Abstract

Neurodiversity is a variation in human cognition, yet dental care in the UK remains largely inaccessible for neurodivergent individuals due to both systemic failures within the NHS, including funding and psychological barriers such as anxiety. Specifically, research tells us autistic individuals face heightened oral health risks due to sensory sensitivities, communication barriers and comorbidities. These factors often result in increased caries, an over-reliance on general anaesthesia, and a lack of anticipatory preventive care. Similarly, research suggests that those with ADHD experience poor oral hygiene linked to impulsivity, executive dysfunction and medication-induced xerostomia. The inequalities faced by neurodivergent individuals are compounded by unsuitable services, underfunding and inadequate professional training. Only through neurodivergent-informed care can equitable dental access be achieved.

Introduction

The decision to complete a dissertation for my EPQ stemmed from my passion for research-based writing and my desire to gain insight into the neurodivergent experience within the healthcare system. I have previous experience writing for a dental student magazine and for my personal website blog; however, this dissertation is my most formal piece of writing and the most in-depth, revealing research to date.

I aim to explore neurodivergency and the potential barriers to dental care, as I am invested in understanding why certain demographic groups face dental neglect and whether this is solely due to systemic issues and/or the condition itself. Through my involvement in academic mentoring and work experience placements, I have developed a strong interest in healthcare equity, particularly for underrepresented groups such as the neurodivergent population. While researching for my literature review, it became apparent that most of the literature was highly clinical and not in-depth, first-person qualitative research. This led me to conduct primary research, focusing on interviewing neurodiverse individuals to gain a holistic understanding of their experiences. Therefore, it potentially allows for a more reliable, representative conclusion, feeding into the development of credible options for future investments in the dental and healthcare fields. This will be important in informing my university education, as I plan to study dentistry. I believe that understanding and caring for patients is a vital skill that I can begin to build upon in preparation for my university course. By exploring these topics now, I am laying the groundwork for my career that prioritises empathy and accessibility in practice. Understanding the psychological and systemic barriers faced by neurodivergent patients will help me become a more responsive and informed practitioner, which is vital for the role.

Neurodivergent individuals encounter unique psychological challenges that can impact their dental care experiences. This dissertation examines factors that affect oral health outcomes and interactions with dental professionals, and identifies systemic barriers within the NHS. My aim is to highlight strategies to foster a more inclusive, responsive dental care environment that meets the needs of neurodivergent individuals. I have conducted both primary and secondary research, as shown in the literature review. I have collected quantitative data from articles and journals to scientifically analyse, and qualitative data from interviews with neurodivergent individuals to gain clear insight and a deeper evaluation of the issues at hand. Reservations regarding my research centre on individuals' varying perceptions of the world and their dental experiences. Therefore, I can not generalise my small sample of results to the wider population. There may be no clear answer to my question, as everyone's experiences and opinions can differ and contradict; this is a topic that isn't as clear as black and white. However, I hypothesise that common struggles could be identified if I were to gain a larger sample from neurodivergent individuals. I do, however, believe I have identified a research gap, and my own findings are merely the beginning of a small part of a much larger picture.

Literature review

Introduction

Dental care is essential to overall health; however, neurodivergent individuals often face undue challenges in accessing treatment; the literature suggests these challenges are either due to systemic failure or psychological barriers shaped by factors such as sensory processing differences, emotional dysregulation and genetic predispositions to addiction, causing poor oral health. Drawing on clinical studies, accessible NHS data, and patient narratives, this review explores disparities in oral health outcomes and concludes that psychological needs and the system itself are critical factors in the provision of high-quality dental care.

Dental health inequalities are due to psychological factors and neurodiversity itself

Autistic individuals perceive and experience life differently from the neurotypical population. “Autistic people can be much more or less sensitive than non-autistic people to the five main senses (sight, sound, touch, taste and smell) and senses for balance, movement, spatial awareness and awareness of internal states (such as hunger and temperature). .” Many neurodivergent individuals experience a sensory overload in environments such as a dental clinic due to unfamiliar sounds, smells and harsh lights; autism is a spectrum and not all individuals will respond the same to a stimulus such as dental drills, which can make specialised dental care difficult. Supporting this, an educational presentation by Yale University has been posted on YouTube: "Every patient with autism is unique, and strategies that might be really effective with one patient might crash and burn with another." [18:38] indicating a general focus on the psychological factors being at the forefront of the reasons for the hindered access to dental care.

Comorbidities are multiple disorders associated with each other, which are much more common in autistic children than in the general population. Some examples of the genetic disorders are FXS, DS, Duchenne muscular dystrophy, NF-1, and TSC. Sleep disorders, which are significant problems in individuals with autism, are present in about 80% of them. GI problems are significantly more common in children with ASD, occurring in 46% to 84% of autistic children, and several categories of metabolism problems have been observed in some patients with autism, as well as other disorders. Some children with ASD have evidence of persistent neuroinflammation and altered inflammatory responses. This suggests that ASD creates a genetic predisposition to poor health. Similarly, research suggests that the use of medication for ADHD, especially stimulant use, showed significantly higher DMFT scores (poorer oral hygiene) and reduced salivary flow rates compared to control groups. Overall, quality of life was lower in ADHD children, particularly older SRM users. The use of medications for comorbidities and other medications used to treat neurodiversity also increases the chances of poorer oral health.

Access to care is also affected by distinct diagnostic and treatment challenges, particularly in understanding gender differences in presentation and manifestation of ASD in female individuals. The male-to-female ASD diagnosis ratio, often cited as 4:1, is increasingly questioned due to the subtler symptom presentation in females, contributing to significant underdiagnosis. A systematic review followed PRISMA guidelines to analyse data from 47 studies, examining gender differences in ASD diagnosis, symptom expression and intervention effectiveness. Analysis of over 1,000 individuals reveals that 75 % of males exhibit hallmark traits like repetitive behaviours and speech delays, compared to only 40 % of females. Conversely, over 60 % of females demonstrate social camouflaging behaviours, masking their symptoms and complicating their diagnosis. This suggests stark gender differences that may influence patients' access to care if they have undiagnosed or unidentified neurodiversity. To further this, patriarchal norms also influence mental health care. Women are more frequently diagnosed with depression or anxiety, while men’s symptoms are often overlooked due to societal expectations around masculinity and emotional suppression. And so emotional dental sensitivities may be disregarded and not addressed appropriately, creating yet another layer to accessing appropriate care.

Research by Frontiers and MDPI both note elevated prevalence in rates of oral disease among autistic children. Frontiers found approximately 60–70% prevalence of caries and periodontal issues, while MDPI reports 48.1% of children experienced tooth decay, with 47.1% presenting malocclusion. Malocclusion is the misalignment of teeth when the upper and lower teeth don't fit together properly. These statistics highlight how psychological barriers indirectly worsen dental outcomes due to delays or avoidance in care, driven by difficulties in emotional regulation, which leads to disease progression, further reinforcing the negative feedback loop of fear and treatment. Additionally, Prynda et al.(2025) found autistic children had significantly poorer oral hygiene and higher caries rates than neurotypical peers. Toothbrushing frequency was lower, and preventive care wasn't implemented.

Similarly stated in an academic journal by research scientists at the University of Padova: “Children with Autism Spectrum Disorders (ASDs) present a major challenge for healthcare professionals, especially dentists, as dental procedures require prolonged physical contact and are often invasive. Oral health is critical for obtaining and maintaining important oral functions, such as mastication, deglutition, proper respiration, and speech production. These functions, in turn, affect overall health, language acquisition, cognitive development, and social life.” Mastication is the mechanical breakdown of food through chewing, whereas deglutition is the process of swallowing, which involves moving food from the mouth down the oesophagus to the stomach. This research supports the argument that psychological factors, rather than systemic failure, are the main drivers of poor oral health.

