Samantha Chamberlin, MOT, OTR/L, Sherrell Lawrence, MPA, Allan Forster, MEd,
and Mary Jane Weiss, PhD, BCBA-D
Melmark

Oral health is a wide-ranging concern among individuals with autism and other intellectual disabilities. Visits to the dentist are an extremely difficult undertaking for many people with autism as they oftentimes occur in an unfamiliar environment with the individual having little understanding of the intended procedure and having to endure novel and/or aversive sensory experiences. Indeed, dental visits can be very challenging events, often resulting in physical restraint, and sometimes being unsuccessful in achieving a dental examination (Altabet, 2002). In a recent study by Ward et al. (2019), 56% of adults aged 20 to 40 with intellectual disability (ID) had periodontitis (i.e., gum disease) compared to 13% of neurotypical U.S 30- to 34-year-olds. This number increases to 92.6% of individuals with ID over the age of 60 compared to just 53% of neurotypical adults over the age of 65. The consequences of poor oral hygiene extend well beyond the mouth, as it is also associated with generally deteriorating health and cardiac issues (Joshy et al., 2016). Furthermore, dental neglect often results in complications, including surgical procedures, infections, and tooth loss (Owens et al., 2006).

To prevent these consequences, it is important to build daily dental hygiene habits. This can be difficult to achieve in individuals with autism. Adults with autism and other developmental disabilities frequently present with aversions to brushing teeth that make oral health maintenance complicated. Compliance with brushing is often challenging. It can be almost impossible to conduct professional oral cleanings and examinations (Hernandez et al., 2011). Oftentimes, annual dental visits are completed under general anesthesia to ensure effective examination and treatment. Parents and providers are frequently unable to coax the individual to comply with the required oral health exams, resulting in frequent delays and cancellations in appointments.

Behavioral interventions offer hope in this context, and a number of evidence-based procedures are showing promise in reducing the challenges associated with dental care. Indeed, there is emerging literature highlighting effective methods, and this information is incorporated into treatment planning. For example, systematic procedures can be used to build tolerance (e.g., Carter et al, 2019; Choudhari et al., 2020; Dunhanyan et al., 2019 ). It may be necessary to begin with extremely short durations. In one case study of a 28-year-old individual with developmental disabilities and low tolerance for dental procedures, initial toleration of oral care initially ranged from one- to two-second periods of allowing a toothbrush in his mouth. The reasons for low tolerance are numerous, and include a wide array of sensory and behavioral challenges. Multidisciplinary collaboration between occupational therapists, dental hygienists, and behavior analysts offers creative solutions. Each discipline lends a unique perspective to the development of shaping procedures to reduce aversion to oral care, increase oral hygiene habits, and build tolerance for dental procedures.

Through their expertise in activity breakdown and the selection of adaptive equipment, occupational therapists can assist in selecting the appropriate toothbrushes based on the specific needs of the individual. In one particular clinical case study conducted by this group of authors, six different toothbrushes were selected with two different goals in mind: maximizing toothbrush surface area to clean a larger percentage of the mouth in a shorter duration and finding alternative bristle types to reduce aversive tactile stimuli. The trialed toothbrushes included: a surround toothbrush where bristles cover the entire toothbrush head, a 3-sided toothbrush to provide increased access to individual teeth, a silicone-bristled toothbrush, a fine-bristled toothbrush (bristles are softer and more compact), a built-up kid-sized toothbrush with a smaller head, and a standard toothbrush as a control. This type of detailed sensory assessment allows for the identification of brushes that may be tolerated more readily. Samples of different brushes and pastes are contained in Table 1.

Dental hygienists also provide valuable insight towards identifying priority areas of the mouth to target based on cavity location and accumulation of plaque. During an initial assessment for the aforementioned clinical case, it was revealed that one individual demonstrated a strong gag reflex that was triggered by light touch to the tongue. Further trials indicated improved success when avoiding touching the tongue with the toothbrush and instead targeting less sensitive areas of the mouth. Additionally, dental hygienists can assist with the recommendation of practical strategies to improve comfort during oral care. For example, using warm water to soften the bristles of the toothbrush can assist with the provision of a gentle tactile experience.

For all intervention cases, collaboration with behavior analysts can help provide an individualized preference assessment and the establishment of reinforcement schedules to promote success. In another recent clinical case at Melmark, preference assessments were completed to establish preferred toothbrushes, toothpaste, and reinforcers (See Table 1) . Initial results revealed that Tom’s Strawberry toothpaste was most preferred when compared to several other brands and flavors, including bubblegum, grape, watermelon, citrus, fruit, and spearmint as a control. While there are limited data to support toothpaste preferences in adults, a recent study by Choudhari et al. (2020) demonstrated that children tend to prefer toothpaste that is red in color, has a fruity smell and tastes sweet. Furthermore, the strongest reinforcer for the individual in this case study was music, which is used to shape positive interactions surrounding oral hygiene. Small changes of this type can make all the difference in how an individual experiences toothbrushing. Issues of swallowing and expulsion must also be addressed, and should be considered from medical and behavioral perspectives. This is exactly why an individualized approach to intervention is so important, as many different antecedent interventions (such as toothpaste colors, brush alternatives, and concomitant reinforcers such as music) can be helpful.

Several recently published articles have highlighted how adaptation can be achieved through systematically desensitizing individuals with autism to oral hygiene procedures (e.g., Carter et al., 2019; Choudhari et al., 2020; Dunhanyan et al., 2019). Specifically, individuals can be helped to tolerate different aspects of the procedure sequentially, and the duration of tolerance can also be specifically targeted. The integration of preferences, especially for brushes and paste flavors, increases independence and eases the acquisition of toothbrushing skills for some learners (Duhanyan et al., 2019). Some extensions of this work are also being done, including exploring the use of biomarkers such as heart rate to indicate calmness with the procedure (Gayle, 2021). Ensuring that the procedures are associated with genuine comfort and calmness, as well as with behavioral tolerance, is important.

