Neurodiversity and Orthodontic Treatment

Autism

Autism is a developmental condition that affects the way a person communicates and interacts with the world around them.⁹ This is accompanied by restrictive or repetitive behaviours, resistance to change and restricted interests.¹⁰ The term ‘autism spectrum disorders’ encompasses autism, Asperger's syndrome and atypical autism. The overall prevalence of autism in the UK is 1.1%, and it is significantly more common in males than females.¹¹ A diagnosis of autism is less common in adults and females, possibly due to affected persons using increased social camouflaging, the unconscious or conscious masking of behaviours ‘to fit in’ socially.^12,13 Undiagnosed autism does not necessarily mean it has had a minimal impact on somebody's life and social camouflaging has been linked to suffering from increased mental health issues.¹³ Autism is a spectrum condition, meaning it can affect people to varying degrees and in different ways. The earliest at which autism can currently be diagnosed is at 2 years old; however, predictors of autism may be present earlier.^14,15,16

There are health inequalities between people with and without autism,^17,18 with the former group reporting a lower quality of life.¹⁹ It has been reported that approximately 70% of autistic people have additional conditions.¹⁰ Epilepsy, sleep problems, delays in language development, dyslexia, anxiety and depression all have an increased prevalence. Dentally, children with autism have been shown to have higher risks of dental disease,²⁰ poorer cooperation and an increased need for treatment under general anaesthetic.^7,21

To help navigate their everyday challenges and interactions in the world, people with autism may rely on specific routines as coping mechanisms. Examples of these routines include wearing specific items of clothing or eating the same foods every day. Seemingly minor alterations can lead to a person feeling overwhelmed. A visit to a new environment is a prime example of a situation where an individual's coping mechanisms can be compromised, leading to heightened anxiety.⁸ Extreme anxiety is a common feature of autism. Even if very motivated for treatment, a visit to an orthodontic setting can be challenging for some patients with autism.⁸ Prior to attending the surgery, an informative website can assist in managing these challenges. A description of things to expect during their first orthodontic visit, photographs of the practice/department and information about the orthodontic team are all useful for gaining a familiarity of the environment. Providing a quiet room in which to wait can be more calming than a busy waiting room prior to an appointment. Arranging appointments first thing in the morning can have the additional benefit of reducing waiting times. Having a trial visit to the practice/department, allowing the patient or carer to take photographs, may help to desensitize them to the new surroundings and team.⁸ Where possible, keeping the same orthodontist and dental nurse pairing throughout treatment is desirable.

Orthodontists may need to modify their communication styles when speaking to autistic patients (Table 1). People with autism can have advanced language skills or delayed language development and up to 30% of people with autism are non-verbal.²² While autistic people struggle with social interaction, people without autism often struggle to identify what autistic people are thinking or feeling. During conversation, statements may be processed literally, causing confusion or misunderstanding. Giving patients time to express themselves, as well as involving parents or carers who understand an individual's behaviour much better, is important for establishing a good rapport and successful treatment. If only standard communication methods are employed, a patient may simply appear non-compliant. Scheduling longer appointments is a reasonable adjustment to allow adequate time for this. Positive framing of instructions, for example, ‘Keep your tongue to the left’ rather than ‘Don't put your tongue on this side’ is likely to be understood better. ‘Tell-show-do’ is a recognized behavioural management technique that can also be effective, where a procedure is explained to the patient and subsequently demonstrated outside the mouth or on a model before being carried out.

Sensory hypersensitivity is a common feature of autism. Individuals may experience extreme tastes, smells, sounds and touch. This hypersensitivity can extend to toothbrushing where an alternative to mint-flavoured toothpaste may be of use. Many autistic patients can be hypersensitive to the texture of a foaming toothpaste, which can be overcome by using a sodium lauryl sulphate-free toothpaste. Another behavioural management technique is distraction. This can be particularly useful when a patient has problems with sensory processing. Wearing earphones during the appointment, holding a ‘fidget spinner’ throughout or using a gaming device may all be useful tools. It is important to note that some patients with autism will prefer darker glasses due to sensitivity to the dental light.

Missing teeth, spacing, reverse overjets, open bites and class II molar relationships have been observed in a higher percentage of patients with autism compared to non-autistic individuals.⁶ Autism has many different presentations and orthodontic treatment planning should consider a patient's individual needs and preferences. Some patients may be extremely compliant with orthodontic treatment, whereas a treatment plan with limited aims is optimal for others. For those patients with sensory hypersensitivity or increased anxiety, avoiding irreversible treatment initially is appropriate. A sectional fixed appliance allows patients and clinicians to assess tolerance of intra-oral appliances before irreversible treatment is started. Appliances that can be removed during eating can bring about the correction of malocclusions in patients with strict eating patterns, and for whom fixed appliances would be incompatible. Depending on the type of repetitive behaviour, an increased breakage rate may be seen if it involves the mouth.

