Autism is a neurodevelopmental disorder that presents itself before three years of age and can last throughout a person’s life. It is characterized by problems with communication and social interactions, including behavioral challenges, such as repetitive and stereotyped behavioral patterns and restricted interests. Communication problems can also affect the oral health of people with autism since they can have trouble verbally communicating about dental problems.
Dental appointments can also be difficult in people with autism due to the lack of understanding of the importance of regular dental check-ups and hypersensitivity issues. New sights, sounds, and sensations in the dental office can be overwhelming in people with autism and may trigger violent reactions during dental treatments. 1 Therefore, finding the right dentist can make people with autism feel more comfortable during dental appointments and greatly improve their oral health.
This article provides insights on the maintenance of oral health in people with autism – its importance and how to combat the challenges involved with oral health maintenance and dental treatments.
Oral health in People with Autism
Children with autism often have poor oral hygiene practices, such as less frequent tooth brushing, which results in dental caries and periodontal disease. Less frequent or improper tooth brushing techniques often require parental supervision. However, supervised tooth brushing can also result in aggressive behaviors due to sensory sensitivities. Moreover, the lack of good oral hygiene habits can also negatively impact the nutritional status of children with autism as they avoid certain hard or chewable foods due to toothaches caused by dental caries or periodontal disease.
Poor oral health in people with autism can also be a side effect of prescribed medications. Prescribed medications in the form of syrups usually contain sweeteners, which can further affect oral health status if combined with a lack of tooth brushing.
Common Dental Problems in People with Autism
The following are common dental problems in people with autism:
- Dental Caries – Dental caries, also known as tooth decay, are caused when bacteria build up on the teeth and produce acids that attack the tooth’s surface or enamel, causing holes known as cavities. Dental caries can easily be prevented by adopting good oral health habits such as regular tooth brushing. However, if dental caries is not taken care of by dental professionals, it can cause pain, infection, or even lead to tooth loss. Dental caries are often seen in patients with autism who face difficulties in tooth brushing and flossing due to poor motor coordination and high sensitivity to the taste of toothpaste. Moreover, people with autism often prefer soft and sweet food, and poor tongue coordination often leads them to pouch food inside the mouth instead of swallowing, increasing dental caries risk. 2
- Periodontal Disease – Periodontal disease impacts the bone, teeth, gums and periodontal ligament. Periodontal diseases are caused when plaque, a sticky film of bacteria, builds up on the teeth. If plaque is not removed, it can harden into tartar, which does not come off with brushing and require dental professional help. Unremoved tartar can cause further build-up and make it hard for the teeth and gums to be cleaned completely, resulting in inflammation of the gums called gingivitis. Gingivitis is the early stage of periodontal disease and presents as swollen, red, and bleeding gums. The majority of children with autism have gingivitis due to irregular brushing or lack of manual dexterity. Gingivitis can also be caused as a side effect of medications used to control autism symptoms such as psychoactive drugs or anticonvulsants such as phenytoin.3
- Bruxism – Bruxism is a condition where excessive grind, gnash, or clench of teeth is experienced. It can happen both while sleeping or while awake. It can lead to damaged teeth, headaches, facial pain, and jaw disorders. Bruxism is sometimes seen in people with autism, which requires medical intervention if it is severe. 4
- Xerostomia – Xerostomia or dry mouth is a condition when salivary glands don’t make enough saliva. The lack of saliva can cause difficulties in chewing, swallowing, or speaking and can increase dental caries risk, tooth sensitivity, and oral infections. Xerostomia can occur in people with autism as a side effect of their prescribed medications.5
- Pica – Pica is an eating disorder characterized by the consumption of inedible or non-nutritive substances such as dirt, clay, and flaking paint. Pica is often observed in people with autism, which can cause dental problems such as tooth abrasion and tooth erosion. Moreover, pica can also cause various other problems such as parasitic infections, lead poisoning, and gastrointestinal problems.6
- Tongue Thrusting – Tongue Thrusting occurs when the tongue presses too forward in the mouth during swallowing, speech, and even while at rest. Tongue thrusting is sometimes observed in people with autism, which can affect dental development resulting in malocclusion or misalignment of the teeth.