Blomqvist et al (2015) conducted a cross-sectional study, which is a short snapshot-like observation with limited ability to accurately establish cause and effect, that compares oral health outcomes in “intellectually able” autistic adults to a group of neurotypical controls. It found notable physiological and behavioural differences. Although caries prevalence was similar, autistic individuals had significantly more buccal gingival recessions, which are the loss of gum tissue along the cheek-facing side of the teeth, exposing the root surface, increasing sensitivity, and increasing the risk of decay. Additionally, autistic participants had lower stimulated salivary flow rates, indicating reduced saliva production in response to chewing or taste stimuli, which increases vulnerability to dental disease. Behaviourally, only 55% of autistic participants brushed their teeth in the morning, compared with 78% of controls, and 35% reported forgetfulness as the main reason for missed dental appointments. However, snacking frequency was lower in the ASD group, which may reduce exposure to sugar and acid and lower the risk of caries.

Dental health inequalities are due to systemic failure

To understand systemic failure we must understand the system itself; on average there are 24,200 dentists performing NHS activity and an average dentist has around 3600 patients. Most dental practice dentists are self-employed. UDAs are the values assigned to a course of treatment; for example, 1 UDA. Dentists are paid per course of treatment, irrespective of how many items are provided within it. Thus, a course of treatment involving one filling (3 UDAs) attracts the same fee as one containing five fillings, a root treatment and an extraction (also 3 UDAs). This factor is behind much of the resentment against this system. The number of UDAs that can be claimed is determined by the treatment bands outlined in the patients' charges regulations. Despite this, they are claimed for those patients who pay charges and those who are exempt (including children). They are divided into four main headings. Band 1 – clinical examination, radiographs, scaling and polishing, preventive dental work, such as oral health advice – 1 UDA. Band 1 (urgent) – treatment including examination, radiographs, dressings, recementing crowns, up to two extractions, one filling – 1.2 UDAs Band 2 – simple treatment, for example fillings, including root canal therapy, extractions, surgical procedures and denture additions – 3 UDAs. Band 3 – complex treatment, which includes a laboratory element, such as bridgework, crowns, and dentures – 12 UDAs. On top of all this, the overall uplift to NHS contract values for the 2025-26 financial year will only be 3.55%, backdated to 1 April 2025. arguably not enough to keep up with the inflating costs of raw materials used in a practice. This has ultimately led to an undesirable business in the UK, of which the dental desert is now a commonly used phrase to refer to the inability to find an NHS dentist willing to take on new patients, and have even resorted to archiving patients they can no longer provide for. In Norfolk and Suffolk, researchers found no NHS practices accepting new adult patients, and only seven dentists across Suffolk were taking on new child patients. One practice in Norfolk told the BBC it had more than 1,700 people on its waiting list. Jeremy Burchell, 69, from Walberswick in Suffolk, managed to get an NHS appointment in November 2021, after 13 years of trying. But not before he had to carry out some personal dentistry in April 2021. "I was in a great deal of pain, to the point I was almost banging my head on a wall," he says. "My gum lines were infected. I went into the shed, grabbed a pair of pliers, twisted the tooth and pulled it out. "I just wanted rid of the pain," he says. "I can't believe in this day and age, in the 21st century, people are finding trouble to get a dentist." This goes directly against the four pillars of medical ethics, which are autonomy, beneficence, non-maleficence, and justice and does not provide fair and equal care for all.

Public Health England’s guidance highlights the alarming oral health inequalities faced by those with learning disabilities, noting significantly higher rates of periodontal disease, gingival inflammation, tooth loss, and untreated decay in comparison to the general population. One-third of adults with learning disabilities have unhealthy teeth and gums, and only 2% use floss or interdental cleaners.

Research by Cumella et al (2000) also suggests that between 40% and 60% of individuals with learning disabilities struggle to tolerate dental treatment, often requiring general anaesthesia even for routine procedures. These disparities have been identified as the cause of systemic barriers, including poor access to dental services, inadequate preventive care, and limited professional training. The Equality Act 2010 highlights dental services' obligation to implement reasonable adjustments, including extended appointments, simplified communication, and sensory-friendly environments. Despite this, many individuals still experience advanced decay and toothlessness, with an Irish study reporting that one third of people with learning disabilities over age 50 had no teeth and most lacked dentures as a result of systemic failures.

In an article written by the Canadian Dental Association, they state that “Individuals with ASD require unique dental care. Yet, they are vulnerable to dental issues that may affect their survival and overall thriving. Children with ASD encounter various obstacles in adhering to oral-care routines at home and in obtaining and enduring in-office dental care. Visiting the dentist can be a challenging experience for many reasons, including sensory sensitivities and communication difficulties. Furthermore, children with ASD encounter significant challenges in unfamiliar situations, such as in the dental setting. The dental environment, with its array of noises, smells and visual stimuli, can significantly intensify their fear and anxiety. Despite these obstacles, there exists a paucity of tailored clinical dental guidelines to cater to the requirements of autistic young patients. Available clinical guidelines are generally characterised by a notably low level of quality. Furthermore, a clear scarcity of dental professionals who possess both the willingness and the necessary expertise to offer services to this special pediatric population is evident, despite the presence of easily accessible online educational materials designed to enhance their clinical proficiency.” The harsh environment of a dental office can be daunting for those with additional needs, and the NHS system does not always have the funding to accommodate them. This aligns with findings from Public Health England, which reports that individuals with learning disabilities face poorer oral health and significant barriers to accessing dental services, such as long waiting times, lack of specialist provision, and insufficient reasonable adjustments, resulting in advanced decay requiring extractions, under general anaesthesia, which is costly and not always accessible through the NHS.

Dental health inequalities are due to a combination of both psychological factors and systemic failure

“Individuals with Intellectual Disability{…}have deficits in intellectual and adaptive functioning, which are observed during development (generally, before the age of 18). Intellectual functioning includes the ability to reason, problem solve, plan, think abstractly, exercise judgment, and learn. Adaptive functioning refers to the skills needed to live independently and responsibly, including communication, social skills, and self-help skills (for example, getting dressed, feeding, money management, and shopping).” This research indicates the importance of specialised interventions, such as the use of high-fluoride toothpaste and three-sided toothbrushes, which have shown promise in improving oral hygiene outcomes. It also advocates for emotionally sensitive care environments, as anxiety is often triggered by unfamiliar settings and sensory overload, which can significantly hinder appointment attainment and treatment success. This suggests that both psychological conditions and systemic interventions influence a person's access to healthcare.

Furthermore, evidence by Faulks et al. (2021) found that individuals with special needs are four times more likely to require general anaesthesia for dental procedures compared to neurotypical patients, due to severe anxiety, sensory sensitivities, and communication barriers. These contribute to reduced cooperation and, therefore, increased appointment cancellations, which leads to a reliance on pharmacological management rather than behavioural strategies. Shockingly, only 10–20% of dentists feel adequately trained to treat neurodivergent patients, indicating another barrier to care. Additionally, the prevalence of untreated dental disease is disproportionately high in this population, with tooth decay rates exceeding 40%. This suggests that dentists themselves are not trained adequately due to systemic failure, as they should be trained to manage anxiety and sensory issues.

Neurodivergent children are found to have disproportionately poorer oral health outcomes, largely due to unmet psychological needs that complicate dental care experiences. Chi and Stein Duker (2022) highlight that sensory sensitivities, communication barriers and behavioural challenges significantly impact both at-home oral hygiene and on-site clinical dental procedures. For example, autistic children often reject the conventional toothbrushing due to flavour aversions, resulting in reduced brushing frequency and therefore increased plaque accumulation. Statistically, autistic children brush their teeth significantly fewer times per week than neurotypical peers. These psychological and behavioural factors contribute to elevated rates of gingivitis, malocclusion and dental caries, with some studies reporting higher decay prevalence in neurodivergent children.

