The Successful Dental Appointment
The day has arrived when the patient with autism is coming in for an appointment. The paperwork has been filled out, the parent interview is complete, the office is ready, the operatory is stocked, now what?
The Introduction When meeting someone with autism for the first time, take a few minutes to just talk and be physically in the same space. Do not be offended if the patient does not shake hands, give a high-five, or make eye contact. Introductions will be the same as with any child. Be yourself and do the things you would typically do when working with small children, even if it seems as if the patient is not paying attention.
In the Operatory Once the child is seated (this may take some practice for first-timers) be brief with small talk. Most of the information on the medical and dental history will be gathered and discussed at the parent interview before the patient even sees the dental office. Allow the patient to sit in the chair for a few minutes and get comfortable. Use a visual schedule to help the patient understand what is next. Avoid wordy descriptions or talking unnecessarily. Stick to the order of events on the visual schedule. After each task is completed, remove the picture from the visual schedule and put it out of sight. Be flexible; do not hesitate to offer breaks, adapt treatment or stop the appointment if the patient is becoming frustrated or overwhelmed.
Completing Treatment Here are a few useful, effective tips in working with patients with autism and other developmental disabilities (or just very small children):
Start lying down. Some individuals may not like the feeling of the chair moving back, if that is the case have them get up, move the chair in position and then have the patient lie down. Have them sit up on their own before moving the chair to the upright position.
Start at the midline. This is effective when polishing, probing, etc. Many patients will have a sensitive gag reflex and anxiety can make the problem worse. If the patient can feel the vibration of the prophy angle on the central incisors and remain slightly closed, they will become comfortable with the sensation before requiring the patient to open wide and work around areas that stimulate the gag reflex. This also keeps the patient from tasting the prophy paste or fluoride until just before the procedure is finished. Always work from least invasive to most invasive.
Count to 10. This teaches a couple of concepts. It gives the clinician control of when the procedure will stop but only requires the patient to work for very short periods of time. If the procedure stops every time the patient raises a hand or makes a noise, treatment will never be completed. This helps the patient understand that a break is coming and it is distracting. When the patient is really struggling the clinician can count very quickly and when the patient is cooperating and the clinician needs more time, counting can be very slow. Without traumatizing the patient always try to get to 10 so the patient will associate the word “ten” with a break and to help the child understand that 10 must be reached and not any other number.
Reward, reward, reward. See next section.
First/Then cards. Putting a “first/then” board together is very simple (Figure 14). This strategy is used to help individuals with autism get through tasks they find particularly undesirable. For example, a patient might really dislike having an injection for local anesthesia but the patient is highly motivated by time spent on the iPad. Under the word “first” is a picture of the anesthetic syringe and under the word “then” is a picture of the iPad. Show the patient the board with both cards and explain, “First we put your tooth to sleep, then you get the iPad, first get numb, then get the iPad.” Here is a link to a DIY first/then board with free printables: First-Then Schedule Board Freebie. This is a great tool for very small children or uncooperative patients that do not have autism.
Figure 14. First and Then Card.
To see how first/then schedules evolve and benefit individuals with ASD, watch this short video. Pay attention to the teachers' voice and the language she uses in the video. Her tone is level, her phrases are concise and she consistently uses the same phrases.