Neurodevelopmental Disorders

1. Recommended oral care programme

• Preparation
• Scheduling appointments
• Adapting the dental care environment
• Approach and personalised adaptations
• Routine during appointments
• Aids
• Perception/sensory experiences Advice for practitioners

2. Survey

3. Visual communication

4. Low-affective approach

5. Aids

6. Sensorimotor stimulation using Z-vibrator

7. Relaxing facial massage

Remember that you must always adapt treatment to suit a patient’s circumstances.

Preparation

Prepare the NDD patient’s personalised acclimatisation programme by first holding a discussion with those who will be involved in their visits. The best alternative is to hold a personal meeting with these individuals at the clinic when the patient is elsewhere. Meeting in person can sometimes pose a challenge, however. In such cases, holding the discussion over the phone is a good alternative. The main thing is that you, the practitioner, and those who will accompany the patient to the clinic have the chance to share important information with one another. Fill in the survey together (see Section 2, Survey) and use the results to design the acclimatisation programme. Set goals and a timetable, design suitable visual communication aids and decide on a rewards system and how best to give praise. Draw up a thorough medical history for the patient and define the acclimatisation programme’s aim.

Scheduling appointments

• Adapt appointment times to suit the patient’s routines.
• Schedule a longer time than usual for the patient’s first visit.
• Send the patient notifications about their scheduled appointments that include pictures as an aid to understanding (see Section 3, Visual communication).

Adapting the dental care environment

• Where necessary, adapt the waiting room to suit the patient’s needs. A day when there are fewer appointments scheduled overall might be a good day to see NDD patients. You can also use the recovery room as a waiting room to provide the patient with a calmer environment.
• The environment inside the treatment room is also important. Try to keep it as simple and uncluttered as possible.
• To avoid unnecessary interruptions, make sure that everything you need is on hand from the start by planning the treatment session in advance.
• Be aware that the patient may perceive sensory stimuli differently (flavour, light, odour, sound and touch).
• Avoid unnecessary talking. Be clear and specific in your communication.
• Inform other staff members that you should not be disturbed.

Approach and personalised adaptations

• Give the patient time. Many NDD patients need time to acquaint themselves with a new environment.
• Modify your expectations to suit the patient.
• Keep your verbal communication brief and specific.
• Build on what works.
• Stop/pause work in time so that the patient’s experience always remains positive.
• Seek guidance from the patient’s carers or personal assistants. They know the patient’s limits best.
• Use a low-affective approach: take a step back, wait, then try again.
• Where necessary, use augmentative and alternative communication (AAC) methods, such as signs/symbols, pictures, or other communication aids (See Section 3, Visual communication).
• Praise the patient generously and often.

Routine during appointments

• Collect the patient from the waiting room on time.
• Follow the patient’s personalised acclimatisation plan and use their visual communication aids.
• Hold brief practice sessions.
• Repeat these practice sessions several times, so that the patient becomes familiar with the routine.
• Take breaks when needed.
• End the appointment in a concrete way, such as by giving the patient a personal reward.
• Homework: Give the patient material (including visual communication aids) to take home related to the activities they will need to practise in preparation for their next appointment.

Aids

• Unbreakable mirror
• Bite support
• Cheek retractor
• Z-vibrator (see Section 6, Sensorimotor stimulation using Z-vibrator)
• Triple-headed, single-headed, electric and extra soft toothbrushes
• Oral wipes
• Unflavoured/mildly-flavoured products
• Ring-shaped ”Omgärdaren” cushion (see Section 5, Aids)

Perception/sensory experiences

Many people with NDD interpret sensory experiences differently from others and may have either strong or muted reactions to flavours, odours, sound, light and tactile stimuli. Helpful tips:

