U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES l National Institutes of Health l National Institute of Dental and Craniofacial Research

Practical Oral Care 

for People With Autism

P

roviding oral care to people with autism requires adaptation of the

skills you use every day. In fact, most people with mild or moderate 

forms of autism can be treated successfully in the general practice 

setting. This booklet will help you make a difference in the lives of people who 

need professional oral care.

Autism is a complex developmental disability that impairs communication 

and social, behavioral, and intellectual functioning. Some people with the 

disorder appear distant, aloof, or detached from other people or from their 

surroundings. Others do not react appropriately to common verbal and social 

cues, such as a parent’s tone of voice or smile. Obsessive routines, repetitive 

behaviors, unpredictable body movements, and self-injurious behavior may all 

be symptoms that complicate dental care.

Autism varies widely in symptoms 

and severity, and some people have 

coexisting disabilities such as mental 

retardation or epilepsy. They can 

be among the most challenging of 

patients, but following the suggestions 

in this booklet can help make their 

dental treatment successful.

contents

Health Challenges 

IN autism and 

Strategies for Care

2 . . . . . . . . . . . . . . . . . . . . . 

Communication problems 

and mental capabilities

Behavior problems

3 . . . . . . . . . . . . . . . . . . . . . 

Unusual responses to 

stimuli

Unusual and unpredictable 

body movements

Seizures

Oral Health Problems 

IN autism and 

Strategies for Care

4 . . . . . . . . . . . . . . . . . . . . . 

Damaging oral habits

Dental caries

Periodontal disease

5 . . . . . . . . . . . . . . . . . . . . . 

Tooth eruption

Trauma and injury

Additional readings Making a difference 

in the oral health of 

a person with autism 

may go slowly at first, 

but determination can 

bring positive results and 

invaluable rewards.


Before the appointment, obtain and review 

the patient’s medical history. Consultation 

with physicians, family, and caregivers is 

essential to assembling an accurate medical history. Also, determine who can legally 

provide informed consent for treatment.

Communication problems and

mental capabilities are central concerns when treating people with autism.

Talk with the parent or caregiver to 

determine your patient’s intellectual and 

functional abilities, and then communicate with the patient at a level he or she 

can understand.

Use a “tell-show-do” approach to providing care. Start by explaining each 

procedure before it occurs. Take the 

time to show what you have explained, 

such as the instruments you will use 

and how they work. Demonstrations 

can encourage some patients to be more 

cooperative.

Behavior problems—which may 

include hyperactivity and quick frustration—can complicate oral health care for 

patients with autism. The invasive nature 

of oral care may trigger violent and selfinjurious behavior such as temper tantrums 

or head banging.

Plan a desensitization appointment to 

help the patient become familiar with 

the office, staff, and equipment through 

a step-by-step process. These steps may 

take several visits to accomplish.

• Have the patient sit alone in the 

dental chair to become familiar with 

the treatment setting. Some patients 

may refuse to sit in the chair and 

choose instead to sit on the operator’s 

stool. 

• Once your patient is seated, begin 

a cursory examination using your 

fingers.

• Next, use a toothbrush to brush the 

teeth and gain additional access to the 

patient’s mouth. The familiarity of a 

toothbrush will help your patient feel 

comfortable and provide you with an 

opportunity to further examine the 

mouth.

When the patient is prepared for treatment, make the appointment short and 

positive.

Pay special attention to the treatment 

setting. Keep dental instruments out of 

sight and light out of your patient’s eyes.

Praise and reinforce good behavior after 

each step of a procedure. Ignore inappropriate behavior as much as you can.

Try to gain cooperation in the least 

restrictive manner. Some patients’ 

behavior may improve if they bring 

comfort items such as a stuffed animal 

or a blanket. Asking the caregiver to sit 

nearby or hold the patient’s hand may 

be helpful as well. 

Use immobilization techniques only 

when absolutely necessary to protect 

the patient and staff during dental treatment—not as a convenience. There are 

no universal guidelines on immobilization that apply to all treatment settings. 

Before employing any kind of immobilization, it may help to consult available 

guidelines on federally funded care, your 

State department of mental retardation/

mental health, and your State Dental 

Practice Act. Guidelines on behavior 

management published by the American 

Academy of Pediatric Dentistry (www.

aapd.org) may also be useful. Obtain 

consent from your patient’s legal guardian and choose the least restrictive technique that will allow you to provide care 

Health Challenges in Autism 

and Strategies for Care

People with 

autism need 

consistency and 

can be especially 

sensitive to 

changes in their 

environment.


safely. Immobilization should not cause 

physical injury or undue discomfort.

If all other strategies fail, pharmacological options are useful in managing some patients. Others need to 

be treated under general anesthesia. 

However, caution is necessary because 

some patients with developmental 

disabilities can have unpredictable 

reactions to medications.