The examples above illustrate how antecedent interventions and positive outcomes can be used to make the experience more tolerable and pleasant. Since toothcare is a health routine with significant health consequences, it is imperative to find compassionate ways to build cooperation for these procedures. Such successes ensure healthy teeth and gums and prevent serious health complications. Individuals who experience cavities, abscesses, and other oral health issues are subjected to even more intrusive and painful consequences. Building tolerance for preventative dentistry procedures helps prevent these procedures, which can be frightening and traumatic.

The combination of perspectives in a multidisciplinary model ensures that all of the relevant expertise is considered. See Table 2 for a review of questions commonly asked during assessment by a multidisciplinary team. This list of barriers is meant to illustrate the need for several disciplines in assessing and planning for oral care needs among those with developmental disabilities. The dental health perspective ensures that the issues are being addressed comprehensively from an oral health perspective. The occupational therapy perspective provides troubleshooting for sensory sensitivity issues, and provides creative sensory solutions and suggestions to make the experience more tolerable. The behavioral perspective can assist in focusing on both antecedent changes (e.g., toothpaste flavor) and positive consequences (e.g., adding music), as well as developing systematic, individualized plans for desensitizing the individual to the experience. Many of these areas also overlap. Occupational therapists and behavior analysts can work together to assess different toothbrushes in a systematic way, to identify one that may be more pleasing to the individual. Dental personnel can work with all other members of the team to suggest strategies for brushing that may be more efficient depending on the specific oral care needs of the individual. Using a multidisciplinary team model helps to ensure that assessment and intervention reflect a comprehensive approach, and that the individual benefits from the expertise of all relevant professions. Such collaboration can greatly reduce the negative experiences for the individual served, and can greatly enhance behavioral and health outcomes.

Oral hygiene and autism

 

Table 2: Questions/Observed Barriers
 

Several common barriers/issues arise in planning that require the expertise of individual professions. This table illustrates how complex the issues in planning for oral care are, and how different disciplines must be involved in a thorough assessment and to guide treatment.

 

  • Diet/Food texture of individual (To be assessed by SLP/OT/NURSING):
    • Is the individual on thickened liquids?
    • Is mouthwash an option?
      • For example, mouthwash was not an option during our case study as our individual

was on moderately thick liquids

    • Is the individual on a modified diet/choking risk?
      • Disposable oral swabs can be used as an alternative to toothbrushes in situations where tolerance is a concern. Swabs may allow for greater access to harder to reach areas of the mouth and can be used with mouthwash for individuals who may not have the oral-motor skills to safely gargle/spit. However, swabs need to be used on a case-by-case basis as the foam tip can be a choking risk for individuals if the foam tip becomes dislodged
      • Oral swabs were not an option for the individual in our case study due to his dysphagia diagnosis and modified diet texture
  • Environment (To be addressed by behavior analyst):
    • Is a natural setting (i.e., bathroom) for brushing teeth a trigger? Can oral hygiene tasks be safely completed in another area?
  • Dental recommendations (To be addressed by dentist and dental hygienist):
    • What is the individual’s current ability to tolerate oral hygiene tasks?
    • What recommendations have been put in place by the dentist?
    • Do more frequent cleanings need to be scheduled?

 

References

Altabet, S. C. (2002). Decreasing dental resistance among individuals with severe and profound mental retardation. Journal of Developmental and Physical Disabilities, 14, 297–305.

Carter, L., Harper, J., & Luiselli, J. (2019). Dental desensitization for students with autism spectrum disorder through graduated exposure, reinforcement, and reinforcement-fading. Journal of Developmental and Physical Disabilities, 31, 1-10. https://doi.org/10.1007/s10882-018-9635-8.

Choudhari, S., Gurunathan, D., & Kanthaswamy, A. C. (2020). Children’s perspective on color, smell and flavor of toothpaste. Indian Journal of Dental Research: Official Publication of Indian Society for Dental Research, 31(3), 338–342. https://doi.org/10.4103/ijdr.IJDR_363_18

Duhanyan, K., Harper, J., Heal, N., & Luiselli, J. (2019). Effects of preference on performing a self-care skill among children with autism spectrum disorder. Child & Family Behavior Therapy, 41, 110-116. DOI: https://doi.org/10.1080/07317107.2019.1599261

Gayle, R. (2021) Dissertation. Autonomic Arousal and Adherence with Appointments. Submitted to Endicott College for fulfillment of Ph.D. requirements.

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, 281-287.

Joshy, G., Arora, M., Korda, R. J., Chalmers, J., & Banks, E. (2016). Is poor oral health a risk marker for incident cardiovascular disease hospitalization and all-cause mortality?BMJ open, 6(8), e012386. https://doi.org/10.1136/bmjopen-2016-012386

Owens, P., Kerker, B., Zigler, E., & Horowitz, F. (2006). Vision and oral health needs of individuals with intellectual disability. Research in Developmental Disabilities, 59, 370-377.

Ward, L. M., Cooper, S. A., Hughes‐McCormack, L., Macpherson, L., & Kinnear, D. (2019). Oral health of adults with intellectual disabilities: A systematic review. Journal of Intellectual Disability Research, 63(11), 1359–1378. https://doi.org/10.1111/jir.12632

 

Citation for this article:

Chamberlain, S., Lawrence, S., Forster, A., & Weiss, M. J. (2022). Clinical Corner: Multidisciplinary collaboration in the establishment of oral hygiene habits. Science in Autism Treatment, 19(3).

 

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