Autism is now recognised as a neurological condition and it is recorded that there is an increase in the number of children who are diagnosed with this condition. It should also be remembered that patients with autism will also usually lack theory of mind. This capacity is usually acquired gradually by children as they pass from age three to the age of seven. It is one of most important developments in early childhood social cognition. It also includes the ability to attribute mental states — such as pretending, knowledge, etc. — to oneself and others and to understand that others have beliefs, desires, and intentions that are different from one’s own.
Social cognition is at the heart of children’s ability to get along with other people and to see things from their point of view. We use theory of mind to explain our own behaviour to others, by telling them what we think and want, and we interpret other people’s talk and behaviour by considering their thoughts and wants. This lack, therefore, seriously impedes the ability to communicate with others in a way that is appropriate to their needs. There may be occasions when the dental environment needs to be changed to one that is less challenging for someone who could be adversely affected by the usual arrangements.
There are two main types of autism: classical autism which is genetically caused and autism spectrum disorder which is environmental and arises from a brain injury that is usually caused during a child’s early developmental period. Both have aspects of neuropathology which affect behaviour.
The signs of autism become obvious around the eighteen month to 36 month period of the infant’s life as its brain begins to develop the more advanced requirements for mental and physical activity.
Since, globally, there are a large number of children affected by this devastating disorder, dental professionals should provide oral health care with family-centred approach comprising a thorough understanding of parental concern, exceptional medical conditions, and vivid behaviours of each personality patient to improve the treatment planning. It is common to find that those who are affected by autism will be seen to have poor oral hygiene and frequently, gingivitis. Some of this may occur, in part, because of the administration of psychotropic medication. It is also necessary to plan carefully any operation under a general anaesthetic for an autistic person and to establish if there has been any adverse reactions in the past. It is sometimes necessary because of the patient’s neuropathology to have a specially prescribed anesthetising process and prescription.
It is also found that patients who have autism frequently also have allergies, immune system problems, gastrointestinal disturbances and seizures. Dental health care workers must be aware of these comorbid conditions so they can provide optimal care to the children with autism spectrum disorders. There may also be drooling and swallowing problems which are often due to poor muscle tone and not because of excessive saliva production. In addition and because of poor tongue coordination, they have a propensity to pouch food inside the mouth rather than swallowing it, thus increasing caries susceptibility. Dental injuries are more common in autistic children and these include enamel fracture.
The child’s parents will have begun to clean the infant’s teeth as they would with any other child and so problems tend to arise only when there is a need for professional attention. Many autistic children may not present problems at this time if their oral hygiene has been supervised in an educated and intelligent manner. As the child grows older, it is often the case that each one will not have managed to replicate the cleaning routines because of some aspect of its neuropathology.
It may also be the case that most autistic children will not demur from the inspection of a dentist if it has been introduced to the idea gradually and in a sensitive way, always considering the child’s individual autistic characteristics. It is important to recognise that these may vary considerably from child to child.
The eventual problems for the professional will arise if the autistic patient develops an antagonism to the process of cleaning. This is most usual if carers who are not the child’s parents become involved in the cleaning of its teeth.
People with autism, like continuity and sameness in their life and environment. Thus they are very sensitive to how people treat them; this includes the way a carer cleans the client’s teeth. They will object if someone attempts to clean their teeth in a way that is inconsistent with their sense of normality.
There can be real problems around this situation if the non-parent carer has not been given adequate training on how to clean a client’s teeth; especially for one who has the difficulties of autism. It is always helpful, as an introduction to this training, for pairs of carers to clean each other’s teeth. The dialogue that will follow this practice will allow both carers to be told by the other where their technique is either inadequate or uncomfortable. It will also allow each to practice the positioning of the hands and toothbrush for maximum effect and minimum discomfort.
In summary, it is essential that the background of a patient with autism is understood if maximum care is to be gained by a professional examination and treatment. There needs to be a very flexible and individual approach to treatment and this includes special care in the use of a general anaesthetic.
Background of author
Alan Challoner completed his Master’s Degree in the Philosophy of Healthcare at the University of Wales. His major subjects were the psychology and psychiatry of learning disability, and medical ethics. Later he did post-graduate research in child development and attachment theory.