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CDHO Advisory: Autism Spectrum Disorder









Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with autism spectrum disorder.


Cite as College of Dental Hygienists of Ontario, CDHO Advisory Autism Spectrum Disorder, 2023-03-29


Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).



Autism spectrum disorder


Advanced practice nurses
Dental assistants
Dental hygienists
Health professional students
Public health departments
Regulatory bodies


To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have autism spectrum disorder, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.


Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Parents, guardians, and family caregivers of children, young persons and adults with autism spectrum disorder.


For persons who have autism spectrum disorder: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.



Terminology used in this Advisory

Resources consulted

Autism spectrum disorder

  1. comprises a group of pervasive developmental disorders that
    1. are characterized by their
      1. appearance in the first three years of life
      2. impairment of the brain’s normal development of social and communication skills
      3. wide range and severity of signs and symptoms, which may be inconsistent or even contradictory
    2. was formerly subdivided (under the umbrella diagnosis of “pervasive developmental disorders”) into
      1. Asperger syndrome, a mild form
      2. autistic disorder, a severe form
      3. childhood disintegrative disorder, a rare form
      4. pervasive development disorder not otherwise specified, a moderate form
      5. Rett syndrome2, a rare form.
    3. is now (according to the Diagnostic and Statistical Manual of Mental Disorders [DSM-5] of the American Psychiatric Association) considered to exist as a range of severity and characteristics within one category.

Nomenclature and classification vary among clinical centres. The following reflects common  usage in the DSM-4 era, though not necessarily universal usage then or now (in the DSM-5 era).

  1. Asperger syndrome
    1. is  often considered a high functioning form of autism
    2. is characterized by 
      1. clumsiness
      2. delay in achieving motor milestones
      3. difficulty in social interactions
      4. repetitive behaviour
    3. may be associated with above-average intelligence 
      1. manifested as excelling in fields such as computer programming and science 
      2. reflected in delay-free development of
        1. cognitive function
        2. capability in self-care
        3. awareness of and curiosity about their outer world. 
  2. Autistic disorder 
    1. is a severe form of autism spectrum disorder
    2. is also called autism and “mindblindedness”
    3. is characterized in children by
      1. developing during the first three years of life
      2. problems that cause children to  
        1. live in their own world
        2. show little interest in other children or adults
        3. lack social awareness
        4. are focused on
          1. consistent routine
          2. repeating peculiar behaviours
        5. often have problems in communication, avoid eye contact and show limited attachment to others.
  3. Childhood disintegrative disorder 
    1. is a rare and severe form of autism spectrum disorder
    2. occurs chiefly in boys
    3. begins between three and four years though may start as early as two 
    4. in which, prior to onset, the child has age-appropriate skills in communication and social relationships
    5. is characterized variously by
      1. extensive loss of motor, language, and social skills
      2. loss of bowel and bladder control
      3. seizures 
      4. intellectual disability.
  4. Pervasive developmental disorder, not otherwise specified
    1. is a general category for a pattern of behavioural differences variously involving children’s
      1. attention
      2. communication
      3. forming social relations
      4. interests
    2. is on some classification methods considered one subtype of pervasive developmental disorders of which the other is autistic disorder
    3. is terminology that may be used, with some difficulty, as a diagnosis when the particular pattern or clustering of symptoms is sufficiently unusual to set it apart from other diagnoses.
  5. Rett syndrome3 
    1. is a rare disorder of the nervous system that leads to reversals of development, especially in expressive language and hand use
    2. occurs almost exclusively in girls and may be misdiagnosed as autistic disorder or cerebral palsy (CDHO Advisory)
    3. is a genetic defect of the X chromosome of which
      1. females have two, which enables a female child to survive a defect in one chromosome
      2. males have one, so that the defect is usually fatal
    4. results in the little girl’s
      1. ceasing talking if she has previously reached this stage
      2. constantly wringing her hands
      3. losing control of her feet
      4. pulling away from all social contact
      5. regressing in mental and social development 
      6. responding no longer to her parents.

