Camosun College Dental Hygiene Desensitization Program

Desensitization to medical or dental procedures is commonly used to help individuals with medical designations or special considerations prepare for health care services. It takes time and effort. In consideration that family members can require many forms of care that require time and patience, the goal of our dental program is to try to help prepare your family member to receive dental care in a manner that minimizes the time required.

Goals of the program:

Use of home kit:

The home kit is designed to use with or without the website.

The goal of the home kit is introduce the process and the words commonly used in the dental environment. The words chosen have been carefully selected to minimize anxiety. A home kit is provided or can be made up if access to the kit is not possible.

Step 1: Waiting room

• A dental visit begins with the waiting room. Waiting can be challenging. The receptionist will greet the patient and ask then to sit and wait their turn. This can be hard for some patients. Most offices will try hard to minimize waiting but it is important to practice. The patient can learn to sit on any chair.
• Music may or may not be helpful, as can a specific book or activity (colouring) or IPAD time. Which is best for your patient is based on which helps calm and distract.  Begin with a short sit.even up to 10 to 15 seconds and slowly lengthened.  Provide the positive reinforcement “reward” used with your patient. The goal is to be able to sit for 5 minutes. Identifying the reward is key to success as we continue through the process.
• Outcomes for this portion: sitting calmly, identifying what distractions can be used to calm (IPAD, music, bears, colouring etc). Learning to wait..sometimes waiting occurs and it is helpful if calm behaviour occurs rather than increased anxiety.

Step 2: The dental chair

• Examinations and care are best accomplished in a reclining chair to provide the best visibility in the safest manner
• The patient will sit with the chair in an upright position until breathing is calm.
• Once breathing is normal and the patient appears “calm”  the bib is usually placed. This is to keep the shirt clean. Practice with the bib. If it is ripped off, a new one is placed. The bib is a step. (note it is not critical and can be placed when the patient is lying down). It is to “keep the shirt clean” 
• It is safest if the patient wears either clear or dark glasses. These would be placed prior to reclining the chair.  Care can be provided without, but safety is always important so if possible glasses should be worn. If the patient has glasses, these are worn. If light sensitivity is a concern, dark glasses are recommended.
• Glasses should not be removed by the patient as this would mean that hands would have come up into the non safety zone. Begin with short time use and extend with reward or praise.
• If the home has a recliner, use the recliner to introduce the patient to going back. If there is no recliner, the patient can be propped up on a bed or the floor and then use two or three pillows behind the back and one under the knees to mimic a chair like position. Removing one of the pillows behind the back will “recline” the patient.
• Many patients experience breathing changes, or other visible signs of anxiety when the chair begins to recline. Identify what calms the patient. Deep breathing, sand bagging, hand on the shoulder . Music,  breathing in and out with the care giver and counting. Many patients find this a “vulnerable” position, so it is important to work on building trust and confidence in this position.
• Once the patient is happy lying down, glasses on, with bib on it is important to establish two very critical pieces. Hands on tummy is very important..and to respond to the care giver when the “hands on tummy” signal is given. Hands coming up to the mouth is dangerous for all, hands on tummy is very important.
• The next critical feature is a “stop” . a signal of some kind that empowers the patient. It is best if the signal is in the left hand (hands on tummy) as it is easier for dental professionals to see..however it is critical that a stop be created, tested and that when used, all care is immediately stopped so that the patient feels empowered and in control.

Outcomes: patient can sit in the chair, have bib placed, and glasses on. The chair can be reclined with the patient demonstrating limited signs of anxiety. Most relaxation techniques can be used in achieve “calm” when lying down. Sand bagging, music, deep breathing and positive reinforcement.  Once lying down the patient understands and can demonstrate “hands on tummy” and has a “stop” signal.

Step 3: Looking in the mouth

• Once the patient is lying comfortably, care can begin.
• The care giver can then put on a mask. “I look different, but sound the same”  Different coloured masks are provided for desensitize to colour. Take the mask on and off and number of times to desensitize the patient to I see you/I do not. If the patient  is visually impaired, the voice can sound a bit different so practice the mask on and off as well.
• Care givers will then put gloves on. Allow the patient to feel the gloves with their fingers.
• Gloves touch the patients hands first, then arms, shoulders cheek, chin, lips. The touch feels a bit different. If the patient reacts to touch in a specific place, begin the sequence again and work to success to get to the mouth

• The next step is to use light. At home, this can be done with a flashlight or head light. Both are included in the kit.  Light begins on the tummy, then chest, chin and lips.
• Opening the mouth is now important. Opening on cue can be accomplished with a touch, following the lead of a care giver (or the clinician) or with words “ open big..big like a lion.” some patients may prefer a more literal term such as “open your mouth” and may not understand or relate to idioms such as “big like a lion” Communication is individualized and can be discussed in advance with care givers
• At all times, “hands on tummy” is maintained
• If at any point, if the patient uses their “stop” signal, the sequence stops immediately
• Care givers can then assess the situation and determine whether it is a rest or a firm stop for the day. Building trust is critical as is the sequence.

