Dental care & I/DD: Challenges and solutions
by Steven A. Crites
Author’s note:
The author wishes to thank Dr. Joseph Brown, DMD. Dr. Brown provided the case studies for this article. In addition, Dr. Brown has provided quality dental services to many underserved individuals for more than 50 years.
Photo Credit: Rick Guidotti for Positive Exposure
Individuals with developmental disabilities (I/DD), including autism spectrum disorder (ASD), often exhibit resistance to dental treatment. This article will review two case studies of successful dental treatment for individuals with autism where a small dog is used to comfort each patient. In addition, the author will discuss additional ways to ease anxiety and increase cooperation during routine dental treatment for individuals with developmental disabilities.
Small dogs like the one pictured are used to comfort patients with I/DD during dental treatment. Photo Credit: Rick Guidotti for Positive Exposure
“Developmental disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a person’s lifetime”1. Autism spectrum disorder (ASD) is considered a developmental disability. Developmental disabilities often lead to less access to dental care2 and poorer oral health.3 Additionally, many individuals with developmental disabilities engage in disruptive escape behaviors to avoid dental treatment, often leading to dentists excluding those with developmental disabilities from their practices.4 Further limiting access to care.
Going to the dentist for emergency treatment or a routine examination can provoke feelings of anxiety and fear for typically developing patients. This anxiety and fear are more pronounced for those with developmental disabilities including autism spectrum disorder (ASD). 40% of individuals with autism also have a diagnosis of anxiety disorder that can be triggered by just going to the dentist.5 One study reported that nearly 1 in 4 (22%) children seen by pediatric dentists have engaged in disruptive behavior.6 In fact, protests such as head banging and temper tantrums may be triggered by invasive dental procedures.7 Research in 2014 found the ASD group experienced pain during dental treatments more often than the control group and 22% had experienced being forced to dental treatment they were not prepared for compared to 3% in the control group.8
Several types of interventions have been used to address problems incurred during dental treatment. Traditionally, chemical and physical restraint have been employed to get individuals with autism to comply with dental treatment.9 Providing pre-treatment medications, and/or using mechanical restraints such as papoose boards are not uncommon.
However, there are more positive interventions being used to assist those with developmental disabilities to have successful dental treatment. For example, researchers developed a task analysis of the steps of the dental procedure.10 The study participants practiced the dental visit by enacting each step of the task. Each participant was presented with a small treat or toy for participating. By learning the procedure, each knew what to expect at each step of the task. This lowered the anxiety and fear of the dental procedure. Results indicated that disruption decreased, and the amount of the dental procedure completed increased.
Photo Credit: Rick Guidotti for Positive Exposure
Additionally, other techniques have been used to improve behavior at the dentist:
Applied behavior analysis (ABA) focuses on reinforcing positive behaviors
Developmental social-pragmatic model (DSPM) focuses on teaching communication skills as they arise.
Picture exchange communication system (PECS) teaches those who have difficulty with oral language to communicate with pictures.
Learning experiences and alternative program (LEAP) is a fully inclusive preschool program.
Plus combined interventions of the aforementioned techniques.
Results indicated ABA yielded a success rate of 95%, DSPM yielded a success rate of 90%, PECS produced a success rate of 85%, and the LEAP model yielded a 100% success rate. 11 Researchers indicated the need for a slow and gradual approach to persons with I/DD. They need to know each step in advance so they know what will happen at each stage. Parents must also cooperate with the adaptations in order for them to be successful.
Animal assisted intervention has also shown to be effective. Two case studies of individuals with autism who were seen for dental care (one on an emergency basis, the other routine visit) are described. In each case the patient was assisted during the treatment by a small dog. The two cases are presented below:
In the first case, a 12-year-old patient with ASD was seen in the clinic for emergency treatment of a fractured tooth. The patient was playing on an outdoor carousel and fell face first and fractured tooth 8 on the mesial aspect, approximately one-third of the incisal. The pulp chamber could be seen bleeding through the dentin. The patient’s mother reported that the last time he was seen at the dentist, he refused to be treated or even examined. After conferring with the patient’s mother, the dentist determined that Dr. Sid, the chihuahua, might aid in the treatment of the patient.