Moreover, neurodivergent individuals are more likely to face severe and multiple disadvantages (SMD) such as homelessness, substance use and repeat offending, leading to a heightened risk of poor oral health outcomes. The 2024 BMJ Public Health found a strong correlation between smoking and oral health deterioration in this population, recognising that “poor oral health is one of the most common health problems in this population and is closely linked with substance use, smoking and poor diet”. Overall, the study suggests that systemic failures as well as individual behaviours drive sustained tobacco use. Participants described fragmented services, lack of funding and inaccessible care pathways as key barriers to quitting smoking and accessing dental support, which will be emphasised in populations that struggle with the management of self-care and communication.

Moreover, smoking causes people to have more dental plaque and causes gum disease to get worse more quickly than in non-smokers. Gum disease is still the most common cause of tooth loss in adults.

To further this, there is an abundance of research linking Attention-deficit hyperactivity disorder (ADHD) -which affects 3-4% of the population -and addiction. ADHD is strongly associated with substance use disorders (SUDs), particularly nicotine, alcohol, and cannabis. The review by Magon and Müller (2018) highlights that individuals with ADHD often initiate substance use earlier and engage more heavily than neurotypical peers, with smoking rates reaching 41–42%.

Primary research

Case study analysis

My case study of a neurodivergent child clearly highlights the key challenges arising from the intersection of individual conditions and systemic barriers within NHS dental services, aligning with the secondary research and the core themes in my dissertation.

The mother’s responses point strongly toward systemic failures in the provision of accessible and responsive NHS dental care due to long waiting times and a lack of specialised care plans for her family. She also identifies neurodevelopmental and medical factors contributing to the child's poor oral health, including medical complexities and behavioural challenges. However, she began to fatigue throughout the interview, replying with ‘I don't know’ and short, restricted answers, as she did not wish to share all the information. This decreases the validity and accuracy of my research. Overall, this focused case study gave me the knowledge to help support points for both sides of the argument. The negative experience described by the mother and the resulting interventions serve as invaluable research evidence for the consequences of this combined failure.

Interview analysis

To enhance the evaluation of dental health inequalities, I conducted primary research through semi-structured interviews, in which my prepared questions prompted participants to share their experiences. I've used 3 groups of individuals: one diagnosed with Autism Spectrum Disorder, another diagnosed with Attention-Deficit/Hyperactivity Disorder and a neurotypical control group over a range of ages. This qualitative data provides a patient-centred narrative that validates and explains how psychological and systemic barriers affect them. My findings reveal three critical thematic areas: the direct impact of neurodivergence on their experience, the effectiveness of systemic accommodations, and the link between executive function, addiction, and oral health risk.

Interviews with individuals diagnosed with ASD confirm the literature regarding sensory sensitivities and anxiety. Participant 5 described her overall experience with NHS dental services as "complicated, stressful and long". The dental environment is often described as stressful, invasive and an unsafe feeling due to "bright lights, alien smells" and the sound of drills, exacerbated by a lack of privacy. This severe sensory reaction directly results in avoidance behaviours, demonstrating that these conditions linked traits lead to delayed care, as one participant reported her mother having to book an appointment without her knowledge, leading to her "leaving kicking and screaming". Furthermore, the need for predictability, a common characteristic of autism, was consistently unmet in the general dental setting. This psychological need was amplified by the systemic failure to adequately prepare the patient, with one dentist reportedly preferring "to get things over and done with" and trying to proceed with an extraction with "no preparation". These are severely amplified by systemic deficits, including a lack of staff training and empathy, rushed appointments in general practice that prevent planning and explanation, and poor communication between specialists, forcing patients to repeat their needs multiple times.

The interviews with ADHD individuals offered an insight into how executive function deficits and impulsivity translate into an increased oral health risk, validating the secondary literature on the connection between ADHD and substance use. Participant 1 noted that consequences are typically the "only thing to get me to do something" related to habits. Crucially, this individual reported significant impulsivity related to consumption, stating, "Once I open a bag of Skittles, I have to finish them”. This participant also demonstrated addictive traits linked to hyperfocus, noting a severe phone addiction and hours of "doom scroll[ing]", illustrating the challenge of moderating engagement. A common trend was identified as a link between medication, appetite changes and increased oral health risk, stating that dysregulated eating habits on medication meant they were "more likely to snack", leading to poorer oral health.

Throughout most of the interviews, a consistent theme highlighted is how systemic deficits turn condition-related challenges into persistent inequities. The patients reported often feeling patronised, reporting that their dentist spoke to them "like a baby", reinforcing the systemic need for training in special needs. When asked about seeking help for a negative habit linked to neurodivergence, all participants stated they would not trust the NHS, believing "private would offer better intervention". This suggests a systemic failure to provide accessible, specialised behavioural health support tailored to neurodivergent needs. Systemic challenges like significant wait times and difficulty finding a dentist affected both the neurodiverse groups and the neurotypical control groups. However, for the neurodivergent patient, these delays lead to a restricted diet and increased physical pain, escalating the consequences of the wait time beyond that experienced by the neurotypical group.

The primary research, while providing rich, in-depth qualitative data, has significant methodological limitations, including a small sample size (6 participants) and all participants from the local area (Doncaster). This severely limits the population validity and external validity of the findings, thus limiting generalisability to the rest of the population. This may be a local NHS crisis rather than a national one. Moreover, demand characteristics with interviewees, as they may consciously or subconsciously provide answers they perceive as desirable or helpful to the research project, as I briefed them on my EPQ topic beforehand for informed consent. A notable methodological limitation in both the existing literature and my primary research is the potential for survivorship bias. This often leads to an underestimation of the true reflection of dental diseases. This issue relates to the inverse care law, as research typically only captures those who are well enough to consent or physically present at a clinic. The inverse care law, first described by Tudor Hart, states that the availability and quality of healthcare are often poorest in the communities with the greatest need. This inequality is especially visible in dentistry today, where areas with high levels of deprivation and complex health needs frequently have fewer NHS providers and reduced continuity of care. For neurodivergent patients who may require longer appointments, sensory‑considerate environments, and flexible communication, these structural gaps intensify existing barriers. As a result, those who most need patient‑centred, trauma‑informed dental support are often the least able to access it, illustrating the inverse care law in practice and highlighting the urgency of more equitable, neurodivergent‑affirming service design. Consequently, current data may predominantly reflect neurodivergent individuals who are relatively well-supported, leaving a critical gap in our understanding of the most severe dental health inequalities.

Conclusion of research

The majority of secondary research suggests that both factors are involved in neurodivergency, and that the system influences access to healthcare as a whole; especially, oral hygiene suffers in those without health care plans to help them manage oral health. My primary research, which supplemented existing research with a neurodivergent perspective, was vital to validating my arguments.

Discussion

What is neurodiversity?

Neurodiversity is the range of differences in individual brain function and behavioural traits, regarded as part of normal variation in the human population as defined by Oxford Languages. Whereas, Councillor Ross Henley and Julie Jordan define neurodiversity as the different ways the brain can work and interpret information, as they highlight that people naturally think about things differently. They argue that we have different interests and motivations and are naturally better at some things and poorer at others. This juxtaposition of definitions underscores the evolving and multifaceted understanding of neurodiversity. While some interpretations focus on biological and statistical normality, others highlight implications for identity, inclusion and reframing societal expectations. Together, these perspectives solicit a more holistic approach to neurodiversity, which can help build a foundation for equity and accessibility, a fundamental building block necessary for the NHS system.