Overview of autism spectrum disorder

Resources consulted

Autism spectrum disorder

  1. Occurrence, causes and risk factors of disorders on the autism spectrum generally
    1. occur
      1. in childhood and persist for life
      2. contributing to prevalence rates of
        1. 1% of the total Canadian population
        2. up to 2% of the Canadian child/adolescent population
      3. at an apparently rising incidence rate but with numbers that are 
        1. not accurately known 
        2. debated because certain studies suggest that autism spectrum disorder is more common than previously believed, though unclear is whether the apparent rise results from increases in one or both of
          1. the rate of occurrence of the condition
          2. the rate of diagnosis arising from 
            1. greater awareness
            2. changes in diagnostic criteria
      4. in all racial, ethnic, and social groups
      5. at relatively high incidence in
        1. boys, who are three to four times more likely to be affected than girls
        2. siblings of a child with an autism spectrum disorder
        3. persons with other developmental disorders, such as 
          1. fragile X syndrome
          2. intellectual disability
          3. tuberous sclerosis
      6. without always being recognized, so that diagnosis may be delayed to adolescence or adulthood
    2. are caused
      1. by abnormalities in the brain that
        1. remain unknown
        2. are likely to involve a combination of factors of which genetic factors seem important because
          1. identical twins are much more likely to both have autism than fraternal twins or siblings
          2. language abnormalities are more common in relatives of autistic children
          3. chromosomal abnormalities and other neurological problems are more common in families with autism
          4. some individuals diagnosed with Asperger syndrome identify similar traits in their family members
          5. of a particular research finding that the fathers and grandfathers of autistic children were twice as likely to be engineers as the parents of children who were not autistic
      2. by factors that may also include
        1. differences in brain function, regulation and structure
        2. environmental factors
        3. immune deficiencies
        4. immune responses
        5. viral infections
    3. may be the subject of risk factors which are the subject of rigorous research, of controversy, and of speculation in relation to various theories, including
      1. diet
      2. digestive tract changes
      3. the body’s inability to properly use vitamins and minerals
      4. mercury poisoning arising from dental fillings, refuted by rigorous studies
      5. vaccine concerns arising from 
        1. the small amount of mercury that is a common preservative, thimerosal in multi-dose vaccines, though 
          1. rigorous studies have failed to validate this concern 
          2. all of the routine childhood vaccines are available in single-dose forms without added mercury
        2. research published in the Lancet medical journal in 1998  
          1. claiming to have demonstrated links between (a) the three-in-one measles, mumps and rubella vaccine (MMR) and (b) autism, other forms of brain damage and bowel disease in children
          2. finally established as fraudulent in 2011. 
  2. Subtypes were previously (DSM-4) considered to be 
    1. Asperger syndrome, a mild form
    2. autistic disorder, a severe form
    3. childhood disintegrative disorder, a rare form 
    4. pervasive development disorder not otherwise specified, a moderate form
    5. Rett syndrome, a rare form.
  3. Signs and symptoms are generally characterized by
    1. behavioural, social and communication challenges that 
      1. vary widely and inconsistently in their
        1. manifestations
        2. effects on day-to-day living: some children and adults
          1. function well, while others are locked in a private world
          2. develop motor, language, cognitive and social skills at rates and in sequences that differ from those of unaffected children of comparable age
      2. include harmful behaviours, such as
        1. aggression
        2. self-injury
      3. include strengths that variously involve
        1. computer interests and skills
        2. drawing skills
        3. exceptional memory
        4. music skills
        5. non-verbal reasoning skills
        6. perceptual motor skills required for motor coordination
        7. reading skills
        8. visual spatial abilities
      4. include weaknesses that variously involve
        1. abnormal, inconsistent or unconventional responses to sensory stimulation
        2. behaviour problems
        3. deficits and difficulties in physiological functioning
        4. deficits in communication and language
        5. emotional difficulties
        6. impairment in social relationships
        7. variability of intellectual functioning
    2. early manifestations in young children that are
      1. first noticed by parents and other caregivers who typically
        1. suspect that something is wrong by the time the child is 18 months (and almost always before three years of age)
        2. seek help by the time the child is two years of age
      2. exhibited as 
        1. difficulties in
          1. pretend play
          2. social interactions
          3. verbal and non-verbal communications
        2. regression of existing language or social skills
    3. later manifestations in children and adolescents that include
      1. abnormal, inconsistent or contradictory responses to sensory stimulation
        1. hypersensitivity to 
          1. normal noises displayed by holding of hands over ears
          2. pain
          3. sight
          4. smells
          5. taste 
          6. touch
        2. hyposensitivity manifested as
          1. high pain threshold
          2. simulated deafness
          3. startle reaction to loud noises is absent
        3. withdrawal from physical contact because it is apparently over-stimulating or overwhelming
        4. fascination with a trivial object, spending hours rocking or watching objects spin
      2. behaviour problems
        1. intense tantrums
        2. property destruction
        3. aggression towards 
          1. others
          2. self though self-injury
        4. use of abnormal behaviour to communicate
        5. intensive focus interests and activities manifested as
          1. preoccupation with specific topics to the point of exhausting the patience of teachers, peers and others
          2. repetitive, stereotyped body movements such as hand flicking, spinning or rocking, which interfere with learning
        6. dependence on routine, departure from which creates stress manifested as tantrums, screaming, and self-injury
        7. short attention span
        8. extremely narrow range of interests
        9. hyperactivity or marked passivity
        10. strong need for consistency
        11. repetitive body movements
        12. behavioural effects on play
          1. impairment of imitation skills leading to difficulties in learning
          2. preference for solitary or ritualistic play
          3. unusual perceptions of toys
          4. refusal to play with toys
          5. low aptitude for pretend or imaginative play
        13. behaviour patterns that
          1. become repetitive
