Learning disability and autism are different conditions which share similar factors contributing to difficulties in communication, sensory, emotional and flexibility challenges.1,2 Not everyone with autism has a learning disability (not to be confused with learning difficulty eg dyslexia).3 People with learning disabilities or autism have the same rights to dental care (access and quality) as everyone else. Dental teams with little experience treating people with learning disabilities/autism may feel uncomfortable providing care. This can lead to misunderstandings, increased anxiety (from both the patient and the practitioner), failures in the provision of treatment, and consequently referrals to already overloaded services.

Each individual is different and it is important to provide patient-centred care. People with learning disabilities have difficulty to face stressing events and therefore are at higher risk of dental anxiety.4 Here are some tips which dental teams can use before, during and after an examination/treatment session to maximise positive and success outcomes before considering referral.3,5

Before the dental procedure

Tip 1

Creating a relationship is essential to achieve cooperation and building trust is crucial for quality of care.6 Small things that may seem insignificant are important in achieving this. Getting prepared before the appointment by contacting the patient or carers can be helpful to find out more about the person. Starting a conversation is easier when the dental team knows what their hobbies are, what he/she likes and dislikes and the best way to communicate with them. Some patients have a hospital passport that details this information (Fig. 1).

Fig. 1
figure 1

Example of a hospital passport that can be filled by the patient with the help of their carer and presented to the dental team

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Tip 2

People with a learning disability have significantly reduced ability to understand new or complex information.7 It is therefore important to develop an effective communicationmethodwithout treating them like a child. Asking their preferred method of communication is the starting point. Only one person should talk at the same time with slower speech. Open questions should be prioritised rather than closed questions (ie yes-no answers). Metaphors should be avoided. Even if the patient is non-verbal or accompanied by a family member, friend, or carer, questions and explanations must be directed to them. Time must be given to allow for a response. A family member, friend or carer can then complete the answers. If the patient has non-verbal communication, body language can be helpful to determine their wishes. Limited communication does not mean limited ability to consent.3

Tip 3

People with autistic spectrum disorders often need routine and regularity.8 Individuals with learning disability need support with daily activities and may be unable to attend early morning appointments.2 Being flexible and pragmatic is key, make appointments at times that suit the patient and their care team.

Tip 4

Sensory and emotional impairments are characteristics of autism and can be associated with learning disabilities. As with any patient waiting time should be minimised to reduce stress, but all the more so in autistic patients. This should be factored into the appointment schedule, and whilst a challenge in a busy practice, pragmatic planning will reduce stress for all. This involves longer appointment time. The dental surgery is a new environment with lots of potential stimuli (sound, light, smell, colours). Music and lighting can trigger discomfort and withdrawal reactions. The dental team can adjust the surgery into a more comforting environment by asking and either providing or removing background music. Take care not to shine the operating light into patients' eyes.

Tip 5

An orientation appointment can be organised in order to allow the patient to meet the staff, to take pictures and to prepare for next visit. Story books can be given to explain what happens at the dentist.9

During the dental examination or procedure

Tip 6

Reducing the patient's fear during a dental procedure can be achieved by non-pharmacological behaviour management techniques. Tell-show-do, counting time ('I will count to five seconds while I am cleaning your teeth, then we will stop'), and allowing time for breaks are proven techniques. Providing distraction (Fig. 2), constant verbal reassurance ('you're doing great!'), positive reinforcement, and congratulating the patient ('well done!') work too. Holding the patient's hand (by carer or dental nurse) is reassuring, brings a sense of security and is a way to avoid unexpected movements. However, ask beforehand how the patient feels about physical contact. Some patients with autism do not like physical contact with other people.

Fig. 2
figure 2

Examples of items that can be used as distractions: a tablet (showing here a page of a story book for patients having a dental visit but that can be used to show videos, games etc) and sensory toys as a liquid motion bubble timer and a squidgy ball

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Tip 7

Agree on a signal in case of discomfort or if something hurts (eg raising hand, squeezing the hand of the person who accompanies) so that the patient knows how s/he can ask for a break and adjustments. Pain management is essential during the dental procedure. Topical gel should be used before local anaesthesia with slow infiltration.

Tip 8

If the patient has tight lips, massaging the lips and cheeks relaxes the area and familiarises the patient with a clinical oral examination. If the patient refuses to open her/his mouth, brushing the teeth with a toothbrush or using toothbrush aids and fingerguards can be helpful.

Tip 9

If things are not going well it is better to stop to avoid creating unpleasant memories meaning the patient will not want to return to your clinic. In addition, depending on the treatment provided, good pain relief should be advised to avoid unnecessary postoperative pain, worries and consequently a bad memory.

After the dental procedure

Tip 10

If local anaesthesia was used, very clear instructions must be given about not eating and taking care drinking. Vigilance should be advised to the carers to avoid lip biting, all the more so if the patient has parafunctions. Being numb is a new sensation to process and may cause distress. Reminding the patient that this is temporary will reassure them. Giving the patient a mirror can help them to understand that this is just an impression and that the face is not actually swollen.

Tip 11

Getting feedback from the patient and their care team is important, especially if they are coming back for further treatment. Find out what has worked for them, and what can be done differently to help them. If the patient reports afterwards wanting some music during the treatment, write in the notes what kind of songs s/he would like. If the patient has come with a carer, friend or family member who has been particularly helpful in helping them to cope with the treatment, ask that person to return at the next visit if possible.

Tip 12

Patients with learning disabilities/autism have difficulty identifying health problems and expressing their needs. Ask the carers to look out for changes in behaviour, reluctance to eat and drink.5 They are more likely to need support for their daily oral hygiene.7 Prevention is key. Oral health information should be provided to both the patient and the carer. More frequent recalls event for short appointments will help to maintain familiarity, improve acceptance of future care and address the needs.10

Conclusion

It has been found that 90% of persons with special needs can be treated in the general dental practice if problems of access were addressed.11 Referrals delay the provision of care and contribute to oral health disease progression and poorer oral health outcomes.12 Changes in the attitude of health care professionals can help to reduce oral health inequalities for patients with learning disabilities and autism. Small changes as outlined can help to gain cooperation and avoid challenging behaviours.