The systemic barriers to accessing dental services

The Local Government Association (2023) states that 15% to 20% of the UK population (69.5 million people as of November 2025) is neurodivergent, that's 10.4 to 13.9 million people. According to NHS England there are 24200 dentists, so on average, we can assume each dentist has roughly 630 neurodivergent patients out of an average of 3600 annually. Yet 90% of dentists feel inadequately trained or prepared to care for neurodivergent patients, as many practices lack the knowledge or facilities to meet their needs. Arguably, this is due to the NHS payment system. Most NHS dental practices operate with self-employed contractors using UDA (units of dental activity) where dentists are paid by the number of UDA’s completed. For example, per course of treatment -irrespective of how many items are provided within it- a course of treatment involving one filling worth 3 UDAs has the same funding as one containing five fillings, regardless of the complexity, time or expense of equipment or materials used. This means that a high-needs patient requiring extensive care may generate the same income as a low-needs patient, despite vastly different costs and time commitments. This also makes complex neurodivergent patients undesirable and costly to a dental practice, highlighting a flawed system that is directly prejudiced against patients with neurodiversity due to the underfunding of complex care. Practices lose money on time-intensive treatments, especially for special needs patients who may require longer appointments for sensory accommodations.

Moreover, NHS contract values are only uplifted by a fraction each year. Last year (2025), rose by 3.55% , which fails to keep pace with increasing inflation, staff wages and material costs reaching an all-time high. This poses yet another issue; a lack of funding has led to a ‘dental drought’ exacerbated by the underfunding in the NHS. So, many turn to private practice, which, as a result, they simply don't have the resources to provide dental care to more patients. This leads to long waiting lists and practices archiving patients they can no longer provide for. Hundreds and thousands of UK citizens are left with limited access to dental care and education, which worsens the condition of oral health and has led to multiple reports of botched DIY dental treatments at home. Alternatively, many have been forced to turn to private dental care that they can not afford, especially those already receiving disability benefits due to their inability to work or support themselves without a carer. This is clearly a case of the failing capitalist societal issues where demand for services far exceeds the country’s ability to supply. Not only this, but also creates an impenetrable and inaccessible system for the neurodiverse population; those who need extended appointment times and specialist-trained staff are unlikely to have their needs met on the NHS. This is a clear case that the UDA model, as part of the NHS system, does not offer inclusive care, which directly opposes ‘justice’ as a principle of clinical ethics. This system is structured to lead to a decline in oral health of the general population, but will disproportionately negatively impact those with additional needs. Neurodivergent patients are likely to be turned away due to their perceived complex needs and placed on indefinite waiting lists or referrals to under-resourced community dental services - as evidenced in my interviews with autistic young adults facing such dental crises. This undermines both clinical outcomes and ethical standards of care, ultimately opposing the protected characteristics identified in the Equality Act 2010 of which it is a dentist's duty to provide fair and equal dental care to all individuals.

Autism and psychological barriers to accessing dental care

Autism is described as a spectrum of unique characteristics by the National Autistic Society. Autistic individuals perceive and experience the world differently from the neurotypical population. For example, communication is a consistent barrier to accessing care throughout their lives, as are struggles with social interaction and understanding social expectations or situations. Applying this to a healthcare setting such as a hospital or a dental clinic, we can begin to understand why their experience of these clinical environments is anxiety-inducing and leads to intense stress and, at times, meltdowns due to heightened sensitivity to alien smells and bright lights. Many neurodivergent individuals experience a sensory overload in environments such as a dental clinic due to the unfamiliar drilling sounds and harsh operatic lights. Often, with autistic children, there are sensory-driven barriers due to refusal of standard home care routines. This is because of rejection of certain toothpaste flavours or textures, which reduces brushing frequency and contributes to higher plaque, caries and gingivitis rates amongst autistic children. Prynda et al.(2025) found autistic children had significantly poorer oral hygiene and higher caries rates than neurotypical peers due to lower toothbrushing frequency as well as a lack of preventive care being implemented. Shifting from reactive treatment to a proactive approach leads to an inclusive prevention where the NHS could not only reduce long-term costs but also uphold its commitment to equitable care. This approach reframes autism not as a barrier to overcome, but instead as a difference to be accommodated.

Moreover, the close physical contact required for examination commonly triggers distress, shutdowns or strong avoidance behaviours. This overall reduces cooperation, increases appointment cancellations and raises the need for interventions such as general anaesthesia. This leads to many individuals undergoing multiple tooth extractions from a young age due to severely damaged oral health, which are often required at a higher frequency for patients with special needs than for neurotypical patients. However, if preventive care plans are put in place, reliance on later, more traumatic interventions would be avoided, saving the NHS both time and money.

Some evidence suggests that other systemic factors can further influence access to care, such as research identifying the differences in gendered manifestation of autism, especially the tendency for females to mask traits more effectively than males. This raises important questions about diagnostic equity and healthcare outcomes. In a dental setting, female masking and imitation of neurotypical behaviour may result in smoother interactions and fewer referrals for specialist care; however, it may also lead to healthcare practitioners overlooking sensory sensitivities, psychological needs and specialist interventions that may benefit autistic females. This disparity reflects broader systemic issues within the global health system as a whole, where diagnostic tools and care pathways often rely on malecentric models that overtly fail to account for the often nuanced presentation of neurodivergence in females. This kind of oversight reflects deeper possible patriarchal patterns within our healthcare systems, such as the NHS, as well as worldwide, where male behaviours and experiences have historically shaped diagnostic standards and treatment models - often at the expense of recognising and meeting the unique needs of females. This is an opportunity for further research, which is evidently needed to explore how these gendered dynamics influence access, treatment quality and long-term oral health outcomes for female neurodivergent individuals.

Furthermore, comorbidities are much more common in autistic individuals; it may be useful to view autism as ever-changing, where the interaction of several different genetic and other etiologies results in different brain wiring. For example, genetic disorders are more prevalent, such as Fragile X Syndrome, Down Syndrome, Duchenne muscular dystrophy, Neurofibromatosis type I and Tuberous Sclerosis Complex. Additionally, children with autism are more likely than the general population to have several neurological disorders, and sleep disorders are identified as problematic in individuals with autism, present in about 80%, as well as gastrointestinal problems, which are significantly more common, occurring in 46% to 84% of autistic children. This is demonstrated in my case study of a young girl, which clearly illustrates the negative influence of her multifaceted disorders on oral health. Suffering from epilepsy and a dairy intolerance from a young age has impacted her oral health significantly. Low levels of calcium and multiple vitamin deficiencies led to weak bones and enamel, and frequent vomiting, where the acidic stomach acid eroded and weakened teeth. Moreover, she consistently disliked the taste of toothpaste and the feeling of brushing teeth, which may have contributed to the 14 extractions under general anaesthesia by the age of 4. Arguably, this is inherently due to the medical conditions themselves, although the family reported this as a stressful time where little support and advice were offered. This aligns with findings from Public Health England, which reports that individuals with learning disabilities face poorer oral health and significant barriers to accessing dental services, such as long waiting times, lack of specialist provision and insufficient reasonable adjustments. This results in advanced decay requiring extractions under general anaesthesia, which is costly and not always accessible through the NHS. And so, in some cases, young children are resorting to the removal of all teeth in aid of managing oral care. While oral health disparities are identified, the extent to which psychological needs directly impact dental care access, experiences and outcomes is not fully understood or adequately addressed in practice. This indicates systemic failure as the cause of dental decay in autistic patients. To further this, an education on good oral hygiene would prevent more serious treatment down the line, in turn decreasing the likelihood of dental fears occurring.

In order to create a positive environment, strategies such as pre-appointment meetings, post-treatment debriefs and sensory accommodations such as music therapy or visual distractions are used to foster patient-centred care. When this is paired with adequate funding and routine undergraduate/postgraduate training for dental professionals, the NHS could theoretically reduce reliance on sedation and general anaesthesia. This not only improves appointment attendance and treatment success but also prevents resource wastage and mitigates inequities linked purely to condition-related factors. Overall, much of the research concludes that creating a positive dental experience is essential. When patients feel understood, they are more likely to associate dental visits with safety and trust, reducing the risk of developing severe dental anxiety or phobias. Preventive education around oral hygiene is also critical, as it reduces the likelihood of needing invasive treatments, which are often the trigger for dental fears and therefore later dental problems. This implies that if a change in the system occurs, there is an eradication of multiple barriers to care, indicating that problems lie within the system.