          2. lack apparent relevance to the particular situation
          3. impair social interaction, through
            1. flapping arms to signal happiness
            2. self-hurting to signal unhappiness
      3. deficits and difficulties in physiological functioning relative to
        1. sleeping, involving
          1. difficulty falling asleep
          2. abnormally short sleep requirements
        2. toileting, which may be attributable to 
          1. sensory issues
          2. actual gastrointestinal problems possibly
            1. manifested as diarrhea or constipation
            2. associated with poor sleep habits
            3. associated with gastroesophageal reflux disease (CDHO Advisory)
        3. eating, associated with
          1. nutritional deficiencies
          2. gastrointestinal problems
        4. immune irregularities, which may be manifested as food intolerance, leading to pickiness in eating
        5. uneven development profile
      4. deficits in communication and language, which are common, include
        1. inability to start or sustain a social conversation
        2. use of gestures instead of words to communicate
        3. slow or absent development of language 
        4. non-adjustment of gaze to view objects that others are looking at
        5. incorrect use of pronouns in self-reference: use of ‘you’ when ‘I’ is intended 
        6. idiosyncratic use of words and phrases 
        7. echolalia, repetition of words or memorized passages, used by some children as a means of communication
        8. use of nonsense rhyming
        9. abnormalities in pitch, stress, rate, rhythm and intonation of speech
        10. difficulty interpreting non-verbal communication such as
          1. social distance cues
          2. gestures and facial cues
        11. repeated ritualistic actions such as spinning, rocking, staring, finger flapping, and self-hitting
        12. restricted interests such as obsessive focus on a single object, idea, or activity
        13. problems talking with other children and adults
        14. not looking at a person trying to communicate by talking 
      5. emotional difficulties involving
        1. abnormal seeking of comfort and reassurance when stressed by changes in
          1. situations
          2. environments
          3. routines
        2. extreme dependence on predictability and highly structured environments
        3. lack of empathy
        4. preference for being alone
        5. unusual attachments to objects
        6. withdrawn personality
        7. abnormal comfort-seeking behaviour in response to stress associated with 
          1. cravings for predictability
          2. attempts at functioning in highly structured environments
      6. impairment in social relationships, including lack of awareness, whereby  the child may
        1. behave as if other people 
          1. do not exist
          2. are inanimate objects
          3. are present with the sole purpose of gratifying the child’s need
        2. be unable to understand another child’s reaction to pain, or other perspective, associated with awkwardness in such social skills as the child possesses
        3. be incapable of responding to affection
        4. be unable to 
          1. relate to peers reciprocally and positively
          2. make friends
          3. play interactive games
          4. adapt interpersonal skills to demands of various social situations
        5. react to eye contact or smiles from others
          1. without acknowledgement
          2. by avoiding eye contact
        6. treat other children or persons as objects
      7. variability of intellectual functioning observed as 
        1. mild-to-severe mental retardation in 70 percent of persons with autism spectrum disorder other than Asperger syndrome
        2. uncertain associations between autistic traits and intelligence as measured by IQ
        3. inconsistent development profiles variously involving
          1. above-normal range of intelligence with ability to attend college, follow a career, and have a family
          2. ability to function in some areas at levels higher than their overall level of functioning
          3. age-level self-help skills 
          4. absent social-skills abilities 
        4. impairment of imitation skills that limits learning by imitation, an important process for children
      8. various comorbidities.
  4. Medical investigation
    1. diagnosis of autism spectrum disorder 
      1. is normally made in early childhood (after infancy and before 3 years of age)
      2. may be difficult because of the lack of a single symptom definitively diagnostic of autism
      3. rests on the presence of some combination of several of the following
        1. lack of interest in other people
        2. inability to talk to, play with, or relate to other persons
        3. difficulty in initiating and sustaining a conversation
        4. speech and language skills that
          1. begin to develop and then are lost
          2. develop very slowly or not at all
    2. is indicated if the child 
      1. fails to meet key milestones such as 
        1. babbling by 12 months
        2. gesturing (pointing and waving) by 12 months
        3. using single words by 16 months
        4. using two-word spontaneous phrases by 24 months 
      2. loses any language or social skills at any age.
  5. Treatment
    1. when provided early, intensive and appropriate treatment improves the prognosis for most young children with an autism spectrum disorder
    2. in the more severe forms variously involves
      1. applied behavioural analysis 
      2. counselling
      3. family intervention
      4. intensive behavioural intervention 
      5. medication
      6. occupational therapy
      7. physiotherapy
      8. psycho-education
      9. social skills training
      10. special diets
      11. speech-language therapy.
  6. Prevention
    1. remains an elusive goal because definitive causes have yet to be established for autism spectrum disorder
    2. is possible to the extent of minimizing various troublesome symptoms, signs and effects through early diagnosis and effective and appropriate treatment.
  7. Prognosis
    1. depends on the 
      1. severity of the autism
      2. effectiveness of therapy received 
    2. relates to the symptoms of autism spectrum disorder that are likely to persist life-long even though they can be minimized
    3. has nevertheless improved in recent years so most persons
      1. are able to live with their families or in the community
      2. are no longer placed in institutions.
  8. Social considerations
    1. despite improved prognosis, autism spectrum disorder continues to create for children and their families major challenges, including 
      1. understanding and responding helpfully and appropriately to the condition in the absence of reliable diagnosis, support and intervention 
      2. communicating with their children
      3. coping with their children’s
        1. abnormal responses to normal stimuli
        2. behavioural  problems 
        3. extremely narrow range of interests
        4. impairment of socialization
        5. limitations in learning 
        6. reliance on set routines that, if not followed exactly, lead to behavioural problems
        7. uneven development of intellectual functioning
    2. include support groups, such as
      1. in Canada
      2. in the US

