Neurodevelopmental Disorders

1. Recommended oral care programme

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

2. Survey

3. Communication

4. Biting needs

5. Digital healthcare meetings

6. Low-arousal approach

7. Aids

6. Desensitisation 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 without the patient. Meeting in person can sometimes pose a challenge, however. You can select to hold the discussion over the
phone or during a digital healthcare meeting (see Section 5, Digital
healthcare meetings). The main thing is that you, as 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 comm-
unication 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, Communication).

Adapting the dental care environment

• If necessary, adapt the waiting room to suit the patient’s needs. A day with fewer appointments scheduled might be a good day to see NDD patients. Consider using the recovery room as a waiting room to provide the patient with a calmer environment.
• Keep the treatment room as simple and uncluttered as possible.
• To avoid unnecessary interruptions, make sure that everything you need is on hand from the start.
• Be aware that the patient may perceive sensory stimuli differently (flavour, light, odour, sound and touch).
• Avoid unnecessary talking. Communicate clearly and be specific.
• Inform other staff members that you should not be disturbed.
• Allow the patient to bring a therapy dog. Schedule the appointment for late in the day and arrange for extra cleaning (see section 7. Aids).

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. Ensure a positive experience for the patient.
• Seek guidance from the patient’s carers or personal assistants. They know the patient’s limits best.
• Use a Low-arousal approach (See Section 6, Low-arousal approach).
• Where necessary, use augmentative and alternative communication (AAC) methods (See Section 3, 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 and introduce the ”stop hand”.
• 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 upcoming activities.

Aids

• Unbreakable mirror
• Bite support
• Cheek retractor
• Z-vibrator (see Section 8, Desensitisation stimulation using Z-vibrator)
• Triple-headed, single-headed, electric and extra-soft toothbrushes
• Oral wipes
• Unflavoured/mildly-flavoured/strongly-flavoured products
• Ring-shaped ”Safe Guarder” cushion (see Section 7, Aids)
• Interactive cat (see Section 7, 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:

• Dental care products are available in different consistencies and
  flavours. Some are also flavourless.
• Avoid strong odours.
• Avoid unexpected noises.
• Dim the lighting or 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 7, Aids).
• Relaxing facial massage – The aim is to get the patient used to physical contact (see Section 9, 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 8, Desensitisation 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, the practitioner singing or
  using a tablet/mobile phone.

Advice for practitioners

• View the person who accompanies the patient to the clinic as a 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, Communication).
• The clinic must allocate resources to support the acclimatisation
  programme, according to your national guidelines.

• 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?

In this section, we cover various forms of Alternative and Augmentative Communication (AAC), including visual communication aids and Total Communication (TC).

Visual communication aids

Individual visual communication aids prepare the patient for the treatment process and make training sessions visual and concrete.

• The visual communication aids should have a clear structure to create security and trust.
• Always stick to the treatment plan. Keep in mind that unforeseen events are often difficult to handle. Therefore, work predictably.
• Allow the patient to be as involved as possible in their acclimatisation programme. Provide tools for expression, such as a rating scale.

Rating scale examples

Engage the patient and provide opportunities to describe their experience of the visit. Use, for example, images where the patient can point to different 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

Talking mats

A talking mat consists of images that represent a visual scale,
conversation topics and questions – all related to the topic at hand. With the help of the talking mat, a patient can visually express their opinions. The same method can also be used digitally.

Total Communication (TC)

Total Communication is a useful method of conveying messages, which a lot of children use to kickstart their language development.

"Brushing your teeth is good" using Swedish TC

An extensive biting habit and/or tooth grinding during the day is a complex behaviour that needs several different approaches. There are different things to try out to manage this behaviour. It’s important that all professionals in your team collaborate when managing oral habits such as biting and/or sucking on hands and objects to explore possible solutions. There is a wide range of toys and devices available, such as chewing jewellery and various other chewing tools.

More information

In our booklet ”Everyday Oral Motor Stimulation” you
will find information about oral habits, amongst many other things.

Read "Everyday Oral Motor Stimulation"

There are several different strategies that can be applied during digital healthcare meetings, depending on whether there is knowledge of a NDD diagnosis or not.

If there is knowledge of the patient’s NDD diagnosis

If this is the case, you can exchange information and jointly develop an acclimatisation programme for the patient.

If there is no knowledge of the patient’s NDD diagnosis

If the first visit to the clinic does not go well, consider it a preliminary ”meet and greet” visit. Then, schedule a digital healthcare meeting to exchange information and jointly develop an acclimatisation programme.

If there is knowledge of that the patient is a school refuser

Conduct a digital meeting with the guardians to exchange information and jointly develop an induction plan. Following this, digital healthcare meetings can be scheduled with the patient.

“Low-arousal” 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-arousal strategies. A Low-arousal 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. You can read more about Low-arousal approach in our booklet ”Low-arousal approach in dental care”. The QR code on the next page will lead you to it.

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

The ”Safe Guarder” cushion can be placed around the patient’s neck, shoulders and arms, with the ends overlapping across their stomach. This provides restriction control and stability. It can be helpful to use it in combination with a u-shaped neck cushion, which supports the patient’s head and neck.

Visual aids

A visual countdown timer, hourglass or a time-management app can help NDD patients understand how long an activity will continue. For example, by counting to five while you examine a quadrant, it becomes easier for the patient to feel in control.

Therapy cat

The purpose of a therapy or companion cat is to create a sense of security, warmth and calm interaction during a visit. If the patient gives the cat a hug, they will feel the therapy cat’s heartbeat. And when touching the cat’s sensors, it responds by moving, meowing, or purring. During inactivity, it will fall asleep – but it wakes up immediately upon your touch.

For individuals with an NDD diagnosis, this type of aid can be used to create
new associations with the clinic environment and examination room. The cat combines relationship building activities, tactile stimulation and distraction.

Companion dog

A companion dog (or service dog) can assist individuals with an NDD diagnosis by providing a sense of security. In situations with a lot of new impressions, the dog becomes a natural point of contact.

Allowing a companion dog during the acclimatisation programme can make a significant difference in building a positive relationship with the clinic. It is important to book the last appointment of the day and arrange for extra cleaning after the visit.

Order our booklet

In our booklet "Low-arousal approach in dental care" you can read more about campanion dogs. Look for the chapter ”Patient case Nelly”.

Read "Low-arousal approach in dental care"

Visual aids

There are several ways to use visual aids before or during an
examination – both to make the patient feel comfortable, but also to clarify the visit’s structure for everyone involved.

A tablet can provide visual stimulation during the visit and serve as a secure focal point.

Take the opportunity to ask questions about the game or movie on the screen – as part of building a relationship with the patient.

A ceiling-mounted screen in the examination room can distract from various elements of the visit. If there is a possibility of a screen, it can make it easier for the patient to maintain focus.

Soap bubbles can also distract from what is happening during an examination or treatment. They can also be used as an indicator that a certain moment is finished – where the bubbles become a delightful reward.

Tactile aids/Stimulation

A pop it, sensory ball, fidget spinner or “Tangle Jr.” are some examples of items that can help distract a patient during treatment sessions.
They also help to create a relaxed situation for the person in the
treatment chair.

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 west

In some situations, a weighted vest can help the patient feel embraced and secure during the visit.

Auditory aids

The most common example of auditory aids is headphones – which can help the patient focus on, for example, a favorite song. But it can also involve sound isolation, using earplugs or earmuffs.

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.
• The same approach can also be used with a battery-powered
  toothbrush

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.