Navigating the Challenges of Dental Care for Children with Autism

While working as an applied behavior analysis (ABA) therapist, Elisa Hegg, adjunct professor for Simmons University’s online Master of Science in Behavior Analysis program, regularly accompanied clients to dental appointments. With the right preparation and the right dentist, Hegg knows that children with autism can have a positive experience with minimal discomfort. However, Hegg recalls that during one dental visit, this was not the case.

“I was once in a room where the dentist was going to try to do a filling. The child was flailing, but the dentist kept approaching with the drill,” Hegg said.

After a short period of struggle, the dentist paused the procedure, which Hegg said should have happened sooner. “What the child learned was: ‘If I engage in enough disruptive behavior, they’re going to have to let me go,’” she said.  “[Stopping] much earlier allows the child to learn not to escalate to a point that is dangerous for everybody.”

According to one study,

81%

of children with autism were unable to complete a dental treatment, compared to

16.1%

of neurotypical patients — those who do not have a developmental disorder that causes impaired function in areas such as communication, behavior, or cognition.

This is just one example that demonstrates the importance of understanding the needs of children with autism. Ignoring sensitivities and failing to communicate in a way that is compatible with language access can cause children with autism spectrum disorder (ASD) to fear the dentist and, ultimately, learn maladaptive behaviors. That is a significant concern, according to the National Institute of Dental and Craniofacial Research (NICHD) (PDF, 636kb), because individuals with ASD are at high risk for developing cavities, periodontal disease, and other dental problems.

To navigate the challenges of dental care for children with autism, parents and caregivers can use strategies that prepare their child for a successful visit. And by establishing these habits early, children with autism can avoid more complicated dental issues later in life.

While every case of autism spectrum disorder is unique, many children with autism face similar challenges that affect their dental health. According to a resource on dental care for patients with autism from the NICHD, barriers to treatment include (PDF, 636kb):

According to Hegg, these barriers can work in tandem to make standard dental exams and other dental procedures challenges for children with autism.

“Part of the diagnosis for autism includes behavior excesses or deficits, as well as language impairments,” Hegg said. “The language impairments may make it harder for parents and caretakers to explain what to expect from a dental office visit, while the behavior excesses and differences in sensory experiences may make it less comfortable for the child.”

Children with autism are also at higher risk for dental damage. Causes for dental damage include:

Research has shown that dental care is a major challenge for individuals with autism. According to one study, 81% of children with autism were unable to complete a dental treatment, compared to 16.1% of neurotypical patients (PDF, 381 KB) — those who do not have a developmental disorder that causes impaired function in areas such as communication, behavior, or cognition. 

In some cases, children with autism who are unable to remain still during a dental appointment are required to go under general anesthesia. Sedation is not considered ideal for routine dental procedures in children, as there is some risk associated with general anesthesia; adverse effects include hypoxemia, respiratory depression, and airway obstruction. It can also be costly — general anesthesia for dental exams may not be covered by an individual’s dental insurance.

The best way to help a child with autism feel comfortable at the dentist is preparation, Hegg said. Like any other learning experience, the use of reinforcement — a tactic where a small reward is given immediately following their performance of a desired behavior — can be implemented to help children with autism learn how to handle the experience. 

Additionally, there are multiple steps parents and caregivers can take before and during their child’s exam to have the best possible chance at a successful visit.

Communication between parents and the child’s dentist can set both parties up for a productive visit. 

Parents can ask the following questions:

Important information to share with the dentist includes:

Preparing a child for his or her first visit to the dentist through exposure exercises can help ease anxiety.

One strategy that has proven effective is the use of desensitization visits. With this method, children visit a dental office multiple times, taking steps to go inside, walk through processes, and eventually sit in the exam chair for a mock exam.

A 2017 study on the use of desensitization on patients with autism found that this method resulted in successfully completing dental exams for most of the children involved. Those with characteristics consistent of a milder presentation of ASD were more likely to be successful.

Another case study on a young dental patient with autism spectrum disorder showed that the use of desensitization techniques resulted in improved behavior and maintenance of his behavior for three years following the study.

However, this level of desensitization therapy is not always practical. It requires extra time from dentists and dental assistants, as well as the use of space in their exam rooms. It also requires the parents and their child to commute to the office multiple times.

A more accessible option is to practice desensitization methods at home, Hegg said. Using a list of steps from the exam process provided by the dentist, parents and caregivers can emulate some of the experiences and go through the process several times leading up to the visit.

Hegg recommends starting with the first step (e.g., “open your mouth”) and practicing it several times. Then, the child can move on to doing step one and step two multiple times, slowly progressing toward completing the entire mock process.

Take frequent breaks before the child exhibits a behavioral problem.

“A natural tendency is to think, ‘Oh, things are going well. Let’s keep going,’” Hegg said. “You have to resist that temptation and give breaks so the child learns they will get breaks without having to have a tantrum.”

Bring the reinforcement tool and implement the reinforcement process.

For example, if the child collects stickers on a chart, bringing the chart and adding stickers after each step of the exam can help encourage continued positive behavior.

When possible, use other distraction methods to help the child feel more comfortable.

Hegg suggested bringing a smartphone that can play videos for the child to watch during the exam. Headphones may also be a helpful distraction for children who are sensitive to noises.

In addition to helping a child feel comfortable in the exam chair, parents can support healthy dental practices at home to minimize risks for cavities and other problems.

According to Hegg, when children begin ABA treatment, food items are often used as reinforcements for positive behaviors. This can contribute to dental issues later, especially if the reinforcement is candy or other foods that are high in sugar. 

Parents can move away from using food as reinforcements by giving an additional non-food reinforcement, such as a tangible item like a small toy or a social interaction like a high five, alongside the food to establish it as a reward. Over time, they can stop using food as a reinforcement and continue using the other reinforcement as a reward instead.

Children with autism sometimes have limited diets due to sensory issue factors such as texture. This can lead to eating a small variety of foods that are more likely to cause cavities.

It is possible to work with a child to explore new foods over time. A 2015 study on the use of graduated exposure showed that the method helped children with autism expand their food preferences.

Following the same steps every time children brush their teeth helps to create a feeling of predictability so they are more comfortable and less anxious about what the outcome of an activity will be. Teaching a child this routine can be done through a strategy called video modeling. 

Video modeling is the use of videos showing another person doing a task in a way that is instructional and shows what the result of the task will be. While instructional videos for this purpose can be purchased or found on free platforms like YouTube, Hegg suggested creating videos at home that are specific to the child. 

“Everybody has a smartphone at this point, so you can record a video that shows where it’s actually going to be happening,” Hegg said. “Somebody who the child knows and trusts and looks to for instructions and models could also be included.”

VIDEO MODELING FOR AUTISM: DIY TIPS

1. Record the video in the setting where the child will be completing the task.
2. Feature someone the child knows and trusts as the model, such as a sibling or parent.
3. Show the person completing the task step-by-step, as well as receiving the reinforcement item used in the child’s treatment.

Legal Disclaimer: Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: Simmons University’s online master’s in behavior analysis program