Enhancing dental care for children with autism spectrum disorder: Simple changes for a positive experience

The impact of early childhood caries on children’s quality of life, their families and the health-care system is significant. Roughly 57 per cent of Canadian children aged 6 to 11 are believed to have encountered dental decay, resulting in an average of 2.5 decay-affected teeth per child. Detecting and preventing these conditions at an early stage is aimed at lowering its occurrence and mitigating its adverse effects.

In assessing caries risk among children with special health care needs, it is important to recognize variability in risk levels based on diagnoses. A 2019 study found that children with conditions like Autism Spectrum Disorder, Down syndrome, congenital heart disease and cerebral palsy faced higher caries risk, with the highest risk among those with congenital heart disease, followed by ASD.

ASD is a heterogeneous neurodevelopmental disorder characterized by impaired social communication, repetitive behaviours, highly restricted interests, challenges with switching between activities, displaying interest in certain details and/or abnormal sensory reactions. Notably, the prevalence of ASD has gradually increased and has become a serious global public health issue.

Children diagnosed with ASD and their families often face health-care related challenges marked by feelings of stigmatization. Language used by health-care providers (HCPs) significantly shapes provider-patient interactions and influences the health-care experiences of children with ASD and their families; therefore, HCPs should be aware of unconscious bias, practice self-reflection and choose language carefully when describing the populations they serve.

According to both the American Medical Association and Canadian Medical Association, the health-care sector’s drive toward culturally competent care and addressing health-care disparities necessitates fundamental preparation in HCP training for serving diverse populations. Despite intensified cultural competency training and extensive guidance on caring for children with ASD, families and caregivers continue to struggle in finding appropriately trained and willing HCPs. Unconscious language persists among both older and younger dentists, spanning generations and educational levels. Therefore, addressing bias remains a significant concern, and even experienced HCPs could benefit from cultural competency training to align their language, actions and practices with patient well-being. Welcoming dental practice can start with this simple change.

HCP language significantly shapes provider-patient interactions and influences the healthcare experiences of children with ASD and their families; therefore, HCPs should be aware of unconscious bias, practice self-reflection and choose language carefully when describing the populations they serve. For the Canadian Dental Association (CDA) working group, the creation of best practices and protocols to address the needs of children with special needs, including individuals with ASD and intellectual disabilities, holds significant urgency.

Individuals with ASD require unique dental care. Yet, they are vulnerable to dental issues that may affect their survival and overall thriving. Children with ASD encounter various obstacles in adhering to oral-care routines at home and obstacles in obtaining and enduring in-office dental care. Visiting the dentist can be a challenging experience due to many reasons, including sensory sensitivities and difficulty with communication. Furthermore, children with ASD encounter significant challenges in unfamiliar situations, such as in the dental setting. The dental environment, with its array of noises, smells and visual stimuli, can significantly intensify their fear and anxiety. Despite these obstacles, there exists a paucity of tailored clinical dental guidelines to cater to the requirements of autistic young patients. Available clinical guidelines also are generally characterized by a notably low level of quality. Furthermore, a clear scarcity of dental professionals who possess both the willingness and the necessary expertise to offer services to this special pediatric population is evident, despite the presence of easily accessible online educational materials designed to enhance their clinical proficiency (Table 1).

Children with ASD encounter various obstacles in adhering to oral-care routines at home and with in-office dental care.

The CDA prioritizes advocating for accessible oral health care, especially for vulnerable populations needing specialized care. Furthermore, the CDA considers equitable access to care an important goal for professional dentistry organizations. While the federal government has implemented the Canada Dental Benefit, aimed at reducing costs for eligible families with a household income below $90,000 per year, children with unique health-care needs, including those with autism, face distinct vulnerabilities.

The dental benefit is specifically designed for children under 12 who do not have access to private dental insurance. It provides tax-free payments ranging from $260 to $650 per eligible child, depending on the adjusted family net income.

With 2 per cent of Canadian children and youth aged one to 17 years diagnosed with ASD, the exploration of oral care within this specific population must be a priority.

