Resources for Promoting Dental Hygiene and Success at the Dentist

David Celiberti, PhD, BCBA-D, Maithri Sivaraman, MSc, BCBA, and Yash Gupta
Association for Science in Autism Treatment

Resistance associated with dental visits is an all-too-common challenge for many individuals with (and without) autism spectrum disorder (ASD).  Such resistance can lead to the use of restraint or pharmacological management, and sadly in some instances can be associated with inadequate preventative dental care or delays to access treatment which can lead to more serious health complications. More specifically, individuals with autism requiring special needs such as anesthesia dentistry, can face long waits for service (Bai, 2020). Furthermore, interventions that rely heavily on exposure training require a clinical setting able to make that investment which is often hampered by billing constraints, limited insurance reimbursement, and other logistical barriers.

This list of annotated resources has been created to serve as a helpful reference for families, clinicians, and educators alike. We have incorporated resources for dental providers as well, since there is some research suggesting that the majority of dentists feel anxious or uncomfortable treating patients with special needs (e.g., Dao et al., 2005).  We showcase online resources that highlight strategies and information to address the myriad of obstacles surrounding dental care. We hope that this information shared below will support your efforts, promote cooperation, and help improve dental outcomes. This piece was initially published a few years ago and is now expanded and updated.

 

Resources for Families (Video/Audio):

Child Preparation- Bergen Pediatric Dentistry. On this very helpful page, Dr. Purnima Hernandez shares several video models and narratives for parents, providers, and children. The videos showcase specific tools and their corresponding sounds which may help prepare your child for a cleaning visit. These videos expose the child to some of the more potentially aversive sensory experiences in a brief and non-threatening manner.

Making Going to the Dentist Easier for Kids with Autism. This helpful video blog by Dr. Mary Barbera describes several strategies you can consider to make dental visits and oral care easier. Dr. Barbera discusses the importance of careful reflection on past visits, learning from those experiences, and setting reasonable goals. She models some of these strategies in this 11-minute video.

Autism: Making Tooth Brushing Possible/Fun. This 12-minute 2013 video by Autism Live includes an interview with Dr. Jonathan Tarbox and addresses the role of reinforcement and shaping/exposure procedures.  Specifically, Dr. Tarbox outlines strategies to reduce the motivation to escape, including criteria to guide gradual progression, and careful use of probes to guide toleration efforts. He also discusses the importance of limiting access to high-ticket rewards so that they can only be achieved by completing one certain task, for example tooth brushing.

Dental Toolkit. In recognition that good oral health habits can be challenging for many individuals with autism, Autism Speaks collaborated with Colgate and Philips-Sonicare to create this 10-minute video. It provides tips for families so they can help their loved ones with autism access a suitable dental care provider as well as how to choose the right brush/toothpaste and practice skills at home, including getting ready for the first visit. Two dentists shared their experiences serving patients with autism offering numerous suggestions, such as how to adapt the examination depending on the child’s reactions.

How To Help Your Autistic Child During A Dental Appointment | Autism Tips by Maria Borde.   

This quick, 3-minute video by Maria Borde showcases many strategies to help prepare for the dentist. Some tips mentioned for children with autism at the dentist are: preparing them in advance by showing them the tools and making them comfortable with the tools, bringing a tablet with your child's favorite shows as a distraction, and using sunglasses and sound cancelling headphones for children who find bright lights or loud sounds aversive.

 

Resources for Families (Print Materials):

Autism Dental Information Guide for Families and Caregivers. In an effort to create information guides for families of individuals with autism, service providers, and dental professionals, the Southwest Autism Research & Resource Center (SARRC) published this booklet in collaboration with dental experts and academics. This well-organized and consumer friendly booklet contains background information on the importance of good oral hygiene and care. It provides a comprehensive list of suggestions for scheduling the dental appointment, including a sample form for use when calling the dentist to set up the initial appointment. The sections related to preparing for the office visit and carrying out oral care in the home are particularly detailed and helpful. Finally, there is information about the use of fluoride and metal fillings (amalgam) to help parents become more informed about these products.

