Last Updated on March 17, 2024 by Partha Protim Choudhury
Autism or autism spectrum disorder is a complex condition that affects communication, behaviour and social interactions. It typically emerges in early childhood and presents a range of challenges including difficulties with social cues, communication and repetitive behaviours. In this in-depth interview, THIP Media invited Dr Shivani Singh is a Paediatric Dentist and Dental-in-Charge at NGM Hospital and Research Centre in CBD, Belapur Navi, Mumbai. For the entire interview, click on the link below.
Q. Could you provide an overview of the specific oral health problems that dental experts typically observe when examining a child with autism?
Firstly, we need to understand what autism means. So, autistic children are those who have neurological developmental delays or disabilities when it is considered. And what we find is a lack of communication with other humans.
And a very common finding in them is also repetitive behaviour. When a patient comes into our dental office and the patient is an autistic child, very common dental findings that we find are first mainly related to the oral health, we find dental caries. These children tend to prefer eating softer kinds of food. Softer food means no chewing and the food will also remain in their mouth. Because these children also tend to hold the food in their mouth, they pouch the food in the buccal cavity or the cheek area.
So, if food remains in these cavities for a long time, the tooth will start decaying. The acidic pH of the mouth will remain high for longer and thus it will decay teeth. So dental caries is highly prevalent, although there are a few studies which mentions that dental caries is comparatively less. But in my findings, it has been like that, only that dental caries is high.
These children are on a lot of medications to suppress their anxiety levels and many of other medications are also on cue. These medications are responsible to reduce the amount of salivation, the condition we call it as xerostomia. In cases of xerostomia, also, swallowing becomes difficult for these children. Autistic children also tend to have larger tongues or edematous tongues. That also creates difficulty in swallowing.
Being a special child, especially having a neurological disorder where even a minor amount of sensation is very much amplified. For these children, brushing and flossing, the normal oral hygiene practices that we do becomes very difficult. So, not practising oral hygiene results in gum diseases also. So, these are a few dental problems which are very prevalent. Other than that, there are malocclusions which can be seen and a few more.
Q. How do you evaluate the particular oral health requirements of autistic children?
Before evaluating, we have to consider what amount of adaptation or sensitization the child has towards a dental appointment. Most probably, especially when we consider India where approximately we have 18 million children suffering from autism, not many go for a dental appointment. We prefer having the concept of a dental home like we have a medical home. Similarly dental homes for these children. So that these children are sensitised at a very young age for the sensations of having something in your mouth or some other person’s hand inside your mouth to evaluate to function for something.
Being a dentist is required to have patience. It’s not easy to just go and check an autistic child like any other child. You will have to build a trust level in the child first so that he comes and sits in your chair. Otherwise, you will never be able to even look into the child. The child will throw a N number of tantrums. But if the child starts to trust you, believe in you, he will cooperate with you. So, trust becomes really important.
Behaviour guidance is also there. Whenever we are doing anything, we need to tell the patient about any future procedure. Other than that, there are various aspects to it where we can go ahead and just ask the parent what difficulties they are finding or what complaints are they having, which they find in day-to-day life so that we can address it.
Q. Do you have to modify your communication style to meet an autistic child’s particular requirements and preferences?
Definitely. Anyways, talking to an adult is different. Talking to a child is very much different to a special child, a child with autism. Every minor word that you are speaking, the tone that you are speaking, in, the expressions that you are having on your face, every minor detail is being observed by that child. We might not remember, but the child is very, very observant, whatever you are speaking.
These patients cannot distinguish or read in between the lines. So, we have to be straightforward. If we want to do a filling, we’ll have to tell them that we are going to do a filling in your mouth. We just cannot say that we are going to put coffee inside your mouth so that your teeth can be better or put something like we do it for other children. Furthermore, we cannot use euphemism in these children. We have to be very particular with what we are speaking. These children are also very imaginative. Using different forms of story, inculcating whatever you want to say in a story format or in a musical tone helps these children a lot. This is how we can go about the communication part.
Also, parents play a very important role here. At times these patients will not coordinate with you or will not respond to you. But it is your responsibility to get all the medical history, the dental history and all the conversations that you want. Dentistry cannot be practised without conversing between you, the patient and the parent when it comes to paediatric. So here the parent is supposed to be the mediator between you and the patient. Wherever you think that you are not able to communicate properly, you always take their parent(s) as your support and then communicate.
