Clare Hutchison provides a succinct reminder of autism with tips on how to deal with autistic patients in the surgery.
Background
In the United Kingdom, more than one in a 100 people have autism spectrum disorder (ASD) (The National Autistic Society, 2016). ASD is a lifelong disability that affects how people interact with the world and people around them. It encompasses a multitude of diagnoses, terminology of which can be confusing.
It affects development and manifests in a spectrum of various presentations. Commonly affecting communication, symptoms depend on the developmental level and chronological age of the individual. Each person’s condition is unique and requires a different type of support.
Classification
Following the release of the Diagnostic and Statistical Manual of Mental Disorders Fifth Addition, common terms such as autistic disorder, Asperger’s disorder and pervasive development disorder not otherwise specified have been replaced by the diagnosis of ASD.
Though the former terms are still understood the aim is to begin advancing from an exclusive focus on symptom-based categories (American Psychiatric association, 2013) (Bejerot S et al, 2014).
A multi-disciplinary diagnostic team formally makes the diagnosis. Depending on the severity, they refer patients to specific care pathways, including community dental services.
Features
It is not always clear if somebody suffers from ASD. Generally, a patient or parent will reveal information during a medical history check.
Patients may appear overly anxious, with a common feature of ASD feeling overwhelmed.
They can find it hard interpreting both verbal and non-verbal language including gestures and tones. With an impairment in social reciprocity, it makes it difficult for those to read and understand feelings and motives of others.
This can be furthered by impaired communication skills, some patients may be non-verbal or unsure of the expectations within a conversation leading to excessive talking or echolalia (Limeres-Posse J et al, 2014).
Atypical behaviour is also typical, patients can demonstrate repetitive motions, strict adherence to routines, self-injurious behaviours, hyperactivity, short attention span, impulsivity, aggressiveness, temper tantrums, and unusual responses to sensory input.
Epilepsy, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD) and schizophrenia also link to such patients. Overall these barriers can make it hard to build rapport with patients and provide treatment.
Relevance to dental practice
Though DMFT is similar to their peers, autistic children generally report greater barriers when accessing dental care (McKinney et al, 2014).
We must recognise the importance of information gathering prior to seeing a patient. Establishing a patient’s tolerance to physical contact, determining level of intellectual and cognitive abilities. Desensitising may help build confidence in the surgery.
Tell show do, distraction, positive reinforcement can all be successful. As well as keeping appointments succinct.
Habitual actions such as bruxism, tongue thrust and self-injury have been reported in many patients, leading to conditions such as tooth surface loss and temporal mandibular disease (Orellana LM et al, 2012).
As with any patient, an importance of awareness of any side effects from medications is key. Some medications treat some symptoms causing xerostomia.
GDPs
In our country, we are lucky to have access to secondary services adapted to helping such patients providing additional services such as sedation and general anaesthetic. Often working in partnership with general dental practitioners (GDPs) to acclimatise.
GDPs can help accomplish short goals such as sitting in the dental chair and reinforce important preventive messages. However, more complex treatment may not be suitable in a primary care setting so it is important to be aware of your own limitations.
In a small number of patients, safeguarding issues may be raised. It can be difficult to assess if sufferers are being abused due to limited speech, issues with communication and difficulty in identifying patients’ emotions.
Problems may be identified by a change in behaviour. As a regular point of contact with families, GDPs can be the first to notice families struggling to cope. It is important to always act in the patient’s best interest.
Capacity for consent is assumed. Unless, significant evidence suggests otherwise. Assessing consent is based on the patient being able to communicate by any method. Understanding, retaining and explaining information regarding their treatment, underlined by working in the patient’s best interest.
Conclusion
Each patient with autism is unique, we need to support and respect these individuality’s. It is important that we as GDPs understand treating these patients can be complex and time consuming. This will be the case no matter what level of experience we have.
Therefore, we must make an effort to understand how to best treat these patients.
For references email [email protected].
This article first appeared in Young Dentist magazine.