ADHD as a predisposition to poor oral health

Attention Deficit Hyperactivity Disorder further introduces a different pathway to poorer oral health through struggles with impulsivity, executive function deficits and a higher prevalence of substance use. ADHD individuals are more likely to start substance use earlier and have higher rates of nicotine and other substance use (SUDs) compared to non ADHD individuals. This worsens oral health by smoking, with rates of 41–42% of diagnosed ADHD individuals and poor snacking habits, as reviewed by Magon and Müller (2018) . Studies have shown a clear correlation between smoking; those who smoke are more likely to produce bacterial plaque, which leads to gum disease due to the lack of oxygen as blood vessels constrict, so the infected gums cannot heal. Today, gum disease is still the most common cause of tooth loss in adults.

Executive‑function challenges such as time blindness, lack of self-awareness and poor organisation skills also make consistent daily oral hygiene harder to maintain, leading to cumulative decay and periodontal problems. These traits can, however, be reduced with integrated behavioural support, addiction services and preventive care plans alongside dental care to reduce oral harm. Neurodivergent individuals face severe and multiple disadvantages (SMD) such as homelessness, substance use and repeat offending, leading to a heightened risk of poor oral health outcomes. The 2024 BMJ Public Health found a strong correlation between smoking and oral health deterioration in these populations, recognising that “poor oral health is one of the most common health problems in this population and is closely linked with substance use, smoking and poor diet”. This suggests that systemic failures as well as individual behaviours drive sustained tobacco use; participants described fragmented services, lack of funding and inaccessible care pathways as key barriers to quitting smoking. Difficulties accessing dental support will be further emphasised in populations that struggle with communication and organisation of self-care, such as individuals with ADHD. Additionally, reduced oral maintenance due to reports of forgetfulness and ‘scatterbrain’ during times of oral maintenance, late at night, and early morning, is a factor contributing to poor oral health. This executive dysfunction impairs crucial tasks such as working memory, cognitive flexibility and inhibition control, which are vital for effective planning and task execution, such as brushing teeth. If dental systems are designed and resourced to meet sensory and communication needs, many of the barriers faced by neurodivergent individuals can be significantly reduced or even eliminated entirely.

Another factor to consider is the impact of various medications, specifically ADHD regulators such as methylphenidate. Studies have found that ADHD children receiving methylphenidate or other medications such as Amfexa, exhibited poorer oral health and reduced quality of life. This was mostly due to increased dopamine and norepinephrine levels from the medication, which, in turn, heightened sympathetic nervous system activity, suppressing parasympathetic functions such as saliva production. A decreased availability of saliva increases the risk of dental caries by reducing saliva's ability to buffer acids and clear food debris. The combination of reduced saliva production and potential neglect of oral hygiene due to executive function challenges creates a demanding environment for maintaining optimal dental health. This highlights the need for dental professionals to be aware of the oral health implications of ADHD medications and to provide targeted and tailored preventive advice to support these patients.

Eliminating barriers to dental care

Dental health inequalities experienced by neurodivergent populations are a multifaceted problem that stems from the interplay between individual neurodevelopmental traits and systemic failures within the NHS. The cascade of systemic shortcomings, such as inadequate training among dental professionals, uncoordinated service arrangements and a lack of funded adjustments, creates inaccessible care that amplifies the inequalities experienced. Collectively, systemic failures transform what could be manageable individual differences into persistent and often pervasive health inequities detrimental to the mental and physical health of the neurodiverse population.

The empirical evidence, further supported by my anecdotal primary research, consistently reveals concerning patterns such as a significant proportion of dental practitioners lacking the specialised training necessary to appropriately treat neurodivergent patients due to compounded underfunding and under-education.

An example of better practice given by several interviewees was a basic slow talk through procedures to reduce anxiety and increase the feeling of control and autonomy over their treatment. Alarmingly, research indicates that only a small minority, approximately 10–20%, of dentists feel adequately trained to provide care for neurodivergent individuals. This stark statistic strongly suggests that a substantial number of neurodivergent patients are not receiving appropriate care, primarily due to a fundamental lack of understanding within the dental profession. This critical deficit underscores an urgent need for comprehensive, built-in anticipatory care planning that proactively identifies potential barriers and implements strategies to mitigate them. These new strategy models must be designed with rigour to appropriately address both the psychological and the structural barriers.

In the final analysis, we can understand that the causes of these inequalities are not exclusive to any single factor. Some inequalities may be primarily rooted in the inherent challenges associated with a specific neurodevelopmental condition, or perhaps may stem predominantly from deficits within the healthcare system itself. However, my research has revealed that the vast majority of these inequalities are a complex consequence of the combined, often synergistic, effects of psychological factors and conditions, as well as systemic shortcomings, which manifest uniquely on a case-by-case basis. The human condition cannot be simplified or generalised. And so, these issues within the system require a holistic approach that tackles both dimensions simultaneously to eliminate the barriers to care.

Conclusion

In this project, I have explored two main areas of discussion: the psychological barriers and the systemic barriers that make the healthcare system difficult for neurodivergent patients to access. Together, these factors explain why dental health inequalities remain so significant for autistic and ADHD individuals.

Neurodevelopmental traits themselves create real risks for oral health. For ASD patients, sensitivities to lights, sounds, smells and touch in the dental environment often lead to distress and avoidance, as confirmed by my interviews with ASD patients. Moreover, the need for general anaesthesia is required more often than for neurotypical patients; this is fortified by both my primary and secondary research. ADHD individuals present with difficulties of executive function, impulsivity and higher rates of substance use disorders that contribute to poor oral hygiene. Primary research confirmed that ADHD traits can make it harder to maintain consistent habits, with compulsive consumption and medication side effects leading to irregular eating patterns. Overall, these psychological and behavioural factors hinder daily oral care, leading to higher rates of tooth decay and gum disease.

While these individual traits create inherent vulnerabilities, systemic failures within NHS dental services amplify them into long-term inequalities. Major issues include the lack of training, inclusive practices, adequate funding, and reasonable adjustments, such as sensory-friendly clinics. My primary research highlighted that neurodivergent patients often experience rushed, stressful and patronising appointments, with NHS services unable to provide tailored support. These named systemic deficits lead to further structural inequalities throughout our UK population.

I conclude that both factors influence access to dental care, and to help address this, future research and development should focus on three main areas. Firstly, introducing mandatory standardised training for all healthcare professionals to ensure they are equipped to treat all patients from all demographics. Secondly, conducting regular, reliable qualitative research to test the effectiveness of sensory and communication adjustments in clinics. And thirdly, developing clear, robust treatment guidelines and care pathways for neurodiverse patients. 15–20% of the UK population is neurodivergent, so improving dental care will have a major impact on public health. Evidence suggests that better training and accessibility would reduce reliance on costly and invasive procedures, making care more efficient and less distressing. Finally, and I would argue most importantly, it would promote healthcare equity. Ultimately, addressing these barriers would help create a more responsive, inclusive and informed healthcare system that meets the needs of all patients as part of the NHS’s core values to provide comprehensive care available to all.

Evaluation

At the beginning of the project, I pursued a greater understanding of neurodiversity, both at a systemic and personal level, of what it means to experience inequalities as a neurodivergent individual. This ultimately led me to my primary research, where I interviewed a variety of individuals, including a control group of neurotypicals and ASD and ADHD groups. With the limited sample I captured, I have identified prevalent inequalities and can report my findings and inform my arguments at a high level. However, I recognise the limitations in my primary research: my sample size was too small and not generalisable, and I was influenced by demand characteristics and social desirability bias during interviews with my participants. And so, my conclusion relies heavily on qualitative narratives rather than large-scale quantitative datasets.

