The following is the testimony
of a clinician demonstrating the use of behavioral
name is Carol L. Teixeira; I am a registered dental hygienist and have
been doing clinical hygiene at the Tufts Dental Facility in Amherst for
10 years. Tufts Dental is a special care practice limited to
the treatment of persons with developmental disabilities attributed to intellectual disability, cerebral palsy, autism, and/or epilepsy.
Special care is an approach to oral health management
tailored to the individual needs of people with a variety of medical
conditions or limitations that require more than
routine delivery of oral care. Special care encompasses a
variety of preventive, diagnostic and treatment services.
Many standard treatment procedures need to be adapted to fit most of
our patients' needs and abilities. Some patients require more
specialized care, such as OR rehabilitation and many can be treated
successfully in the office setting, especially for routine recall
Today I would like to talk about some of the different
techniques that I have used at our office to desensitize and treat the
patient specifically with autism.
communication skills are extremely important when dealing with the
patient with special needs or autism; even more so than with the
non-special needs patient. Communicating effectively may take
some extra time and patience because of the disability. Here are some
Approach the patient in a caring and compassionate manner.
Use a calming, pleasant, and reassuring voice. Speak to the
child or patient appropriately by using simple direct language. Give
specific warning about what to expect next. Be honest and
respectful. Try to establish a positive rapport with the
patient and the care provider.
Use specific, positive reinforcement for all cooperative
Recognize the patient’s feelings by asking questions and then
listening to their response.
Get feedback from the parent or care provider accompanying
Encourage the patient to bring along a favorite toy, squish
ball or stuffed animal to hold.
Allow the parent or care provider to accompany the patient
into the operatory.
After the patient is seated in the chair for a procedure it
is often necessary to provide repetitive verbal
reminders of the expected behavior, such as “head back in the pillow,
hands down”. Always remember to reinforce a positive response
I like to greet the patient and their family or care provider
in the waiting room. I introduce myself to the family and
specifically to the patient. I sit down or kneel to place myself at
eye level with the child or patient in a
wheelchair. Speaking in a calm, normal manner is
more effective than “talking down” to a patient.
People often change their manner of speaking when they are with a child
or a person with a disability. Artificial speech, a high pitched tone
of voice and baby talk are all inappropriate methods of
important when working with a patient with autism. It can
sometimes take several visits before the patient is comfortable enough
with you and the surroundings to allow comprehensive
Many autistic patients do not like to recline in the chair,
and prefer to keep their feet touching the floor. Some will
only stand for the procedure, or they may be coaxed into sitting in a
regular chair close to the door.
Some patients will need to move frequently during a
procedure. This will require several breaks to allow them to stretch
their arms up or to just readjust themselves in the chair.
Occasionally it is necessary for them to get up and walk around before
they are able to sit quietly again.
Many will require gentle but firm stabilization of their head
and gentle retraction of the lip by the operator.
It may be necessary for the patient or care provider to watch
or hold their hands and provide gentle reassurance during a procedure.
“Tell, Show, Do”
Patients appreciate honesty. They
need to know what is to be done before the action is taken.
The patient should be informed of the expected mode of behavior, and
then be provided with continuous positive feedback throughout the
procedure. Giving the patient a sense of control over what is
happening is extremely important and
Tell the patient what to expect, invite them to
come and see the room that you work in. If they refuse a
little encouragement may be necessary from the parent or care provider.
Give them a few minutes to explore, look around
and familiarize themselves with the surroundings before asking them to
sit in the chair.
Tell them how your chair works and let them
touch the buttons, show them how the chair goes up and down, back and
forth. Offer to give them a ride in the chair. They
may be more comfortable sitting on their parent’s lap at
first. The movement of the chair is often very frightening to
them and they may prefer not to sit in the chair at all on the first
visit. Others may sit but often will need to keep their feet
on the floor, and sit in an upright position. Some will only
stand for the entire visit.
Tell them how the light works and let them turn
it off and on. Explain that it helps you to see inside their
dark mouths. The light may be sensitive to their eyes, offer
Show them your gloves and mask, let them touch
them and try them on. Many children enjoy wearing the gloves
and being a helper during a procedure.
Let them pick out a color of toothbrush to
place on your tray table. I usually start every procedure
with a toothbrush. This is a familiar sensation and many
children with autism are orally sensitive. Explain to the
child that you are going to brush their teeth, invite them to help you,
hand over hand. Point out the area to be brushed,
i.e.: bottom back right, place the brush in their mouth and brush the
area while counting slowly to five, then
stop. Point out the next area and tell
them that you are going to brush again, count slowly to five and
stop. Proceed to all other areas repeating this counting and
stopping technique. This will give the patient a
beginning and an end to the procedure.
They will know what to expect and will eventually trust you enough to
know that you will stop when you get to five. Often they will
sit calmly for the entire count. Eventually you can increase
the number as their behavior improves.
Show them the mouth mirror; explain that you
will use the mirror to see their teeth better. Let them look
at themselves in the mirror and hold it if they want. Tell
them that you would like to count their teeth.
I have a puppet that has teeth and I usually
start by counting the puppet’s teeth. I invite them to help
me count. Next I proceed to count their fingers and again I
ask them to help me count, finally we are ready to count their teeth
Tell them about your tooth polisher, show them
how it works, let them touch the rubber cup, and listen to the sound
that it makes, this noise may be upsetting and they may
resist. Try to show them how it tickles on their
fingers. I follow the same procedure with polishing as with
counting, first the puppet then the fingers then the teeth.
When working in the mouth I always point out the area to be worked on,
count to five and stop, increasing the count as their behavior
improves. It has been found that a patient’s cooperation
increases when they know what to expect.
When introducing floss, let them feel it first,
then have them hold up a hand, floss between their fingers first and
let them feel the sensation before trying to floss between their teeth.
Be sure to continually provide positive
feedback and praise for every procedure that is allowed.
Tooth brushing and a visual exam may be the only procedure
accomplished on the initial visit and sometimes even this is a
challenging task. Sometimes there is a limited cooperation
and getting the patient to just open their mouth may be
difficult. We do as much as we can for as long as we
can. Our goal is to see improvement each time we see the
patient at a recall visit, even if the goal is to be comfortable in the
chair. It may be necessary to do a “step-back” visit after a
Occupational Therapy Associates,
The Journal of Practical
Hygiene, January/February 2000
The Journal of Practical
Hygiene, May/June 2001