Taking Your Son/Daughter with an Autism Spectrum Disorder to the Dentist. This resource was prepared by the Indiana Resource Center for Autism. The article contains many helpful tips, such as bringing the child’s toothbrush and toothpaste to the dental visit for familiarity and having the dental chair already in a reclined position for those children who may not like to be moved backward mechanically. A Tell/Show/Do strategy is described for promoting cooperation and participation during dental routines. This strategy first involves verbally describing the forthcoming step, followed by displaying the tool or instrument and allowing the child to see it, and finally, carrying out the step. Appendices include a list of books, a sample social story, and a visual schedule for visiting the dentist.

Healthy Smiles for Autism: Oral Hygiene Tips for Children with Autism Spectrum Disorders. This publication is based on a collaboration of the National Museum of Dentistry, the Kennedy Krieger Institute’s Center for Autism and Related Disorders, and the University of Maryland Dental School. It showcases best practices related to oral health care for children with ASD. This booklet highlights the importance of parental modeling and recommends that parents invest time in choosing a toothbrush, toothpaste, and flossing materials that work best for the child. Guidelines for helping children brush and floss successfully are consistent with well-established behavior analytic principles and are consumer-friendly, as are the suggestions surrounding how to access dental care (e.g., finding a dental provider, getting ready for the initial visit). This booklet includes well-designed visual sequencing cards, social stories, and a picture dictionary.

Helping Your Child Overcome Fear of the Dentist and Develop Lifelong Oral Hygiene Habits. In this resource shared by Solving Autism, readers will find a brief overview of the common challenges observed in children with autism, tips for finding the right dentist including helpful questions to ask, and proactive strategies in preparation for the visit. There is also a user-friendly set of suggestions for developing sound oral hygiene habits.

Autism and Dental Care: A Guide for Their Oral Treatment. In this resource, Drs. Greg Grillo and David Hudnall offer many helpful strategies in preparing for upcoming dental visits, as well as tips and techniques to promote the development of proper oral health habits. They discuss sedation as well as the benefits of splitting examination components over multiple visits. This resource is available in Spanish (Autismo y el Cuidado Dental) and also refers to a blog in Spanish.

Dental Health Guidance for Parents and Caregivers of Children with Autism Spectrum Disorder. This fact sheet put together by the Washington State Department of Health and University of Washington’s DECOD (Dental Education in the Care of Persons with Disabilities) Program provides a very helpful list of questions to guide initial conversations with the dentist. It includes an array of tips and strategies to prepare for the visit, as well as some action items for the day of the visit.

 

Resources for Dental Professionals:

Autism Dental Information Guide for Professionals. This guide has been created by SARRC for dental professionals. Besides information on relevant dental issues associated with ASD, and what to expect with a patient with ASD, the guide offers valuable input on specific items to include in a welcome package. An important strategy for an individual with ASD to have a successful visit to a dental clinic is the preparedness of the professional and the patient for the experience. The guide offers suggestions such as sending pictures of the dental team and the office prior to the visit and providing pamphlets (when appropriate) and parent questionnaires to learn about existing behavioral challenges and sensory preferences towards preparedness.

Autism Speaks Dental Toolkit. The dental toolkit by Autism Speaks is aimed at both parents and professionals. Specifically, the 10-minute video has advice from dental experts with experience treating patients with ASD and highlights the importance of rapport-building for a successful experience. The toolkit also offers a visual schedule that dental professionals can adapt to help their patients anticipate and tolerate the different steps and activities that will occur during their visit to the clinic. Autism Speaks also offers a detailed task analysis for toothbrushing. As is the case with every task analysis, this should be individually tailored to target the child’s needs, skills, and deficits.

University of Washington’s Fact Sheet for Professionals.  This fact sheet put together by the Washington State Department of Health, and University of Washington’s DECOD outlines the symptoms of ASD, commonly associated comorbid conditions, and strategies for dental professionals to manage patients with autism. This resource offers guidance for promoting cooperation in the dental chair and specific tips on techniques to use before and during the appointment. In addition, seizure management during treatment, and ways to handle visible signs of trauma are briefly summarized. This is important given that many individuals with autism develop seizure activity. An analogous Fact Sheet for Dental Professionals has also been developed for ADHD, Down Syndrome and cerebral palsy.

