Before the appointment, obtain and review the patient’s medical history. Consultation with physicians, family, and caregivers is essential to assembling an accurate medical history. Also, determine who can legally provide informed consent for treatment.

 Talk with the parent or caregiver to determine your patient’s intellectual and functional abilities, and then communicate with the patient at a level he or she can understand.

• Use a “tell-show-do” approach to providing care. Start by explaining each procedure before it occurs. Take the time to show what you have explained, such as the instruments you will use and how they work. Demonstrations can encourage some patients to be more cooperative.

BEHAVIOR PROBLEMS –which may include hyperactivity and quick frustration–can complicate oral health care for patients with autism. The invasive nature of oral care may trigger violent and self-injurious behavior such as temper tantrums or head banging.

• Plan a desensitization appointment to help the patient become familiar with the office, staff, and equipment through a step-by-step process. These steps may take several visits to accomplish.
  • Have the patient sit alone in the dental chair to become familiar with the treatment setting. Some patients may refuse to sit in the chair and choose instead to sit on the operator’s stool.
  • Once your patient is seated, begin a cursory examination using your fingers.
  • Next, use a toothbrush to brush the teeth and gain additional access to the patient’s mouth. The familiarity of a toothbrush will help your patient feel comfortable and provide you with an opportunity to further examine the mouth.
• When the patient is prepared for treatment, make the appointment short and positive.
• Pay special attention to the treatment setting. Keep dental instruments out of sight and light out of your patient’s eyes.
• Praise and reinforce good behavior after each step of a procedure. Ignore inappropriate behavior as much as you can.
• Try to gain cooperation in the least restrictive manner. Some patients’ behavior may improve if they bring comfort items such as a stuffed animal or a blanket. Asking the caregiver to sit nearby or hold the patient’s hand may be helpful as well.
• Use immobilization techniques only when absolutely necessary to protect the patient and staff during dental treatment–not as a convenience. There are no universal guidelines on immobilization that apply to all treatment settings. Before employing any kind of immobilization, it may help to consult available guidelines on federally funded care, your State department of mental health disabilities, and your State Dental Practice Act. Guidelines on behavior management published by the American Academy of Pediatric Dentistry (www.aapd.org) may also be useful. Obtain consent from your patient’s legal guardian and choose the least restrictive technique that will allow you to provide care safely. Immobilization should not cause physical injury or undue discomfort.
• If all other strategies fail, pharmacological options are useful in managing some patients. Others need to be treated under general anesthesia. However, caution is necessary because some patients with developmental disabilities can have unpredictable reactions to medications.

People with autism often engage in perseveration, a continuous, meaningless repetition of words, phrases, or movements. Your patient may mimic the sound of the suction, for example, or repeat an instruction over and again. Avoid demonstrating dental equipment if it triggers perseveration, and note this in the patient’s record.

UNUSUAL RESPONSES TO STIMULI can create distractions and interrupt treatment. People with autism need consistency and can be especially sensitive to changes in their environment. They may exhibit unusual sensitivity to sensory stimuli such as sound, bright colors, and touch. Reactions vary: Some people with autism may overreact to noise and touch, while exposure to pain and heat may not provoke much reaction at all.

• Use the same staff, dental operatory, and appointment time to sustain familiarity. These details can help make dental treatment seem less threatening.
• Minimize the number of distractions. Try to reduce unnecessary sights, sounds, odors, or other stimuli that might be disruptive. Use an operatory that is somewhat secluded instead of one in the middle of a busy office. Also, consider lowering ambient light and asking the patient’s caregiver whether soft music would help.
• Allow time for your patient to adjust and become desensitized to the noise of a dental setting. Some patients may be hypersensitive to the sound of dental instruments.
• Talk to the caregiver to get a sense of the patient’s level of tolerance. People with autism differ in how they accept physical contact. Some are defensive and refuse any contact in or around the mouth, or cradling of the head or face. Others find such cradling comforting.
• Note your findings and experiences in the patient’s chart.

UNUSUAL AND UNPREDICTABLE BODY MOVEMENTS are sometimes observed in people with autism. These movements can jeopardize safety as well as your ability to deliver oral health care.

• Make sure the path from the reception area to the dental chair is clear.
• Observe the patient’s movements and look for patterns. Try to anticipate the movements, either blending your movements with those of your patient or working around them.

SEIZURES may accompany autism but can usually be controlled with anticonvulsant medications. The mouth is always at risk during a seizure: Patients may chip teeth or bite the tongue or cheeks. People with controlled seizure disorders can easily be treated in the general dental office.

• Consult your patient’s physician. Record information in the chart about the frequency of seizures and the medications used to control them. Determine before the appointment whether medications have been taken as directed. Know and avoid any factors that trigger your patient’s seizures.
• Be prepared to manage a seizure. If one occurs during oral care, remove any instruments from the mouth and clear the area around the dental chair. Attaching dental floss to rubber dam clamps and mouth props when treatment begins can help you remove them quickly. Do not attempt to insert any objects between the teeth during a seizure.
• Stay with your patient, turn him or her to one side, and monitor the airway to reduce the risk of aspiration.