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with autism spectrum disorder but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

The range, complexity, variability and inconsistent and even contradictory nature of the effects of autism spectrum disorder, possibly complicated by delays in diagnosis, create difficulties in differentiating among comorbidities and complications.

Comorbid conditions, complications and associated conditions for autism spectrum disorder are chiefly as follows.

  1. Gastrointestinal problems
    1. such as 
      1. abdominal pain
      2. constipation
      3. diarrhea
      4. foul-smelling, light coloured stools
      5. gaseousness and bloating
      6. gastroesophageal reflux disease (CDHO Advisory) 
    2. leading to toileting problems, possibly linked to poor sleep habits that may be attributable to gastroesophageal reflux disease (CDHO Advisory).
  2. Immune-system-related food intolerance, possibly explaining
    1. finicky eating
    2. narrow choice of preferred foods.
  3. Mental health disorders, such as
    1. anxiety (CDHO Advisory)
    2. depression (CDHO Advisory).
  4. Intellectual Disability.
  5. Neurological disorders including 
    1. seizures (CDHO Advisory) especially after puberty 
    2. fine and gross motor deficits. 
  6. Poor sleep habits
    1. trouble falling asleep
    2. requirement for only a few hours of sleep, which
      1. creates problems for families
      2. may entail parents’ sleeping in shifts to prevent the child from getting into trouble around the home.