- Self-injury – People with autism often participate in self-injurious behaviors such as picking and rubbing the gingiva or biting lips, creating ulcerations and resulting in significant dental damage. Furthermore, people with autism are also more prone to accidents and falls resulting in dental trauma.
Autism Medications and Side-Effects
Medications such as antipsychotics, anticonvulsants, and antidepressants used to control manifestations of autism such as aggression and hypersensitivity can have oral side effects. The following is a list of medications that can affect the oral health of autism patients and their associated side effects: 7
|Antipsychotics (Clozapine, Quetiapine, Olanzapine, Risperidone)||Xerostomia, gingivitis, glossitis, tongue edema, discolored tongue, sialorrhea, dysgeusia, dysphagia, and difficulty in swallowing|
|Anticonvulsants (Valproate and Carbamazepine)||Xerostomia, glossitis, dysgeusia, stomatitis. Excessive bleeding may occur with prolonged therapy or medication combined with aspirin or non-steroidal anti-inflammatory drugs due to leukopenia and thrombocytopenia|
|Antidepressants (Sertraline and Fluoxetine)||Xerostomia, gingivitis, glossitis, stomatitis, sialadenitis, bruxism, dysphagia, dysgeusia, and a discolored tongue|
|Antihypertensive (Clonidine)||Xerostomia, sialadenitis, and dysphagia|
|CNS Stimulants (dextroamphetamine salts, methylphenidate)||Xerostomia|
Behavior Guidance Techniques for Dental Treatment of People with Autism
Dental appointments can be challenging for people with autism, so behavior guidance techniques can lessen anxiety in autism patients and provide quality dental treatment. Moreover, a good and trusting relationship between autistic patients and their dentists makes dental appointments easier.
Communication between dentists and people with autism helps establish trust and build cooperation. Dental professionals usually communicate using simple, short, and clear sentences. Dental professionals also communicate with parents or caregivers before initial appointments to discuss the medical and medication history and any comorbid conditions.
Familiarity with the Dentist’s Office
People with autism are more comfortable in the dentist’s office when they know what to expect. Before dental appointments, allow autistic patients to familiarize themselves with the dental office using stories, books, or photos. Parents and caregivers can even ask dental professionals if they can arrange a tour of the dental office before appointments to familiarize the patients with the sound, smells, and setting of the office and understand what will happen during the dental appointment. Familiarity helps ensure a more successful dental visit.
The Tell-Show-Do method can be used as effective exposure therapy to introduce dental equipment, instruments, and procedures to autism patients. Parents or caregivers can tell and show an autistic patient what will happen during the appointment using stories or pictures, and then practice certain parts of the procedure at home before actually experiencing them in the dental office, making the autism patient more comfortable during the dental appointments. Parents or caregivers can use rubber gloves, a small flashlight, and a dental mirror to roleplay what will happen during the appointment.
Positive reinforcement rewards preferred behaviors and therefore strengthens those behaviors from recurring. Parents or caregivers can use positive reinforcement through words of affirmation or tokens of appreciation to decrease negative behaviors and increase compliance during dental appointments.
Parents or caregivers sometimes use voice control to elicit appropriate behaviors or even use nonverbal cues if the patient understands nonverbal communication. These voice control phrases such as “look at me” or nonverbal cues can also be used during dental appointments to elicit appropriate behaviors to make the appointment successful.
Distractions might help some dental procedures to be more successful. Distractions can be in the form of the patients listening to music, watching their favorite show, or holding favorite toys.
If dental treatment is urgent and the autistic patient is too difficult for the dentist to work with due to aggressive behaviors, dental sedation becomes a necessity. There are three levels of sedation used during dental treatments. The type of sedation used depends on the age, cognitive level, communication skills, coping mechanisms, and physical health of the patient, including the urgency of the procedure.
