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Authors: John Morgan, Bonnie F. Zimble

Preventive Care in Special Care Dentistry:

Tips for Successful Home Care

Special Care in Dentistry
John Morgan, DDS
Tufts University School of Dental Medicine, 2008


Study Questions:
 

  1. Describe the rationale and procedures of:
    1. Oral desensitization
    2. Task analysis
  2. Explain the process of backward chaining.
  3. Describe other steps that can be taken to promote improved daily oral hygiene:
    1. Brushing in alternate settings
    2. Motivational aids
    3. Visual aids
    4. Adaptive aids
    5. Good nutrition

What are some tips for promoting good oral care at home? 

The methods and products discussed in the Behavior Management module can be beneficial as indicated for the individual. Recall that they included aids, such as battery-operated or electric toothbrushes, flossing aids and egg timers, and behavior management procedures, such as working oral home care in to a daily plan (for example, brushing teeth in the shower) and using systematic desensitization. Desensitizing appointments, as described previously, can help immeasurably for some patients. 

The completion of an effective daily oral hygiene regimen represents a major concern for individuals with special needs and their caregivers. Specific disabling conditions can pose unique difficulties when performing oral hygiene procedures. The purpose of this section is to identify strategies that can be utilized to help people with special needs achieve optimal oral health. 

When providing preventive oral hygiene procedures such as toothbrushing, there may be many obstacles. Individuals with certain disabling conditions such as cerebral palsy, pervasive developmental delays and sensory impairments may be acutely tactile defensive. In these situations, it may be impossible for the caregiver to brush the individual’s teeth because of total resistance to a toothbrush being inserted into the mouth. Quite often, the caregiver will discontinue toothbrushing due to lack of cooperation. A preferable solution to this dilemma would be to develop and implement an oral desensitization program

Oral Desensitization 

A successful oral desensitization program should be carried out in successive steps. Materials that could be used include a cotton ball, gauze, toothette, Q-tip or washcloth. Here’s an example: 

Step 1: Teach the patient to tolerate facial contact—gently rub cotton ball, gauze, or washcloth on the face a few times daily.  

Step 2: Teach toleration of oral contact—once the individual is comfortable with facial contact, gradually approach lips, teeth, tongue and gingiva with the material used above.

Step 3: Introduction of a toothbrush—at first, only a few teeth and surfaces may be accessed. Gradually, and with much patience, effective toothbrushing can be achieved. 

These steps are only guidelines, and you can see how each program would need to be individualized. The idea is to move slowly in incremental steps that can be mastered, and thus serve as positive reinforcement to the caregiver. It is important to make the situation, and individual, as relaxed as possible before beginning. Still, an individual may become resistive and pull away or turn their head to avoid contact. It is important that the caregiver be prepared for this response by cradling the head in a manner that would prevent the toothbrush, q-tip etc. from causing trauma to the oral cavity. The rate of response varies for each individual, so the process may take an extensive period of time - but the results can be dramatic and well worth the effort.  

Click here to read a published case study of a desensitization program 

Reference: Conyers, C., Miltenberger, R.G., Peterson, B., Gubin, A., Jurgens, M., Selders, A., Dickinson, J. & Barenz, R. (2004). An evaluation of in vivo desensitization and video modeling to increase compliance with dental procedures in persons with intellectual disability. Journal of Applied Behavior Analysis, 37, 233-238.

Task Analysis 

For individuals capable of independent toothbrushing who don’t require a desensitization program, another technique that can be employed to improve oral hygiene is a task analysis. A task analysis divides a sequential multi-step task into clearly defined steps. Toothbrushing, for example, can be broken down into a series of steps. Initially, the individual picks up the toothbrush, wets it, and applies toothpaste. The individual then brushes the teeth, gingiva and tongue and concludes by rinsing the brush and putting the brush and toothpaste away. Here is a complete task analysis for toothbrushing: 

TOOTHBRUSHING TASK ANALYSIS

Child brushing teeth. Photo by Anita
Patterson.

 

Name:______________________________            KEY                                      

                                                                            I=Independent                          

Month:______________________________           A=Assistance                            

                                                                            N/A=Not Applicable    

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Get out toothbrush and toothpaste.