Moreover, I encountered several time management issues due to the demanding schoolwork and the revision for my year 13 A-level mock exams. I resolved this by allocating one hour a day to predetermined tasks during the week, with longer hours available on weekends. Next time, I would begin data collection earlier to mitigate the issues surrounding interviews and sourcing volunteers to participate in primary research. I would also seek to include a broader range of interview subjects earlier in the process, as I found that my original question regarding psychological needs was too one-sided and could impact the participants’ interviews, creating bias. This required me to pivot, changing my question to include systemic barriers for a balanced argument, capturing a full data set.

I am aware that further research could negatively impact wider society, as it may stigmatise neurodivergent patients as problematic in requiring more time and money. This potentially absolves the government/NHS of responsibility, leading to further inequalities. On the other hand, highlighting the reasonable adjustments, such as longer appointment times or desensitisation techniques. This may significantly reduce the need for general anaesthesia, which provides a financial incentive for the government to change policy. This promotes a more inclusive healthcare system. Through my research, I have gained an understanding of the psychological and systemic barriers faced by patients. Learning skills to mitigate this is a vital skill for any practitioner, and arguably, additional training should be provided to ensure all healthcare providers are qualified.

Through conducting this in-depth project, I have further developed my passion and interest in healthcare equity, providing a stepping stone towards higher education. I believe that this will contribute to developing my empathetic skills as a dental practitioner, ready to provide high-quality care to whoever requires it.

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Appendix

ADHD interviews

Participant 1: ADHD diagnosed male 17 years in education

1. Could you walk me through a typical morning or evening routine, focusing on tasks that require consistent effort or memory?

I make breakfast, lay in bed, brush my teeth and I don't need to remember to do these because it's just part of the routine.

2. When you're trying to establish a new habit, like flossing regularly, what usually makes it easy or difficult to stick with over time?

Consequences are usually the only thing to get me to do something.

3. How do you generally feel about attending regular medical or dental appointments? What are the biggest logistical or emotional barriers, if any?

I get nervous going to the dentist or a doctor's appointment as I'm worried I can't communicate effectively.

4. Have you ever noticed yourself getting intensely focused or absorbed in a particular activity or substance for long periods?

Yes, various tasks and substances. I like to research things intensely and doom scroll for hours. I definitely have an addiction to my phone.

5. When you feel compelled to do something (e.g., eat a specific food, engage in an activity, use a substance), how easy or difficult is it for you to stop once you've started?

Once I open a bag of Skittles I have to finish them.

6. In your experience, do you find there's a connection between your level of stress or boredom and certain habits or consumption patterns you engage in?

Yes, when I'm stressed about school my food consumption can go up or down. And when I'm bored I will use my phone for hours at a time.

7. Are you taking any form of medication for ADHD and have you learned about any potential connections between the effects and long-term oral health?

I find I have less of an appetite, and dysregulated eating habits on medication. This means I'm more likely to snack.

8. What role, if any, do you believe factors like high sugar consumption, stress-related habits (like clenching), or medication side effects have played in your own oral health history?

I'm not sure, I suppose if I'm eating more sweets I'll have a worse oral health.

9. Imagine you needed specialised support for a dental issue that you believe is linked to your neurodivergence. What steps would you anticipate needing to take, and do you feel confident that the NHS would have appropriate, accessible services ready for you?

I don't know.

10. If you felt you could not stop a negative habit, what would you do, would you trust the NHS to have resources to help you?

No, private would offer better intervention

11. When interacting with healthcare providers (e.g., dentists, GPs), do you feel that your specific needs as a person with ADHD are acknowledged and accommodated? Could you give an example of what works well, and what doesn't?

No accommodation of needs is required and I don't feel like a strategy would be provided anyways.

Participant 2: ADHD diagnosed male 56 years in self -employment

1. Could you walk me through a typical morning or evening routine, focusing on tasks that require consistent effort or memory?

Get up in the morning and feed the cat and empty the dishwasher erm and then go and make a cup of tea for my wife while she has a bath in the morning . I turn the computer on while it turns on, I do my morning prayers about my day ahead. I then write on my whiteboard my day schedule mapped out where I jot ideas to track my thoughts. Mindmapping helps me. I then get dressed and washed, get the children up for school. Clean the cat litter and take recyclables out. Then get ready for work. Log in and get working.

2. When you're trying to establish a new habit, like flossing regularly, what usually makes it easy or difficult to stick with over time?

Leaving it in sight or leaving a note so I can't miss it. Make it a heading on my whiteboard as a secondary reminder. Id put it next to my asma medication, so like I would inbuild it with my already occurring events in my routine.

3. How do you generally feel about attending regular medical or dental appointments? What are the biggest logistical or emotional barriers, if any?

I don't like going to the dentist, one because I don't like the thought of pain and spending so much money and having to get there and taking time out of my day.

4. Have you ever noticed yourself getting intensely focused or absorbed in a particular activity or substance for long periods?

Yeash, programming. Computer tasks and intense focus on football.

5. When you feel compelled to do something (e.g., eat a specific food, engage in an activity, use a substance), how easy or difficult is it for you to stop once you've started?

I can stop depending on what, I replace it or do something else.

6. In your experience, do you find there's a connection between your level of stress or boredom and certain habits or consumption patterns you engage in?

Yeah, there is when I'm really stressed and focused I drink more coffee. It's my answer to give me more energy. It's like a ritual it helps me confront tasks.

7. Are you taking any form of medication for ADHD and have you learned about any potential connections between the effects and long-term oral health?

No, I'm looking into beginning medication as I was only just diagnosed in the past couple of months.

8. What role, if any, do you believe factors like high sugar consumption, stress-related habits (like clenching), or medication side effects have played in your own oral health history?

Yes, I grind my teeth and I love to eat chocolate and suck on sweets. When I wake up with a sore jaw, I often think about my teeth grinding problems especially during a stressful week of work etcetera.

9. Imagine you needed specialised support for a dental issue that you believe is linked to your neurodivergence. What steps would you anticipate needing to take, and do you feel confident that the NHS would have appropriate, accessible services ready for you?

No, I don't think they would have any services. I don't feel confident at all. Probably put me on a waiting list for 3 years. It will be a random person with no personal touch because there is no consistency within the system.

10. If you felt you could not stop a negative habit, what would you do, would you trust the NHS to have resources to help you?

I would trust they would have some sort of proposal but my confidence level is not always high in suggested remedies.

11. When interacting with healthcare providers (e.g., dentists, GPs), do you feel that your specific needs as a person with ADHD are acknowledged and accommodated? Could you give an example of what works well, and what doesn't?

Yeah I find that they only work well when they are acknowledged only when I bring it up. Once it's out in the open and they understand and are reminded then there is a clear pathway forward. If not brought up it's not catered for it feels swept under the carpet and like an afterthought and I feel I need to be upfront about it or things don't get done.

Participant 3- ADHD diagnosed female 17 years in apprenticeship

1. Could you walk me through a typical morning or evening routine, focusing on tasks that require consistent effort or memory?

Okay i have an alarm set for 6 am 6.15 6.20 6.30 6.45 6.50 6.55 and 7 then i will lie in bed and go on my phone until 7.20 i then get up for a wee then ill brush my teeth then ill go into my room and make my bed then ill find my uniform screwed up on my floor and put it on my bed then look in the mirror and stare for 5 mins brush my hair and put in bun or poney tail then ill do my face my serum and moisturiser then i put my uniform on then ill find my glasses and lanyard then ill go down stairs and make a cup of coffee and breakfast then i sit in the in the armchair with a blanket watching tiktok until 8.15 put shoes and coat on and leave the door at 8.16. This requires lots of effort and memory. I always lose my things even if they are in a safe space. Like even if I have my lanyard in a specific place every morning I'll still not be able to find it for some reason it'll just disappear or I'll forget that I left it somewhere else.

