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Making dental practices more autism-friendly

Malcolm Hamilton is an NHS Highland dentist and a member of their Autism Strategy Group. Malcolm explores how best to support autistic patients and their carers within a dental setting, offering practical advice and tips that can be passed on to dental practices.

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Author: Malcolm Hamilton

Making dental practices more autism-friendly

This article explores various tips and strategies that can be used to support autistic people before and during visits to the dentist. 
 
Pre-visit information
 
We include a specific autism question on our medical questionnaires, giving patients and carers the chance to inform us of a diagnosis or even pre-diagnosis. 
 
When we know an autistic patient will be attending for the first time then we send them a pre-visit questionnaire. This lets us find out how we can make the visit easier for them, with particular reference to: 
 
sensory sensitivities
best time of day for an appointment
anything else that might help us.
 
As well as a questionnaire we offer to send out a pre-visit pack to those attending for the first time so patients can see some of the items the dentist will use. These can be especially useful to children. The contents of the pack can vary but our usual pack contains a pair of gloves, a mask, a disposable mirror, a cotton wool roll and a sticker.
 
Times and length of visits
 
Unsurprisingly the timing of an appointment can have a significant impact on the success of an appointment. This can be due to how it fits into a patient’s normal daily routine, and also how that person copes with change at different times of the day. Only by speaking with patients and/or carers can we know. As such blind sending out of appointments may not result in a successful visit. 
 
The other issue around timings of appointments is the impact a full or semi-full waiting room may have upon an autistic patient, as well as the physical wait itself. Ideally, there should be no waiting as this can cause stress and distress. It may be better to schedule autistic patients at the start or end of the day. 
 
If the end of the day is chosen then care should be taken to ensure that appointments are running to time. We encourage those for whom waiting is an issue to contact us shortly before their appointment to ensure we are running on schedule. We also allow patients/carers to tell us they have arrived but are waiting in the car park.
 
We usually give a slightly longer appointment time for autistic patients to allow time for them to become comfortable in unfamiliar surroundings, and because communication may take longer.
 
Low-arousal environment
 
When working with autistic patients we try to have a low-arousal environment. Many autistic people experience hyper or hyposensitivity - this means there can be reactions to lights, noises, tastes or movements. To address this we can:
 
turn off overhead lights, especially if they are fluorescent tube lights as these can cause hypersensitivity due to flicker
turn off the radio and ringer on surgery phones
place a notice on the door to prevent interruptions
use plain water as a mouth rinse. 
 
Movement and balance is an often overlooked aspect of autism but we can help prevent any discomfort by having the chair in a reclined position before the patient sits on it. 
 
Social stories
 
Social stories can be used to represent a variety of different topics, from general examinations to more specific treatments. 
 
A simple example might be:
 
1. “This is the dental clinic where I will go to have my teeth counted” with a picture of the building. 
2. “This is the room I will sit and wait until it is time for my teeth to be counted,” with a picture of the waiting room.
3. “This is the chair I will sit to have my teeth counted,” with a picture of the dental chair.
4. “The dentist will wear gloves and use a mirror to count my teeth,” with a picture of gloves and a mirror (this ties into the pre-visit pack).
5. “This is the dentist who counts my teeth,” alongside a picture of the dentist
6. “After my teeth are counted I will get a sticker,” with pictures of stickers.
 
With modern cameras they are extremely easy to produce by any member of the team, and can be used for all patients, not just those who are autistic.
 
Special interests
 
On the pre-visit questionnaire we ask about special interests. Autistic patients may have a favourite topic which they like to talk about or are interested in. Special interests can be used to encourage patients to be more relaxed during their visits.
 
We had a patient who liked lights, so we let them play with the dental light after they allowed us to examine their teeth. Another patient asked for a number of large elastic bands, but more often for autistic children it is stickers or colouring sheets of favourite TV characters.
 
Distracters and comforters
 
Autistic patients may already have their own objects for distracting or comforting them. This may be a set of headphones, iPads or items such as toys, pieces of clothing etc. We should allow them to use these objects during their visit unless they directly interfere with treatment. It may be useful to have squeezy stress balls available that can be offered to those who might benefit from them.
 
Communication
 
We can help autistic patients by adjusting the way that we communicate, and there are a number of simple strategies that can help. 
 
1. Say the patient’s name so that they know you are talking to them. “John, please open your mouth” rather than “Please open your mouth.”
2. Consider reducing your language and being concise with what you ask.
3. State exactly what will happen and in what precise order, explaining when it starts and ends e.g. “Glasses on, then sit on the chair then teeth counting, then we will be finished”.
4. When giving options, be clear on the choices and keep them concise. 
 
Summary
 
The above is a very brief summary of a large number of approaches that can be used when working with autistic patients. With small changes to the preparation, environment and communication we can make visits to the dentist a lot less stressful that they might otherwise have been. 
 
Further information
 
This article is an edited version of Dentistry and Autism, originally published in Scottish Dental, June 2017. For more information please contact malcolm.hamilton@nhs.net
 
 
Date added: 8 November 2017

Comments

Thu, 16/11/2017 - 17:29

Working within Occupational Therapy with children with disabilities, I have supported many children and their families with trips to the Dentist, so I was really pleased to read this article to see practical advice and support being put out there for Dentists.

In my experience most children with autism / additional needs, along with their parents, find going to the dentist a difficult and stressful experience and in some cases, it is not unusual for parents to avoid these appointments altogether so they do not have to deal with the stress and upset it can cause.

What I have learnt over the many years of working with children with autism and additional needs is that planning and sharing of information is key and below are some of the considerations /strategies that have I have used which have been successful in supporting children to attend their appointments.

  • Visiting the surgery is often the first step. Going in the car and parking in the car park may be the first visit. Second visit might be the child getting out of the car and walking up to the front door. Third visit might be the child actually entering the building and then leaving again. These visits are then supported with visual picture cards of the surgery, along with a social story. All of these initial visits and visual supports will enable the child to become familiar with the building, the feel of the building in terms of space, as well the smell of the environment. These visits are then supported with visual picture cards of the surgery, along with a social story . For some individual children I have gained permission to take photographs of the dental team which have then been incorprtated into their social story.

  • Having the opportunity to see and touch dental instruments is a fantastic way of supporting a child to prepare for their trip. It may be that visual cards are shown to the child first and then the corresponding piece of equipment.

  • It is always important to consider sensory issues too and give thought to the environment for the child. Dentists do not have be trained in sensory integration to be able consider and plan accordingly. X-rays for example may be difficult, as having a tab in the child’s mouth could be distressing. Simple adjustment to positioning for the x-ray by having the child lean forward may reduce anxieties around choking.

  • When checking the child’s teeth it is sometimes helpful for the child if the dentist counts aloud as each tooth is checked.

  • Allowing the child little breaks during the dental exam can reduce sensory overload and support the child to remain calm.

  • Allowing the child to have a fidget toy or favourite toy they can hold during the exam will support the child to remain calm and focussed.

  • If possible arrange for the child to attend their appointment at specific times of the day when the surgery is less busy, so noise levels are reduced.

  • If parking at the surgery is limited perhaps offer a reserved space for the child and their family, so walking distances are reduced.

  • Discuss with parents the child’s preferred method of communication. Not all children with autism have verbal communication.

  • Sometimes it may take several visits in order to complete a dental exam. If you work with the family on this process, a positive and trusting relationship can be built.

 

Justine Dawes - Occupational Therapy Practitioner - Children with Disabilities Team, Norfolk.