People with autism often engage in perseveration, a continuous, meaningless 

repetition of words, phrases, or movements. 

Your patient may mimic the sound of the 

suction, for example, or repeat an instruction over and again. Avoid demonstrating 

dental equipment if it triggers perseveration, and note this in the patient’s record.

Unusual responses to stimuli

can create distractions and interrupt treatment. People with autism need consistency 

and can be especially sensitive to changes 

in their environment. They may exhibit 

unusual sensitivity to sensory stimuli 

such as sound, bright colors, and touch. 

Reactions vary: Some people with autism 

may overreact to noise and touch, while 

exposure to pain and heat may not provoke 

much reaction at all. 

Use the same staff, dental operatory, and 

appointment time to sustain familiarity. These details can help make dental 

treatment seem less threatening.

Minimize the number of distractions. Try to reduce unnecessary sights, 

sounds, odors, or other stimuli that 

might be disruptive. Use an operatory 

that is somewhat secluded instead of 

one in the middle of a busy office. Also, 

consider lowering ambient light and asking the patient’s caregiver whether soft 

music would help.

Allow time for your patient to adjust 

and become desensitized to the noise 

of a dental setting. Some patients may 

be hypersensitive to the sound of dental 

instruments.

Talk to the caregiver to get a sense of 

the patient’s level of tolerance. People 

with autism differ in how they accept 

physical contact. Some are defensive 

and refuse any contact in or around the 

mouth, or cradling of the head or face. 

Others find such cradling comforting. 

Note your findings and experiences in 

the patient’s chart.

Unusual and unpredictable

body movements are sometimes 

observed in people with autism. These 

movements can jeopardize safety as well as 

your ability to deliver oral health care.

Make sure the path from the reception 

area to the dental chair is clear.

Observe the patient’s movements and 

look for patterns. Try to anticipate the 

movements, either blending your movements with those of your patient or 

working around them.

Seizures may accompany autism but can 

usually be controlled with anti­convulsant 

medications. The mouth is always at risk 

during a seizure: Patients may chip teeth 

or bite the tongue or cheeks. People with 

controlled seizure disorders can easily be 

treated in the general dental office.

Consult your patient’s physician. 

Record information in the chart about 

the frequency of seizures and the 

medications used to control them. 

Determine before the appointment 

whether medications have been taken as 

directed. Know and avoid any factors 

that trigger your patient’s seizures.

Record in the 

patient’s chart 

strategies that were 

successful in

providing care. 

Note your patient’s 

preferences and 

other unique details 

that will facilitate 

treatment, such as

music, comfort 

items, and flavor 

choices.


Be prepared to manage a seizure. If 

one occurs during oral care, remove 

any instruments from the mouth 

and clear the area around the dental 

chair. Attaching dental floss to rubber 

dam clamps and mouth props when 

treatment begins can help you remove 

them quickly. Do not attempt to insert 

any objects between the teeth during a 

seizure.

Stay with your patient, turn him or her 

to one side, and monitor the airway to 

reduce the risk of aspiration.

autism

Tips for caregivers are available in the booklet

Dental Care Every Day: A Caregiver’s Guide, also part of this series.

People with autism experience few unusual 

oral health conditions. Although commonly used medications and damaging 

oral habits can cause problems, the rates 

of caries and periodontal disease in people 

with autism are comparable to those in the 

general population. Communication and 

behavioral problems pose the most significant challenges in providing oral care.

Damaging oral habits are 

common and include bruxism; tongue 

thrusting; self-injurious behavior such as 

picking at the gingiva or biting the lips; 

and pica—eating objects and substances 

such as gravel, cigarette butts, or pens. If 

a mouth guard can be tolerated, prescribe 

one for patients who have problems with 

self-injurious behavior or bruxism.

Dental caries risk increases in patients 

who have a preference for soft, sticky, or 

sweet foods; damaging oral habits; and 

difficulty brushing and flossing. 

Recommend preventive measures such 

as fluorides and sealants.

Caution patients or their caregivers 

about medicines that reduce saliva or 

contain sugar. Suggest that patients 

drink water often, take sugar-free 

medicines when available, and rinse 

with water after taking any medicine. 

Advise caregivers to offer alternatives to 

cariogenic foods and beverages as incentives or rewards.

Encourage independence in daily oral 

hygiene. Ask patients to show you how 

they brush, and follow up with specific 

recommendations. Perform hands-on 

demonstrations to show patients the 

best way to clean their teeth. If appropriate, show patients and caregivers how 

a modified toothbrush or floss holder 

might make oral hygiene easier.

Some patients cannot brush and floss 

independently. Talk to caregivers about 

daily oral hygiene and do not assume 

that they know the basics. Use your 

experiences with each patient to demonstrate oral hygiene techniques and sitting 

or standing positions for the caregiver. 