- Conscious sedation induces a minimally depressed level of consciousness where the patients can still respond using verbal commands or physical stimulation and can maintain an open airway independently. Conscious sedation helps reduce anxiety in the patients and makes them more relaxed.
- Deep sedation induces a loss of consciousness in which the patient is not easily aroused. During deep sedation, the ability to breathe independently is often impaired, and intervention may be required.
- General anesthesia induces a state of unconsciousness where the patients cannot respond to any verbal or physical stimulation. Dentist’s usually recommended lower levels of sedation, and general anesthesia is usually the last possible choice.
Home Care Oral Health Tips for Children with Autism
The following good oral health habits should be regularly practiced at home and be supervised by parents and caregivers.
- Regular tooth brushing – Regular tooth brushing should be practiced for good dental health. Tooth brushing should start as soon as the child’s first tooth pokes out of the gums. Tooth brushing should be done at least twice a day, once in the morning and at night using fluoride toothpaste. People with autism can be overly sensitive to sound, sight, taste, smell, or touch, so the taste of toothpaste or the sensation of the toothbrush can be undesirable for them, which can affect their oral hygiene. Toothbrushes of different textures, colors, designs, or electric toothbrushes can be used if the autistic patient dislikes regular toothbrushes. Moreover, tasteless toothpaste, tolerable taste, or non-foaming toothpaste are more acceptable for autistic patients.
- Having visual supports and schedules – Some people with autism benefit from having visual supports and schedules. Visual support of tooth brushing can be provided by placing pictures of the process in the bathroom. Moreover, visual schedules can be made by checking off the tooth brushing activity written on a board or paper after they occur.
- Reducing sugary foods and beverages – Reducing sugary foods and beverages can decrease the risk of dental caries or tooth decay. If some medications for autism contain sugar, parents or caregivers can try asking their doctors if there are any sugar-free alternatives available.
- Observing signs of tooth pain – Since people with autism have trouble communicating, they may not verbally communicate if they have tooth pain. Therefore, observing signs of tooth pain such as eating only at one side of the mouth or unexplained behavior or outbursts can help indicate it. Tooth pain is often a sign of cavities, which requires treatment by dental professionals to prevent the problem from worsening.
Tips to Prepare for Dental Appointments
Children with autism may not understand why they need to go for a dental appointment, and it can be a struggle persuading them to go into the dentist’s room for a check-up or treatment. Moreover, children with autism may also struggle in waiting areas. The following are tips to prepare children with autism for dental appointments:
- Take a tour with the child of the dental office before the appointment so that the child is comfortable with the environment.
- Talk about what will happen during the dental appointment.
- Read books about going to the dentist’s office.
- Show them pictures of the dentist’s office, dental equipment, and instruments.
- Roleplay the visit to the dentist’s office.
- Direct the child about what to do during the appointment such as, putting their hands on their tummy, putting their feet up straight, holding their mouth open, opening their mouth wide, spitting into a sink, etc.
Below are some tips for parents or caregivers for dental visits to run smoothly:
- Get an early appointment to minimize waiting time.
- Make sure the child gets a good night’s rest before the appointment.
- Communicate with the dentist about what may trigger stress in the child, things the child may do or act, and the best way to deal with it. Suggest things that make the child feel good. Moreover, always inform the dental office ahead of time if the child is sensitive to sounds, bright lights, smells, or other stimuli present in the dental office.
- Bring a list of all the medications your child takes.
- Bring a preferred toy to distract or occupy the child during the appointment.
- Bring a reward to incentivize the child for their cooperative behavior during the appointment.
Finding the Right Dentist for People with Autism
Finding the right dentist that successfully works with individuals with autism helps ensure a successful dental visit. Regular dental check-ups are needed to ensure that individuals with autism have good oral health with no visible signs of tooth decay or infections. Moreover, regular check-ups can help treat cavities or infections at early stages before it gets worse. The right dentist can make individuals with autism feel more comfortable during the appointment. Since dental check-ups are needed at least twice a year, the right dentist can help maintain a good relationship with the autistic patient. When looking for a good dentist, it is essential to ask them questions to assess whether they can accommodate an autistic patient. The following are some questions that can help parents or caregivers of autism patients make the right decision:
- Are you comfortable working with autistic patients?
