Orthodontics: The challenges in caring for patients with autism

Orthodontic care for children with autism spectrum disorders requires a lot of love, patience, and expertise, as the communication difficulties between doctor and patient create particular challenges.

“Autism spectrum disorders are complex developmental conditions that disrupt communication and social, behavioral, and cognitive functioning,” says Dr. Katerina Douma-Michelaki, DDS, PhD, Specialist Orthodontist for Children & Adults. “Some individuals with these disorders appear distant, indifferent, or detached from others or their surroundings, while others do not respond to typical verbal and social cues, such as a parent’s voice or smile. Stereotyped routines, repetitive behaviors, unpredictable bodily movements, or even self-injurious behavior, which may coexist with sensory disabilities, intellectual disability, or epilepsy, place patients at an increased risk of developing oral diseases and can complicate orthodontic care.”

Although autism and other disorders are quite common (in our country, for example, it is estimated that more than 25,000 children and adults are affected), research conducted on their dental and orthodontic care is limited.

In 2013, scientists from the Netherlands and Switzerland published a combined analysis (meta-analysis) of all relevant studies published up to that year, concluding that children with autism disorders have poor oral hygiene and the same (though more frequent) dental needs as their healthy peers.

Furthermore, “they often have clinical manifestations that require orthodontic intervention, such as anterior open bite (the front teeth of the upper and lower jaws do not meet), dental crowding (teeth do not have enough space to develop properly due to a mismatch between their size and the size of the jaw), and other orthodontic problems,” says Dr. Douma-Michelaki. “As it seems, poor oral hygiene combined with harmful habits such as bruxism (teeth grinding) and lip biting, which are common in children with autism spectrum disorders, leads to bite problems that need early and proper intervention to be corrected.”

In general, it seems that most patients with moderate to mild autism spectrum disorders can be successfully treated in general dental practices, as long as certain obstacles are overcome. The same meta-analysis showed that the main obstacles are the child’s behavior towards dental procedures, their cost, and the lack of insurance coverage for these treatments. Additional barriers include the patient’s aversion to dental treatments, complications related to their condition, and the difficulty in finding a healthcare professional who is willing and has the necessary expertise to deal with such challenging cases.

The first and perhaps most crucial step for proper care of the patients is for the orthodontist to understand in depth the behavior and characteristics of the child. Autism spectrum disorders have a wide range of symptoms and severity, and it may take multiple short visits to the clinic before the patient becomes accustomed to the space and accepts the presence of the orthodontist and the equipment they will use.

“Before the first appointment with the child, there should be a discussion between the doctors and the family with the dental health specialist, who will receive the detailed medical history and the child’s symptoms will be described,” explains Dr. Douma-Michelaki. “Communication difficulties are the biggest problem we need to manage because the child may not understand what is happening or why we are doing it or may not understand what we are asking them to do.”

Many autistic children also have sensory processing disorders, which result in the brain misinterpreting sensory messages. For example, a smell that is pleasant to everyone may be unpleasant to an autistic child, or they may not tolerate a particular texture in their mouth.

Additionally, the child may be frightened by typical movements (e.g., when someone suddenly stands up from their chair), and this is something the specialist should also know in advance. The same applies if the child has visited a dentist or orthodontist before, what dental procedures were performed, and what their outcomes were.

“These and many other factors must be taken into account when preparing to treat the child, because our goal is to slowly help them feel comfortable with us and trust us, so that eventually we can provide the care they need,” adds the specialist.

She continues: “This is also why the first meeting is generally not held in the room with the equipment or when there are other people in the clinic, but rather at a quiet time in a simple office room, because loud noises and many people often cause anxiety or scare children with autism spectrum disorders.”

During this and any subsequent visits that may be needed, the orthodontist assesses the child’s social skills, checking for example if they make eye contact or avert their gaze, if they smile, how much they understand of what is being said to them, whether they can follow simple instructions, whether they brush their teeth, whether they can write, etc.

Depending on the problems identified, the orthodontist will suggest and/or implement appropriate solutions, which generally become increasingly effective over time.

“For a specialist to make a difference in the oral health of a child with autism can be a slow process at first, but with patience and persistence, it can lead to positive results and invaluable benefits for both,” concludes Dr. Douma-Michelaki.