Dyspraxia

Dyspraxia is a neurological disorder that affects the way in which the brain processes information. It is associated with problems of perception, language and planning, resulting in a motor disorder.²³ People with dyspraxia may produce clumsy movements, have an increased tendency to fall and have trouble changing directions. Manual dexterity is limited to varying degrees and poor hand-eye coordination is often a feature.²³

Dyspraxia affects up to 10% of the UK population. Males are four times more likely than females to be affected.²³ Dyspraxia affects people to varying degrees and an individual's symptoms can be greater one day than the next. Although learning new motor skills can be challenging, it is often possible with adequate time and adaptations.

Orthodontic treatment may be limited due to poor oral hygiene. Clinicians should assist patients who are accessing care by suggesting tailored oral hygiene routines for them (Table 2). A person with dyspraxia, who is unable to use floss, may not necessarily struggle with a water flosser. An electric toothbrush can be easier to hold and require less fine movement.

Patients with dyspraxia may have difficulty following instructions, particularly if several are given at one time. If practical instructions are given to patients, they should be clear and address every practical point. Interactive demonstrations of any practical procedure allow the clinician to assess whether the plan needs to be altered. Elastic placement may be extremely difficult for patients with dyspraxia and treatment plans heavily reliant on prolonged elastic wear may not be successful. An orthodontic elastic placer (Figure 1) or disposable mosquito forceps can be given to the patient.

Attention deficit hyperactivity disorder

ADHD is a common developmental disorder that affects 4% of the population.⁴ The disorder is significantly more common in males than females.⁴ People with ADHD may have difficulty paying attention, controlling impulsive behaviour or may be overly active. When hyperactivity is not present, it is termed as attention deficit disorder (ADD). ADHD can cause significant problems at school and in social situations. Patients with ADHD vary dentally from other patients. Studies have found they have an increased rate of malocclusion, parafunction, dental trauma and mineralization disturbances.^3,4,5

During orthodontic treatment, children with ADHD can demonstrate behavioural difficulties, short attention spans and poor cooperation.³ Certain times of the day may be better suited to orthodontic appointments when attention span is at its greatest. Separating appointments into upper and lower bond up visits can also be beneficial by limiting the time patients sit in the dental chair. Oral habits including nail biting, lip biting or chewing on other objects (pens and pencils) are common in patients with ADHD; determining whether these are present prior to starting orthodontic treatment is important in assessing the potential appliance breakage rate.²⁴

Patients with ADHD can find the dental surgery an overwhelming experience and commonly exhibit significant anxiety associated with treatment.³ Behavioural management techniques including ‘tell-show-do’ and distraction can be valuable (Table 3).

When giving instructions to patients, it is important to be clear and concise. Short-term memory deficiencies and a reduced attention span mean lengthy, conversational instructions are likely to not be followed. Using the patient's name at the start of the instruction during appointments can be a simple way to encourage compliance, for example choosing to say ‘Sam, bite together’ rather than simply ‘Bite together’ as it draws the patient's attention just prior to the instruction.

Dyslexia

Dyslexia is a learning difficulty that primarily affects the skills involved in accurate and fluent word reading and spelling. Characteristic features of dyslexia include difficulties with phonological awareness, verbal memory and verbal processing speed. Dyslexia occurs across a range of intellectual abilities.²⁵ Many people only associate dyslexia with reading and writing; however, it is also characterized by poor short-term memory and organizational skills.²⁶ In addition to this, people with dyslexia can have increased anxiety and low self-esteem. It is present in 10% of the population.²⁶

Failure of patients to correctly interpret information given to them presents potential problems for informed consent and compliance. Giving dyslexic patients ‘dyslexia-friendly’ written information can overcome any short-term memory problems and allow them to read information at home in a less pressured environment (Table 4). The British Orthodontic Society's patient leaflets have been created with advice from the British Dyslexia Association. Any other literature in the practice can be altered to accommodate people with dyslexia. Alterations include selecting a rounded font with space between the letters. For example, Arial is preferred to Times New Roman for this reason because it minimizes ticks and tails that can create difficulties.²⁶ Font size should be a minimum of size 12 and line spacing should be a minimum of 1.5. Italics, underlining and uppercase letters should be avoided as these are less familiar and add confusion, but bold can be used to draw attention. Paper should be matt rather than gloss. Colours should be chosen with care. White backgrounds can appear too dazzling, so cream or a pastel colour can be beneficial. Some people with dyslexia have their own colour preferences, which are often highlighted during their dyslexia assessments. If this is the case, an acetate overlay in the desired colour can be used.²⁷ During treatment, clinicians should be mindful that dyslexia can affect a patient's ability to multi-task. Giving instructions one at a time, supported by ‘dyslexia-friendly’ written information, is important.

Conclusion

Neurodivergent patients have different requirements to most other patients, which extends to their orthodontic treatment. Compliance may be improved if practitioners have an awareness of common needs and management techniques when providing treatment to this group of patients.