National Institute of Child Health and Human Development Resource Center (NICHD)’s Practical Oral Care for People with Autism. This is a handbook for oral care physicians created by the NICHD in collaboration with the National Association of Dental and Craniofacial Research. The booklet is one in a series on providing oral care for people with developmental disabilities including ASD, Cerebral Palsy, Downs Syndrome, and intellectual disability. The autism handbook lists the issues and oral health challenges common in individuals with ASD and provides care strategies for them. Specific ways to prepare for patients who present with “unusual and unpredictable body movements” and sensitivity to sensory stimuli are offered.

Dental Care – Continuing Education course. Dental Care offers a free continuing education course for dental professionals, with an aim to promote understanding of ASD and prepare learners to serve patients with this diagnosis. The course content is extensive and provides modules on creating a sensory friendly office, developing an office protocol for patients with ASD, utilizing a visual schedule, and behavior management strategies to increase appropriate behavior. The course is intended for all types of dental professionals as well as dental students, and is self-instructional.

Dental Exam Tolerance with Dr. Kelly McConnell — ABA Inside Track. This 1 hour and 22-minute podcast with Dr. Kelly McConnell by ABA Inside Track showcases recent behavior analytic research to help children with autism better tolerate dental appointments. It mentions strategies that could be considered when children with autism meet with their dentists, as well as things to avoid. A distinction is made between desensitization and graduated exposure as the latter may be a more accurate description of the procedures typically used.  As shared throughout many of the resources described in this article, it was discussed that adjustments and increased demands should be made gradually.

We hope you will find these resources beneficial whether you are an individual with autism, a family member to someone with autism, an education or behavioral professional, or a dental care professional. We will continue to update this annotated list and reshare with our readers as new resources become available. Together, we can help to make dental visits successful for people with autism. Please consider sharing this article with clients, friends, and colleagues.

 

References:

Bai, N. (2020, February 24). For patients with special needs, any dentist is hard to find.    https://www.ucsf.edu/news/2020/02/416726/patients-special-needs-any-dentist-hard-find

Dao L. P., Zwetchkenbaum S., & Inglehart M. R. (2005) General dentists and special needs patients: Does dental education matter? Journal of Dental Education, 69(10), 1107-15. PMID: 16204676.

 

Citation for this article:

Celiberti, D., Sivaraman, M., & Gupta, Y. (2021). Consumer Corner: An updated and annotated list of online resources for promoting dental hygiene and success with dental care. Science in Autism Treatment, 18(5)

 

Please also see other related ASAT articles:

• Interview with Dr. Purnima Hernandez, DDS
• Clinical Corner: Cooperating with dental exams
• Clinical Corner: What are some essential skills in a COVID-19 era?
• ASAT Responds to West-info.eu’s Special dental care for children with autism
• A Review of Healthcare for children on the autism spectrum: A guide to medical, nutritional, and behavioral issues

 

A Non-exhaustive list of recent research in the area:

 

Allen, K. D., & Wallace, D. P. (2013). Effectiveness of using noncontingent escape for general behavior management in a pediatric dental clinic. Journal of Applied Behavior Analysis, 46, 723-737. https://doi.org/10.1002/jaba.82   

Altabet, S. (2002). Decreasing dental resistance among individuals with severe and profound mental retardation. Journal of Developmental and Physical Disabilities, 14, 297-305. https://doi.org/10.1023/A:1016032623478  

Appukuttan, D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clinical, Cosmetic and Investigational Dentistry, 8, 35-50. https://doi.org/10.2147/CCIDE.S63626   

Blitz, M., & Britton, K. C. (2010). Management of the uncooperative child. Oral and Maxillofacial Surgery Clinics of North America, 22(4), 461-469. https://doi.org/10.1016/j.coms.2010.08.002   

Carter, L., Harper, J. M., & Luiselli, J. K. (2019). Dental desensitization for students with autism spectrum disorder through graduated exposure, reinforcement, and reinforcement fading. Journal of Developmental and Physical Disabilities, 31, 161-170. https://doi.org/10.1007/s10882-018-9635-8   

Chandrashekhar, S., & Bommangoudar, J. S. (2018). Management of Autistic Patients in Dental Office: A Clinical Update. International Journal of Clinical Pediatric Dentistry, 11(3), 219–227. https://doi.org/10.5005/jp-journals-10005-1515

Cuvo, A. J., Godard, A., Huckfeldt, R., & Demattei, R. (2010). Training children with autism spectrum disorders to be compliant with an oral assessment. Research in Autism Spectrum Disorders, 4, 681-696.

