The following is the testimony of a clinician demonstrating the use of behavioral modalities. 

Introduction 
My 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 visits.  

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.

Improving Communication Skills 
Good 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 guidelines: 

• 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 behaviors.

• Recognize the patient’s feelings by asking questions and then listening to their response.

• Get feedback from the parent or care provider accompanying the patient.

• 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 with praise.

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 communication. 

Be Flexible
Flexibility is 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 treatment.           

• 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.

Use “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 reassuring. 

• 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 sunglasses.

• 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 negative experience.  

References

Occupational Therapy Associates, Watertown, P.C. 

The Journal of Practical Hygiene, January/February 2000 

The Journal of Practical Hygiene, May/June 2001 

RDH, February 1996