appliance only. This would eliminate the overjet, improve appearance and reduce the risk of trauma to anterior teeth. Continuing to use fixed appliances after the functional phase of treatment may present less benefit than risk, and therefore limiting the treatment aims to the reduction of overjet and accepting some irregularity in alignment may be entirely reasonable. Such an example is illustrated in Figure 3.

    Figure 3. (a–d) A Class II division 1 malocclusion with limited treatment aims. Treated with a functional appliance only.

    Conclusion

    As we continue to see a higher number of autistic patients, it is essential for clinicians to be aware of the challenges that treatment can provide. Implementing the strategies discussed can help to break down the communication barrier, enhance the patient experience and ultimately improve outcomes for affected individuals.