Delli, K., Reichart, P. A., Bornstein, M. M., & Livas, C. (2013). Management of children with autism spectrum disorder in the dental setting: concerns, behavioural approaches and recommendations. Medicina Oral, Patologia Oral y Cirugia Bucal, 18(6), e862–e868. https://doi.org/10.4317/medoral.19084

Du, R. Y., Yiu, C. K., & King, N. M. (2019). Oral health behaviours of preschool children with autism spectrum disorders and their barriers to dental care. Journal of Autism and Developmental Disorders, 49(2):453-459. https://doi.org/10.1007/s10803-018-3708-5.  

Fakhruddin, K. S., Yehia, H., & Batawi, E. (2017). Effectiveness of audiovisual distraction in behavior modification during dental caries assessments and sealant placement in children with autism spectrum disorder. Dental Research Journal, 14(3), 177-182.

Ferrazzano, G. F., Salerno, C., Bravaccio, C., Ingenito, A., Sangianantoni, G., Cantile, T.  (2020). Autism spectrum disorders and oral health status: Review of the literature. European Journal of Paediatric Dentistry, 21(1):9-12. https://doi.org/10.23804/ejpd.2020.21.01.02.

Friedlander, A. H., Yagiela, J. A., Paterno, V. I., & Mahler, M. E. (2006) The neuropathology, medical management and dental implications of autism. Journal of the American Dental Association, 137(11): 1517-1527. https://doi.org/10.14219/jada.archive.2006.0086  

Hernandez, P., & Ikkanda, Z. (2011). Applied behavior analysis: behavior management of children with autism spectrum disorders in dental environments. Journal of the American Dental Association,142(3):281-7. https://doi.org/10.14219/jada.archive.2011.0167

Jaber M. A. (2011). Dental caries experience, oral health status and treatment needs of dental patients with autism. Journal of Applied Oral Science: Revista FOB, 19(3), 212–217. https://doi.org/10.1590/s1678-77572011000300006  

Loo, C., Graham, R., Hughes, C. (2008) The caries experience and behavior of dental patients with autism spectrum disorder. Journal of the American Dental Association, 139, 1518-1524. https://doi.org/10.14219/jada.archive.2008.0078.

Marion I. W., Nelson T. M., Sheller B., McKinney C. M., & Scott J. M. (2016). Dental stories for children with autism. Special Care in Dentistry, 36(4):181-6. https://doi.org/10.1111/scd.12167.

McConnell, K. L., Sassi, J. L., Carr, L., Szalwinski. J., Courtemanch, A., Njie-Jallow, F., & Cheney, W. R. (2020). Functional analysis and generalized treatment of disruptive behavior during dental exams. Journal of Applied Behavior Analysis 53(4), 2233-2249. https://doi.org/10.1002/jaba.747   

Ming, X., Brimacombe, M., Chaaban, J., Zimmerman,-Bier, B., Wagner, G. C. (2008). Autism Spectrum Disorders: Concurrent Clinical Disorders. Journal of Child Neurology, 23, 6-13. https://doi.org/10.1177/0883073807307102

Nelson, T., Chim, A., Sheller, B. L., McKinney, C. M., & Scott, J. M. (2017). Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program. The Journal of the American Dental Association, 148(7), 485-492. https://doi.org/10.1016/j.adaj.2017.03.015  

Nelson, T. M., Sheller, B., Friedman, C. S., & Bernier, R. (2015). Educational and therapeutic behavioral approaches to providing dental care for patients with Autism Spectrum Disorder. Special Care in Dentistry, 35(3). 105-113. https://doi.org/10.1111/scd.12101

O’Callaghan, P. M., Allen, K. D., Powell, S., & Salama, F. (2006). The efficacy of noncontingent escape for decreasing children’s disruptive behavior during restorative dental treatment. Journal of Applied Behavior Analysis, 39(2), 161-171

Stark, L. J., Allen, K. D., Hurst, M., Nash, D. A., Rigney, B., & Stokes, T. F. (1989). Distraction: its utilization and efficacy with children undergoing dental treatment. Journal of Applied Behavior Analysis, 22(3), 297–307. https://doi.org/10.1901/jaba.1989.22-297

Virdi, M. S. (2011). Application of contingency management in pediatric dentistry practice. Journal of Innovative Dentistry, 1(1), 1-4.

 

 

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