2. When you're trying to establish a new habit, like flossing regularly, what usually makes it easy or difficult to stick with over time?

Erm interesting makes it easier if im motivated like if im getting enjoyment its so much easier as soon as its not enjoyable i dint want to do it if someone makes me do it i have no interest. Something I won't want to do it or especially if I know something's important or procrastinate as long as I can

3. How do you generally feel about attending regular medical or dental appointments? What are the biggest logistical or emotional barriers, if any?

I hate medical appointments i have diabetes and i firstly hate talking to doctors as it's a lot of listening because im so emotional and i cant take in the information and i dont want to be there so you know i dont really want to go. i get anxious knowing have to take it out of wok so i try and take a day of to manage my time It's a lot of mental processing and preparing for these simple tasks and appointments although it's a big thing for me to be able to plan and take time up my life to go to these different appointments especially by myself. I hate going alone I have to have everything perfectly right and this is stressful for appointments i have to know everything thats happening i work well on routine but that is lacking when i go to appointments.

4. Have you ever noticed yourself getting intensely focused or absorbed in a particular activity or substance for long periods?

Yes, photography at GCSE is the only work I could do all day at school and at home and my job is highly focused where I am hyperficated on something and my phone I could be on my phone all day. And with sweeties I used to have to eat all the bad flavour then the good flavours so i have to eat all the bag. I'm an addictive personality. I could get addicted to things easily.

5. When you feel compelled to do something (e.g., eat a specific food, engage in an activity, use a substance), how easy or difficult is it for you to stop once you've started?

If I start eating cake even if I don't want the cake i have to finish it. I sometimes get bored of food though, like at dinner when the dinner is boring i dont want anymore so i easily got room for dessert.

6. In your experience, do you find there's a connection between your level of stress or boredom and certain habits or consumption patterns you engage in?

When i get stressed im not a bad thing but i need a bad food like a treat to make me fell better and i wash my hands more when im stressed mand people tell me to slow down because i going 1000 miles an house ill put on comfy clothes to try and relax and music to calm me down. I also fiddle a lot when I'm stressed

7. Are you taking any form of medication for ADHD and have you learned about any potential connections between the effects and long-term oral health?

No but considering getting some meds

8. What role, if any, do you believe factors like high sugar consumption, stress-related habits (like clenching), or medication side effects have played in your own oral health history?

I grind my teeth very badly and it hurts my head and affects my everyday life. I find it hard to remember to brush my teeth at night and to put my retainers in. It's a hard effort to have to do these and so may lead to negative oral health. I already have some gaps forming I can tell.

9. Imagine you needed specialised support for a dental issue that you believe is linked to your neurodivergence. What steps would you anticipate needing to take, and do you feel confident that the NHS would have appropriate, accessible services ready for you?

No i dont know. Probably not because there are so many guidelines to get help. And I don't think the system is funded properly.

10. If you felt you could not stop a negative habit, what would you do, would you trust the NHS to have resources to help you?

No because it such an unreliable system so many people fall through the net of the nhs its an sieve that on the biggest can not fall through so many things they dont pick up its a bokeh system. And it takes forever even though there's so many patients and lack of funding things happen so long.

11. When interacting with healthcare providers (e.g., dentists, GPs), do you feel that your specific needs as a person with ADHD are acknowledged and accommodated? Could you give an example of what works well, and what doesn't?

Certain things like if they see i've got ADHD like my diabetic nurse and asked what i want to do to accommodate my needs.I've told her not to talk at me or else I can't take in the information and to use visual aids and to write down notes and also send me a follow-up message on WhatsApp so I can keep track of all the things that have been said and all the things I need to remember.

ASD interview

Participant 4: ASD boy full time education 13yrs

1. “Can you tell me what it feels like when you go to the dentist?”

It's annoying because i dont like people looking in my mouth.

2. “What do you like or not like about the dentist’s office?”

I don't like that the room is small or the noise from the machines and the dentist person wearing a mask is scary.

3. “Is there anything that makes you feel scared or worried at the dentist?”

The dentist being too close makes me uncomfortable.

4. “Do the lights, sounds, or smells at the dentist bother you?”

I hate the bright lights and I hate the feeling of the drills and tools in my mouth. I don't like the mould they put in my mouth and all the bits.

5. “Do you like it when someone explains what’s going to happen before they do it?”

Yes, I feel safer when I know what's happening.

6. “What helps you feel calm or safe when someone looks at your teeth?”

My mum by my side and the dentist being nice saying reassuring things.

7. “Does the dentist talk to you in a way that’s easy to understand?”

Sometimes, it depends on how fast they talk and if they're wearing a mask

8. “Do you get to ask questions or say how you feel at the dentist?”

My mum does that for me

9. “Is it easy or hard to get to the dentist?”

Easy because I live near it.

10. “Do you have someone who helps you get ready for your appointment?”

My mum tells me to brush my teeth

11. “Have you ever had to wait a long time to see the dentist?”

Not really, sometimes we wait for like 15 minutes.

Participant 5:Female 17 autism full time education

1. “Can you tell me what it feels like when you go to the dentist?”

I feel stressed and awkward and I don't know what to expect

2. “What do you like or not like about the dentist’s office?”

I like that it's quiet in the dentist I don't like the bright lights particularly when I'm laid in the dentist chair

3. “Is there anything that makes you feel scared or worried at the dentist?”

I don't like someone standing over the top of me and someone else like a nurse in the background moving around I don't feel like I know what's happening

4. “Do the lights, sounds, or smells at the dentist bother you?”

there is a funny smell and the lights are too bright

5. “Do you like it when someone explains what’s going to happen before they do it?”

I prefer one someone tells me what is going to happen before they do it it helps me prepare for what is about happen

6. “What helps you feel calm or safe when someone looks at your teeth?”

Having my trust person my mum with me

7. “Does the dentist talk to you in a way that’s easy to understand?”

not really

8. “Do you get to ask questions or say how you feel at the dentist?”

yes

9. “Is it easy or hard to get to the dentist?”

no accessible parking so we need to plan ahead

10. “Do you have someone who helps you get ready for your appointment?”

my mum she helped and encourages me to get here on time and keeps me calm

11. “Have you ever had to wait a long time to see the dentist?”

no

Participant 6: ASD diagnosed female 18 years in education

How would you describe your overall experience with NHS dental services in 3 words?

Complicated stressful long

Do you like your dentist?

No, I've had negative experiences with her.

Have you had any dental procedures, can you tell me about them?

Yes ive had a tooth removed and put back in, a root canal, 4 filings, tooth filling and about to have a crown next week.

Have you ever felt that your autism affected the way dental staff interacted with you? If so, how?

Yes, ive been patronised alot my dentist speaks to me like a baby and in some ways it's good because I was offered accommodations others aren't given. Erm.

What aspects of visiting the dentist do you find most challenging?

Sensory wise it's stressful, it feels invasive bright lights alien smells are stressful in the hospitals we don't get our own room so there's no privacy i can hear drills and doesnt feel safe.

Have you ever avoided going to the dentist because of how the environment made you feel?

Yes, my mum had to book an appointment without me knowing and I left kicking and screaming. I hate unpredictability because I can't plan or prepare.

Do you feel that NHS dental staff understand your communication or sensory needs?

I think it's hard because there's not obviously a lot they can do, in the dental hospital they split up my appointments so they can explain the procedure then let me process it before doing it. This was very helpful.

Have you been offered any adjustments or accommodations during dental appointments? If yes, were they helpful?