After consulting with the patient’s mother, Dr. Brown introduced the patient to Dr. Sid. The patient immediately bonded with Dr. Sid. The dog sat in the patient’s lap during the procedure. He played with the dog’s ears and the dog licked his hand, distracting him as the dentist completed his treatment. His mother stated that this was the most satisfactory doctor or dentist appointment that her son had ever had.
In the second case, the patient was referred by his mother, a dental patient herself. When she was visiting the dentist for a routine visit, the subject of her son came up. He was a 10-year old child with ASD in need of a dental exam and cleaning. However, he hated to be touched, hated strangers, and hated doctors the most. Dr. Brown explained his previous experience treating patients with ASD and told her he was willing to see her for an exam and cleaning, but made no promises or guaranties. The dentist arranged an appointment time where he could have Dr. Sid present. The mother prepared her son, telling him what was going to happen, what the dentist was going to do, and that Dr. Sid would be there to help him. The appointment went as planned and the patient and Sid got along famously. Again, the dog helped to relieve the anxiety of the patient and the dentist was able to examine and clean his teeth without incident.
In both cases presented, the introduction of the small chihuahua into the clinical environment of the dentist’s office served as a calming anxiety reducer for the patients. In each case, the patient with ASD focused on Dr. Sid rather than the dental procedure that they feared. Interacting with Dr. Sid during their dental treatment kept the focus on the dog and not on the dental procedure being performed, reducing anxiety and acting out behavior due to the dental procedure.
Interacting with Dr. Sid seemed to lower the anxiety of each of the individuals with developmental disabilities. This lower anxiety allowed the dentist to treat each patient. These results are similar to those in a literature review of animal-assisted interventions. In that review, several studies found that individuals with ASD exhibited less stress and engaged in fewer problem behaviors while in the presence of a service animal. 12
Unfortunately, not all dentist offices come equipped with a Dr. Sid to assist with patients. So, what can the dentist and his or her staff do to assist individuals with developmental disabilities in their dental care? Researchers have been working on answering that question. 7,8 Here are some ideas for the patient, caregiver, and the dentists and their staff.
Before the dental appointment, the patient and caregiver and the dentists and their staff can:
Explain to the patient why they will be visiting the dentist.
Allow the patient to see the office and treatment area before the dental appointment.
Schedule early in the day, or a time when the office is less busy.
Allow the patient to ask any questions. This may need to be assisted by the caregiver.
During the appointment, the patient and caregiver and the dentist and staff can:
Keep the visit positive and short.
Allow the patient to have his/her service animal present (if they have one).
Inform the patient what the dentist is about to do.
Speak to the patient directly and not to the caregiver, but do not overestimate the comprehension abilities of the patient. People with developmental disabilities often have problems saying what they want to say and understanding what is said to them.
Allow caregivers to come into the treatment area to help the patient effectively communicate.
Show the patient what you are about to do using visual aids.
Dentists may calm the patient by holding hands.
Reinforce successful patient efforts and cooperation each time.
Be sure to praise the patient as she/he complies with the treatment.
If possible, delay more difficult procedures until after the patient becomes familiar with the dentist, assistants, setting, and instruments.
Dental treatment for people with developmental disabilities is important. In the past, people with developmental disabilities were often medicated, physically restrained, and forced into treatment without knowing what was happening. Dental treatment can be frightening, and this article has provided two examples of successful dental treatment of individuals with developmental disabilities with the help of a small dog. The patients each held the dog while the dentist was working on the teeth. The dog lowered the patient’s anxiety and provided a distraction from the procedure. Additionally, some general tips were provided for the dentist, caregiver, and patient to do before the first treatment and during the treatment. Overall, reducing the anxiety and fear over visiting the dentist will allow the patient to receive better treatment, with the prospect of better overall oral health.
The author
Dr. Steven A. Crites is an associate professor at Morehead State University in Kentucky. He has spent his entire career working with individuals with developmental disabilities in residential facilities, state developmental centers, and schools, and teaching both undergraduate and graduate students how to become special education teachers.
Notes
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