Emphasize that a consistent approach 

to oral hygiene is important—caregivers should try to use the same location, 

timing, and positioning.

Periodontal disease occurs in 

people with autism in much the same way 

it does in persons without developmental 

disabilities. 

Some patients benefit from the daily 

use of an antimicrobial agent such as 

chlorhexidine.

Oral Health Problems in Autism 

and Strategies for Care


Stress the importance of conscientious 

oral hygiene and frequent prophylaxis.

TOOTH ERUPTION may be delayed due 

to phenytoin-induced gingival hyperplasia. 

Phenytoin is commonly prescribed for 

people with autism.

TRAUMA and INJURY to the mouth 

from falls or accidents occur in people with 

seizure disorders. Suggest a toothsaving kit for group homes. Emphasize to 

caregivers that traumas require immediate 

professional attention and explain the 

procedures to follow if a permanent tooth 

is knocked out. Also, instruct caregivers 

to locate any missing pieces of a fractured 

tooth, and explain that radiographs of 

the patient’s chest may be necessary to 

determine whether any fragments have 

been aspirated.

Physical abuse often presents as oral 

trauma. Abuse is reported more frequently 

in people with developmental disabilities 

than in the general population. If you 

suspect that a child is being abused or 

neglected, State laws require that you call 

your Child Protective Services agency. 

Assistance is also available from the 

Childhelp® USA National Child Abuse 

Hotline at (800) 422–4453 or the National 

Clearinghouse on Child Abuse and Neglect 

Information (http://nccanch.acf.hhs.gov).

Making a difference in the oral health 

of a person with autism may go 

slowly at first, but determination can 

bring positive results—and invaluable 

rewards. By adopting the strategies 

discussed in this booklet, you can 

have a significant impact not only on 

your patients’ oral health, but on their 

quality of life as well.

Additional Readings

Klein U, Nowak AJ. Autistic disorder: a 

review for the pediatric dentist. Pediatric 

Dentistry, 20(5):312–317, 1998. 

Klein U, Nowak AJ. Characteristics of 

patients with autistic disorder (AD) presenting for dental treatment: a survey and 

chart review. Special Care in Dentistry,

19(5):200–207, 1999.

National Institute of Child Health and 

Human Development, National Institutes 

of Health (NIH). Autism Questions and 

Answers for Health Professionals. NIH Pub. 

No. 01–4964, 2001.

Towbin KE, Mauk JE, Batshaw ML. 

Pervasive developmental disorders. In 

Batshaw ML, Children With Disabilities 

(5th ed.). Baltimore, MD: Paul H. 

Brookes Publishing Co., 2002.

pp. 365–387.

For more information about autism, contact

National Institute of Child Health and Human 

Development Information Resource Center

P.O. Box 3006

Rockville, MD 20847

(800) 370–2943

www.nichd.nih.gov 

NICHDInformationResourceCenter@mail.nih.gov
Acknowledgments

The National Institute of Dental and Craniofacial Research 

thanks the oral health professionals and caregivers who 

contributed their time and expertise to reviewing and 

pretesting the Practical Oral Care series.

Expert Review Panel

• Mae Chin, RDH, University of Washington, Seattle, WA

• Sanford J. Fenton, DDS, University of Tennessee, Memphis, TN

• Ray Lyons, DDS, New Mexico Department of Health, 

Los Lunas, NM

• Christine Miller, RDH, University of the Pacific, 

San Francisco, CA

• Steven P. Perlman, DDS, Special Olympics Special Smiles, 

Lynn, MA

• David Tesini, DMD, Natick, MA

NATIONAL INSTITUTE OF

DENTAL AND CRANIOFACIAL

RESEARCH

This booklet is one in a series on providing oral care for people 

with mild or moderate developmental disabilities. The issues and 

care strategies listed are intended to provide general guidance on 

how to manage various oral health challenges common in people 

with autism.

Other booklets in this series: 

Continuing Education: Practical Oral Care for People 

 With Developmental Disabilities

Practical Oral Care for People With Cerebral Palsy

Practical Oral Care for People With Down Syndrome

Practical Oral Care for People With Mental Retardation

Wheelchair Transfer: A Health Care Provider’s Guide

Dental Care Every Day: A Caregiver’s Guide

For additional copies of this booklet, contact

National Institute of Dental and Craniofacial Research

National Oral Health Information Clearinghouse

1 NOHIC Way

Bethesda, MD 20892–3500

(301) 402–7364

www.nidcr.nih.gov

This publication is not copyrighted. 

Make as many photocopies as you need.

NIH Publication No. 06–5190

Reprinted May 2006

NATIONAL INSTITUTE OF

DENTAL AND CRANIOFACIAL

RESEARCH

National Institute of Dental 

and Craniofacial Research

Centers for Disease Control 

and Prevention

National Institute of Child Health 

and Human Development

Special Care Dentistry