Bright lights nearly blind you. A jackhammer rumbles in the distance. And suddenly, you’re falling backward while a masked individual hovers over your face, approaching you with a metal pick. This imagery might conjure memories of a horror movie. But for some people with autism, it represents how they perceive a routine dental visit.
While our brains naturally process multiple daily stimuli such that we hardly notice them, these same stimuli can become significantly exaggerated for an individual with autism. Imagine the comic book character Clark Kent before he was Superman, a boy attempting to block out the “surround sound” reverberating in his head from his heightened sense of hearing.
With varied sights, sounds, smells, tastes, and sensations, dental visits can be extremely taxing for a person with autism. With that reality in mind, how do we, as dentists, alter this negative experience to one of familiarity, comfort, and trust?
The Autism Spectrum
Since autism is a developmental disorder characterized by difficulties with social interaction and communication, as well as restricted, repetitive behavior, these patients present with emotional and behavioral barriers—challenges quite intimidating for a practitioner.
As a spectrum disorder, it includes a range from high-functioning people who present as a “bit quirky” to those who are lower functioning, requiring more support and who lack the ability to communicate verbally. Too often, patients present for their first comprehensive dental visit as adolescents or older, all with a similar reason—no dentist wanted to deal with the behavior.
Perhaps the most important advice for any dentist (including ourselves) is to remain honest regarding our level of comfort treating a patient within this spectrum. For this reason, including dentists who treat patients with special needs (both children and adult) on referral contact lists is essential to ensuring access to and continuity of care.
We impart to our students at Touro College of Dental Medicine that while special needs dentistry can be frustrating, it presents a unique opportunity to provide empathetic care, understanding that the patient is more than their disorder.
Some days, only a fraction of planned treatment is accomplished due to behavioral challenges. Along that train of thought, one of our students recently asked, “Do you feel like you are less thorough with patients with special needs because of their barriers?”
The answer to this query is germane to special needs dentistry. As dentists, we are charged with providing the standard of care for every patient. Thus, when challenges interrupt treatment, we do not stop at “it cannot be done.” Rather, we ask, “Howcan it be done?”
How to Provide Care
While we may anticipate certain reactions based on the patient’s diagnosis, efforts to understand the unique individual enhances our ability to adapt the dental setting and experience for that patient. From the first visit, observing the patient in the waiting room, parents interacting with them, and body language helps us understand a patient’s triggers.
Moreover, we acknowledge that dental appointments can be just as onerous for a parent as they are for the patient. They may have to deal with tantrums in the parking lot, be scared how another person will view them in the waiting room, or worry that the dentist will be mad if their child goes into “behavior.”
A calm yet discerning response helps parents see us as members of their child’s extended care-giving team. We show empathy for their experience by listening to their concerns and demonstrating from the beginning that we will work with them.
To alleviate possible behavior triggers, we can schedule morning appointments and limit waiting time. Also, staff can offer a private office or operatory for them to feel comfortable while they wait. Understanding both the patient andthe parent experience is vital to the success of the team.
Although bringing a child with special needs to the dentist can seem like a daunting task, encouraging parents to do so at a young age (at 6 months or when the first tooth erupts) is ideal for multiple reasons.
Of course, our goal is prevention with an added benefit of an early established routine for patients with autism who crave schedules. Additionally, the patient is desensitized to oral stimuli, which can improve dramatically the experience at regular hygiene visits.
A similar approach can be employed for patients who have had limited access to care until an older age. Parents can introduce routines and “instruments” similar to those in the dental office, such as an electric toothbrush that mimics a slow-speed handpiece. Models such as counting or playing a favorite song while brushing can transfer to the operatory as well.
Selecting one change at a time will avoid dramatic interruptions in their daily routine, and an open dialogue with parents helps us track how the patient is responding to these new routines.
While establishing a dental home early in life is ideal, every patient is different, and different days present different results. While attempting to accomplish our goal with minimal sensory experience for the patient, observation and patience are key.
For example, if the patient appears to shudder when the cavitron turns on, we start with hand scalers. When sensory stimuli cannot be avoided, tell-show-do can be employed. The patient may display fear at sight of the air/water syringe. Explaining the “water gun” to them first and then demonstrating on their hand can acclimate them to the sensations.
Giving them time and then graduating to the mouth walks the patient through a procedure, allowing them to accept the process. Regardless of the technique, consistently talking to the patient helps maintain a rapport that strengthens mutual trust and builds a lasting, successful relationship.
As you surely recognize, special needs dentistry is dynamic and requires a certain amount of adaptation and improvisation. The dialogue expands well beyond the content of this article, and we encourage you to continue the conversation with providers in the field. Together, we can create a network of professionals to enhance the dental experience for these patients who deserve our time, empathy, and excellent oral care.
Dr. Erdfarb is an associate professor of dental medicine and the course director of Operative Dentistry and Dental Anatomy and Occlusion at Touro College of Dental Medicine. As a parent of a 10-year-old son with autism spectrum disorder, she has personal experience navigating the healthcare system and advocating for patients with special needs.
Dr. DiSenso-Browne is an assistant professor of dental medicine and serves as course director of Oral Health Care for Patients with Special Needs as well as preclinical instructor at Touro College of Dental Medicine. Prior to joining TCDM full-time, she practiced out of the Westchester Institute for Human Development Dental Services, an article 28 clinic dedicated to providing comprehensive and continued dental care to persons with disabilities.
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