• Unflavoured toothpaste/fluoride varnish with a mild flavour
• Avoid strong odours
• Avoid unexpected noises
• Dim the lighting/offer the patient sunglasses
• Bear in mind that NDD patients’ pain thresholds can be perceived as being uneven, with areas of both hyper- and hyposensitivity.
• Using a ring-shaped cushion can be helpful for patients who are sensitive to physical contact (see Section 5, Aids).
• Relaxing facial massage – The aim is to get the patient used to physical contact (see Section 7, Relaxing facial massage).
• Intraoral desensitisation using a Z-vibrator – The aim is to get the patient used to physical contact inside their oral cavity (see Section 6, Sensorimotor stimulation using Z-vibrator).
• Time aids – Make the duration of activities tangible for the patient by counting or using a visual countdown timer, ordinary timer, or hourglass.
• Distraction – The following may help distract NDD patients during treatment: holding a tactile toy in their hand, listening to their favourite music, singing by the practitioner, using a tablet/mobile phone.

Advice for practitioners

• View the person who accompanies the patient to the clinic as part of your team. The patient’s acclimatisation programme will be most successful if you work together.
• Cultivate good relationships with the patient’s carers and personal assistants.
• Invite their help prior to, during and after treatment, since they know the patient best.
• In some cases, switching the practitioner or the accompanying carer can help the patient make progress.
• The practitioner should be both competent and devoted to the task.
• Keep calm, organised and creative in your approach to treating the patient.
• Keep running documentation for feedback purposes. Filming appointments is especially helpful.
• Feedback among the various professionals involved is important.
• Allocate time for preparation and post-appointment work.
• A patient will intuitively recognise when a practitioner feels insecure.
• Avoid talking about the patient’s treatment, scheduling appointments, etc. when the patient is present. Where possible, hold these kinds of discussions with carers over the phone.
• Be sympathetic to the family’s overall situation. Encourage them and provide feedback on their efforts.
• Offer them practical advice about oral care and oral care aids that can be of help to them in the home.
• Personalised visual communication aids and time aids can be used to remind patients about their oral care routines (See Section 3, Visual communication).
• The clinic must allocate resources to support the acclimatisation programme.

• Patient’s name:
• Patient’s Personal Identification No.:
• Diagnosis/Functional impairment:
• Does the patient take any medication? If yes, please specify.
• Is the patient sensitive to light or sound?
• Is the patient sensitive to physical contact?
• Is the patient sensitive to flavour or odour?
• What are the patient’s dietary habits?

A knowledge of the patient’s general circumstances is helpful in designing the most appropriate acclimatisation programme.

• Carers/personal assistants:
• Activities/interests:
• Fixations/phobias:

• How does the patient communicate? (Gestures/speech/signs/visual communication aids)
• What type of visual communication aid works best? (Photos/symbols/smartphone/tablet)
• Does the patient have any previous experience with dental care/health care?
• How successful is their toothbrushing routine at home?
• Has the patient ever been given any premedications (i.e., medication prior to surgery or treatment) or been treated while under anaesthetic?
• What do you suggest is the best way for us to prepare for the patient’s treatment?
• How should we praise/reward the patient?
• How can we end appointments in a concrete way?
• Is there anything else you would like to share with us/explain?

Personalised visual communication aids prepare the patient for the treatment process and make practice sessions both visual and clearly-defined.

• These materials must have a clear structure if they are to inspire a sense of security and confidence in the patient.
• Always stick to the treatment plan.
• Keep in mind that NDD patients often have difficulty handling unexpected events. For this reason, always work in a predictable way.
• Allow the patient to be as fully involved in their own acclimatisation as possible. Provide them with aids to help them express themselves, for example a rating scale.

Example of a rating scale

Involve the patient in their treatment and give them the opportunity to share their feelings about their appointment. For example, use pictures that allow the patient to point to different evaluation alternatives.

Example of appointment notification with visual aids

You can create your own appointment notifications containing visual aids on the website bildstod.se. An example of what an appointment notification containing visual aids might look like is shown down here. Remember that any text you use should be brief and simple.