Oral health considerations

Adapted from

  1. Children and adolescents with autism spectrum disorder
    1. have rates of caries and periodontal disease similar to those of the children of the same age without autism spectrum disorder
    2. are more likely than children of the same age without autism spectrum disorder to
      1. show more signs of bruxism if they are younger children living at home
      2. exhibit higher incidence of gingivitis and plaque, especially among older children, when in residential schools compared to children living at home
      3. be uncooperative even to the extent of requiring general anesthesia to undergo dental treatment
    3. may not have access to or be receiving adequate oral healthcare because of uncooperativeness and behavioural challenges, which may
      1. make the providing of care difficult and at times stressful for the
        1. oral healthcare provider
        2. parent or family caregiver
      2. require special training, techniques and office adaptations on the part of oral healthcare providers
    4. may not be receiving adequate and appropriate instruction in oral self-care.
  2. Oral healthcare visits for persons with autism may require pre-visit communications with the parent, family caregiver or professional caregiver to 
    1. identify the sensory, communications and behavioural difficulties likely to be encountered during oral healthcare
    2. alert the oral healthcare provider to matters pertaining to the individual child, adolescent or adult, such as 
      1. techniques likely to be helpful in avoiding or anticipating uncooperative behaviour, such as
        1. giving the person as much advance notice as possible of the oral healthcare visit and what it is likely to entail, and finding effective ways of conveying this notice if the person’s perception of time is likely to be problematic
        2. starting a program of treatment with a familiarization visit, at which care is not delivered
        3. making appointments early in the day, and allowing extra time
        4. using social stories, comic strips and story books to convey explanations of oral healthcare procedures
        5. using pictures to identify the various stages of the care
        6. using audible timers to reinforce the understanding that the care is time-limited
        7. allowing comforters and toys as distractions
        8. considering sedation, in consultation with the family physician
      2. actions likely to be upsetting to the person during the provision of care
      3. the person’s lack of understanding or inability to understand the importance of oral healthcare and the consequences of not receiving it
      4. anxiety triggers related to sensory issues, including
        1. colour
        2. noise
        3. smell
        4. taste
        5. touch
      5. distress factors, such as 
        1. invasion of the person’s personal space
        2. departure from set routine.


Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Adapted from


  1. specific medications
    1. currently there are no medications to cure autism spectrum disorder or eliminate all of the symptoms  
    2. the U.S. Food and Drug Administration has not approved any medications specifically for the treatment of autism spectrum disorder, with the exception of
      risperidone (Risperdal®), an anti-psychotic medication, which is

      1. approved as an autism medication to treat behaviour problems in autistic children and adolescent
    3. and aripiprazole (Abilify®), an anti-psychotic medication, which is
      1. approved as an autism medication to treat irritable behaviour in autistic children and adolescents. 
  2. medications used to treat some of the symptoms associated with autism
    1. anticonvulsants
    2. antidepressants
      1. selective serotonin reuptake inhibitors and close relatives
        1. used to
          1. reduce the frequency and intensity of repetitive behaviours
          2. decrease irritability, tantrums, and aggressive behaviour
          3. improve eye contact
        2. include 
      2. tricyclics
        1. used to treat depression and obsessive-compulsive behaviours
        2. include
      3. antipsychotics
        1. used to reduce one or more of:
          1. hyperactivity
          2. withdrawal
          3. aggression
          4. stereotyped behaviours
          5. temper tantrums
          6. frequent mood changes
        2. include
    3. anxiolytics 
      1. used to relieve anxiousness and panic disorders associated with autism spectrum disorder 
      2. include
        1. benzodiazepines, such as
        2. newer anxiolytics, such as 
    4. stimulants 
      1. used for increasing focus and decreasing hyperactivity 
      2. require careful and frequent monitoring by the prescribing healthcare providers because of the risk of side effects
      3. include the following 

Side effects of medications

See the links above to the specific medications. 


