By Bethany Durden, RDH
"He is very afraid of chairs," the mom said as I started to lay the chair back. "He will not even sit in a high top chair at a restaurant. We've had to change tables because he went into a meltdown about the chairs."
This was not a two-year-old. His mother was talking about her seven-year-old son who was unnaturally afraid of chairs that were high, or of any seat that moved. She seemed disgusted by her son's fear and was not at all supportive.
"He just needs to get over it," she exclaimed.
This is an example of someone's sensory input going awry. People rely on their senses to provide both good and bad feedback about their environment. Sometimes this very important system can go awry and problems come up, such as sensory processing disorder (SPD).
Unlike special needs patients with physical disabilities that others can easily see, the symptoms of patients with behavioral disorders such as sensory processing disorder are often not apparent. This disorder is often not even realized by parents until much later in their child's life.
SPD is chronicled in the book, "The Out-of-Sync Child." As with other disorders, there are broad ranges of severity. The American Academy of Pediatrics has not made it its own diagnosis because it often coexists with other disorders. It can overlap with ADHD and autism spectrum disorder, as well as Asperger's syndrome. If a dental clinician is educated about the disorder, this can help the parent and child achieve success with the child's oral health care in the clinical setting and at home. This article will shed light on the disorder so that dental clinicians can provide a more stress-free dental visit for everyone.
What is sensory processing disorder?
Research on SPD began in the 1960s and 1970s with the work of neuroscientist and occupational therapist Dr. Anna Jean Ayres. She described SPD as a neurological "traffic jam" that prevents the brain from receiving the information necessary to accurately interpret sensory information. Accurate interpretation of sensory information is critical, especially in dentistry where so many of the senses are bombarded during treatment.
Education for clinicians is important because cases of children with this disorder are on the rise. A 2004 study by the SPD Foundation found that "at least 1 in 20 children's daily lives is affected by SPD." A 2009 study suggested that "1 in 6 children experience sensory challenges sufficient to disrupt their academic, social, and/or emotional development." Understanding the disorder is key to knowing how to modify treatment in the dental setting.
The major categories of sensation experienced by individuals with SPD include oversensitivity and undersensitivity to stimuli. In such cases, a tap on the shoulder can feel like a hit, or it may not even be registered by the brain. The other lesser known senses that can be affected are the vestibular and proprioceptive systems. Vestibular refers to movement and balance. In this case, the movement of the dental chair is a major cause of stress. The individual may be severely uncomfortable with movement such as swinging or sliding. With the proprioceptive system, a person doesn't realize how much pressure to exert and may seem clumsy or aggressive.In a dental situation this patient may want to touch things and even break them.
There are two types of oral SPD, or oral defensiveness. The hyposensitivity type of oral defensiveness is when patients have very little awareness of what's going on inside their mouths. An example of this condition is Down syndrome patients. The other form of oral defensiveness is hypersensitivity. In this form, a patient is overly sensitive to any oral stimulation, and measures must be taken to desensitize for treatment. It's easy to see how the dental environment, with its moving chairs, loud noises, bright lights, and strangers touching your face, would push the buttons of all areas of the disorder.
SPD in the dental setting
Information about SPD can be found on the Internet and in books in much greater detail, so there are many opportunities to learn more about the types of SPD. This article will deal less with the intricacies of the disorder and more with how to deal with the disorder in the dental setting, as well as bring attention to its existence. So the question is, how can dental hygienists help SPD patients get through their appointments successfully?
First, have a plan. One strategy is to give "homework" before an appointment. If there is a time that the patient and caregiver could come in and familiarize themselves with the office in a "friendly" visit, this could help allay anxiety for the "real" visit. There is also a series of three children's books written by Sara Cremeno in which Melvin, who has SPD, meets some challenges. One of the books is "Melvin Goes to the Dentist," which was written to help SPD patients know what will happen at a dental visit. Another of Ms. Cremeno's suggestions is to make a picture book of the office and staff starting from the waiting area to the different rooms the patient will be visiting. A YouTube video would also work well.
In her interview with Sara on the Crosslink Radio Podcast, Shirley Gutkowski suggests a bag for the parent and patient that contains a mirror, prophy angle, and suction straw so that a patient can get used to the look and feel of these things before the appointment. Patients often find comfort in heavy blankets or the feeling of tightness. The SPD Foundation offers suggestions such as wearing an x-ray vest during an appointment as a weighted vest to provide that comfort.
Some patients need to touch everything, in which case a fidget toy could be used. Just like treating pediatric patients, clinicians should "tell, show, do" and verbally warn these patients before each procedure to prepare them. If noises are a source of stress, have patients listen to headphones with their favorite music. When lights are problematic, patients can wear sunglasses and the overhead lights can be turned off and just the operatory light used. Other modalities can also be used, such as massage and firm touch.
For oral hyposensitivity, Debra C. Lowsky, MS, CCC-SLP, founder of Ark Therapeutic Services Inc. suggests, "waking the mouth up" by using massage techniques. For gum massage, start at the midline and go posteriorly in one direction, return to the midline, and go the other way toward the posterior. Do this in sets of three. If you're unable to do this inside the mouth, you may do the same technique on the face. For more information, visit the Ark Therapeutic Services website and YouTube channel for demonstrations.
On the other hand, for the hypersensitive child, Lowsky suggests testing the mouth to see which part is sensitive-the cheeks, tongue, etc.-and applying gentle pressure to desensitize the area. Some other desensitizing techniques are to have the patient eat a Popsicle or chew xylitol-based gum before the visit. At the beginning of the appointment, instead of going straight for the mouth, start with the hands and squeeze gently, repeating up the arms and shoulders to see how the patient tolerates touch.
I had the opportunity to use these techniques on a SPD/autistic child at my office. The mother was very nervous about the visit, but we started with the hand and moved up the boy's arms with light squeezes and eventually to his face for the outer massage. I was then able to use gauze with prophy paste to "massage" the gingival margin and teeth. His visit was very nice and though we did not accomplish a full prophy, we all considered the appointment a success. At the end of his visit, the boy was very eager for "Dr. Mouth" to examine his teeth.
Some patients are not able to receive optimal treatment in the traditional office setting. In this case, Greg Evans, DDS, suggests that sometimes we must do the best we can in the dental office, but we may have to do general sedation every two years or so in order to perform a thorough exam.
The senses are valuable assets, but when these senses are under- or overstimulated, they can be a distraction rather than a help. Being mindful of sensory processing disorder and having a plan for the dental appointments of patients with SPD can help in long-term dental success for these patients. Remember that the caregiver is a resource for learning about the patient because dental hygienists deal with their patients for 60 minutes, while caregivers must navigate every anxiety in the child's life.
Give homework to help these patients get to know the office staff and routines. Use touch and massage to help stimulate or desensitize a patient as needed. Help them be comfortable with music, low light, and a fidget toy before the appointment begins. Do what you can for the patient in the office, and when necessary, refer to a specialist for sedation. Always remember to celebrate any successes for both hygienist and patient. There are no patients more special than those who come with fears and anxieties, and over time and with patience, they gain dental success and confidence. RDH
Bethany Durden, RDH, graduated from Clayton College and State University with a bachelor's of dental hygiene in 2003. She has practiced clinically in Calhoun, Georgia, for the past seven years. She enjoys pediatric care the most, and she's always looking for new ways to help dental patients and create a positive perception of dentistry. With new innovations in the understanding of how the mouth can affect overall health, she looks forward to helping usher in a new era of dentistry.