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.

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
• The National Autistic Society, Going to the dentist