With a few simple changes and considerations, dental practices can create a more comfortable and supportive environment for autistic children with simple, practical strategies that professionals can implement to enhance dental care for  children with ASD.

Focus on prevention and home dental hygiene routines:

• Train parents. Randomized controlled trial evidence shows that parent training represents a promising approach for improving oral hygiene and oral health in underserved children with ASD at risk for dental problems. Encourage parents to establish a dental hygiene routine for their children at a young age, starting with the eruption of the first tooth.
• Provide guidance on selecting toothpaste flavours that are well-tolerated or offer unflavoured/nonfoaming options.
• Recommend appropriate toothbrushes, such as spinning or battery-powered toothbrushes for children who prefer vibration.
• Suggest incorporating toothbrushes into daily routines or preferred activities to increase compliance.
• Collaborate with speech language therapists, occupational therapists, or behavior consultants to support independent brushing skills.

Create a comfortable dental clinic environment:

•   Call ahead to discuss the child’s specific needs and preferences. Offer modifications such as noise-cancelling headphones, music, weighted blankets, vests and sunglasses to address sensory sensitivities.
•   Dim the lights or turn off fluorescent ceiling lights to reduce visual overstimulation.
•   Minimize talking during dental procedures to create a quieter environment.
•   Provide a hand mirror for children to observe the procedure, helping to increase their comfort level.
•   Consider panoramic X-rays as an alternative to intraoral X-rays, which can be more challenging for children with sensory sensitivities.
•   Allow a parent or caregiver to remain in the room for support and head stabilization during X-rays.

Utilize visual support and positive reinforcement:

•   Use visual support, social stories and video models to help children with ASD to understand dental procedures and expectations.
•   The Picture Exchange Communication System (PECS) is a widely used augmentative communication method that utilizes picture cards to teach functional communication to non-verbal or limited speech children, providing an effective means of communication.
•   Introduce first/then statements to provide a clear sequence of steps, e.g., “First we count your teeth, then you go home.”
•   Incorporate positive reinforcement throughout the visit, offering rewards that are not sticky or sweet foods.
•   Break down dental visits into manageable steps and gradually introduce each step over multiple visits if needed.
•   Consider desensitization visits to familiarize the child with the dental environment before a cleaning or procedure.

Collaborate with medical care team to reduce anxiety:

•   Work collaboratively with the child’s medical care team to develop an anxiety reduction plan.
•   Explore the use of anxiety-relieving medications and light sedation before dental visits for children who require additional support.
•   Specialized centers may offer dental examinations and treatments under general anesthesia when necessary.

Enhancing oral care is critical for children with special needs. Implementing simple changes in dental practice can significantly enhance dental care for ASD children. According to research conducted by an interdisciplinary team at the University of Southern California and Children’s Hospital Los Angeles, the utilization of a sensory adapted dental environment (SADE) demonstrates practicality and positive treatment effects, including a reduction of physiological and behavioural distress during dental care. A recent systematic review also provides evidence that SADE interventions can enhance the experience for children with special needs, including those with ASD. Understanding the specific sensory adaptations employed in SADE, such as sensory-friendly lighting, noise reduction or tactile accommodations, would provide more insights into their effectiveness. Implementing this kind of dental environment holds the promise of enhancing dental care not only for children with ASD but also other children with special health-care needs and/or dental fear and anxiety.

It is crucial for dental professionals to stay updated with clinical guidelines, seek further education and make use of available resources to provide the best possible care for autistic children.

Additionally, it is important to note that the success of Canada’s new federal dental plan for children and the accessibility of dental care for individuals with ASD  may be limited without the implementation of these simple changes and the education of dental office staff.

Table 1: Online Courses, Clinical Guidelines, Position Statements and Evidence-Based Interventions from Randomized Controlled Trials

Acknowledgement: We would like to express our gratitude to Dr. Stein Duker, an assistant professor of research at the University of Southern California, for providing valuable feedback and generously sharing resources.