Splitting up my appointments helped me manage my anxiety and many staff explained the procedure to help me understand. However in the normal dentist, it is different so it's more rushed so they can't plan and explain it all. It's too quick and doesn't translate to them. I need more time to process.

How easy or difficult is it for you to book and attend NHS dental appointments?

Very difficult, wait times are significant, I'm waiting for a crown. I've waited 3 months in pain and restricted what foods I can eat. It's difficult to ignore pain and is difficult to adjust my lifestyle to what and how I eat.

Do you feel that your dental health needs are taken seriously by NHS dental professionals?

My dentist would prefer to get things over and done with and she wanted to do it in the practice. I needed an extraction but I was distraught and crying. She tried to convince me to have it done there and then, no preparation. At general practice they don't talk me through options catered for me which helps inform my health decisions. I think they need to put more time aside for me.

Have you ever had to explain your diagnosis or needs multiple times to different dental staff?

Yes, my normal dentist needs reminding and the surgical team and after the extraction surgery failed I had to explain to children and adult staff all about the same issue which doesn't get passed on and lack of communication between specialists as I am referred from place to place.

What would make NHS dental services more accessible or comfortable for you?

Having someone who knows how to explain procedures and notice when a patient is overwhelmed or triggered and del witnthat better. Longer appt for mentally anxious patients. I feel traumatised and I feel all nhs dentists should be trained in special needs to cater for the population.

Control group - neurotypical

Participant 7: 17 in education neurotypical female

How would you describe your overall experience with NHS dental services in 3 words?

Slow effective cheap

Do you like your dentist?

Yeah i do

Have you had any dental procedures, can you tell me about them?

I've only had braces. Which was very effective, quick and easy.

How frequently do you attend dental check-ups, and what influences your decision to go?

I go twice a year. Dental appointments are a priority.

Have you ever felt anxious or uncomfortable during a dental appointment? If so, what contributed to that feeling?

no.

Do you feel your dentist takes time to understand your personal needs or preferences during treatment?

Yes, if I ask .

7. When you're trying to establish a new habit, like flossing regularly, what usually makes it easy or difficult to stick with over time?

Laziness make it part of my moring and evening routine

8. Have you ever noticed yourself getting intensely focused or absorbed in a particular activity or substance for long periods? How does that feeling compare to your typical level of focus?

Erm. Maybe on my phone I can get caught up in social media.

9.Have you ever struggled to book or attend a dental appointment due to logistical or communication barriers?

Yes, like when im in school i cant book an appt but when i get home the dentist is closed so i cant book

10.Have you ever needed adjustments (e.g., sensory accommodations, extra time, simplified communication) during dental care?

Erm. Yes, my parents aren't as fluent in English so I have to simplify complex ideas so we can understand clearly.

Participant 8: 17 neurotypical in education female

How would you describe your overall experience with NHS dental services in 3 words?

Do you like your dentist?

I haven't had a dentist since I was 13

Have you had any dental procedures, can you tell me about them?

I've had one filling on my back tooth a while ago.

How frequently do you attend dental check-ups, and what influences your decision to go?

Haven't been in ages. I couldn't get a dentist to take me in after I moved house.

Have you ever felt anxious or uncomfortable during a dental appointment? If so, what contributed to that feeling?

Nope, I always feel safe and cared for.

Do you feel your dentist takes time to understand your personal needs or preferences during treatment?

Yes, I assume asking questions beforehand is what must be a standard.

7. When you're trying to establish a new habit, like flossing regularly, what usually makes it easy or difficult to stick with over time?

By embedding it within my routine like in the morning makes it easier to keep over time.

8. Have you ever noticed yourself getting intensely focused or absorbed in a particular activity or substance for long periods? How does that feeling compare to your typical level of focus?

Yes, I feel neutral and I let it happen passively.

9.Have you ever struggled to book or attend a dental appointment due to logistical or communication barriers?

Yes, I haven't been able to register for a long time at a dentist. I'm lucky to not have had any dental problems in the meantime.

10.Have you ever needed adjustments (e.g., sensory accommodations, extra time, simplified communication) during dental care?

Nope

Case study interviews

Interview of subjects: family members

Mother: interview 1

1. How would you describe your overall experience with NHS services in 3 words?

difficult tiring frustrating

2. Do you like your dentist?

No I'm trying to change but nowhere is taking on

3. Has your child had any dental procedures, can you tell me about them?

teeth taken out

4. Have you ever felt that your autism/ your child's autism affected the way dental staff interacted with you/them? If so, how?

Not sure

5. What aspects of visiting the dentist do you find most challenging?

Don't like going

6. What diagnoses (health problems) has your child got, at what age?(answer can be approximate) e.g. insomnia, epilepsy etcetera

Epilepsy, Autism, Allergies

7. Do you believe these have affected your child's oral health, in what ways?

yes, doesn't want to brush her teeth, allergies and epileptic medication might also

8. Do you feel that NHS dental staff understand your communication or sensory needs?

no

9. Have you been offered any adjustments or accommodations during dental appointments? If yes, were they helpful?

not really

10. Do you feel that your dental health needs are taken seriously by NHS dental professionals?

wait times are bad

11. Have you ever had to explain your diagnosis or needs multiple times to different dental staff?

I dont know

12. What would make NHS dental services more accessible or comfortable for you?

I dont know

Sister: ASD diagnosed 18 years in education interview 2

• What kinds of challenges does your sister face day-to-day because of her conditions?

Sensory issues, emotional regulation difficulties, sleep issues/insomnia, communication difficulties.

• Are there particular sensory issues or routines that are especially important to her?

Specific sleep routine must be followed to get to sleep, sensory issues around clothes, environment, and food - restrictive/particular food habits.

• Has your sister ever had difficulties with brushing her teeth or other oral hygiene routines?

Especially in earlier childhood she struggled with brushing her teeth and sensory issues, now she struggles to know when to brush her teeth/for how long alongside only using non-foaming and often flavoured toothpaste for sensory needs.

• How do your sister’s mental health needs affect her ability to attend or cope with dental appointments?

Doesn’t necessarily struggle with appointments but may build up emotions as she masks them at appointments and then become more sensitive when at home. When she was younger she would not deal with appointments and wouldn’t let dentists near her due to stress/sensory overload.

• Are there physical health issues that make dental care more complex or stressful for her?

Not necessarily,

• Do you think her overall health influences how professionals treat her or understand her needs?

I dont know

• What role do you or your family play in helping her access dental care?

Go to appointments with her, prepare her beforehand for what they might say/do, comfort during appointment, distress after appointment.

Help brush her teeth and remind to brush teeth daily

• Have you ever had to advocate for her needs in a healthcare setting?

Yes all the time, she can't express her health needs.

• What do you wish dental professionals understood better about children like your sister?

They can't quantify their experiences, and don't explain them in ways that other kids might.

Individual: ASD diagnosed female 11 years in education interview 3

1. How would you describe your overall experience with NHS dental services in 3 words?

clean refreshing whitening

2. Do you like your dentist?

yes

3. Have you had any dental procedures, can you tell me about them?

yes - I had my teeth pulled out when I was little, they read me a story to get me to sleep and I had a teddy. I enjoyed playing with the toys

4.“Can you tell me what it feels like when you go to the dentist?”

tickles. I like the dentist

5.“What do you like or not like about the dentist’s office?”

I dont like when the appointment gets delayed. I like the paste they put on my teeth.

6.“Is there anything that makes you feel scared or worried at the dentist?”

no

7.“Do the lights, sounds, or smells at the dentist bother you?”

no

8.“Do you like it when someone explains what’s going to happen before they do it?”

I dont know, they've never actually done that really.

9.“What helps you feel calm or safe when someone looks at your teeth?”

eating oreos

10.“Do you have someone who helps you get ready for your appointment?”

my sister and mum