The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. pointers in the history of significance to autism spectrum disorder, such as self-hurting 
    2. symptoms indicative of inadequate control of autism spectrum disorder, such as behavioural problems
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements
    5. problems with previous dental/dental hygiene care
    6. problems with infections generally and specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.


Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.


Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.


The dental hygienist 

  1. should not implement the Procedures without prior consultation with the appropriate primary or specialist care provider(s) if the patient/client’s history includes 
    1. behaviour problems and aggression sufficient to create risk
    2. indications that premedication was previously required for oral healthcare or minor surgical procedures
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears unduly distressed
    2. is experiencing symptoms suggestive of complications of autism spectrum disorder or its treatment 
    3. has not complied with pre-medication as directed by the prescribing physician 
    4. has recently changed significant medications, under medical advice or otherwise
    5. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. or the family caregiver is unable to provide the dental hygienist with sufficient information about
      1. medications
      2. medical history
    7. has symptoms or signs of 
      1. exacerbation of the medical condition
      2. comorbidity, complication or an associated condition of autism spectrum disorder, such as seizures
    8. has not recently or ever sought and received medical advice relative to oral healthcare procedures
    9. or the family caregiver is deeply concerned about any aspect of the patient/client’s medical condition.


Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.


Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of autism spectrum disorder, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.


The dental hygienists should 

  1. urge the patient/client or the family caregiver to alert any healthcare professional who proposes any intervention or test 
    1. that patient/client has a history of an autism spectrum disorder
    2. to the medications the patient/client is taking
  2. should discuss, as appropriate, with the patient/client or the family caregiver 
    1. the patient/client’s past experiences with oral healthcare including behaviour modification exercises
    2. desensitization techniques for use by the family caregiver prior to the appointment for oral healthcare, such as providing a mouth mirror and use of light to practice looking in the mouth
    3. behaviour modification procedures that work for the patient/client
    4. scheduling and duration of appointments to provide the client/patient with predictable and consistent experiences
    5. comfort level during appointment, and stress and anxiety related to the Procedures
    6. needs of the parent, family caregiver or other caregiver in supervising or helping the person with oral self-care 
    7. the importance of the family caregiver or the patient/client’s
      1. checking or self-checking of the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    8. the need for regular oral health examinations and preventive oral healthcare 
    9. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    10. the importance of an appropriate diet in the maintenance of oral health
    11. for persons at an advanced stage of debilitation
      1. regimens for oral hygiene as a component of supportive care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
    12. medication side effects such as dry mouth, and recommend treatment
    13. mouth ulcers and other conditions of the mouth relating to autism spectrum disorder, comorbidities, complications or associated conditions, medications or diet
    14. pain management.



  1. Promoting health through oral hygiene for persons who have autism spectrum disorder.
  2. Reducing the adverse effects, such as provocation of aggression, uncooperativeness and behavioural problems, on persons who have autism spectrum disorder 
    1. by generally increasing the comfort level of persons in the course of dental hygiene interventions 
    2. through communication, predictable and consistent experience, and provision of advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.


  1. Causing or aggravating behavioural problems of an uncooperative or aggressive nature.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client’s autism spectrum disorder is inadequately controlled
    2. during an active phase of a gastrointestinal or other comorbidity
    3. in the presence of complications for which prior medical advice is required
    4. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with autism spectrum disorder.
  4. Inappropriate management of pain or medication.






2018-03-23; 2023-03-29


College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists


College of Dental Hygienists of Ontario


College of Dental Hygienists of Ontario, Practice Advisors


Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow

Lisa Taylor

Giulia Galloro

Carolle Lepage


The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2018, 2023 College of Dental Hygienists of Ontario


1 Persons includes young persons and children.
2 Rett syndrome, according to recent reclassification (DSM-5), is no longer automatically considered part of the autism spectrum.
3 See footnote #2 regarding recent (DSM-5) reclassification of Rett syndrome.