It is essential that you first ask the dentist if they are comfortable working with autistic patients since not all dentists will be comfortable, confident, and know how to handle autistic patients. If you are looking for a dentist for your autistic child, searching for pediatric dentists can help you get started in finding the right dentist since they usually have a few additional years of schooling and learn how to deal with special needs children. Moreover, pediatric dentists’ offices are often designed for kids, so your child might be more comfortable there.
- Do you have any experience working with autistic patients?
Ask potential dentists if they have experience working with autistic patients or any other special needs patients to find out how they worked with them. If the dentists have prior experience working with autistic individuals, they will have more knowledge on how to be accommodating for autistic patients and will naturally be more comfortable working with them.
- Can you make special accommodations for my child with autism?
Even if the dentist has experience working with autistic patients, each child is unique, so it is essential to ask if the dentist can accommodate any specific needs of your child to make the appointment successful. For example, if your child is sensitive to movements, ask if the dental treatment chair can remain in the same position throughout the appointment. Although some accommodations may seem small, asking your dentist if they can meet them can assure that your child is comfortable.
- Can I accompany my child throughout their dental appointment?
Parents or caregivers can provide individuals with autism comfort during their visit. You can ask prospective dentists if you can remain in the same room during the entire visit to help provide support to the autistic patient. Moreover, if the autistic patient finds comfort in another person, such as a sibling or any other family member, you can ask the dentist if they too can remain in the room.
- Can the same staff be available during future visits?
If your first dentist visit with your child is successful and feel like the staff was a good fit for your child, you can ask the dentist if it is possible to have the same staff during future visits to provide consistency for your child. In this way, your child will know what to expect during each visit, and the child can also build a relationship with the staff.
Autism is a complex disorder that can make practicing proper oral hygiene daily difficult. Good oral health habits and regular dental check-ups are essential to prevent dental caries and oral infections. Parents and caregivers need to find effective ways or creative strategies to guide and show individuals with autism what they need to do for good oral health. Moreover, dental treatment can also be challenging for autistic patients as well as for the dentist. Finding the right dentist who is flexible and can accommodate autistic patients is crucial for a successful dental appointment. The right dentist can help individuals with autism improve their oral health, which can greatly impact the quality of their lives.
- Chandrashekhar S, S Bommangoudar J. Management of Autistic Patients in Dental Office: A Clinical Update. Int J Clin Pediatr Dent. 2018;11(3):219-227. doi:10.5005/jp-journals-10005-1515
- Jaber MA. Dental caries experience, oral health status and treatment needs of dental patients with autism. J Appl Oral Sci. 2011;19(3):212-217. doi:10.1590/s1678-77572011000300006
- Ferrazzano GF, Salerno C, Bravaccio C, Ingenito A, Sangianantoni G, Cantile T. Autism spectrum disorders and oral health status: review of the literature. Eur J Paediatr Dent. 2020;21(1):9-12. doi: 10.23804/ejpd.2020.21.01.02.
- Armstrong A, Knapp VM, McAdam DB. Functional analysis and treatment of the diurnal bruxism of a 16-year-old girl with autism. J Appl Behav Anal. 2014;47(2):415-419. doi:10.1002/jaba.122
- Loo CY, Graham RM, Hughes CV. The caries experience and behavior of dental patients with autism spectrum disorder. J Am Dent Assoc. 2008;139(11):1518-1524. doi:10.14219/jada.archive.2008.0078
- Singh H, Agarwal S, Singh V, Rehman R, Patwardhan N. Pica disorder with autism: intervention in dental settings. J Res and Adv Dent. 2015;4(3):281-91
- Chandrashekhar S, S Bommangoudar J. Management of Autistic Patients in Dental Office: A Clinical Update. Int J Clin Pediatr Dent. 2018;11(3):219-227. doi:10.5005/jp-journals-10005-1515