Step 4 Counting

This has usually begun already with tooth brushing. It is nice to have a friendly toy/stuffie that can be brought to an appointment..not necessarily the “special sleeping bear”..but a health care stuffie that is there to help with appointments (happy tooth, etc) 

Tooth brushing from behind the patient is favourable. It provides better access, visibility and control of the head. Tooth brushing does not need to occur in a bathroom, which are often small cramped rooms that potentially increase risk of injury for care givers and patients. It can occur in the bedroom, family room or living room where ever the patient feels most comfortable.

If possible remove any food from the mouth. This can be done with any toothbrush. The best tooth brushing targets where the gums meet the teeth.  This is best done with wet toothbrush gently brushing this area to remove/disrupt any plaque/biofilm in the patient’s mouth. The hardest places are the inside of the lower teeth and the outside of the upper teeth. It is important to lift the lip to see front teeth. Remember the target is where the gum meets the tooth zone. Brushing the tops of teeth is good too if there is food or visible plaque on the teeth.  If possible use two brushes, one in the hand of the patient and the other in the care givers hand. Use my turn your turn… if music is a positive choose a song for toothbrushing..something the patient loves that is 1.5-2 minutes long .  Once this is done with a wet brush, fluoride toothpaste can be used to introduce fluoride to the saliva.

Cues are introduced  “wide like a lion/tiger”   “  how wide can you open”  “wide like a dinosaur” if these are helpful for the patient. If the patient prefers a more literal approach, use ” open your mouth” or show your mouth opening modeling what you want them to do.

Once toothbrushing can occur, the care giver can wear gloves while brushing..let the patient feel the gloves and taste them..record if the colour of the gloves is ever an issue.

At this point it is important to introduce a stop. This can be a card, a red paper, a hand signal (left hand if possible as is easier for health care providers to see )..It is important that the patient feels empowered in any way..once this is introduced and used, it is imperative that “stop” always occurs. It is natural for the patient to try to use it a lot at the beginning, but this is when trust is developed. This is a very important skill to have.

Introduce the mask on the care giver.”.I look different  but you can still hear me” ( note if lip reading occurs, do not talk with the mask on..)

Once the toothbrushing is going ok and access can be gained with gloves on, introduce the light to see in the patient’s mouth, First put the light on the tummy, then chin, then lips, then open wide like a lion(or any other animal)  or mimic the care giver

Then the idea of counting can begin..count finger with the long q tip then count teeth..this is a very good introduction..count fast initially then slow the counting down..count up to 20 if possible..this give lots of time for checking.

Other things to try:

• Placing cotton gauze into the space between the cheek and the teeth..roll up the cotton and place it in the area..count to 10 and remove it..
• Also wrap the gauze around the tongue and hold the tongue..this allows the health car worker to see in the mouth better.
• Placing the bib on the patient..”bibs mean business in dentistry”..meaning that once the bib is on, the chair will go back so that the health care worker can look in the mouth.  Introduce the use of the bib after tooth brushing is going well.
• Suction straw..the patient will need to get water?saliva out of their mouths..the patient closes their mouth, and prepares their lips by kissing and the straw is placed on the lips in the kissing position.

Note: the order of how you use the kit is entirely flexible..because toothbrushing is often already occurring it is good to build off this.

In addition to building the skills to open, and close the mouth when asked,  have gloved hands in the mouth, light in the mouth, etc   the need to sit and wait for a turn is important.

This can be done by having the patient sit in any chair for a short period of time..”so glad to see you”, sit..(time the sit and reward)  10 s, 20 s—try to build to 5 minutes if possible..it is ok to look at a book, colour or use an IPAD if these distractors are helpful.

Use of Website: Follow social stories and use video to introduce the office to your patient.  Can be used as many times as is helpful..please also provide feedback. Lots of great information for care givers on the site. www.dentaldesensitization.com

Please check in with progress or if you have any questions at morch@camosun.bc.ca