Q. How can we provide autistic children a sensory friendly environment in a dental office in terms of lighting, noise levels, physical space?
See, very frankly, dental setup is one of the most sensory generators of a place where everything is so loud, so bright, everything is just lit up. Whether it is light, noise, smell, colours, everything. Especially when we talk about paediatric setups, they are so, so colourful. Yes, the general population will enjoy these things, but autistic population finds it really difficult to adjust and adapt to all this setup. One should remember this.
On the parents’ part, please take a pre appointment schedule. Schedule an appointment beforehand. Inform the operator about the condition of the child so that you as well as the operator are ready about the treatment that the dentist is going to provide.
When you’re bringing the autistic child to get the treatment, we provide a dark room. We tend to switch off all our lights and close the windows if possible. We put on the curtains also. There are very mild lightings which are present so that it is not absolutely dark. Very mild. The ones that we use while sleeping, the blue lights.
Secondly, we advise the parents to get noise cancelling headphones. If they don’t have that or if the patient is okay with having a headphone, we can play soft music on that. If the patient is okay with playing music in the surrounding, also we put it on the music system. This is how we can take care of the sound.
Then we ask the patient, either they can get a heavy blanket, or we can arrange. Usually, it is call it a butterfly wrap. It is not to restrain the child. It is just to make the child feel like he’s hugging on to something. So, that they feel that they are in a secure place. The more comfortable the child can be, the better they perform.
After all these things are taken care of, then we also consider patients who have a lot of gagging. There is a lot of gagging reflexes that are seen. So, for them, distractions can be useful. We can use topical anaesthetics, of course.
Q. Could you provide some strategies that could be used to make autistic kids more comfortable and eager for their future dental appointments?
To create any kind of sensitization, I think as a society there are many people who come across or come in contact with our autistic children. Firstly, the parents and the caregivers, siblings, immediate family members, the paediatrician, and then comes the paediatric dentist. As early as possible in the life of the child, a dental appointment should follow. That is where the concept of a dental home comes in.
Secondly, even though the child is not cooperating with the parent, maintain their oral hygiene. It will take time for the child to adjust towards the oral hygiene procedures. Because seriously, there is a lot that goes inside your mouth when you are even brushing. So, for the child to adapt it will take time. But patience and perseverance work a lot. So, the parents have to really be dedicated towards all this functioning.
When it comes to the first experience on the dental part, we try our level best to give a positive experience to the child. I think encouraging the child is important after you complete a dental appointment, or minor things, if you can just give a child a small treat or take the child out for a walk or do whatever the child likes, just throwback in the sense like it will help the child to feel rewarded. It helps the children have regular follow-ups with their dentist. You should at least visit the dentist once a year for those with a higher risk of dental caries. We demand visits up to three months or six months depending upon what the rate of caries in them is. Anything that will relax the child, you may bring. That will help the child a lot.
While practising the oral hygiene measures, I would like to mention a few things when you’re brushing your child’s tooth in very young children, they will not be stable. So, you will have to hold their head from behind and then clean their teeth. Eventually they start adapting to their motion. These children also have a lack of motor coordination.
So, you cannot expect, like any normal child, they’ll brush their teeth by the age of four or five years. You have to continuously supervise them. Electric toothbrushes have been found to work better in these children. But not all children can adapt to the sensation of that battery or motor vibration. So whatever your child, go ahead with that.
There are many people who ask whether the child will swallow the toothpaste. Is it okay? The toothpaste that we advised for these children is fluoride-based and ingestion of fluoride-based toothpaste is not recommended. It is always advisable that you ask the child to spit.
The quantity of toothpaste is very important. We just take a bulk of quantity on the toothbrush, and we try to brush. It is not how it happens. Specific amount of toothpaste, like a pea size or two pea size. Depending upon the age of the child, the toothpaste is sufficient enough to brush all the teeth in your mouth. Once done with tooth brushing, like normally, we floss using a dental floss. We can go ahead with a jet flosser or water flosser.
You can use a mirror in the hand of your child, and you can brush their teeth or ask them to brush their own teeth. Eventually, by slow and consistent working, this oral hygiene practice will become a routine. And there are (autistic) kids if you don’t follow these routines, they become annoyed now.
There are many children who are having functional needs, and it is our responsibility to consider them our family only. I have published a book on that by the way and it has a line that these people are not different, they just have different requirements.
As much empathy, love, care that we can give to these children, it will be great for our society itself.
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