	Picture Picture of the clinic and waiting room. Text Patient’s name, date, day, time and the clinic’s address.
	Picture Symbol for parking. Text Describe the parking options available.
	Picture Screenshot from the clinic´s website. Text Enter the address of the website where the patientcanfind more information, such as directions to the clinic.
	Picture Symbol for "time". Text The scheduled timeforthe appointment.
	Picture Photo or symbol depicting the practitioner.  Text Include the practitioner’s name.
	Picture Step 1. Text Write, for example: ”Sit in the dental chair, switchon thelight”.
	Picture Step 2. Text Write, for example: ”Inspect your teeth using a mirror”.
	Picture Step 3. Text Write, for example: ”Clean/polish your teeth”.
	Picture  Step 4. Text Write,for example:”Treat your teeth with fluoride varnish”.
	Picture  Step 5. Text Write,for example:”Reward”.
	Picture. Symbol depicting a conversation via phone. Text Information about how the patient can contact the clinic if they need to cancel or reschedule their appointment,for example.

Make your own invitation with images on bildstod.se

“Low-affective” pedagogy is a methodology aimed at helping practitioners create a pedagogical environment characterised by tranquillity. Children can become frustrated when they have difficulty making themselves understood or expressing themselves. In such instances, you can help them by using low-affective strategies.

A low-affective approach helps a child feel acknowledged and competent and promotes their self- esteem. It is an especially helpful approach for children with NDD and children with externalising behaviour problems.

Low-affective approach strategies

• Speak calmly.
• Be aware of the impression your body language conveys.
• Do not threaten the child with punishment or other consequences.
• Take a step back, wait, then try again.
• Don’t lower your expectations, modify them instead.

Lasal cushions

Lasal’s ring-shaped ”Saveguarder” cushion can be placed around the patient’s neck, shoulders and arms, with the ends overlapping across their stomach. This provides both restriction control and stability. It can be helpful to use the Omgärdaren cushion in combination with the Ostbåge cushion, which supports the patient’s head and neck.

Visual aids

A visual countdown timer, hourglass, or time-management app can help NDD patients understand how long an activity will continue.

Tactile aids/Stimulation

A “Tangle Jr.” fidget toy, sensory ball, or fidget spinner are some examples of items that can help distract a patient during treatment sessions.

Fidget spinner – Improves focus and calm

Tangle Jr. – Helps with focus and concentration

Sensory ball – Massage and relaxation

Tablet cover/protector

A tablet cover/protector provides the patient with a good grip on the tablet while also protecting the device if they drop it.

Weighted sensory cushion

A weighted sensory cushion can mimic the feeling of an adult’s hand lying reassuringly across the child’s chest.

The Z-vibrator is intended to help get the patient used to physical contact inside their oral cavity, with the long-term aim of facilitating dental examinations and toothbrushing.

How to use the Z-vibrator

• Turn the vibrator on and let the patient feel the vibrating sensation on their hand, first.
• Next, let the patient experience the sensation around their mouth.
• Continue by letting the patient feel the Z-vibrator on their lips before gradually working your way inside their mouth.
• In the beginning, the most important thing is not the patient’s sitting position, but that they can tolerate the Z-vibrator in and around their mouth.
• If possible, use the palm of your non-dominant hand to support the patient’s lower jaw throughout.
• the activity (see images below). If the patient is unusually sensitive to physical contact, using a cushion as a support can be a good alternative.
• Remember to work in short bursts and to take frequent breaks. It is important that the patient’s visit be a positive experience with no pressure.

Temporalis muscle

• Massage the patient’s temples with your fingers using a circular motion.
• Next, apply firm, static pressure against their temples and hold for a moment.
• Continue the massage by using a slow, gliding motion that progresses diagonally forwards and downwards to stretch the temporalis muscle. Repeat several times.

Massetermuscle

• Massage the masseter muscle using small circular movements starting from the cheekbone and moving downwards towards the lower jaw.
• Use your hands to apply momentary pressure to the muscle.
• Finally, stretch the muscle using a gliding motion, working downwards towards the lower jaw.
• Repeat this slow stretching motion several times.

Underthe chin

• Loosen the muscles under the patient’s chin by massaging them with your fingertips.