 

 

 

 

 

 

 

 

 

 

2. Wet toothbrush and apply toothpaste

 

 

 

 

 

 

 

 

 

 

3. Brush the outside surfaces of the upper teeth.

 

 

 

 

 

 

 

 

 

 

4. Brush the chewing surfaces of the upper teeth.

 

 

 

 

 

 

 

 

 

 

5. Brush the inside surfaces of the upper teeth

 

 

 

 

 

 

 

 

 

 

6. Brush the outside surfaces of the lower teeth.

 

 

 

 

 

 

 

 

 

 

7. Brush the chewing surfaces of the lower teeth.

 

 

 

 

 

 

 

 

 

 

8. Brush the inside surfaces of the lower teeth

 

 

 

 

 

 

 

 

 

 

9. Brush the tongue using small strokes

 

 

 

 

 

 

 

 

 

 

10. Rinse mouth.

 

 

 

 

 

 

 

 

 

 

11. Rinse toothbrush.

 

 

 

 

 

 

 

 

 

 

12. Put away toothbrush and toothpaste.

 

 

 

 

 

 

 

 

 

 

 

HELPFUL HINTS

*Use a soft toothbrush 

*Use a pea-sized amount of toothpaste (toothpaste not mandatory if not well tolerated) 

* Position the toothbrush at a 45-degree angle to the gumline and brush in small back and forth motion for 30 to 60 seconds

Why might a task analysis be needed? Although proper toothbrushing technique is obvious to dental professionals, caregivers need to be taught. An effective behavioral technique that dovetails with the task analysis is backward chaining. With backward chaining, a caregiver uses gentle hand over hand assistance to guide the patient through each of the task analysis steps, stopping just before the last step that the patient can do independently (without caregiver guidance). The patient then finishes the task analysis step(s) on her own and receives immediate praise and other positive reinforcement. Each time toothbrushing is taught thereafter, the caregiver works to gradually remove physical guidance from the next step back from the independent step. The idea is to remove guidance and add one more step that the patient can do independently. Reinforcement is used to encourage progress.   

Brush in an alternate setting. Oral hygiene can be improved in some cases by simply brushing in an alternate setting. Although the bathroom has always been the traditional place for toothbrushing, it may not be the ideal location. For someone who is confined to a wheelchair, has spasticity, or is resistant, the bathroom can become unwieldy or unsafe. Rather, toothbrushing can be successfully accomplished in a room that provides a more relaxing, comfortable environment. The use of a beanbag chair or simply sitting on the floor may make the individual more at ease. In these settings, an additional person could provide assistance by holding the individual’s hands or by providing head support. It is also acceptable to eliminate toothpaste if that becomes problematic.  

In addition to these procedures, motivational aids can be used by the family or caregiver to increase compliance during toothbrushing. Most individuals with developmental or intellectual disabilities relish praise, which can be used frequently. A reward chart for daily toothbrushing with checks, stars, or stickers can also be very effective. When there are the specified number of checks, stars or stickers, the individual receives the agreed upon reward. Another motivational aid can be music. “Music to Brush Teeth By” with catchy beats can improve compliance. They are easy to make and can be individualized to personal music preferences. At the same time, these tapes incorporate learning additional concepts, such as following directions and spatial relations (right vs. left). 

Visual aids can also help to improve oral hygiene. The use of various disclosing solutions can be beneficial in identifying areas where the individual needs to brush better. Other toothbrushing devices are called adaptive aids. They can include mouth props and bicycle grip handles, rubber balls, or extension handles, which can make the toothbrush easier to hold and thus more accessible to the mouth. 

What about nutritional practices? As important as good toothbrushing is to achieving optimal oral health, there is another component worth noting. The caregiver must provide good nutrition, both at home and at school or work. It is important for the caregiver to know that behavior modification programs that rely on food for positive reinforcement can be detrimental to oral health. Some programs rely on foods such as pre-sweetened cereals, M&Ms, sugary coffee or juice or other cariogenic foods to reward appropriate behaviors. The decision to do so may be based on difficulty identifying non-food or healthier food “reinforcers.” Whenever possible, alternative non-sugary food rewards will reduce the susceptibility to dental caries.